Full text of "A manual of the practice of medicine"

See other formats

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 marginalia 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 this resource, we have 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 fi^om 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 attribution The Google "watermark" you see on each file is essential for informing 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 liability 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

aqhttp: //books. google. com/

A MANUAL

PRACTICE OF MEDICINE.

WOaKS B7 THE SAKE AUTHOB.

A PRACTICAL TREATISE ON THK DISEASES OF INPAIfCY

AND ClIIhDIIOOD.

Trier tl 60.

ThU liook differs from other works of the kind, in embracing a
wider range of subjects than is usually contained in treatises on
children's diseases. Besides the ordinary complaints, it includes
many affections which, though common to adults and children, yet
offer some modification in form, or in the indications for treatment,
when occurring in the latter. Thus, we have an account of diseases
of the eye, ear, and skin, of small-pox, scrofula, tuberculosis, syphilis,
bronchocclc, and cretinism, diseases of the kidneys and geuito] or-
gans, and some of the accidents common to childhood.

OPINIONS OF THE PRB8B.

W« reoommrnd thia e)ieelIi>Dt mannBl to the attention of oar readers,
as woU worthy a iilace nmang the more elaborate treatises in their libra-
ries.— Med. and iSarg. lirportrr.

We hare much satisraction in cordially resommending thin rolame >•
one of the most carerni, acuarate, and accessible manoals on the soljeot.
— EtUuhur^k Mfd. Jnuiiiiil, Aug. 1868.

It is oancise, clearly written, Tree from all ambiguity of thought or ei-
preedion, and directly practical throughout. — Chnrltatun Med. Journal
and Rpvirw.

Dr. Tuunor hat acquitted himmlf with the skill of a practical author
doaling with d subject with which he is iieoaliarly conrenant. The re-
sult is a book good in matter and in style. — London Latuft.

MEMORANDA ON POISONS.
Price SO els.

A MANUAL

PRACTICE OF MEDICINE.

THOMAS HAWK.E8 TANNER, M.D.. P.L.8.,

MOUn or THB BOTiX COLLEOl OF rHTSlCIAlia; AHlSTAnrPBTnCIAll rom TOB DU&UB9
or WOMXK AKS CHILDKUI TO KWO'S OOLLUI BOarlTAL, ITC (N.

rSOM THB LAST L 0 N D O !l B D I T I 0 K.

(Enlarged anb .^mprobtb.

LINDSAY & BLAKISTON.
18 04.

•• *«• • • *••••■
• ••••• ••• •

- /rss-

c. miiiiiAR, son * CO., pRixTiiiit.

PREFACE.

A Nkw Edition of this Manual having been
demanded, I have endeavored to render it more
worthy of the great encouragement hitherto be-
stowed upon it. In doing this, the original plan
has l^een adhered to, of making its pages the
medium of as much practical information as the
limited space at my disposal would allow ; my
aim having Ijeen to obtain brevity, not so much
by omission as by a strict avoidance of all reitr
eration; by on all occasions saying what I mean
in the fewest number of words ixtssible ; a.s well
as by a careful selection of those points only
which can aid the practitioner in the discharge
of his responsible duties at the Ix'dsidc, In
short, I have endeavoix'd to paint tlie features
of disease not imperfectly, but, as it were, in
miniivture.

XIT

Without attempting in any degree to depre-
cate criticism, it iw still due to my readei-s to
say, how sincerely I trust it may not be thought
that too dogmatic a tone has been adopted in
the remarks upon the treatment of disease. My
excuse, however, if one be necessary, is, that I
feel great conGdence in the strength of the gene-
ral principles which I have tried to inculcate ;
and being thus zealously impressed, it is difficult
to do otherwise than speak jjositively.

In conclusiim, I cannot help expressing a
hope that, with all its faults and imperfections,
this little work may still prove useful to many
practitioners and students ; and especially to
those whose occupations prevent them from stu-
dying larger treatises.

Obarlotti Btbht, BioroBD 8<)dabk.

TABLE OF CONTENTS.

PART I —GENERAL DISEASES.

PAOC

I. Morbid States of the Blood, 25

1. Introduction, 25

2. HypeT<Kmia, 30

3. Anamia, 31

4. Leucoci/themia, 33

6. Piarrh(rmia, 35

6. Olueuhremia, 37

7. Urtemut, 41

8. Acholia, 44

9. Icliorrhwmia or Pyamia, .... 45

10. Deposition of Fibrin, 49

11. EiUozoa, 55

n. Scurvy, 66

IIL Purpura, 58

IV. Hydrophobia, 60

V. Glanders, 65

VI. Hemorrhage, 68

1. Introduction, 68

2. Cerebral Hemorrhage, 72

3. Epislaxii 73

4. Stomatorrhagia, 75

5. Hcemoptytis, . 76

6. Hasmatemeaii, 78

7. Hcematuria 80

B, Menorrhayia, 82

Vll. Inflammation, 83

VIU. Dropsy 93

^^^Ri

■

CONTENTS. ^^^H

^^^ FAOB

^^^K^^ IX. Carcinoma, 96

^^^^^^L 1. General Paiholotfi/,

^^^^^^M Varieties of Cancer,

^^^^^^P 3. Caiuet of Cancer,

105

^^^^^^■^ 4. Trr.atmenl of Cancer,

106

^^^B X. Tuberculosis, .

113

^^^H XI. Melanosis,

120

^^^B 1. True Mclanosiii,

120

^^^H 2. Sjntrions Mdanotii,

123

^^^V XII. Fatty Degeiierntina,

124

^^H XIII. Amyloid Degeneration, .

127

^^^H XIV. ConfitltutioQal Syphilis, .

131

^^^^ XV, Urouclioifle niid Cretinism,

1.38

^^^^^^L 1. BroHchocele or Goitre,

138

^^^^^^[

140

^^r XVI. Gout, ....

141

^^^B XVII. KhcumntisiD, .

150

^^^P 1. lilieiimaiic Fever, .

151

^^^" 2. Chronic liluumatijini,

156

^ XVIII. Rheumatoid Arthritis,

159

^^M PART n.— FEVERS.

^^B^ 1. Continaed Fever, 164

^^^^^^L Simple Fever,

165

^^^^K 2. J)/i>fius Fever,

167

^^^^H 3. Tijithoid Fever,

1T6

^^^^^K 4. Jielapsintj Fever, .

180

^^^B n. Intermittent Fever or Ague,

182

^^H IK. Remittent Fever, .

187

^^^H 1. Remittent Fever, .

187

^^K 2. Tellow Fever,

190

^^^^^^ IV. Eruptive Fevers,

191

^^^^^^fc Variola or Small-pox,

. 193

^^^^^^^B 2. Vaccinia or Cow-pox,

. 197

^^^^^^B H. Varicella or C/tieken-po^

, 198

^^^^^^K 4, Morbilli or Measles,

193

^^^^H 6. Scarlet Fever,

. 200

^^^^^^^B (i. Enjsijielas,

. 207

^^^^m

. 210

CONTENTS.

PART m.— DISEASES OF THE NERVO08 SYSTEM.

PACB

L Inflammation of the Brain, 212

1. Ariilt Injliimmalion, . . . . .212

2. Chronic lujlitmmatiun, . . . . .217
H. Tubercnlar Meningitis, 219

in. Hydrocephalus, 222

IV. Apoplexy, 226

V. Concussion of the Brain, 232

VI. Coup de Solell 234

VII. Delirium Tremens, 237

1. Delirium Tremens, 237

2. Dipaomania, 240

VIIL Insanity, 243

1. Oeneral Obtereations, 243

2. Varieliet of Intaniti/, 247

3. Principal CauttM, 254

4. Diagnosit and Proj/nosis, .... 235

5. Paihologji and Morbid Anatomy, . . . 266

6. General Treatment, 259

IX. Cephalalgia, 262

X. Diseases of the Spinal Cord, ..... 2C5

1. Spinal Meninyitis, 266

2. Mijeliti.1, 268

3. Spinal Hemorrhage, 269

4. Tumom, 270

5. Uydrorachia, 270

6. Coitcutnon 271

7. Spitxal Irritation 273

XI. Paralysis, 274

1. General Paralyn», 275

2. Hemiplegia 276

3. Paraplegia, 280

4. Local Paralysis, 282

6. Wasting PaUy 283

6. Mercurial PaUy 288

7. Lead Palsy, 288

8. Paralysis Agilans, 290

XII. Epilepsy 291

XVIII

XIII. Hysleria,

XIV. Catalepsy and Ecatac-y,
XV. Chorea, .

XVI. Tetanus, .
XVII. Neuralgia,

"ONTENTS.

p*r.r

> ■ • •

. ayo

LC-y, .

. .^01

. HOI

. • • •

. 'AOi

• • • •

. 307

PART IV.

-DISBA8ES OF THE ORGANS OF RE-StPIBATIO}! AND

CIRCULATION.

I.
II.

III.

IV.

VI.

VII.

VIII.

IX.

XI.

XII.

XIII.

XIV.

XV.

XVI.

XVII.

XVIII.

XIX.

XX.

XXI.

XXII.

XXIII.

XXIV.

XXV.

XXVI.

Catarrh, . , 312

Chronic Inflammaliun of the Nostril.-i, . , . 314

Diphtheria, . 31 G

Croup, 322

Laryngitis, 327

Laryngismus Stridulus, 329

Dyaphonia Clericorum, 33 1

Bronchitis, . 334

1. Ani/e Bronchiiis 334

2. Chronic Bronchitis, 337

3. Hay Anlhma, 339

Iiilluenza, 340

Pertussis, or Hooping-Cougb, 342

Asthma, . 345

Emphysema 350

Pleurisy, 352

Pneumonia, ........ 358

Phtiiisis, 364

Cancer of the Lang, 375

Pericarditis, 376

Endocarditis 382

Myocarditis, 383

Valvular Diseases of the Heart, .... 386

Hypertrophy of the Heart, 394

Atrophy of the Heart, 397

Cyanosis, 400

Rupture of the Heart, 401

Angina Pectoris, 402

Cardiac Ancurisin, 404

CONTENTS.

XIX

PART v.— DISEASES OF THE ORGANS OF DIGESTION.

II.

IV.

VI.
VII.

vin.

IX.
X.

XI.

XII.

XIII.

XIV.

XV.

XVT.

XVII.

XVIII.

XIX.

XX.

Inflnrnmation of the Tongac,
Iiiflammnlion oftlic Mouth,

1. Folliailar Stomatitis,

2. Ulcerative Stomatitis,

3. Cnucruin Oris,
AphthtL- of the Moulh,
Iiiflnm million oftlie Parotid,
Inflammatioti of the ToDsils,
Diseases of the CEsophagus,
Dyspepsia,
Gastritis,

1. Acute Gastritis,

2. Chronic Gastritis, .

3. Gastric Catarrh, .
A. Induration of the rytoriix,
5. Dilatation of the Stomach,

Ulcer of the Stomach,
Cancer of the Stomach, ,
Enteritis,

Inflammation of the CffiCum,
Dysentery,
Diarrhoea, . .
Epidemic Cholera, .
Colic, ....
Constipation, .
Obstruction of the Bowels,
Intestinal Worms, .
Perforation of the Bowel,

PAflE

40t;
408
408
409
410
411
411
412
413
417
425
425
427
429
4.t0
432
4.34
437
440
443
446
450
452
4G0
461
465
471
474

PART VI.— DISEASES OF THE LIVER, PANCREAS, AND
SPLEEN.

L Congestion of the Liver, .
II. Inflammation of the Liver,

1. Hepatitis,

2. Cirrhosis,

3. Inflammation of the Veins,

4. Inflammation of the Gall- Bladder, d;c.,

477
480
480
485

4H8

488

CONTENTS.

rAOB

lU.

SuppreHsion of the Functions of the Liver,

. 489

\. Acule Atrophy of the Liver, .

. 4S9

2. Acholia Jrom other Can.ta, ,

. 492

3. Chronic Atrophy of the Liver,

. 492

IV.

Degenerations of Ihe Liver,

. 494

\, Fatty Deyeneralion,

. 494

2. Amyloid Degeneration, .

. 495

3. Pigment Liver, ....

. 496

Cancer of the Liver

. 498

VI.

Hydatid Tutnora of the Liver,

. 499

VII.

Jaundice,

. 602

Diseases of the Pancreas,

. 505

IX.

Diaeaaes of the Spleen, ....

• . 506

PART TII.-

-DISEASES OF THE PERITONEUM, OVARIAN
DROPSY, ia.

I. luflamination of the Peritoneum, .... 508

1. Actilc I'erHoniiit, 508

2. Chronic Peritoniiia, 511

II. Ascites, 513

IH. Ovarian Dropsy, 515

IV. Tabes Mesenteriua, 519

PART Vni.— MSEA.SES OF THE KIDNKYS, SDPRA-RENAL
CAPSULES, AND BLADDER.

I. Inflammntion of the Kidney, ,
IL Acute Uesquamative Nephritis,
HI. Chronic Desquiimativc Nephritis,
IV. Fatty Di'generalUm of the Kidney, .
V. Amyloid DegetiiTalion of the Kidney,

VI. Gravel

VIL Diabetes Mellitug, ....
VIII. Cancer of the Kidney,
IX. Disease of the SupraRcnal Capsules,
X. Irritability of the Bladder,

CONTENTS.

XXI

XI. SpaKRi of the Bladder 545

XII. Paralysis of the Bladder 64(i

XIII. InflatnniaUon of the Bladder, .... 550

PART IX.— DISBASES OF THB SKIN.

Order I. Exanthemata, 5.'>2

1. Erythema, 555

2. Roiieoln, 555

3. Urticaria, 55(>

Order II. Vesiculie, 557

1. Sudamina, 557

2. Herpet, 658

3. Eezemoj 559

Older ni. Halite, 560

1, Plnnp/uyvn, 560

2. Rupia, 560

Onler IV. Pustulte, 561

1. Ecthyma, 561

2. Impeliijo, 562

Order V. Parasitici 562

1. 7Yn<a Tonsurans, ..... 56.3

2. Tinea Favosa, 56H

3. Tinea Decalvan«, 66S

4. ISii^a Sycosis, 564

5. Plica J'olonica, 564

6. Chloasma, 565

7. Scabies, 565

PapuliE, 566

1. Lichen, 566

2. Pruriyn 567

aamip 569

I^ejira, 670

Psoriasis, 670

Pityriasis, 571

Ichthyosis, 671

Order VI.

Order VII.

XXII CONTENTS.

FAOa

Order VIH. Tuliercula

. 572

1. ElephanHaiia, ....

. 572

2. MuUuacum, ....

. 673

K 3. Acne

. 673

H 4. Lupus,

. 574

H 6. Frambasia

. 674

K C. Keloid,

. 575

PART X.— DISEASES OF THE EYE.

I. Impaired Vision, . .

1. Myopia,

2. Presbyopia, .

3. Asthenopia, ,
i. Color Blindness, ,

II. Iiiflammaliou of the Conjunctiva,

1. Catarrhal Ophthalmia, .

2. I^nileiU Ophthalmia, .

3. Strumous OphUtalmia, .

4. Oranular Conj^tnctiva, .
m. Inflammation of the Sclerotic, .

1. Rheumatic Ophthalmia,

2. Calarrho-Illieiimatic Ophthal
IV. Diseases of the Cornea, .

1. Conical Cornea,

2. Inflammation of the Cornea,

3. Opacity of lite Cornea, .
V. Diseases of the Iris,

1. Iritis, ....

2. Inflammation of the Iris and

3. Mydriasis,

VI. Inflammation of the Choroid, .
VII. Inflammation of the Retina, .

Vni. Cataract,

IX. Glaucoma, ....
X. AmaaroBJs, ....

mid,

Cornea,

676
676
677
578
578
579
680
680
583
583
684
584
585
685
685
686
686
587
687
590
690
691
592
592
693
695

CONTENTS.

XXlll

FART XL— DISEASES OF THE EAR.

I. Otalgia,

II. OtorrhoBa,

III. Inllamiiiation of the External Heatna,

IV. Diseases of the Membrona Tympani, . .
V. Inflammation of the Cavity of the Tympanum,,

VL Diseases of the Enslachiaa Tube,
VII. Rheumatic, Gouty, and Nervous Deafness,

PAGE

598
599
600
601
602
604
606

PART Xn.— DISEASES OP THE BLOODVESSELS.

I. Aortitis, 608

IL Aortic Pulsation, 609

III. Aneurism of the Aorta, 609

1. Anevri»m of the Thoracie Aorta, . . 610

2. AneuTum oj'tlte Abdominal Aorta, . . 612

IV. Phlebitis, 613

V. Phlegmasia Dolens, 613

APPENDIX OP FORHUL£.

1. Aliments, 621

2. Alteratives and Resolfents, 625

3. Antacids, 633

4. Antiseptics, 634

5. Antispasmodics, 635

6. Astringents, . . . , 637

T. Baths, 641

S. Cathartics and Anthelmintics, 643

9. Caustics and Counterirritants, 652

10. Diaphoretics, 65.')

11. Diuretics, 655

12. Emetics and Expectorants, 656

XXIV CO^TENT8.

PARK

13. Emmenn^ogues, .,,...,. 659

14. Gargles and Inhalations, 660

15. Lotions, Liniments, anH Collyrin, 661

16. Narcotics and Sedatives, 665

17. Ointments, 669

18. Refrigerants and Salines, ...... 671

19. SthniilanU, 673

20. Tonics, 674

A CLASRiriED List or Mineral Springs, .... 682
Proportions or Activk Inoreoients in Imi'obtant Prepa-
rations, 68.3

Indbs, 686

A MANUAL

PHACTICE OF .MEDICINE.

PART I.
GENERAL DISEASES.

I. MOHBID STATES OF THE BLOOD.

1, Introduction. — In vain shall we attpinpt tn understand
tho uaturc of many of the diseases tu whicli the human frame
is liable, unless wc possess an accurate kni)wled<»o nf the con-
alitation ancl properties uf the blond ; that fluid which has heoii
no appropriately termed "the life of the flesh," thn-u^h tho
iovtruuHMitaliiy of which the various chancres which attend the
pbcnoDiciin of life arc aecornplished, and by means of which
the different organs and tissues of the body are direefly nou-
rished. Hence nn attempt will now be made to p\vc n brief
account of the present state of our knowled<i;G of this iniport-
,iiit Hubjeet.

Lifu is only to be maintained by the circulation of arterial
bl'iod; and whether no blood circulates thr(iu;;li the arteries,
or only vemms blood, the result is the same, — death. When
BO blood eireiilatcs, death is said to take place from nj/nvupe;
and this is of two kinds. Firstly, death by "H«m/o, in which
there is u want of the due supply of blood to the heart, ns is
w]tnevi«d in fatal htemorrhuge, &c.; secondly, death by<t«/A«-

GENERAL DISEASES.

ni'a, where there is a ftiilure in the contraelile power of the
heart — and this is seen to occur from the action of cerU-iin
poiBuns, from intense grief or terror, from lightning, concuB-
sioD, blows on the epigastrium, as well as from certain forms
of apoplexy. It must be reniombered that in some instances
death is due partly to atiicniia and partly to asthenia; as may
be particularly noticed in fatal cases of starvation, and iu linger-
ing disorders like phthisis, dysentery, &c.

When vcflous blood circulates through the arteries, death
itiiiy happen in one of two ways. In the first place we have
death by nsphycin (more correctly speaking, by apncca — pri-
vation of breath), or tvffocatian, where the Access of air to the
lungs is prevented; as occurs in drowning, stratiguhition,
choking, immobility of the respiratory muscles from tetanus,
section of the phrenic and intercostal nerves, obstruction of
the larynx by false membranes, many diseases of the lungs,
and so on. Secondly, there is death by coma, in which the
muscular movements reijuircd for respiration cease, owing to
insensibility produced by some cerebral mischief; examples
of which form arc seen in ninny affections of the brain. Thus,
in death by apnuea we have successively impeded respiration,
the circulation of venous binod, and insensibility; while in
coma the order of the phenuiiiena is reversed, and we find
insensibility, cessation of the thoracic movements, and a stop-
page of the chemical functions of the lungs.

The blood is a viscid, albuminous fluid, charged with salts,
and containing i-orpuscles ; it is of high Mpecific gravity
(1041 — 1082, Simon); its temperature varies from 100° to
10.5°; its reaction is slightly nkaline, the degree of alkalinity
being greater during fasting than after food has been tnkoii ;
and its rjuantity is estimated by V^ilentin as about thirty-two
pounds for a male weighing one hundred and forty-tive pounds
(lOst. .!)lbs.) There is an iranicn.se difference — a difference
of life and death — between the blood whicli enters, and that
which issues from the lungs. The latter — arterial blood — is
the fluid which maintains life, and which circulates between

MiiKRll) STATKS OP THK BLODD.

27.

tht! lunifs and the capillaries; being carried to the left auricle
bj the pulinunury veins, pa&sing thenoe to the ventricle, and
then by the aorta to the various organs of the body. The
change of dark venous blood into bright red arterial blood
depends upon the removal of carbonic acid gns and the absorp-
tion of oxygen ; the seat of this change being in the red glo-
bules, though its prcci.se nature has hitherto balflcd the
scrutiny of chemists and physiulogists.

On minutely examining the blood, it is found to consist of
a transparent yellowish liquid called the liquor sanguinis ;
which is formed of serum holding fibrin in solution, and in
which are contained very nunieroui< red discs termed bluod-
corpuscle.s, together with a few larger colorless corpuscles.
A human blood-corpuscle is a cell without a nucleus, having
an external membrane and red contents. In the first months
of intrauterine life, with all the mammalia, the corpuscles
have nuclei; while the same is the case during the whole
existence of frogs, fish and birds. The contents of the cells
consist of red coloring matter, summarily called hiematinc.
This latter contains a large amount of iron, and from it, under
certain circumstances, three kinds of microscopic cry.stals can
be obtained. The first variety of crystals has been named by
Virchow hcematoldinc ; and they are important, because an
eflfumid mass of blood, !is in apoplexy, cannot be removed,
except by a large poKion of it undergoing thia form of crys-
lliisation. Moreover, haemuloidine presents properties which
iIjow that it is allied to the coloring matter of the bile — cho-
lepyrrhinc. The second kind of crystals has been called
hfrmitie, and these are important to the medical jurist, as
oflFering a test of the presence of blood :* while the third class
baa received the name of htrmato cri/sfal/iii. This crystalline
substance was formerly named globulin, owing to its crro-

• The mode of obtaining theci" erystnls lu" tests for the delecliun of
hIooil-*tsinaU <howD in Virohow'a work on Cel/ii/ar Pulhologi/, triinalated
Sfj Dr. Chanoe, p. Ui, London, 186fl.

riENF.KAI. DIRGASCS,

neously (supposed identity with the protein-body obtnincd fmm
the crystalline lens. The colorless corpusules are smnll in
number (the proportion to Ike red ia in health, as I to 800),
are perfectly ^plieiiciil in shape, desititute of all color, very
delicate in sirueturo, nnd have (;ninuhir contents with one or
Djore nuclei. When Brst discovered they were tuistaken for
pus-corpuscles, the rcs\ilt of pyremiu. The juiport.niiee of
these corpuscles will be !<liown in the remarks presently to be
uiude on leucocythcniia ; but ut present it need only be added,
that many physiolo<rist9 iillow that they are ideutical with
those bodies occurring in lymph, chyle, mucus, and pus, to
which the general term lytuiil inrfimuUif has been applied.

When the blood is jast drawn from the botly, it fornix
quickly a gelatinous mass ; the primary and essentia) part of
this process consistint; (if the views of Dr. RiHh,Trd.iijii are
correct) in the evolution of ammonia from the serum. In
about fifteen minutes the gehitinouA uiusa will bo found to
have shrunk and resolved itself into two portions, called clot
and serum; this chungc beint; due to the ciuijiuhition of the
fibrin contained in the lifjuor sanguinis. The ciot consists,
then, of the fibrin holdinji the red corpuscles entangled within
the nieshcs it h; s formed. The .serum is the liijuor sanguinis
niinns the libriii; and is a jwlc-eolorcd, watery solution of
albumen, having a density of abont 1029, being of alkaline
reaction, and holding in solution many important substjinces.
When the blood cojinulutes imperfectly, this is due either to
an absolute doliciency of fibrin, or perliaps to excess or slow
evolution of its solvent.

It is difficult to give the exact chemical composition of the
blood, since this fluid is altered uot only in different diseases,
but also by the fiuantity and variety of food taken. The fol-
lowing table, however, may be regarded as indicating the
composition of healthy blood iu 1000 pits.

MOKHHI STATKS uF TItE BLOOD.

Wnler, 784,

Oxygen, |

Carbonic acid, j- dissolvied ia tlie tluid,

Nitrogen, J

^'"•"^ '^'f"*' I conarituting the red corpuscles 131.

Hosmatiiiei )

Fibrin 2.2

AlbiiDien, 70.

8«lU:

Phosphate of soda, lime, magnesia, and iron.

Sulphate of potash, ^ . . . C.

Chlorides of sodium and potassium, silica, kc.
Fat« :

Margarine, ....

Oleine,

Seroline,

Choltslerine, . . .

Phospliuretted fats, tec,
Extractive matters (unknown substances), with |
traces of nrea, uric acid, creatine, Ac, . . )

.il

1..-!

Whatever interferes with the process of ehylification, with
respinitioti, with the excretory organs (as the bowels, liver,
kidneys, and skin), and perhaps with the healthy condition of
the nervous system, will aifeet the composition of the blood.
Mr. Paget adopts the proposition of Treviranus, that " each
single part of the body, in respect of its nutrition, stands to
the whole body in the relation of an excreted substance ;" and
this is probably true. Thus, to take only one example, it can
readily be understood that the phosphates deposited in the
ones arc as effectually excreted from the blood ns those which

di-scharged with the urine.
The chunpes which take place iii the blood under different
uircuMistancas will be noticed in treating of the various diseases.
It may, however, be useful to premise that inflammatory dis-
orders remarkably modify the composition of the blood, and
especially increase the quantity of fibrin. Venesection, or
htemorrhage in any form, chiefly reduces the amouat of the red

CIENKRAI. I1ISKA8K8.

pnrticlfs, mid to a slight de;;rec lessens the «juantity of the
albuiuon and fatly iimtt-ers ; while it also diminishes the den-
sity of the serum. Moreover, under the influence of bleeding,
starvation, anicniia, and other states of oshaustiirf; or iiicreaaed
waste, the librin either remains unaltered, or is diminished in
quantity. It will now be convenient to notice in succession
those disorders wliich are generally specially known as Llood
diseases.

2. Hypersemia. — llypcranuia (^pu/i/umin, plrtfiom, or ful-
ness of bloijtl) consists either of an excessive quantity of the
vital fluid ; or, as is most commonly the case, of a superabun-
dance of the red globules, the quantity of the blood remain-
ing unchanged, while in quality it becomes over-rich. The
projiortion uf fibrin is also increased (/i_i/periiio.ii»}. It is a con-
dition often plainly indicated by distension of the capilhiries,
08 nay be obser\'ed on the cheeks, lips, and mucous mem-
branes; by a full, strong, resistant pulse; and by a turgid
appearance of the veins. Obesity, also, is often an accom-
paniment, though by no means an inliilliblc sign of plethora.
When the blood merely exists in too great abundance in one
or more particular organs or tissues, we say that there is par-
tial plethora, or a local eoiigc.<tion or determination of blood.
I'artial plethora not uncommonly occurs in cases where tho
blood, taken as a whole, has been much diminished in quantity
or quality by disease. If wo irritate an org.111 mechanically,
we cause an increased flow of blood to it tliruugh the arteries,
which gives rise to active coDgestion ; a condition which, after
K Ume, either decreases insensibly, or ends in ha'morrhage, or
piaaes into inflammation. When the return of blood to the
heart through the veins is impeded, us by the compressiou of
one or more venous trunks, wo h;ive what is called mrthmiiral
congestion. Or again, the circul.ition of the blond through
the ciipillarics of a part may be sluggish, as is often seen in
persons debilitated by age or disca.'H;, and we then have itassive
congestion.

MORBID STATES OP THK BLOOD.

The bloud boiiifx directly led by the chyli', it is evident that
too free livinj; iiiust be one of the most uotniiion couju-i of
hypersemin. The noruial waste of tissue, and conscinient
expenditure of blood, is also impeded by a sedentary mode
of life.

The Itf.nimvnt of general plethora niuht consist in the
adoption of a restricted diet, or the employment of non-
nutritious Kubtitiinccs ; in the avoidance of beer and all other
alcoholic drinks; in lessening the hours devoted to sleep; and
in the use of active exercise in pure air. Saline purgatives
often do good ; while the li(|Uor potassa;, in rather large doses,
is fre<|uently an efficacious remedy, especially where there is a
mjiidly-inereusing tendency to grow fat. In extreme cases the
abstnictiun of a small quantity of blood may be necessary.

3. Ansmia. — Deficiency of blood {poverli/ of blootl,
*paiiiiiniu, lii/dramiii, or olii/crmlti) arises generally in ca.ses
where there has been deprivation of the proper materials
neeessiiry for the formation of heulihy blo«)d, and in the course
of severe chronic maladies; as well ns in those diseases which
are attended with ii gradual draining of this fluid, as in persons
RufTering from bleeding piles, women with menorrhagia or
cancer uteri, &c. It may of course bo produced artiticially by
excessive vencj^ection, and such like means. If the blood bo
analyzed, it will be found that the red globules arc deficient;
80 that, instead of cxi.sting in the proportion of about ISO per
1000, as in health, they are reduced to 80 or 60, or even (in
severe cases) to 30. The proportion of tibrin either remains
onchungcd or it is diminished (hi/piiioAis).

A peculiar form of anaemia, termed Chlorosis, frequently
afTccts young women about the age of puberty ; being generally
dependent on, or at least connected with, di.surdcred menstrua-
tion, and probably certain sexual caui-es. Sufferers from it have
a peculiar pallor of the skin, whence the name of the disease, —
i/rtru tirlciiett. lleiilth may generally be restored by a course
of cLalybeatcs. In producing this effect the iron not only acts

IIKNKRAI. DIHEA8K8,

as a general ionic, but in all probability becomes asniiiiilated
and enters directly into the formation of the blood f;lobale.
The soluble preparations of steel are much more active than
the insoluble; while the less astringent the former can be pro-
cured, the more energetic will be their influence.

Those varieties of anaemia which are caused by tuberculosis,
amyloid degeneration, fatty degeneration, carcinoma, scurry,
&c., will be treated of at length in succeeding pages.

Sj/mptontt. — The chief symptoms of ansomia are — a pale,
waxy, blanched appearance of the countenance and integu-
ments generally, as well as of the lips, tongue and inside of
the mouth ; a pulse feeble and small ; loss of appetite ; apparent
enlargement or protrusion of the eyeballs ; low spirits; and
great general debility with languor. Any exertion is attended
by a sense of sinking, and fainting or syncope, together with
hurried breathing and palpitation ; x>dema of the ankles is
often present; and sometimes there is albuiiiinuriii. On
practising auscultation over the base uf the heart, a loud sys-
tolic bruit or bellows-sound will frequently be detected ; which
may bo traced distinctly up the aorta, and in the subclavian
and carotid arteries. liy placing the stethoscope over the
jugular vein, especially over the right, a continuous humming,
or cooing, or even whistling sound — the hruif ile diabk — will
be heard ; a sound which is caused, as Dr. Ogier Ward tir,«t
pointed out, by the descent of attenuated blood through the
great cervical veins.

Treaiment. — Occasionally we meet with such serious cases,
that we can for a time only trust to the most careful nuraing,
to the guarded use of some preparation of cinchona, to the
very frwjuent administration of wine or brandy and fluid
nouri.ahnient, and to the strict nuiintenanee of the recumbent
posture — possibly on a watt!r-bed. But generally speaking the
patient is seen before matters have arrived at this state, and
then the various preparations of iron (F. 449, 4r>0, 458, 403,
461), 472, 484, &c.) ; aloetic purgatives, combined or not with
8l«el (F. 188, 187, 199, 447, 459 or 487); good nourishing

MiiKIIIT) STATES OF THE BLIIOD. 38

food; ciut-(l(>(ir oxerci^c, short of fali^iio ; the rospinitioti of
pure iiir ; and cold bnthini;, pnrticiiliirly in sca-wiittT, are the
remedies we trust to. Under their judicious use, all the for-
midable symptoms ju.st enumerated entirely disappi'ur ; but it
must be remembered that uk it takes a longer time to restore
the red globules than the other constituent!) of the blood, so
the remedies must be persevered with for many weeks.

In unaemiu dependent on too severe mcnt.il occupation, the
phoHphuto uf iron or the phosphoric sicid in some tonic infu-
sion (F. 470, 471, 476), together with cod-liver oil, does much
good. In such coses the blood is poor and watery ; and hence
re<)uires to be enriched by rest from intellectual pursuits, good
diet, fatty articles of food, .ind chalybeates. Overwork of the
brain produces deterionilion of the blood as certainly as too
prolonged or too intense muscular action, or an iusufficient
supply of nourishment.

4. Lencoc3rthemia. — This is a ronmrkable affection, which
Las been particularly inve»^tigated by Viruhow and Hughes
Bennett. The first has named it Ltukivmia, or white blood;
an objectionable term, inasmuch as the blood is nut white, but
of its usual color. Dr. Bennett h.-is therefore substituted tho
word Li-nrwi/lltfmin, from ^ieyxOf white, xot"? a cell, and iu;xa
the blood ; literally white cell-blood. It may be best defined
as a morbid state of the blood, in which the white corpu.selea
nrc greatly increased in number, while the red arc much
diminished.

Sffmptomi. — Very little is known of thi.s disease or its onuses
at present. In cases where it has been found to exist, the
majority of the patients have suffered from an unusual pallor,
like that of anaemia ; from great emaciation and debility ; from
more or less swelling of the abdomen, owing to cnl.irgcment of
the spleen, or liver, or both ; from disordered respirntion ; and
from incren.sing prostration and emaciation, gradually ending
in death. In many cases, moreover, there has been diarrhcea;
btcniorrhage iu some form or other, but especially cpistaxia;

UKNKK'AL DltlKABIW. ■

urine loaded with uric ncid ; nnusca, jaundice, fever, and loss
of appetite ; together with (joilenia of tlie legs, anasarca, or
ascites, dependent on the abdominal enlargement.

Proijnosu. — This is alwa3'8 unfavorable. All that we can
do is to try and put off the faUil termination, in which attempt
we may sometimes be successful for one or two years.

Puiholfxji/. — On placing an ounce or two of leucocylheraic
blood, which has been freed from fibrin, in a narrow gla.ss, the
red corpuscles sink to the bottom, while the upper part of the
mass looks like milk. This appearance is due to the colorless
corpuscles, and it may be distingui.shed from that caused by
fat, as it is not removed by ether. In extreme cases portions
of the blood look like pus.

On examining the blood microscopically, under a magnify-
ing power of "250 diameters, the yellow and colorless corpuscles
are at tirst seen rolling together; the excess in the number of
the latter being at once recognizable, and becoming more evi-
dent as the colored bodies get aggregated together in rolls,
leaving clear spaces between them filled with the colurless ones.
A drop of blood taken from a prick in the finger is sufficient
for examination. The results of chemical analysis on nitie
occasions recorded by Dr. Bennett, show an excess of fibrin
and a diminution of blood corpuscles.

The blood glands are very commonly found enlarged in leu-
cocythcmia, especially the spleen, liver, and lymphatics; leas
fref|uently the thyroid body and the suprarenal capsules are
affected. The condition in which the increased proportion of
colorless corpuscles appears to be dependent upon an affection
of the lymphatic glands has been designated Leworyiosi* by
Virchow — an unnecessary distinction, which, as it seems to
me, can only lead to confusion.

Tre.nlmenl. — The remedies which would appear to promise
the most success are certain tonics, especially iron in various
forms, and (juinine. Iodide of potassium and the chloride of
potassium have been fruitlessly tried. Good nourishing food
will be indi.spensable, and ood-liver oil may ollen no doubt be

MORBID 8TATKS OF THE BUtOD.

beneficial. The practitioner must, however, in a great luoa-
sure be guided by the prominent symptoms in each case.

6. Piarrhaemia. — Milkiness of the scrum or fatty blood
(piarrhirmt'a, pioxu-mia, or lipirmia) i» met with under cer-
liiin circuuititanceA in disease, and hence demands attention,
lis physical causes are two — viz., free fat, and uiuleculur
albumen.

In the fir^t plate, pinrrhseinia is a pliysiolnifiad result of
digestion, prejinancy, lactation, and hibernation. During the
process of digestion, the laclescence of the serum is said by
Bcc(|uerel and Rodier to begin about two hours after the in-
gestion of aliment, and to continue for two or three hours.
The serum is found to be turbid, opale.scent, and semi-opaque;
a condition which is only transitory, and is due to the absorp-
tion of the fatty matters of the food, formed into an emulsion
by the pancreatic juice, and ab.sorbed as such in the duode-
num. Examined microscopically, this condition of the serum
is found to be due to the presence of a large number of fat
globules and of molecular granules of albumen. According to
Chrislison and Lccanu, the passage of the chyle into the blood
renders the serum turbid; this turbidity lasting until the in-
soluble fatty matters — oleine, stearine, and margarine — enter
into combination with the free soda of the blood, and become
converted into the oleic, stearic, and margaric acids.

Secondly, lactescent serum is a patkoloi/ical result of dis-
ease. The cases in which its occurrence has been noted are
diabetes, chronic alcoholism, dropsy, jaundice, nephritis, hepa-
titis, pneumonia, and especially Bright's disease. In an inte-
resting case of piarrhicmia accompanying acute diabetes, re-
corded by Dr. Charles Cootc, which ran its course very rapidly,
and was attended with great prostration, the blood after death
wag found fluid, bomc^encous, and of a dull-red color like rasp-
berry cream ; while in a few seconds it scparateil into two dis-
tinct p<irtion8, the supernatant l.iyer bcini: of the color and
appearance of thick cream, and the subjacent portion present-

OENERAL DISEASES.

in;r flio appearance of fluid venous bloud. The creamy layer
was ccrtaitily free fat, for it was wholly taken up by ctbcr.

Various I'xjiLinatioiiN have been given uf the uceurreiice of
fatty blood hi disease. Formerly pathologists attributed it to
the pnssnpe of unaltered chytc into the circulation ; an ex-
planation which, (houjiii in sunu" measure true, was slinwn by
Hcwi<on t<j be iiisufiictt'ut, since he observed this condition in
many instances where the patients had tjiken little' or no food
for ninny days. Ra.spnil maintained that the fat was set free
in tlic blood f<ir want of a free alkali to huld it in the form of
a coop. Dr. Babington appears to rei;nrd piarrhasniia as a fatty
defeneration of the albumen of the bhuul. Itokitansky thinks
it is often due to fatty degeneration of the eolDrles.-* corpuscles,
which arc previously formed in excess, so that it is to bo re-
garded as a modification of [oucocythemia ; but he ulso admits
the direct introduction of fat into the hluod, and the liberation
of combined fat contained in it, to be possible cuuses. Vir-
chow regards it as dependent upon the uon-eunibustion of fat,
and its consequent accumulation in the blood ; while he con-
siders the presence of iimlecul.ir albumen to be only a second-
ary phenomenon, the slow sjipoiiification of the excess of fat
nbstnictin(r from the iilbumcn of the blood the alkali rcf(uired
to keep the latter in solution. And histly, l)r. C. Cootc, from
a cijoiparisoii of all tin' ficts whicli have been published upon
this topic, concludes,* — 1. That piarrhajmia consists in an ex-
cess of saponiliable fat in the blood, and not in the mere libe-
ration of fat from its eonibitintions. '1. The exces.s of fat may
be the result of two eau.^es — viz. (</) the excessive ingestion
of ful, HS in piarrhicniia during digestion ; (h) the diminished
cliniinatiou of the .same, as in hibernation and pnlmonary dis-
eases. 3. Fat, if directly ingested, may enter the blood with
the chyle (hrouLih the thoracic duct ; though from the con-
sidernlion of the case recorded by Dr. Coote, it seems that it
may also be elahomted in and absorbed directly from the liver.

• Ijiiinl, Ifiinilon, 8r|il. xih mul llUb, IH«(K

MORnil) STATES OF TPK BLOOD.

4. PiarrhaMuiu is not a resull of diabetes nicllitu^, for cither
may exist witliout the other. 5. The pathology of blood iiiilky
from molecular albumen must be considered as still almost
wholly negative. Thouj^h probably never an indi'pcndent
affection, yet it is not a rocro accidental occurrence of piarrhio-
miu. It« apparent relation to albuminuria seems to point to
Bome organic clian<.'e in the constitution of the plasma of the
bluod itself.

6. Olacoheemia. — The excretion of sugar by the kidney,
constituting a disease known as diabetes mellitus (saccharine
lii'abetes, mrliliiri'a, (jlj/oujruvstf, ijlnrohrrmiti, or iilncoiuriu),
ha.s attracted considerable attention since the time (1600)
when Thomas Willi."! Bi-st observed the saccharine condition of
the urine in this affection. Without, however, tracing the
history of our knowledge of diabetes, it may at once be .said
that the first hypothesis of any moment which we find pro-
mulgated was to the effect that the sugar formed in the sto-
mach and alimentary canal, from the starchy and saccharine
elements of the food, instead of being converted into other
compounds, was absorbed and excreted by the kidiicv's. Dr.
Mucgregor positively detected sugar in the sernm of the blood,
and published the result of his investigations in lS;i7. It fol-
lowed that the treatment consisted in allowing a diet free from
substances which could be converted into saccharine matter;
and it is ccrmin that thus the general .symptoms were fro-
i|uciilly alleviated, while the amount of sugar which could be
detected in the urine was diminished

Then came the elaborate researches of M. Claude Hertiard,
who, while allowing that sugar may be formed during diges-
tion, and that a certain portion may become ab-sorbed, yet fur-
ther taught that this substance is a normal secretion of tbo
liver. He also proved that sugar may be formed in abnormal
quantities by irritating the eighth pair of nerves at their ori-
gin in the fourth ventricle; while section of both these nerves
Eospendj!' the Hugnr-foniiing function of the liver. In health

■\

OENERAt. mSflAOES.

the sugar formed by the liver passes into the hopntic veins,
the inferior vena cavn, the right cavities of the heart, and
tbcncc by the pulmonary artery to the lungg, where it is con-
sumed. When abnormally increased, the lungs cannot ex-
crete all of it, and hence it passes off by the kidneys, pro-
ducing diabetes. But although the division of the pncurao-
gastric nerves has the effect just uientluned, yet the sugar-
forming power of the liver is restored by irritating; thoir upper
cut ends; and diabetes may be produced ju.st as if the nrigins
of these nerves were excited. On the other hand the appli-
cation of nn irritant to the lower ends of the divided nerves
gives no result. Bernaid therefore concludes that the ner-
vous power which excites the liver to secrete the saccharine
matter, do^'s not originate in the brain, to be carried by the
pneumogastrics to the hepatic organ ; but rather that the
stimulus proceeds along these nerves to the brain, and thence
by reflex action is transmitted to the liver. Further consid-
eration led to the opinion that in health tlie reflex action
which excites the hepatic sugar-forming function originates ia
the stimulus given by the air we breiithe to the pulmonary
bninchos of the pneumogastrics. He believes, in short, that
at each inspiration these branches receive a stiuiulus which is
transported through the main trunks of the nerves to the
brain, and ia thence reflected by the spinal curd and the tho-
racic portion of the sympathetic to the liver. Expi^imenls in
proof of the foregoing showed th.it when tlie i'uuclion of respi-
ration is stimulated — as by the exhibition of ether or chloro-
form— sugar temporarily appears in the urine. Again, it is
supposed that just as the lungs act by reflex influence on the
liver, so increased action of the liver acts upon the kidney;
and hence that sugar produced in excess in one urgiin is ex-
creted by the other.

Pursuing his investigations still further, Bernard wiis led
to the conclusion that the liver secretes a substance wbich is
changed into sugar by some ferment, instead of forming the
sugar directly. This glucogenic substance, when separated

MORBID STATES OF TUK DLOUlf.

from the liver, presents the characters of hydniled starch, and
when it comes into contact with the supposed ferment in the
iiluod the transformation is effected. The sugar in the blood,
when the latter reaches the lungs, is decomposed by the oxy-
gen and disjippears ; so that the liver produces the glucogen
which forms the sugar, whilst the lungs are the organs in
which the latter is consumed. Of course in health only the
blood which circulates between the liver and the lungs con-
tains saccharine matter ; and, therefore, when this material
is found in the circulation generally, it may be the conse-
quence either of excess of hepatic power, or of diminished
pulmonary action.

Id July, 1857, Dr. Harley published in the Bri/iih and
Foreif/n Medico- Chirurffi'cal Review, his views on the patho-
logy of diabetes, and showed that while agreeing in the main
with Bernard, he yet doubted the conclusion of this physiolo-
gist that in the normal state respiration is the excitor of the
plucogenic function of the liver. His experiments seem to
iDdicate that if the pneumogastric carries the stimulus to the
brain, to be thence tnuismittod by the spinal cord and
splanchnic ner\-e8 to the liver, the point of departure of the
stimulus is probably in the liver itself; and that the cause of
the reflex action may originate in the stimulating effect of the
portal bhxid u[>on the hepatic brunches of the pneumogastrio.
Thttfl, if the stimulating effect of the blood of the portal vein
be imitated by injecting into that vessel ether, chloroform,
alcohol, or ammonia, the liver is excited to secrete an excess
of Bugiir, and the animal operated upon is rendered for a time
diftbetic. Dr. Uarley also conBrms the opinion of M. Cha-
veau that the sugar is not destroyed in any appreciable quan-
tity during its passage through the lungs; but nuher that this
agent, formed by the liver, goes to the support of the general
system, and hence that in health it di^iappenrs from the gene-
ral circulation during its transit through the minute capilla-
ries of the different tissues.

These plausible theories may possibly require moditicution,

OENERAL mSKASES.

owing to recent analyses of tlio bl(K)il by Hr. Piivy. This
gentlcnisn — in papers eotutnunicatcd to the Royal ^ufiety in
1868 and 1S60 — states, that altboui;li the blond collected
from the right side of the lieart after death coiilitins abun-
dance of su^r, yet when it is removed from the same part by
catheterisni durin<r life it presents but a trace. Inferences,
therefore, that have been ^Irawn of the ante-vmrlem state from
pott-mortem examinations must be abandoned. Very slight
causes — e. 7., such as interfere with the breathing — determine
the presence of a large (juaiitity of sugar in the circulation
during life. As the mode of exaraininp the blood hitherto
adopted has led to false inferences, so the plan pursued with
regard to the liver has bad the same effect. The liver forms
a material which has been called the frlucofrenic sub.stance :
but as Dr. Pavy does not regard this material as a sugar-form-
ing sabstancc under physiological conditioiw, he calls it hcpa-
tine, as belonging to the liver. What purposes this hepatine
serves in the economy are at present unknown, but it has
been found that although under natural circumstances during
life it resist* transforiiiatinn into sugar, yet after death such a
change is rapidly effected. Abnormal states of the circula-
tion, and probably of the blood, also lead to a similar produc-
tion. Certain altered conditions of the nervou.* system like-
wise occasion an extensive formation of sugar in the body.
Injury to certain parts of the sympathetic rapidly produces a
strongly diabetic state, while the introduction of carbonate of
soda largely into the circulation, altogether prevents this
effect.

Although my chemical knowledge is not sufficient to enable
tne to give any satisfactory solution to the difficulties thus
raised, yet I believe that Dr. I'avy's opinions will not pass
unchallenged ; and it is only right to suggest to the reader the
necessity for not coming to any conclusion on the subject until
he is in pos.session of further evidence. It secm.s neces.sary
to ooucludcj however disappointing may be the coufeiwion.

MORBID STATES OF THE BLOOD.

tbat the patliology of diabetes still remains a problem to be
solved.

For the sake of convenience, and in accordance with custom,
the symptoms, dingnoais, and treatment of this affection will
be considered in the section on renul disorders ; though it is
hardly necessary to say that the occurrence of saccharine urine
is only a prominent symptom of one or more unknown diseases.

7. UrEemia. — One of the chief depurating secretions by
which the normal condition of the blood is maintained is the
urine. When, from any cause, the function of the kidneys
becomes impaired or suppressed, urea is no longer eliminated
by these organs ; and therefore it accumulates in the blood,
producing that morbid condition known ns urojmia.

The term ura'^mic intoxication is employed to denote the
peculiar kind of poisoning which is supposed to result from
the accumulation of urea in the blood, and the tniusformation
of this salt into carbonate of ammonia. The direct effects of
this poisoning are seen in a disturbed action of the two great
nervous centres, — the brain and spinal cord. These centres
may be affected either separately or together. Consequently
we have three forms of urjemic poisoning : 1. That in which
a state of stupor supervenes rather abruptly, and from which
the patient is aroused with difficulty. It is soon followed by
complete coma, with stertorous breathing, as in ordinary
p<ji8ouing from opium. 2. The variety in which convulsions
of an epileptic character suddenly set in, often affecting the
entire muscular system. Consciousness remains unimpaired.
And 3. That kind in which coma and convulsions are com-
bined.

Albuminuria with unemia may arise from other conditions

than structural disease of the kidney. The convulsions which

occur during pregnancy and parturition are 8uppo.sed by some

to be caused by the pressure of the uterus, giving rise to active

Boal congestion ; while others regard them as due to a degni-

4»

nENKRAL DISEA8K8.

dntion of the niulernal blood. Suppression of urine (J$churla
renulii, or auun'a) le a frequent and oflen fatal result of
cholera, and of other morbid poisons in the blood. It may
fonii a very dantterous symptom Juriiif; the progress of fever,
and of the exanthemata — particularly scarlatina.

The phenomena of nrtemic poisoning do not iirise, as was
formerly thought to be the case, from the blood being con-
tamiuuted by urea. The views of Frerichs have been con-
firmed by other observers; and it is at least highly probable
that nrsemic convulsions are not produced by urea nor any
other ingredient of the urine, but that they eonitnonly originate
from large ijuuntitics of urea retained in the bluod being
transformed into carbonate of ammonia under the intluenoe of
some peculiar ferment. Hence can be explained those cases
where individuals in the Inst stage of renal disease have their
blood highly charged with urea, without any uncmic phenomena
taking place; simply because the unknown ferment, by means
of which the urea is converted into carbonate of ammonia, is
absent. The quantity of ammonia required to hold the blood
fluid is exceedingly small ; and therefore it seems that these
views do not clash with Dr. Richardson's, because in cases of
urjEmic intoxication the aminnnia is; present in large quantities.

UrsBUiic poisoning may arise from the retention of urine in
the bladder, or in the pelvis of the kidney, and its decompo-
sition. Either in or out of the bladder urea is readily trans-
formed into carbonate of ammonia ; one atom of urea, with two
atoms of water, being equal to two atoms of carbonate of
amnionia.

UraMnic convulsions (iinrmic erlampsin, rpi/fj>tta revalit,
&c.) may be distinguished from fits due to habitual epilepsy,
apoplexy, hysteria, anceiiiia, acholia, cholfeniia, &c., by atten-
tion to the following pointu : The urine is highly albuminous,
and commonly is either very scanty or of low spoelfic gravity;
there is usually more or less usdema of the face and extremi-
ties; the fits are severe and recur frequently, and they are
often preceded by headache, giddiness, sickness, and delirium ;

MORBID STATES OF THE BLOOD.

the pupil is generally fixed and diluted ; and the breath tuny
be iiniinoniacal. The convulsions often pass off, and recovery
ensues, except in those case* where they occur from chronic
structural disease of the kidney; and even in these the patient
often rallies for n time. The existence of renal disease is to
be diagnosed by a microscopical examination of the urine, as
will hereafter be shown.

Dr. Todd employed the followiup method for deteclin}^ urea
in the blo<jd during life : The serum from a good-sized blister
was evaporated to dryness over a water-bath, and the residue
extracted with alcohol, which is a ready solvent of urea. This
alcoholic extract was then evaporated to dryness, and a little
water added to make a syrupy mass, which was plunged into
a freezing mixture, and a few drops of pure nitric acid added.
If urea were present, the characteristic crys-tals of nitrate of
urea soon appeared in the solution, and were positively recog-
nized by the microscope.

When we fear the occurrence of ursemic poisoning, we
should attempt to purify the blood by means of those extensive
excretory channels — the skin and intestinal canal. Sweating
may be induced by the hot-air bath, with the copious adminis-
tration of diluents, such as tea, iced lemonade, water, &c.; or
by wrapping the patient in the wet sheet ; or by sponging the
body with tepid vinegar — a proceeding which often produces
copioUK diaphoresis. The best purgiUives, perhaps, are .issa-
fa'tidii and vinegar cncmata; or elaterium, jnlap, calomel, or
croton oil. Medicines should also be administered which will
prevent the decompc«ition of the ure.n, or which will neutralize
the carbonate of ammonia if it be formed in the blood. For
this purpose Freriohs speaks highly of benzoic acid in five or
len-finiin doses, with iced drinks which have been stixvniily
acidulated with tartaric acid or lemcin-juice. The iiihiilation
of chloroform may do good by temporarily producing diubeli's,
fur it has been proved that sugar in small quantities added to
the urine out of the body prevents for a time the ordiimry
decomposition of urea into carbonate of ammonia. When

■

GENERAL DlSEAaES.

there is evidently congestion of the head, the application of
ice should be resorted to ; blisters and dry cupping to the nape
of the neck may also be useful ; but general depletion is to be
avoided, if there be evidence of the system having been weak-
ened by pre-existing disease.

8. Acholia. — There are certain diseases of the liver — such
as acute atrophy, impermeabilily of the bile ducts, cirrhosis,
fatty degeneration, &c., which lead to complete disorganization
of this gland, and therefore to an arrest of its functions.
Under these circumstances symptoms of blood-poisoning may
arise, which very generally lerminato fatally in a short time.

It is now commonly allowed that the matters which consti-
tute bile do not exist preformed in the blood, so that the con-
stituents of this fluid arise not by a process of simple secretion,
but by one of actual formation in the liver. The hepatic cells
not only attract certain niiitters from the blood flowing through
the capillary vessels, but they effect within their cavities a
transmutation of these matters. Hence, disorganization of
these cells — or, in other words, arrest of the functions of the
liver — from any cause must lead to acholia.

Abnormal conditions of the nervous system arc the essen-
tial tti/mplomt in these cases. Usually there is first a stage of
excitement, characterized by noisy delirium and convulsions;
which is followed, secondly, by deprcRsion marked by somno-
lence and progressively increasing coma. Sometimes the first
stoge is absent, and the patients rapidly fall into a state of
typhoid prostratiou, which passes into coma. Along with
these symptoms we have hiemorrhage from the mucous mem-
bnine of the stomach and intestines, petechia; and ecchymoses
of the skin, and in a few cases jaundice.

The treatment must consist in the administration of purga-
tives and of the mineral acids, by which agents life «my per-
haps be prolonged for a brief period. Beyond this the cases
■re hopfh'ss.

Acholia ( from a privative ; and X"^y bile), or deficiency or

MORBID STATE*; OF THE ! I.OfiH.

Mbfoiicc of bile, must not be conrniDded witb jntinilico nr
cbolaMjiia (from /"^if. and «!/»«, b'.nod), a morbid ntnte in
which bile exisls in the blood owinfr to its rcabsorplion after
having been formed by the liver, lu the one case we have
retained in the blood those substancca by the metaroorphosia
of which bile is produced ; in the other the blood contains the
bile itself The sUtte of our knowledge with regard to the
mode in which jaundice is produced will be shown in the sec-
tion on hepatic diseases.

9. Ichorrhsdmia. — Ichorrhajmia (commonly known tia pye-
mia) is a luorbiJ state of the blood, caused by the introduction
into it of ichorous or putrid matters ; which state generally
displays its effects by producing severe conslitutinnal distur-
bance, as well as by inducing suppuration in certain impor-
tant organs.

The (|uestion as to whether this condition depends upon the
presence of pus cells in khc blood, hsis given rise to a vast
amount of controversy. Until recently this point was always
answered in the affirmative, and three hypotiieses were current
to explain whence the pus so found was derived. Thus it
was said — 1. The pus globules are absorbed (purulent nlnorp-
<i'on) fi^ro a suppurating cavity. 2. The pus is the result of
phlebitis occurring in the veins which are in contact with the
suppurating tissues. 3. The pus is furnished by the blood
itself. How little dependence is to be placed on either of
these theories will now be shown.

For the detection of pus in the blood the microscope h:i8
been almost exclusively depended on. But since the publi-
cation of Dr. Ilugh&s Bennett's researches on Leucocytheniia,
in 1852, it has been genenilly allowed that the so-called pus
corpuscles which have been detected in the blood are identical
with the colorless cells of that fluid, constituting, when in
excess, the while-cell blood. Moreover, most pathologists
agree that there is nothing peculiar in good and laudable pns
which necessarily leads it to poieon the blood. The absorp-

OENERAL DISEASES.

tion of puH in its entirety is not posnible; but there c«n be no
doubt that the fluid portion of pus may be entirely absorbed,
leavins; behind merely the shrivelled cells deprived of their
vitality. This inefiisnation of pus occurs without producing
any symptoms of the so-called purulent infection. A^in,
there is a second way in which the whole contents of an
abscess may disappear — v'n., by the pus cell:- under!.'oinfr fatty
degeneration, beconiiiij< disiote<rrated, and reduced to a fluid
condition in whicli absorption is rendered easy. There is, of
course, the possibility of an abscess bursting into a vein; but,
in all probability, before this took place the canal of the ves-'el
would be obliterated. And so, again, the peripheral lym-
phatic vessels may in the same way be tilled with pus ; but
before they reach a bloodvessel their course is interrupted by
lymphatic glands, in which they break up into small branches,
and through these no pus corpuscle can pass. Virchow well
illustrates this occurrence by showing that in the process of
tattooing some of the cinnabar, gunpowder, or the like, finds
its way into the lymphatic vessels, but is always sepanited by
filtration in the nearest lymphatic glands. Ilencc, while leu-
cocytheniia proves that corpuscles, identical in form, size,
structure, and chemical composition with those of pus, may
float in the blood and circulate innocuously, the fact of the
absorption of abscesses, either wholly or in part, demonstrates
that healthy pus is not poisonous. The truth seems to be
that what has been called pvasmiu is not dependent upon pus
cells mingling with the blood, but on a mnttor derived from
some kinds of pus, which poisons the blood and occasions the
secondary phenomena.

Ichorrhscmia is particularly dreaded by obstetricians and sur-
geons, since it not unfrccjuenlly is the cause of very dangerous
symptoms after parturition {pvrrpernt fever) and surgical opera-
tions. It may display itself in more ways th.in one. Thus, in
some cases, the patient seems to be so immediately and deeply
affected by the morbid matter that he dies before any local
phenomena can be developed. In a second class, the intensity

MORBID STATES OF THE BLOOD.

of the poison seems to be exerted upon the liver or the mucous
uienibrane of the intestinal canal; in the one case Nature
appearing to make efforts nt elimination bj the discharge of a
large quantity of dark bile, in the other by a severe attack of
diarrha-a or dysentery. Then there is a third set of cases
where the serous tnenibrancs bear the brunt of the poison, and
vre have pleurii>y, or pericarditis, or peritonitis ; or the cuta-
oeous surface is the part affected, and we find erysipelas, or a
more or less copious eruption of boils. And again, there is a
fourth class in which profuse suppuration ensues, giving rise
to lecomiart/ or melattatic abscessea in the lungs, liver, joints,
eyes, &c.

Amongst the various forms of suppuration is one to which
the term CvHulifi* vtneuitta is applied; meoning thereby a
diffused form of influninintion of the cellular tissue which
arises from punctures received in dissecting the dead body.
Some animal fluids are more dangerous than others, as the
scrum found in the abdomen after peritonitis, and that left
after gangrenous inflammation. The bites of certain venomous
reptiles, as the cobra di cnpello, will also produce the same
effects; and even the sting of the bee has proved fatal. The
poison thus absorbed gives rise chiefly to inflaminattnn of the
collnlar tissue and absorbents, generally of the wounded litub,
bat sometimes of remote parts. The lymphatic glands are
very often affected. The skiti over the affected part is pale
but tense and shining, while the swelling which occurs com-
municates a peculiar boggy feel to the touch. These inflam-
mations are attended with rigors, restlessness, extreme pain,
and great depression ; and they either cause death in a few
days or even hours, or they end in .suppuration or gangrene.
Ill (ata.1 cases, death is preceded by delirium, offensive perspi-
rations, a yellowness of the skin, dyspnoea, drowsiness, and
deep stupor. When patients recover, it is often only to find
the constitution permanently injured.

The effluvia given off from the dead body may be the cause
of extensive toxasmia or blood poisoning. These effluvia may,

OENERAL PISEASEB.

without injuring the p:irty exposed to thera, be carriod by liim
to a third person, and give rise to the most distressing
results — a fiict which demands the particular attention of
obstetricians. Mr. Teale gives the following evidence of the
pernicious influence of these poisons: "One cvcuing, at the
dissection of the body of n patient upon whom 1 had operated
for stranffuluted hernia, several surgeons were present. Of
these, two attended one case of midwifery each during the
following night, and a third three cases. The two patients
attended by the first two purgcons died of puerperal fcvor.
Two of those attended by the third surgeon also died; and
hi.s third patient escaped death from this formidable malady
with the greatest difficulty, after having been in extreme
danger several days. It is an important fact that no other
cases occurred in the pructice of these gentlemen."* Unfor-
tunately the foregoing is no isolated example of the truth of
my remark. In the lying-in hospitals of Vienna and Prague,
a very large mortality was distinctly traced to a want of cau-
tion in admitting students from the dissecting-rooms to the
wards. The danger which arises from handling morbid prepo-
rations, unhealthy purulent secretions, &c., h erjuuily great;
and consequently the obstetric practitioner cannot exercise too
much caution. If obliged to be present at a post-mortem
examination, he should not visit any parturient woman until
ho has changed all his clothes, and hns washed his hands
thoroughly with some chlorine solution or other disinfectant.

The prot/iwfis in all forms of ichorrhEemia is unfavorable,
but especially so when the patient has been previously
lowered by exh.'iusting disease, by hiemorrhiigG, by i» severe
operation, or by insufficient food with residence in ao unhealthy
bouse.

In our ireiifmrnt, the endeavor is to be made to sustain the
vital powers and puuify the blood. It follows that we are to

* -4 Proclicai Trtatiu oh Abdominal Hrrnia. p. 62, LouJuu, 184C.

MORBID STATES OF TUE BLUOD.

■tn

adniinistpr strong beef-tea, ftnd such stimulants as tho patient
i.s arciistouicd to. In urgent cases, brandy must be freely
allowed. Elimination of the poison by the liver and bowels
f>hould be attempted ; with which object eight or ten gninn
of calomel is to bf piven, followed by purgatives (F. 180, 196,
201), Pain is to bo relieved by opium and by the application
ofpoultices or fomentation cloths; iced drinks will remove the
thirst ; while any other symptoms must be treated as they
vrise. If abscesses form, or if the skin gets inflamed and tense,
great relief will be given by free incisions.

In wounds from dissecting, or froui the bites of reptiles,
attempts should be made by sucking or by the application of
a cupping-gla.s8 to remove the poison from the puncture or bite,
while a ligature is at the same time tied between the wounded
part and the trunk. It will also be advi.sablo to apply lunar
caustic freely to the wound. In other respects the treatment
must bo that just mentioned.

10. Deposition of Fibrin in the Heart and Bloodvessels
dnring Life. — There can now be no doubt (fur the fact has
been proved by many independent observers) that when the
blood contains, either absolutely or relatively, a great excess
of fibrin (Jii/i>erino*!>), or when there cxisLs any obstuclu to
the normal circulation, fibrinous formations may gradually take
placn during life in the heart, or in tho arteries, or in the veins,
or in the cerebral sinuses; these forinjitions giving rise to such
symptoms that their presence may with care be diagnosed.
The concretions — or polypi, as they were formerly termed —
teem to be peculiar to diseases attended with great exhaustion
or debility ; and they have been especially found in cases of
croup, pneumonia, bronchitis, phthisis, typhus, purpura, erysi-
pelas, haBmorrhage, and prostration from natural decay as well
at* from dissipation. Their formation also seems to be particu-
Urly favored by the condition of the blood during pregnancy
and the puerperal state. A delicate young lady under my own
care, had such syDiptome after the delivery of her first child,

GENERAL DItSEASES.

that I believe a small clot formed in the right side of the
heart, though her labor had neither been difficult nor attended
with more than ordinary hajmorrhagc. For six weeks after
her nccouchcnicnt, the muscular prostration was so extreme,
that she lit<;rally could not turn over from one side to the
other; and when the least attempt was made to raise her in
bod, 80 88 to change her linen, &c., the most severe attacks of
dyspnoea set in.

The fibrinous masses may form suddenly, and at once cause
dt'iilh by obstructing the circulation ; or they may arise
gradually and produce symptoms which creep on insidiously
and last a long time. In the latter ease, the masses may be-
come ori^tiizcil and uttaclied to the walls of the heart, or they
may soften ; while frtim these attachments portions may be
dtrricd away by the blood, so as to block up the circulation of
at some extreme point. Perhaps the right auricle is their
meet common scat ; but it can be easily undcrstoood that the
edges of the valves, as well as the muscalar and tendinous
curds of the ventricle.", are parts to which they readily become
attached. Pos.iibly also the siiiull bead-like and warty exuda-
tions thrown out in endocarditis may sometimes form a founda-
tion on which a concretion may become depasitod. The
particles of solid fibrin carried away by the blood from the left
side of the heart are usually arrested in the vessels of the
brain, spleen, or kidney ; while those from the right cavities
pass by the pulmonary artery and its branches into the lungs.

Symptoms. — The syiiiptoiiis caused by a fibrinous deposit in
the heart are always well-marked, and are of the same general
character, whatever may be the disease from which the patient
is MufTcring at the time of its formation. Their nature varies
according as the concretion is deposited on the right or on the
left side of the heart. AVlieu the obstruction is on the rtyht
side, as is most comnionly ^he case, the return of blood from
the systemic veins is prcveiiled ; and as the flow of blood to
the lungs for aeration is impeded, so arterial blood is not duly
snpplicd to tha brain and different organs. Hence, if death

MORBID 8TATK8 <IF TlIK III.OOI).

resulu, it happens frnm s^'ncope rather than from asphyxia.
The course of tlic symptoms mny perhaps be best shown by
n-ferring to the case to which allusion has already been made.
Thi.s patient had a favorable labor of some eight hours' duration,
and when left by me at midnight, about an hour and a half
after the birth of the child, was in a favorable condition.
The pains of parturition had been very severe ; but although
the use of chloroform was su^^ested, the inhalation of it had
been declined. Prior to my depwture, and afterwards, brandy
with arrowroot was pven ; and at about two A.M. the lady ex-
preiised herself as feeling comfortable, and quietly fell asleep.
She passed a f^ood night ; but on the following morning, at
eight A.M., I was hastily summoned, as a most severe and dis-
tre».sing attack of dyspna'a had just set in. On my speedy
arrival, I found the breathing hurried and gasping, the surface
of the body pale and cold, the pulse feeble and intermittent,
and the patient very faint and alarmed; but the administra-
tion of some brandy with ether nnd ammonia, and the appli-
cation of a largo linsecd-incal poultice with mustard in it, gave
Bcusible relief in about three-quarters of an hour. I could only
venture to place the stethoscope over the apex of each lung,
but I thus learnt that the respiratory murmur was natural ; and
hence this fact combined with the symptoms, seemed to point
out the heart as the seat of obstruction. The moi^t perfect
quiet was enjoined; gmall quantities of essence of beef, am-
monia, and brandy were given at short intervals; and at the
end of the day, the extract of belladonna was freely applied
ovei' the breasts, to prevent or check the secretion of milk.

Now the foregoing symptoms were quite sufficient to teach
nio, even if I had not been aware of the fact from the writings
of others, that cases of this description must generally end in
sudden death ; and in this instance, it was clear, that very
little more was required for the obstructed heart to become
quite paralyzed. We know that patients prostrated by acute
diseases, and also parturient women, have died suddenly after
an Bttompt to sit up in bed or to pass a stool, and the fatal

OKNKKAI. DISGABF.H.

event has been referred simply to fainting; but it seems to mo
very probable that the real couse may have often been the
sudden blocking up of one of the cardiac orifices or of the pul-
monary artery by a mass of fibrin.

When the clot obstructs the circnlution by its situation in
the Irft cavities of the heart, or in the aorta, death, if it occur,
takes place cither sviddetilj or at the end of a few hours, from
coma, and not from syncope. The symptoms then are violent
action of the heart, great congestion of the lungs with dyspnoea
of a suffocative character, expectoration of a bloody and frothy
mucus, a leaden hue of the surface, and coldni.'.«s of the ex-
tremities. Supposing the patient to recover from the first
argent stage, the symptoms will degenerate into those of val-
vular obstruction of the loft side. Such a condition might bo
diagnosed by the sudden appearance of a muniiur where the
heart bad jjreviously been healthy, aud where there had existed
no signs of endocarditis. It imint he reiuemhcrod that con-
cretioDH have more than once been found to exirit on both sides
of the heart at the same time, and the symptoms have then
chiefly resembled those which arise from deposition in the
right cavities.

When fibrinous concretions are discovered in any of the
•rteries or veins, they may have formed at the parts where
they are found. For example, Dr. Humphry records, amongst
other cases, that of a pale, ana;iiiie, very weak jjirl, wiio was
being dressed by her friends in order that she might bo taken
out of the hospital. ^Suddenly she fell fainting, and quickly
died. During her stay in the ward the right arm had been
swollen, and had been kept hanging out of bed \ as the patient
found this position, with the head inclined towards the right
shoulder, the most cu[nfi>rtablc. On examining the body
there was slight emphysema of the lung, but otherwise the
organs were healthy. The right innominate, subclavian, and
internal jugular veins were obstructed by a large clot. That
iu the innominate vein was firm, of u buff color, scarcely
tinged with red, and adherent tu the vessel's coats; while in

MORBID STATES OF THE IlUlon.

ftS

the jufrular vein the clot was soft, and looked like a mixture
of blood and pus.

But it must aim be remembered, as beTorc stated, that the
concretions which form in the heart may be carried by the
blood, wholly or in part, into some artery which they block
>; and thus the supply of blood to an important part may be
iiddcniy out off, producing alarming and even fatal results.
Whou the particles are minute they may be carried into the
capillaries, and merely j^ive rise to local congestion and stagna-
tion ; while it is also not improbable that the masses sometimes
soften and break up, and the disintcf^rated portions by mingling
with the blood contaminate it. The effects which have been
found to ensue from a fibrinous deposit being carried from the
left side of the heart, are as follows : in several instances,
softening of the brain, ending in hemiplegia, owing to the
plugging of the middle cerebral artery; paralysis and loss of
sensation in the arm, from the obstruction of the brachial and
ulnar arteries ; temporary loss of power in one of the lower
extremities, which has become relieved on the solution of th
dot, or on the establishment of the collateral circulation
disease of the kidney from obstruction of the renal artery ; am
disease of the spleen. The consequences which follow frou
the propulsion of masses of fibrin from the right side of thi
heart are shown in the lungs, by the presence of ooagulu ii
the pulmonary arteries and different kinds of deposit in tht
pulmonary tissue. Perhaps in this way may also be esplaincd
the occurrence of some forms of pneumonia. Obstruction in
the pulmonary capillaries is indicated by oedema or infiltration
of the lung tissue, and by pulmonary apoplexy. In the same
way Mr. Paget has shown that particles of cancerous matter
may be brought from remote organs to the right side of the
heart and thence transmitted to the lungs, where tliey become
■arrested in the pulmonary capillaries, and so induce stagnation
and subse<|uent changes in the blond.

Fittt-morlvin Appearances. — When a fibrinous deposit is
found in the heart, it may become a question whether it was

GENKRAT. DISKASES.

formed during life or nf^r death. Supposing the fibrin to
have separated after death — the blood being stagnant — it
forms onlj a light-colored layer on the upper part of a red
clot. On the contrary, when the deposition has taken place
dnrin<; life — the blood being in motion — we find a mass which
is modelled to the cavity containing it, which is adherent to
the walls, and which is grooved by the blood that has passed
over it. In some instances also, the fibrin has been seen
lining one of the cavities of the heart like a fwlse endocardium ;
or else, forming an additional coat to the aorta or some large
vessel, without obstructing it

Sometimes the fibrinous masses — or thrombi, as Yirohow
calls them — soften in their centres; and they are then dis-
covered containing a fluid of s dirty reddish-brown color, or
of a lighter hue resouibling pus. Kxaniiiicd microscopically
no pus-coTpuscles can be found in this fluid, and hence it can-
not be a purulent substance. If the process of softening goes
on to a great e-xtent, we may find only an outer shell or cyst
remaining. Occasionally the walls of this cy.st get ruptured ;
and the contents becoming mingled with the blootl, poison
this fluid as eff'ectunlly, and give rise to the same typhoid
symptoms as if disorganized matter had been injected directly
into a vein.

The limited si«e of this volume unfortunately precludes my
entering into many argunients which need discus-siou on this
interesting subject; but 1 would refer ihiise who wish to
investigate the matter further t-o the writings of Virchow,
Richardson, Gulliver, Humphry, I'ligot, and Kirkes.

Treatm.eitt. — The object of our treatment in these cases
must be to keep the patient alive by propar support, and to
effect the solution of the deposit by alkalies. The admirable
series of experiments by Dr. Richardson teaches us that all
the alkalies are resolvent — /. «., they lead to solution of nitro-
"enous tissue. This gentleman proves that after death from
the alkalies, from antimony, or from many of the alkaloids (as
strychnia, morphia, belladonna, and arnica) there is the same

MORBID 8TATKS OF THE BLOOD.

fliiidit)' ur partinl fluidity of the blood, tbe same dis.snlution of
the blood-corpuscles, the same 8oftenin>; of the soft parts, the
sniue nbsenuo of cadaveric rigidity, and the same extensive
but simple vascularity of mucous surfaces and vascular or<can8.
In the sesquicarbonate of ammonia wc have an admirable
agent; since it is not only possessed of the pamo power ns the
other alkalies, but it has also the valuable property of exciting
the heart and circulation, as \rell as the muscular system.
This agent, freely diluted, may then always be administered;
while sometimes it can be advantageously combined with bark,
and if there is any pain or restlessness, with opium (P. 488,
489 ). The mineral acids, inasmuch as they favor eouji^lation,
are to be avoided. It is hardly necessary to add, that the
sick-room must be freely supplied with pure air; that brandy,
wiue, essence of beef, raw eggs, and milk, are to be freely
administered ; and that the patient should be kept as quiet as
possible until all the symptoms cease. The practitioner must
be prepared to lind that the very tedious convalescence will
excite the displeasure of the patient's friends ; but his aonoy-
ance at this circumstance will be lessened when he remembers
the great danger from which he has rescued the sufferer.

11. Entozoa, — Certain animalcules are .said by two or three
physicians to have been found in the human blood; but some
of the statements of these gentlemen have not been confirmed
by other observers. Bush nan has reported tho case of a man
affected with influenza, in whose blood worms half an inch
long were found an hour after bleeding. But according to
Rhind, these wore merely the larvse of Tipula oleracea, or,
according to Von Siebold, the red larvae of Chironomut, and
were accidentally introduced into the fluid.

MM. Uruby and Delafond have often detected a species of
microscopic thread worm in the blood of the dog. They pro-
pose to give this hcmatuzcion the name of Fltaria pnpiltota
tictmalica cants domestui.

Andral found true hydatids in (he pulmonary veins of a man

01 !i Tittle fluid blood. In tracing th|
the vein he discovered four or five other'
line kind, all of which were about one in|
half an inch in width. There were none
branches which form the portiil vein, and no
in the liver — or, indeed, in the body — excel
The distoinn hepaticum and the distoma lancQ
found together in great nuiobcrs in the gull-dl
of the sheep and other graininivoroos animi
disease known as the distemper or rot.

II. 8CUEVY.

Scorbutus, or scurvy, is a complex morbid i
lung-continued privation of fresh succulent v
sufficient or improper food, foul drinking wat
impure air, and previous attacks of ague or djrt
have a predisposing influence; but they will
selves produce this disease.

Of lat<' years scurvy has been rarely seen i

lln our navy it has been gradually becoming e:

year 1705, when an Admiralty order was first

lishing the fleet with a regular supply nf le-

cases still occoj^ionally occur in the nierca

. « »— .r f ..

SCURVY.

:>(

crt'wti; wliilist ill 1795 tin; Kifcty of Ijonl Howe's Channel fleot
was st-rionsly cndiiiijrert'd by its virulence.

Our kiiowledire ol" the //n/Ao/w/// of this disease is not very
precise. Certiiiii ehiinges are said to occur in the grosser con-
Btituents of the bloud, but the statcnients on this head are very
coutnidiclory. The red corpuscles are probably diuiinishcd,
while the water and fibrin are iucreascd. Dr. (larrod believes
that the bloud is deficient in potash, and that all antiscorbutics
owe their virtues to the ((uuiitity of this salt that they contain.
He pays, moreover, that ."curbuJic patients will recover when
some of the salts of potass are addeil to their fo<jd, without the
use of succulent vegetables or milk. Land scurvy and sea
scurvy are identical complaints in all respects.

The »j/rnj)t(jms of scurvy show themselves gradually ; cora-
nicncing with lassitude, mental anxiety, offensive breath, the
appearance of petechia! oa the legs, and dyspncca on the least
exertion. Then the countenance gets sallow and of a dusky
hue; the gums swell, are spongy, of a livid color, and bleed
on the slightest touch ; the teeth loosen ; and the breath be-
comes still more fetid. As the disease advances, the debility
inureaHe«; the dyspna'a often becomes most urgent; the gums
frequently slough ; and hceinorrhages occur from the gums,
mouth, nose, stotnach, and intestines. Ecchynioses, or effu-
sions of blood beneath the skin, also appear, especially on tho
lower oxtremities and trunk ; many parts of the body becoming
80 discolored with bruise-like marks that the patient appears
as if he had been severely beaten. The legs swell, and at-
•tempts to move them give pain; tumors occasionally fortn in
the extremities; there Is stiffness and contraction of one or
more joints ; putrid fungoid ulcers ari.«e, which have u ten-
dency to bleed copiously ; the skin is dry and rough ; the
urine is scanty; in some instances there has been spontaneous
isalivation; and there is generally constipation. Unless re-
lieved, the heart's action gets very feeble; and at the end of
some weeks the patient either sinks from a sudden attack of
diarrhoea, dysentery, or dropsy, or he more slowly dies from

OENERAI. DISEASES.

exhaustion. In many instances, too, some slight exertion has
been immediately followed by fatal syncope.

Ill the (liii(jn<i»i» of scurvy no difficulty is lik«ly to arise,
since there is only one affection with which it can bo con-
founded,— purpura. From this it is to bo di.'itinguished by the
gradual way in which it comes on, nud the cause; for purpura
often appears suddenly, and is iu no way due to abstinence
from fresh vegetables. In purpura there is no spon^iness or
lividity of the gums, the skin is not of a du.sky hue, nor is the
disease prevented or cured by antiscorbutic retuedies.

The treatment resolves itself into keeping the patient warm
in a pure atmosphere, while we administer some one or more
of the well-kniiwn antiscorbutics ; especially lemon or liuie-
juice, oranges, salads, watercress, potatoes, pickles, &e. I>r.
Lind, in bis work on scurvy, published in 1757, clearly proved
the efficacy of oranges and lemons in prcvctvting this di.sease;
though his earnest suggestions to the (lovcrnuiont were but
little heeded for nearly forty years. In addition to these re-
medies, luilk, nourishing soups, and wine must be allowed;
while, us soon as the state of the guius and the digestive organs
will permit of it, plenty of fresh meat and vegetables should
bo given.

If we believe in the soundness of Dr. Garrod's views, and
if we wish to administer physic, or if wo have not the power
to regulate the diet, we may employ the tartrate, chlorate, or
phosphate of potash — F. 80, 87, &c. Opium is sometimes
needed to give sleep, and to relieve irritJibility. In all severe
cases the recumbent posture should be strictly maintained, as
fattil syncope may arise from any cause which in the least de-
gree impedes the force of the heart's action.

in. PURPURA.

This disease probably consists of some morbid state of the
blood and capillary vessels, though the precise nature of the
alteration, in its early stage, is unknown. The result, how-

PUBPUBA.

ever, is timt the red blood-corpuscles become disintegrated,
while the contents oF these cells arc of course diffused. Hence,
purpura niiiy be said to be chariieterized by the occurrence of
sanguineous effusions into the difioreut tisfiues of the body,
producing red or claret-colored patches, which are unaffected
by pressure. When the hiemorrhagio spots arc very small,
they are termed pclei-hi'(r ; when large, viiices or eccJij/miiH<t.

This disease is often treated of as a cutaneous affection ;
and Willan — who erroneously considered it as nearly identical
with scurvy — enumerates five varieties of it, viz., purpura
simplex, p. urticans, p. hamoTrhaijica, p. senilis, and p. pvlc-
chia/ia or contaijiota. Such a subdivision seems, however, to
bu a very unnecessary refinement; for whether the spots be
small as in the first form, or large as iu the third, or whether
they be clcvut<5d as iu the second, matters but little with re-
gard to the nature of the affection or its treatment.

The aiuses of purpura are obscure. Sometimes it seems
due to the excessive use of salt provisions, or to insufficient
food with the other ills of poverty, to chronic exhausting affec-
tions, to degenerations of the liver or spleen, to Bright's dis-
ease, to intemperance, and to long-coutinucd mental anxiety.

The ti/mptoms are principally great languor and debility;
sallow or dusky complexion ; epistaxisf bad appe.ite, some-
times alternating with an inordinate craving for food ; pains
about the epigastrium ; palpitation of the heart, with giddiness
on making any exertion; constipation, iic. The ecchymoscs
generally appear OD the legs first, and then on the trunk.
They are of variable size, from minute dots like flea-bites, to
pitches several inclics in extent, while they are occasionally of
a scarlet color, and sometimes of u dark livid hue, like the
appearances presented by recent contusions. As they fade
uway they assunje a dirty yellow tinge. The mere fact that
the prominent feature of purpura is this exudation of blood
from the cutaneous capillaries would lead us to fear that simul-
taneously hsemorrhagc might take place into the substance of
the mucous membranes, &c. ; and nut only is this the case,

60 r.ENERAL PISEASES.

but it is this occurrence which renrlors purpura a dnnpcrous
affection. As a rule, in fHtai cases, blood is found copinusly
effused into the mucous lining of the whole digestive troct
from the mouth to the anus ; beneath the serous inembrunes
of the heart, luugs, and ubdomeii ; between the iiraehnoiil and
pia matfr, or even into the cerebral substance, as well ns into
the muscular and glandular tissues. Another chnrncteristic
chiinp;e, moreover, is to be detected in tlie spleen, which Im
enlar<:ed and suiYened, and studded with pale yellow spots.
By some authorities this condition of the spleen is regarded
not as the effect of tlie disca.te, but as its cause.

The Imilmriii should consist in llie e.vbibition of full doses
of castor oil until the bowels are thoroughly cleared out ; fol-
lowed by the udministration of quinine and iron, or cif the
mineral acids, or of arsenic with steel ( V. 445, 45'i, 4(»l, 471,
and 401). A good nuurishiiif; diet, a fair ;il!i>waiR'e of stout
or ale, and rest in a pure atnio»phere, will be indispensable.
The oil of turpentine, in small but frorjuently repeuted doses
(F. 60), has been strongly recommended where there is inter-
nal hfcmorrhnge.

ry. HYDROPHOBIA.

Of the disea-ses which may arise from inoculation with poi-
RoDS gcnerntcd by unhealthy animals, hydropliobia (rrtbif») is
the most distressing. It is, indeed, a fearful malady, not only
on account of its almost universal fatality, but also because of
the great suffering it gives rise to. Rubies is said to occur
spontaneou.sly in the canine and perhaps in the feline races;
but it is eomniunicatcd by inoculation with the saliva to other
animals and to man.

Si/mptomn. — The pathognomonic signs are, — cramps of the
uiusclcs of the pharynx and thorax ; spiismodtc action of the
diaphragm; a great dread of fluids; difficulty in drinking;
resllessncs and anxiety; delirium, exh:iustiun, and ileatli.

A person, we will suppose, is bitten by a rabid animal.

HYDROPHOBIA.

After an uncertain interval, called the ttage of tneubation, or
the lalftit p^rioif, he begins to complain of mental uneasiness,
chilliness, lancruor, and lassitude ; there is restlessness also,
loss of appetite, and more or less headache. Sometime a sen-
sation of numbness, or even of groat soreness, in the bitten
part is experienced ; but in any c.ise the precursory symptoms
ore fnllowed in two or three days by the confirmed stage of
the disease. This commences generally with jrarrulity, pecu-
liar sighinpp), nausea, and fever; to which succeed stiffness of
the neck, difficulty of breathing and swallowing, a horror of
liquids, an alarming sense of suffocation, and an excessive se-
cretion of saliva, causing frequent hawking and spitting.
There now set in violent spasmodic convulsions of the whole
body; the paroiysnis being occasioned especially by the sight
of liquidii, or the sound of running water, or any attempt at
drinking. The spasmodic terror inspired by the sight of
wafer has been well described by Dr. Marcet, who, in relating
the history of b case of hydrophobia, says: "On our pro-
posing to him to drink, he sb.-irtcd up and recovered his
breath by a deep convulsive inspiration ; yet he expressed
much regret that he could not drink, as he conceived the
water would give him great relief, his mouth being evidently
parched and clammy. On being urged to try, however, ho
tixik up a cup of water in one hand, and a teaspoon in the
other. The thought of drinking out of the cup .seemod to
him intolerable; but he .^eca)ed determined to drink with the
spoon. With an expression of terror, yet with great resolu-
tion, he filled the spoon, and proceeded to carry it to his lips;
bat before it reached his mouth his courage forsook him, and
he was obliged to desist. He repeatedly renewgd the attempt,
but with no bett«r success. His arm becnras rigid and ini-
innvablc whenever he tried to raise it towards his mouth, and
ho struggled in vain against this spasmodic resistance. At
Inst shutting his eyes, and with n kind oif convulsive pfTort, he
suddenly threw into his mouth a few drops of the fluid, which
be MCtually swallowed. Hut at the same instant he jumped

OENKRAI, DISEASES.

up from his cljair, and flew to the end of the room, pnnting
for his breath, and in n state of indescribable terror."*

About the sjccond day the sjnijitoms become more sorere.
The thirst gets di.stressinjr ; there is pain at the epij^astriuro,
and flatulence ; the countcnnncc is anxious, and indicative of
despair; the forehead is, perhaps, covered witii cold clammy
sweat; and there is, acncrally, much mental dit<tres.s, thou^jfh
the intellect remains perfect. — As the fatal issue quickly ap-
proaches, the sense of suffocation becomes more urgent; tha
surface of the body is so sensitive that a draught of cold air,
or the lightest touch, brings on convulsive |«iroxysuis ; the
senses of bearing and vision get morbidly acute ; the saliva is
more difTieult to expel, though the attempt,'! at spitlitig are ip-
oessant; there is fro<(Ucnt niieturitiiin; until at length the
terror becouies succeeded by wild delirium, which ends in
exhaustion and death.

The stage of incubation in hydrophobia may be said to vary
from forty days to eighteen or twenty months; the duration,
perhaps, depending upon the virulence and quantity of the
poison, as well as upon the constitution of the party inocu-
lated. Cases are recorded where the symptoms have set in as
early as the eighth day ; but others are known in which their
appearance has been delayed for four years, while in one in-
stance related by Dr. Bardsley, it is said that twelve years
intervened between the bite and the first hydropliobic symp-
toms.

The general duration of the disease is from two to four or
even six days, counting from the commencement of the con-
firmed stage. — There seems reason to believe that only a small
number of those bitten by rabid animals suffer from liydropho-
bia. Jolin Hunter mentions an iiLstJince in which of twenty-
one persons bitten by a dog, only one suffered. The bite of a
rabid wolf appears to be more dangerou.s ; for M. Trolliet states
that of seventeen persons bitten by a wolf ten died, and on an-

* JUu/u-t-C/iinirgical TraiuadioHS, vol. i, p. 1.'1H, Londnn, ISDO,

IiyOROI'HIiBIA.

other occasion ont of twentj-three thirteen perished. More-
over, it 18 possible that an altauk of hydrophobia may entirely
go off after the premonitory symptotusi have commenced,
Dr. ElliutBon relates — Lancet, May, 1829 — the fullowini; in-
stance : Two little girls were bitten in the face by the same
dofj, while they were Htiinding at their father's door. She
who was bitten the second became hydrophobic and died.
The other, at exactly the same time, experienced precisely
the same premonitory symptoms as her sister — heavincfu and
general indisposition — but they all went off. Mr. Youatt has
proved that hydrophobia has occasionally a favorable termina-
tion in the dog.

Morbid Analomif. — The rigor mortis is of short dnratinn.
The dependiui; parts of the body are usually very livid. The
fauces and pharynx are vascular, and sometimes covered with
lymph. The lungs may be congested. In some oases the
stomach and intestines have presented ovirlenco of partial in-
flammatory action. But the mast constant morbid appear-
noes arc dotecU.'d in the brain and spinal cord; the moninges
eing congested, the ventricles containing a slight excess of
fluid, and blood or serum being effused around the cervical
portion of the cord. Occji-sioniilly there has been a complete
absence of any discoverable lesion in the body.

PiiiIioUhji/. — The symptoms, together with the absence of
any constant .itructural change, seem to show that this disease
depends upon soma peculiar alteration in the bhxid, whiuh
affects the nervous system, and especially the three divisions
of the eighth pair. The poison, when absorbed, seems to
slowly effect some change in the blood, while at the same
time it increases in ((uantity and virulence. The process by
which this occurs has been compared to that which takes
place in fermentation. According to some luitliors, a double
symosis or fermentation ukes place; tirst in the part wounded,
and secondly in the system at large. The question is often
asked, — Is the disease due to the slow operation of the poison
on the lyslom, or to the mental anxiety which the patient

(IKNF.RAI. niSKAMKS.

undergoes from the consciousness of his danger? Although
our knowledge of the nature of this afTectiou is very imper-
fect, still I know of no reason for believing that mental anxi-
ety will give rise to hydrophobia any more than it will pro-
duce variola or syphilis — Whether in u rabid animal other
secretions than the saliva are poisonous is uncertain; but it is
very probable that they are so.

Trriitimnt. — This must be prophylaL'tic, for the euro of the
disease seems in tlie present state of medical knowledge
almost hopeless. The wounded part is to he excised as soon
as possible after the bite ; care being taken to remove every
portion touched by the animal's teeth, and to obtain a clean
mw surface. The wound is then to be thoroughly washed by
a stream of water long pouiX'd over it; and lunar caustic
afterwards applied. 3Ir. Yuuutt prefers the nitrate of silver
freely used, to every other caustic ; and he also recommends
that after its application the wound should be t|uii.'kly healed,
though many authorities advi.se that it. should be kept open by
irritating ointments.

In treating the disease itself, I should resort to the inhala-
tion of chloroform, the use of opium, pruiisic acid, Indian
hemp, and ice: though without much hope of success. l)r.
Todd kept a patient under the influence of chloroform for
about eight hours; but it did not seem to retard the fatal ter-
mination. So severe are the sufferings, however, that it is a
great point to give oven temporary relief. Dr. Marcet's patient
said imploringly — " Oh, do something for me. I would suffer
myself to he cut to pieces ! I cannot raise the phlegm ; it
sticks to n)e like bird-lime.'' And after trying to collect him-
self, he again exclaimed — "Gentlemen, don't ask me ques-
tions, 1 cannot say more, my feelings cannot be described I"
When the case is seen early, it might perhaps prove beiioficiai
to induce free perspiration by the vapor bath. If the theory
of n double zymosis be true, it may do good to lay open the
cicatrix and induce suppuration in it. Tracheotomy has been
proposed, but it would be a useless piece of cruelty to resort to

(1LAXDERG.

it. — The prautitioner should remember that iooouliition with
the saliva of a patient with hydrophobia seems by oo means
impossible ; he should, consec|ucntlT, earctuUy guurd ac;uinst
this secretion coming in contact with any scratch or abraded
surface.

V. GLANDERS.

The disease known as (j landers (^eqiiiniti, farciiiomu, or
/arrjf'), io the human subject, is a malignant febrile affection,
which is both contuvjous and inrcotiuus, and is due to a spe-
cific poison received from glandcred horses. Glanders and
farcy are essentially identical, both having their origin in the
same poison. But when the effects of the morbid ajjcnt are
manifested in the nasal cavities, the disease is known &s yltin-
den ; while, when the lymphatic system saffers, it is called
farcy.

In the /lorae, glanders is a disease which has long been
recognized ; for, according to Mr. Youatt, few veterinary
writers have published a more accurate account of it than was
given by Ilijipocmtes i2300 years ago. It is a loathsome and
incurable malady; beginning in tlii.snnim.il with a contagious,
constantly-flowing, aqueoub discharge from the nostril — com-
monly the left. In the second stage of the disease, the
discharge becomes viscid and glutinous ; then it gets purulent,
ftod the neighboring glands, especially the submu.xillary, begin
to enlarge; spot« of uloeratiou soon appear on the membrane
covering the cartilage of the noso ; and the poor beast loses flesh
and strength, his hair comes off, his appetite fails, and he has
a more or less urgent cough. As the disease progresses, the
ulcers increase in size ; the discharge is rendered bloody and
offensive ; the membrane lining the frontal sinuses inflames and
ulcciittca ; the forehead is tender ; more of the absorbents are
involved ; the conjunctivaj swell and suppurate ; little tumors
appear about the face and soon ulcerate ; and farcy is now
superadded, or the glanders degenerates into farcy. The

6»

OENEBAL DISEASES.

progress is henceforth rapid ; tho deep-seated nbaorbents are
iBOOti affected; one or both of the hind legs swell ton great
size; the discharge increases in quantitj and fetidity ; and
the animal seeius to present a mass of putrefaction, until at
length he dies completely exhausted.

Farcy in the horse is an inflammation of the lymphatic
glands and vessels, giving rise to small tumors called " but-
tons," or " farcy-buds," that gradually suppurate. The
ulcers which form have tho same character as the glanderous
ones in the nose ; while the virus they secrete is just us infec-
tions. I5y slow degrees the virus poisons the whole system ;
all the capillary ab.sorbouts become inflamed; the legs and
head swell enormously ; nud generally the disease surely miiB
on to a fatal termination.

In man the symptoms which rasult from the absorption of
the poison may show tlietnselves as acute or chronic glanders,
or as acut« or chronic farcy. — The ai-iilc ij/unijers is attended
by BufiFering somewhat similar to that which occurs in the
horse : the prominent signs being fever; great debility; rheu-
matic kind of pains in the limbs; profuse offensive discharge
from the nostrils; and the formation of a number of pustules
and tumors in different parts of the body, which have a great
tendency to suppurate and become gangrenous. The pustular
eruption does not occur until about the twelfth day ; it is
accompanied by profuse fetid sweats, and sometimes by the
formation of black bullie. Abscesses appear in tho neighbor-
hood of the joints; the nose, eyelids, and face swell and
perhaps ulcerate ; and the constitutional disturbance is shown
by greiit weakness and delirium. The disease generally proves
fatal before the twentieth day. It occure for the mo.st part in
grooms, stable-men, &c. Of fifteen cases collected by llayer,
fourteen died.

Clirouic i/lnnderf runs its course more slowly to a disastrous
termination ; the symptoms consisting especially of a discharge
from the nostril, offensive perspirations, and tho formation of

OLA.VDERS.

absoeues in the neighborhood of the large joints. Out of
three reported ciises only one recovered.

In acule farcy, the iufiamiuatiun begins in the lymphatics
lending from the part wounded, nnd \i followed b; swelling of
the glandei and extensive suppunitinn in the subcutaneous
areolar tissue. Great cxhaastion soon sets in, from which,
however, the patient may recover ; but if a pustular or gan-
grenous eruption appears, together with the glanderous dis-
charge from the nostril, the case may be looked upon as hope-
less. In fifteen examples of acute farcy death resulted in ten.

Chronic farcy produces the following effects. Suppose a
groom has a (>li<;bt abrasion on one viK hi.s Gugers, and that it
comes in contact with a little of the discharge from a glan-
dercd horse. A few days subse()uently, a painful sore appears,
which is poulticed. In a day or two an eschar forms ; on
removing which a deep, unhonUhy ulcer is seen. Similar
ulcers form about the head, upon the arm, in the course of
the absorbents, and in the axilla. The health begins to
Buffer ; and unless the patient can take plenty of nourishment
and perhaps remove to the sea-side, symptoms of acute glan-
ders will soon set in and destroy him. This unfavorable result
way, however, be often averted ; for out of seven oases only
one died.

For the treatmenf of acute glanders all kinds of remedies
have been ineffectually employed. — In any of the modified
forms of this disease, all that we can do is tu support the
strength, give the patient pure air, open the abscesses, and
syringe the nostrils or wash the ulcvrs with plenty of water
containing a little chloride of zinc or some other disinfectant
solution. The internul administration of creasote, together
with the application of lotions containing this medicine to the
ulcers, has been thought sometimes to do good. With a few
cases we might pgrliaps assist nature in eliminating the poison
through the ekin, by using the vapor bath.

iiknusat, diseases.

VI. HEMOEEHAGE.

1. Introduction. — The escape of blood from the vessels in
which it is naturally contflined constitutes hajraorrhage. For
many years it has been maintained that blo<id may exude, as
sweat dues from the skin, from the unbroken surfaces of or-
gans, without aoy rupture of arteries, capillaries, or veins ; and
in this w.iy most of the cases of hajinorrhage which come under
the notice of the physician have been accounted for. Hr. Todd
first taught me to doubt the occurrence of haomorrhape by ex-
halailon ; for he argued that if blood-corpuscles, which mea-
sure about ^o'ofl "'' "" ''"^^ '" diameter, could pass throtigh
pores in the capillarios, such openings must be large enough
to be detected by the microscope. More recently Virchow
has insisted upon the fact of the vascular system being every-
where closed by merabrnoes, in which it is not possible to dis-
cern any porosity ; and hence he asserts, that although we
cannot, in every individual ca.se, point out the exact site of the
rupture, yet it is (|uitc inconceivable that the blood with its
corpuscles should be able to pass through the vessel's walls in
any other way than through a hole in them.

Many classifications of hsomorrhago have been attempted.
The chief subdivisions made by authors in the present day are
these : (1.) traumatic when a vessel has been directly divided,
nnd tpinitiiveous when the bleeding has resulted from some
constitutional cause; (2.) ti/niptom<ilic w\it;n clearly a result
of some disease, as tubercle, cancer, &c., and iifioputhic, or
euential, when no such connection has been perceptible ; or,
(3.) active ha-morrhage when congestion or inflammation has
preceded the flow, and pamire when there have previously
existed signs of debility, with poverty of btood. Moreover,
htcraorrhages have been termed consiitiitiona! when they occur
nt intervals, and seem to be of service to the general health,
as in the bleeding from piles in plethoric people. They arc
often called iiicarlotu when supplemental of some other hscmor-
rhage, as where a woman has a periodical bleeding from the

HAMORRHAIIE.

(50

Oi»e in pince of the usual cntanieninl discharge ; and they are

aetimes spukco of as rri/fcal when they occur during the
progress of some disense, and produce marked good or bad
effects.

The cawief of hajniorrhiipic arc hoat, violent mental enm-
tions, muscular exertion, tho use of stimulants, and exposure
to variouH irritants. A predisposition to it appears sometiwcH
as if it were hereditary, and then there is said to bo the
biBmorrhagic diathesis. Mechanical obstacles to the circula-
tion are powerful causes, a fact which is exemplilied in the
case of valvular disease of the heart, as well as in those affec-
tions of tho liver which — by obstructing the flow of blood
through the inferior vena cava and the vena portie — produce
congestion of the whole portal system, and as a consequence
haemorrhage into the aloniiioh or bowels. Morbid states of
the blood — as, on the one band plethora, on the other anaimia
— are also favorable to hEemorrhage. And, lastly, diseases of
certain organs, as of the liver and spleen, also tend to produce
the hicujorrhagic diathesis, by exercising some deleterious in-
fluence upon the composition of the blood.

The leat of the biBmorrhage, speaking with some latitude,
ni»y be said to vary with the patient's age, bleeding from the
nose being common in youth, from the lungs and bronchial
tubes io adults, and from the cerebral vessels, urinary passages,
uteru!*, and rectum in old age.

The ti/mpiomt necessarily depend upon the cause, seat, and
extent of the loss, as well upon the condition of the patient.
Where signs of plethora have previously existed, with hoad-
nche, heat of skin, and a full bounding pulse, a moderate
bleeding may prove at the time bencticial ; whereas, in cases
of a»thenia, every ounce of blood that comes away servos but
to increase the vital depression. The effects which should
raise the practitioner's fears are depression of the pulse, pallor
of the face, coldness of the extremities, syncope ou attempting
Ut sit up, and delirium. Sometimes there is no loss of aon-

oosDes*, even though the powers of life arc almost ex-

OF.NKRAI, DISEAKKB.

faaugtcd ; ond then amongst the inanj unmistaknble symptoms
of !ipy)roacliin|; death, I know of none more alarming than the
puticnl's feeble expression of perfect ease and contentment,
and desire to be let alone.

The pro(/iiosiii is unfavorable when the hsoniorrhage takes
place into a serous cavity, or into the substance of an organ.
In other instances it is generally favorable, death very rarely
resulting. The obstetric physician especially must often be
surprised at the large quantity of bluod which is lost without
the patient succumbing.

With regard to the general principles of Irfalmenl, it may
be first noticed that as a rule it is desirable to suppres.s the
haemorrhage. Some authorities affirm that there is danger in
stopping a discharge which may almost be called hubitual ; but
1 have seen nothing that leads me to acquiesce in this opinion.
On the contrary, many elderly people have come under my
notice who have been injured, and greatly inconvenienced, by
the ft-equent bleeding ari.sing from piles. Of course, however,
when such cases are interfered with, it is nece.s.«ary to guard
against congestions of internal organs, which may be best done
by attention to the diet, and by taking care that the bowels
net regularly. The few exceptional instances where attempts
to arrest a bleeding would be liaMrdous are found in plethoric
people, who seem occasioiiully to be relieved from a threatened
fit of apoplexy by a timely attack of cpistaxis. In vicarious
hasmorrhages we should try to procure the flow frtun the natu-
ral seat.

In endeavoring to control any form of hnemorrhagc we raust
keep the patient as ijuict as possible; his apartment should be
cool; he must rest on a mattress without much covering; his
diet ought to be simple and unstiniulating; while the position
of his body is to be such that the afflux of blood to the bleed-
ing organ may bo impeded.

Our chief resources are then to be found in the use of as-
tringents. One of the best of these agents is cvtd ; and there-
fore iee is to be applied locally, while it may also be freely

n.CMriRRirA(se.

Ikllriwcd. A vuluable nnd most cfliciont drug is 'jallic arid,
given in dosos of ten grains every fonr or six hours. The
ummop I'o-gu/ph'tte of iron (iron alum) is an excellent styptic,
from wiiich I Iimtc seen the best effects in bicnioplysis, while
in all cuses I think it better than the muriuted tincture of
iron. The minertil acids (\mc)s.en coii<;ulation, and hence may
often be used with uJvnntage. Jjieraciinnha appears some-
times to exercise a fnvorable influence on internal haemor-
rhages, but it must generallj be piven in doses of one groin
every thirty or sixty minutes until a feeling of nausea is pro-
duced. In cases nf hajmorrhtifro from the lunps or «tomacIi,
the act of vomiting woul i prububly do harm, but I have often
seen it do marked good in flooding after labor. The arelate
of Itad was long recommended as an oBicacious styptic, but I
now never use it, since I have found it very inferior to piillio
acid, &e. The oil of turpentine, has also been esteemed a good
astringent, especially in bleeding from the lungs, stomach, or
kidneys. Ten or twenty minims may bo given in mucilage
every two or three hours, while sometimes it may be benefi-
cially used in the form of inhalation, or as a stape (u hot flan-
nel .sprinkled with the oil ).

In obstinate cases virrcurij is a very valuable remedy. At
one time 1 thought the beneficial effects were not induced
until salivation was effected, but I believe this to be an error.
The liquor hydnirgyri bichloridi may be given in doses of one
to two drachms (gr. j'j to gr. ^) every three or four hours,
Dntil a good effect ensues. This metal is contraindicatod
whm there is any predisposition to pulmonary or renal disease.

When the hirmorrhage has been excessive and has pro-
duced exhaustion, opium is invaluable aa a stimulant. I
enerally ])rcfcr the extract, in doses vorying from one to three

ins, and it is better usually to combine it with cordinls.

Formerly blerdini/ was resorted to, in order that while the
force of the heart's action was lessened, llie current of blood
might be diverted from the affected organ. When there ia
ot^goDtc disease, venesection i^ most objectionable ; while in no

r.ENERAL DISEASES.

cnsc does it possess such advantage OTer other remedies as to
lead t4j its rocomniundation.

Lastly, it must be remeinbered that in very severe cases —
particularly such as occur in obstetric practice — when other
means f;iil, wo may resort to (runt/uston. This operation will
be much simplified by adopting Dr. Richardson's snggestioa
that the blood to be injected should be kept in a liquid state
by means of ammonia. About two minims of the strong liquor
ammonite with twenty of water may be added to the ounce of
blood, and even a little more if n tendency to coagulate is
manifested. As the blood from n healthy individual fiillsinto
the vessel contniiiiog the ammonia and water, it should be
gently stirred. Then the syringe being completely 611ed, so
88 to exclude even a bubble of air, and its nozzle introduced
into one of the pntienl's veins at the bend of the arm, the
operator must take care to proceed very slowly ; for one of the
great dangers of transfusion consists in forcing in the blood
too rapidly. With regard to the quantity of blood to be trans-
fused, it may be said that the operation should be stopped
when the patient has rallied; which will generally occur when
from six to twelve ounces have been injected.

2. Cerebral Haemorrhage. — When cerebral sanguineous
effusion occiirs in childhood it most frequently assumes the
form of hoBtiiorrhage into the cavity of the arachnoid. This
form of meniiii/'nl npij/>lrTif differs from rerebral apoplejcif,
inasmuch as it rarely gives rise to paralysis, owing perhaps to
the pressure acting uniformly upon the contents of the
cranium When only a small qtiaiitity of blood is effused,
absorption may take place, and recovery ensue.

Disease of the brain may give rise to hsemorrhage into the
ventricles — a form of apoplexy which is more rapidly fatal
than any other kind.

Hemorrhage into the substance of the brain is the most
fVequeiit variety of apoplexy which occurs in advanced life.
The aniouiil of blof»d poured out varies from a drop or two to

n^MORRIIAOE.

tnsDy ounces ; and althoagh all parts of the enccphnloo may
be the seat of the effusion, yet the latter is most frequently
found in the vicinity of the corpora striata. The fatality of
apoplexy seems to be in proportion to the amount of injury
done to the cerebral tissue, as well as to the nearness of the
effusion to the medulla oblongata. Hajtnorrhuge into the
oerobcllum may take place alone, or combined with effusion
into the cerebrum : it is not very common, but when it occurs
it very quickly causes death.

In searching for the immediate cauK of apoplexy, attention
mast be paid to the composition of the blood, the state of the
vessels, and the condition of the surrounding tissues. With
regard to the first, our knowledge is imperfect ; but, according
to Andral and Gavarret, there is an essential connection be-
tween cerebral Iiaemorrfaages and a diminution of the fibrin of
the blood with an increase of the red globules. Apoplexy
not unfrequently occurs as a sequel of renal or cardiac disease ;
when it is probably due in part to an altered condition of the
blood, though we know that in Bright's disease the coats of
Uie arteries are also of^en the seat of some degeneration. In
the majority of cases disease of the vessels is the cause of the
effusion, and occasionally aneurism of the cerebral arteries.
Chronic arteritis by producing pulpy softening, or calcareous
or atheromatous depuait;:, may render the vessels unable to
bear the force of the blood current. If the uutritioii of the
nerve tissue becomes diminished, sofbening ensues j and the

ne result 8omctime.s follows from acute inflammation. The
in which the cerebral arteries get occasionally plugged by
a portion of fibrin has been already described.

For the further consideration of this subject the reader is
referred to the article on Apoplexy, in the section on Diseases
of the Nervous System.

3. Epistaxis. — Probably every one remembers the frequency
with which, in his school-days, he suffered from "a bloody
nose," and the famous plans by which old ladies were wont to

liENtKAL UlriF.ASKS.

cure it. Unless this bleeding comes on during the progress
of some disease — as hooping cough, &c. — it is Heldoni trouble-
some in youth.

But episUixis often gives rise to much anxiety when it
occuns in advanced life. If there be a tendency to apoplexy,
or if the patient be afflicted with heart-disease, the bleeding
may prove beneficial. This is by no means the ease, however,
when it sets in during the progress of disorders which injure
the (juality of the blond ; as in renul mid hepatic diseu-ses, ia
fever, scurvy, purpura, &.c. Exhausting cpistaxis may be the
immediate cause of death in cases of leueucythcniia, when this
affection is approaching a fatal termination.

The bleeding seldom takes place from both nostrils; and it
may be continuous, or it may cease and return after an uncer-
tain interval, or it may happen periodically. The blood may
flow in drops, or in a complete stream ; wliile it niay not only
come from the nostrils in front, but may pass posteriorly into
the mouth and fauces. Tn adiilLi, males .suffer from it more
ot\en than females; and it may be caused by direct violence,
by whatever obstructs or greatly quickens the circulation, by
morbid states of the blood, by congestion of ncighboriiig parts,
by the suppression of some habitual discharge, as well as by
polypus and disease of the pituil.iry menrbrune.

In the treatment, care must be taken to discriminaie between
those cases where interference is reifuisite, and the contrary.
Supposing the aid of our art is needed, it will be bettor to
have the patient sitting upright in a cool apartment, and with
the neck uoconfincd by collars, &c. Dr. Negrier says he hue
always found the bleeding arrested by making the patient
raise one or both of his arms above bis head, and letting him
hold them in that position for some time. This simple plan
failing, cold applied to the neck and buck may, by reflex
action, check the discharge ; or cold water, or ice, may be
applied directly over the nose and forehead. In urgent cases
I have successfully swabbi'd the no.stril with a .saturated solu-
tion of perchloride of iron ; and I have seen injections of uluiu

n.«MOHRnAaE.

•5

and water, or of the niuriated tinctnre of iron and water, or of
the iron alum in solution, do pood. Plugging the nostril with
eharpie, or with cotton wool wnked in some astringent lotion,
often succeeds; but unless everything else fail, I would not
annoy the patient by plugging the posterior opening of the
nostril.

With reg-.ird to internal remedies, the condition of the
patient must be our guide in selecting either mercury, or
gtillic ncid, or the ummonio-sulphate of iron, or the murintcd
tincture of iron, or turpentine (F. 66, 127, 128, 132, 148,
149, &c.) Sometimes mild laxatives may be used ; or if there
be any liver derangement, nitric acid and taraxacum will do

4. Stomatorrhagia. — Discharges of blood from the mouth
and throat .«eldom give rise to any trouble, except when they
occur during the hist stages of scurvy or purpura, or after the
excessive use of mercury. In some few instances the small
veins about the mouth and pharynx become varicose, and
should their walls rupture, severe or fatal bleeding may result.
Ulcers about the tongue and fauces rarely bleed much ; but
once or twice glossitis terminating in gapgrenc^ has produced
t'ftlBmorrhage ending in death.

Dr. I'ondie, of Philadelphia, hius recorded u ease where the
blood flowed from the mouth in a stream, and on the gums
being wiped with a sponge, it " was seen to start up at every
I>ore from the whole surface." Now, this would by many be
regarded as an example of hfrmorrliiirjr hi/ ex/tafaiion ; just
BS the occurrence of cutaneous bleeding, where the blood ap-
pears like a dew upon the skin, has been explained. But in
all these cases there is simply an exudation of serum colored
by the red matters of the dissolved blood-corpuscles.

It is worthy of note that prisoners, hysterical females, and
others, often feign haemoptysis by pricking their gums, suck-
ing oat the blood, and mingling it with phlegm — an imposi-
tion which will be readily detected on examining the moulb,

nENERAL DISEASES.

as well as by noting; the absence of ail signs of thoracic or ali-
doniinnl disease.

The Irralment of stomatorrhagia must be conducted on the
general principles already laid down. Medicines need not be
administered unless the use of a cold astringent wnsh fails to
stop the bleeding.

6. Heemoptysis. — The term hffinioptysis may be applied to
those cases where the blood escjtpes through the mouth from
the larynx, trachea, bronehiiii lubes, or air-fulls of the iunj^.
Sometimes the bluod is poured iuto the lung tissue without
any external discharge, and then the disease is generally
spoken of as pulmoimry apoplexy.

In by far the greater number of cases haemoptysis is merely
symptomatic of tubercular phthisis; though it may also, and not
nnfrequcutly, be due to disease of the heart — especially of the
left cavil ies — impeding the relurn of blood from the lungs.
Very rarely it may arise from some ulceration of the air-pns-
sages; from inflammation, abscess, gangrene, or cancer of the
lung; from the detachment of librinous casts of one or more
of the small broDchial tubes ; from aneurism of the great ves-
sels ; while, lastly, in females, it may be connected with some
irregularity or suppression of the catamenia, though I have
aeon no ca-ses of thif! kind wliere there was not reason to sus-
pect tuberculosis. When there exists a predisposition to this
form of haemorrhage, it may be immediately brought about by
anything which harries the circul.itioti, by congestions of vari-
ous important organs, by violent coughing, playing on wind
instruments, ascending high mountains, tight lacing, &c.

The discharge, when proceeding from the lungs, is often
preceded by pain or oppression in the chest, a sense of heat
and soreness beneath the sternum or between the shoulders,
lassitude and mental depression, flushings of the face, a salt
tasto in the mouth, dry cough, dyspnoea, and palpitations;
while sometimes I have noticed that there has been a com-
plete absence of premonitory symptoms, with the exception of

ItiCMriKHItAOK,

pnlse. The quantity of blood which may be expelled
varies from a streak on a peilf't of mucus or a minute clot or
two, to one or many pints; and the blood is eenerally frothy,
of a bright florid hue, and is expectorated, unle-ss the bleeding
excessive, when it is gulped up or vomited. HiumoptyBig
m in about two thirds of all the cases of phthisis, and it
does so under two circumstances. Thus, it may happen from
the rupture of a small vessel, owing to the tubercular deposit
producing congestion, when it is to be regarded more as a
warning of coming mischief, rather than as a proof of the lung
being irremediably injured; or it may take place when the
tubercles have begun to soften, and the coats of some vessel
have been destroyed by the spreading of the ulceration. The
hsBniorrhnge very rarely destroys the patient at once ; though
in the cases which I have watched, it has certainly seemed to
hasten the fatal termination of phthisis.

In jjvlmoiiari/ apoplexy — an absurd name, for there is no
sadden stroke, no loss of sensation or power of motion — the
blood is effused into the air-cells and pulmonary tissue, where
it coagulates. There are two forms of this affection, — one
where the effusion is circumscribed, and we find small, hard
masses in the substance of the lungs, varying in size from a
pea to a small orange ; the other, in which the blood is rf//-
futed through tlie broken-down pulmonary tii«uc.s. Pulmo-
nary apoplexy most frequently arises from disease of the heart,
particularly of the mitral orifice ; but it may be due to some
disease of the pulmonary tissue or vessels, or to such an im-
poverished state of the blood as occurs in scurvy, fever, &o.
Sotnetimes the internal bleeding is attended with spitting of
blood. If only a small qu.intity be extnivasatod, the patient
rocovors; but if the loss be excessive, symptoms of internal
btemorrhage with great dyspnoea will manifest thvmselves,
and most probably end fatally. Au.'icultation often tells us
nothing in these cases; though if we listen before the blood
coagulates, we, perhaps, may find large crepitation from the
air-bubbles passing through the fluid and bursting, while sub-

OEVKRAI. DX8KASES.

sequently there will be dulness on percussion, with absence
of all respiratory iiiumiur in the affected portion.

But a few special remarks are called for on the treatment
of hiemoptysis. The haemorrhage should always be checked
as quickly as possible ; and for this purpose, af^er enjoining
strict quiet and rest in bed with the head and shoulders ele-
vated, I have found no remedy so efficacious as gallic acid.
This agent should be given in the proportion of ten or fifteen
grains every two, three, or four hours, according to the ur-
gency of the symptoms; sometimes commcnciog with a half-
drachm dose in five or six ounces of water. When there ore
indications of great anaemia, from five to ten grains of the
ammonio-sulpliate of iron (F. 149) may be preft-rtible to the
gallic acid. Sucking VVcnham Luku ice does great good;
and occasionally the applic^itiun of cold over the chest is nse-
ful, though the effects of this practice must be watched.
Some authorities state that a teuspoonful of common salt dis-
solved in a little water, or taken dry and swallowed as best
the patient can, seldom fails to stop the bleeding for a time;
others advise bleeding, leeching, antimony, or digiLilis; some
prefer the ergot of rye, or turpentine, or emetics of ipecacu-
anha; many, again, recommend dry cupping over the chest, or
the application of turpentine stupes; and a few speak highly
of the use of a ligature ruuitd the lijubs, so as to impede the
return of blood through the veins. To prevent the recurrence
of the bleeding, we niubt relieve nny cough which may bo
present by anodynes — especially by mor]iliia ; and then en-
deavor, as much as possible, to improve the general health.

6. Hsematemesis. — This term, signifying strictly vomiting
of blood, is generally omplnjcd to denote haemorrhage from the
stomach. The blood is usually vomited in large quantities, is
not frothy, and is of a dtirk color from admixture with the
hydrochloric acid of the gastric juice (all acids blacken the
blood). Hence it presents marked differences from the blood
in hsBinoptysis ; in which disease the heemorrhage is generally

H^CJIORRHAOE.

preceded bj- cough, dyspnoea, tickling in the thront, nnd a pe-
culiar sensation in the thorax, while the blood is brought up
by coughing in mouthfuls at a time, is of a florid red color,
aod is mixed with a little frothy mucus.

Hsematemesis may arise without any appreciable cause ; or
it may be vicarious of some other hoeinorrhage, especially of
the catamenia ; or it may result from changes in the blood it-
If, as in scurry; or it may be owing to congestion of tho
"stomach from some impediment to the free passage of the
blood, such impediment being due to disease of the heart,
liver, &c. But its most direct cause is either passive conges-
tion of the walls of the stomach, or simple or malignant ulce-
ration. In simple ulceration, the blood most frecjuently comes
Bwuy slowly, in small quantities, and often afler a meal ;
though sometimes a large vessel is laid open, and a gush of
blood takes place which m:iy prove fatal. So also in the ul-
ceration of a cancerous mass the bleeding is usually slight.
When from any causes tho extravasation is moderate, tho
vomited matters arc said to resemble " coffee-grounds."

Ha)niatemesi.« is generally prccoded by a feeling of oppres-
sion and weight, by dull paiu or tenderness in the epigustrio
and hypochondriac regions, as well as by a sense of anxiety and
faintness. Often there is only nausea, dizziness, and depres-
sion of the pulse. The hajmorrbage frequently produces great
depression, owing to alarm as often as to the quantity of blood
lost.

Id gastric haemorrhage, the blood sometimes passes into the
intestines, and is voided per anum ; or part may be vomited
ftod part expelled with the fsEces. When tho intestinal

acuations contain bloud, whether this comes from the vessels
of the stomach or only from those of the intestines, the patient
is said to be suffering from mdana. As this name implies,
the evacuations are often black, and sometimes resemble tar;
but this dark appearance is by no means constant, and does
not occur if the blood comes away too quickly to be acted
upon by the intestinal juices. Cirrhosis of the liver, or any

cinomntous ulccrntionx, ancurismal and other to
I must not be confounded with bleeding from the i
' to the presence of hojuurrimidg.

The treatment oi htetuatooiegis must consist 1
: abstinence from food, perfect rest, and the horizq
while cold acidulous drinks, ice, and gullic ucidl
prescribed. The oil of turpentine is thought by
specific. In one case, a single dose of a concentr
of the perchluride of iron (one toaspoonful in plyocil
a cure. Cold to the epigastrium is occasionall)
the patient be prostrated, encniata of beef-tea wil
or brandy nnd a little opium will da much good,
niehena, where there is no gastric disease, acti
be necessary; and hence a full dose of call
be given, followed by the common black draught c

7. Haematuria. — Ilicmaluria, or haoraorrhage

Innicou.s mcmbrnne of the urinary passages, may p

Ithc kidneys, bladder, or urethra. It is conimuii ii

stages of those forms of renal disease which arise

bid stjite of the blood ; hence, as we shall see, it ii

|osult of acute desquamative nephritis. It may ale

uuliguant disease of the kidney or bladder; from)

'b calculus either in the kidney, ureter, bladder,

HJuMORRHAiiE.

suspected rerinl disease tlie practitioner siiould not venliiiv im
opinion if the woman ha.s her courses on.

Urine containing blood will be found of a peculiar smoky
hue, or even of a black color, nnd loaded with albumen. The
diMinction of renal from vesical hwrnorrluige is important. Dr.
Prout states that when the "blood is derived from the kidmty,
it is in general equally diffused throusrhout the whole urine ;
ou the contrary, when derived from the h/nil</rr, the blood for
the most part conies away in (greater or less quantity at the
termination of the discharge, the urine havine previously
flowed off nearly pure." Lir. Watson has also remarked that
the expulhion of slender, cylindrical pieces of fibrin, which
have evidently been moulded in the ureter, is characteristic of
haemorrhage from tlie kidney or comnienceuieut of the ureter.
Moreover, in hjemorrhage from the kidney, the urine on being
examined microscnpically is sometimes found to contain casts
of the renal lubes formed of coagulated blood (often spoken
of as llniMlrailf) ; while there is also seen the delicate round
renal epithelium, with casts cooiposcd of epithelial cells and
blood corpuscles. When the bleeding is from the bladder,
the blood corpuscles are observed mixed with the flat scaly
vesical epithelium ; and the urine contains also more or less
njuco-puralcnt mutter. When the biood comes away in drops
or in a stream, unmixed with urine, the urethra is in :Ji
probability its source.

The treatment will vary with the circumstances under which
the hsemorrhage occurs. Where there is malignant disease,
or a calculus present, Bstringent.s may be resorted to; the best
being the tincture of the scsquichloride of iron, gallic acid,
the diluted sulphuric acid,&c. The fearofciusing strangury
must prevent the use of turpentine. Where there is some
morbid poison in the blood, or actual renal disease, we ought
to rest the kidneys, and promote elimination by the skin and
bowels ; for which purpose hot-air baths, simple warm baths,
and purgatives, will prove the most effectual. Htomorrhage
from the urethra may often be checked by the application of

T8P.A8E8.

icp, or by passing a Inrpe bougie, and leaving it in the passage
for «ome hours. I^^sdy, in vesical hxmorrhagc, a solution of
alum or of tannic acid may be injected into the bladder; while
the iron alum can often be advantageously administered at tho
same time.

8. Menorrhagia. — Ha'morrhagc froti) the uterus is a
Bymptom of ^'o many different diseases, that to consider it
properly, one ought to write a treatise on the various functional
and organic derangements of this organ. Strictly speaking,
the term menorrhagia should only be applied to oases of in-
croasod menstrual flow ; but very often it is employed to sig-
nify any sanguineous discharge from the uterus other than the
noniinl monthly escape.

Tho catanionia may be abnormally increased from conditions
which produce attenuated blood ; as tuberculosis, granular
degeneration of the kidneys, affections of the spleen, anaemia
from prolonged lactation, kc. Another common cause is ex-
cessive congestion of the ovary and uterus during the matura-
tion and escape of the ovule ; while the same result is pro-
duced by any great excitement iit the monthly period, or ex-
cessive sexual indulgence at other times ; by metritis and
ovaritis ; and by such relaxation of the uterine tissue as ia
oflon associated with abrasion of the lips of the cervix. The
diseases which give rise to utorino haemorrhage are principally
oanocr, fibrous tumors or polypi, inflammatory diseases of the
cervix, and the presence of moles in tho cavity of tho uterus ;
affections which may merely increase the catamcnial flow, or
which may produce frcijuent attacks of bleeding — .sometimes
b:i severe ns to amount to flooding. The practitioner must
also remember the fref|uenpy with which lippmorrhnge proves
to be the precursor of abortion.

In making a few remarks on the Irralment of the.sc cases, it
will be necessary to confine them to the steps to be adopted for
controlling the hrcmorrhage ; since it would bo out of place
here to allude to tho proceedings required for removing its

INFLAMMATION.

oauso. At onco, therefore, it may be siiid tliat nstrin5!;('titsare
the remedie§ clucfly to be trusted to ; and the best ol' these
are gallic acid and cinnamon, cither alone or in combination
(F. 130, 133 and 134). Where any inflammatory action
exists, mercury will he the best agent to employ ; and, as be-
fore mentioned, I prefer the bichloride. The ergot of rye has
no styptic property, but when the bleeding i.s due to a flabby
state of the uterus, it may do good by inducing contraction.
When there is anroniia, the animonio-sulphatc of iron is very
efiBcncious. Occasionally we meet with cases where the dis-
charge of blood is excessive, though we can detect no cause
for it, and where no kind of astringent or tonic him the least
effect. In such I have found most benefit from the bichloride
of mercury; the infu.-iion of digitalis, in hall-ounce or ounce
doBCS, as strongly recommended by Mr. Diekin.wn and Dr.
Robert Lee, having given me nought but dL-jappointmcnt.

The local remedies to be resorted to are either the applica-
tioD of cold over the pubes, and the passing of ice up the va-
gina; ur strong injections of tannic acid or infu.Mun of niatico;
or the use of galvanism where there is a want of muscular eon-
tmction ; or plugging the vagina firmly with some soft material
like cotton-wool, or a sponge soaked in vinegar.

VII. IITFLAMMATIOJf.

Every part of the body is liable to inflammation (I'njlammo,
to burn), and much of the premature estinction of hniuiin
life is due to it. Its di.stinetive external marks are the combi-
nation of pain, swelling, heat, and redness: " Notus inflaiu-
mationis," says Celsus, " sunt quatuor, rubor et tumor, cum
cnlore et doloro." The con.stitutional symptoms are fever and
bui&ness of the blood. Thus, if h]ood be drawn from a vein,
it will (»hibit, ufler standing and coagulating, the biify coal ;
i. c, the upper part of the clot will consist of fibrin unmi.\ed
rith red corpuscles. It must be reniembered, however, that
bis sppearauee is not characteristic of inflammation; it will

OCNERAL DI8EAREB.

generally arise when, from any circum!<tuDce, the fibrin ooaga-
liites more slowly, or the corpuscles subside more riipitlly, than
ill lienlthy blood. It is also (Vmiucnlly found in the blood of
plethoric persons, and in that of pregnant women. Some-
times the surface of the buify coat is contracted and concave ;
the blood is then said to be buffed and cupped.

Infiuuimntion occasionally arises unexpectedly and from
caiitei unknown. In other instances it will be found to have
been produced by some mechanical or choiuical irritant, or by
cold, or some morbid poison in the system, or contagion, or
metastasis. It is now admitted by many as probable that
inflammation is not an affection of the capillaries, nor an altered
state of the nerves, nor a change in the blood, but that it is a
form of abnormal nutrition — that where it has its scat, the
series of changes by which the tissue is renovated is deranged.
It is said to be acute when it runs its course rapidly, and is
attended with severe constitutional and local disturbance ;
chronic, when its phenomena are less strongly marked.
Suhacute inflammation is marked by symptoms which are
intermediate between acute and cbroiiiK, and which do not
attain any great severity. By some authora the term latent
has been applied to those cases in which internal inflammation
proceeds silently and treacherou.'sly, and without ninnifesting
signs by which its existence might be suspected. And then
there are certain upeci/tc influmraatiyns, examples of which
may be seen in scrofula, gout, rheumatism, the exanthe-
mata, &c.

The conditions of the healthy maintenance of any part by
nutrition are, observes Mr. Paget,* Ist, a regular and not far-
di»<tant supply of blood ; 2d, a right state and composition of
that blood; 3d, in most cases at least, a certain influence of
the nervous force; and 4th, a natural state of the part in
which nutrition is to be cflected. In inflammation these are
altered. The supply of blood is increased ; the vessels are

• Lniiiif' ni! Surgiro/ PalAology. vol i, p. 294 London, 183S

INFLAMMATION.

dilated and elongated, so that&uch as wore previously invisible
cotuciiito vii'W, owing to their distensiou with red corpuscles;
there is a lendeocy to stagnation — not coagulation — of the
blood in many of tho turgid vessels ; and when lymph ia
effuaed, and begins to be organized, new vessels are formed in
it. The purity of the blood is more or less disturbed ; the
fibrin is probably increased, so is the water, so — sometimes —
are the white corpuscles; while the red corpuscles are dimin-
ished, and when drawn from the vessels have d tendency to
cluster into masses very rapidly. The nervous force is not
normal, but how it is changed we no more know than we can
explain how it operates in ordinary nutrition. And lastly,
the healthy condition of the part it.»olf is changed in the
infiamuialury state ; such change being due to more or less
degeneration from hindered nutrition, as well as to the pene-
tration of the inflammatory product into the elemental struc-
tures and the interstices between them.

The lermiiiations or events of indantinatory action are reso-
lution or cure, or delitescence — as it ia called by the French
pathologists when the piienomcna disappear suddenly and
rapidly ; metastasis, or change of scat from one part to another ;
the effusion of serum ; the exudation of coagulable lymph ;
the formation of pus, or suppuration ; ulceration ; and gan-
grene, sphacelus, or mortification. When inflnmniation attacks
the areolar tissue, all the results of inflammatory action may
occur. So also when the larger glands and the solid viscera
of the body .^ufier. In iuflaiiiiiiiUion of the serous membmoes
we expect there will bo exudation of serous fluid, and coagu-
lable lymph or fibrin — in other words, that it will prove adhe-
sive inflammation. The synovial membranes are less liable to
this disease than the serous, aud cuuguluble lymph is seldom
poured out. The mucous membranes are rarely affected by
the adhesive form of inflammation; but when attacked the
inflamed membrane pours out serous fluid, or viscid mucus,
or puB, or blood — as is well seen in pneumonia, when the

«fl

nEyER.lI, niSKASEB.

extravitKiled rod corpuscles ^ive a rusty tinge to the sputa.
Il may be observed that the iiurmbruiious exudation in croup
is Biiid to differ from cou^ulable lytDph in beinn; softer, in not
oontractiug permanent adhesions to the subjacent tissue, and
in never becoming organized.

When the iiiiiaiuuiatory action reaches to a certain degree,
the nervous and vascular systems become generally affected ;
the general derangement which ensues being spoken of ns
injtammalon/ or ni/mplomo lie /ever, or as foiislitutiona/ tlitlur'
bancc. This fever manifests itself by depression, chilliness
followed by boat, frequency of pulse, headache, a furred tongue,
thirst, and loss of appetite. Sometimes the chilliness amouuts
to shivi ring ; and it is generally allowed that the onset of
Bpontiinc us inflammations is more fre'iucntly attended with
rigors, than that of inflummntiun due to external injury. If
tlie inflammatiou goes on to suppuration, the coniiuoncement
of this event is commonly marked by the occurrence of shiver-
ing, and the constitutional disturbnnco is then culled hectic
fr.vtT ; the leading symplouis of which are fre(|uency and weak-
ness nf pulse, alternations of chilliness with heat and flushing
followed by sweating, a gradual wasting of the body, and daily
increasing debility. Hectic fever also accompanies other dis-
eases, us phthisis, dysentery, &o.

The general principles of tnintment only admit of being laid
down. lu the commencement the cause of the inflammatiou
should, if possible, be removed. Attempts must then be made
to obtain resolution j or, if this seems impos.'-ibk', the next best
termination, which, in cases of external inllummntiou, will
generally be suppuration ; in internal, sometimes suppuration,
Bnmetiuies adhesion. The imp<}r(ant point, then, for considera-
tion is this : How arc these desired results to be best obtained?
For very many years but one answer has been given to this
question. The reply has been, — By the iidnption of theun/i-
phliMjUtic reijinun ; which consists essentiully in the use of
low diet, bloodletting, active purging, counter-irritation, mer-
cury, and antimony. It is to be feared that these remedies

IJiyLAMMATION.

«7

still find favor with gome practitioners ; but I cannot help
thinlcin^ that the more closely disease is studied, the smaller
will become the nniuber of the upholders of these antiphlo-
pistjc apents. My reasons for this opinion are — that ^hon an
inflnmioation is establisihed it is not |>os8ible to cut it short ;
that general bleeding, unless carried to a very dnn§:crous
extent, will not diminish the amount of blood in an inflamed
part; that bleeding will not render an impure blood pure;
that depressing agents favor the extciisi'.Mi of the morbid
avtion, and deprive the system of the power of rallying from
the effects of the disease ; that in many instances of inflamma-
tion there is depressed nervous power, an impaired action of
the heart; and that in all cases a lowering plan of treatmeut
is found to be very badly borne in the present day, whatever
uioy be said to have been the case in former times.

It is a favorite theory with some pathologists that inflam-
uiulion, as wo now see it, is of u ditferent type to that which
formerly existed, periiaps being more readily excited by mal-
nutrition, being more prostrating, and possibly being more
dangerous to life through its incapacitating the system for the
samo degree of reaction as that which formerly followed an
attack. In other words, the febrile symptoms accompanying
inflaniination are said to have altered from an inllauimatory to
n typhoid diameter. This view has been ably suggested by
Dr. Aliison,* though it is well disputed by Professor Bennett,f
who believes that inflammation is the same now as it has ever
been, that the analogy sought to be established between it and
ilic varying types of fever is fallacious, and that bloodletting
and antiphlogistic remedies have been all along opposed to u
fniund pathology. As these opinions cannot be di.icussed suffi-
ciently fully in these pages, I would especially recommend the
pcmsal of Dr. Alison's and Professor Bennett's very admintbic
CMwys to my readers, though at the same time, I must say that I

• EilinkHrgh ^Micrtt Journal, U*y, 186T.
1 Uem, Mttroh, 1857.

nF.NERAL DISEASK):.

agree with Dr. Bennett. For if Dr. Alison be correct in all his
assumptions, we must grant that not only the type, but the
cause of disease has changed ; since, if we are to place implicit
reliance upon the experience of Cullen, Gregory, Mason Good,
and others, upon some points on which they are likely to have
erred from the imperfection of the means of diagnosis, we
surely must credit their etatoments where simple observation
alone was necessary. Yd, only fifty years ago — to take one
example from many — inflammation of the brain was supposed
to bo the constant cause of insanity ; and at Bcthlem Hospital
the system of treatment consisted of bleeding, purging, and
vomiting in the spring months. " A certain day was appointed
in which the patients were bled, another in which they were
purged, another in which thoy were vomited. They were bled
again iu Maj' and June, the precise lime depending on the
tceather. All this had been the practice for many years, and
no better practice, it was stated, was then known."*

Again, for how itinny years were the sympathetic disorders
of pregnancy attributed to plethora, and bleeding resorted to,
when iu fact they were due to aiueiuia. Vet no one will argue
that the blood of a woman with child is different now to what
it was fifty yeai-s aco. The cxperimeiits of Andral and Gavar-
ret showed that the mean normal profwrtinn of blood globules
is about 127 ; that the essential character of plethora is that
this proportion is greatly increased, while in pregnancy they
may be said to be always diminished. Pnictttioricrs then
began to remember that they had found but little advantage
from bleeding in the disorders arising from the progress of
gestation, though many, perhaps, like Dr. Sangrado, attributed
their want of success to not having practised depletion to n
sufficient extent.

But something more may be said upon the practical bearings
of the question — i. c, upon the treatment of inflammation.

* SlHli$liet of Intonity ; iting n Dtetnnial'Rtporl of Btthtem Ho*'
piiiil. By Dr. W. 0. Hood. London, 185(1.

INFLAMMATION.

On this point I think it may be remarked that those praoti-
tioners who have the greatest amount of practical expcricnco,
eonibiiiod with an extensive knowledge of |)hy,siology, patho-
lo}iy, and therapeutics, are now mostly agreed that our study
should be coulincd to simply attempting to guide the morbid
process to a favorable termination, just in the same way as we
at present try to conduct cases of typhus, smallpox, scarlatina,
&o., through their natural progress, without making heroic
and injurious efforts to cut short the disease. This object is
to be obtained by supporting the vital powers instead of lower-
ing them, and by assisting the excretion of eflFete products.
During the early stages of the attack all sources of irrilatiua
should be removed, so that the patient may enjoy perfect quiet
of body and mind ; the sick-room should be well ventilated,
and kept at a tetiiperatnre of about 60° Fahr. ; the diet should
be light, and cold water freely allowed ; opium is generally to
be administered if there be pain or much irritability ; and if
the febrile excitement be great, salines in smull doses (F. 312,
316, 318, 323, and 327) may be ordered. When the pulse
becomes soft, good beef-tea and nutrients arc to be adminis-
tered J and directly there are indications of weakness, we may
be sure that wine is rci|uired, in ijuantity varying from four
to twenty ounces in the twenty-four hours. In oil acute dis-
orders the various organs arc much weakened, so that their
functions are either partially or entirely arrested. To give food
when there is a perfect loathing of it is worse than useless;
but wc may advantageously give alcohol and wine to retard the
destructive metamorphosis of tissue, to afford to the system
the elements for the generation of heat, to repair the nervous
energies, and to supply a stimulus tu the nervous system. As
the period of crisis ap])roaehes, Dr. Bennett's example may be
followed of giving a diuretic — spirits of nitric ether ^as., with
or without ten minims of colchicum wine — thrice daily, to favor
the excretion of urates, while, when a cri.fis occurs by sweat-
ing or diarrha:a, care is to be taken not to check it in any way.
The success of this plan is apparent from the following :

»0

OEKEBAL DISEASES.

Daring the eight years ending in 1857 Dr. Beonett had thai
treated all the caf>es of poeamonia which had been ooder his
care in the clinical wards of the Royal Edinburgh Infiniiary,
amoanting to pixty-five, of which number sixty-two were dis-
Diiit^d cured, and three died — that is, one in 21^. Of the
sixty-two cases cured, fifty-Cve were uncomplicated, and seven
complicated ; of iifly-one of the uncomplicated, forty were sin-
gle and eleven doable pneumonias, the average duration of the
former being 14^ days, and of the latter twenty-one days;
while of the seven complicated, one supervened on bronchitis
and emphysema, two on typhus fever, one on bronchitis and
pleurisy, one on pleurisy with effusion of eight weeks' stand-
ing, one on rheumatism with heart disease, and one on severe
rheumatism with endocarditis and pericarditis, the average
duration of the pneumonia in these seven being 21] days.
The three fatal cases were all complicated; the first, with un-
controllable diarrha-a and follicular disease of the mucous
membrane of the small intestines; the second with persistent
albuminuria and anasarca; and t,hc third with dcliriam tre-
mens and universal cerebral meningitis.

When this result is contrasted with that obtained from an
opposite course of treatment, it seems to me that all doubt on
the subject must be removed. Tlius, during ten year? — from
Ist July, 1839, to 1st July, 1849 — 648 cases of pneumonia
were treated, by different phycicians, according to the rules
then enforced by all writers, in the lloyal Infiriunry of Edin-
burgh, of which number 388 were cured, 38 relieved, and 22*2
died. Of 107 cases, recorded by M. Louis in 1S35, and treated
by bleeding and tartar emetic, 32 died. So, of 648 cases treated
by llusori, in the hospital at Milan, by large doses of antimony,
143 died. Again, Lacnnec, who bled moderately at the com-
mencement of the disease, regarded the mortality as one in six
or eight. And lastly, Dr. Diptl treated iJ.'^O ea.«cs of primary
pnoumotiia, in the Charity Hospital of Vienna, thus : 85 by
veneseetiou, one death in five resulting; 106 by large doses of
tartar emetic, with one death in 5.22 ; and 189 by diet only,

INFLAMMATION.

with one denth in 13}, all the fntal cases, moreover, being
complicated.

At the same time that blecdin'^ as an antiphlojristic remedy
should be rarely if ever practiMed, it may be remembered lliat
a small loss of blood may nfteti be beneficial, particularly in
relieving excessive pain, and in niudeniting attacks of dyspnoea
due to some obstruction to the circulation in the heart or lun^s.
As Dr. Bennett remarks : " I have often been struck, especially
in cases where large thoracic aneurisms cause these symptoms,
with the small loss of blood which will occasion marked relief.
The same re.sult may be hoped for in other ca.ses where the
congestion is passive, even when that is associated with active
repletion of blood, followed by exudation. But I need scarcely
remark that this mere palliative object of bloodletting is not
the ground on which the practice has hitherto been bused, and
that in this point of view it requires to be very differently ex-
plained." The same remarks apply to the use of tartar emetic ;
which is valuable in small do^^cs, and combined with other
neutral salts to favor excretion by the skin, kidneys, or intes-
tines ; but most injurious when employed in the heroic way
often recommended.

With regard to the use of mercury, there appears to be
every reason to believe that its utility in cuntrulling inflamma-
tion or in promoting absorption of the effused products, has
been very much overrated ; and indeed it seems highly pmbable
that inflammatory diseases will progrc'-s more favorably without
the use of this medicine than with it. Few practitioners even
now would think of treating pericarditis or iritis without mer-
cury ; yet more than fourteen years have elapsed since Dr. John
Taylor's valuable contributions to clinical medicine were pub-
lished,* in which it was clearly shown that the opinions then
current on this subject required revision. For example, of
the cases on which this excellent physician founded his obser-
VBlions, four got well without any treatment; in twelve, ptya-

• Lanrtt, IVom 17tb Vi*.y, 1845. to 31<t October, 1648,

CiK.Vr.BAL DIBEASeS.

Htm waa aot followed by ony abatement nf the pericarditis; in
fix, ptplium was followed by pericarditis; in three, by endo-
carditis; in two, by cxteiiBive pleurisy; in four, by pneumonia;
in one, by erysipelas and laryngitis ; in one, the pericarditis
and pneumonia both increased in extent after ptyalism ; while
in only one inwlanoe was fialivution followed speedily by relief,
and in two or three by a gradual diminution. More recently,
l)r. Henry W. Williiims* has cured sixty-four cases of iritis,
of every degree of severity, including its idiopathic, traumatic,
rhoumaUe, and tiyphililic varieties, without a dose of mercury ;
the Iroutnicnt having chiefly consisted in sustaining the general
aystom, in relieving pain by narcotics, and in keeping the
pupil diluted by belliidunna.

From all this it I'uUuvrs that, in the treatment of acute in-
flammatory diseases, practitioners must be content to trust more
to Nature and less to heroic remedies' than they have been in
the habit of doing ; for it is highly probable that though we
may be able to guide inflamniationa to a successful termination,
yet we cannot cut tlicnr short, and any attuinpt.s to do so will
merely increase the patient's danger. It should never bo for-
gotten that " the body possesses a perfectly marvellous power
whereby it protects itself against diseases, wards off some, cores
in the best and speediest way many of those that have .set in,
and by a process of its own brings others more slowly to a
favorable issue. This innate power is culled the vis Ndlunr
fiinliattrix, being justly appreciated by physicians and philoso-
jihcrs, and highly praised by them. Of itself it is sufficient
to cure numerous diseases; in almost all its iulluence is benefi-
cial ; aod, moreover, the remedies that arc in their own nature
(III- best, are only of use in as far as they stimulate, direct,
and control this inherent virtue."|

•

• Thr Boiioii AMiral and Bvrgital Journal, toI.It. pp. ii, 69, 113.
I8&S.

t ('out/wiin MfJirinit Themfiirir. Auctoro Jaoobo Oregory, M.D.
Editiu Quiota. Beet. A.'i, M. Edinliurgi, 18IS.

DROPSY.

VIII. DROPSY.

Dropsy may be de6ned ns an accamulation of watery or
serous liquid in some one or more of the natural serous cavities
of the body, or in the interstices of the areolar tissue, or ia
both, independent of infiauimation.

It is a result of many different conditions ; and consoquently
each case of dropsy will present two classes of dangerous symp-
toms,— those due to the original disease, and those produced
by the effusion. When the cerebral ventricles are distended
with water, we say the patient has hi/t/roirphiiluit. When
serous fluid occupies the pleura or the pericardium, we ox-
press the di.scascd conditions by the terms hi/drofhorax and
hydropericnrd tum. If the cavity of the peritoneum bo the
seat of the collected water, the complaint is called aariteg.
Dropsy of the tunica vajrinalis testis is termed hi/ilrocele.
Should the areolar tissue of one region only become infiltered
with serous liquid, the part is said to be ouhmatous ; while
anoiarcii is the terra applied to the more or less general
accumulation of serum in the areolar tissue throughout the
body. Lastly, the combination of anasarca with dropsy of one
or more of the large serous cavities is known as ijenerul
dropty.

Now, to explain the mode iu which dropsy may originate,
it must be remembered that from all the surfaces of the healthy
body a kind of excretion or oozing forth of fluid is constantly
taking ploce, accompanied at the same time by absorption ; so
that when the two processes of exhalation and absorption are
properly balanced, the surfaces will merely be kept moist. But
suppwo that the btilance from some cause is disturbed ; imagine
exhalation to take place more rapidly from the surfaces of one
of the shut sacs, or absorption more slowly, than in health ;
under such circuuistunces it is clear that dru[)sy must result.
It is probable that absorption takes place by the lymphatics, by
the l^etealg, and by the veins ; the first removing the worn-out

GENERAL DISEASES.

piirticlee uf the body, the second takiog ap the chyle from the
alimentary canal, while the third imbibe the fluid exhaled
from serous tneinbrniies. In dropsies, the veins are generally
in fault; and it often hnpiiciis that from congestion these ves-
sels arc not only unable to take up more fluid, but when much
distended the watery portion of the blood trauBudcs through
Iheir coats. The process by which this latter occurrence takes
plnc« is explicable on the principles involved in the process of
endasmose and exosmoso.

When dropsies arise from defective absorption, they are
called rlironir or pntti've dropsies ; when from excessive exhala-
tion of stTous fluid, aclire or acute. Those due to cardiac or
renal disease, producing some alteration in the blood, with
obstruction to the circulation, are usually of the first kind;
those caused by cold, by sudden checking of the urine or per-
spimtioo, by the poison of scarlatina, &c., of the second.

The »i/mptom» of dropsy may come on rapidly or slowly ;
there may be excited or depressed vascular action ; the urine
is goiiernlly scanty, and in renal cases is albuminous; there is
thirst, deficient jierspiration, and constipation; and it is in-
structive to remember that in cases of spontaneous cure the re-
moval of tliciluid is accompanied by profu.sc sweating, diuresis,
or diarrha-a. Effusion of fluid within the cranium causes
convulsions, coma, paralysis, nnd apoplexy; the pressure of
lii|uid in the thorax impedes the action of ihp Irc.irt and lungs;
oedema of the extremities maypwduce inflaiiimiition and gan-
grene; while death generally results from the primary organic
disease, unless some inflammatory intercurrent aflfection, as
ploirisy or enteritis, proves fatal.

The cavte* which produce those conditions on which dropsy
depends, are firntly, any circumstances which can induce irrita-
tion oroongeslion of secreting tissues — as cold, the retrocession
of skin eruptions, and the poison of gout, rheumatism, &o. ;
secondly, whatever weakens the tissues or impoverishes tho
blood — as insuiUcieut food, loss of blood, exhausting diseases,
malaria, and scurvy ; thirdly, anything which ubstructe the

nnopsv.

circulation and produces venous congestion — as obliteration of
the veins, abdominal tumors, and organic diseases of the
heart, lun^s, liver, sploun, kidney?, and lymphatics.

The prot/nosts will depend upon the cuuse. When there is
no organic disease of important viscera, a cure can frequently
effected. When the heart, liver, or kidneys are perraa-
Bntly affected, the dropsy may often be, at least tcmptirarily,
removed.

The treatment of dropsy will be discussed in speaking of
the different varieties; but it may here be remarked that in
all cases two indications necessarily re<iuire to be followed —
viz., the'cure of the effusion, which is only the symptom of
other disease, and the relief of the disease itself. For the
former we trust chiefly to diuretics, purgatives, diaphoretics,
emetics, and the meclianicnl removal of the fluid by tapping
and acupuncture.

Many authors on tropical di.soa.ses describe certain compli-
cated cases of general dropsy under the name of Bkriuehi.
From the writings of Dr. Morehead I gather that the t^mptomt
of this affection ore chiefly increasing weaknes.s, with stiffness
and U'deum of the lower extremities. The trunk and face
then become swollen, there is difliculty of breathing, the liniba
pet almost paralytic, and there is vomiting — sometimes of
blood. The urine is almost suppressed, thirst is great, the
pulse is intermittent and fluttering ; and then palpitations arc
experienced with a sense of sufl'ocation, there is exhaustion,
and in two or three weeks from the commencement, death.
The mnrbkl tippenrtinces afterwards fnnnd arc anasarca, oedema
of the lungs, hydrotliorax, hydropericardiura, ascites, and
cranial effusion. Cold or wet is the exciting cause, and a
watery condition of the blood the predisposing condition.
Sometimes the effusion is favored by coexisting heart, liver,
or renal disease ; and often the persons affected ar« favorably
circumstanced for the development of scurvy — that is to say,
lliey have a scorbutic diathesis. In the Irrnlnuiil, attention
tu the means which prevent scurvy will be advisable, wilb

OENERAI. DISEASES.

wiirm clothing, &c. Then if tho vascular action be not
depressed, purttativcs may be used, as clateriam; or diuretics
can be truiited to. The vapor or hot-air bath will often prove
useful. Slimuluuts will geneniUj be required.

IX. CASCINOMA, OR CANCER.

1. General Pathology. — There is scarcely an organ or
tissue in the body which may not be attacked by this disease.
It occurs most frcijuently in women, on account o the liability
of the breast and uterus to be affected by it; otherwise it
would seem to be more common io men, since the skin, bones,
and digestive organs are more prone to it in the male thiin in
the female sex. It is very uncommon in children ; but wlicu
it occurs in them it is generally located in the bones, or in
the eye, or — very rarely — in the testiule.

A cancer may be described as a local manifestation of a
BpociCc disease of the bloi^d, having incorporated in it peculiar
morbid materials which accumulate io the blood, and which
its growth may tend to increase.* As it is of constitutional
origin, so the removal of tho local manilestation docs not effect
a cure ; but the cancer returns, cither in the i^eat of the original
disease, or in some other parts. Moreover, when the primary
affection has existed for a variable period, secondary deposits
are very apt to be formed in the lymphatic glands, lungs,
liver, spleen, &c. This definition of cancer does not meet
with universal acceptance; since some authorities now assert
that the disease is at first local, though at an early period it
becomes general. Any way, the practical point is thnt the
surgeon does not seem to be consulted while the affection ia
only local ; for otherwi.sc the a.«sertion made in Franco that
cancer is completely incurable could not have been successfully
m:iiatuined, as it has been.

* Mr. Paget Oputjam at. Vol. ti, p. 287.

CABCINOMA, OK CAiMCER.

fl7

Although the tendency of c&Dccr, however, is to increase
constantly und mpidly until lite is destroyed, yet in a very lew
instances, it beeouies latent ; that is to say, after it has reached
a certain line of development, it remains in a state of quies-
cence, neither advancing; nor receding. iSir B. Brodic refers
to a case where the cancer was quiescent for twenty-five years ;
Dr. Biibington knew an instance in which scirrhus of the
uianiaia was stationary for twenty-four years ; and Sir Astiey
Cooper attended two women in whoiu the period of latency
was respectively seventeen and twenty-two years. Equally
rare is (ho spontaneous cure of cancer by inflammation, ulcera-
tion, and slou;^hing, or by fatty or calcareous degeneration ;
yet it is certain that nature has by these means effected at
least temporary, if not permanent cures. And if we consider
the matter fairly, the wonder is that a cancerous growth docs
nut undergo spontaneous cure more frequently, rather than so
very seldoiu. All cancer-cells have a period of development,
growth, and decay; but unfortunately, though tliey perish,
they leave behind germs which perpetuate the structure. In
a monograph On ihe Hfnlimj Prwrss of C'uncer in the Li'vri;
published by Bochdaiek of Prague, in 184,5, is described a
mode of cure as it sometimes occurs in this organ, the disease
breaking down into a purulent-looking matter; so that the
fluid portion being absorbed, the whole shrinks together, leav-
ing a small inert fibrous or fatty mass.

If any cancerous growth be minutely examined, it will be
found to consist of peculiar nucleated cells, called " cancer-
cells," and of their free nuclei ; with a milky tiuid or semi-
fluid mixture, termed " cancer-juice." The more dry and
juiceless the growth, the less is its malignancy. The cancer-
cells und juice arc either infiltrated into previously healthy
t)K^lle:$, or they are contained in a stroma or bed of now fibrous
tiwue. The cancer-cells are of various shapes, being round,
oval, fusiform, triangular, or elongated into one or more sharp
processes ; they vary in size from the ^J,, to the jn'nn '-•' ""
inch, the medium being T«'nn> ""^ '^^y chiefly ree«-mblf> in

nEVERAL DISEA8FS.

Structure and aspect the secreting t^land-cells. On magnifying
a specimen of scirrhiis nbout two hundred diameters, the ceils
will be seen contaitiing a comparatively large, regular, oval or
round, and well-defined nucleus ; sometimes two nnclei exist
in the same cell ; and each nucleus has one or two nucleoli.
Moreover, mingled with these cells, we find free nuclei, and
numerous degenerated cancer-cells ; sonic of these cells appear-
ing withered and full of oil globules, others being transformed
into granular matter — in the (Ubri* of which the nuclei lie
loose.

I/ebert thinks that the cancer cell is pathognomonic — that
it may be di»tingui.<hed from every other kind of cell growth,
and that it positively indicates the nature of the formation.
Dr. Hughes Bennett and Miiller consider, on the other hand,
that no single element is diagnostic. Hence, their opinion
seems to confirm that generally entertained — viz., that the
microscope is tuerely an aid to diagnosis ; and that, conjoined
with a consideration of the symptoms, progress, form, and
gcneml appearance of the morbid growth, it may freijuontly
enable uh to arrive at a correct conclusion ns to the nature of
any particular case.

Dr. Wilks, writing in 1858, states his conviction that can-
cer has no peculiarities which can always distinguifiii it from
other morbid growths, or even from many healthy structures.
He sugg08ts that if we make a list of diflereiit abnormal struc-
tures, arranging them according to their rapidity of growth,
disposition to spread, propagation, itc, those nt the top of the
scale may be styled cancerous; but no boundary line can be
drawn between the last which is styled cunccr, and the next
on the list which has acquired some other name. Or again,
if the term malignant bo applied to the highest on the list,
Bemi-malignaot to those below, and innocent to the lowest,
that still no clearly defined lines can be made between these
divisions.

2. Varieties of Cancer. — There arc three principal varie-

CARCINOMA. OR CANCER.

ties, aud five lub-varieties of malignant disease,* the latter
being probably more modifications of the former. They oon>
sist of —

Scirrhus, or Hard Cancer.
Medullary, or Soft Cancer.
Epithelial Cancer.

Colloid — Gelatiniforni, Alveolar, Cystic, or Gum Can-
cer.

Melanoid, or Black Cancer.

Osteoid Cancer.

Hsmntoid Cancer, or Fungus Haemntodes.

Villous Cancer.

A scirrhus cancer never becomes medullary or epithelial,
nor does the converse happen. But a medullary or an epi-
thelial cancer may become niclanoid or hsematoid ; a scirrhus
or a firm medullary may become osteoid; or either of the
three chief forma may assume the colloid ehnracter.

a. Scirrhiit, or Hard Uancer. — Thi.s is the most fretiuent
form of cancer. It is seen occasionally in the stomach, in the
upper part of the rectum, and elsewhere ; bat most freijuently,
by far, in the female breast.

In the breast it is found as an infiltration, affecting part or
the whole of the mammary gland. The di8ca.sed mass \a ex-
tremely hard, correspondingly heavy, and inelastic ; while the
increase in si^e is not great, for the part of the gland afiscted
18 not much larger than it was in health. After a variable
period, the tumor, with the proper tissues of the breast in
contact with its surface, and the skin, which is often adhe-
rent to it, ulcerates ; a foul, excavated, spreading ulcer, with

* To avoid any error, it eboald be meotiooed that the terms "okooer"
uid "mulignimt, " employed in tbo text, are regarded S8 ijnonymoiu.
The expre»«ioii "malignttnt" is no generally used that — provided a deB-
oite meaning h attached to the word — I cannot see bow any good wonid
ariie from abandoning it. If oreorer, it li eoDTenient, since it allowt its
to speak of the dtgrn of malignancy of any particular variety of cancer.

100

OKNERAt. DT8EA9ES.

everted edpes, beinjr foTined, from which there is n cotistnnt
sanions diM-hnrfie, and very often attacks of hremorrhape.
The ulceration soniotimrs extends from the skin inwards;
Bometimes from the substance of iho cancer outwards. The
amount of sufferinp varies; occaMJonallj the pain is very slight,
but generally it is severe, laneinating, and most exhausting.

As the local disease advances, the health faits, and the can-
cerous cachexia becomes fully o.^tablisbed. This condition
has been well described by Sir Charles Bell : " The general
condition of the patient is pitiable. Suffering much bodily,
and everything most frightful present to the imagination, a
continual hectic preys upon her, which is shown in increasing
emaciation. The countenance is pale and anxiwi.«, with a
slight leaden hue; the features have become pinched, the lips
and nostrils slightly livid ; the pulse is frequent; the pains
are severe. In the hard tumors the pain is slinging or
sharp ; in the exposed surface it is burning and .sore. I'ains,
like those of rheumatism, extend over the body, especially to
the back and lower part of the spine ; the hips and shoulders
are subject to those pains. Successively the glands of the
axilla, and those above the clavicle, become diseased. Severe
pains shoot down the arm of the affected side. It swells to
an alarming degree, and lies immovable. At length there
is nausea and weakness of digestion. A tickling cough dis-
tresses her. Severe stitches strike through the side ; the
pnlse becomes rapid and faltering; the surface cadaverous;
the breathing anxious; and so she sinks."*

Rcirrhus of the breast is very rare in men ; it occurs in
women most frequently between the ages of forty-five and
fifty.

Records, made by Mr. Paget,t of 139 cases of scirrhus of
the breast, watched to their conclusions, or to their survivals
beyond the average duration, give the following results: In

• MtHiro-Chimrfrin)! TrauuclioHi, vol. xU, p. 323.
t Lancrt, 1«lb Januurv, 1660.

LoDdon, 1622.

CARCISDMA. on CANCER.

101

75 not submitted to opeiatioti, the average duration ol' life,
after the patiuiit's first ubservation of the disease, has been 48
months. In 64 nubmitted to operation, and surviving its im-
itiediat« eonse(|uenccs, the corresponding averajjc has been a
little more than 52 months. The longest duration of life, in
the former class, has been 216 months; in the latter class,
146 ; the shortest in the fonner was 7 months ; in the lat-
ter 7i.

jS. Medullary or Soft Cancer. — Medullary, or enccphaloid,
or cerebriform cancers are of two kinds — soft and firm ; the
former being the most frequent. In either condition they
are found in about equal proportion us separable tumors, or as
infiltrations. As feparabh tumorx, when occurring in the
testicle, the breast, the eye, the intermuscular and other spaces
in the limbs ; as infillratiuiu, when occupying the substance
of the uterus, the alimentary canal, the serou.>( membranes,
and the bones. In either form their course towards a fatal
career is rapid ; the average duration of life, from the patient's
first observation of the disease, being little more than two
years. Moreover, they occur at an earlier age than other
kinds of cancer, being sometimes mot with before puberty.
The soft mediiUary tumon are commonly round or oval ; and
present to the touch a sense as of the Buctuation of some thick
fluid, so that the most experienced are often deceived. They
are very vascular; the material composing them re.ieuibles
brain substance, partially decomposed and broken up; they
jrield abundance of cancer-juice on being pressed or scraped ;
and they frequently contain extravasated blood. The firm
meiluUart/ cancers are clastic and tense, but not hard, like
scirrhus ; in their shape and size they resemble the soft ;
while they may possess distinct investing capsules, or may
extend into the substance of organs.

Medullary cancer of the breast is so rare in this country
that, even in our museums, specimens are but seldom seen ;
on the Continent, however, this form is more common. The

102

nKNF.RAI. mSKASES.

lymphatic glands are inueh more frequently primarily afTecteS
with medullary cancer ihan with seirrhus.

y. Epithelial Cancer. — Some difference of opinion exists as
to whether this disease is really a form of cancer ; or whether
it is not an aficction sui ycnrris, consisting of an infiltration
of cells of scaly epithelium, with a serous liijuid different from
cancer-juice. Hence some authors speak of it as " epitheli-
oma," or as a " cancroid" nffcction. In its clinical history,
however, it resembles cancer; inasmuch as it returns after
being removed by operation, it is prone to incurable ulcera-
tion, it affects the lymphatics vented near it, and it destroys
the patient. On the other band, it is peculiar in two respects
— it is very little liable to muitiplicutiun in internal organs,
Bnd it appears often to be produced by local causes only. As
pathologists seem divided upon this question, it will he better
to treat of it in this place, as if it were undoubtedly a true
form of cancer : a plan which has at least this recommenda-
tion, that it is convenient.

This disease is generally located in or beneath some portion
of skin or mucous membrane ; its most common seats being the
lower lip, the scrotum in chimney-sweeps, the tongue, the
larynx, the nynipbas, the labia niajora, and the cervix and lips
of the uterus. True " cauliflowcr-cxeresocnce of the uterus"
is, in all probability, iilwiiys a variety of epithelial cancer;
commencing on the surface of the os uteri in the form of
small papillary or villtius eminences, which by their growth,
expansion, and branching, t;ike on the peculiar cauliflower
appearance. It is a rare disease ; so much so, that during the
six years I was physician to the Huspital fur Wmiicn, there
came under my care — according to the observations which I
have recorded — 59 cases of carcinoma of the uterus amongst
the out-patients, only one of whioh was an example of cauli-
flower excrescence ; the remaining 58 being instances of
seirrhus, or of the medullary cancer, or more frequently of
epithelial cancer not assuming the appearance of an excres-
cence.

C«re must be taken to dislinpuish epithelial cancer from
rodent ulcer and from lupus. Roilml ulcer hnn indurated
nmr^ins; it praduoily spreads in nil directions; it most
fre(|uentl_v att^icks the cyelid.t, and next to those parts the nose
or checks: it does not affect the lymphatic glands; it docs not
destroy life or only does so very slowly, and the general health
is not injured unless there be pain or hseniorrlinge ; it occurs
after the middle period of life equally in both sexes; and it is
only to be cured by complete removal with the knife, or by
thorough destruction with caustics — especially by the chloride
of zinc. If a portion of the edge of the ulcer be minutely
examined, it will be found to consist of fibrous tissue, and not
of cell-structures. Lvpiis commences frequently by the forma-
tion of a dull red tubercle, which has its seat most often ou
the ala or tip of the nose; the resuUinji; ulceration is alow, it
is superficial, only involving the skin, and its edges are not
indurated ; it seldom commences after the middle period of
life ; and it has a great tendency to heal spontaneously. Epi-
theh'al cancer occurs much oftener in the male than in the
female sex, and it is most common after the ago of 50. When
once established it pnidutiliy progresses to destroy life, but
more slowly than medullary cancer; rather less than four
years being the average durntion of life from the conimenco-
ment. Its malignancy seems greater when it is seated on the
tongue or on the penis, than when on the scrotum or the lower
extremities; and the removal of the disease by operation
probably gives a better chance of recovery than the excision
f any other variety of carcinoma. The essential character of
this disease is, that it is composed of cells of epithelium and
their nuclei ; the cells varying in size and shiipe, and being
infiltrated, together with a juice or serous fluid, into the
intenstices of the affected tissues.

S. Colloid Cnnrer. — This variety of cancer — to which the
names of Alveolar, Cystic, Gelatiniform, and Gum Cancer
have been applied — consists of a clear viscid substance some-
what resembling sofl gelatine or gum. Its most frequent

104

nENKRAL DISEASES.

primary seat is the stomach, intestinal canal, uinentuni, breast,
and peritoneum ; secondarily, it atfects the lymphatic glands,
lungs, &c. A section of a colloid cancer prcseuta to the
ntiked eye a clear, sofl, gelatinous mass, intersected and sur-
rounded by tough fibrous-looking tissue; the intersections,
wlien numerous, forming small cysts or cavities filled with
colloid mutter. Such a cancer often attains considerable
sixc : in the museum of King's College is a preparation show-
ing a tumor of this nature, connected with the omentum, us
large as a cocoa-nut. It probably always occurs as an intiltm-
tion, superseding the natural tissues of the affected part as it
grows. It occurs equally in both sexes ; it is very rare in
children ; and in its progress and symptoms it corresponds
jrith other cancers.

Colloid matter mny occur independently of cancer, as hap-
pens sometimes in the thyroid gland in bronchocele, and in
Bomo multilocular ovarian tumors. The latter often attain an
immense size, but they may be removed by operation without
any fear of the return of the disease.

e. Melanoid Cancer. — Melanotic, melanic, or black cancer,
is generally medullary cancer moditied by the superaddition
of a black pigment. Scirrhus sometimes becomes associated
with melanosis, and still more rarely opitheliuma does so.

C. Otieoid Cancer. — The nature of osteoid cancers may be
best expressed, according to Mr. Paget, by calling them ossified
fibrous or medullary cancers; and by regjirding tlicra as illus-
trating a calcareous or osseous degeneration. Their growth is
usually from some bone, and especially from the lower part of
the femur. Their generul history corresponds to that of the
tcirrhus and medullary varieties ; they are as malignant and as
quickly fatal as the medullary ; and they give rise to secondary
deposits in the areolar tissue, lyuiphittics, lungs, &c.

rj. Hcematdid Cmiccr. — Ilicniatoid cancer — fungus haema-
todcs — is probably a soft medullary or other cancer, the sub-
stance of which is more or less infiltrated with blood. When

CARCINOMA, OR CANCTR.

Ifl.i

it pnitrudes throui^h the skin it foriDs a large vascular mass,
goiitewliiit rcscnib!iii<; a clot, of blood.

0. Vi/h'ix C'liticrr. — This is a variety of iiiednllarj and
perhaps of epithelial cancer, occurring most frequently on tho
mucous raetubrane of tho urinary bladder. Their histories
coincide with those of medullary cancers.

3. Causes of Cancer. — With regard to the causes of this
disease but little i« known. All classes of society are equally
subject to it ; the rich and poor, the idle and industrious, the
gay and the melancholy, all suffering from it in equal propor-
tions. The only known predisposing causes are thus suramed
up by Dr. Druitt : "1. Dt^Kfnt from a cancerous parent,
which seems to have some slight influence, and was found by
Lebert to exist in about onc-seTenth of a certain number of
cases. 2. Sex, for cancer is at least from one-third to one-
half more prevalent in the female. 3. A'je, because nearly
half of the entire number of cases occur between forty and
sixty. Lu.stly, although cancer is not contagious in the
ordinary sense of the term, there seems reason for believing
that, if fresh cancer-cells are introduced into the blood, they
may be deposited and propagate themselves. The experiment
has been tried on dogs by Langenbeck and by Lebert ; and
cancerou,s tumors were found in various parts, when the ani-
mals were killed some time ailerward.s ; yet it must be remem-
bered that some of the tumors found in these cases may have
existed before the inoculation."* The experiment of Langen-
beck was carefully repeated by Vogel, but without producing
the same result ; while Gluge also failed in his attempts at
inoculation. From all this it is evident that our knowledge
of the cause of this disease is very slender. In the groat
majority of cases the patient is unable in any way to account
for its origin ; very fre<(uently — in scirrhus of the breast espe-
cially— the tumor is only discovered by accident; and it is

• Tkt Sutgtcn't Vadt Mteum, Ttb «<1., p 112. Loodon, 1856.

106

(iKNKKAL. LHHEASKS.

nlmost certain that mental anxiety, peculiar temperaments,
particular occupations, injuries, &c., have nothing to do with
producing the caucerotis diathesis. Tubercle ia deposited in
the most active organs; cancer, on the contrary, attacks an
injured or weak part. Hence it sometimes seems to follow a
blow. In listening to the histories of patients afflicted with
cancer of the uterus, 1 have heen struck with the frequency
with which they have told me of the loss of one or more of
their relatives from phthisis. The same circumstance has
been noticed by Mr. Zachariah Laurence, who seems rather
inclined to entertain the opinion that there may be some con-
nection between the two diseases.

4. Treatment of Cancer. — The trenttnciit of cancer is nt
present, as far as 1 positively know, in just the same unsatis-
factory condition as was that of phthisis only a few years ago.
But inasmuch as we have every ground for believing that well-
iTinrked cases of pulnii>nary consumption, which would have
been regarded as utterly ineuriihlc a few years .since, arc now
sometimes restored to health by the aid of mcdiciuo ; so we
have every reason to trust that iit no distant day cancer may
be made to yield to sonic remedy, or conihination of remedies,
yet to be discovered. In the rac-intime much may be done to
relieve the patient's sufferings, and to prolong life.

a. PalUalive Treatment. — The great point is to keep up the
constitutional powers to as nc;ir the standard of health ns the
disease will allow ; which may best be done by tonics, nour-
ishing food, pure air, warm clothing, great cleanliness, mental
occupation, and by preventing or relieving pain. In carrying
out this important indication the physician will not only be
deservedly earning the gratitude of his patient, bat he may
likewise, by kindness and judicious advice, be preventing hira
from consulting those callous charlatans who will make the
most solemn assertions of their ability to cure him, until he
cither sinks into the grave, or has expended every guinea
that he posaeesea. Moreover it is the positive duty of the

CARCINOMA, "iR rA-NTER.

107

pracfitioncr to make every effort to give even leniporary relief;
for, as HucoD hus well said, " I esteem it the oflBce of a physi-
cian not only to restore health, but to mitigate pain and dolors,
and not only when such mitigation may conduce to recovery,
but when it may serve to make a fair and e.isy passage."

The best means to adopt in addition to all known hygienic
moasares for the maintenance of the general strength are,/i'r»/,
to do all that ia possible to relieve puin ; which may be done
eithec by the administratioD of opium, oonium, or henbane,
or by the application of intense cold. By this alone much
good may be effected ; but we mu.st. mcnuillj/, try to improve the
blood by ferruginous tonics, and by the use of the most nutri-
tious kinds of food. Wine, beer, milk, raw eggs, and different
varieties of animal food, should be freely given ; bark and cod-
li^'er oil will often be valuable; and the patient must breathe
pure air. Thinlfi/, the growth of the cancer may perhaps be
checked by the administration of the bromide of potassium,
or by the iodide of iron, or by the iodide of arsenic. My
experience has been greater with the bromide of potassium
than with any other remedy, because I have found it give most
relief; but the practitioner who expects it to effect a cure
will be only disappointed. Hy these measures, perseveringly
ed, mentitl and bodily case maybe given, and life prolonged
~ven for a few years.*

* At illuslratWe of these obaervationn, the following cue ma; be
relAled ; M»ry Stunning, tbirty-two years of age, married, but nevt^r
pregnant, came un<ler my care nt the Farringdon Di^pen^ary on 20th
March. IS.*!!, suffering fromecirrhus or the rectum. Finding that Iconid
Dot cure her. nhe applied and wat admitted into one of our metropolitan
horpitalii, which she left in an apparently dying ^tate in April, I86l£. On
the 28th of the name month I woe Knt for ; and found her Tory low, and
U if ehe conld not live many honrf. The eminent iiurgeon under whoso
treatment fhe had been in the hospital wrote to say that he bad heard M.
S. wat under my care, thot she wa? dying, and that he would like to be
preeoot at the post-mortem esamtnation. By attendance to the bygicnio
role* laid down in the text, by the occasional exhibition of steel and other
tonics, by the em])loyfnent of wine and nourishing food, and by the daily
use of large rjuautitiet of opium, this patient slowly Improred ; she wa»

108

GENERAL DISEASES.

(3. Curative Trcaimeiit. — In attempts to effect a cure, one
of tiiree plans has usually been fullowed; viz., either excision;
removal by caustics ; or the promotion of absorption by metho-
dical compression, sometimes combined with the application of
intense cold.

First, a» to Exrinioii, — A genera! opinion can only bo
formed with great difficulty, since the views of surgeons are
BO divided. But I think no one will deny that extirpation by
the knife is quite insufficient to etfect a cure : it may relievo
the local distre.>-s, it may prolonfi life for a few weeks, and, as
cliloruform rendera the operation painless, it may, perhaps,
occasionally bo worth while resorting to it to pain these
objects. But, on the other hand, it must not be forgotten
that the operation may itself prove fatal, while in some cases
it certainly appears to increase, the malignity of the disease.
Thus, I)r. Walshe points out that " excis-ion of a cancerons
tumor .seems to awaken a doriiiunl force. Cancers spring up
in all directions, and enlarge with a power of vegetation almost
incredible." Again, of the cases of cancer of tho tongue
which arc described by authors, the most frightful are those '
which have beeu operated upon. jMr. VVeedun Cooke says
that " the disease reappears with intense malignity, not only
in the tongue itself, but in all the neighboring glands. The
tongue sloughs more rapidly, and bleeds profusely, the glands
enlarge to an enormous size, interfering with the powers of
deglutition ; they then ulcerate, and discharge serum, or pus,
or blood, rapidly destroying the patient by a hideous death.
This is the rule in palieiiLs operated on : it is the exception in
cases treated only constitutionally." With regard to the time
at which, if an operation be determined upon, it should be
performed, authorities differ. Some surgeons recommend
excision when the disease is tirst discovered ; others, as I think

■ Me to gel abcml, and to keep hvr rooma clono, it.. : and altbougli her
•uffcrinKii "t limp!< w«re >ciit(>, yvl she generally wm tolerably Tree from
• pain tintil the ln«l few w«ok« uf her life. She died on the Ifitb of Jans,
IBM.

3M.A. OU CA.NCEa.

100

crroneonsly, ndvise delay. Mr. Spencer Wells, in laying
doTTD some rules tis to the use of the knife, observes, — " U is
Dot to use it iu the early stages of cancer, not to use it unless the
cancer is actually ulcerated, or jjrowing so fast that the skin
is about to <^\e way. In such cases, especially where an
open cancer gives great pain, and is wearing away the patient
by bleeding or profuse fetid discharge, the knife is used in
the hope of relieving suflFeriug, and prolonging, not saving
life. In some other cases, where a cancer causes great mental
anxiety to a patient, you may remove it at her earnest entreaty,
after explaining fairly (he danger of relapse."* While
speaking of the knife, it may also be mentioned that attempts
have been made to destroy malignant tumors by lowering
their nutrition ; with which object practitioners have tied the
chief nutrient arteries of the affected part. No real success
has attended these efforts.

Secondli/, Removal hy Cau»tie$. — This method has found
many advocates in the present day ; and it possesses at least
this advantige, that it may be uselul in deeply ulcerated, and
some other cancers, where the knife is objectionable. The
chief agents which have been used are arsenicril pastes, chlo-
ride of zinc, chloride of bromium, sulphnte of /.ine, manganese
cum pot-assA, the strong mineral acids, and the concentrated
alkalies. The arseiinul patlen cannot be employed without
great caution, inasmuch as their action is nut merely loeal
bat pervades the whole system. M. Manoc, of the Salp6-
Iriftrc Hospital, Paris, has largely used them ; he believes
that arsenic has a peculiar destructive affinity for cancerous
growths, and that its action does not extend to healthy tissues.
Uis formula — almost the only one which should be tried — is
one part of arsenious acid to seven or eight of cinnabar, with
four of burnt sponge, made into a paste with a few drops of
water. He does not apply it to a surface of greater extent
than the sice of an English florin at each application ; and he

* On CuDcer Cur«« and Oknoer Curers.
I1»h Jan». 18S7.

MtJifiil Times and Gaittit,

CIE.NERAL bISEAMES.

Btntcs Ihnt the quuntity of arsenic absorbed frotn bucIi a
surfnco never pnxluecs uiipleusiiiit sytiiptoins. Should severe
paiti arise, it may be mitigated by applying bladders contjiiiiiDg
ice and salt.

The rhiun'ite of' si'uc is a valuflble agent, especially as there
is little U) fear from its absorption. The epidermis must
first bo destroyed by a blister or by strong nitric acid ; and the
caustic is then to be applied, mixed aeeordinfr to F. 245, in
quantity varying with the amount of destTQetion retjuired.
Dr. Fell's plan of treatment consists in the use of the chloride
of zino combined with a perennial plant known among the
North American Indians by the name of puecoon, but described
by botaiiists — owing to the blood-like juice which exudes from
it when mt — us the Sanguinaria Canadensis (F. 244). The
chloride of zinc is the essential agent, however, and this
creates a superficial slough ; which .-"louL'h is daily scored to a
certain depth by several incisions with tlic knife, strips of linen
covered with the caustic being afterwards laid in the furrows.
At each dressing the tumor is dci'troyed deeper and deeper;
until at length it becomes converted into a large e.schar, which
separates by a line of demarcation according to the general
principles of surgery. Together with this local application, the
general health is attended to ; a nourishing and sustaining diet
is allowed; and the puccoon is administered thrice daily in half-
grain doses. Frerjueutly also. Dr. Fell combines with this
drug the .sixteenth of a grain of the iodide of arsenic, and one
grain of the extract of conium. The i-h/nriiie of bntmlutn
has been highly praised by Landolfi, who uses it made into a
paste with floor, or combined with other caustics (F. 243).
The proper method of applying the paste is on a piece of
liuun out to the size of the part to be de.'<troycd. At the end
of twenty-four hoars the rag is removed ; the slough sep-nretes
afler a few days ; and the sore is then dre."sed willi charpio
Bosked in a, solution of chloride of bromium — 9.'<s to 9j in
water Jsij. The patient lakes a pill morning and evehins:,
containing onc-CcntU of a groin of the chloride. I have tried -

CABCI.V'OMA, OR CANCER.

Ill

tfaifl plan in one instance of the cancer uteri : the local disease
seemed to be much diminished by it, but the putient diud
with all the constitutional symptoms unrelieved. — Su/jihule
of zinc has been strongly recommended by Professor Simpson;
who says, that when it is applied to an open and diseased
surface it acts as a safe, mast powerful, and manageable
caustic. It rafiy be employed in the form of a dry fine pow-
der; or as a paste made with gj of the salt to 3J of glycerine ;
or as an ointment — sj to gij of lard. When used in either
way to an open or ulocratcd surface, the part to which it is
applied is rapidly destroyed to a depth corresponding to the
thickness of the superimposed layer; the slough usually sepa-
nites on the fifth or sixth day; and there is left behind, if the
whole morbid tissue be removed, a red, granulating, healthy
wound, which rapidly cicatrises. Until all the disease b
destroyed, the applications must be repeated. The sulphate
of zinc will only act as a caustic to a broken or open surface ;
hence, when the epithelium is entire, this must be removed
by a small blister, or by a strong acid, or by the supersiilphate
of zino (F. 246). It.s application gives rise to local pain and
burning in most instances, but never to any constitutional
disturbance. — The mmnjnncK cum potatjid is recommended
by Mr. Weedon Cooke in ulcerated cancer; it is efficacious,
causes but little pain, removes all unpleasant odor from the
Bore, and does not injure the general health. It may be used
as a powder, or made into a paste with water ; it must be
applied in a layer as thick as the ti.ssue to be destroyed. By
means of carrot poultices the eschar drops off in three or four
days ; when, if necessary, the manganese is re-applied until
the diseased mass is all destroyed, and the subjacent healthy
tissues granulate and cicatrize by means of a slightly stimu-
lating lotion of chlorate of potash. With regard to the strong
mineral (/ciW* and the lonKintraleJ alknlio but little need be
8)iid. If the former be used, sulphuric acid, made into a
pnst€ with safFron, will pruvc the most efficacious; if the latter,
the Vienna paste (F. 251).

TUBEKCUL08IS.

ll.S

spocalum, daily, for fifteen or thirty uiinutes, or even oflener.
I hnvc used it in a few instances only; for althoagh I found
that it allnyed pain, yet it did not seem to posses? any efficacy
as u means of cure.

X. TTTBERCXTLOSIS.

The term tuberculosis is employed to desiftnate an idiopathic
blood disease, which manifests itself by producing conditions
coniinouly known as scrofula, puhnoiiary consumption, tuber-
cular hydrocephalus, tubercular peritonitis, and ttibes moscn-
terica. The precise nature of the change in the blood is un-
known ; but it would seem that the aqueous part ie increased
in proportion to the solids, while the red corpuscles are espe-
cially diminished. The importance of paying particular at-
tention to this affection can hardly be over-estiuiatcd. The
deaths in England for the year 1858, with an estimated popu-
lation of lit, 523, 103, were 449,656; of which number con-
siderably more than one-seventh were from tuberculosis in
some form or other. Thus there died of —

Scrofula, .... 3,004"

Tabes mescntericn, - 6,017

Plilhisis, .... 50,442 f 65,626.

Ilydroccphalus, - - - 7,103

This number, it must be noticed, is fiuito independent of 6."),-
G16 deaths from other affections of the lungs, pletirae, bronchi,
or laryn.x ; some of which are not unlikely to have been more
or less closely connected with the tuberculous cachexia.

Tubercle, or tuberculous matter, is the specific product of
thin disease. It is deposited in a fluid state from the citpilla-
ries, just as lymph i.s ; the deposit coagulating, and forming a
foreign body, llence it exists in isolable majises, or is intil-
tmted into the tissues of many different organs; being most
fref|uently found in the lungs, constituting pulmonary tuber-
culosis, or tubercular disease of the lungs, or phthisis, or con-

10*

114

GENERAL DISEAeES.

sumption — these t«Tnis being generally regarded ss synony-
mous. Next in frequency to the lungs must rank the lym-
phatic glands. Pulmonary tubercles are found in two forms,
as grni/ and yellow tubercle. The gray tubercles are soft,
compressible, and sumi-transparcnt ; and by the microscope
are seen to be composed of minute irregular-shaped bodies
with connecting substance. Their resemblance to millet
seeds leads to their being spoken of as miliary tubercles. The
yellow tubercle is found in larger ma-sses, presenting an opaque
cheesy appearance. It is now generally believed that these
two varieties merely represent two stages of the same sub-
stance, the gray being sooner or later converted into the yel-
low deposit. Of course there has been a vast amount of spec-
ulation as to the mode of formation and nature of tubercle.
One chiss maintains that tubercle is only a retrograde meta-
morphosis of pre-eiisting structures, tissue elements, or mor- |
bid products. Another cxplunalion, and that to which many
authorities — as Rokitjuisky, Lebert, Anccll, and Hughes Ben-
nett— subscribe, is that it consists of an exudation of the
liquor Kinguini.s, presenting marked differences from the sim-
ple or inflammatory exudation on the one hand, and the can-
cerous exudation on the other. As the blood is of course
dependent for its constitution on the results of the primary
digestion in the alimcntjiry canal, on the secondary digestion
in the tiasues, and on the lieiilthy performance of the function
of respiration, so we must agree with Dr. Bennett that the
causes of the tubercular exudation are to be sought in the
circumstances which operate on, or influence, those results:
" The successive changes which occur for the purposes of
assimilation in the healthy ci'onomy may be shortly enu-
merated as follows : 1st. Introduction into the stomach and
alimentary canal of organic matter. 2d. Its transformation
by the process of digestion into albuminous and oily com-
pounds : this pn>ceBS is chemical. 3d. The imbibition of
these through the mucous membrane in a fluid state, and
their union in the termini of the villi and lacteals to form

TUBKRGIIL08II;.

11;")

elementary molecules : this process is physical. 4th. The
Irnnsformntion of these, first, into chyle corpascles, and,
Bceondly, into those of the blood, ihroufrh the agency of the
lymphatic frhindular system : which is a vital process. It is
from this fluid, still further elaborated in numerous ways,
that the nutritive materials of the tissues are derived, so that
it must be evident, if the first steps of the process are imper-
fectly performed, the subsequent ones must also be interfered
with. Hence we can readily comprehend how an improper
quantity or quality of food, by diminishing the number of the
elementary nutritive molecules, must impede nutrition."*

From the chemical analysis of tubercle, it would appear to
consist of animal matter and earthy salts; the former being
principally albumen and cholestcrine, while the latter consist
chiefly of insoluble phosphate and carbonate of lime, with the
soluble salta of soda. Tubercle has a low and feeble vitality;
each mass as it forms obliteratinj; the capillary vessels within
its sphere of infiltration, so that it is essentially bloodless.
When deposited it has a tendency to perish or soften, and to
caa.se its expulsion by inducing disor^nization and ulceration
of the surrounding tissues. The destructive or ulcerative
tendency may, however, be sometimes cheeked; as is proved
by the occasional detection in the dcudhouse, of lungs marked
with cicatrices. The testimony of Laennec, Carswell, Bennett,
and Sir James Clark, also goes to confirm the truth of this
observation ; and though I have beard physicians of repute
state that thet/ have never cured a case of consumption, yet I
L«m sure that I have seen cases recover. There are three
rways in which it is probable that a cure may result, — either
by the conversion of the tubercular matter into a cretaceous
or calcareous substance; or by the expectoration of the exu-
dation, the collapse of the ulcerated walls, and the cicatriza-
tion of the cavity; or by the ulcerated walls becoming covered
with a false membrane, and forming a ohronio cavity. In

• Onihe Palhologi/aitJ Trfatment of Piilmnnary ComumptioTi. By
John Hoghei Bennett. M.D.,&c Second Edition, p. 3.1. Edinburgh. I8i9.

116

r.ENERAI. DIUEASES.

any case it is of course inferred that the blood is rendered
bealthj, and consequently that the deposition of tubercle is
stopped.

A necropsy of a tubercular patient is seldom made without
findin|j; ftitty degeneration of the liver, kidneys, or arteries;
but whether these degenerutiuns stand in the relation of
secondary dependence upon the tuberclc-fonning diathesis, b
uiicerluiii.

Tlie causes which have been most frequently assigned for
tabcruulosis are hereditary influence, syphilis, bad air, bad
food, mid a cold and damp aliuDsphero. As regards hereditary
influence, it may bo noticud thnt if by this is meant that there
is u certain poison or struiiKjus virus transmitted from parents
to children, the position is hardly tcnablo; but, on the other
hand, if it be ouly undtTstood tliat the children of tuberculous
parents arc more liable to have the disease developed in them
on the application of the exciting causes than the children of
healthy parents, as was the opinion of John Hunter, the
position is most probably true. That it is not contagious is
certain. Many authors have imagined that a syphilitic taint
in either parent will induce tuberculosis in their ofispring;
while some have even maintained that this disease is only a
degenerated species of syphilis. There seems, however, to be
no truth in cither of these suppositions; tubt'rculiir affections
and syphilis being very difieront diseases, quite independent
the one of the other. Neither does tlio devclopmunt of
tubercle appear to be itiflueiieod by cliniiito or temperature.
But it is to diseased uutrittun, Imwever brought about, that
we may refer the production of tuberculosis; and it is to in-
BufTicient, iiinutritious, or improper food, that the vast majority
of cases iif di.sensed nutrition are due, though it may also arise
from breathing a vitiated atmosphere, or from want of uleanli-
iiesfl, and healthy exercise.*

"In nil purls of Europe," mys Dr Bnly, Ute rhjr»icmn to the Mill-

Penilcntiar;, "the proporlion of ileatbi has been maoh greater

^V eriminnla io prieao, Ihno amongst pemuDi of a corretpondiog claM

TrBERCPLOSlS.

By many nuthorities it is stated — though the truthfulness
of ihc statcuieiit nuiy be qaeslioned — that persons possessing
the tuberculous or struinuuii diathcsi.s manifest certain peculi-
ariticH, such as a coldness of the body ; a dull white, but very
delicate skin ; a rounded graceful outline of the face, with a
delicacy of feature, and msy hue of the cheeks, strongly con-
trasting with the surrounding pallor, and oflen giving to the
countenance, especially in women, a characteristic beauty ; hair
which is usually blonde or auburn; and eyes large, blue, pro-
jecting, and humid, with the pupils habitually dilntcd. More-
over, it is said that such persons are remarkable for the
development of the head, of the alas nasi, and of the upper lip,
as also for the large size of the lower jaw, and the milk-white
teeth which early become carious ; while it is also assorted that
the brciitli is habitually sour and fetid, the neck long and
rounded, the chest narrow and flat, the shoulders high, the
abdomen large and prominent, the limbs thin, and the flesh
soft and flabby. It is commonly believed that in youth all

ofulous persons manifest great cerebral activity; that they
impatient and passionate ; that their intellectual system ia
largely developed ; and that although many have more imagina-
tion than judgment, yet some occasionally arc capable of sus-
tained mental exertion. There are very few cases, however,
where the actual appearances will correspond with this descrip-
tion. The most coiislaut peculiarities are the paleness and
coldness of the body, and the tumidity of the abdomen.

Tubercular disease may set in at any period of life, though
it is peculiarly a disease of childhood and youth. Perhaps
the liability to it is greatest from three to fifteen, and from

ODt of pri>oD ; Bod the ineroaaod mortnlity ia due to varioaa tontt of
MrofuU, andeapeciolly tuberoul&r phtbitls. The causes wbiob coiitribnte
to tbif result are cold, pnorDcsa of diet, deficient Tenlihition, wtini of
ruOi<Ment bodily exercise, and dejection of mind. In a great number of
case.* of pbtbisis in tbii* prison, apparently bopoless, tbe disease wo.* im-
mediately cbecked on Uie release of the prisoner!, many of whom entirely
rocorered." Quoted by Dr. William Addison. — On Healthy ami Diieaitd
Strneture. p. 48. London, \%Vi.

118

OENEttAL DT8EABE8.

eighteen to thirty-five or forty. Its dovelopment is favored
by all conditiciiis which tend to render the blood unhealthy ;
such as (iiiilfonualions of the chest, dpfeetive structure of the
lunps, a small heart, diseased nutrition, sexual excesses, &o.
When these causes act upon a frame hereditarily predisposed,
the disease ia almost sure to be developed ; but it is not certain,
though it is very prolmhle, that they can give rise to it whore
there is no such predisposition.

The conuncnccment of tubercular diseases is often indicated
by a disordered state of the pritiijo viau, with "biliousness,"
acid eructations, flatulence, a distaste for fatty food, and a
generally bud appetite ; conditions which are so constant, that
some authors speak of them as strumous (tj/apcpnia . Then
wo find paleness and puffiness of the face, swelltn;^ of the lips
and nostrils, purulent discharges from the ears, vesicular erup-
tions about the head, enlargement of the glands of the neck
and of the tonsils, disagreeable exhalations from the skin,
especially of the feet and axillso. feebleness with rapidity of
the pulse, weakness, and loss of flesh. Moreover, together
with a diminished power of maintaining the animal heat,
there is general uneasiness or irritability with a susceptibility
to attacks of fever. As the disorder progresses, so all those
symptoms which arise from depraved or impoverished blood,
and from enfeebled vital energies, become manifested.

It is a matter of common observation that tuberculous
patients arc often very sanguine in expecting recovery ; though
unfortunately they generally imagine a cure is to be effected
without any great esertiim on their own parts. It seems to
me that in no disease is it more tuiportiint to impress upon tho
sufferer tho absolute necessity for steady perseverance in the
use of remedies; and the hopelessness of giving way to thnt
want of energy and determination, which many excuse by the
expression of their devout desire to " trust in Providence."

Remembering what has been said upon the hereditary
nature of tuberculosis, it may be noticed that there are three
points to bo particularly attended to, in order to prevent its

TUBERCULOStS.

119

transmission. These are, — 1. To obtain well-assorted nmrri-
nges — iho marriages of parlies in .sound h(.'alth and vigor, and
not reiiited by blood to each otlier. 2. Where this discaflo
ttdsts ill the parents, or in either of them, great care must bo
taken t<j maintain the liealth of the motlicr durini; the period
of utcro-ftestation. She siiould wear warm clothiug, take
regular exercise in the open air, avoid heated rooms and lato
hours, sleep in a larc;e roiun, and have a plain nourishinp diet.
3. On the birth of the child, every means ought to be taken
to strengthen its general health, and to counteract the heredi-
tary influence, by attention to the food, air, clothing, &c. If
the mother be free from the struiiiou.s habit she may suckle
her offspring, but otherwise a young and healthy nurse should
do so. At the age of nine or ten months the infant should be
weaned and fed on cow's milk, a small fjuiintity of light
nutritious vegetables, and a little broth. Dr. Paris strongly
recommends milk impregnated with the fat of mutton suet,
which he orders to be prepared by iiiclasing the suet in a
muslin bag, and then .siiiinicring it with the milk. The child
should be warmly clothed; should live in apartmcntj* which
are airy and well-lighted; ought to have plenty of exorcise in
the open air; and once daily should have n cold sea-water
bath, or a cold bath with bay salt dis-^olvcd in it. Ill-ventila-
ted, damp houses must bo avoided; as well as localities
Bnerally rcgiirdcd as unlioalthy.
For remarks on the treatment of tuberculosis, the reader
lUOBt refer to tho sections on Phthisis, Hydrocephalus, Tabes
MoBcnterioa, &c. But it may bo briefly stated that the object
always to bo held in view is to improve the faulty nutrition, so
as to promote the formation of healthy blood, and thus prevent
the fresh exudation of tubercle ; while we abo try to favor the
absorption of that which has been deposited. Everything
which can serve in any degree to deteriorate the constitution,
will increase the severity of this disorder; and therefore in
pnch instance special attention must be paid to the subjects
uf diet, dress, exercise, rcjjOKO, and air to be breathed — iiut

aCNEKAL DISKASVS.

forgetting also to sec that the functions of the digestive organs
and the skin are properly performed.

XI. MELANOSIS.

This is a very rare disease, concerning which our knowledge
is not very extensive. It is eharat'tcrizod by tlie deposition
in various tissues of the body, of a bl.ick or d;irk-brown sub-
stance; whence its name, from /i'xu;, blauk, and vuitm;, disease.

Melanotic formations may take place in various parts of the
body, may present much variety of form, and may owe tiieir
producticm to different agents. They are divided by Dr. Cars-
well into two great groups:* 1. True Melanosis, of which
there is only one kind; and 2. Spurious Meluiiosi.i, of which
there are throe kinds — a, that arising from the introduction
of carbonaceou.s mutter; /;, from the action of chemical agents
on the blood ; and c, from the stagnation of the btuud.

1. True Melanosis. — This disease has its seat most
commonly in the cuiinectivc and adipose tissues; but it is ulso
found, thon^rh rarely, in (he mucous and serous mcuibntnes,
in tendons and cartilages, a.s well as in the osseous system —
particularly the bones of the cranium, the ribs and the sternum.
The organs it most coinindiily affects are the liver, lungs,
spleen, pancreas, lymphatic glands, brain, eye, kidneys, testes,
ntcrus, ovaries, rectum, and mummip. Moreover, melanotic
matter has been deU'cted in the blood — particularly in that
taken from the mitiute veins of the liver. It is sometimes
found associated with various forms of cancer; and Andral
states that he has met with it in the false membranes formed
on serous surfaces. Mehmotic disease has a great tendency to
extend to different parts of the body through the lymphatic
gyslom.

Dr. Carswell describes four forms of true melanosis : I. The

* PatkologieaJ Anatomy. Scotion on Mclnnoinii. Loodoo, 1838.

MELANOSIS.

121

pmncliform, in which the black coloring matter appears in
luintite points or dots, grouped to«.'ctIier in a small space, or
irregularly scattered over a largo surface; this variety being
most frequently seen in the liver, which then looks as if it
had been dusted over with charcoal. 2. Tuheri/orm melauoiix
(the most coiumon and conspicuous of all the forms) may
occur in most of the oi^ns, and sometimes on .serous surfaces,
such as the pleura and peritoneum. The tumors vary in
sire from a pin'.s head to an orange; they may be single or
aggregated together, in the latter case producing irregularly
shaped masses of great bulk ; they may be inclosed it) a mem-
branous covering, or they may be non-encysted ; and co-
existent with them the punctiform variety is found in the
liver, lungs, and kidneys. 3. Straii/orm melanosin occurs
only on serous membranes. The black matter may be so
small in quantity, that the tis.^ue on which it is deposited may
merely appear as if stained with it; or it may be more abun-
dant, so as to form a distinct layer of the consistence of firm
jelly. This form is much more frer|aently met with in the
horse than in man. 4. Liqiii/urm mflunosU is chiefly formed
in natural or morbid cavities. Dr. Carswell says that he
never saw it in man as a product of secretion, but that he met
with it in consequence of the destruction of melanotic tumors,
and the effusion of their contents into serous cavities. The
accidental cavities in which it has been found have been
chiefly ovarian cy.iLs.

It is probable that the melanotic matter is deposited in a
fluid state, and that it acquires consistence by the absorption
of its more liquid parts. It is never found solid in serous
cavities, where its diff'usloti is not impeded by unyielding
tissues ; but in the liver and lungs the tumors may have about
tbo same consistenco aa a lymphatic glaud. The black matter
is almost tasteless and odorless; and chemical analysis shows
that it is essentially composed of the constituent elements of
the blood. According to M. Foy, it is the coloring matter of
the blood highly oarbonizod.

122

The .\^mpfoms of melanosis are rarely well-marked, so that
its presence is often only ascertained after death. Dr. Cop-
land states,* that as fur as the syniptoius have been recorded,
and as far as lie could observe them in a single case, melanosis
i characterized by a gradual sinking of the vital energies, a

ohectic habit of body, and a dusky or ash-colored counte-
nance. There ia also a marked chanf!;o in the nutritive ftjnc-
tiong, slowly giving rise to emaciation, dropsy, weakness of the
pulse, and night-sweats towards the termination of the disease;
while occasionally, when the lungs have been affected, there
has been a blackened mucous expectoration.

Palholuiiy. — It ia still a matter of uncertainty whether true
melanosis is simply medullary cancer modified by the forma-
tion of black pigment in its clunicntal structures. Mr. Paget
gays :f " On this long-disputed point there can, I think, be
no reasonable doubt. I have referred to a ca.se of melanotic
epithelial cancer ; but, with this exception, I have not seen or
read of any example of nichmosi.s or melanotic tumor in the
humau subject which might not be regarded as a medullary
cancer with black pigment. In the horse aud dog, I believe,
black tumors occur which have no cancerous character; but
none such are recorded in human pathology." On the other
hand, l>r. Wolshe entertains a directly opposite opinion, and
for the fiillowing reasons:* "1. That the melanic pigment
should in itself constitute cancer is an absurdity : it never
even forms a stroma, as the cells continue permanently free.
2. The stroma of many melanic tumors is perfectly distinct ia
ite physical, chemical, and microscopical characters from all
cancerous stromata. 3. Many melanic tumors do not contaiaj
cancerous juice. 4. The microi^copical characters of the pig-
ment-cells and granules ore the same in all kinds of growth in
which they occur. 5. Melanic tumors, when no ordinary

* A DiHiotiary of Pradiatl Medinne, vol. ii, f. 8,10. London, 1868.
t Ltfturet on Surgicot Pathology, vol. ii. p. 483. LdtiiJud, 1843.
I Th* Naluri and Trmtmeiit of Cancer, p. ISi. Iionilon, 1840.

eanccruu» elements exist in them, cause no local or general
Bjmptoms, except those dcpendeat on the size and seat of the
growth. 6. When luelanic tumors produce the local or
general symptoms of cancer, they are found either to be com-
posed of cncephaloid or scirrhus, wholly or in part, impregna-
ted with black pigment. 7. Neither the local nor general
symptoms produced by carcinoma are raodiBcd in cases in
which melanic matter is found to pervade it. 8. The circum-
staooc that melanosis is rarely solitary, is strongly insisted
upon by Cruveilhier, as a ground for ranking it with cancer.
But tubercle multiplies siiiiilnrly, yet assuredly tubercle is not
cancer." Unfortunately, I can myself say but little upon thia
matter; though it seems to me, from a careful study of many
of the recorded cases, that there is reason to doubt whether
melanosis is as closely allied to cancer as many pathologists
assert. It is not a very nncommon disease in horses, especially
in those of a gray color; and it is said that life is scarcely
shortened by its presence, though it exhibits the .«ame tendency
as iu man to multiply itself in diOcrent parts of the system.

Melanosis is most often met with in the middle-aged, or
even in those advanced in life. Mr. WarJrop, however, has
seen it in a little girl only two years old, in whom " the hu-
mors of the eye were converted into a Hack gelatinous sub-
stjince." When the disease attacks the skin, it will often bo
found to have commenced near a congenitiil mole or a wart.

Id the Ireatment of melanosis we can only endeavor to com-
bat any distressing ."tymptoras tl).Tt may present themselves.
The two classes of medicines wbii'h will be found most useful
are tonics and cholagogae purgatives. The necessity for
diet, sea air, and a moderate amount of exercise, should
be borne in mind.

2. Spurious Melanosis. — There arc three kinds of this
spurious disease :

a. From the Introduction of Carbonaceous Matter. — The
luiigfi (it occurs only in tho.se organs) present a black carbn-

124

CiFAEUAL nrSKASES.

naccous culor; the bmncliiul glands are til!<u blsickencd ; and
tbe puliiiuiiury tissue is indiiruted and friitblc, infiltrated with
black scrum, and often broken down into irregular cavities.
The discoloration has its orijrin iti the inhalation of the car-
bonaccouH product of ordinary combustion ; and it is chiefly
found in the lungs of those who have worked in coni mines.

b. From (he. Action of Chrmintl Aijeiil* on tin- BIdml. — In
digestion of the coats of the .stoninch l»y the gastric juice after
death, and in poisoning by acids, the blood contained in the
gastric capillaries, as well as that which is exiravasated, will
generally present a blackii-h tint. The inliahitioii of sulphu-
retted hydrogen gas will also darken the blood in the intesti-
nal capillaries.

c. From ike Staynatlon of BiooO. — Retarded or impeded
circulation may produce black discoloration of the blood.
When the blotid ceases to circulate in the capillaries of an
organ if coagulates, the serum and salts become absorbed, and
« black substance remains. This probably consists of fibrin
and hoeuiatin. The organs in which this change occurs are j
the digcative and tbe re.<:pinitory.

XII. FATTY DEGENERATIOH".

The designation of fnttif ilri/nnTdlion, or fol/i/ melnmnr-
jihosif, is given to a certain class of cases which during life
are marked by anaemia with great prostration, and after death
are found to he distinguished by the more or less perfect
transfoniiation into fat of various important textures, but
especially of the muscular fibres of the heart.

There is the adijiose tissue, in which fat is naturally stored
np for the welfare of the individual : and there are other tex-
tures— as the villi of tho iiuicous coat of the duodenum and
jejunum — where this element transitorily abounds after the
digestion of particular kinds of food. But in the oases about i
to be treated of, fatty matter is present in abnormal situations,

FATTT DEOBNEKATtON.

125

tlie tissues being converted into this substance; in consequence
of which there result the most disastrous lesions.

A fatty degeneration of one or more of the viscera is very
commonly found after death from flironic disease, or even
from old age. Intcmpcnince is also a fruitful .source of this
change, as is also a residence in tropical climates. The liver
is particularly liable to be thus affected, the hepatic cells be-
coming enlarged and loaded with oil granules. In certain
forms of Brigbt's disease, the epithelium of the convoluted
urinifcrous tubules is found in a state of fatty degenoriition ;
the degenerated epithelium so filling the tubules that they
present a yellowish opa(jue appearance. In fatty degeneration
of the walls of arteries, the change takes place in the internal
coat, being often visible to the naked eye in the shape of round
or angular white spots ; such parts on being minutely exam-
ined, presenting the usual characteristic appearances. The
atheromatous change which occurs in the arterial walls nf old
people — particularly in the aorta- — is a form of fatty degene-
ration; beginning with inflammation of the arterial i-oat, and
often ending in softening and ulceration. If an atheromatous
patch be submitted to microscopic examination, it will be scon
to consist of fat globules, plates of cholestcrine, granule cells,
and amorphous fragments of tissue. In certain diseases — as
paralysis, deformities of the limbs, spinal curvature, &c. —
the muscular structures of the affected part may undergo
transformation into fat ; so that they are observed, on dissec-
tion, to be pule, thin, and yellowish, or marked longitudinally
with alternate red and yellow streaks. This latter appearance
is due to the deposit of fat between the primitive muscular
fasciculi, combined with real fatty degeneration. It is a con-
dition which can be well examined in any of the voluntary
muscles of over-fed prize cattle.

The designation of idiopathic /ally ilet/eiiera/ion has been
given by Dr. Wilks to a class of cases in which excessive onse-
mia and debility are the peculiar phenomena during life ; and
a fatty degeneration of mafiy parts of the body, but more espe-

12ii

OF.NF.RAT- DrSKASES.

cially of the heart, the characteristic changes delected after
death. The term idiopathic is used to disconnect these cases
from those instances of fatty change of organs which are found
as accuRipauimcnts of other diseases.

Perhaps the syniptorns and progress of a case of idiopathic
fattj degeneration may be made more clear by the sketch of a
typical example : A wooinn, thirty j-ears of age, married but
never prejinant, cnmplnins of great and increasing debility.
For the last eighteen months she has bad much mental anxi-
ety ; but her diet has been good, her home healthy, and she
has not suffered from any exhausting disease, such as hiemor-
rhagc, diarrhoea, &c. Moreover she has never had ague, nor
lived in a maIariou8 district. She has taken tonics of all
kinds without any benefit for almost a year. The catamenia
are regular, and there is no leucorrhcoa ; she is thin but not
wasted, is weak, and she presents a marked pallid aspect;
there is no arcus senilis ; the pulse is quick, and there is an
anaemic cardiac murmur; the lungs, lymphatic glands, liver,
spleen, &c., appear not to be diseased; the urine contains
neither albumen nor sugar; and on examining the blood mi-
croscopically, no excess of white corpuscles is detected. We
hope that by the careful administration of a nourishing diet,
with bark, or quinine and iron, that the symptoma m.ay be
ameliorated ; but this expectation docs not get realized, and at
the end of a month or two we find that she has had frequent
attacks of sickness and purging, the legs have become slightly
oedematous, while she is reduced to such a condition of weak-
ness that she cannot raise herself in bed. In a few days she
is found in a half-con.scious state, and at the end of some hours
she dies. At the autop.^y it is noticed that the body is spare,
but not wasted as in phthisis; it is very pale, and the viscera
appear bloodless. The brain, lungs, intestines, spleen, and
supra-ronal capsules, arc healthy ; as are also the generative
organs. But the liver is pale and fatty ; while the muscular
tissue of the heart has undergone an estrunie degree of fatty
degeoenttion, presenting a pale mottled appearance to the

AMTLOIB DKOEI^RATIOV.

naked t-ye. This change is chiefly seen in the left ventricle,
which exhibit; the nppearunce of white striae of fat, every part
being occupied by this fatty change ; the ri;;ht ventricle is
less affected, and the auricles look healthy. On ex:iininini>;
with a quarter-inch object glass some of the fibres from the
left ventricle, no traces of transverse strite can be seen, but
only a large number of snutl! tiil globules, with free fat glo-
bules, which have escaped from the ruptured fibres. The
kidneys are pale, and healthy to the naked eye; bnt on a
microscopic examii)ntion, the tubules and secreting cells are
found to contain a considerable utnount of fatty molecules.

For the further consideration of this subject, the reader is
referred to the section on Atrophy of the Heart; where ho
will find the distinction clearly drawn between fatty degene-
rotioD and fatty growth.

Zni. AMTLOIB DEGESTEBATION.

The discovery in the animal kingdom of starch, or at least,
of a substance which possesses properties allied to those of the
amylaceous group in the vegetable world, i.s full of interest to
the pathologist and phy-sioian. For some few years it has
been, known that the liver, spleen, and kidneys, occasionally
undergo a peculiar degeneration, which has been described
under the names of the Lnrihicfoux, Waxy, Cknlesterine, or
Albuminous Infiltration ; thougli uotil the publication of the
researches of Virchow (185-t — 1859), we were not only igno-
rant of the nature of this substance, but of its exact seat,
while oven now our knowledge of this morbid process is very
imperfect.

What wo do know of the matter, as far as I can gather
from a careful htudy of the writings of Virchow, Wilks, Fran-
cis Harris, Gairdner, and the author of an excellent article in
the liritifh and Foreit/n Medito-Cliinin/iial Revirw for Oc-
tober, 1860, together with the close observation of a case
" 'ch was under my charge for some months, seems to be as

128

OKNERAL DIMEASRS.

follows : In the Imiimn body there are to be found, accord-
ing to Virehow, two allied, but not identical, substances. In
tbe first place we find bodies which, in their chemical pro-
perties, are analogous to real vegetable starch, and in their
form bear an extraordinary resemblance to vegetable starch-
gmnules, inasmuch- as they constitute more or less round
or oval structures, formed by a succession of concentric
layers. To thi.s class belong the little corpora araylacea of
the nervous system ; the laminated bodies that are found in
the prostate of every adult man, and which, under certain
circumstances, accumulate in large quantities, so as to form
the so-called prostatic concretions ; and rare forms of a similar
kind which occur in cerUiin conditions of the lungs. These
formations assume a blue color by the action of iodine, as
vegetiiblc stiirch docs ; the blue becoming green if they are
mixed uji with much albuminous matter, since the nitro-
genous material being rendered yellow by iodine, the amyloid
blue, the result must be green. The greater the quantity of
nitrogenous matter the browner does the color become.

In the foregoing instances the starch-like matter lies bt-
tveen the elements of the tissues. Very diftereiit are the
cases of disease, where there is a degeneration of the tissues
themselves; in which all their component parts become filled
with an amyloid substance, and get gradually infiltrated with
it, just as lime is diffused through tis.«ucs in calcification.
The change commences in the muscular fibre-cells of the
middle coat of the small arteries ; the walls of which vessels
gradually get thickened, while their calibre becomes dimiu-
ishcd. Then the morbid process involves the surrounding
anajmio parenchyma; extending until the whole tissue in the
neighborhood of the arteries is altered. This amyloid sub-
stiiuce, thus infiltrated, has the peculiarity of not becoming
blue under the infiucnce of iodine ulone, but of assuming a
peculiar yellowish red color; though it assumes cither u blue or
a violet color, if the application of iodine be followed by the
very cautious addttion of sulphuric acid. Hence this material

AMTtOID DKOESKRATlnV.

IL"J

gepmD less allied to starch properly so called, than to thnt sub-
stnnce which forins the external membrane of vegetable coll?,
— cellulose; thoufili it differs from this in becoininj; colored
upon the applicution of a pure sohition of iodine, whilst runl
cellulose is not at all colored by iodine alone. Owinjj; to this
multiplicity of reactions, it is difficult to sny to what class the
niaterinl really bolonirs; thn«;:h we may assume, from its reac-
tion with iodine and sulphuric acid, that it is analogous to the
substances of the aniylaeeous group. Meckel, in an essay on
Lardiireoiis Ditf(t*r, cite.* the cheniico-physical appearances
as favoring the presumption that the luatcrial is cholcsterine,
or some closely allied fat; but Virchow and others show that
the substance does not in any way behave like a fatty matter,
while the reactions of cholestcrine and the apparent amyla-
ceous compound »re so different that the two cannot be con-
founded.

Whatever the particular substance may be, however, the
important fact remains, that in the so-called amyloid, or cel-
lulose degeneration, we liave a remarkable constitutional dis-
eilse; which generally invades several organs at the same time,
and renders them incapable of performing their functions.
^_ The patients gradually assume a cachectic, broken-down ap-
^P pearnnce; they lose flesh and strength; dropsy often super-
' venes ; the urine gets albuniiiums if the kidneys be afTeetL'..' ;

^^ diarrhoeji sets in when the digestive tract is involved ; and iu
^B Bpite of remedies dcAth soon takes place.
^^^^ When the liver, .«pleon, or kidneys are the organs affected,
^^^Hb unpractised eye may fail to detect the alteration in stnic-
^H ture unless there is tin extreme amount of disease. But when,
^H for example, we incise a liver where the pmce.ss of amyloid
^H degeneration is far advanced, a feeling is couimtinicatod like
^H that experienced on passing a knife through a piece of wax ;
^" while the cut surface presents a semi-transparent appeanince.
The gland is also found increa.sed in sixe ; it has some resem-
blance to a fatty liver, thnugh its increased weight distin-
guishes it; B sense on bandting is given like that received

130

OENKRAI. DISKA8K8.

from a lump of wax ; and if the disease be very extensive, no
trace of noniiiil structure can be distinguished, though in an
earlier stiige the lobules are seen distinctly miipped out, owing
to the matter being deposited within the lobule and in and
among the secreting cells. Dr. Hnrns first employed chemi-
cal reagents to detect the presence of amyloid in the walls of
the intestines ; and he noticed that on brushing a Evolution of
iodine over the imicous nieiubnuio of Jlic aflected portions,
innumerable dark red points corresponding with the villi ap-
peared, whii-h became changed to a bluish stcel-eoior on the
suporadditidti of a drop of dilute sulphuric acid.

Virchow speaks of the occurrence of auiyloiJ degeneration
of the lyrupbatiu glands us an undoubted fact; and in all pro
bability he is correct. Dr. Wilks, however, with more cau
tifiti, says, that the change in these organs is not strictly lar
daceous, but is either u variety of it, or has a close relation
ship with it. It produces a lingering form of fatal cachexia
"The enlargement of the glands is in most cases gradual, ex
tending sometimes over a period of two, three, or more years,
and oflcD from conmienciog in the neck in weakly children
is called scrofulous. When the mischief is thus gradual in its
commencement, and affecting only part of the glandular sys-
tem, no marked symptoms ensue, but as time tends to its
development in the thoracic and abdominal glands, a slow
prostrulion ensues, terminating in death.'"* The glands often
get an enormous size ; they have a peculiar elastic feel ; they
may form large tumors in the neck and groin, and the poste-
rior mcdia.stinal and lumbar glands may all he affected; or
only these latter glands along the course of the aorta may bo
diseased without any affection of the external glands. When
these diseased bodies are removed, they are found as distinct
tumors, very tough and solid. On making a section of one
of them, the cut surface looks to the naked eye as if dotted

' (rwy'« Hotpital Rfpnrlt. Third Series, nil. U, p. 103. London,

IBit.

fAL srpniLis.

131

over wilh points of wax ; and thoui^h Dr. Wilks sajs no effect
is produced by the applicsilion of iodine, yet Virchow miiin-
tains that this agent colors the disonsed parts of the gland
red, whilst the norniiii portions are rendered yellow. If, when
the iodine red hue is obtained wo use sulphuric acid, a blue
color may be procured if the exact proportion of acid neces-
sary to effect this change be hit upon. Sometimes the disease
in the glands is associated wilh the peculiar wiix-like substance
in the spleen, or with iardaceous liver, and with tuberculosis.
The symptoms in any case are tho.so of aiiicmia, prostration,
and final exhaustion. The lyiophntic glands and spleen being
oonncctcd with the blood-making process, if a gradual destruc-
tion of their texture goes on, the most injurious results must
ensue.

There is only one more important point to be briefly noticed
— vii., that amyloid degenenilion may either exist alone, or it
maybe present in connection with tuberculosis, diseases of the
bones, and syphilis. Thus, in phthisis, this form of hepatic
disease is said to be much more common than fatty liver;
while sometimes the amyloid and the fatty degeneration occur
together. So frequently has amyloid degeneration been found
connected with caries or necrosis, that at one time it was
thought the osseous disease exercised some determining in-
fluence on the production of the amyloid bodies. Multiplied
researches have proved, however, that amyloid degencnition
is as frequently associated with phthisis and syphilis, as with
bone disease. So, also, it was considered that Briglit's disease
was often associated with amyloid degeneration, until it was
foond that the former was sometimes merely a symptom of the
latter affecting the kidneys.

XIV. CONSTITUTIONAL SYPHILIS.

The phenomena of syphilis are divided into the primary,
the secondary, and the tertiary. The primary symptoms are
due to the application of the venereal poison by sexual inter-

132

OENFRAIi OtSKASKB.

course or by inoculation, nnd their cure belongs to the depart-
ment of surpery. As physicians, we have to deal with eon-
Htitutional or secondary syphilis, which may make its appear-
ttuce two or three weeks, or not for several months, after the
hoalinp of a priniaiy sore; beinp due to the tainting of the
lijoiid by the Fyphititic virus. The longer the duration has
been of ihc primary sore, and the more marked the induration
with which it has been attended or followed, the greater the
probability of secondary symptoms. Moreover, the worse the
pcncrjil licalth at the time of contracting the primary ulcer,
the greater the risk of the constitution subsequently suBfering.

There is every reason to believe that constitutional syphilis
may be communicated from «n infected to n healthy person
directly — /. r., without the intervention of primary disease —
especially where there is frequent contact between the two
parties. Secondary skin diseases and condylomata may be so
comaiuiiicated from the husband to the wife; the seminal
fluid of a tainted man deposited in the vagina of a healthy
woman may act thus, without pregnancy occurring ; or the
husband being cotistitulionully affei-ted may taint the ovum,
and through the latter tfie mother may get infected. — Tertiary
symptoms generally appear at a long period after the primary
disease, nnd usually some time after the secondary symptoms
have disappeared. The diseases which have been termed
tertiary are commonly deep-seated uft'ectious of the skin, aa
tubercles; and morbid actions in the bones, as periostitis,
exostosis, caries, and ntcrtisis. Possibly the children of
parents suffering from tertiary symptoms ore predi.sposed to
scrofula, or pulraoimry cuusuniption, or tabes niesentertca, or
hydrocephalus.

Si/nip(om». — Constitutional syphilis very frequently mani-
fests itself by the production of certain cutaneous diseases^ by
ulcers on the skin ; by warts, condylomata, nnd mucous tuber-
c\v9; by tumors of the skin, and subcutaneous areolar tissue;
by alopecia or buldiiess, loss of the eyebrows and eyelashes ; by
inflammation and ulcorution about the roots of tlio nsils; by

CONSTITUTIONAL SYPHILIS.

133

superficial ulcerations on the tonpue, lips, or pillars of the
fauces ; by ulceration of the larynx ; by cnlarjrement of the
testicle — syphilitic sareocele ; by disensea of the pcriostoum
and bones; and, in a few iustauces, by a peculiar form of
bronchitis.

The syphilitic cutaneous affections are of various kinds; for
they may belong to either of the orders or classes Exanthe-
mata, Ve.sicute, Pustulie, Papulw, Squainse, Tubercula, or
MjcuIsd. Probably the s<[uniiiou8 or scaly diseases are the
most common ; appearing; in jmtohes, being of a red copper
color, having the scurf renewed as fust as it is shed, often
showing a tendency to excoriate or ulcerate, and being attended
with fever or some constitutional disturbance. The syphilitic
tubercle varies in size from a pea to a pigeon's egg, is of a
polished browo hue, is very prone to ulcerate, and most fre-
ijuently has its seat on the chest, fiioe, or abdomen. Small
groups of tubercles sonietinies attack the nose, or forehead, or
tongue; usually terminating in the fnrnintion of inveterate
ulcers. The syphilitic niiiculio or stiiins nmy be of a brown or
dirty yellow color, and as they are often incurable it is fortu-
nate that they are of little conseriuence.

Syphilitic tumors of the skin and subcutaneous areolar
tissue, or of the muscles — soraetimos called muscular nodes —
generally occur long after the cure of the primary sore. They
may have their .scat on any part of the btnly, the forearm and
outer part of the leg being the regions in which I have n)08t
often met with them. If their resolution i.» not effected in the
earlier stages, they graduully soften and ulcerate; or if in
ignonince of their true nature they be kneed, or if attempts
be made at their excision, the most foul, painful, and invete-
rate sores are produced.

Loss of hair from syphilitic causes seldom occurs without
other symptoms ; and it may take place not only on the head
(filo})rciu, or liah/iirit), but may affect the eyebrows, eyelashes,
whiskers, &o. This result is often combined with the excessive
formation of scurf uii (he sc«lp; ns well as with inflammation

GENERAL PTSEASES.

of the roots of the nails, so that these structures become thick,
cmck or break easily, and even fall off. — In woriion affected
with cotistitiitioiial syphilis the uterus <;enenilly suffers; there
bein}; niacu-puriilont disch.irfres from tlie uterine eavitj-, exco-
riutious of the lips of the urj;5an, uiid induration with enlarge-
ment of the cervix. These cases are cured with difficulty,
and only by a coinbitiatinn of local with constitutioual treat-
ment.

The syphilitic ulcers of the fauces, tonsils, and pharynx
are often excavated, covered by an ashcolorcd sl<iu;,'h, and
suiTouiided by a livid unhealthy appoaranco of the mucous
membrane. Occasionally they sloufih, and extend rapidly;
they give rise to pain, and difficult di'slutitiuu ; and they are
always attended with inure or less constitutional disturbance.
Ulcemtions of the nostrils ore also not uncoiiinionly the only
symptoms of the penernl infection of the system : they give
rise to offensive and profuse dischar^res, a marked alteration in
the voice, and, if not checked, to disease of the cartilages or
nasal bones. Deep fissures, ulcerations, and fungoid vegeta-
tions upon the tongue may arise from the poison of syphilis, or
from the use ofuicrcury : in the former ca.so there will generally
be found other symptoms of tijis disease, while, in the latter,
the submaxillary glands are frequently also swollen and tender.
The enlargements of the huiies called rtdes arise only when
the systeni has been much tifleeicd by the poison of syphilis:
they are the result of effusifm between the periosteum and
bone, and are, perhaps, raused by superfioiiil infliimmation of
the osseous tissue. All the syphilitic affccttuiis of the perios-.
team and boiies are attended with pains; which latter are in-
creased by warmth, arc aggnivafcd at night, and arc relieved
by iodide of potassium. This agent, however, seldom cflfecta
a penimncnt cure; mercury in some form — best by the vapor
bath — being required to prevent their return.

DiiKjtwtif. — The longer the interval which elapses between
the primary disease and tlio appearance of the secondary
symptoms, the greater will be the dilHculty of diagnosis. It

rossTiTUTioxAL .svrHn.is.

]3o

mny be of assistnnce to remember that syphilitic cutaneous
affections frenerally occur in cotiiiection with various forms of
ulceration about the soft pnlaie and fauces; and that the skin
disease often assumes a dusky copper color. 5"ometimes the
suboccipiuil lymphatic jilands are enlartred in these cases. Of
symptoms which exist singly, syphilitic sarcocele is the most
common. The syphilitic tubercle of the face, when ulcerated,
is not unfrer|ueiilly mistaken fur lupus ; but it may be distin-
guished by its greater depth, the sharpness of its edges, and
its dusky copper color. The hi.>itory of the case often throws
liglit upon its nature ; and when the patient is mariied the
health of his wife and children will form a guide in enabling
us to make a correct diagnosis.

Many cutaneous diseases arc erroneously referred to the
poison of sypiiilis, and much unlia))[>iiU'ss produced. Suicide
has cveu been attempted under the distress thus produced.

Proijnonk. — Constitutional syphilis, if neglected, is very
likely ultimately to destroy lifu. It may do .so directly by
inducing some affection of the larynx, or intestines; but very
ol\en it acts indirectly by bringing out latent pulmonary disease.
Certain authorities state that a perfect cure is never effected ;
but in patients under Ibrty, at all events, cuinplcto recovery
generally follows well-directed treatment. I am rather skep-
tical of cases petting well when left alone; but some writers
think the disease may wear itself out.

Treatment. — Directly the constitutional affection clearly
manifests itself, attempts should be made to effect a cure;
pregnancy even being nci bur to the treatment, since abortion
is much more likely to follow from the disease than from the
remedies.

The therapeutical agents required in the treatment are not
very numerous, but they demand great caution and discern-
ment ill their applicaliou. Tho ilict should usually be light
but nutritious ; meat may be allowed, milk is an excellent
article, and with thy exception of ii litliu wine and water,
stimulant.^ arc to be Ibrbiddcn. Coutinemcnt to the bouse is

13fi

GKNKRAL DISKA-SES.

very seldom neKCssory, but care is to bo taken to avoid expo-
sure to wet ur to the night air. In all cases the use of toarm
water or vnpor hiitht once or twice a week, will prove of great
service; and, provided they do not induce debility, cannot be
productive of any mischief. Opium, also, will be needed
when there is much ptiin, or when there is an inability to
sleep at ni<:lit, or when there is f^cnoral irritability; and
it may be piveii to the extent of three or four grains in the
twenty-four hours. The extract is the preparation which
I usually prefer. When the use of mercuri/ is indicated,
there are two ways in whivh this mineral may be introduced
into the sy.stem — viz., either by inunction with the mercurial
ointment, or by the employment of the nicreiirial vapor baths
(F. 1C3, 1(54). The latter will often cure cases that have
resisted all other plans of treatment. In many chronic oases
the bichloride of mercury (F. 24 and 61), repeated for many
weeks, proves very useful. In the squamous cutaneous dis-
eases, the iodide or the biniodide of mercury (F. 74, 75) may
be advantageously used ; e.speciully if the mercurial viipur biith
be employed at the same time. The subcutaneous and mus-
cular tumors may generally be dispersed by the iodide of
mercury, the mercurial vapor, blisters, and pressure with the
mercurial plaster.

Amongst other remedies which deserve a brief notice,
mention may be made of Donoi-nn'x solution (F, 67j, which
will often cure the s(|uamous cutaneous diseases : the iodide of
potnuiuni (F. 27, 36 atid 37), which is invaluable when the
bones are affected, if the mercurijl vaptir bo used at the same
time : the iodide of mdium (F. 78) : and of the iodide of
iron (F. 29, 33, 38 and 40), which i.s particularly valuable in
advanced stages of the disea.se, or in weak anjemic subjects.

These remarks would be ii>complete without a notice of the
treatment of this affection by nyphilization. A few years only
have elapsed since Auzius Turenne, in performing some expe-
limcnls on animals with the poison of syphilis, ascertained
that each succeeding chancre produced by inoculation became

CONSTITUTIONAL SYPH1M8.

187

I
I
I

and less, until a period arrived when no sore of any kind
could be produced by the application of the venereal virus.
FruQi this the inference was drawn that, by prolonged inocu-'
lation with the syphilitic poison, a ciuistitutional state was
produced in which the system was no longer capable of being
affected by syphilis ; just as happens in inoculation for small-
pox, vaccination, &e. Hence, to obtain porfect syphilizatiou
or immunity, an individual must undergo conslituliunal syphi-
lis; but he must be forced rapidly through this state by
repeated inoculations, in order that his constitution may not
be injured. This practice has found — and will find — but
little favor in our country; but recently in France, Germany,
and Italy, attention ha.s been paid to it, and important facts
brought to light. Sperino, I'hysician to the Venereal Hos-
pital of Turin, publiihod in 1863 a detailed account of 96
cases of sypliilization ; of which 53 were examples of aggra-
vated primary syphilis, and 43 of severe constitutional disease.
Of the primary cases 00 were cured, 2 failed, and 1 was
treated by other means in addition to syphilizatiou : of the 43
with constitutional syphilis, 26 were treated by syphiiization
alone, 25 of these being cured ; 17 were treate<l by syphiliza-
tiun, with mercury and iodine. Sperino inoculates ior from
10 chancres at each sitting; and allows about three or
lUr days to elapse between each operation. By continued
inoculation the ulcers become less and less until no effect is
produced ; but the individual is still susceptible, though in a
less degree, to another kind of rantter, again to a third, and so
OD until at last no effect is produced by any syphilitic poison.
It is curious that the genend health does not suffer, but
improves during the process of inoculation. The time required
to produce immunity varies : in one case it was obtained afler
71 chancres, but this number scenn to be much smaller than
usual ; for in most instances upwards of 300 were produced,
the treatment lasting for six months and more. 3Iost of
Sperino's patients were prostitutes, and they submitted them-
selves most readily to the treatment. It may be practised at

12*

13>5

UENEBAI. DI8KA8E8.

any age. To obtain a complete cure whuii the patient has pre-
viously been mercurialized, the use of iodine has often to be com-
bined with syphilizalion. Dr. Boeck asserted in 1858, in conse-
quence of results he had obtained from sjphili/ation alone in
those who had not been previously mercurialized, that in no
diseate have we a more certain method of ritre. The disad-
vantage of the method is its offensive nature, and the leni;th
of time necessary for effectually carrying it out ; but then, on
the other hand, the immunity produced is thought probably to
last for life.*

XV. BRONCHOCELE AND CRETINISM.

1, Broncfaocele. — This affection, called Goitre by the Swiss,
and in this country Derbyshire Neck from it.s prevalence in
some parts of Derbyshire, consists of a morbid enlargement of
the thyroid gland. The whole gland may be swollen, or the
centre only, or cither side. According to Alibcrt, the right
lobe is more frequently affected than the left. The swelling
is unaccompanied by pain, and usually causes but little iucOD-
venionce beyond the deformity wliich it produces. Some-
times, however, distressing syiiiptoms are induced by the pres-
sare of the enlarged gland on the surrounding parts; and rea-
piration and deglutition may be rendered painful and diflBcult
by the compression of the truclioa and ujsophagus. It is much
more common in women than in men, almast in the proportion
indeed of twelve to one. Wherever goitre prevails, popular
opinion justly regards the water used for drinking as its cause.
Mr. MoClcUnnd has affirmed as the result of his personal inqoi-

* For further inrormalion on this sobjeot, the reader thould «OD*iilt
Smjt by Dr. Radclifl's, Victor de M6rii?, Mr. Henry Lee, and othen. In
Th» Balf-Yearly Ahslract of Medical Scienees, vol. xvi, p. 333, t853(|
Tht Lancrl for 1853 ; The British and Foreign Mrilieo-Ckirurgital
Stvifw, vol. xix, p 410, April, 1867: Thf EJinitirgli MtdiaU Joiirmtl,
vol. iii, p. 012, 1668; and A Sgtfm of Surgny, rol. i, p. 384, Londoo,
1800.

BBONCHOCELK ANIi CRETINISM.

loll

ries that goitre never prevails to any extent except in villages
situated upon, or close to, limestone rocks. Hi.s views are,
however, up.set by M. Chatin, who mentions that in Savoy there
are two villages divided from each other by only a narrow ravine.
Both villages stand on rock and soil of the tmnie nature, their
elevation is the same, and they seem subjected to the same
influences. But in one goitre prevails, while in the otfier it
is unknown ; in the tirst, the water supplying it contains a
trace of iodine ; in the second there is uo iodine io the water.

Sometimes there appears to be a connection between bron-
chocele and irregularity of the uterine functions. Thus I
have noticed in many cases that the enlargement of the gland
is greatest at the catamcnial periods, and especially when
the flow is scanty. Some authors have also noticed that the
disca.<>e makes the most progress during the puerperal state.

There is a peculiar form of tbis afiection which has been
named exvphtlutlmii: yoitrc, owing to the prominent condition
which the eyes assume in it. Not only is there protrusion of
the eyeball, but gcucmlly more or less short-sightedness ; the
thyroid body as well as being enlarged, is the seat of strong
pulsations; whilst there are frequent attacks of palpitation of
the heart, with occasionally a bruit (anaemic ?). The general
health is always deranged.

Again, there is a cyslic variefi/ of bronchocele ; in which
cysts are developed in the thyroid body, instead of this gland
becoming uniformly enlarged with solid matter. The lining
nicmbrane of these cjivities is very vascular; so that if they
be opened and their brown-colored serous contents evacuated,
they require to be well 8tuff"ed with lint to prevent hsemor-
rhage. As granulationsare thrown out from the walls, the cyst
contracts, and entirely elo.se.s. The use of iodine iujeotions
in such cases is not to be recommended.

The first point in the treatment of bronchocele is, if possi-
ble, the removal of the patient from the infected locality. As
regards therapeutic agents, the introduction of iodine, by Dr.
Coindet, of Geneva, has superseded all other remedies. The

140

OENKRAI. DISEASES.

liquor potassii iodidi coinpositus of the I'har. ]iond. should be
ordered in dose? of3'j to Sj- or the iodide of potassium and
ood-liver oil : or the iodide of iron : or (juinine und steel with
nlootic j(urg:itivea. Tlie unpiii'iituin iodinii coiupusituio, or
the pijiiueiituti) iudiiiii should be applied iouully.

In cxophLlinliuie goitre 31. Trousseau objects to iodine and
to iron ; but rccoiinueiids the u.se of bladders of ice to ihe neck,
full dose.s of digilidis, hleedinj; during imy teniponiry iiggra-
vation of the Bymptouis, niid cold hiithing with douches. This
physiciiin allows, however, that the malady seldom completely
disappears ; tlie swelling jtnd enlargement of the thyroid
usually persisting, the proptosis never entirely subsiding, mid
the palpitation rciippoaring under the influence of slight
uienlul etuotion.

In this country when medical treatment fails, surgeons have
atteiupted to give relief by one of three opcrutiuDS. Thoa
some cases are recorded as having been cured by the intro-
duction of scions into the disea.sed gland ; and in one obsti-
nate case which was unrelieved by the iodide of iron, quinine,
&c., I effected a cure by passing a thin double iron wire
through the gland, and leaving it (here for a week. Occa-
sionally the operation of tying the thyroid arteries has been
practised; and these uicnns having failed, attempts have been
made to extirpate the gland. To a physician, however, the
last operation &ccnis unjustitiahle.

2, Cretinism. — This is a strange disease, a sort of idiotcy,
accompanied by deformity of the bodily organs, which has a
oloae but ill-understood connection with goitre. Most cretins
are goitrous; but bronchoccle tuay prevail where there are no
cretins.

The cretin is found principally in the valleys of the Alps,
ibc I'yrcuecs, and the Biinulnya Mountttins. His stature is
diminutive ; his head of great size, flattened at the top, and
spread out lalendly ; countenance vacant, and void of intelli-
gence; nose tlat, lips thick, and tongue large ; abdomen sunken

oorr.

141

and pendulous; legs short and curved; while the skin is dark-
colored, coarse :iiid roiifih. Idiottnii) of the lowest grade is
fre(|iiently his lot; sometimes he is deiifaiid dumb, or blind ;
and, in short, if neglected, he more resembles nn aniinul than
a human being. 1 say, if nefrlected ; for thanks to I'r. Gug-
genbiihl — the humane and talented director of the establish-
ment at Abeudbcrg, near Intcrkchen, for the treatment of
cretins — it hns been proved that even for these apparently
hopelessly wretched beings much may be done. The chief
remedies are pure ninuntain air; plenty of exercise ; a simple
Dourishin;^ diet into which milk largely enters; the occasional
use of such medicines as cod-liver oil, carbonate of iron, phos-
phate of lime, valerianiite of zinc, &e. ; with moral control,
and judicious riicntiil training.*

Dr. Guggenbuhl has recently directed attention to the
highly arched palate of the idiot, as indicative of atrophy of
the base of the brain ; just as depression of the vault of the
cranium shows imperfect development of the cerebral convo-
lutions. He also insists upon the necessity in training the
idiot, of ascertaining the prominent instincts, and the amount
of intelligence which exists ; so as to encourage those faculties
which are not altogether wanting.

XVI. GOUT.

Podagra, or gout, may be defined as a specific inflammation,
having a constitutional origin, and being much fiivorcd by nn
hereditary tnitit. It is accompanied by fever and general dis-
turbance, and especially by some disorder of the digestive
organs. The disease has a tendency to recar again and again,
after variable intervals.

The inllamtnatory action most frerjuently invades the ball of
the great toe, or the metatarso-phalangcal joint. Thus, out of

* Ad int«roiilin|( nocount or IhU eelablinliment i< giren by Sir John
Forbes, in TItt Phytieian't HoliHuy.

142

OENERAL DISEASES.

516 cases of f^ont, Sir C. Scudamore found that only (he ereat
tou uf one foot was affected in 314 ; the great toe of each foot
in 27 ; the ankle and great toe of the same foot in 11 ; the
outer side of one foot in 10 ; the instep — one or both — in 31 ;
the nnltle — one or Imth — in 47 ; wliilc in the rciuaindor, the
part was either the heel, the teudo Achilli», the liani, knee,
wrist, thumh, or (iiifrers.

Sijmpioms. — The acute attack may be preceded by premoni-
tory syiiiplonis, or it may come on suddenly. In the former
case, the patient complains for two or three diiy.s prior to the
seizure of heartburn and flatulence, and of dull pain in the
left side of the chest, with inability to lie comfortably on that
side ; while, in many instances, there is also fluttenng irrcpu-
larity, or interniis.sion in the heart's action. There are also
Byniptoms of iiij[ii!ded cutaneous action, the skin beiiia; dry
and hot, and soiuutiiucs aflt'cted with scaly eruptions or with
urticaria; while the urine is loaded with urates.

Very often, however, there is no warning. The victim
goes to bed apparently well ; but about two o'clock in the
morning awakes with severe burning, throbbing pain in the
ball of the great toe, or the heel, or the fascia covering the
instep of the foot, or the thumb. There is often a slight
rigor succeeded by heat. The pain is most excruuiattng, but
it abnten towards the dawn, nnd the patient falls asleep. On
awaking the affected part is found red, swollen, and exquisitely
tender to the slightest touch ; the sufferer is feverish, restless,
very irritable, nnd much depre.s.''ed ; his tongue is furred ; his
bowels are eon.sti pa ted; and hi.s urino will be found high-colored,
aeid, and loaded with urates or with uric acid, sometimes with
phosphates, while occiuionully it contains a little albumen. On
the second night the pain again becomes aggravated, and,
perhaps, also on the third ; but in a few days the attack pas-ses
off, the uedcina disappciins, the cuticle over the inflamed part
desquamates, and the patient regains his usual health. Very
fre<{ueutly he is conscious uf feeling better than he has been
for a lung time previously.

OOITT.

143

With improved strenfrth and spirits, bat little attention is
pnid tn hygienic rules; forgetful that the disease will return.
At 6rst, a happy time of two or three years inny elapse ; with
each paroxysm, however, the interval will shorten, until at
length, perhaps, the patient is hardly ever free from an attack,
except it may be for a few weeks in summer. At first, also,
it confines itself to a single joint; by degrees, sevfrni joint.'*
in both feet or in the hands suffer. Depasits — called tophi,
tophaceous deposits, or cbalk-stones — are formed around and
outside the joints, of n material reseuiblini;"' moist chalk, and
consisting of urate of soda; small spots of which substance
may oi\en olso be seen just beneath the skin of the auricle of
the ear.

The disease is generally spoken of as chronic (7011/ when the
attacks are numerous, and the constitution impaired by them.
The actual pain, perhaps, is not f|uite so intense as in the acute
form; but the distortion and partial or complete anchylosis of
the joints, the inipairment of the various dijjestive organs,
and the effects upon the kidneys, render these cases very
serious. Sometimes the coucretinns round the joints give rise
to suppuration and ulceration of the skin, and (hen masses of
urate of soda mingled with pus globules are discharged; such
discharges, however, ofteu proving beneficial to the general
health.

Complications. — In one variety, called by Cullen retrocellent
mout, luetastssig occurs from a joint to some internal organ,
more especially to the stomach. In such cases there is sick-
ness and vomiting, hcematemesis, violent spasmodic pain in
the ftomach, and great distress and anxiety. When the
retrocession is to the brain, it produces intense headache,
lethargy, and sometimes apoplexy or pjiralysis ; when to the
heart, dyspnoea and syncope.

A few years ago. Dr. Todd drew attention to a condition of
the kidney which frequently occurs in chronic gout, and
which he named the //'»»/// hidnef/. In this state the gland is
found contracted to one-half or one-third its usual size ; and

144

GENF.RAL PI8F.ABKS.

it has a slirivRlled appearance. The capsule is thickened and
opaque, and the surliice is grnnuhir. The decrease in gize
tflkcs place at the expense of the cortical portion. Oa
uinkiiig a section of a pouty kidney, white streak.s may some-
times be seen, chiefly running in the direction of the tubes of
the pyramidal portion ; which streaks, when microscopically
examined, are found to consist of crystals of urate of soda.
The urine in these cases is generally natural in rjuantity, of
low specific gravity, and coulains a small <|UiiDtity of albumen.
Thuro may be aWo more or less dropsy with this condition ;
while the cases frequently end in convulsions, delirium, and
coma.

Diaf/non's. — The diagnosis of acute guut is in general
simple enough. It is only likely to be confounded with
rheumatic fever, but the following distinctions may serve to
prevent any error. In gout the blood is impregnated with
uric ncid, in rheumatism this principle is absent; gouty in-
flammation is attended with the deposition of urate of soda in
the affected tissues, but nothing of the kind occurs in rheu-
matism; gout occurs in men, rheumatism in men and women
of|U!illy ; gout at first attac-ks only one or two joints — usually
the ball of the groat toe — while rheumatism affects many
and large joints : while, Ijistly, we must take into considera-
tion the general history, and the assigned causes of the
disease.

We sometimes nioct with puzzling cases where the gouty
diathesis seems to be developed in individuals who never suffer
from its local manifestations ; so that many obscure pains,
which are often regarded as local neuralgic diseases, are really
mere results of the poison of gout in the system. This has
been particularly insisted upon by Dr. William Gairdner, who
believes that the strumous is not more frequent than the gouty
habit.

When the heidth and strength have been much diminished
by frequent attacks of regular gout, decided paroxysms are
rarely experienced ; but the patient suffers severely and fre-

GOVT.

116

qnentlyfroui tl>e difiease in its irregular forms. The syinptonis
are then chiefly as follows: Painful dyspepsia, with heart-
burn; flatulency and constipation ; frequent attacks of fiiint-
ness and palpitation of the heart; nervous weakness and great
irritability of temper, so that the patient is feared by his rela-
tives, who too seldom make allowance for his sufferings; pain
in the occiput and nape of the neck ; diminished strength, so
that a little exercise fntigues, and noise or bustle alarms ; a.
desire for quiet and seclusion ; susceptibility to every atmos-
pheric change; and frequent annoying; neuralgic pains. As
these symptoms continue, the debility becomes greater, until
the entire system is ruined ; and the patient ether dies front
apoplexy; or from hydrothorax, caused by the disturbance of
the heart ; or from ascites, due to disease of the liver and
kidnej's; or even, perhaps suddenly, froiii profound syncope;
or he gradually sinks exhausted and imbecile.

Vau»e». — Women are much Ic8.s liable to this disease than
men. It generally begins between thirty and forty years of
age. It is often hereditary ; but more trequontly is ac<|uircd
by a luxurious mode of livinir, sedentary habits, and over-
mental toil and anxiety — especially when stimulants are re-
sorted to for the purpose of making this toil more support-
able.

Gout is especially induced by the use of port wine, strong
ale, and porter. Over-rich food \s a frequent cause, especially
when combined with the employment of port, sherry, &c.
Alcohol in the form of distilled spirits — partieuliirly gin and
whisky — has but little cff'ect in producing it. All depressing
influeuces — great fatigue, hajmorrhage, mental anxiety, po-
verty, &c — may eaiise an attack, in one predisposed. The
spring is the season in which the disea.se is mo.st apt to occur,
while the autumn niiiks second. Plumbers, painters, and
others who become the subjectj^ of lead poisoning, seem to be
pDriiculariy predisposed to gout.

Piilholii:/!/ — If we analyze the blood in gout we sliall Cnd
the L'lohulis in their normal proportion, unless the attack has

146

OF.NK.rUI. DISEASES.

been lorip; and has much flepreased the pntient, or unless the
diseuse has uccurred in a previously debilitated subject, vrhen
they Diny be considerably diminished. The fibrin is increased
in quantity if the local inflammatory action has been severe;
Bi> that it be augmented to five or six parts in 1000. The
specific gravity of the serum is lowered in the cases nrhere tbo
disease has been of long standing, as well as in those accom-
panied with albuminuria; but the important point with regard
to the scrum i.n this, — that it invariably cuntains uric acid ia
the I'urtu of urate of soda in an abaoruinl rjuantity. Dr. Gar-
rod points out that in health the merest traces of both uric
acid and urea can usually be detected by very great cure in
manipulation ; but this trace is by no means sufficient to be
detected by the thread esporiment. This gentlcuiAn says that
in several experiments on the blood in gimt and albuminuria,
where quantiljitive deteruiiuations were made, the amount of
uric acid in the 1000 grains of serum was found to vary from
0.045 to O.I7J> grain. Hence it seems very probable that in
uric acid we have found the actual mafericB morhi* Certainly
the benefit which arises from the use of colchicum confirms
this view, if it acts, as it probably does, by increasing the dis-
charge of urea from the system, such increase being accom-
panied by a decrease of the urates in the urine ; urea and uric
acid being plausibly regarded as correlative and vicarious
substances.

• Dr. Gorrai'$ P/ii» of a$f»iiaimng iht PrettHet of an Ahnorntal
Qiiaiiiiiy of Urir Acid in ihr Srnim of ihe Blixnl. — Take about two
drnobinr or the (eruin nnd plnce it in n flat glass dish or iratob-glua. To
this add tweiro drnps of acetic noid of the London Pharmaoopceia, uid
put in two or Ihrve threads of cotton, or one or two ultimate fibres from a
piece of unwashed hueknbaclc. Allow tbo glass to stand on the mantel-
piece, or on a shelf in a warm room, for from twenty-four to forty-eight
hours, until its contents set. from eTapornlion. If the cotton fibres b«
then removed and examined microscopically with an inch objeot glass,
they will be found covered wilh crystals of nrio acid, if this agent ba
present in Ihe serum- The crystals form on the thread somewhat lika
the crystals of tugnr-citndy on a siring. Henee this prooeu is termed tb*
nrto acid thread experiment.

Trentment. — The treatment of gout naturally divides itself
into that proper durinp an attack, and that to be adopted in
the interval. That this malady is curable, there is no doubt;
though it has been — and as Dr. Gairdner insists ever will be —
the opprobrium medi'conitn, if extirpation by means of the
medicines of the Pharmacopoeia bo only aimed at. The fit
may be mitigated, shortened, and often cut asunder by drugs;
but only temporary relief from this source must be looked for.

It is generally considered that bleeding during an acvte at-
tack is unnecessiiry. Dr. Gairdner well observes: "I am
convinced that bleedings to such an amount us is necessary to
subdue inflammation are much to be avoided in ^out. Those
who prescribe them will not fail to find out. in a very short
time, particularly in London practice, that they have sacrificed
their best resource in the cure — namely, the strength and sta-
mina of the patient ; and have made a lengthened and dis-
tressing case, where they meant to make a short and brilliant
enrc." Although, however, depletion is in every way contra-
indicated, yet thi.<5 physician states that he bus often found a
very small bloodletting (three or four ounces) productive of
the greatest good by relieving the overloaded heart and con-
gested vessels; but I would advise that even this be practised
with very great caution. Leeches arc sometimes applied to
gouty joints, but I have very rarely seen any benefit result
from the practice. — Laxative* must almost always be em-
ployed; not violent, but mild warm aperients, such as aloes,
senna, rhubarb, jalap, &c. The compound gentian mixture
will agree well, or any one of F. 173, 174, 177, 184, 185,
186. Anthony White, who had much experience in the treat-
ment of this disease, maintained that the liver was the organ
in which the poison of gout was elaborated ; and hence that
the physician's chief object should be to restore the natural
fanctions of this gland, as indicated by a copious discharge of
bile through the bowels. He relied almost exclusively on the
use of a pill made of one grain each of calomel, colchicum,
uloes, and ipecacuanha ; which at first was given six times a

148

nE.NKKAL DISEASES.

day, and afterwards every eight or twenty-four boors, aocoid-
ing to circuuistaiicei".

With regard to diurelirg and diaphoretics, there can be no
douht that they often do great good. Hence we may give the
acetate, cilrafe, or nitrate of potash ; we may administer some
preparation of opium; and often we may employ the hot-air
or the vapor bath with adviintage. But in all cases, speaking
generally, with these retiiedies we must combine colchicnm ;
since there can be no doubt that it may be ref;ardcd as a spe-
cific for the gnuty paroxysm. It ought not to be administered
until the bowels have been well opened, and it must be given
not (ns often recommended) so as to gripe and purge, but in
Bniali doses, easily borne without pain or inconvenience. Ten
or Bfteen minims of the wino three times a day, in Vicby
water, or with sedatives and alkalies, or with iodide of potas-
sium, will often suffice {F. 30, 35, 259, 271,426, 427). The
affected limb must be kept elevated and warm ; and the painful
part should be covered with cotton wool and oiled silk, or else
with an anodyne lotion (F. 38S), or with a poultice on which
some extract of belludnnna has been spread, or sonte tincture
of opium sprinkled. It is only in cases of chronic gout that
small blisters can be of any service. If the foregoing local
remedies give but little relief, thoy can do no harm, which
cannot be said of cold applications, iaeveral cases are known
where death has occurred in a few hours from patients plung-
ing their feet into cold water, with the idea of cutting short
the lit. And, lastly, during the early stages the diet must
be light, consisting chiefly of milk, arrowroot, tea, da. Dilu-
ents may be taken freely with advantage. But when the fever
has diminished, beef-tea, tisli, and poultry may be gradually
allowed, with perhaps a little good sherry or whisky well
diluted.

But the most important question is : How are io« to pre-
vent tht reliirit uj youtf Cleiirly, by entbrciiig the observance
of u well-regulated diet ; by exchanging a life of indolence for
one of bodily activity ; by adopting early and regular hours ;

QOUT.

I4y

l»y avoidinc too greiit sexual indulgence, as well as by omitting
all severe mentjil nppliwition, and by the aid of medicine.
Starving the disease will not cure it. An animal and vege-
table diet should be used ; the point being to take care that,
both as regards quantity and quality, the stomach can digest,
and can consequently extract healthy chyle from the materials
put into it. Ale, porter, and our heavy wines, especially port,
are injurious ; whisky or gin and water may gomctimcs be
allowed. It ia very probable, also, that some light wines —
such as claret, hock, a little good champagne, &c. — may be of
service rather than otherwise. The be.st medicines will be an
occasional mild purgative, and some of the neutral salts fre-
quently used. The citrate, tartrate, or phosphate of potash,
are valuable remedies, taken in very smnll doses, in half a pint
of water, onco or twice a day ; or a bottle of Vichy water may
be drank in the twenty-four hours, or a tumblerful of a weak
infusion of the leaves of the Fnixinus excelsior or common
ash — one ounce of the leaves infuso<l in a pint and a h.ilf of
water — may be taken on an empty stomach, night and morn-
ing. During the Inst two years Dr. Garrod has mode iiiany
trials of carbonate of llthia as an internal remedy, both in
oases of uric acid diathesis connected with gravel, and in
chronic gout. When given internally, in doses of from one to
four grains dis-solved in plenty of simple water, or of aemted
water, and repealed two or three times a d.iy, in patients
voiding uric acid gravel, it causes the deposits to become less,
or even to cease altogether. If a large amount of alkali be
desirable, the carbonate of lithia may be prescribed in combi-
nation with the carbonate or citrate of potash. My own expe-
rience with this remedy has been small ; but so far it has only
diaappointed me.

In chronic gout we must regulate the diet, maintain the
proper action of the bowels and skin, and trust to such reme-
dies as colchicum, alkalies, iodide of potussium, guaiacum, &c.
In weakly subjects, when the disease lingers about the system,
tonics — such as quinine and iron, do much good. The collec-
ts*

150

OKNEBAL UlSKASKS.

tions of chalk-stones should not be oponod. Mr. Spencer
"Wells sajs that they may be oltcti dispersed by the adminis-
tratioD of the iodide of potassium, which possesses the power
of dissolving urate of soda ; while local friction with the same
salt (F. 335) will ollen do good.

In attacks of irrej/ular or mixplaced gout, salines and col-,
chicuiu are generally needed ; while we should try to bring the
disease to the extremities by mustard pcdiluvia, &c. With
regard to retrocedciit ijout we must especially avoid cold, us
this is often the cause of the luetnstasis. Antispasmodics are
the remedies which give most relief; chlorotbrm, ether,
ammonia, and brandy being often needed. If the stomach be
affected, vomiting docs good ; and afterwards a sinapism or
turpentine stupe should be applied over the epigastrium.
Warmth or counter-irritiitiim may also be employed to the
juinU, to bring back the inllunimution.

After an attack of goat in any shape a wise patient will
take a thorough holiday. A visit to some of the mineral
waters — to Bath, Buxton, Cheltenhum, or Leamington ; or for
a greater, and therefore perhaps better change, to Wiesbaden,
Vichy, Carlsbad, or Aix-la-C'hapelle, will be productive of the
greatest beoelit.

XVII. EHETIMATISM.

Rheumatism is one of the most common, psiiifii!, and severe
diseases of this country. It arises from an ubiiorinal condi-
tion of tho blood. The action of the poison is not limited to
any one texture or organ ; though it particularly affects the
white tibroas tissue which enters into the formation of the
aponeurotic sheaths, fasciee, ligaments and tendons, and the
fibro-serous membranes. Oonscqacntly the parts most fre-
quently affected are the joints and surrounding structures,
with tho pericardium and endocardium. There are two forma
of rheumatism, the acute and chronic.

BHKDMATISM.

Iftt

I
I

1. Acnte Rheumatism, or Rheumatic Fever. — This
di8U!i6o is especially formiUuble from the suffering it ciiuses,
from the intensity of the fever, and from the diimsgc which is
8o frequently produced by it to the heart.

St/mptomit. — The earliest symptoms are usoally restlessncRS
and fever, with stiffness and aching pain in the limbs, follow-
ing exposure to cold and damp, and similar depressing in-
fluences. The pain quickly increases ; and in a short time is
accompanied by swelling and great tenderness of one or more
of the large joint*, together with high fever and much con-
stitutional disturbance. When the disease is established, the
f>atieiit presents a pitiable spectacle of helpless suffering. He
is very restless, yet dare not or even cannot move; the pain
in the affected joints is so agonizing, that the weight of the
bed-clothes can barely be borne ; the skin is generally batlied
in sweat, of a disagreeable acid or sour odor; the pulse is
full, bounding, and quick ; there is constipation ; the tongue
is moist, but furred ; the saliva is acid ; and the urine is high-
colored, scanty, of high specilio gravity, very acid, and loaded
with urio acid, or more frequently with urates. It has lately
J)fnn shown that the deposiLs formerly regarded as consisting
df urate of ammonia, have a variable composition ; being made
tip of the urates or lithntes of lime, potash, and soda.*

A remarkable feature in this disease is the tendency to
metastasis : thus the inflammation may suddenly leave one
joint and appear in another, and then in another, .<it\erwards
jumping back again to its original seat. But the most serious
change is when it shifts its place, or extends to the mem-
branes of the heart. This it is mo.st likely to do in severe
cases, when we may suppose the blood to be loaded with the
mcileries morbi ; in young persons ; and when the irritability

• TTrine eontaising an txeeu of urates may be dutingnUheU by it<
high color, increajed doiuity, and turbid appearance Trben cold — some-
what rewmbling pea-Boup. On applying beat to a portion in a teat-tube,
it becomes bright and clear. Examined by the miorosoope, an abundant
ansrphoua precipitate Is seen.

152

liENKRAL DI8KA8K8.

of the heart is great, as it is after bleeding and excessive pros-
tration. Since, however, rheumatic endocarditis and rheuma-
tic pericarditis do not differ I'roin simple inflammation of the
heart or pericardium — except perhaps in being less fata! — I
shall defer further notice of tlic signs of tiiese aHectious until
treating of tiie diseases of the heart generally ; mcrel)' urging
here, that as they are very likely to occur, their symptoma
should be daily and carefully looked for.

Rheunialic fever may also, but more rarely, be complicntod
with bronchitis, pleurLsy, pneumonia, or even with inflaramn-
tion of the brain or its tuerabranes : while very rarely the
local effeots are such as to lead to disorganization of one or
more of the affected joints. Whenever uncomplicated, its
average damtion under proper treatment is from ten or twelve
doys to eighteen or twenty. When death occurs, it is almost
always ftoni tbc cardiac itiflaiumation. When recovery takes
place after the heart bus been affected, the patient has very
often a sad time in store for him, — future bad health, palpita-
tion on any excitement, dyspiia'a, and dropsy. The great
majority of cases of acut« rheumatism occur in persons
between fifteen and forty years of age. Undoubtedly it is
sometimes hereditary.

Patholoiji/. — Dr. Prout first suggested that the presence of
a superabundance of lactic acid in the system was the cause
of rheumatic fever ; a view which has been since entertained
by many authors. Dr. llichardson has made an interesting
series of experiments; from which be infers that " lactio acid
has the power, when existing in an animal body in excess, of
producing a class of symptoms attaching themselves mainly to
the fibro-serous textures, and which, regarded in all points of
view, arc essentially the symptoms of acute rheumatic inflam-
mation."* Thus he injected into the peritoneum of a healthy
cat, seven drachms of a solution of lactic acid with eight of
water. Two hours after the operation the action of the heart

• Tkt CauM of iht Coagulation of ikt Blood, p. 389. London, 18M.

RRKDMATISM.

1-|3

became irretrtilar ; in four honrs more the animivl was left fur
ihu ni^ht ; and in the n)orniiin it wn.s found deiid. The in-
spection showed no perilonciil niischief, but the most luurkeil
endociirditis of the left cavities of the lieurt. The initrul
valve, thickened and iitfluuied, wu8 coated on it« free borders
with firm fibrinous deposit. The whole endocardial surface of
the ventricle was intensely vascular. On repeat inj; the ex-
periment on a dof;, the inspection revealed most striking
pathological signs of endocarditis. The tricuspid valve was
inflamed and swollen to twice its ordinary size. The aortic
valve, swollen and itiflamed, was coated on its free border with
fibrinous beads. The endocardial surface was generally red
from vasculiirity. The pericardium was dry and injected. As
before, the peritoneuui escaped injury. The joints were not
affected, but there was distinct sclerotitis il the left eye.
Again, in a third instance not only did endocarditis result,
but there was well-marked vascularity of the sclerotic, and
various joints wore affected ; while there was mctarjtasis, now
one joint suffering, then another, and again the heart. As
Dr. Richardson remarks, it has yet to be learned by experi-
ment whether acids of an analogous character to the lactic —
such as fbnnic, acetic, lithic, and butyric — will produce the
same results.

In rheumatic cudocarditis, the left side of the heart only is
affected as a general rule. Ilcncc Dr. Richardson infers that
the chemical change whereby the materiea morbi of acute
rheuniali.sm is produced, is completed in the pulmonic circuit ;
that in the respinitory act the avid fjuulity of the poison is
produced ; that thus formed, the poison is carried by the
arterial circulation to be disposed of by decomposition, or
elimination, or both; and that it docs not return as an acid
by the veins, but simply as a product which admits of re-
tmnsformtttion in the pulmonic circuit into the acid state.

Kegardiiig the origin of the lactic acid, Dr. Headland sug-
gests that ordinarily the starch of the food is tirst converted
into this agent, which then combines with oxygen to form

154

OENKRAL l)I8EA*<EP.

carbonic ncid and water, in which state it is excreted by the
lun^ ; but that under conditions unfnvorablo to this series of
changes, the lactic acid accumulates.

Trrulmtnt. — A vast number of different plans have been
recommended in this disease. Veneneetion will merely give
temporary relief, at the expense of future Buffering; while
remembering also that it increases the irritjibility of the heart,
and consequently predisposes to rheumatic inllummation of
this organ, I should, as a nile, never resort to it. Saline
purt/dli'veK (F. 16f(, 181, 185, 197, 205), given so as to obtain
one free evacuation daily, will be beneKcial ; especially after
the bowels have been weli acted on by a large dose of calomel
and julap. Opiairs in full doses are usually necessary to
relieve the pain, and to allay the general irritability; they will
also help to •encourage sweating, and thus aid nature in
eliminating the poison by the skin. Two grains of solid opium
may be given every night; and unless the skin acts freely, 6ve
grains of the compound ipecacuanha powder every four hours
will do good. The cGieacy of the latter will be increased
if the nitrate of potash be substituted for the sulphate in
making it (P. 261.) Quinine in large doses has been used by
some phy.sicians, but I am not in a position to speak of its
effects. Lemon-juice, in two or three ounce doses, repeated
three or four times a da}', bus been recommended by Dr. Owen
Rces; who couaiders that the citric acid undergoes changes
in the stomach, supplying oxygen to such eleinenis as tend to
produce uric acid, and inducing thereby the formation of urea
and carbonic acid instead. The result of its use, however, has
not been such as to make mo recommend it; for I have not
only found it fail to do as much good as other remedies in the
few instances in which I have tried it, but more than once
alarming depression has been induced.

The treatment which I believe to be the best is essentially
the same as that advised by Dr. Garrod, Dr. Fuller, &c. It |
oousists in relieving the pain by opium ; while the alkalies and
their salts are freely adniiriistered to correct the abnoruutl

HHEt'MATISM.

Id5

•

condition of the blood and excretions. Thus, from two scru-
ples to one dracbin uf tbc bicarbonate of potash or soda may
be given every three or fear honrs, in half a bottle of soda-
water, or in an .effervescing citiiite of aninioiiia or potash
dnupht; continuing it regularly until the articular affection
and febrile disturbance are very much lessened, till the pulse
is reduced, and the urine rendered alkiilitie. If the patient
be robust, and the urine much loaded with lithates, ten min-
ims of the wine of colchicuni may be added to each draught.
So also the hot-air or vapor bath may be siniultaneously
employed, if the perspiration be scanty. Duiiii<; convales-
cence, few mcdicim'.s will do so niiich good as bark and ammonia,
with subsequently some mild preparation of steel.

The iliel should at first be low, consisting of slops, arrow-
root, &c. Directly there are signs of depression, good beef-tea,
milk and lime-water (F. 13), or prepared milk [F. 14, 15)
may be administered ; and, if necessary, wine — especially
sherry in soda-water. In the early stages, when there is much
thirst, a refreshing saline drink {F. 420, 4*21, 425) will be
beneficial ; or plenty of good lemonade may be allowed. Sugar
is bad for the dyspeptic, the gouty, and the rheumatic ; for it
is transformed into fat, lactic acid, and other substances which
readily disagree with the stomach. Moreover perfect rest
must in every ca.'<e be enjoined, and all sources of mental
anxiety shonld, if possible, be removed.

With regard to the Iwa/ renu<lirx, it may be remembered
that great relief is often e.\pcrienoed from wrapping the
affected joints in cotton wool and oiled silk, by which a sort of
local vapor bath is formed. So, wheti the wrists or ankles are
chic6y affected, I have seen benefit arise from frequently
Bonking them in a hot alkaline bath ; or from fomenting theui
with water to which a mixture of the bicnrbonute of soda and
opium has been freely added. When the acute symptoms
havo partially subsided, smiill blisters, the size of a penny
piece, may be advantageously applied ; or, the swollen joints

15«

OENERAI. DISEASES.

may be paintod with iodine (F. 252), and then covered with

wool.

Supposing any signs of cardiac affection — such as Tiolent
and irroi^ular action of the heiirt. prajcordial pain, altered char-
acter of the sounds, dyspna-ii nnd fever — manifest themselves,
what is to be done ? Most authors say, apply leeches over
tliD region of the heart or resort to penernl blcedinp, and
quickly get the pystem under the influence of mercury. If
the remarks which have been made in the section on inflnm-
raation, however, are true, no such remedies will bo necessary ;
and, I believe, it will be better merely to get free cutaneous
action by the administration of opium or by the use of the vnpor
bath, and lu .-upport liic .system. 1 h.ive now been able fully to
carry out this pinii in many !4orere cases of rheumatic pericar-
ditis ; and the rii|)id recovciy of these patients, together with
the general train of symptoms during the treatment, has con-
vinced me that I am bound to strongly recommend it. Shonld
effusion take place into the pericardium, the :ipplicaiion of a
blister, or of a succe.'^sion nf blisters, will dn great pix)d ; and,
perhaps, diuretics with the iodide of potassium may, in certain
iiistnncea, be beneficial.

2, Chronic Rheumatism. — This is sometimes the sequel
of acute, but mure commonly I believe a sepiinito constilu-
tiijiial afl'ectiun, comin;; on i[uitc independently of any previous
acute attack. It is apt to I'ullow ^(jnnrrha'u ; hence one variety
of this disease has been ttTtncdi/ONO/'/'/iorfi/ rheumatism. The
librous textures around the joints, or the fibrous envelopes of
the nerve.?, or the aponeuroti(^.shenths of the muscles, the fasciae,
and tendons, or the periosteuni, are the parts which suffer. In
any case there is, at first, little constitutional disturbance; bat
the sufferer is constantly annoyed, and his existence made mis-
erable with chruiiic paints, causing hiui to bo restless at night,
and destroying ail comfort during the day. In some instances,
the pains are worse at ni^lit, being aggravated by the warinih
of the bed ; in others, warnith afford.'- tht- greatest relief; tbc

RHEUMATISM.

157

former is usually the case when the blood is oireiilating a poi-
sonous luuterial through the systora, ns iu venereal rheumatism,
or in that due to dernnj^eraent of the digestive organs and
secretions ; the latter, in rheuiuatisni of an erratic kind,
dependent on cold, kc.

There are two or three different /ormi of chronic rheuma-
tisni. Thus, rheumatic inflaiinuation of the lutiibar fusciu is
termed lumhnijo} tiie pain bt-ing referred to the fleshy mass
of muscles oa one or both sides of the loins, and being
increased by every movement of the back. In eclulica the
suffering is due to disease affecting the sciatic nerve j but it
will be treated of in describing the forms of iieunilgia. When
the intercostal muscles, or the fibrous fasciaj lining the chest
are affected, the disease is called ^i/cu*'f«////!i'(j.

The diaynosis of chronic rheumatism is generally easy.
There are, however, certain painful muscular affections which
Mimetinies simulate it. These pains — mi/alyia — are familiar
to us all as " soreness and stiffness," following upon some
extraordinary exertion; but they are not always as readily
recognized when they occur during convalescence from any
long illness. Yet it is clear, that the mere sitting upright
in a chair, without any support for the head or arms, may be
Ijiatiguing to some of the muscles — e. //., the trapezius — of
Ri invalid, as the ascent of Mont Blanc may prove to an ordi-
nury gentleman only accustomed to a daily desultory siiuiit«r
through the parks. The.se muscular pains are not uncommon,
also, in persons suffering frura general debility. They have
their scat in the fleshy parts of muscles, in their tendinous
prolongations, or in the (ibrous aponeuroses. Dr. Inman, of
Liverpool, in a pjiuiphlet on this subject, states th.it they are
usually described as hot nr burning ; ihcy are absent on rising
ill the morning, and incvea.se with fatigue; thopuin is referred
to some muscle or its tendon, and is relieved by relaxing or
■npportiog this muscle ; the pulse is gcnenilly weak and fast,
but is unaffected by the pain; and the patient frei)uently
»uffcrK from cramps. The diagnosis is inip<jrtant, because if

158

OENERAL PI8EA8E8.

we foil to administer ferruprtnnus tonics nnd nourishinj: diet,
or to afford proper rest and support to the weak muscles until
tlicy regain their tone, we shall fail to give any relief to the
poor sufferer; who, possibly, in his justifiable contempt for
meilicine, wii! hasten to fry the cood diet and pure air oCHuoie
bydropnlhic establishment, and then circulate reports of bis
cstraordinnry euro, " after bciiis; given over by the faculty."

In the ircaiment of chronic rheumatism it is always
necessary to attend to the genera! health, as by doing so the
disease will often be materially niititrated. There are several
special remedies which give relief, the best being the iodide
of potassintu with serpentaria ( F. 27). If the secretions are
very acid, liquor potassa* should be combined with them (P.
28). The uiistura guaiaci, cod-liver oil, cinchona, liquor
potossaj and bark, the nil of turpentine, colchicuin, sarsapa-
rilla, sulphur, and the hydrochlorate of ammonia with bark,
have all their advocates. (F-SS, 36, 62,53, 54,66,65,84, 86,
464.) AVheu the symptoms are very chronic, the alkuline
waters of Vichy do good ; or, if there is constipation in addi-
tion to rheumatism, the antacid springs at Carlsbad may be
advantageously visited. The latter, however, take a longer
lime to act on the sy.stem than the former.

Hot-water, or hot-air, or vapor baths — either plain, or alka-
line, or medicated with sulphur — are often very serviceable in
this disease, especially when the pains are severe. During
the intervals of the attack, the tepid salt-water .sponge bath
tihould be employed every morning with a flesh-brush, coarse
towel, &c.

Local applications to the painful parts, such as blisters,
iodine paint, and stimulating or anodyne liniments (V. 262,
336, 346, 348), often give temporary relief. In lumbago, a
large belladonna plaster, or (he emplastruin ferri, applied over
the whole loins, will be productive of great comfort. Dr.
O'Connor recommends the external application of sulphur —
either powdered or as an ointment — with bandages of new
flannel ; the latter being again covered with oiled silk, to

RtlEl'MATOID ARTHRITIS.

15fl

increase the wartntfa, and obviate any disagreeable smell.
When the pains are decidedly relieved by heat, acupuncture
is said always to pive ease, and often to effect a cure; but 1
have had no experience in its use. All suiferers from chronic
rheamatism should wear flannel, and beware of exposure to
dump and cold. They must also be careful in their diet, and
should particularly avoid beer and heavy wines; as I am con-
vinced that many paroxysms of this disease are brought on
through disorders of the digestive organs,

XVIII. RHEUMATOID ARTHEITI8,

It liiis been a matter of some controversy whether gout and
rheumaligm can cucxist — in other words, is there any disease
which oao be regarded as a compound of these two afiections '(
Dr. Garrod has long maintained that such a disease as the
terra rheumatic ijout implies, is never seen ; and this opinion
is now almost undisputed. The cases usually spoken of under
this name arc examples of chronic arthritit, or chronic rtteu-
malic arthritis — rheumatoid arthritis seema a better term;
which affection may be described as a chronic inflammatory
afl'ection of the joints, not unlike gout in a few of its charac-
ters, somewhat resemblinv! riiciimatism in other points, bat
differing essentially from both.

Rheumatoid arthriti.s is often one of the most troublesome
and obstiiiate affection.^ which the practitioner can have to
treat. It may attack eiiher the large or small joint.s, or the
temporo-maxillary articulation, or the articular processes of
the vertebrae — especially of the cervical region; but the hip,
lioulder, and elbow or knee, appear to be the most favorite

Bts of this disease. It may also be a constitutional, or simply
a local disorder. Thus, Dr. llobert Adams remarks that,
" when we observe it affecting all the joints in the same indi-
vidual on both sides syninietrieiiily, we may feel assured that
the chronic articular affection in such a e;ise has proceeded
from Bome deep constitutional tuiut. In the majority of such

1(50

(iKNKHAI. llISfEASKS.

cases we Rhall, I believe, discover that the general chronic
affi'ction has been iinmcdialely preceded by an nttack of rheu-
matic fever, from the linperint; remains of which the chronic
rheumatic arthritis had evidently sprunjr"* On the other
band, as a local disease it may arise from accident or from the
over-use of some particular joint. Id the examples which
have come under my own csire the nffection lias been constitu-
tional, and it has seemed to nie that mul-assimilation has ^'en-
emlly been at the root of it. Home of the most annoying
oases, moreover, wliich I have met with, have occurred in
women at the critical period of life ; thou;;li I have also seen
it in girls at puberty, and in men at different ages.

The ni/mploms consist chiefly of pain, swelling, and stiffness
of the affected joints. In acute cases the di.scaso may come on
abruptly with considerable fever and i;oncr.il disturbance ; but
usually the affection a.ssumesa chronic form, cominencinir with
lan^ruor, restlessness, loss of appetite, and vitiated secretions.
The joints then become stiff and painful, while effusion into
the synovial membranes causes them to appear .swollen and
distended ; and if the hip, knee, or ankle be the parts affected,
there is more or less lameness. If we plivce a hand on each
side iif the joint, tluetuation can soiiictioK-.s be deloclcd ; or, if
we grasp the part, a distinct kind of crepitus may often bo felt.
A peculiar craoklinp of the joints on mnvcinent is also appre-
ciable to the patient. If the disea.«e is nf long continuance a
degree of rigidity may occur from thickening of all tlie articular
textures, e<[iial to that produced by bony anchylosis ; or the
joint may even become cjuito disorganized from a gradual
wasting of the cartilages. In addition to the foregoing, the
articulations become nmre or less deformed; there are fre-
quently painful spasms in the muscles of the affected limbs;
there is groat mental depres.«ion, and general lassitude ; there
is dyspepsia with acidity of stomach and flatuleacc ; the rest

• A Trralitr on Rheumalie Ootit ; or, Ckrom'c Hheumalie Arlhritii
ii/a/l iJu JuitUt, p. 0. London, lUil.

HHKDMATOIt) ABTIIRtTIS.

ini

at tiijzht is disturbed, and every chnnge in the weather is felt;
whilu owing to tlic languid circulation the putient suffers
much from cold. The compluint often lasts for several months.

With regard to the morbid anatomy of rheumatoid arthritis,
the following points are worthy of notice. If the disease be
in an early stage, the synovial membranes are found thickened
and distended with a quantity of synovial fluid ; while inter-
nally the hypertrophied synovial fimbriae are seen as va.scular
tufts. Id a more advanced state the capsular membranes are
of increased density ; the articular cartilages are more or leas
absorbed ; while the cxpased surfaces of the bones either
pre.sent an ivory-like appearance frota the friction they have
undergone, or the fine caneelli are kid bare. The heads of
the bones are generally enlarged in an irregular way owing
to new 06sific deposit; while frequently the joints contain
numerous cartilaginous or bony foreign bodies, cither loose, or
attached by little pedicles to the articular surfaces.

If mention be made of the patholo</y of this disease it is
only to show what the affection is not. Dr. Todd believed
that this rheumatic affection of the joints might be most cor-
rectly described as an abnormal nutrition, occa.«ioiied by the
presence of a " peculiar matter" in the nutrient fluid ; uflordiug
certain points of resemblance to simple chronic infiammation,
yet differing from it in a niiirkcd manner. What this " pecu-
liar matter" in the nutrient fluid may be, we do not know;
but it is certain that it is not uric acid, and there is no
reason to believe that it is lactic acid.

The trratmenl is often very unsatisfactory, and always
tedious. A generous diet, without sugar or beer; exercise in
the open air, with warm clothing; mild aperients, especially
the sulphate of soda ( F. 185, 225) ; cod-liver oil ; warm douches
over the affected joints; and vapor or hot-air baths, may be
used in all cases. Then, as a special remedial agent, I have
found most benefit from ar-senic ; which must be given alone,
or with quinine, .*iyrup of iodide of iron, iodide of potassium,
liquor potasse, taraxacum, or colchicum. {F. 68, 69, 70, 72,

1«2

OENERAL PIREA8R6.

and IS). Each of thcBo drugs has also been separately landed
by different writers. If the gums be pale and spongy, lemon-
juice does good; or the mineral acids (F. 458, 460, 4G3) are
occasionally to be recommended. I have seen guaiacum (F.
63, 54) prove useful ; I have also occasionally been pleased
with bark and serpentaria (F. 493); and whore the skin is
inactive and the nervous system depressed, twenty minims of
the tincture of ariiiea montaiia thrice daily, cotnbined witb
other remedies, is worth trying. Some practitioners recom-
mend the repeated application of leeches to the affected part,
but they must be used cautiously if at all. Blisters some-
times do good. I am fond of strapping the joint with the
iodide of potassium or the mercurial pliuster spread on charooia
leather; a proceeding which is occasionally varied by covering
the part with sulphur ointment and applying a flannel band-
age, or by Using a lotion made of equal parts of glycerine,
compound tincture of iodine, tincture of aconite, and tincture
of opium.

Other means failing, recourse must be had to the internal
&nd external use of the Harrowgate, Buxton, or Bath waters, at
homo; or to the springs of Aix-la-Chapelle, Wiesbaden, BadeD-
Baden^ Carlsbad^ or Vichy, abroad.

PART II.
FEVERS.

Fever (Pyrexia) may be defined thus : After a prelimi-
nary stage of languor, weakness, defective appetite, and some
degree of chilliness or shivering, there is preternatural heat of
body, increased waste of tissue, acfeleration of pulse, great
muscular debility, and disturbance of most of the functions.
This morbid state accompanies many diseases as one of their
phenomena — symptomatic fever; but under certain circum-
stances we meet with idiopathic fevers, which are quite inde-
pendent of any local lesion.

Much has been written on the c!as.sification of fevers, each
author having some favorite arran-jement which does not
always simplify the subject. In order to be as clear as possi-
ble, I shall consider the different varieties of fever according
to the following plan :

I. Continued Fever.

1. Simple Fever, or Febricula.

2. Typhus Fever.

3. Ti/pho id Fever.

4. Relapsing Fever.
II. Intermittent Fever, or Ague.

III. Remittent Fever.

1. Simple Remiltenl Fever,

2, Yellow Fever.

1(54

FEVEB8.

IV. Eniptive Fevers.

1. iSmal/'Pox.

2. Oow-Pox.

3. Chuken-Fox.

4. Meaifet.
6. Scarlet Fever.

6. Erf/iipelai.

7. Playue.

I. COUTINTTEB FEVER.

Continued Fever is so called from the fact that it pursaes
its course without any wcli-tuarkcd remissions.

The cause of fever is the contami nation of the blood by
some morbific agent. When this change — the nature of
which is unknown — has proceeded to a certain extent, the
researches of Dr. I'urkes teach us that the nervous system, or
rather that part especially connected with nutrition and organio
contractility, bej^ins to suffer alterations in composition. The
moscles, and probably some of the orpnns, deprived more or
lc58 of nervous influence, beiriu to disintegrate, this disin-
tegration producing undue heat ; the condition of the vagoa
and vasi motor nerves induces increased action of the heart
and dilatation of the vessels; the contaminated blood is still
further deterioriitcd by rceeivinj; the rapidly disintegrating
tissues, by the continued action of the morbid agent, as well
as by the functions of the lungs, liver, spleen, &c., being im-
peded; while as no food is taken, the various alkaline and
neutral salts no longer pass into the system.

There are four varieties of continued fevers: 1. Felrkula,
which is non-contagious, and arises from over-fatigue, errors
in diet, and exposure to the sun's rays. 2. Ti/phus, which ia
infectious, occurs amongst the poor, and is duo to some poison
generated by famine and destitution, as well as by over-
crowding in prisons, workhouses, or ill-ventilated rooms. 8.
Typhoid, met with equally amongst rich and poor, generated

CONTINUED FEVEP..

icr.

by the putrid emanations from deeayinp; animal matter, most
prevalent in aututtin, and which, though iiifectinus, is less so
than typhus. 4. Rf/nptim/ /evf.r, very contagious, and which
Dr. Murchison believes will be proved to be produced by
famine alone. To show the relative prevalence of the dif-
ferent forms it may be mentioned, that durinj^ the ten years
endint^ with December, 18.57, there were admitted into the
London Fever Hospital 0628 cases of fever; of which 801
were Febricula, .S506 Typhus, 1820 Typhoid, and 441 Re-
lapsing fever. With the exception of the years 1850 and
1851 there was a preponderance of typhus; but in one of
these two years the typhoid cases, and in the other therelaps-
inpr, were in excess. There seeuis to be a comparative im-
munity from typhus in certain years in London; a.s may be
shown by the returns for 1858 and 1859, in which years there
were admitted into the hospital only 63 examples of typhus
a<rainst 356 of typhoid fever. Moreover, in neither of these
years was there a single instance of relapsing fever, although
in 1851 there were more cases of this kind than of any
other.

1. Simple Fever or Febricula. — This variety of fever,
when it runs an uncomplicated course, is always a mild
disease; having a variable duration of from one to t«n days.

It commences for the most part without any warning; the
patient being suddenly seized with lassitude, disinclination for
bodily or mental exertion, loss of appetite, sickness, headache,
dull aching of back and limbs, coldness of the surface —
especially of the back, and often shivering. At the end of a
few hours, in most cases, the chilliness passes off, and the
skin becomes dry and hot ; the pulse is then found hard —
Bometimes full and bounding — often small, wiry, and rapid,
100 or VlO, or even 130, in a minute ; there is increased head-
ache and restlessness; a dry and furred tongue ; urgent thirst;
constipation; and the urine is scanty and higb-oolorcd. More-
over, the patient usually complains of pains in his limbs, or of

160

FKVKR8.

a feeling of soreness over his body; he rapidly emaciates; his
countenance becomes pale nud haggard ; he niny have eli^rht
delirium ; and he seems very seriously ill to his friends. An
exacerbation or afrgravation of all the symptoms frequently
occurs towards night; with a slight remission at the approach
of morning, when sleep is often obtBiQcd. These symptoma
usuiilly continue for three or four days : when, frequently on
the fourth day, sometimes on the fifth or sixth, the tongue
becomes moist; the skin gets less harsh and dry; the head-
ache and pains in the limbs abate ; and then a profuse sweat-
ing follows, whifh proves the natural crisis or t«rn)inatioD of
the disease, leaving the pnticnt iunguid and exhausted, but
with a pulse of the natural standard, and a complete freedom
ftx)m the fever. Convalescence gradually and slowly takes
place, some weeks often elapsing before the patient thoroughly
regains his flesh and strength.

Simple fever is very seldom attended with any danger, and
is not infectious. Nosologists have divided it into dilTerent
olaasos, according as one particular organ has been more
affected than another ; so that in some books we find unneces-
sary distinctions into brain, catarrhal, gastric, mesenteric, and
bilious fevers.

All fevers seem disposed to run a certain course, and to
terminate naturally in the re-estiiblishment of health when
uninterfered with by art. But, as in the treatment of other
disease, there are certain general objects, called the iinlica-
tioiis of cure, which must bo kept in view. In fever these
indications are — 1, to moderate, where necessary, the violence
of arterial excitement by saline laxatives, rest in bed, and low
diet ; 2, to supjiort the powers of the system as soon as they
begin to flag ; H, to obviate local inflammations and conges-
tions ; and 4, to relieve any urgent symptoms as they nriso.
It was well observed by Pitcnirn — " I do not like fever-curers.
Yon may yuitie a fever; yon cannot cure it. What would
you think of a pilot who attempted to f|uell a storm ? Either
position is equally absurd. In the storm you steer the ship as

CONTIMED FEVER.

IfiT

well as you can ; and in a fover you can only employ patience
and judicious measures to meet the difficulties uf the ciise."
What these judiciou» meamirfi are the reader will be able to
deduce from the remarks on the treatment of typhus.

2. Typhus Fever. — This form of fever is eminently con-
tagious and infectious ; it often prevails epidemically ; and it
is the accompaniment of destitution, being generated in over-
crowded and ill-ventilated dwellings.

Si/mptomg. — After the reception of the fever poison there
is commonly a period of tncHftn!ii>ii,in which the patient com-
plains of chilliness, nausea, loss of appetite, thirst, languor,
and headache. The duration of this precursory stage varies ;
but it is usually short, and ends in the symptmus which ore
common to many acute affections. Those are chiefly dryness
with heat of skin, thir.^t, con.stipation, rapid pulso, dry tongue,
prostration, and muscular pains; while towards the evening of
each day there is great irritability and restlessness, causing a
wakeful night. The peculiarity of the disease is the typhus
rath — sometimes called a morbilliform eruption, from its
resemblance to the efflorescence of measles — which appears
between the filVh and eighth days from the commencement of
the disorder; and which consists of irregular spota, of a dusky
or mulberry hue, disappearing on pressure, and feeling as if
slightly raised above the skin. These spots may be few and
single, or they may be numerous and large owing to the coale-
scence of several, or they may bo pule and produce merely a
mottled appearance; their number and depth of color will be
found to be in proportion to the severity of the attack; they
aro most commonly seen on the chest and abdomen, and then
on the extremities ; in a day or two they become of a brick-
dust color, and only slightly fade on pressure; while each
patch of eruption remains permanent til! the end of the fever.
This eruption is often accompanied by petechia;. It is very
rarely indeed absent in adults ; but in children, particularly in

168

FEVEKR.

it it! only three enscs out

III fid ca!>cs, it may perhaps be [
of Hiur.

During the first week the patient generally complains much
of headache; the sense of toste is impaired, as is also that of
smell ; there is loss of appetite, but no symptom of intestinal
irritiition, no flntulenee, no diarrhoea ; the tongue is brown
and dry, and in grave cases becomes almost black and covered
with offensive bloody sordes; while the urinary secretion is
generally natural. The weakness which affects the muscular
systom is remarkable ; those who have been strong and robust
becoming so powerless that they cannot turn in bed, while the
countenance gels wasted and pinched to an extreme degree.
Muscular twltchings of the face and hands are not uncom-
mon ; or there may be some irritation of the diaphragm
causing troublesome hic<'up. — Ddiriuui is seldom present
bclbre the end of the fiiat week, and the way in which it
then comes on is worthy of notice. The patient from being
perfectly rational passes through every j;rade of delirium,
perlmps in the course of two or three hours, to the most wild
and furious perversion of mind. At first there is merely
" wanderiup," and the suil'erer is conscious every two or three
minutes that he is talking nonsense; then there is confusion
of ideas with vague rambling talk, from which he can be
roused; this is followed by illusions, espcciiilly of the senses
of hearing and vision; and then every function of the mind
becomes disordered by unreal images and aberrant trains of
thought, which cannot be corrected by any exienial impres-
sions. Sometimes this delirium ends in coma; but in favor-
able cases it gradually passes off in three or four days, and
the patient begins to recover his memory and other mental
powers.

With regard to the condition of the heart, Dr. Stokes points
out that it is liable, in common with other organs, to suffer
fmm organic and functional alteration ; in one set of cases
there being excitement of the heart, while in another class
we may find depression, but neither of these results being

CONTINCKI) FEVEH.

169

■

due to inflammalloD. A progressive loss of inipuli^ as well
as of the systolic sound, slow pulcc, siphing rcppir.ition, and a
tendency to syncope, are the principal iiidicafions of the de-
pressed state of the heart; this depression being generally
due to a softened state of the walls of the venf ricles, especially
on the left side, though undoubtedly the heart may be found
simply weakened withoiit softening. Conversely, a strong and
jerking impulse, with distinctness of both sounds, indicates
the excited condition ; in which, however, the pulao will be
found feeble and the extremities cold, while occnsionnlly there
is loss or diminution of the second sound. The production of
a murmur, in connection either with the excited or depressed
state of the heart, is of rare occurrence.

The lungs may also become secondarily affected; and the
danger may thus be increased by the oecurrenee of acnte
bronchitis, or pleurisy, or pneuninnia. The hitter may run on
to pulmonary gangrene, which is almost always fatal. Id a
few instances there has also been inflammation of the larynx
and pharynx ; and in a still smaller number of cases, inflamma-
tion of the brain or its membranes.

The approach of convalescence is in the majority of cases
gradual, being indicated by a diminution in the nervous symp-
toms, by the eruption completely fading away, by the tongue
getting cleaner, and by the partial return of the muscular
power; while the pulse also beats more quietly and with less
rapidity, the appetite improves, and the patient sleeps at
night. The amendment generally begins between the tenth
and sixteenth days; and only occasionally is preceded by some
critit, SDcb as a prolonged sleep, or copious sweating, or an
attack of diarrhoea, or the deposit of a hirge quantity of urates
in the urine.

When the disease proves fatal, it usually does so between
the twelfth and twentieth days ; death being preceded by very
great prostration, retention of urine, involuntary defaocation,
the formation of bed-sores, great rapidity and weakness of

tiiBultus teudinum or involuntary muscular twitchings,

170

FEVERS.

lividity of conntenance, very rapid breathing, and Boranolence
passing into stupor or coma.

Diagnosis. — A great deal has been written as to the identity
or non-identity of typhus and typhoid fever; oiid the subject
is sufficiently iinpurt.int to demand eonsidemble attention.
Until very recently these two fevers were generally confoun-
ded together, and reparded as merely two stapes of the same
affection ; being fre(|uenfly described as typhus, or low nervous,
or jail, or hospital, or camp, or malignant fever. There appear
very good grounds for believing, however, that they are essen-
tially distinct diseases ; attended by different important symp-
toms; and due to different blood -poisons. They commence
much in the same way, and at first present the same features,
as simple fever; and like it, they occasionally become compli-
cated with inflammation of the brain or its membranes, with
bronchial congestion, or even with pneumonia. But they
differ from /ebricula thus: instead of terminating in the crisis
of sweating, in typhus and typhoid fever the symptoms increase
in severity; the febrile action becomes much ujure intense;
in each case the pulse becomes more frequent, weaker, and
more comprcs.<!ible ; the tonpiic grows drier and browner; cer-
tain cniptions show themselves ; mure sordes, and of a darker
color, accumulate on (he teeth and lip.'*; the hand.t are moved
restlessly toand fro;* the fajces areoften pns.«cd involuntarily;
bed-sores are produced unless great care is paid to keeping the
patient clean and dry, &c. ; delirium ensues; there is great
prostration of the vita! powers; and often a strong tendency
to death by exhaustion or coraa.

The way in which typhufi and typhoid fever differ from

w The^e movements of the bunds were well described by Ilippooratea
more than 2O0O ytart »go : "I bare made those observations upon tba
mnrements of the hands. In acute fevers, in peripneumonias, in phreni-
tis, and in headaches, the bands moved to and fro before the face, banting
throogb the void, as if gathering bits of straw, piclting at the coverlet,
or t«aring objects from the wall, are all so many bad and deadly symp-
lonu." — T/u Book of Prognottiet

OONTTNCKD FKVEK.

171

each otber may he btst shown by a cuinparisoii of thfiir most
prouiiriettt ^yiiiptuiiis. Thus, in li/pliH», the eruption consists
of a mulberry rii)>h, coming out between theHftij and eiglith
days, and JHstin^ until the terniiniititin of the disease ; the
general hue of the skin being at the same time dusky and
mottled. In typhoid fever the eruption is Ibrnied of rose
spots ; aj)pe.aring uputi the thorax, back, and abdomen between
the seventh and fourteenth days; being thinly scattered, so
that they often require to be carefully looked for, and even
then probably are not found in at least ten or twelve per cent,
of the cases; and then in two or three days fading and giving
way in one place to a new and equally sparing crop on another
part. — In lyphits, diarrheoa seldom occurs, and hBemorrhage
from the bowels never. In tt/fthniil, diarrhiea ia very common,
and there is haemorrhage from the bowels in about one case
out of every three. In an eKoellent monograph on these
fevers, by Dr. Jooner, publislied in 1850, this gentleman
shows that in all the fatal cases of typhoid Jfuer which he ex-
amined, the agminatcd glands or Peyer's patches, situated in
the ileum, were found ulcerated ; the ulcerations increasing in
extent as they reached the ileo-caecal volve. In a few instances,
also the solitary glands were ulcerated; and one-eighth of the
oases recorded died from extension of the ulceration, with per-
foration of the intestine. As regards the cases of typhus,
ulceration did not exist in a single instance. — Typhut may
occur at any age, while typhoid fever rarely attacks persons
after forty, and is most common in youth ; the former is less
dangerous than the latter; and lastly, relapses do not occur in
typhun, while they occasionally happen in typhoid. — Both
diseases are contagious, but each propagates itself, and not the
other ; an attack of the one does not act as a preventive to in-
fection by the other at any future period. In typhus the
duration of the symptoms is from fourteen to twenty-one days,
whereas in typhoid it is not less than thirty days : moreover, in
the former ihc danger increases until the end of the second
week, when the disease reaches its maximumj whereas in the

172

FEVERS.

liittor the uiiixiiiium is not nttaitied fur at least a week longer.
In eitlicr case it occasionullji Imppcns that the patient Falls a
victim to the disease at the very ons«!t ; knwked down, and
killed lit once, as it were, hy the virulence of the poison,
i^penktnr; generally, Dr. Murchison shows that the rate of mor-
tality (roni continued ('ever, during a series of years, ha.s differed
hut Itliie in ihc various liospitala of England and Scotland,
being about one in eight. The fatal cases in typhus aod
typhoid are one in between five and six ; whereas in relapsing
fever they only average about one in forty.

Id some very few cases both typhus aud typhoid fever have
existed to'^ethur in the same individual; a circuiustancc which
is no 8tnin<;er than the coe.Kisteiiec of typhus and erysipelas,
or of uioask'S and siuull-pos.

Morbid Aiiiiinmi/. — A case of typhus may run its course and
end fatally, without leaving any traces of its existence. In
the majority of ca<<e9 there is nothing more than slight conges-
tion of the niucuus surfaces of organs.

When the case has been complicated with secondary aSbc-
lionx, we of coursi- look to the organs which havesulVcred. The
brain is seidoin altered ; but there may be engorgement of the
sinuses, or conguUien of the cerebral subtttanoe. The pianiatcr
is occasionally loaded with blood, and sometimes there has been
found slight h;omorrhagc into the cavity of the arachnoid. The
effects of infiamnjHtion may, perhajw, be discovered in some
part of the respiratory apparatus ; while occasionally the muscu-
lar substance of the heart ii< found soft, so that it is easily torn.
The couditiuti of the alimeivtary can:>l is nonual ; the liver is
healthy; while in about half the cases the splcvn is sotlened,
and in a much smaller proportion is likewise enlarged.

The blood enntains a deticieiit amount of librin ; and ac-
cording to some authorities, an increased cjuantity of oorpus-
oles. Dr. Richardson says that in a case of typhus which he
examined duiitig life, the presence of ammonia in excess in
the bi>dy was iudioated by prominent signs. The cliief of
these were that the breath was so markedly ammoniacul that it

CONTINUED FEVER.

coated acidiSed glass with crystals of the chloride oramnionium,
and restored the blue color to reddened litmus ; the blood-
corpusclea were misshapen, agploiuerated, and partially dis-
solved, precisely as they arc found when weak solutions of the
alkali are added to healthy blood; while the symptoms were
also those of alkaline poisoning. These tests are more delicate
than that of holding a plass rod moistened with dilute hydro-
chloric acid before the mouth ; thuu<:h if, when this is used,
there is distinct evidence of white fumes, it is sufficient to
prove that the amount of amruonia expired is beyond the Dor-
Dial proportion.

Treatment. — When it is possible ttie practitioner should
choose for his patient a large, well-ventilated apartment; which
ought to be free from bed and window curtains, carpets, and
all superfluous furniture. The chloride of lime, or a weak
solution of the chloride of zinc may be used as a disinfectant.
A fire in the room acts as a ventilator. All unnecessary inter-
course between the patient and his friends should be forbid-
den ; while care must be taken to select one or two trustworthy
nurses, since much depends upon their fidelity and compe-
tency.

Id the early stages, and in the whole course of mild cases,
it is particularly neces-sary to beware of doing too much — of
interfering too actively with Nature. It ought to be remem-
bered that we cannot cure these maladies any more than we
can cure scDall-po.x or measles; and therefore our aim must be
to keep our patient alive until the fever poison has expended
itself. In opposition to this opinion, however, I must mention
that Dr. Goolden, I'hysiciau to St. Thomas's Hospital, informs
me that, after more than ten years' experience, he regards
quinine in large doses iis utmost a specidc for cutting short
cases of typhus and typhoid fever. He gives ten grains in
solution with a few drops of diluted sulphuric acid, every two
hours, until an effect is produced — i e., until either the fever
is lessened, or cinchooism la induced ; and be thus continued
it for three days. He states also that it may be given even if

174

FEVERS.

there be diarrhtea irith bloody stools ; that he haa never see
it do harm ; and that it has saved hopeless cases. Qaioine
when thus ailininisturcd acts on the nervotis system and on the
heart a.s a depressant ; hence the patient's powers must be
snpported with beef-tea, and wine or brandy.* It is often very
advant.i^euu.s, when the patient is seen early, to comtuenoe the
treiitDient by the aduitnistration of an emetic, the ipecacuanha
wine in doses of one ounce, with plenty of warm water, being
preferable to antimony or the powdered ipecacuanha ; while
at the same time a purcrntive, to thoroufihly clear the intes-
tines, will generally be usrcful. All other medicine had better
bo avoided. At this stage the pitlcnt's unea.sy sensjitious will
be much soothed by sponging the surface of the body with
cold or tepid water. Dr. Ariujtat:;c speaks highly of the uso
of cold affu.-sion, especially where there is a tcodency to stupor,
or where the delirium threatens to merge into coma; but I
cannot help thinking that the tepid sponging is a much safer
proceeding. When there is a great degree of in-itability, the
warm bath, 93° to 95° Fahr., prolonged for three-quarters of
an hour, oiiiy be very useful. In all cases a freo supply of
toast-water, iKirley-watcr, plain water, or ice, may be allowed;
while sometimes I have found a drink containing the dilated
hydrochloric nr pho.sphoric acid (F. 422, 424) very grateful to
the patient. The diet should be restricted to milk, farinace-
ous food, and thin broth.

Directly the powers of life begin to fail — as soon as there
u signal loss of strength, a dark-brown tongue, a rapid feeble
pnl.se, or an abruptness and weakness of the first or systolic
sound of the heart — %\ stitnulaling plan of treatment should
be commenced, by ordering strong beef or chicken tea, with
wine or gin, or the mistura spiritQs viivi gallici of the London
Pharniacopcoia, or brandy. The last is, in my opinion, the
agent generally to be preferred. It should be given in small

• Dr. DaotU.', of LiTcrpooI, hu >1<o gUen srideooc to (aror of Or.
Ouoldi'n'i tUw< in hi> work on Fevar.

CONTINUED IKVEB.

175

Ipiantities — 5ij to ^ea, or even 3j — in water or beef-t«a
every two hours, or every hour, or even — in bad cases — each
half-hour; the effect produced being closely watched, and its
repetition guided by such effect, reniembering that severe
febrile Bymptonis do nut coiitruitidicate it. When its fr«|uent
adriiinistrtitioD i.s culled for, cure must be taken not to allow
ihe patient to sleep too long without it. One is naturally un-
willing to rouse a patient who may have previously been with-
out sleep for days, to give biin hi.s nourishment; but unless
we do so at each appointed hour, ho ia not unlikely to awake
and pass into n state of fatal collup.se.

When there is much general irritability and sleeples.-fness, a
Well-timed dose of opium will work wonders; it being better
to give about half a grain of the extract every three hours
until the ptitient is eulined, tlnni to give a single large dose.
If there bo much heiKhic lie, injected conjunctivje, or active
delirium, the opium may be guarded with a small dose of
ipecacuanha, or perhaps even of tartar emetic, as recomnieuded
by Dr. Graves. Some cold lotion may also be applied to the
scalp; or if we fear any cerebral effusion, blisters may be ap-
plied to the temples.

The secondary affections which occasionally arise are not to
be looked upon as ciinlraindicating the use of stimulants. I
aiu sure that 1 have seen fever prove fatal, because the practi-
tioner has thought that pneumonia was also present, and hits
been conscfjuently afraid to aduyinister wine or brandy. But
while giving stimulants in these pulmonary disorders, we should
also apply turpentine stupea to the chest, or siDapisuis, or plain
lin.sced poultices. — In every ca-ie, the skin over the hips, sa-
crum, and other prominent parts of the body should be fre-
quently lo<)ked to; so that if there be found any redness or
tenderness, we may at once order a water-bed. The bladder
ought aUo to be daily examined, lest there be retention of
urine. — Under this luuuagement, the patient may often remain
in a very precarious state for some days; but at last he will

176

FEVERS.

begin very gradually to reuover, slccpiiifr much as he improves.
A course of tonics will uttiinately eoraplclc the cure.

3. Typhoid Fever. — An endemic, slightly infectious and
contagiou.-i Tcver, most prevalent in autumn, and generated by
putrefying animal matter. The effluvia from drains, or the
contamination of drinking water by the sewage making its way
into the wells, are frequent sources of this disorder. It attacks
rich and poor indi^eriminntely ; but is particularly a disease
of early youth antl ailolescenee.

Typhoid fever has been described under many names; such
as abdominal lyphuii,/i:ljn'ii putriihi,tjai'lro-hUious. fever, fehrit
gaitr!cii,fehri« mairnleriia ma/iijnn, 9ud niffhtsoil /ever. In
the present day many writers justly object to the appellation
Typhoid ; since, in the first place, this term literally means
" like Typhus," and the disease is essentially diflerent; while,
secondly, the word is often used us an adjective, to designate
a set of symptoms which come on in the course of many acute
diseases, and hetice may arise confusion. It has therefore
been proposed to call it Enteric /fvfr ; but Dr. Murehison
thinks it undesirable to have a name derived from the abdo-
minal lesion, as such may tend to revive in the minds of many
the exploded doctrines of Uroussais. This pentleimin, there-
fore, looking to the cause of the affection, suggests the appel-
lation of Fj/thngenic fever, — jroffo^'tv;};, froDi -KuOan (izuOufiat,
pntresco), and yivvdu).

S^rnptomn. — The disease usually sets in slowly and insi-
diously, to that the sufferer feels languid and uneasy without
being exactly able tu define the nature of his sensations. In
a day or two, however, he has chills, headache, intolerance of
light, thirst, complete loss of appetite, and pains in his limbs;
followed by a sense of weakness, a quick soft pulse, a ten-
dency to diarrhtea, more or less drowsiness, and a disinclina-
tion to sit up. At night there is great heat of skin and rest-
lessness, while the bed is hot and unconifortuhle ; change of
posture gives no relief, and the patient is tormented by a fierce

CONTINUED FEVER.

177

thirst which nothing seems able to assuage. The expression
of the couutunaace now gets altered ; and there is much
anxiety and depression, a dry brown tongue, and some abdo-
minal tenderness.

These symptoms slowly become aggravated ; until at the
commencement of the second week the characteristic eruption
generally begins to show itself on the chest or abdomen, in
the shape of rose-colored dots. Thes« spots hardly exceed
a lioe in diameter, they ore few in number, are circular, dis-
appear temporarily on pressure, and fade away in two or three
days to be replaced by a fresh crop; this latter going through
the same course, and so on agaiu and again until the end of
the fever. They are seldom accompanied by true petechiae.
Altbough the r(«c-colored rash is never met with in any
other cases, yet it is certain that typhuid fever may sometimes
ran its career without our being able to discover a single
spot. Dr. Tweedic thinks that in ten or twelve per cent,
the rash may be absent. Occasionally sudamina also appear
on the neck, chest, abdumeii, ur inguinal regions, about the
eud of the second week ; while the skin is warm, and at times
covered with sweat.

Amongst the other symptoms which may bo present we
frequently have violent dcliiium ; spasmodic contractions of
many of the muscles, and hiccup; tinnitus aurium, or deaf-
ness; muscular pains with debility ; and occasional attacks of
epistaxis. The belly is also enlarged, and resonant on per-
cussion ; while carciul pressure in the right iliac fossa often
gives pain and causes gurgling. At a later stage, meteorism
or tympanitis, from the accumulation of nir in the colon, may
give rise to much distress, and rcr(uire to be relieved by the
passage of a long stomach-pump tube. There is sometimes
nausea and sickness, but almost always diiirrha>a; which gene-
rally increases towards the end of the second week, so that
there may then be eight or ten stools a day, some of them
ctintiiiniug blood. Occasionally we thus havu .wrious attacks
of haemorrhage from the ulcerated patches in the ileum and

178

FEVERS.

cecum ; one of which l(if:t!c.« miiy oither produce fatal syn-
cope, or so depress the pntient that he has no power left to
bear up npiinst the continuance of the disease. Another
danger to be feared is the extension of the ulceration till the
coats of the bowel ore perforated; an oecurrcnee whieh may
take pince and cause falHl peritonitis at an advanced sta^e of
the fever, or even just as we hope that convalescence in setting
in. This chance of rupture U)n.st a\so be retneiubered by the
phyKiciiiii in exauiiiiini» the abdomen by palpation ; while it
ought certainly to forbid the euiployuient of purgatives after
the lapse of the first two or three dnys from the setting in of
the di.'^ease. The symptoms of intestinal perforation are well
and curtly laid down by Louis, who says that "if in the course
of a severe or slight typhoid affection, or even under unex-
pected cireuriistanees, the disease having been latent to that
uioinent, there supervene suddenly, in a patient with diarrhoea,
abdominal paiu aggravated on pressure, altered expression of
the features nnd more or less quickly nausea and vomiting,
there niu.st be perllpnitiori of the small intestine."

There are other perils, too, which jeopardize the patient's
safety. Thus, as in typhus, we may have some cerebral com-
plication ; or a pulmonary affection may set in, such as bron-
chial catarrh, pleurisy with effusion, and pneumonia. So, too,
the di,«case may destroy life from the simple eshaustion which
it induces, though this occurrence is rare. Typhoid fever is
often prolonged to the thirtieth day, and in some few instances
is foil iwed by a relapse. During convalescence — as happcDs
also after relapsing fever — a venous murmur in the neck may
not unfrequcntly be heard ; while on nusculting the heart an
inorganic systolic bruit ciin often be detected, having the soft
blowing eharncter generally observed in anteniio murmurs.
Dr. Stokes states, that it usually disappear.'? or diminishes on
the patient nssuining the erect position; while it if quickly
cured when tonics iind suinible nourishment can be borne.

Morbii} Anntomif. — It is only necessary to allude, under
this bead, to those alterations which are found in the ileum,

C30RT1NUED KEVKR.

179

probably as the remilt of the fever poison ; since they consti-
tute the true puthologieal peculiarities of typhoid fever. We
may find, it is true, congestion of the brain or its uieuibrnnes,
or ulceration of the ccsophaj^us, or foftenitig or ulccriition of
the mucous membrane of the stomach, or enlargement and
softening of the spleen, bat these changes are in do woy to be
regarded as essential elements of pythogeiiic fever. The two
lesions which may be said to be invariably present, are certain
changes in Peyer's patches, and in the corresponding glands
of the mesentery. The alterations in the agminated glands or
Peyer's patches, are the most marked in the groups of glands
which are nearest the ileo-csecal valve. If the case has ter-
minated fatally at an early stage, we may merely detect a
swollen condilion of the mucous membrane over the diseased
patch ; or we may, perhaps, find the typhoid deposit more or
less copiou.«ly effused into the solitary glands, as well as into
the tissue of Peyer's patches. But death generally happens
at a later period — tow:iidf llioendof the third week — and then
we find that the patches have undergone ulceration ; the fever
product having been transformed into a brownish slough,
which has become detached, and has loft a cavity or ulcer of
a sire varying from a pea to a florin. Perhaps one or more of
these ulcers, instead of cicatrizing, may have been the imme-
diate cause of death', owing to their extension until perfora-
tion has happened and allowed the escape of the intestinal
contents into the peritoneum. The mesenteric glands in the
neighborhood of the patches are very generally enlarged and
BoAened ; and occasionally they have been seen in this condi-
tion when the intestinal lesion has only been very slight.

Treatment. — This is in most respects the same as that re-
quired in typhus; but thereare two or three exceptional pointa
which require notice. When the disease is seen at its com-
mencement emetics do good ; and we may administer an ounce
of ipecacuanha wine every eighteen or twenty-four hours for
the first three days. Aperients, however, should seldom be

1«0

FKVKRS.

given, US the bowels will most probably net sponJaneonsly ; but
if they do not do so, a simple enema may be administered.

With regard to the intestinal irritation and diarrhcea, no
remedies are so useful as astringents combined with opium j
which may be adniini8t«red by the mouth or rectum (F. 122,
124, 131, 138, 139, 140, and 146). If there he hsBmorrhage
from the bowels, wo must carefully apply cold over the abdo-
men, and adojinistorgallie acid with opium (F. 132). In such
instances the patient must be assiduously watched by his medi-
cal attendant, and wine or brandy administered in exact pro-
portion to the demand for stimuhmts by the system. The skill
of the physician is shown by his commencing the remedy at
the proper time, and adrnini.sterinf; it to the requisite amount :
but this power can only be acquifed by assiduous study at the
bedside.

During convalcitcence greater care will be required than
afier other forms of continued fever; since any irritation ap-
plied to a cicatrizing ulcer in the ileum will pos.eibly affect it
unfavorably, nnd re-excite that morbid action which may end
in perforation. Tonics are to he carefully given ; none being
more suitable in the commencement than some preparation of
bark. The return to a generous diet must be very gradual, no
solid food being allowed until the tongue has become clean
and moist, the pulse soil, and till all feverish excitement has
vanished ; until which time, also, the patient should neither be
allowed to leave his bed, nor even to sit up much iu it.

4. Relapsing Fever. — The name of rdapting or recurrent
ferrr bus been bestowed upon this infectious disease, owing to
the fact that at a certain period of the convalescence there is a
relapse of all the symptoms. Epidemics of it have been re-
cognized, during seasons of famine and destitution, since 1789 ;
and have been described under the various names offivt-dat/
ftver, ieven-day /ever, bilioua remittent /ever, mild yellow
/ever, n/norha, and Irish /amine /ever.

The rymplomi commence abruptly with rigors, frontal head-

rONTINUEn PEVER.

181

aclie, and muscular piiina ; while soon felmle renclion sets in,
find we find prcat boat of skin, anxiety of countenance, into-
lerance of liprbt and sound, a white tonfrao, and n full rapid
pulse. (Joiiiplaint is made of urcient thirst ; and often there i»
pain nt tlie epipnstriuni, with voniitinp; of a bitter bilious fluid.
When night comes on the symptoms become njreravated,
giving ri.«c to much irrilnbiltty and sleeplessness. As the dis-
order advances there if. also constipation, scanty high-colored
urine, sometimes jaundice, and increasing prostration ; but
just as matters seem to be assuming a tlireateninc aspect, on
about the fifth or seventh day, a profuse perspiration breaks
out over the whole body, the fever disappears, and the patient
is left almost free from the disea.ie, though weak. The conva-
lescent, of course, fancies that his troubles are over, and that
tonics and nourishment will soon rc-forc him ; butthe npyrelic
interval is short, for about the fourteenlli dfiy from the com-
mencement of the disorder, or the seventh from the critical
sweating, there is iin abrupt relapse with a repetition of all the
symptoms. Generally about the third or fourth day perspira-
tion again sets in, and for a second time is followed by complete
relief; the return to perfect health being then nipid, except in
the aged and such as were previously in a bad state of health.
Moreover, it is very rare that a second or third relape takes
place. ,

Troublesome sequelse sometimes delay recovery; such as
muscular weakness, oedema of the legs and feet, boils, or oph-
thalmia. When relapsing fever occurs in pregnant women
it has a greater tendency than many acute disorders to cause
abortion or premature labor. It is seldom fatal ; but some-
times death takes place during the progress of the fever from
eudden syncope. No special le.'ion can be detected upon
making a post-mnrtem examination ; but often the liver is
discovered to be enlarged from congestion, and still more fre-
quently the spleen is found considcnibly increased in size.

The treatmriit is very simple. Gentle aperients will at first
be required ; while afterwards we should order refrigerating

182

FKVER8.

drinkf, a farinaceous diet, ami perfect repose. Where there
is much irritability <ipiatos are useful ; and if the prostration
be great, wine and nnurishinent will be needed. The head-
ache may snuietitnes be rolicvod by dry cupping to the napo
of the neck, and by ullitwiiifi the patient to drink freely of
coffee. Quinine has been frequently giveti in the hope of
preventing the relap.se, but it docs not seem to hitve exerted
any bcuclicial influence-

II. INTEEMITTENT FEVER, OR AGUE.

Intermilttnt, or Puludal, or Periodic Fever, or •'l.'/iir, may
be defined as a disease chiefly due to marshy miasms, in which
the febrile phenomena occur in paroxysms, nrc ui^hered in by
rif^ors, and end in a critical sweat. Duri(j<j the remission
there is good health ; but at the end of a, definite interval the
pheDomena arc repeated, and this happens again and again
until a cure is effected.

Varieties. — There are three species of intermittent fever or
ague, viz., QuoliJian, Tertian and Quartan Aijtie : of which
the tertian is the most coin inoii in this country, and tlic quotidian
in India. When the paroxysm occurs at tho same hourevery
day, it is called quotidian ague; when every other day, tertian,
though sccuiidan would be more appropriate; and when it is
absent for two whole days, and then recurs, quartan. In the
first species the interval is twenty-four hours; in the second,
forty-eight ; in the third, seventy-two. The time between
the coniuiencement of one paroxy.'iin and the beginning of the
next is termed the interval ; that between the termination of
one paroxysm and the commencement of the next, the inler-
mi$»{ou. In quotidians the paroxysm occurs, for the most
part, in the morning ; in tertians, at noon ; in quartans, in the
afternoon. The first is most coainion in the spring; the s«-
cuiid, in the spring and autumn ; the third, iu the autumn.

CnuKt. — The itreiiiipating cnutei of ague are fatigue, tn-

INTERMITTENT FEVER. OR AOUE.

183

vellinp, reetlesflneas, exhaustion, mental depression, improper
or insufficient food, intemperauee, esjiosurc to the night air,
and the circumstance of once having suffered from it. It is
worth reiiieuiberioc thut tnahirious districts are most danger-
ous at night, utid (hat tlii.s poison lies low ; or, as Dr. Watson
says, " loves the ground." The exciting cauxe consists of cer-
tain emanations jr invisible etHuvia from the surface of the
earth, known as malurtu. These cttiuvia or miasms eiunnatc
chiefly from marshy hinds; hiit their nature is still a mystery,
for though cheuiist.s huve ana!y7.ed the air of malarious dis-
tricts, they hare not been able to detect any poisonous princi-
ple. The (general belief, that malaria is produced by decom-
posing animal and particularly vegetable matter, is probably
true; the air being more noxious where both matters are
undergoing deca^', than where vegetable matter alone is doing
80. At all events, it is found in the tropicji that muUrious
diseases are most oommon in the season succeeding the cessa-
tioD of the rains; when the teinpcraturo is high; and in parts
where the surrounding country abounds in dense jungle and
low swamps, and where insects and reptiles are abundant.

The form of disease which arises from exposure to malaria
varies pos.sibly according to the conslttutioual predisposition of
the individual ; that wliich will produce ague in one person,
giving rise to remittent fever or to dysentery iu another. So
agnin when the poison hasbecD imbibed, it may remain latent
in the system for sotnc week.s or even months ; n point neces-
sary to remember in the diagnosis of obscure cases where the
ague fit is not well developed.

Si/mploms. — The disease may set in suddenly ; or the symp-
toms may come on gradually with a feeling of general indis-
pasition, which at the end of a few days culminate in a regu-
lar paroxysm. An ague lit is composed of three stages, — the
cold, hot, iind swealiii;;. The rnhl stage is ushered in with
feelings of languor and chilliness, though the hwit of live body
itioy not be really lcs.sened ; then sensations us of streams of
Culd water running dowu the back are complained of, and

184

FEVERS.

shivering ; the skin is shrivelled and the papilla} rendered
pruniineiit — poose skin or cutis anserina — from the cootmutioD
of luicniscopiciil uiusdcs called the arrectores pilorura ; the
teeth chatter, the nails turn blue, and the whole frame is
shaken ; there is exhau8tion ; often urgent thirst; the counte-
nance appears anxious, the feutures shrunk and pale, and the
eyes dull and hollow ; the pulse is sniull ; the respiration hur-
ried and oppressed ; and there is a peculiar mental irritability.
The duration of this stajie varies from half an hour to three or
four hours, and is gradually .succeeded by (he hut st«;;e, which
is one of reaction. The .lurtiice of the body then becomes dry
and intensely hot, the temperature being raised considerably
above the natural standard, fur Dr. Muckiiitoiih says that ho
has known it to be an hij;h as 110° F. in Great Britain; the
mouth is parched ; there is excessive thirst ; frequent bound-
ing pulse, with a painful sense of fulness in the head ; and
great restlcasness, general uneasiness, and sometimes delirium.
This condition continues rarely less than three or more than
twelve hours, and then follows the isu.'fu/i'n^ stage; commencing
with a gentle moisture, which appears first on the forehead
and brea.xt, increases, and gradually extends over the whole
body. The pulse and breathing become natural ; the head-
ache, heat of skin, and thirst abate; the bowels and the kid-
neys act freely, the urine containing an iucrea.seJ quantity of
uric acid ; and all the distressing symptoms are relieved, so
that the patient, if the case be recent, often feels in perfect
health. Occasionally, however, and especially in tropical cli-
mates, this stjigc enj.s in great exhaustion ; so that the free
use of alcohol is required to prevent fatal collapse.

Effei-li. — Disease of the spleen is a very frequent con-
comitant or result of intermittent fever. This gland is
found enlarged, sometimes to a great extent, and occasionally
indurated ; in which condition it is popularly spoken of as
a(jue rnlce. Some authors say that the spleen may be fouud
invariably to enlarge during the cold stage ; owing to the blood
being driven from the surface of the body to the viacora, but

INTERMITTENT KEVEK, OR AUUE.

186

eopoolally to this organ. The enlurgetnent subsides during
the iiilflriiiission, but not completi^ly ; so thiit iifter eacli nttjick
the size of the gland is a little greater than it was previously.
In like manner, morbid changes occur in the liver; giving
rise to depraved secretions and disturbance of all the digestive
organs, and in a few cases to permanent enlargement and
induration.

In protracted cases complications are not unlikely to arise;
and the brain, or the lungs, or the stomach and bowels, ntay
become the seats of inflauimatory action.

Treatment. — When the patient is obliged to remain in a
malarious district, the difficulty of curing ague will be very
much increased. The diet should be gix)d and nourishing,
with a regulated supply of stimulants, from the first; unless
these is evident derangement of the nlvine secretions, and
then we must commence with beef-tea, arrowroot, &«. In the
cold stage, warm diluent drinks — as barley-water, weak tea,
or weak negus, or white-wine whey, may be freely allowed ;
while the application of external warmth is to be assiduously
employed, by means of warm clothing, hot bottles to the feet,
and hot-water or hot-air baths. The latter may be easily pre-
pared by means of a long wicker-work cradle, closed at one
end by a board. This is laid over the patient and covered
with blankets ; a curved tin tube is then pa.sised through a
hole in the centre of the board, the other end of the tube
expanded info a bell looking downwards, ntid having a spirit
lamp placed beneath it; and thu,ii the iiir under the wicker-
work soon becomes rerj hot. An opiate given a little before
the cold stage, is often beneficial. During the hot stage an
opposite plan should be pursued ; cooling drink.s being then
required, while the surface of the body is sponged with tepid
or cold water. When the hot has gub.«ided into the sweating
stage, the action of the skin should be encouraged by tepid
drink«.

Purgatives must always be given at the outset ; four or sis
gniins of calomel, and the same of rhubarb, followed by an

186

FF.VERS.

aperient dniuphl. The bon-ela having been thnroiiizhly emp-
tied, the use of one of the two specific rcinudics for ague —
burk or arsenic — niny be coinujenccd. The b<.'St plan is to f^ivc
two or three grains of the disulpiiute of quinine dissolved in
the compouud infusion of roses, every four or six honra, during
the intermission; taking care to continue its use for some short
tiuie after an apparent cure has been effected. In Indiau
intcruiittents the exhibition of quinine in a scruple or half-
drui-hu] dose, instead of sinall«r portions frcfjuently repeated,
has been strongly advocated. These iiuantities are generally
well borue unless there is exhaustion, when they would be
dangerous ; cinchonism being less readily produced in ague
than in other afToi'tioiis. If it be desirable, on account of its
cheapness, to enipltiy arsenic, it must be remembered that large
doses will be needed (F. G8 or 72). Br. Morchuad culuulutes
that half a grain of arsenious ncid — one drachm of liqaor
potas.sa; nrsenitis — is equivalent in power to Bfteen grains of
quinine; but as such a dose of arscuic can hardly be given
without some risk, he has suggested tbut it is better to prevent
the expected fit by ijuininc, and then trust to mudenite doses
of arsenic to complete the euro. The salt of the willow bark
(saliuine) has been recommended as a substitute for quinine;
but it is by no means as efficacious. In ca.«es of enlargement
of the spleen, great benefit will bo derived fruni a combination
of quinine and sulphate of iron, perseveringly used (F. 449,
452) ; or perhaps from the bromide of potas-sium (F. 51).

In treating the coiiiplieatioiis we must carefully avoid deple-
tion. Quinine is still the remedy to trust tn, the dose being
large in proportion to the urgency of the symptoms. Intropi-
od regions it sometimes happens that a patient is not seen until
he is delirious or comatose ; but even then an active purgative,
followed by a scruple or half a dracliui of quinine, may soon
restore consciousness and health. If troublesome vomiting
prevent the retention of the remedies, a large blister should
be applied over the stomacli ; while an enema of quinine and
infusion of coffee is administered. In malarious distriota it

REMITTENT FEVEK.

187

will probiibly be found that pwd diet, warm clothinfr, Jind a
due uinuuiit of rofinse, arc tnuub more ciTectual propli^'luetics
that) any prep»nitioa uf bark.

III. KEMITTENT FEVER.

1. Remittent Fever. — The causes of remittent fever are

the Kline as those of the disease just described ; and hcace we
iuij:ht appropriately speak of it under the desijjnutioii of niins-
mutie or paludal remittent fr.ver. The symptoms also bear a
rcMMiiblance to those of interuiitlcnf fever; with this notable
diflference, however, — (hat in the intervals there is no cessation
of the fever, but simply an abatement or diminution. The
period of remission varies from six to twelve or fourteen hours ;
at the end of whieii time the feverish excitement increases,
the exacerbation being often preceded by chilliness and rigors.

This Ibrin of fever varies mucli in severity accordiu;; to the
nature of the climate in which tiie poison is generated. The
autumnal reniillents of countries like England iind France are
wjniparativcly mild ; whereas the endemic remittents of tropi-
cal climates Bre often very severe and fatal. Moreover the
locality where the fever prevails socms often lo impress some
peculiarity upon it, especially as regards the nature of the com-
plications which arise ; and hence wo find rctnittent fever
described under the names of the Walcheren fvver, the Medi-
terraneuu fi-vtr, the Jumjlc or Hill fever of the East Indies^
Jieni/al fever, the Biliout remittent of the West Indies, Sierra
Leune feoer, Jifrican fever, &c.

Sj/mplvins — The paroxysm of remittent fever commenoes
usually with chilliness, languor, lus.<itiido, mental depression,
a feeling of cold down the buck, and headache. To these
seosalioDS soon succeed febrile symptoms, constituting the hot
stage; the prominent phenomena consisting of great heat of
skin; severs headache and giddiness, often accompanied by
delirium ; a frequent and full pulse ; a dry and furred tongue ;

188

FEVERS.

nauseii and vomiting — f^nerelly of bilioas matter ; sense of
pain at the epi<!nstrium, nnd tenderness on preesare ; with

tWgns of puImoDury congeiilion, such ns dyspnoea, a feeling of
oppression at the chest, cough, and a livid color of the coun-
tenance. The urine \s often scanty, high-colored, and loaded
with lilhatcs; but it is passed in increased quantities during
the reini-ssions.

The remissions usually occur in the morninf;, and have a du-
ration generally of ten or twelve hours. The principal exacerba-
tion ^enemlly takes place towards the evening, and continues for
the greater part of the night ; though sometimes the paroxysm
lustfi for twenty-four, or even thirty-six hours. The disease

p.Biay run on for about fourteen or fifteen days, unless shortened
by proper treatment, nnd then terminate rather abruptly in an
attack of sweating ; or its symptoms may merge into those of
low fever. The period of convalescence is usually ehort, except
snnie organic mischief has occurred; in which case conmder-
allc time may etupsc before a restoration to health is effected,
the debility being kept up by night-sweat<<, sleeplessness, dy.«pep-
sia, hypochondria.sis, neuralgia, jaundice, and even dropsy.

In tropical clinintes remittent fever may prove very dan-
gerous from the general severity of the symptoms and the
high degree of febrile reaction ; or from a depressed condition
of the vascular and nervous systems, with defective secretions;
or from the sudden seltitig in of great exhaustion towards the
close of an exacerbation, which exhaustion has a great ten-
dency to end in fatal collapse ; or, lastly, from its being oom-
plieiited with convulsionii, or with delirium pa.ssing into drow-
aincs? and coma, or with groat gii.«tric irritability, or with
bronchitis and pneumonia, or with hepatitis and jaundice.

Treiilmf.nl. — The principal iiidieiitions to be followed must
be the same as are demanded in tlie trcutment of ague ; if the
supposition that both are due to malaria be correct. At the
sanie time it must be remembered that, as the febrile exacer-
bnlion is uf niuiJi longer duration in remittent than in inter-
BiittcDt fever, so there is a greater fear in the first of internal

KKMITTENT FEVEH.

189

orgnns being damaged, and ultiriuitoly of more severe depres-
sion ensuing. Our object must therefore be to shorten the
period of the exacerbation, and lengthen that of the remission;
and this we try to do by saline and effervescing draughts (F.
413, 414, 417), cold drinks, an aperient if tlie bowels are
confined, an emetic of ipecacuanha (one scrnplc of thepnwder,
or an ounce of the wine) if tliorc be nausea without vomiting,
and fre(|uent tepid sponging of tlie whole surfuco of the body.
Immediately retnission tjikes place n dose of ijuinine, varying
from two t<> six grains, should be exhibited, and repeated every
third or fourth hour; taking care to omit this remedy directly
the hot stage again sets in. At the next remi.ssiun wo again
resort tn the bark, and so on until it seems certain that the
febrile phenomena have permniientty disappeared. If the
bowels are sluggish, one or two ol" the doses of quinine may bo
oonibincd with two or three drachms uf sulphate of niiignesia ;
or, in the event of the stomach being irritable, with an effer-
vescing draught; or, if there be diarrhcea or restlessness, with
half a grain of morphia.

In tropical cliroutea the complications of remittent fever
must be treated very cautiously. When there is much cere-
bral derangement, an active purgative, with the constant ap-
plication of cold to the head, or the occasional use of cold
afTusioD may prove very bencBcial, in addition to the remedies
already mentioned; while if there bo great drmysiness during
the remission, a blister should be applied to the nape of the
neck. On the contrary, the low delirium with drowsiness from
exhaustion demands the free use of stimulants and nourish-
ment. When th« stomach is irritable, or when [here is jaun-
dice, the application of a few leeches or of a blister to the
epignstrium will give relief; while we may allow ice to be
freely taken. In all cases, (|uinine is to be given during the
intermission. And lastly, where there seems any reason to
fear the occurrence of any permunent structural disease, the
patient must be sent to a temperate region, free from maluriu.

190

FEVERS.

2. Yellow Fever. — This is a disease of warm climates;
an average tcnipcmture for some weeks of at least 12° Fnhr.
beinji necessary for its production. It is not of infrequent
occurrence in the soa-purt towns of the West Indies, Africa,
the southern parts of Spain, and some parts of Aoicrica.
Yellow Fever lias been described under the various names of
Bii/tim Fcvrr, Mill <ie Sitim, Tj/phiis Jrtirut/es, &c. It occuis,
like all other fevers, in different decrees of severity. At
one lime it attacks only a few individuals sporadically, at
another period it prevails epidemically; ha outbreaks are
generally preceded by some unusual meteorological condi-
tions; an<l it is still a uiatter of dispute whether it be coDta-
gio\i.s or not.

The striking ni/mjtiom* of this peculiar disorder, in addition
to the general pyrexia, arc the fuddennew! with which the
attacks come on — often in the middle of the tii-iht; the pecu-
liar yellowness of the skin; the loaded tongue, deep red at
the tip and edges ; the anxiety of countenance ; the severe
headache — referred to the forehead and bottom of the orbit;
the mental and bodily prostration ; and the great irritability
of the stomach, the matter vomited being nt first slimy and
tasteless, but gradually assuming the appearance of coffee-
grounds, when it is called the Murk cnmit. The dejections
generally have a lurry uppoaraiice. There is often suppression
of urine ; or this secretion may be smoky-looking, and loaded
with albumen and casts of tubes. A copious renal secretion
is the most fnvorable sign. The fever iu women always causes
the catamenia to appear ; even if the normal menstrual period
has only just ceased.

The u.sual duration of the fever is from three to five or
even seven days. When the sixth day elapses without the
occurrence of black vomit or suppression of urine, there is
great hope of recovery ; but if all other symptoms arc absotit,
and only one of ilie.«o present, our pru^inosis must be very
unfavonible. The mortality seems to be at least 1 in 3.
Death usually occurs from exhaustion, or urzcmia, or apoplexy.

ERUPTIVF. FEVERS.

191

The ppecinl poison of mellow fever appears particularly to
affect the liver ; and Professor A. Clark, of New York, has
Buppested that the chaoge so constantly observed in this organ,
in fatal cases, is an acute fatty defeneration. Pr. La Rnche
confirms this opinion ; for, he says that in all the examinations
made durint; the epidemic of 1853 at the Pennsylvania Hos-
pital, this chanpe in the liver was discovered.*

The indications fur trfalmcnt are not very promincDti
Hence it will be better to follow Dr. La Roche's advice, and
treat the urgent .symptoms as they present themselves ; leaving
the rest to the reparative powers of the system. The diet
must be very simple ; consistinp of barley water, arrowroot,
broth, brandy-and-water, &c. Purgatives are at first almost
universally employed ; beinf; sometimes combined with large
doses of f|uinine. The prolonged use of the warm bath, or
wrapping the patient in the wet sheet, may occasionally be
advisable. Morphia (gr. \) may be given once in (he twenty-
four hours, if there is pain or restlessness, provided the urine
is copious and free from albumen. Turpentine, by its action
on the skin and kidneys, is thought u.sef'ul by many observers ;
if tried, it should be administered in small doses — m. xx to
3J frequently repeated, almost from the cunimencement of
the attack.

If stimulants be rerjuired wo ehould carefully avoid giving
ammonia; for Dr. Blair particularly notices the ammoiiincal
state of the blood, breath, and vomited matters. In some
cases, this observer says that the blood was found as fluid as
port wine, and the corpuscles wore all dissolved j while it was
strongly ammoniacat.

IV. ERUPTIVE FEVERS.

The eruptive fevers may be regarded as continued fevers,
having an eruption superadded. The chief are — small-pox.

♦ Yfiloir Fever nrnitiere/i in its Jlittoriaii, PtithoU^ira/, Etiplagieai,
and Theropeulieal Rtialtoiu, Tol. i, p. 404. PhiUdelphis, ISSi.

192

FEVER8.

cow-pox, rlilehen-pnx, nieatlfg, and icnrlel frrcr : fo wliicli it
is convenient to add erj/gipelns and p/oi/ne.

Tlie principnl diseases of this class have these common
characters : a variable amount of time elapses between the
reception of the poison and the setting in of the symptoms,
called the period of incubation ; they are accimipmiied by
fever, whieli runs a defined course; they are attended by an
eruption, which (iocs throuph a regular series of changes ; they
for the rao.«t part affect every individual once, and once only,
during life; and they arise from specilic contagion. Of all
the eruptive fevers, scarlatina is probably that which most fre-
quently affects the system a .second time.

In the year 1858, searlaliiia wa.s the most fatal of the crnp-
tive fevers in England ; the deaths from small-pox being
6460, from measles 9271, from erysipelas 2026, and from
scarlutinu 30,317.

The following table shows the period of incubation, together
with the date of eruption and time of its disBppcarance in the
three chief eruptive fevers:

DiKaM.

Period or
iDi'tibfttton.

Measles. ilO tol4dys,
Scarlet )

fever. J

Small. )
pox. I

4 to 6 days.

12 days.

Eruption ap|i«ari.

On 4th day of
fever.

On 2d day of
fever.

On 3d day of
fever.

Eruption AmIm.

On Till day of
fever.

On 5lb day of
fijver.
'Scobs form on 9lh
or 10th day of
fever, and fall
off about the
I4th.

It is doubtful wliether a disease should be described which
presents many of the characters of measles and scarlet fever
conjoined ; and which has been described as Rubeola, li'olheln,
or Sear/(ttinit morbilhsn, or a Ui/hriil uf Mrnnhs and Srarlet
/ever. I thitik such a special description unnecc.s.sary, beettuse
ire know that measles and scurlutina may exist in the body at

ERUPTIVE FEVERS.

198

tlie twme time; and hence the affection will merely be a com-
pound of the two. Moreover, measles may coexist with
smnll-pos, or hoopiiip-cough, or chicken-pox, &c., as Mr. Mar-
son has well shown.*

1. Variola, or Small -Fox. — This affectioi) is due to the
reception into the blood of a specilio poison, which beiiins to
give indications of its power about twelve days after its absorp-
tion. In its entire course each case of variola goes through
four stages, — that of incubation, of primary fever, of eruption,
and of secondary fever.

Sniall-pox may be defined as a continued fever, which after
a period of latency or incubation eomincnce.s with lassitude,
headache, vomiting, and muscular pain.s in the buck ; these
symptoms being succeeded on the third day by an eruption of
small red pimples, which in the course of a week inflame and
suppurate. In many instiince.s it is aceompaiiieJ by a similar
affection of the raucous tncnibrane of the nose and mouth ; io
some, by swelling and inflammation of the subjacent cellular
tissue ; and occasionally by marked irritation of the nervous
system. When the vomiting and pain of the back are vio-
lent, they are generally the precursors of a severe form of the
disease.

The peculiar eruption of pimples or papu1i« always begins
to show itself on the third day of the lever ; appearing in the
following order, — first on the face, the neek, and wrists, secondly
on the trunk, and iiwtly on the lower extremities. The papulae
then gradually ripen into pustules, the suppuration being com-
plete by the ninth day ; at which time the pustules break, and
crusts or scabs form. In four or five days more these scabs
are falling off.

Now the severity of the disease almost always bears a direct
relation to the quantity of the eruption. When the pustules
are few, they remain distinct, and separate from each other ;

■ MtdiohVhirurgital Trantactiotu, Tol. zxz, p. 139.

London, 1847.

194

FEVERS.

when very numerous, they run together, coalesce, and loee
their regularly circuiiiscribod circular form. We thus have a
division of small-pox into two varieties, — variola dltcrtta, and
variola eimflnait. The former is seldom attended with dnnjrer ;
the latter is never free from it. The eruption on the face may
be of the conflucot form, while it \& scanty elsewhere ; still the
disciise ia of the confluent kind. Sometimes the pustules are
BO numeroua that they touch each other, but nevertheless do
not coalesce ; the disease has then been said to be of the
cohering or temiconfivtnt form.

In tmrwla discrela, the eruption, in the words of Willan, is
pnpular. On the tliiril day a smiill vesicle, with a central de-
pression, appears on each papula, coDtaininj; some thin trnns-
ptarcnt lymph ; around this an inflamed areola forms. About
the fifth day of the eruption, or the eighth of the disease,
the vesicles lose their central depression, become turgid, and
hemispheroidal. Suppuration has occurred, and the vesicles
have become pustules containing yellowish mutter. A peculiar
disagreeable odor now begins to emanate from the patient,
which once smelt cannot be forgotten j so that from it alone
the disease may be diagnosed. About the eighth or ninth day
a dark spot appears on the top of each pustule, the cuticle
bursts, the matter oozes out, and the pustule dries into a scab.
In about ten days more the crusts fall off, leaving a purplish
red stain, which slowly fades ; or where the pustule has gone
so deep as to destroy a portion of the true skin, tliut permanent
disGgarement — the so-called pitting or pock-mark — results.

Variola conjiuens is usually u.'*hered in by more violent fever
than is the distinct variety. The eruption comes out earlier;
the eyelids swell, so that by the fifth day the patient is often
aottble to see ; the parotid glands become affected ; there is
salivation also, or in children a vicarious diarrhcca ; and the
limbe swell. The vesicles on the face run together into one
bleb, containing a thin brownish ichor; the face is iIho pale
and doughy. The vesicles on the trunk and extremities,
though often nut cooflueut, have no areola and are pale. Oo

KRt'PTIVE FKVER8.

195

the breakin;j of the pustulou, hirfre. blnck or brown scabs are
formed, cxbalint; great footer ; while the pulse gets mpid,
great debility sets in, and there is restlessness. The mucous
inerabnines become involved; those of tlie nose, mouth, lar3'iix,
and trachea being the scut of an eruption. The tongue and
palate become covered with vesicles; the throat is very sore,
there is difficulty of swallowing, hoarsoiies.t, dyspnoea, and
cough ; while the glottis often becomes narrowed, and suffoca-
tion perhaps ensues. Delirium frequently occurs. When to
the foregoing symptoms malignancy and putrescency are added,
the di.sease becomes vi'ilit/uanf amall-pox.

But the greatest difference between the distinct and confluent
forms of the disease is in the geromiari/ fetitr; which, slightly
marked in the first, is intense and perilous in the second. It
sets in usually about the eleventh day of the disease, or the
eighth of the eruption, and occasionally at once proves fatal ;
the system appearing to be overwhelmed by the virulence of the
poison. During its course, various troublesome complications
may arise ; such as erysipelas, swelling of the glands in the
groin and axilla, phlebitis, pneumonitk, ulceration through the
cornea, .liuppuriition of the ear, &c.

There is no eontagion so powerful or so certain as that of
Bmall-pos. One attack exhausts the susceptibility of thesystem
to the future influence of the poi-son, as a general rule. Variola
occurring in persons unprotected by inoculation or vaccination
is fatal on the average to one in every three When the vario-
lous matter is introduced into the skin — inoiulnlrd rnnnll-pox
— the disease is in all respects of a remarkably mild nature.
The practice of inoculation, introduced into this country by
Lady Mary Wortley Montague, is now illegal.

The less drugs are used in the treatment of small-pox, the
better; since they will neither shorten the disease, nor exert
any favorable influence upon the eruption.* In the early

* " It it m melancholy reflection, but too trae, that for many hondred
year* the eCTorU or phyaicians were rather exerted to thwart Nature, and
to add to the malignancy of the disease, than to aid her in her efforts.

19G

FF.VEBS.

sf:i<,'es, the patient should he kept quiet in bed, in b well-vcn-
tilutfd r«Hiiii ; lili diet should oin.sist i)f arrnwrnot, gniel, weak
beef tea, and ripe fruits ; he shoald be allowed plenty of lem-
onade, or barley-water, or plain water, or F. 421 ; and when
the skin is very hot, tepid >'fwii;.'ini; will prove very refreshing.
Siippcwiiij: that the bowels are confined, a few doses of some
mild saline laxative (F. 172, 181, LSli, &c.) may be adminis-
tered ; or if there be prcat irritability and nervousness, a dose
of opium or henbane (F. 860, 364, Hb7, or 388) at bedtime
will do pwd ; or if the maturation of the pustules goes on
tardily, jUKtd broths and stimulants — wine or ammonia — are
indicsited.

In managing the trcondary frtrr, the physician ought to
keep the bowels gently open by mild laxatives; admiuister
sedatives, if needful, once or twice a day ; and support the
system by a nourishing but digestible diet, such as strong beef
tea, good soup, milk, the yolk of one or two eggs daily, &c.
Stimulants are to be given in proportion to the weakness of
the patient. Slmighv and gangrenous sores demand the
liberal admintstnition of tight bitter ale, or of wine, or even of
bnindy. When iliere is the least fear of their occurrence on
the back or nates, the patient should bo placed on a water-bed,
or on one of Hooficr's; large watcr-pilluws. — To relieve the in-
tolerable itching, the pustules should be smeared with cold
cream; or, with what is better, carron oil (F. 3*27). When
the pustules have burst, some dry powder — as the oxide of

Blirterr, Iipitting slcxiphnrmicii, large blpedinj^, opintu, ointments,
maslu, nii'l Irilom? to prevent pitting, were tlie grent metiBurea formerly
pnr«ue(l. nnt on<> oT which can be recoinmendeil. Wlint tliink you of »
prince of thr blnuj royal of England (Jobn. the ran of Kdwnn) the Second)
baing treated for rmoll-pox by being pat into a berl surrounded with red
banging*, eorerrd with rod blankets nnd a red oountorpane, gargling hia
tliront with mutliorry wine, and sucking the red Juice of pumogranates f
Tet tbi> wa« the 1ioa>ted prescription of John of Onddeiden, who look no
■mall credit to himself for bringing his royal patient nafely through the
di>aaiie." — Leriu,t\ on the Eriipiivt Ftvm, p. T8. By George Uregory,
U.D. London, It-KI.

KBrPTIVB FEVERS.

197

riiic, or powdered starch — is often freely applied, to absorb the
matter, and perhaps to prevent the pitting.

2. Vaccinia, or Cow-Pox. — Since the discovery of the
protective influenee of vucciiiatiun bj Jenncr, towards the
clo5« of the eighteenth century, the fatality of small-pox has
been very much diminished.* It is now highly probable that
efficient vaccination confcTS a depree of immunity quite equal
to that obtained by inoculation ; while it is safer, much less dis-
gusting, and docs not tend to perpatnate a loathsome disease,
as the practice of inoculation does.

When vaccination has been successfully performed on a
healthy child, an elevation may be felt over the puncture on
the second day, accompanied by slight redness; on the fifth,
a distinct vesicle is formed, having an elevated edge and de-
pressed centre; on the eighth, it is of a pearl color, and is
distended with a clear lymph. The vesicle is composed of a
number of cells, by the wall.i and floor of which the lymph
is secreted. An inflamed ring or areola now begins to form
ronnd the base of the little tumor, and to increase during the
two succeeding days ; about the eleventh day it fades ; and
the ve.sicle, which has now burst and acquired a brown color,
gradually dries up, until by the end of the second week it has
become converted into a hard, round scab. This fulls off about
the twenty-first day ; leaving a circular, depressed, striated
cicatrix, which is permanent in after-life. The first vaccina-
tion certainly affurd.« protection for ten years, and perhaps fur

* Not only bus the mortal ily frotu ^mall-pox been very much lesMned,
bat the good loukn of the people hAve been preserved by TfteoinRtion.
" Unteaa the reftder hnji pcannert the long liitt of villnnnuB portraits exhi-
bited by the Hue and Cry in the old papers of the last portion of the seven-
teenth and first portion of the eigbteenth oentaries, ho can form hut a
faint conception of the mrnge? eoramitted by tho small-pox upon the
population. Every man seemed more or less to have been speckled with
' poekholes;' and The race must bare presented one moving mass of pita
mad tenn."— Quarterly Renew, Jnly, 1855. Article "AdTertiaeroenla."

IT*

198

FEVERS.

louder ; but it is clearly a nafe proceeding to revaccinntc after
this hiji!»L' ul' lime.

The coiictitutional disturbance which accompanies vacciua-
tion is UKuullj vcrjr slight. Some interesting esperiments
hUi]y maiie by Dr. Gustuv Wertheiiu, of Vienna, tend to show
tliat the fre([iieiicy of the pul.so is pcriiianentiy increased by
the process of vaccinatimi. Thus, a man aped thirty-eight,
atid u woiiiiin tiged thirty-three, neither of whom had suffered
fniiii siiiiill-piix, wore vaccinated for the first time; the
pulse, in both cases, increased in frequency up to the sixth
day after vaccination, when it began to decline ; never de-
clining— nut at least for the four months during which the
observations were continued — as low as it was before the intro-
duction of the vaccine virus. For example, before vaccina-
tion, the man's pulse was on an average 6G ; afterwards the
average was 78.

In practising vaccination, it is better to use recent lyiuph,
which should he taken from vesicles between the fifth and
ninth days, the eighth being probably the best. If preferred,
the virus luiiy be taken direct from the cow. Dairj-- women
are often infected from milking cows with the eruption of
vaccinia on their teats. — According to the Act of Parliament
— 16 and 17 Victoria, cap. 100 — every infant is to be vacci-
nated withiti four months from birth, unless its health rendent
the pMcecding objectionable. When small-pox occurs after
vaccination, as it sometimes will, the disease is much milder
and shorter, and is uniicconiputiied by secondary fever. It is
spoken of under these circumstances as varioloid, or motlijietl
itnall pox.

3. Varicella, or Chicken-Pox. — This is a trifling com-
plaint, almost peculiar to infnn(.8 and young children; which
completely runs thrimgh all its phases in six or eight days. It
consists III' an eruption of pimples, which on, the second day
become converted into transparent vesicles surrounded by slight
redness. The rash commcneeB on the shoulders and back,

ERDPTIVK FEVKRS.

inf)

and afterwards affects the scalp, but often spares the face;
while about the fourth day the vesiclefl ibriu smnll scnbs, which
rapidly desiccate. There is no constitutional disturbance of
the least importance ; and the accompanying pyrexiii is .slight.
Dr. Gregory 8ay.s that when the eruption is abundant, the body
presents the appearance of having been exposed to a momen-
tary shower of boiling water; each drop of which has caused
a small blister.

It occurs but once (o the same person ; it has a short tnoa-
bation, probably of four days; it is infectious and noutafiious;
and it requires no treatment beyond alleiitiun to the lK)wel8,
and restricting the diet.

4. Morbilli, or Measles. — This disease may be deBncd as
a continued infectinu.i and conlajrious fever, which is preceded
by catiirrh, i.^ accompanied by a crimson rash, and is often at-
tended or followed by infliimniation of the mucuu.q membrane
of the orpans of respiration. Sume authors divide measles
into two grades, — the nwrhiU! millurfx, and the morhitli yra-
viorrt; but the latter only differs from the former in its proater
severity, and in the fact that the eruption assumes a dark pur-
ple color.

TIte early tymptoms of measles arc lassitude, shivering,
pyrexia, and catarrh ; the conjunctiva), Schneidcrian nicm-
brnnc, and mucous membrane of the fauces, larynx, trachea,
and bruuchi beinc; much affected. There is also swelling of
the eyelids, with eyes suffused and watery, and intolerance of
light; sneezing; dry cough, hoareeness, and severe dyspucea ;
drow.sinc.ss ; groat heat of skin ; together with frequent and
hard pulse. The period of incubation — or, in other words,
the time which elapses between the date of infection and the
appearance of the eruption — is from ten to fifteen days. Dr.
Watson has known several instances in which it was exactly
n fortnight. The eruption cornea out on the fourth day of the
disease, seldom earlier, often later. It consists of small circu-
lar dots, like flea-bites, which gradually coalesce into small

200

FEVERS.

blotches of a raspberry color ; these presenting often a horse-
shoe shape, and being slif;htlj' raised above the surface of the
skin. The rash appears Brst ou the forehead and faoe, and
gradually extends duwiiwurds; it bct^ins to fade on the seventh
day in the same order ; and is succeeded by slight desquama-
tion of the cuticle, and ^Tcnt itching.

It is worthy of notice that the fever docs not abate on the
appeaniiicu of the eruption, as iu sinull-pox ; nor does the
severity of the attack at all depend upon the quantity of the
rasb. The cuiitagioii of nieaslus iHStron<;; but less powerful
than that of variulu. The disease is mostly seen in children.

The /jrff^nom mu.sl depend upon (he mildness or severity
of the chest syuiptouis ; the coraplicaliinis most to be feared
being croup, bronchitis, and pneumiiiiiu. The diarrhoea, which
often sets in as the rash decline.'*, is for the most part bene-
ficiul. The uiurtality is {greater in large cities than in the
country.

The treatment must not be too active. Expo.sure to cold is
to be carefully avoided. The patient should be confined to
bed, in an apartment moderately warm. Putting the feet in
hot water every evening is often beucfieial. Milk diet, muci-
laginous drinks, gentle aperients, and mild diaphoretics may
be had recourse to. A draught, containing one drachm of the
liquor uinnionite acctatis, ten or twenty drops of the spiritus
setheris nitrici, and half an ounce of camphor mixture, may
be given to a child six years old every fimr or six hours.

The state of the three great cavities must be carefully
watched, especially towards the dcclioe of the eruption.
•Should any complications arise, thi.-y must be treated accord-
ing to the rules which will be laid down in speaking of each
afiection. After the disease has subsided, the patient should
bo warmly clad, and not allowed to go out of doors too early.

6. Scarlatina, or Scarlet Fever. — This well-known disease
may be defined as an infectious and contagious febrile uflectioo,
characterized by scarlet efflorescence of the skin, and uf the

ERUPTIVE FFAERS.

201

tnncous membrane of the fauces and tonsils ; the efflorescence
comuioncin-j; about the second day of the fever, and declining
about the fifth. It is oflen acoonjpanied b; infiamraation of
the throat, and sonietinics of the submtixillnry glands. Like
measleii, it is essentially a disease of childhood ; but it is uiore
to be dreaded. As a rule, scarlet fever occurs only once dur-
ing life ; but in the event of a second attack there is often no
rash, no throat affection, and the disorder runs a favorable
course. From my own personal experience, I can state that
trarlatinn fine exanthemnlf may be followed immediately by
desquamation of the cuticle ; and snbsei^ucntly by renal disease.

There are three varieties of this disorder. Scarlatina lim-
plfc, in which the .skin only is aftectcd ; scarlatina anijinogn,
in which both skin and throat arc iuiplicated ; and scarlatina
mrilii/iKi, in which all the force of the disease seema to be ex-
pended upon the throat.

It may just be mentioned, that in certain parts of the East
Indies, in the Southern States of America, as well as in Phila-
delphia and New York, a peculiar infectious fever sonictinicii
prevails, in which the eruption of scarlatina is combined with
severe rheumatic pains in the limbs and joints. Sometimes
the ihnxit is implicated, occasionally the tQsticle.H enlarge, and
often the lymphatic glands of the neck and groin swell. The
disease (known as trarhitiiia rheumntini, or ihnyite) generally
lasts about eight days ; and demands no special trcatniuot be-
Jfond the use of opiates to relievo pain.

Si'ar/atinn simp/ex, or sraiFttfiiii xliie atiijinS, conitucncea
— after a latent period of fnun four to six days — with slight
fever, lassitude, and headache. The eruption appears on the
second day, in the form of numberless red points; which show
themselves first on the face and neok, then on the amis and
abdomen, and lastly on the lower extremities. Sometimes the
rash comes out so quickly that in twenty-four hours from its
first appearance it covers the whole body; but more commonly
a day intervenej! between each crop. On tho limbs, but es-
pecially about the fingers, there is a diffused, continued efHor-

202

FEVERS.

esccnce ; but nn tlic trunk the rnsh is distributed in irre;»iii.ir
patches. Tho eruption is of a brit;ht .scarlet color, most
distinct about the loins and tho flexures of the joints. The
efllorescence commonlv teriniintes by desquBmation of the
cutiule ; which begins about the end of tlie liflli day nn those
parts where tlie rnsh first ajipcared. On tho face and trunk
the dei-nuamalion is in the form of scurf; while on the bands
and feet larjre flakes of cuticle are detached, so that i^umetiuies
a jilove or slipper of scarf-skin ciinies away at once.

At the same time that the efflorescence bus been spreading
on the surface of the body, the raucous membrane of the mouth,
fauces, and nostrils has also been aflfected. The tonsils are
often congested and swollen, but the tongue especially puta on
an appearance characteristic of scarlatina. This organ is at
first covered with a thick white fur, through which the red
elongated papillae project; but a.s this fur clears away, it be-
CDtnes clean and pretcrnaturally red, and of a strawberry
appearance. The affection of the mucous membrane of the
mouth, Ac, feruiinates by resolution; with the disappearance
of the rash the febrile symptoms subside ; and the disease
terminates at the end of eight or nine days, leaving the
patient very weak.

Scarfttfina nni/inn/n is ushered in with more violent symp-
toms than the preceding. There is headache with some deli-
rium, more pungent heat of the skin, nausea or vomiting, reat-
lessnes.s, and marked pro.stration. About the second day there
is stiffness of the neck, uneasiness in the throat, hourseness,
and pain on swallowing. The fauces, palate, uvula, and toosila
are red and swollen ; while the inflamed surfaces are covered
vrith an exudation of coaguktblu lymph. As this inflamma-
tion goes on, all the febrile symptoms increase, and the skin
becomes very dry and hot. The tonsils got gorged with blood ;
and foul, deep ulcers form on them. The efflorescence does
not observe tho same regularity ns in the simple form: it does
not appear so early, is delayed to the third or fourth day, comes
out ia scattered patches on the chest and arms, and shows a

ERUrriVE FEVERS.

203

tendency to vanish the day nfter its appearance, nnd to re-
ippear partially nt uncertain times. With the fudinn; of the
eruption about the fifth or sixth day, the fever and inflaiumution
of tJie throat begin to abate; althou^ih the throat often rr'tnains
sore, causing the act of deglutition to be painful and difficult
for a week or ten days af^r the disappearance of the rash.
Occasionally this variety of scarlet fevor as^uuici a more aggra-
vated form ; being accompanied with an acrid di.scharge from
the nostrils and ears, deafness, and infiammation of the parotid
and cervical glands — sometimes going on to suppuration.

During the progress of the disease particular attentioa
shoaid be paid to the internal orginis, since there is a great
predisposition to inflammation of the serous and mucous mem-
branes.

Sciirl(ili)iii mnli'jna, described by (Jullen under the title of
cj/nanche maliijna, differs but little in its symptoms, at first,
from scarlatina anginosa. The fever, however, soon assumes
a malignant or typhoid character; great cerebral disturbance
being saperaddcd to tbe affection of the fauces and .skin.
There is great irritability, restlessness, a feeble, irregular pulse,
oppressed respiration, obstruction of the fauces with viscid
phlegm, sonietiinea diarrlioju, and generally delirium ; the
latter being sometimes violent, but usually of the low mutter-
ing kind. The tongue is dry and brown, tender and chapped;
the lips, teeth, and gums are covered with sordcs; and the
breath is extremely fetid. The throat is not much swollen,
but appears of a dusky red hue; while the velum, uvula, and
tonsils are coated with dark incrustations, consisting of exuda-
tions of lymph. In sonic cilscs there is gangrenous inflain mo-
tion of ihcxe parts, followed by sloughing. The cervical glands
are often involved in the inflammation. The rash isexceedingly
irregular as to the time of its appearance and duration; often
coming out late, disappearing af\er a few hours, and being
renewed several times during the progress of the disorder. It
is at first of a pale hue, but soon becomes changed to u dark
livid red ; while petechias alk) of^n appear upon the skin.

204

FEVERS.

In many instances this iiiiilijrnant form of flcarlet fever
terminates fatally on the third or fourth day. It is always a
disease of such extreme danger that only patients with vigor-
ous constitutions survive it : great hopes may be entertained,
however, if the seventh day be passed.

Sequdae. — Children who have suffered from scarlatina are
very liable to have their health permanently affected, and to
become afiiicted with some of the many forms of scrofula ;
especially strumous ulcers, ophthalmia, scrofulous enlargements
of the cervical glands, diseases of the sculp, &c. They also
seem predisposed to suffer from arute rheumatitm and firom
rheumatic pericardifi*.

Not unfre<juently, after the decline of the eruptive stage, a
muc-o-purulcnt discharge takes place from the nares, and even
from the mouth and fauces; and in a few instances an acrid
secretion, similar in character, has flowed from the vagina in
female children and women. — Considering how extensively
the various uiucuus tracts arc uflbctcd in this disease, it scorns
strange that xcurlatinal vagliiid's is not of more common
occurrence. In one case (a girl twelve years of age) about
which I was consulted, the iiares, mouth, and pharynx were
abo affected; but the vaginal inflammation was the most ob-
stinate, and persisted for some time after convalescence had
been firmly establiRhed. A cure was effected by the admin-
istration of steel and cod-liver oil, and by the local use of
astringents. Dr. llobert Uurncs and Dr. J. K. Cormack have
noticed the occasional occurrence of this form of vaginitis ;*
though mo.st authorities omit all nicntiuu of it.

But the most freijuent, aud by fur the most serious sequel
b atiiuarra — serous inflltnttioD of the subcutaneous areolar
tissue — often accompanied by dropsy of the larger serous cavi-
ties; which occurs ab<jut the twenty-second day from the oom-
mencement of the fever. Now it is curious that this scarla-
tinal dropsy is more frequent after a mild than after a severe

• LontioH Mtdteai GattUt, pp. 46 uid 128. July and Augiut, 1860,

EKUPTIVK FKVER8.

205

attack, owing probably to the want of eimtion which is often
observed in such cases daring the period of desquamatiua,
The patient gets exposed to cold, and iinmediatclj the escape
of the fever-poison through the pores of the wkiii is checked;
which, as a consequence, is directed to the kidneys in larger
quantities than they can bear, giving rise to acute desquama-
tive nephritis. This renul affection has its origin from many
causes (inteuipcmnce, cold, the cholera poison) besides the one
we are considering; but, however produced, its syuiptoius are
the saiue. It commences usually with rigors or chilliness, suc-
ceeded by feverish reaction, headache, restlessness, pain and
tenderness in the loins, and often vouiiting. The dropsy is
an early s^'mptom ; the face first becoming puffy, followed by
general swelling of the areolar tissue throughout the body,
and by effusion of fluid into one or mora of the serous cavities.
At the same time there is a frequent desire to pass urine,
which is scanty, of a dark smoky color, and on being tested
by beat and nitric acid, is found to be highly albuminous.
Examined microscopically, it is seen to contain masses of
coagulated fibrin, blood-corpuscles, epithelial ca-sts and cells,
and occasionally crystals of lithic acid. When the progress
of the case is favorable, the earliest signs of improvement
are the disappearance of the dropsy and an increase in the
quantity of urine. It is not uncommon for a patient, during
convalescence from acute desquamative nephritis, to pass from
four to six pints of urine in the twenty-four hours; the
natural quantity averaging only from a pint and a half to two
pints.*

Treatment. — The treatment of acariatina yet remains to be
considered. The simple form, says Sydenham, is " fatal only
through the officiousuess of the doctor." It requires no treat-
ment beyond confinement to the house, warm clothing, spare
diet, and attention to the bowels. Medical advice ought

* For the more full consideration of thia renal afeotion, as well aa for
its treatment, Ik., the render murtoonenlt the Section on Acute Deeqiu-
■Batire Mephritia, in Part VIH.

206

FEVERS.

nlwajs to be sought, ho

tiowever, in these cases; since thej are
just those in wiiich the most troublesome sequelae often occur.

Id ncnrlatinn anijinota the treatment is often much the
same as that for many cases of continacd fever. Cold or tepid
sponging where there is great heat ; emetics of ipecacuanha
when the tongue is much coated, and when nausea and
irritability of stomach exist; shaving the scalp and the ap-
plication of cold lotions, where there is much delirium ; and
the cautious adnrinistrntioii of aperients when the bowels are
confined. Saline medicines are grateful and cooling; or,
where the pulse is feeble, good beef tea, port wine, and
ammonia (F. 429, 442), may be bencfleinlly ordered.

In malignant tea r/et /ever, a stimulating plan of treatment,
such as that recommended in typhus, alone offers any chance
of success. The vital powers are so proMrnted by the deadly
force of the poi.son, that unless we support them by the free
administration of brandy, wine, or ammonia and bark, they
will fail altogether. When seen early, however, the treatment
may often be adviintageously commenced by a mild emetic
(F. 280, or 283). The gangrenous ulceration of the fauces,
which often complicates this form, will be also best combated
by the use of sliniulant-s ; and perhaps by the free local ap-
plication of the nitrate of silver, or the employment of gargles
where patients are old enough to use these agents properly
(F. 307, 308, or 313). Sucking ice or calfs-foot jelly gives
temporary relief, at lea.it. The chlorate of potass drink (F.
4-b) will be useful. Chlorine itself is used by some practi-
Uonen, who speak highly of its good effects, in even the
worst cases (F. 102).

In dropti/ following tearlet fever elaterium often does great
good ; provided it be given early in the disease, and before the
patient is very weak. Its effects must be carefully watched,
however, as the severe purging and t'omiting which it. induces
may give rise to great exliaustion. It can bo given to childrea
of ten years of age, in doses varying from the twelfth to the
sixth of a grain; repeating it every two hours until its action

XBUT>TIVE FEVERS.

207

I
I

is freely manifested. On the day fnllowing its exhibition the
tincture of the sesquiohloride of iron may be commenced, or
the synip of iodide of iron with cod-liver oil. The diet should
be very {icnerous, wilhnut any 8timuianta. Wiirni baths are
often useful. After an attack of acute dest|uamativo nephrilis
great care should be taken for a lon^ time to clothe the
patient warmly, with flaone! next to the skin; and to feed
him well.

Belladonna, in very minute duses, has been recommended us
a prophylactic atrainst scarlatina. In an epidemic of this
disease which occurred on board her Majesty's ships Ai/nmcm-
non and Odin, in 1853, this remedy was freely tried without
the slightest benefit. It baa also now been used by many
practitioners, and found useless.

6. Erysipelas. — This disease — called in Scotland the rose,
in this country St. Anthony' t fire — is a diffused, spreading,
inflammatory affection of the skin, and very commonly of
the areolar tissue. It is characterized by the affected part
becoming of a deep red color, hot, painful, and swollen ; and
is due to the absorption of a speoiGu prji.son. No portion of
the surface is exempt from attacks of it, but the integuments
of the face and head are most commonly the seats of idiopa-
thic erysipelas — that which arises from internal causes ; while
tranviatic erysipelas — that which follows wounds — may occur
on any part.

Idiopathic erysipelas resembles the other eruptive fevers;
inasmuch as its phenomena are preceded by a period of
incubation which varies from three to fourteen d;iysi, and are
accompanied by fever and general constitutional disturbance.
It often sets in with chilliness followed by distinct rigors; sore
throat is an early and fretjuent accompaniment of it; oc-
casionally the urine coiit^iins albumen, but the chlorides are
always diminished; and disturbauce of the cerebral functions,
Dausea, vomiting, and diurrlta>u, may also be present. Then,
on the second or third morning from the rigor, redness aud

208

rEVERS.

'. iwelling appear on some part of thh skin ; fre<|uently on one
'side of the nose, spreading to the rest of the face, and often
eztendinp over the scalp, neck, and shoulders. The lips swell,
the cheeks enlarjre, the eyes become closed by their puffy lids,
and all traces of the natunil features are completely lost.
After three or four days, the redness fades, the swelling sub-
sides, and the cuticle descjua mates. In most cases the in-
flamiuatlou is merely superEciul, and the disorder is then
I spoken of as nimpfe erysipelas ; but occasionally it affects the
subcutaneous areolar tissue — phlegmnnoux orj-sipelas — and is
then apt to be followed by suppuration and sloughing, or even
by gangrene.

Erysipelas may prove fatal, by the extension of the inffum-
mation to the brain or its membranes, giving rise to effusion
and coma. The same result may occur from the mucous
membrane of the glottis becoming affected, so that the chink
gets closed, and the patient dies unexpectedly from suffoca-
tion. In other cases, death is owing to failure of the vital
powers. Erysipoliis may arise from infection or from contagion.
When it prevails epidemically, as it sometimes does, intem-
perance, insufficient food, foul air, and trifling injuries favot
its occurrence. When the disca.se breaks out in an bospitni,
the ward whore it has appeared should bo cloarcd out and
thoroughly cleaned, to prevent the spread of the poison
through the entire building.

The trrdlmrnt must be conducted on the principle that it
is more important to lead the di.sorder to a safe tcriuination,
than to try and cut it short by active remedies. At the com-
mencement, an active purgative, — such as a full do.se of the
neutral .snll.i, — will be benefici.il; while the diet must be light,
cooling drinks may be freely given, and the patient must be
confined to bed in a well-ventilated room. In the country,
when the patients are young and vigorous, bleeding is com-
monly considered necessary ; in London such practice would
almost invariably be bad. In the ca-ses which have fallen
under my own notice, there has always been marked evidence

ERUPTIVE FEVERS.

209

of debility ; and I have consequentlj followed the practice of
those phpicinns who adopt'a tonic mode of treatment ns the
great rule in idiopathic erysipelas. The latp Dr. Robert
Williams, of St. Thomas's Hospital, gave all his erysipelatous
patients milk diet, sajjo, very gentle purgatives, and from four
to six ounces of port wine daily, from the very first appear-
ance of the disease, irrespective of the symptoms or the part
affected; and he says, in his admirable work on Morbid
Poisons, " I have pursued this system for several years, and I
hardly remember u case in which it has not been successful."
The ses(|uicarbonate of ammonia (F. 420 or 442) will often
prove an excellent substitute for wine.

In addition to the administration of wine, there are some
cases where the tincture of sesquichloride of iron does great
good. This medicine must only be given when the secretions
of the liver and bowels have been g;ot info a healthy condi-
tion ; and the dose must vary from twenty minims every four
houqi in mild cases, to half a drachm every hour in urr;ent
instances. According to some writers, attacks of erysipelas
which would probably run on for eight or ten days, may be
cured in three or four days by this preparation of iron.

Of all the local applications which have been recommended,
that which gives the most relief is the fomentation by flannels
wrung out of a hot decoction of poppy-beads, assiduou.sly ap-
plied. Flour freely dusted over the inflamed part has often a

Dthing, cooling effect in mild cases; but it is apt to form a
orost, whicli adheres to and irritates the inflamed part. Some
surgeons recommend painting the affected region with collo-
dion; which not only serves to protect the skin, but to con-
tract the congested vessels. To check the extension of the
inflammation, boundary lines may be drawn on the .sound skin
with tincture of iodine or the solid nitrate of silver.

In the phleguionnus form of the disease, when suppuration
has taken place, and pus has become iuliltratcd (hruugh the
areolar tissue, long and free incisions must be made to give it

18*

2in

PKVKRP.

exit. In these cases opistos, tonics, wine or brandy, and
nourishing food, will have to be nssiduuusly given.

In tn/nnlife eryntpehm, the child's strength must be sup-
ported. If the mother's milk be deGciont in qunntify or
quality, a vigorous wet-nurse should be obtained. Cordials,
as white-wine whey, wine-and-water, &o., may be given to the
youngest patient.

7. The Plague. — This most mnlignant disease, thong:h
genernlly classed among the e.xantheiuata, is jaid to be,
strietly speaking, a continued contagious fever, bearing a
slight re.wmblance to Revere typhtus. As it is now a disease
exclusively of Knstern occurrence, it is only necessary to
briefly mention it in these page.«<.

The plague may be defined as a fatal eontagious fever, which
is due to the absorption of a poison that infects the blood.
The force of the pmson is chiefly exerted on the cervical, axil-
lary, inguinal, and mesenteric glands, as is shown in the pro-
duction of buboes; on the skin, causing carbuncles; and on
the heart, liver, and spleen, giving rise to great congestion
and softening. The disea.se produces at once great restless-
ness; extreme and rapidly increasing exhaustion; an inde-
Borihable feeling of oppression about the prsccordia; fever of
greater or less intensity; nausea and vomiting; emaciation;
bleeding at the nose; swelling of the tongue; laborious
breathing ; darting pains in the axilhc and groins, with large
buboes, carbuncles, &c.; constipation; and soraetinios suppres-
sion of urine. The powers of life soon give way, and death
either onsuesi without a struggle in two or three days, or is
ushered in by an attack of convul.sions. Thi.^ intense form of
the diseft-se is generally observed at the commencement of an
epidemic, when the deaths may be ninety per cent.; but after
a time a milder, — but still very dangerous, — variety sets in.
When recovery is going to take place, profuse sweats occur
about the fifth day.

At the time this fearful pestilence, — described by Heberden

ERUPTIVE FEVERS.

OS the Black Death, — desulatcd Europe, Asia, and Africa, in
the fourteenth century, the mortality nmst have hcen immense ;
for it has been computed that Eunipc alone lost 25,000,000
of inhabitants by it. The last epidemic which ra:;;ed in Eng-
land,— the "Great Pla^'uo," — was in 1665, the year preced-
ing the great fire of I^rfindon.

Most authorities now ai;ree that the only place in which the
plague originates is Egypt, from whence it is imported into
other countries. To prevent the crew of a vessel with plague
on board infecting the inhabitants of a sciiport town, recourse
must be had to quarantine; which ought to be of not less than
twenty-one days' duration. In attendance upon any oajie the
practitioner must most carefully avoid nil contjiet with the
patient, or his clothes, or bedding ; but with this precaution
he may regard himself as safe, since the disease docs not seem
to be infectious.

PART III.
DISEASES OF THE NERVOUS SYSTEM.

1. INFLAMMATION OF THE BRAIN.

Our knowledge of the effecls of inflammation of the parts
within the cninium is not sufficiently perfect to enable us to
point out with certainty the symptoms which indicate inflain-
tnation of the aub.stance of the brain — crrehridt, vs distin-
gaishcd from that of the nienibranes — mrnhujillt. Fortunately
the distinction is not of much practical importance; for if we
allow that in a very few case.s cerebritis occurs simply, or that
meninfjitis happens alone, still it is certain that in the majority
of instanccH the two afTcctions are combined.

Inflammation of the brain is of two kinds, acote and chronic.

1. Acute Inflammation of the Brain. — This disease may
be roughly described as a morbid proce.«s which gives rise
to more or less complicated phenomena during life, accord-
ing to its extent and the degree to which the membranes of
the brain are involved ; while after death traces of its power
are to be detected in the form of dusky redness, softening, or
suppuration.

Symptoms. — The chief and most common early indications
of encephalitis, or acute influuimation of the bniiti and its
membranes, are, — fever, nausea and vomiting, acute headache,
frequent ami irrc;:ular pulse, bowels >rcnenilly con-stipated,
impatience of light and sound, watchfulness, a look of opprea-

INFLAMMATION OF THE BRAIN.

213

1
I

gion, suffusion of the eyes, and confusii>n of thoufrht or even
delirium. At the end of from twelve hours to two days, the
second stage of the complaint sets in, — the period of collapse.
The patient falls into a state of stupor; his artiouliilion pets
difficult or indistinct; his vision and hearing become dull;
the pupil — from having been contracted to a pin's point —
becomes dilated ; thi;ro may bo Sfjuintinj;, and paralysis of the
muscles of the eyelids; there are frer|uent twitchings of the
muscles ; the countenance is (ghastly ; sordes form on the gums
and teeth ; the body is covered with cold sweats; the sphincters
relax ; and there are a few convulsive paroxysms, paralysis,
and profound coma, which usually soon ends in death. — Oc-
casionally the first symptom that attracts attention is a sudden
attack of convulsion ; in some cases occurring without any
previous illuess, sometimes preceded for a few days by head-
ache and slight complaints which have pas.sed on unnoticed.
The eonvulsion is generally long and severe ; it may be followed
immediately by coma, which in a few days is fatal; or it may
recur frequently at short intervals, and pass into coma at the
end of twenty-four hours. Dr. Watson thinks that when
nausea and vomiting are the earliest symptoms, the inflamma-
tion has had its origin in the cerebral pulp — ia the substance
of the brain ; and that when the attack commences with a
convulsion, the inflammation has commenced in the pia mater
or the arachnoid.

In all the forms of this dangerous complaint there is great
variety in the symptoms, and much observation is ncces-sary to
put us on our guard against tbo insidious characters wiiich
many of the cases a.ssunie, and the deceitful appearances of
amendment which often take place. Fortunately the disease
is of rare occurrence. It may terminate fatally in a few hours ;
or the patient may struggle on fur two or three weeks.

CaitifH. — These are often difficult to detect. Inflammatory
affections of the brain sometimes arise without any appreciable
cause. I'lethuric persona, and such as have a short neck, are
■aid to be uior« liable to them than others. Occasionally

INFLAMMATION OF THE BRAIN.

215

hare serous effusions beneath the pia mater and into the
ventricles.

The dura ninter is seldom involved in the morbid action,
unless the iiiflanimation is the result oF violeuce. In such
cases there may be a deposition of false membranes between
the bone and dura mater, or between (he dura mater and
arachnoid ; or wc may find tliickeiiin<^ of all the membranes.

Ti'i-almaU. — The principal mca.sures usually recommended
are, — strict observance of the antiphlogistio regimen ; that is
to say, diet of the lowest kind, general and local bleeding,
antiuioiiials in some stages of tlie disease, digitalis, itctivo
purgatives, mercury, blisters to the back of the hefld and neck,
mustard pediluvia, and the constant application of cold to the
scalp after the hair has all been shaved off. With regard to
venesection it is advised that the blood be allowed to flow until
a decided impression is made upon the pulse, or until the
patient faints; which will perhaps happen when twenty-four
ounces have come away. Afterwards, it ia said, that leeches
or cupping may be resorted to.

When it is remembered that encephalitis is one of the most

quickly depressing and fatal diseases that can affect the human

body, it may readily be imagined — from what has been already

staled — that ito dangers are not lessened by such treatment.

And this seems really to be the case ; for one of the strongest

advocates of this practice, Dr. Abercrouibie, in speaking of

the results of such a course of remedies, says: "The cases

which thus terminate favorably, form, it must be confessed,

but a small proportion of those which come under the view of

a phy.siciiin of considerable practice; hut they hold out every

encouragement to persevere in the treatment of a class of

diseases, which, after a certain period of their progress, we are

loo apt to consider as hopeless." With the greatest respect

for this excellent physician's opinions, it still seems to me

that the extensive failure of one plan of treatment should

merely lead us to try another; and more e.«pi'ci.illy, perhaps,

to SCO if Nature unaided, or only gently guided, will not carry

216

DISEASES OP THE NERVOUS BTSTEM.

the patient throuj;h n disease, where the efforts of Art are
notoriously so futile. Ue this as it may, let us determine not
to thwart Nature, aa wo nay easily do by acting upon the
fallacious notion that the free loss of blood is well borne ;
neither let us credit those who asiiert that untiuiony is capable
of effecting a cure in these cases. On the contrary, we shall
do much more good if we will be cont«nted to prescribe for the
urgent syiiiptunis as they arise, to culm excitement by seda-
tives, to lessen increased heat of body by diluents and tepid
sponging, to prevent accumulatioos in the intestines by purga-
tives, and to diminish maniacal delirium by the application of
cold to the head.

Active cathartics of calomel and jalap, followed in three or
four hours by an aperient draught, are often deemed indispen-
sable (F. IGS). Juliip and suuna (F. 180) is a favorite re-
medy wilL me ; or simply such a saline aperient as F. 196.
Croton oil is a most valuable purgative in some of these cases
(F. 20 Ij where there is obstinate constipation. Dr. Aber-
erombic rather illogicntly says : "Although, bloodletting is
never to be neglected in the earlier stages of the disease, my
own experience is, that more recoveries from head-affections
of the most alarming aspect take place under the use of very
strong purging, than under any other mode of .treatment."*

The application of cold to the head, after it has been shaved,
is a remedy of importance. Pounded ico in a bladder, or a
c-old evaporating lotion (F. 331), or especially the pouring of
cold water in a stream upon the vertex of the head, will best
effect our object of reducing the temperature and calming ex-
citement. By the cold douche, cautiously used, a strong man
in the highest slate of maniacal delirium may often be sub-
dued in almost a few minutes; but it must be remembered
that this practice, if long continued, has a very depressing
influence.

With regard to medicines for directly modifying the morbid

• Optu dl., p. 163.

ISPtAMMATlON OS THE BRAIM.

217

action, I know only of one on vrhicli the least reliance can be
placed, and that is the iodide of potassium. I have seen this
agent, in dones of three or four grains repeated every four or
six hours, do so much iiood in a few apparently hopeless cufics,
that I think it ought alway8 to be tried. I have, of course,
found it fuil ; bat in my hands it has never done niischicf. It
may often be advantarrcously given at the same time that stimu-
lantB are being employed.

When, from exhaustion of the nervous force, nn extreme
degree of ciiliupse occurs, the only chance of rescuing tlic
patient will consist in the administration of stimulants ; such
aa ammonia, sulphuric ether, strong beef-tea, wine, or brandy.
In all stugcs of the disease, the practitioner must watch his
patient almost hour by hour, must ascertain tliat he is kept
dry and clean, and must be careful that the bladder does Dot
become distended.

Should the disorder happily yield to the-c measures, great
care will be re<|uiBite for some time — espivially with regard
to diet and the avoidance of all cxcitcn.cnt — to prevent a
relopsc.

2. Chrome Inflammation of the Brain. — This disease
may follow an attack of acute meningitis, or it may come on
independently as the primary di.sorder.

The phenomena which k, presents are sir. -.niltirly di verbified;
but they may be briefly said to be commonly allied to those
which mark the commencement of insanity. Hence, we find
either ^ix-at mental excitement or dcprc^iun ; some absurd
whim exists, to gratify which, everything must be sacrificed ;
and the patient either believes that he is about to make a for-
tune, or to become a parish pauper. Amongst the general
symptoms, hesitation in speaking or a slij^'ht stammering, a
stiffness of some of the muscles, slight head^iche, loss of appe-
tite, constipation, and irregularity of the puliie, are perhaps
the most prominent. As the disease slowly progresses, how-
ever, the evidences of cerebral disorder become fully deve-

218

DISEASES OF THE NKKVOUS BVSTEM.

loped ; the memory fails, the external senses become impircd,
paraly.sis shows itself, and the general health couipletely
breaks up.

Chronic ineninpitin may run its course in a few months, or
it may last for years. In our treatment we can only attuiiipt
to combat the syiiiptnnis as they show themselves, while we
try by jadiciuuH hygienic measures to support the general
health.

Acute ramollintemrnt, or rfil sojleni'ntj of the brain, is one
of the terminations of the inflammatory process ; being due
perhaps more oi\en to the acute than to the chronic foria of
the disease. The r.iimillis.'>emcnt is usually partial ; the soft-
ened parts becoinin<; P^'p^r '^^^ ultimately of the coosistcnoe
of thin cream. It may sometimes be diagnosed by the ooour-
rence of paralysis, with spiism ; or by the permnneut contrac-
tion of the flexor muscles of one or both extremities. When
resulting From inflammation, the corpus callosuDi, septum luci-
dum, fornix, and the cerebral substance surrounding the ven-
tricles, arc the piirts which usually euflcr. In such instances,
too, the Boflened matter is often inbltrated with pus ; while
occasionally the purulent matter is contained in a well-defined
cavity, foniiing iihmrsx of the Itrnin. The ecn-bellum is but
rarely iiflccted. Infhiuimatory red softening must be distin-
guished from uhite H1//1 II I nij of the cerebral substance; which
U a morbid proi'c.'^.-< that may occur in aged persons, from an
opposite condition to the inflammatory — from an insufficient
supply of blood, owitig to disease of the cerebral arteries.
The gray matter of the convolutions at the base of the braio,
the optic thalauii, and corpora striata are the parts then
affected. It has been already pointed out that the detach-
ment of filirinous deposits from the valves, or interior of tlie
left side of the heart, and their circulation with the syslemio
I blood until they become arrested in one of the cerebral art«-
I lies, niay — by impeding the transit of a due f|uaDtity of
I blood — lead to imperfect nutrition, and hence to softening.
Induralioti — is another lertuinatioQ of either acute or chio>

TUBERCULAR MKNIN'IITIS.

219

tiic inflammation. The indurated portion is generally of small
extent; presenting the appearance of wax, or of whit« of egg
boiled hard. The change is probably due to a great increase
of albumen.

Tumort — both simple and mniignant, {itfositx o/ tubercle,
and lit/tlalid» have also been found in the bruin. Dr. Jcnner
has lately discovered lutrchur ventrirnli in the fluid removed
from the ventricles of a child who died of acute tuberculosis.

n, TUBERCULAR MENINGITIS.

Acute inflammation of the bruin is a vury common disease
of early life — of children under five years of ape. It rarely
occurs, however, in such ns are previously healthy ; when it
does 80, it may be regarded us simple encepbalitis. When it
is the result — as it most frequently is — of tubercular deposit
in the brain or its membranen, when it oocuni, in fact, in scro-
fulous children, it is then known us tubercular meningitis.
Formerly the name of acute hydrocephalus was given to this
disorder; but thi.s term was evidently badly chosen, since it
refers only to one of the possible results of the diseui-e, not
to the disease itself.

Si/mplnmt. — The symptoms of tubercular meningitis are
various and uncertain. For convenience, they may be arbi-
trarily considered as exhibiting three stages. The _/ir»< or ^re-
monitori/ Uoijf is attended with indications of mal-nutrilion ;
and there are mure or less perfect sifrns of the strumous dia-
thesis in the child or its parontw. There is often a short dry
cough; much pecvi.ihncKS, intolerance of light and sound,
headache, giddiness, and other warnings of cerebral congea-
tion ; together with general fever, prcsonting exaeerbutious
and remissions at irregular periods. The skin is hut ; the
appetite cnprioious — sometimes bad, soiuetimes voracious; the
tongue is furred, and the breath ofTeusivo ; there is often nau-

. and vomiting; and the bowels are disordered — generally

DISEASES OF THE NERVOUS 8TSTEM.

constipotcd. The child is drowsy, yet restless ; it sleeps budty,
lunaus ur grindH it^ ccetli, screniiifi and uwukes suddenly in
alarm withant iiity nppuruiit cause ; while uftoo it \» delirious.

At th(! end of four or live days, the disease, if unchecked,
passes into the semnil nlmje ; when its nature bccoraes very
apparent, and its euro almost hopeless. The child wishes to
remain quiet in bed ; its countenHncc is expressive of anxiety
and !<nfierin<;, tiud !» alternately flushed and pale ; its eyes are
closed, and eyebrows knit ; and it is annoyed by li>;ht and
the least rioii^e. If old cnua<;h (o reply to qacstions, it eom-
plains of heiiduehc, weariness, and sleepiness ; crying out fre-
(|ucntly, " Ob. uiy head !" As this stage advances, the pulse
— which has hitherto been TJipid — becomes irregular and
diminished in frequency, often falling in a few hours from 120
to 80; the ftliplitest exertion, however, at once accelerates it.
tjtupor and heaviness now conic on ; there is often squinting ;
the little pitient lies on his back aliiio.<it in a slate of in.«ensi-
bility, p<;rh.ips picking, with tremulous lingers, his nose and
lips; convulsions Cr-equeiitly occur, and sometimes paralysis;
while, at the same lime, the urine and fieces are passed uncoa-
scious^ly.

The transition to the ihiril ilatje, at the end of a week or
two, is sometimes cfTuvli'd very gradually by the drowsiness
passing into pi-ofjuiid coma, from which it is impossible to
rouse the child ; while the pulse gets feeble, the extremities
loPc their waniitb, :iiid a cold clammy sweat breaks out over
the body. In other instances the child becomes comatose
quite suddenly, and i mined i:itely afterwards is attacked with
paralysis and convulsions, which oflen put an end to the pain-
ful scene. Occasionally, however, death does not occur until
the lii]r>i<e of several duj's.

When tubercular meningitis occurs in the adult, there is
generally a hislipry of previous lung affection, which affection
seems to becoiiK' anicltnnitcd as the cercbnit tlitiordcr sets in.
The symptoms ni;iy ciuly assume an apiplcctic or a convulsive
form. More frc([ucnlly they come on gradually with vomiting,

TUBEBCULAK MGNINOITIH.

221

slight fever, and most ncute pin in the head ; the piiticnt
seems unable lo collect his thoughts, and is dull and heavy j
there may be inulism and somuolenee; and the pulse is irre-
gular and feeble. In the second Btape tlieiiepre.ision increases,
there ie greater mental dulness or delirinin, and there are
olooic or tonic spasms. While in the third stage the sphinc-
ters relax, and there i.s increa.siiig stupor, paraly.si.s, and death.

Fott-morirm Apfienruniet. — Those u.sually found are — traces
of inflammalion of the nicnibrnnes of the brain; Specially
effusion of serous fluid bcncnlli the arachnoid and in the
meshes of the pia luater, as well as the presence of f;dse mem-
branes between the arachnoid and pia mater. The cerebral
substance often contains scrofulous tubercles, while granular
tubercular deposits may be seen .scattered upon and between
the nieiubnnies. Hut the characteri.'^tic morbid appearance
consists of suftetiing of the central parts of the brain, with
effusion of thin watery serum into the ventricles.

Ttexilmvnt. — The treatment of tubercular incningilis hag
always been said to be beset with difficulties; inasmuch as,
being an inflammatory affection, it was thought to demand
remedies which the patients — strumous subjects — could not
bear. Fortunately, the difficulty is abolished, if the okxerva-
tious made in the preceding pages are at all sound; and, hav-
ing acted upon rules deduced from these observations, I can
express my Gnu belief, from the cases I have seeTi, that the
more we act up to tiicir spirit, and the less we deplete in this
disease, the greater the chance of the ultimate recovery of our
patient.

It i.s only fair to mention, however, that most authors agree
that depletion is not to be had recourse to without great con-
sideration ; that if there is much doubt, the practitioner should
first try the effect of a strong purgative; and that if it be ne-
cessary to take blood, local bleeding — by leeches — will gene-
mlly answer every purpose.

In almost all instances purgatives are very useful; and I
think perhaps that most good is derived from such as contain

19*

222

DISEASES OF THE NERVOUS SYSTEM.

or consist of mercury. After the bowels have freely acted, I
am in the habit of trusting to the iodide of p<)ta.ssiam ; which
is adiuiuistered in diise.s voryins; from half n f^rain to three or
four grains, every four or six hours. The local employment of
cold is likewise an important remedy. A rag wetted with
cold wntcr, or the evaporating lotion (V. 331), laid on the
ciiild's head ami frf(juently renewed, will generally suffice.

When the child is teething, many practitioners resort, as a
matter flf course, to Rcarification of the pums ; forgetting that
the irritation arises from the pas-snge of the tooth through the
bony canal of the jaw, rather than from pressure on the gum.
■Such practice is u piece of barbarous euipiricisra ; but when
the gum is tender and swollen, then the use of the lancet
dves great relief. Supposing that tlie vita! powers become
much depressed, either from the course of the disease or from
the use of the reiuedie.i, stimulants must be freely had recourse
to. I have fre<iuently given a child of from six to twelve
months old a teaspoonful of equal parts of port wine and
water, or port wine and beef-tea in the same proportions, every
hour, or every .second hour, with the greatest advantage. If
physic be preferred, some amiuoniii with Uoffmana's anodyne
(F. 43'2) may be ordered.

III. HYDEOCEPHALUS.

Hydrocephalus, or dropsy of the brain, is met with in chil-
dren at various ages, as the result of a great variety of circum-
htances. When congenital, as it often is, it is generally asso-
ciated with matformation of the brain. It is sometimes the
result, pometimcs the precursor, of tubercular meningitis ; and
it is then generally spoken of us iiciitf hydrocrphnlus. When
congenital, or wben it arises slowly from oonstitutiona! causes,
it is termed chronic hi/dincrphalui.

The head jittaiiis a very great size in this disease, the nnos-
BiGcd sutures n adily yielding to the pressure of the liquid.

nvDROCErnALua.

223

ide of the craniuni is snnietiiiiCH larircr tlian the ntlior,
the bones are mostly thin and transparent, while the niem-
branes of the brain are thickened. The fluid is usually con-
tained in the lateral ventricles, which are often expanded into
one larpo cavity ; but occasionally, it is collected in the sac of
the arachnoid, and luay then c^jmpress the brain to a remark-
able extent. The ((uunlity of fluid may vary from two or three
dnnees to as many pints. In the woU-knuwn ea.ie of a man
named Cardinal, the head measured in circumference thirty-
three inches; while after death nine pints nf water were found
in the cavity uf the arachnoid, together with one pint iu the
ventricles.

The bodily functions arc frequently but little inipnired,
sometimes not at all, till a short time before death ; while it is
remarkable also, how little the mental powers are aftV'Cted in
some cases. Hebcrden has related an instance where there
were no si^ns of drop.'jy of the brain during life, and yet eight
ounces of fluid were found in the ventricles after death. Al-
though essentiallj" an affection of childhood, yet cases are re-
corded in which it has affected adults; and amongst others
the celebrated Dean Swift suffered from it. According to Dr.
West, almost every case is fatal. Professor Golis, of Vienna,
alfirmj, on the contrary, that of the cases which began after
birth, and which were seen and treated early by hitn, he saved
the majority.

The fi/Mploms generally begin to show themselves before
the child is six months old in caaes where they do not exist
from birth. Although the child takes its food eagerly, it does
not thrive ; and consequently, after a time, the manisnius be-
comes extreme. The wasted appearance of the body makes
the increased siee of the bead the more remarkable ; so that
he who has once noticed the .email face with the prominent
heavy forehead, the protrusion and downward direction of the
eyes, and the extended globular cranium with its open sutures
and foiitanelles, need.s no pen-and-ink sketch of the hydroce-
phalic infant to Gx the features upon his memory. The in-

HVPROCEPHALUS.

225

lion. The cases wtiicli have come under my own care Lave
occurred chiefly in ho.«pit;il practice ; and I have trusted to
gentle purputives. plain nourii<hing food, cod-liver oil or glyco-
rinc, and sonicliracs iodide of potassium or iodide of iron.

The course advocated by Professor Giiiis, after prent expe-
rience, consists in the adiiiinistnition of calomel in ijuarter or
half-^rain doses, twice daily ; topether with the iiiunftion of
one or two drachiuii of the mild mercurial ointment into the
shaven scalp once in twenty-four hours. At the saiue time
the head is to he kept constantly covered with a flannel cap, to
prevent all risk of the perspiration being checked. If no im-
provement be perceptible after a lapse of six or eijrht weeks,
diuretics — as the acetate of poUish, or squills, or both — lire to
be combined with (ho treatment ; and au issue may be made
in the neck or on each shoulder, to be kept open for months.
When convalescence is once established, he thinks benefit is
derived from small doses of quinine — a quarter of a grain three
or four times daily.

Two remedies — vumpressitm of the head, and ^>u»ic(uriH</
it — have been strongly advocated by some writers. Compres-
sion is be^t effected by banda<rinj;, or by the application of
strips of adhesive plaster applied over the whole of the cra-
nium, 80 aa to make equal pressure on every part. In cases
where there are no symptoms of active cerebnd disease, pres-
sure will probably do K'^od; and from my own experience I
am inclined to think favorably of it. I'uncture is performed
with a small trocar and canula at the coronal suture, about an
inch and a half from the anterior ffintanellc, sous to avoid the
longitudinal sinus ; while the fluid is to be evacuated slowly,
only a portion is to be taken at one lime, and gentle pressure
must be kept up both duriuj; its escape and afterwards for
some weeks. This opei'ulion is only to be had recourse to
when other means have failed. It has occasionally proved
successful in very young children.

Dr. Watson mentions two hopeless cases successfully treated

226

PI8EASES OF THE NERVOrs SYSTEM.

on a plan suggested by Dr. Govrer.* Ten grains of crade
mercury were rubbed down with a scrapie of munnn and five
grains of /rr»h squills. This formed a dose which w.is taken
every eight hours, for three or four weeks. It e^iused a profuse
flow of urine, great debiiity, and emaciation : no ptyalism.
"When the syitiptonia of hydrocephalus h;id disappeared, the
hcaltli was restored by steel.

The foregoing remarks show the necessity of attending to
prophi/hctic measures. A child with any tendency to hydro-
cephalus should be reared so as to stren^jthen its system as
much as pos.«ible ; and therefore it should have a nourishing
diet with plenty of milk, a salt-water bath every morning, and
plenty of exercise in pure air. In some instances residence at
the sea-side, with the adininistrutiori of cod-livt-r oil, may bo
needed. Slitnulants are always to be avoided ; and only the
most gentle atlenipts at education are to bo permitted. Such a
child is generally precocious; and often is only too happy to
over-work its brain, if permitted to do so.

IV. APOPLEXY.

By the term apoplexy is meant sudden insensibility — the
loss of sensation, thou<;ht, and voluntary motion, with a more
or Ic88 severe disturbance of the functions of ro.spiration and
circulation. It is a state of coma occurring suddenly from
pressure upon the braitr ; the couipres.sing power having its seat
within the cranium.

There is a popular belief that ptitietits suffer from three dif-
ferent attacks of apoplexy; the first being mild, the second
followed by paralysis, tiud the third ending in death. Whether
or not this be exactly true, it is at least certain that the danger
greatly increases with each attack.

* Prine4flu atui Proefirf of Phytic, vol. i, p. 4&8, thirJ oditlun. Lon-
1 doD, 1848.

APOPLEXT.

227

It is often n matter of difficulty to di.«tit)puish between apo-
pli'ctic coma, and that due to a narcotic poison or to drunkcn-
iiesa. The dibtinetion is most important as rcjiards the treat-
ment. The coma iij profound in each instance, though arii^ing
from 80 different a cause : the history of the tsase, the general
sppeamncp and age, and the presence or absence of the odor of
i>pirit» in the breath, are the only points which help to solve
the difficulty.

The stale of coma in apoplexy may end in three ways.
Either it may jrrudually pa.ss off, leaving the patient well; or
it may terminate in incomplete recovery, the mind being ioi-
pnired, and some parts of the body paralysed ; or it may cea.se
in death. On examining the brain we find either no appear-
ance whatever of disease; or extravasnted blood ; orctfusion of
serum into the ventricles or beneath the arachnoid. Dr. Abcr-
crombie calls the first — that which is fatal without leaving any
traces — simji/e apoplexy ; the second sniii/uinrous apoplexy, or
cerebral, lunmorrhtiife ; the third uerou* apoplexy. During life
we are unable positively to distinguish by the symptoms these
three varieties.

Waritiiiyt. — This dreadful visitation is seldom experienced
without some previous thrcatenings ; which properly inter-
preted, should put the [luticnl oti his guard. Tlie following
individuals may be said to be predisposed to apoplexy : Those
whose ancestors suffered from it; men of peculiar habit of body,
of sedentary habits, accustomed to high living, with protube-
rant bellies, large heads, florid features, and t^lmrt thick necks ;
and individuals advanced in life, beyond fifty. A predisposi-
tion may also be engendered by disease of the kidneys, of the
heart, or of the cerebral bloodvessels; by intemperance; and
by thcces-sation of hubitnul discharges. Among the threalen-
ings, the fol towing are the most important: Headache and
giddiness, particularly on stooping; a feeling of weight and
fulness in the head, with noises in the e,ir», ami temporary
deafness ; transient blind ness, or sometimes double vision ; ucca-
sionaily epistaxis ; numbness ; loss of memory, great mental

228

DISEASES OF THE NERVODll SYSTEM.

depression, incoherent talking, drowainesa, with indistinctneas
of articalation ; and partial paralysis, sometimes affecting a
limb, sometimes the muscles of the face, sometimes the eye-
lids.

Moda of Seiture. — Dr. Abcrcrombie has shown that the
apoplectic attack commences in three different wajs. "In the
^rsl form of the attack, the potient falls down suddenly, de-
prived of sense and motion, and lies like a person in a deep
sleep ; his face generally flushed, his breathins; stertorous, his
pulse full and not frc<|uent, sometimes below the natural stand-
ard. In some of these cases convulsions occur; in others
rigidity and contraction of the muscles of the limbs, sometimes
on one side only."

In the tecond form, the coma is not the first symptom, bat
fathers sudden attack of pain in the head; the patient becomes
pale, sick, and faint ; sometimes he vomits ; while fre<|ucntly
he falb down in a state resembling syncope. Occasionally he
docs not fall down, the sudden attack of pain being merely
accompanied by slight and transient loss of consciousness.
After a few hours, however, the headache continuing, he be-
comes heavy, oppressed, and forgetful ; and gradually sinks
into perfect coma, from which recovery is rare. A large clot
is usually found in the brain.

The i/n'rd form of apoplectic seizure begins with a sudden
attack of paralysis of one side of the body, with loss of speech,
but no loss of consciousness. The paralysis pttsses gradually
into apoplexy; or, in some favorable cases, it slowly goes off
and the putirnt recovers.

I'/ii-nimiriia durimj the Fit. — The duration of the apoplectic
fit varies from two to three bonis to as many days. There is
total uiicotisciou!<nct<s. Pulse, at first gener.illy small, becomes

11 and strong, according as the system recovers from the

wk ; it is usually slower than natural, sometimes intermit-

Rvspiration slow, eniburrassod, often acconipnnied by

or ; frothy saliva about the mouth. lu bad cases, the body

ered with a cold clammy sweat; the face is pale, and the

APOPLKXY.

220

eyes dull nnd frlassy, with dilatntion of the pupils ; the teeth
are firmly clenched, and all power of deglutition is lost, or
much impeded ; there is stertorous breathing; the bowel? are
torpid, or, if they act, the motions arc passed involuntarily;
and there is either involuntary micturition, or, as most fre-
quently happens, retenlion of urine, until the bladder becomes
distended, overflows as it were, and causes the urine to be con-
stantly dribbling away. When the patient recovers incom-
pletely, more or less paralysis of the limbs often remains.

Pott-morirm Appearutieei. — It is only necessary to notice
those found in eases of sanguineous apoplexy. The blood may
be effused upon or between the membranes of the brain ; into
one of the ventricles ; or into the cerebral substance itself. In
the latter case, it is usually found in the corpora striata, the
optio thalami, or that part of the hemispheres of the brain
which is on a level with these bodies. Dr. Craij;io arranges
the parts which may be the seat of the hjemorrhage in their
order of frequency, thus : the corpus striatum, optic thala-
mus, hemispheres, pons varolii, crura of the brain, medulla
oblongata, and cerebclluni.

When death occurs within a few hours of the effusion of
blood into the nieoibraiies of the brain, the cerebnd substance
will usually be seen simply flattened from the pressure which
the eitravasated fluid hai5 exerted j but if some days have
elapsed, there will probably be evidence of meningitis as well
as of softening of the eonvolution.s. Supposing the blood to
have been poured into the substance of the brain, a cavity
(varying in she from a barleycorn to a hen's egg) will be
found containing semi-coagulated blood nnd softened cerebral
matter. At a rather later period the clut may be much firmer,
while the walls of the cavity have undergone some amount of
inflammatory softening. And lastly, if life has been prolonged
for about twenty-five days, the clot may be discovered small
and isoliited, a mcnihrane can he detected around it, iind the
cerebral walls of the cyst are found to be perceptibly getting
indurated. At this time, moreover, the walls of the blood-

280 DISEASES OF THE NEHVOrS 8T8TE.M.

corpuscles will have ruptured through endosuiosis ; and the
contents of these cells having escaped and crystallized, blood
or hniiuatoid crystals may be discovered on a microscopic exa-
uiinalioD.

The rupture in the vessel cannot always be made out.
When the walls of the carotid, busilnr, or meningeal arteries
have given wny tliruugh ossification, or anourismal dilatation,
there is no difficulty in showing the source of the haemor-
rhage ; but it is not so easy when some of the minute vessels
have ruptured, perliiipb owing to futly degeneration of their
ooats.

Trealmtnt. — This may be divided into that which is pro-
phylactic, and that which is required when an attack has
occurred.

Only a few remarks are needed oo the pro/j%^ac<i'c maoage-
nient. When a predisposition to apoplexy is suspected, the
individual should avoid strong bodily exertion, the venereal
cxuitenieiit, the Etiniuiusund irritution of drunkenness, violent
mental emotion, exposure to extremes of temperature, strain-
ing at stool, long-continued stooping, tight neckcloths, too
much indulgence in sleep, and warm baths. lie ought to
observe a cool spare diet, free from alcoholic drinks ; should
take daily exercise in the open air; and niu!<t pay great atten-
tion to his bowels. Washing the head daily with cold water
is often useful ; or esliiblishing a drain near the bead, by means
of an issue or sctou in the neck, will perhaps do good. When
giddiness, headache, throbbing of the arteries of the head, and
epistaxis are present, much benefit will re.^tilt from active
purging, and from blistering the nape of the neck.

But supposing that an attack hai occurred, what are we to
do ? Formerly, the treatment of every case of apoplexy wan
commenced by bleeding ; and statistics prove that the more
freely the blood was taken away the greater was the morta-
lity.* This can ea.-iily be imagined, for we only see the patient

• " The univfri-Hl rxno/y, jw il incnlloj, for apoplexy, la blooclK-lting;
at taut to f;cii«rally has il been employed thai of 1S6 oa«eB in wkicb th«

APOPLEXY.

231

when the mischief is done ; ruptarcwith extravasation of blood
has taken place, and blecdin;; will ni)t remove it. But, it is
Mid, depletion will prevent further extrava.siition. I believe,
with Mr. Coperaan, that so fur from its doing so, it promotes
it, by inducing greater thinness of the blood, and by dimi-
nishing the power of coagutntion. In proof of this it is only
necessary to read the reports of not a few eases, where it is
distinctly stated that the abstraction of blood was immediately
followed by an aggravation of the .■symptoms and by paralysis.
As regards my own practice, it may be mentioned that among
the several ca-ses which came under my care when house phy-
sician to King's College Ho.Kpital, I never .saw one in which I
considered bleeding necessary; and certainly the majority of
the cases, at least, recovered. The lessons then learned have
since guided me in treating this disease, for I very rarely see a
case where venesection or leeching appears to be called for.

The best rule to adopt in practice is that laid down by Cul-
len, — to obviate the tendenei/ to death. If the tendency be
towards death by coma ; if the pulse be full, or hard, or thrill-
ing ; if the vessels of the neck are congested; and if the face
be flushed and turgid, then bloodletting may be called for.
But, on the contrary, when the patient is dying from ."yncope,
with a feeble or almost iniperceptiblQ pulse, and a cold clammy
skin, then bleeding will only insure a speedily fatal termina-

tr«atm«nt is apcoifled. 129 wer* bled, iind only 2S were not ; of tho 129
wfan wera bid, til recorered nud 78 diod — the cares being 1 in 2), the
deaths I in l| ; of the 20 who were tint bled, \B were cured and 8 died,
the pro|turtioD of en ret being I in 1), and of deathit 1 in 3;. But the
murlnlilj varioi a good deal according to the pnrtiuular method in which
bloodletting was performed. In 2 vasea tlia temporal artery was openo'l ,-
both died. In 11 ca^es cupping only wae employed ; 0 were cnred and 5
died. 14 were treated by leeching; 4 cnred, 10 die<I. 17 wore bled in
the foi*t, a plan strongly recnmmeodeU by M. Portal, of which 13 were
cured and 4 djei, S."* were bled generally and copioujly, of which num-
ber 28 reooTcred and 57 died ; that i« to .«oy, 2 in every 3 ciuies terminated
fatally." A Col/iviioH of Qattt of Apopltxy, p. 9. By Edward Cope-
nao, Loodoo, 1845.

2S2

DISEASES OF THE NEBVOUS SYSTEM.

tion. In either ease, the pstieot shoald be removed into »
cool well-veiidlated room ; hia head should be well raised ; all
the light parts of his dress niuHt be loosened, especially his
cravat and i^hirt-collnr ; und cold is to be applied to the head
by means of pounded iec itt a bladder. If the practitioner
think it proper to bloed, let htni do so by opening a vein in
the foot us re L'um mended by Purtul ; ur lot hiui take only a
very auiall quantity of blood from the nape of the neck by
cupping.

Active purgatives do ^ood in most cases. If the patient
can swallow, a full dose of calomel und jalap followed by the
couiuion black drauj^ht may be given (F. 16S). If thepower
of deglutition be lost, three or four drops of croton oil should
be put on the back part of the tongue. Stiiuuhiting encmata
(F. 2'i'A, 236, or '237) should also be thrown up the rectum.
Pediluvia containing mustard can seldom do any harm. Blia-
tera are often subsequently of use, applied over the scalp or to
the neck. Some practitioners recommend emetics; but unless
the attack was clearly due to an overloaded stomach, I should
avoid them, and even then it inu.st be remembered that these
agents cause a determination of blood to the head.

Supposing the pritient to recover from the fit, great care will
afterwards be require.! to prevent a second attack. Strong medi-
cines, great_ excitement, or much mental occupation should
be avoided. The diet ought to be light but nutritious ; milk
is useful, taken to the extent of a pint and a half or two pints,
ia the day; and, aa a rule, only light Freuuh wines should be
allowed.

V. CONCUSSION OF THE BRAIN.

Concussion of the brain is signalized by fainting, sickness,
itupor, insensibility, or sudden death, succeeding immediately
to some blow or some act of external violence. Although
oues of this kind are usually regarded au surgical, yet their
importance demands so imperatively that every practitioner

OONCU88IOM OF THE BRAIN.

233

should be well nc(|uainted with their symptoms, treatment,
Ac, that DO apologjr is needed for the introduction of this
section.

Sj/mptomi. — These will vary according to the degree of con-
cussion. When the shock has only been slight, the person
soon recovers from the state of unconsciousnes.", and complains
merely of confusion of ideas, fairitDcs-s, »icknc.«s, a desire to
sleep, and ringing noises in his ears. In a, more severe case,
the insensibility continues longer; the patient lies as if in a
deep slumber, his pupils are insensible to the stimulus of light,
and his broatliiiig is often scarcely perceptible. When — after
a variable interval — partial recovery ensues, there is great con-
fusion of thought, often an inability to articulate distinctly,
frequently severe vomiting, and sometimes paralysis of one or
other of the extremities. In the worst forms of concussion,
the person is felled to the ground by the shook — whatever it
may be — and dies upon the spot.

Diiigno»ii. — The following circumstances — according to
Chelius — distinguish c^jncussion from pressure upon the brain
caused by extravasation of blood. In concussion which imme-
diately follows external viivlonce, the jKiticnt usually recovers
himself in some degree. In extravasation he lies in an apo-
plectic state, with snoring and dillicult breathing ; he has a
hard, irregular, intermitting pulse; his pupils are widely di-
lated; but there is no vomiting. In concussion, the body is
cold; the breathing easy; the pulse regular and small; the
countenance little changed. — Extravasation and concussion
may, it must be remembered, occur together. — It is often
difficult to distinguish between concussion and drunkenness.
The history of the patient, his gunenil appearance, and the
smell of his breath, are the chief points to attend to.

Prot/notu. — This must in all ca.ses be guarded. In a severe
form of concussion, the convalescence is always tedious; and
it frequently leaves behind it permanent impairment of the
memory, loss of smell ur tuslu, and weakness of sight or even
amaurosis.

20»

234

DISEASES OF THE XEKVOUB SYSTEM.

Treatment. — It is essential that the patient be carefullj
watched. If— a few hours after recovery frora the shock — the
reaction seem to be intense, the head should be elevated, and
cold applied: two or three dropti of croton oil may alsio be
placed on the ton^e. Generally speaking;, however, the
•hock to the system is so great, that niild stimulants are ne-
OMnry; and a little wine, or brandy and water, should be
cautiuuHly administered. At the same time, if the surface be
cold, warmth ma«t be applied by means of blankets, bottles of
hot wnter, hot bricks, &c. In the afler-treatment of these
cases, a mild unstimulating diet, absolute rest from all mental
occupation, bodily repose and quiet, with gentle purgatives,
will alone be necessary.

VI. COUP DE SOLEIL.

<!oup dc Boleil [tun-ttroke, intolalion, hiat apophxy, or ere-
ihinmut irnplriui) \s a disease allied to simple apoplexy. In
iu perfect form it is met with only in the tropics; in which
region it is often fatal to the Europeun soldier, especially at
MMons when the heat is very oppressive. The more severe
tba r(');iiiicrital duty, the more the men are harassed or de-
prudMod, the more defective the cumin issariat arrangements,
•lid the wnrwc the supply of drinking-water, the mure liable
will till) Knldicr be to this affection. It has been noticed that
(hoao iittnckcd have often been irregular in their habits; while
p(<rliii|iN llitiy hnvc also been indulging freely in alcoholic
drIiikH, niid jirowling about under exposure to an almost verti-
i<nI kiiii lor two or three days previous to the seizure.

lij/mj>lom»,—^\xoTii Is always severe headache, great heat

llO f'kin, and (mistration, In many cases, a

•cross Illy rhoet is complained of. Gene-

l(|a)ck and full, but sometimes it is thin and

I Mo toarcely be felt. As the disease advances

'oleut, the patient can scarcely be

COrP DE 80LE1I,.

235

roused, the fuoe gets pallid, nnd po^)lllp^< uti attuck of vomiting
ushers in the stage of coma. When the pntient is comatose
the skin is found very hot, the breathing is performed with
difficulty, the pupils are contracted, the conjunctivae are con-
gested, and the action of the heart is intermittent. Just before
death the pupils dilate, the respiration is gasping, and the
patient may vomit.

This affection sometimes comes on very insidiously. A man
will be seen to be listless and stupid; but he makes no com-
plaint beyond saying that his head feels a little queer. Yet in
twelve hours he may be dead. — In some instances, after eipo-
Rtire to the sun, the individual has fallen down insensible, made
one or two gasps, and at once died from syncope — Mr, Cotton,
surgeon of a regiment of infantry, met with twelve cases of
sun-stroke when at Meerut. The ssiiure usually happened
towards evening with symptoms of stupor and insensibility;
loss of speech ; burning of the skin; at first contraction, and
afterwards dilatation of the pupils; with great rapidity, hard-
ness, and fulness of the pulse. In some of the men tetanic
convulsions occurred. They almost all sank rtipidly; death
usually ensuing within two or three hours from the commence-
ment of the attack.

In the event of recovery taking place, the eonvalesceneo
may be retarded by deranged secretions, partiid paralysis, and
great prostration of strength. It is usually allowed that the
patient cannot be considered free from danger until the skin
gets cool and moist.

Pofl-morirm Appearances. — It is seldom that any cause for
the symptoms can be detected. Sometimes there is found nn
effusion of serum at the base of the brain ; or the vessels of
the membranes may be congested. The brain itself is usually
bealthy. The kidneys are very often much congested; but
the other viscera present no changes of any importance.

Dr. Morehead agrees with those observers who refer the
phenomena of sun-stroke to depressed function of the cerebro-
spinal and sympathetic nervous systenis.

286

DISEASES OF THE NEBVOOS SYSTEM.

Treatment. — The course which has often been pursued con-
sists of Tcncscctiun, cold to the head, and blisters to the back
of the neck. The fatalitj attending; this plan has been such,
that the practice is only mentioned in order that it may be
avoided f<ir the future.

The remedies upon which it is probable that most reliance
may be placed are cold to the head, and the frequent adminis-
tration of stimulants. The cold should be applied by pouring
a continuous stream of water over the head and chest, and
afterwards by the use of evaporating lotions. The douche
mast not be used, however, if the pulse be very weak and the
skin cold. The best stimuli are ammonia and brandy; given
in doses proportioned to the depression, and persevered with
to the la-st. Counter-irritants to the extremities have been
t]iou<rht to do good. Attempts have been made to induce
swcatinfr by wrapping; the patients in the wet sheet; but the
proceeding ha.i not been succcssrul. — Dr. Edward Smith has
proved that all animal foods, alcoholic drink$>, and coffee lessen
the activity of the skin, in the first stages of their digestion ;
but that tea and sugar have the oppusito effect. lie therefore
urges that an infasion of good lea should be very freely given
in this disorder; since beyond its effects on the skin it tends
to directly stimulate the nervous system, and has also a power-
ful effect in increasing the respiratory functions. Consequently
it may be found to meet three of the most urgent wants in
sun-stroke, viz., cooling of the body, removal of the listless-
ness and oppression, and increase of the respiratory acttoD.
The same writer also suggests that, as the act of vomiting
tends to induce perspiration, so it might be useful to give
ipecacuanha as an emetic early in the disea.sc.

A.ssistiint-Surgeon Chappie, of the lioyal Artillery, says that
he has srived a few cases which had advanced to the stage of
coma ; and he attributes his success chiefly to the use of
stimulant cncmata. lie remark.s that there is a failure of nerv-
ous energy from the commencement of this disease, and that

DELIRIUM TREMENS.

'237

therefore our chief endeavors onght to be directed towards
supplying this defect. The putients, in fact, generall}' die quite
worn out.

VII. DELIRIUM TREMENS.

Alcohol is an agent which directly affects the nervous sys-
tem, and particularly the bruin. When tjikcn in a large dose
it may directly destroy life, like any other active poison. In
smaller quantities, frequently repeated, its effects are very pre-
judicial; and these will now be considered under the two
divisions of delirium tremens and dipsomania.

1. Delirium Tremens. — Delirium tremens {delirium ipolu,
or tic/irium ebriositatit) is a very common disease in this
country. It may be described as un acute attack of poisoning
by alcohohc drinks. The delirium is chnrncterized by hallu-
cinations, fear, trembling of the muscles of the extremities,
weakness, and watchfulness. The natural tendency of the
disorder is to teruiiiiate in a critical sleep, nt the end of from
forty-eight to seventy-two hours from the comincnccu)cnt of
the delirium.

Symptoms. — These are chiefly — sleeplessness, a busy but
not a violent delirium, constant talking or muttering, tremors
io confirmed dram-drinkers, hullucinatioos of sight and hear-
ing, a drcnd or suspicion of every one, mental and bodily prus-
Iration, and a generally excited and eager tnanner. The skin
ia commonly moist, from copious perspiration ; the face is
sometimes pale, but often flushed and wikl-luokiug; the tongue
is muist and covered with a white fur; and the pulse ia fre-
quent and soft. In severe cases there is an increase in the
sulphates and in the urea, with a diniinution in the quantity of
phosphates contained in the urine ; while in phruuitis, ou the
contrary, the phosphates are increased. Dr. Watson well' de-
scribes the delirium. He says — " If you question the patient
about his disease, he answers quite to the purpose; describes,

288

DI8KASE8 OF THE NEHVOUS KT8TEM.

in an agitated manner, his feeling, putfl out his tong:ue, and
does whatever you bid him ; but immediately nfterwards he is
wandcriiifT from the scene around hiiii to some other that exists
only in his iinngination. Generally his thoughts appear to be
distressful and anxious ; he is giving orders that relate to his
business to persons who arc absent ; or, be is devising plans to
escape from some imaginary enemy ; he fancies that rats, mice,
or reptiles are running over his bed, or that strangers arc in
Lis room. He looks suspiciously behind the curtain, or under
his pillow, and he is perpetually wanting to get out of bed;
but he is readily induced to lie down again. It is very seldom
that he meditates harm, either to himself or to others ; there
is rather a mixture of cowardice and dread with the delirium."

In favorable cases the critical sleep comes on about the third
or fourth Jay, when the patient falls into a sound slumber,
which lasts many hours. From this ho awakes very feeble,
but cured of his disease. In fatal cases the watchfulness con-
tinues, there is muttering delirium, subsultus tendinum, and
exhaustion, ending in death between the third and lifth day.

6V/tt»cii — It arises generally from the excessive use of ardent
spirits, wine, or beer. The habitual use of opium, and exces-
sive nieutal excitement, will also cause it. Men are very
much mure subject to it than women.

Aucording to some authors the symptoms of delirium tre-
mens may set in after a protracted debauch of six or eight
days, or upon the sudden withdrawal of the accustomed pota-
tions. The latter observation has been repeated so frc<^|ucntly
that at lust it has almost become a sort of recognized law, but
for all that it is probably thoroughly untrue. Evidence derived
from hospital practice, and from the reports of convict prisons,
seems directly to negative it; and it may now he said to be at
least highly probable that a per.son accustomed to the very free
nac of stimulants may at once give them up, without any dan-
ger whatever. In fact, as with other poisons, the only risk to
be feared is from continuing their employment.

Treatment. — Tbo great point, it has always been thought,

DELIRIUM TRKMEXS.

239

is to procure sleep. For this purpose opium has been p;ivcn in
full doses ; either morphia, or polid opium, or Uattlcy's Ii(|Uor
opii sedativus, or the couuiion tincture. At the same time
stimulants hare been deemed necessary ; and as a rule, that
stimulant has been considered the best to which the patient
has been accustomed. Thus, if he has ppnerally besotted
himself with beer, pood ale or porter has been freely admi-
nistered; while, if brandy or gin has been the favorite liquor,
he has been supplied according to bis fancy.

Now it is not pretended that this plan of adding fuel to the
fire is always prejudicial ; but it seems certain that when in-
discriminately practised, as it has been, great mischief must
often result. The cases to which it is Applicable are, indeed,
the exceptional ones; white in the majority of instances, it is
as absurd as it is injurious to treat a case of alcoholic tiisoimia
by continued doses of the poison that has caused all the mis-
chief. The practice to adopt is to bring about the critical
sleep as soon as possible by removing the cause of the disease;
to give ice and perhaps salines, to cool the irritable, if not in-
flamod stomach ; and to support the strength by milk, raw
eggs, beef-t«a, &c. — Sometimes a cold .shower-bath gives so
much relief, that the patient will ask to have it repeated.
Where the dopres.sion is very great, stimulants must undoubt-
edly be adniiiiistcrcd, as in other cases of prostration ; and iu
each, a well-timed dose of opium with ipecacuanha will often
prove u.seful. In one instance, where the delirium and con-
stant talking seemed to be exhausting the p.Ttient, I resorted
to the use of chloroform with manifest advnntage ; but I have
also seen this aua^ithetic act prejudicially, the excitement re-
turning in an aggravated form .so soon as the influence of the
vapor subsided.

Mr. Jones, of Jersey, states that for the last twelve years
he has treated all his cases of delirium tremens by large doses
of digitalis, with a remarkable degree of success. lie gives
half an ounce of the tincture with a little water, fur a dose.
In aome few instances, one dose is suQicicnt; but generally a

240

msEASEs or the nervous system.

second is required four houni nfter the first. Very seldom a
third dose of two draohins is called for, owing to the absence
of sleep. The effect of this drug is to produce a warm sitin,
a more regular and fuller pulse, and six or eight hours' good
sleep.*

Oceasionally it is tlioufiht neoes.sary to restrain the patient's
niovemetits by strappinf; him down to his bed, or by putting
CD a strait-waistcoat. This should never be done, however, if
it can possibly be avoided ; as it always increases the excite-
ment and prevents sleep. It will invariably he much better
to huve an attendant at the bedside to quietly control bim.
The apartment occupied by the patient should be darkened,
kept quiet, and well ventilated ; and nothing is to be done
that can in any way produce mental irritation.

2. Dipsomania.— Within the Inst few years the word Dip-
somania has been coined, to express that craving for intoxi-
cating liquors which, according to some physicians, partakes
of the character of insanity. Now, although a fit of intoxi-
cation is undoubtedly an attack of temporary mania, yet it
seems to me a highly unphilwophical view (and one, too,
which is fraught with the greatest danger to society) to regard
a dipsomaniac as an irresponsible being; to lo<ik upon him, in
fact, as an individual affected by some recognized form of lu-
nacy. Hard-drinking is a degrading vice, and, like many
other vices, the more freely it is indulged in the more difficult
is its discontinuance. It seems absurd to say that the desire
for alcoholic stimulants is a disease — that it is symptomatic of
some abnormal cerebral condition, unless indeed we say the
same of every act of wickedness or folly. Not only is the
experience of the dcad-hou.oe against such a view; but if we
set aside this evidence as being of little value, we yet know
that there is no ditEculty in curing the most inveterate sot,
provided we are but able to deprive him of his poison. The

• Medicol Tinui ojui Gasfttt, London, Sept. 20tli, 1H6U.

nELIRIVM TBKMEN8.

241

f«cl is indisputable that many who drink to excess can bo per-
suaded to abstain temporsirily, if only a limit to their abtti-
Dence be fixed, so that they mny enjoy the anticipation of a
debauch ; while a few can be so influenced thit they renounce
this habit entirely.

The drunkard is a nuisance to himself and all who are
broupht into contact with him ; and it is to bo rcjrretfed tluit
there are no legal means of controlling him until he is cured
of his folly. The man who attempts suicide by some sum-
mary process is liable to imprisonment; while he who slowly
poisons himself may proceed to certain destruction with impu-
nity He may niin himself and his fiimily, but bo that he
breaks only moral laws and oblipitions he cannot be stopped
in his downward career. The wclfareof society deniandsenme
place of detention for such men; and even if an Act of Parlia-
ment cannot be obtained to sanction tlie necessary interference
with the liberty of these misguided people, yet I believe that
there are many who would voluntariiy enter and submit to
the rules of an institution for the cure of dmnkenness. Mr.
Dickens in his "American Notes" mentions' the case of a man
who {rot himself locked up in the Philadelphia prison, so that
he might rid himself of his projvensity to drink ; where he
remained, in solitjtry eontinement, for two year?, though he
had the power of obtaining his liberty at any moment that he
choec to ask for it. Patients have ntore than once toid me
that they would gladly submit to any treiitinent or surveil-
lance; but they have also said that without restraint all else
would be useless, for they could not trust themselves.

Our knowledge of the precise effect of alcohol upon the
living body is becoming more and more perfect, though many
pointA still remain for elacidation. An admirable series of
experiments by MM. Ludger Lallemand, Maurice Perrin, and
J- L. P. Duroy,* seems to show that alcohol is not only scpa-

* Dh Rote lie t Alnol et del Aneilkttignu dam VOrgamtme; Re-
e^rehe* KcperimtH^aUi. PsrU, 18A0.

242

DISEASES OF THE NERVOUS SYSTEM.

rated frou the blood bj the tissues of the body — especinlly the
substance of the brain and of the liver — but that the excretory
orpans freelj help to eliiiiin:ite it; the lotij;th nf liirie rc"«|uired
for its entire retirova! from the circulating; current depending
of course upon the quantity introduced into the systeni. The
experimenters believe themselves justi6ed in deducing the
conclusion ttiiit alcohol is neither transformed nor destroyed in
the living body, but that the whole of what ia ingested is
excreted unchanged ; so that this substiince has no claim to be
regarded a,s a producer of heat — as a true fcxid, but must be
placed in the cati'f;ory of those medicinal or toxic agents whose
presence in the living body cxert£ a most important influence
on its functions, though they do not themselves enter into
combination with any of its components. These opinions are
80 directly contradictory of those which have been accepted
from Liebig, that it is necessary to carefully examine and test
them before they can be adopted ; but it cerUiinly seems very
probable that the right of alcohol to be considered a respiratory
food will have to be abandoned.

The pernicious effects of the excessive u.so of aluoholio
stimuli, as revealed after death, are found to be induration of
portions of the nervous centres, congestion of the respiratory
organs, amyloid and fatly degeneration of the liver, with
disease of the substance of the heart and kidneys. But it
must be remembered that these morbid changes are the conse-
quences— not the c^use — of the abuse of stimulants ; for in no
instance is it pretended that the condition of brain has been
deuioustrated, which, according to some writers, gives rise to
the propensity to drink.

A few words must suffice on the medical treatment oTcJirom'e
ithiihutUm ; wliicli differs from delirium tremens inasmuch as
it is not an acute disturbance of the functions of the nervous
system, but a protracted state of general depression with rest-
lessness. The chief points that demand attention are these :
To enforce total abstinence, to afford mental occupjition and
amusement, to administer tonics and such remedies is will

INSANITY.

243

pive gastric fone, and (o rejrulate the tliet. Dr. Miin-et Mttttes
that the nervous syiupt^jins jireseiit in these oases iiiiiy be best
relieved by the oxide of line, which is to be given in two-grain
doses, twice a day, gradually inereiisiiiig the (|uaiitily until
twelve or sixteen grains are titJcen in the twcnty-tbur hours
(F. 492). The effect of thi.s powder is to induce sleep, to re-
move the tremor of the limbs, to relieve the headache and
giddiness, and to destroy all hallucinntions. The chief other
remedies arc aninmniu atid hark, the niinera! acids and pentian,
quinine and citrate of iron, pepsino or ipecacuunha, and rhu-
barb with magnesia. It is often a question as to what shall be
substituted for beer or wine at mcal-tiiues, and I generally
recuuimend some agreeable fruit syrup in soda water.

VIII. INSANITY.

1. General Observations. — Few subjects more deserve the
ciireful study of the medical practitioner than the diseases
which affect (he int/>llectual function.-i, and few have been
more neglected. "The care of the human mind," says tiau-
bius, "belongs to the physician, — it is the most noble branch
of our office."

Many <lrfinition* have been given of insanity, but the only
one which will enibrace all forms is, — That it is a general term
used to expre.s8 the mental condition opposed to sanity ; sanity
being that stiite of mind which enables a man to discharge bis
duties to his God, his neighbor, and himself This definition
is open to many objections ; and let doctors and lawyers vex
themselves as they may, every definition will be so. For, as
nothing can be nmre slightly defined than the line of demarca-
tion between sanity and insanity ; so if we make the definition
too narrow it becomes meaningless, and if too wide tlie whole
human race may be involved in it.*

• The Rr/Hirl from lit* StUet Committet on Luimtirt, ordered by the
Uoiue nf Commuui to be prloted 3Ttb of Juljr, 1800, ihotva that Ibe ouia-

244

DISEASES OF THE NERVOUS STSTEM.

The indicntions of iinpcndin<r cerebral mischier may pene-
nlljr be detected by the careful phyxician some months before
ihey attract the scrioa'^ uttciiliou of the piilient or his friends.
The chief prciiioiiitury sjtuptDms or prodroitiata have been
especially pointed out by Dr. Forbes Winslow; who forcibly
insiists upon ihc fact that cerebral afftH'tions are not cnddenly
developed, whilo tiiey are often reiidfiw) incunible by nejjltct
of treatment iu the early stages. The liireateninps of incipient
insanity which shniild excite nl.nnn, arc, — hetidachc, nitneksi of
giddiness and iiioiilal cniifusion, paroxysms of irritability and
loss of temper, inaptilude lor >i«nal oecupntions, a weariness of
life, a state uf sleuplessne.s.'i or of lethargy, loss tif memory,
defective articulat'un, dimness of sight, and fiightiness of
manner. The piilinit feels too that he is not <|uite right, but
docs not like to consult u physician. He also shun.a his old
friends, is tortured ivith blasphetncius or obscene thoughts, has
frightful dreams, and generally ."ufferw from dyspepsia.

.Mental diseasis are most freiioenfty accompjinicd with
symptoms of a variety of bodily disorders, Kven the Greek
and Roman physicians were aware of this fict ; yet in the
present day it is often forgiJtti'U, and the disorder is allowed to
pass on unnoticed, simply because it is not at first apparent.

bcr of Innotios in EogUod nod Wile« in ]Mi, ISiS, bqi] 1850, wti." n>

follow* :

IftJanuarj, IM4. 18.'>8. 1859.

In Prirat* Krtabli'bnienlf 3,790

In I'lmper Avjlauis, Workhourat, &o., . . 16.821

. . 4,SI2
..30,7.15

. *,78J
. 31,330

35„'l47 .<I5,983

ToUl 20,B11

Thar, it rcem*, tbnt tbc increase or lunatics i> much in eiceoa of Ibe in-
crrajtr uf populatifin between the abnvo pcriivd* ; but nllownnoe mast be
ninilo lor improved regi'tmtion. u well a> for Ihe iliminished mortAlity
nmoDg Ibe inwme. The figurei, howerer, show tbnt ai least one person
oat oferer; SOO In England and VValea i> incapkbis ot managing biniaelf
«Dd his ilTairi. Doublleif a vast proportion of tbeae are ooma of idiocy,
or of mantal itnbccilit.T from age, fitg, Ac. Thera cases are incnrabla; but
of the reit, rnnje 51), UO, or perhaps 7U per cent., are curuble, if taken in
lime and rnroful'v trt.-at«d.

INSANITY.

245

There arc two morhii] affections cspceiully, however, which
dcinunJ our ntlt'tition. Of all the forms of insanity those
which are coinpHcated with general paralysis, or with epilepsy,
are the most terrible.

Jnsanily reith i/eiifr>i/ }>'irnlj/»is is a disease which has
attracted much attention on the part of those haviiii£ the
medical charjie of lunatics. Physicians generally, however,
know but little of this disorder; a circurastonce which may
partly be due to its inappropriitle designation. For the term
grvfrral piirali/fis, as thus employed, does not mean complete
loss of sensation and mutton ; nor in fact does the disease at ail
re-iemble ordinarj* paralysis — the result of compression or dis-
organization of some part of the cerebro-spinal system. But it
is an affection »ui genrrl*, which it has recently been proposed
to call the proijrr$iiive parnh/m's nf the insane; and I cannot
but think that the sooner this term is adopted, the better.

Ksquirol tirst drew attention to the incurable nature of this
uiulady ; and wc now know that pitralytic lunatics seldom live
more than from one to three years. At whatever period the
paralysis KuperveTics, its coiitruenceiiiont is generally unmarked
by any striking symptoms ; while it increases as the mental
powers diminish. Its first indication is commonly nn iuipcdi-
mcnt in the movement of the lips and tongue ; the articula-
tion is muffled and imperfect. I'his increases, and is followed
by tottering, uncertain, and vacillating movements in walking ;
or the impairment of locomotion may be the earliest symptom.
Then also, there is a want of expression in the countenance —
a heavy vacant look; the pulse is feeble and frerjuent; the
tongue on being protruded moves tremulously from side to side ;
usually the mobility of the pupils is lessened, and oltcn they
are of uneijual siec, or one pupil may he dilaicd and sluggish
while the other is permanently coiitriieled ; the excretions
escape involuntarily, cither from want of attention, or from
paralysis of the sphincters; and there is e.xaltalion ol tlie mind,
with the formation of childish hopes and schemes. Uemi-
plegic seizures, attended with convulsions or ooma, arc not

21*

24'»

DISICUKtt or TBI 5UlVorS SYtiTm.

niiconiiiion ; bat tbey ^Denllj pa» off after the use of stiiiin-
latihg enemata. aod the removal of any oiHectiou uf hardened
faeces As the tlbon^e progresses, the patients become unable
to articulate a ."iugle word ; they continually ^nd their teeth,
onen produciiis a roost diacordaot noise during the stillness
uf the nifrht ; tlieir weakness is such that they cannot walk or
even stand; all traces of intelligence become abolished; thej
get motionless and insaensible ; and their torpid existence ia
reduced to a kind of slow death. With resrJrd to its nature,
Pr. C!onolly says : " Ik seems to origtiiale in a general aflfec-
tioo of the brain, scarcely indicated after de^iih by more than
greater softucss «r greater firmness, general or partial, of the
cerebral substance, and by ventricles full of semui, combined
merely with other appearjnccs common to all chronic cases of
mental malady ; and it leaves the practitioner, after longest
reflection, ignorant of its primary nature, and helpless as to its
cure."* All, tlierefore, that wc can do is to relieve any
painful symptoms, to give sleep by large doses of henbane,
and to Btipport the strenL'th by a nourishing diet, warmth,
and cleanliiic-.". Mr. Austin stutesj" that when the patient
is not very feeble, one scruple of the extract of henbane is not
too l:ip/e a du:<c- to bc^in with ; and that this (quantity may he
grndunlly increased to half a draclim, twice or thrice a day.

Intimity with rpi/fpKi/ is also suid by Rsquirol to be incura-
ble. The conduct of insane epileptics is often characterized
by the mo.st ferocious, murdcruus, or suicidal aberrations; it
is frei)uently also most filthy and disgusting. Notwithstand-
ing these unfavorable .■tyinptoms, however, residence in a well-
ordered asylum will do luucli to induce a certain uiuount of
menial tr.iiKjuillity ; whilst a gcxid diet and daily exercise will
conlribiilo to the physical improvciiient. If early death do
Dot rc.xiilt, the disease usually subsides into incurable dementia.

* Oh th* Trfalmnl of tkt Ituaiu vilhont Mtrhaniral ReUrainl:
Luuduu. ISM.

f G*iitrol Pur/t/iftis ; itt Symptoms^ Cnittrs, Srnt^ ^,, p. 206. Lon-
don, 18i8.

INSANITV.

24;

Dr. Bucknill sUites ihnl in epileptic cii.ses where no consid-
erable amount of deiticniiu hus rosultcil, ttie brain is not found
atrophied or prrsenliiii; :iny apfMiii ranees of disease. In the
examination of tliirty-ihrce brains of epileptics, this geutlemaa
only once found a spiculu of bone projecting from the cranium,
and once onlj a tumor.

2. Varieties of Insanity. — Much diversity of opinion
exists ns to the best ilusnijifiition of mental disea-ies. As the
most intelligible and simple, I shall adopt that proposed by
Pincl and Ksqutrol, who divided insanity into mania, moiio-
mnnin, drmrnlin, and itfw/i/. It must be reinerobored, how-
ever, that the differences between these varieties are almost
always indistinvlly marked; thut the deiicript ions laid down in
books are extraordinarily distinct compared with the medley of
symptoms presented by real cases; and that the varioas forma
fre<|uenlly run into each other.

a. Muniii. — Mania, or raving madness, may be said to be
characterized by t/rueral delirium. The reasoning faculty, if
not lost, is disturbed and confused ; the ideas are abundant,
erronetms, absurd, wanderinf; — tiot under control. The muu-
ners are violent, excited, and exceedingly mischievous.

Although mania rarely niukes its incursion suddenly, still
it is that form of insanity which nnjst frequently dues .so.
From its commencement the delirium is general, and the fury
extreme. Then it is, that maniacs often destroy themselves,
either from not knowing; what they do, or from despair —
being con.scious of their condition, or from accidentally injur-
ing themselves. The difficulty of describing the symptoms of
mania is extreme. " Where is the man," says Es^juirol,
" who would dare tu flatter himself that he had ibserved and
could describe all the symptoms of mania, even in a single
case ? The maniac is a Proteus, who, assuming all forms,
escapes the observation of the most practised and watchful
eye."

In jrcneral, nianincssoon bccotne weak and emaciated. The

248 DISEASES OP THE XERVOUS SYSTEM.

mere physical exertion which they go throogh, sometimes
shouting, howling, hushing, reciting, 4c-, for hours together;
often restless, constantly and rapidly moving about, would
quickly exhaust a strong man. Combined with this fatigue
is B want of refreshing sleep, and not unfreqnentlyon aversion
to all food. Where recovery takes place it is invariably pre-
ceded by sleep, a desire for food, and a gradual cessation of
the agitation and delirium.

Pnerpernl Manui is a peculiar affection occurring to women
almost immediately — or about the fourth or 6fth day — after
delivery. It cnmmencus usually with restlessness, insomnia,
severe pain In the head, and a diminution in the secretion of
milk. Sonu'timrs there is no fever, sometimes the skin is hot
and dry; while the pulse is full and quick, and the tongue
thickly furred. In the cases which I have seen there has
been great debility; the patients having been prostrated by
fliM)dings during their labors, or by the presence of some mor-
bid poLsuii- — US that uf erysipelas — in the sj-stem, or by some
other cause which hus lowered their vital powers. The deli-
riniii is often vitilciit, there may be a tendency to suicide or
ohild-uiurder, and tlierc is great general irritability. In their
treatment the.«e puerperal cases require peculiar care. The
indications are to rouse and suppurt the powers of the patient;
and t(> allay the irritiibility of the bruin and the nervous .sys-
tem. The first is to be accomplished by a cordial, stimulant,
and nutritious diet. The mistiini npirililn vi'ni f/nliici of the
London I'hiiriimcopwia will often be very useful, given fre-
quently in small ([uantittes ; while good beef-tea and wine are
also beneficial. The ccrcbr.il excitement is to be calmed, and
sleep procured by sedatives : full rloses of the liquor opt! ttJa-
tivin, or of rumphur with vniiphia, or of heiihanr (F. 360,
803, 3tt4, 371, 389j, often do great good. The patient must
be controlled efTcctually, but mildly, by a good nurse acous-
tonicd til the maMagcnient of these case; ; and when the dis-
ease thi'cateuH to be uf considerable duration, she should cer-
tainly be separated from her family and friends.

INSANITY.

249

/?. 3toiiovuni!ri. — Monomania, or ymrtinl insnnity, ia Ibut
form in whii^h the uiiderstiintliii^ ia piiiiiiilly tlfriuifrcd, nr is
under the influence of some one particular delusion. The
mind is viponms ; the ideas arc few, erroneous, fixed, not under
control The manners are in accordance with the predomi-
nant idea or train of ideas. .\t one time the iuteltoctual dis-
order is confiited to a single object, nr a limited number of
objects. The patients seize upon a fiilse principle, which tlu-y
pursue lo^icjdly, atvd from which thov deduce leiritimate con-
sequences, that modify their acts and affections. Thus, a
nionoiunnino will insist that his body is made of filass, and
being thoroujriily impressed with this idea, will reason cor-
rectly that slight causes may injure it; he consecjueiitly walks
with care, and avoids any rough handling. Aside from this
psirtial deliriuui, he often thinks, rea-'^ons, and acts like other
men. Another, in the belief that he is a bad half-crown,
will go round to the neighbors warning them not to lake him
in payment or to j^ive chanpo for him when his wife offers him
at the counter. Again, a third will fancy himself suspected
of some horrid crime, or may think he is po,<3scssed of a demoo
or evil spirit, or will believe himself to be a god — imagining
that he is in communication with heaven. Occasionally,
under the idea that he is a divine instrument of vengeance,
the monomaniac commits murder. He will often be happy,
full of joy, and communicative, unless attempts are made to
control him, when he becomes wild and furious. Such indi-
viduals ask the most cvtraordinary favors, and make the most
absurd demands.*

# The following copy uf u Iplter, pressDied bj s mnnomanino to Dr.
Conolly, if a good example : "In the name of the Mu.wt tli|rh, Elernul,
Almighty Odd (if llonvcn, Eurtli, unJ 8pnco. I ounimnn'l you lo procure
me the followiag ■rliclen iiiimF<liat<-ly : A Il«ly Bible wilh rngrrivinga,
Ac. : K CoDCordunce ; a Mnrtyrotogy. w tlh plnteti ; nomc olhor religioua
books ; a Iftte Gpugraphioiil Qrainmar, tt raoUern Qazcttror, newcipjiper?,
magmzioea, aliiiaiinckR, Ac, of any kind or date; musical iuftrumeutfl
and mufio ; Iitrge planF, guides, mnpti, directories,'' — and many other
«orki>, concluding with — '* winrs, IVuit, loiengos, tobsceo, snuff, oyster*,

250

DISEASES or THE NEETOCS ST8TKM.

Another remarkable and not Dncnmmon effect produced in
the mind by insanitv, is the hjpochondriaeal snppoation of the
exbtence of venereal diseve. In one instance related bj Sir
W. C. Ellis, althoagh there was no possibility of the disease
having existed, the patient fancied she had been infected, and
ooald not rest satisfied antil pat under a course of what she
imagined to be mercurial medicines. After having taken these
for mme days, though nothing more than pills made of bread-
crumbs, the patient, from the expectation that they were to
produce salivation, spat such a quantity of saliva as to re^juire
a vessel constantly by her side for that purpose. When this
had continued for some time, she imagined that the medteiiie
had produced its effect; she discontinued the bread pills, and
the excessive action of the salivary glands ceased.

Almost every insane patient labors under hallticiivniinns of
one or more of the senses, — he sees or converse.'' with iiungi-
B«ry beings. When he is satisfied by the evidence of his other
senses that what he sees or hears is only an il/iiaion, he is said
to labor under a hiif/iirinit(i'n> ; whereas, whun he believes in
his fulso perception.-i, the hullucintition becomes a drlunioa.
Some authors use the terras liallucinuliun and illa'tioD in a
sumewliat difTtTent sense. Thus if a man hears voicesspeak-
ing to him which no one else can hear, or sees objects no one
else can discover, they say he hibors under a haUueinution ; but
to lay the foundutiou fur an illu.siun there must be presentsome
material object, — thus tlio elmid.'' arc firmed into angels sound-
ing truinpcUs, the windmill is regarded as u giant, and so on.
Ilallucinaliuiis may exist where the senses of sight and hear-
ing are absent, but illii-siona of course cannot do so. Illusions
are frccjucntly (ib.served iti u state of mental health, being cor-
rected by the reason.

Sonuitinie.H the symptoms are so far obscure, thi»t although
l!u' conduct of the pritii'iit, the expression of his counlenanco,

maor; — »v«rylhlug dtiiug to Alniiglity 0<m1. Answer lliii in lUree days,
or you go to boll. P. 8. — A portable ilealc and atalionory, aud a drcariog-

INSANITY.

251

nnd liis demeanor siipgest mental delusions, yet he nmnifesfs
nothing of the sort in bis coiiveisiitioii. The insanity may
then frequently be detected by the written letters. Such a
case occurred in my own pructiee. I was sent fur one morn-
ing to see a younj; >;entloiiian whose manners were peculiar,
but who spoke rationally. A few hours afterwards he wrote to
me — " I find that after a physician lias received his fee ho
must do whatsoever the patient wishes, unless he (the physi-
cian) can and dues ccrlilicBte that to be peculiarly hurtful and
detrimental. I require you to come prepared to lave my
bowels completely, and apply the aiiti-co.itivc oil j prepare tho
perineum for a bli.ster; and put three ounces of castor oil in
the bladder. I have got a preparation made to keep the blLster
open." — Again, Dr. Noble mentions the case of a youth,
twenty-one years old, the son of a publican, who had beouiue
reserved, disdainful, and tutally changed in dittpusitiun shurtly
before being seen. No pcrversiuo of ideas was apparent,
excepting from his demeanor. Attempts to gain an expla-
nation were quite vain; still the intuitive gciod sense of tlio.se
about him suggested that he was not in his right mind. An
accident at length revealed the fact. The draft of a letter to
the Queen Dowager was found, showing tlmt he believed him-
self to be her son, and was indignant at being temporarily
deprived of his birtliright.*

That form of taonomania which is chanicteriKed by feur,
moroseness, and prolonged sadne.f.H, has been separately de-
scribed by some authors as hfprmiiuiit or vtihtmhulia. Such
cases are painful to have charge of, the despondency is often
80 great. A lypemaniuc is unwilling tu move, or talk, or to
take food; be will often remain a whole day without change of
posture, or without uttering a word. He dreads solitude;
sleeps but little; sometimes tortures himself by the anticipa-
tion of future puni.«hmciit; while at other times he is bent on
maiming or destroying himself.

• Blfmenti of Ptr/fhologicul Midiatu, lecond edition. London, 1866.

DISEASES OF THE NERVOUS SYSTEM.

The attempt to commit suicide (^autuphomanin) is not, as a
general rule, mnde from any sudden impulse, but nitber from
a tong-premeditatcd deteriuimition ; and often when patients
find that they are so watclied that it ia impossible for them to
carry out their design, they will nssunie a cheerful manner for
days or weeks so as to lull suspicion, and then ai^ail themselves
of the first opportunity which offers. Hanging seems to be a
favorite mode of self-destruction among the insane in this
country. When a suicide h.is determined — ui^ually after muoh
consideration— upon the manner in which he shall destroy
himself, it may be practically useful to remember, that he will
very often wait and neglect all other means which may present
themselvca until be can accomplish his death after his own
fushiun. Sir W. C. Ellis mentions the ca.sc of an old gardener
who one day consulted him as to the best mode of destroying
himself, since he said that he bad made up his mind not to live
any longer. The hcinousness of the crime contemplated, and
the fact that hanging was a most painful death, wiis pointed
out; his wife was directed never to leave him abme; and he
got better by the use of medicines which restored the healthy
character of the secretions. 8ome time afterwarda, however,
he was discovered dead in a little shed in his garden, where
he used to keep his tools. It appeared that so determined
was he to die by hanging, that though the place was so tow he
could not Ptand upright in it, and he had not a rope or even a
string with which he could suspend himself, yet he contrived
it by getting a willow twig and making it into a noose, which
he fastened to one of the rafters. He stooped to put his head
through it, and then pushing his feet from under him, sus-
pended himself until he died. Had he not made up his mind to
destroy himself in this particular manner, he might have done
so much more easily by drowning himself in the pond which
was in his garden, or by cutting his throat with the knife which
he always had about bim. — In some instances melancholies
having a tendency to suicide will resort to modes of destruo-
tioo such as baffle all ordinary precautions. For example,

INSANITY.

258

tliey will set fire to their clothinp, and while parts of the body
are burninj: nppear neither to suffer pain tiur fear, but rather
to triumph in their uiurtjrdom; so also they will tear their
night dresses, and by stufinnu; the shreds into their mouths,
endeavor to produce suffocution; and lastly, when takinj; pills
containing narcotics, they have been known to hoard succes-
sive doses, until they have accuiuulatcd a poisonous quantity.

Another variety of niononiania has also been described as
moral inganili/ ; in which there is perversion of the natural
feelings, affections, temper, hiibita, and moral dispositions,
without at first any remarkable disorder of the intellect. Ec-
centricity of conduct, an impulse to commit crime, a projjen-
8ity to every species of mischiei, are oReti the leading features.
These cases Bometiuicg assume an uncontroltnhlc dcstrnotive
tendency { ami rophonmnia), and the lunatic commits murder;
or there may be a propensity to set houses on fire (pyroma-
nia); or the disease may give rise to an irresistible desire to
steal (Jdrp(omania).

y. Dementia. — Dementia, or incoherence, is that condition
in which weakness of the intellect, induced by accident or
age, is the prominent feature. The mind is altogether weak;
the ideas are confused, obscure, vague, incoherent, unfixed,
and the memory is impaired. The patients are ignorant of
time, place, (]uantity, property, &c. They forget in a moment
what they have just seen or heard. Their manners are unde-
cided, childish, and silly; their conversation is incoherent,
and they repeat words and entire sentences without attaching
|iy precise meaning to them. They have neither partialities
'IIOT aversions ; neither hatred nor tenderness. They see their
best friends and relatives without pleasure, and they leave
them without regret. Soniotimes they are constantly but
slowly moving about, as if seeking for something ; on other
occasions, they will pass days in the same place and almost in
the same altitude. The ultimate tendency of mania and mono-
iimoiu is to pass into dementia. It is very rarely, if ever,
cured ; and in its last stage there is complete paralysis. Cere-

254

DISEASES (IF THE NERVOUS SYSTEM.

bral atrophy is a constant concomitant of dementia, its extent
varying with the loss of niorital power.

i. IiUoitf. — Thin condition is chnracterized by partial or
complete absence of the intellect, either congenital or occur-
ring in early life. The mind is not developed ; there arc no
ideas, or they arc few. The manners are childish, with occa-
sional transient gusts of passion. The countenance is vacant,
and void of aught approaching to intelligence. The articula-
tion and the gait are often imperfect.

The bniin of an adult ni.in weighs about 50 ounces, or
rather more than .^ lbs. avoirdupois. Cuvier's brain weighed
very nearly 60 oz. avoirdupois. Dr. Peacock found the brain
of an idiot boy, who died of scarlet fever when nearly eleven
years old, to weigh only 21 oi. 3i dr. avoirdupois; its propor-
tion to tho whole body being as 1 to 16.2. Dr. Todd also
dissected the brain of an adult idiot, which weighed 20i^ ox.
avoirdupois ; while Ur. Tuke mentions the case of an idiotic
female, who died in ihu Retreat at York, at the age of 70, in
whom the brain weighed 'l'i\ oz.

3. The Principal Causes. — These are often difficult to de-
tect. It IB no doubt frequently hereditary ; or it may some-
tinies be traced to marriages among near relatives, "breeding
in and in," as fiirmcrs sny ; or it may perh.ip.s be due to syphi-
lis in the system of the parents, or to drunkenness on their
part. The more immediate causes may be injuries of the
head ; abuse of alcohol or narcotics — as tobacco and opium ;
sexual excesses, and particularly masturbation; very rarely,
perhaps, continence ; fevers; and the retrocession of erysipelas
or pout in persons predisposed to insanity. Then there are
certain moral causes, as blighted ambition, disappointment in
love, perverted religion, immoderate grief, long-continued
anxiety and distress, prolonged intellectual exertion, and pecu-
niary reverses. I think it is Dr. Noble who remarks, that the
more advanced the civilization of any cDUiniunity, tho more
abundant are the diseases of the mind. Humboldt states that

INSANITY.

255

he looked in vain for cases of insanity among the nativo In-
diana of America.

One undoubted cause nf insanity seems to l)c defectivo nu-
trition of the brain, whether this originates from a. morbid
oondition of the blood, or in some obstruction to the capillary
circulation. Wantof refreshino; sleep ititorrupfs the natrition
of the brain nio.st seriously; and many patiuuls, after recovery,
have attributed their disease either to comptetc insomnia, or
to their repose havitij; been long disturbed by frightful dreams.
Those slumbers which are *' but a cotitinuatiun of enduring
thought" are quite opposed to the nutritive rcgeooration of
that part of the cerebral or>;anisin on the action of which the
emotions depend.

The age at which insanity appears to be most common is
etwcen twenty and forty ; in women, perhaps, between twenty
sd thirty, and in men between thirty and forty.

4. The Diagnosii and Prognogis. — In exatuininga lunatic
we shall often tiiid that (lULStnl' his actions are not more extra-
viij^iit than those of ninny pcculi;ir, though sane men ; but
we shall probably learu I'roin those about him that his conduct
\a totally at variance with thut which he manifested prior to
his attack. In short, ihf individual is not what he was ; there
baa been a frradual chaii're of demeanor, perceptible to all ac-
quainted with him ; while no pood reason can be given for
the altpnilion. hVeijuootly, there is souie difficulty in finding
out the patient's delusions, and on this point nt!:iiti we must
make intjuiricsuf the friends. But with regard to uU hearsuy
evidence, the physician must be cautious; since, without any
wish to deceive, it yet often happens that the friends have a
bias, towards which they may unconsciously lean.

With rej^ard to the prognosis, it may be .said that it is more
favorable when an acute disorder of the whole system, or some
cerebral malady attended with fever, has eonstiluted the bcfiin-
liiof? of the mental aberration, than in those cases where the
alietialion of mind has slowly exhibited itself, perhaps uUnost

258

D1SEA8KS OP THE NERVOUS SYSTEM.

imperceptibly iit the onset, but itdvanciiis; progressively to coii-
liniicd insanity. Wlitn physiciil vinlennc sustained by iho
head is the cause, I he pnifrnosis is uncertain, ina.sniuch as very
severe lesions of the encephalon may thus arise. Moreover,
if the mind has been overthroirn by sudden and severe cala-
mity, the prospects of recovery are great. Apain, if the
mind breaks down after protracted cares, the case is bad ; es-
pecially if the physical energies also become depressed. When
insanity is complicated with general paralysis or with epilepsy,
it is generally quite hopeless. — Probably more cases of mania
are cured than of any other form of insanity : the probability of
restoration is very much greater in the early than in the ad-
vanced periods : according to Esi(uirol the most favorable ago
for recovery is between twenty and thirty, few being cured
after fifty : most authors assert that insanity in women is more
curable than in men ; and la.stly, when the mental disease is
connected with some bodily disonlcr which admits of removal
by the progress of age, or by medical troatnaent, the grounds
for hope are much increased. To form u correct prognosis,
no link in the chain of circumstances must be overlooked.
I>r. Noble well observes : " The causes, moral and phy.sical,
predisposing and exciting; the hi.story of the invasion and
progress; the actual stnte, and the reactiuna taking place un-
der influences of every kind, — must all be known and rightly
appreciated if nn opinion is to be formed of the slightest
value."

In advanced insanity, when the patient is happy in his delu-
sions, he often gets stout, fur his appetite is good and his mor-
bid ideas give him no trouble. It is an unfavorable symptom
■when the bodily health improves, without the mental disease
becoming at all alleviated.

A very common cause of death in the insane is some disea.sc
of the thoracic viscera, especially of the organs of respiration.

6. Pathology and Uorbid Anatomy. — The two chief
hypotheses on the nature of insanity which are entertained in

INSANITT.

257

the present day nre, — iho mftnphytlcat or api'rihta/ theory,
and tlie ccfrlinif hjpjthesis. The first conjecture, that insa-
nity is a di.xorJcr of the inimatcrial principle, nnd not of the
material instrument by which the mind manifests itself, seenis
qnil.e untenable. The second theory is the only plausible one
— viz., that the bniin, or instrument throui^h which the mental
phenomena are expressed, is the part affected

The cerebral disease may be such ns is visible on esaminn-
tion after de.ith, or it m.ty consist of some change which we
cannot detect. If the brain be iuiperlectly nourished, through
aome morbid condition of the blood, we may have diseased
action without iiny structural chaiijje bcinpr left which our mi-
croscopes can detect. — The most distinct thei)ry of the patho-
logy of insanity with which I am acquainted is that put for-
ward by Dr. Henry Monro,* which I shall jjivo in nearly the
author's own words: 1. That it is an affection consequent on
depret«ed vitality ; which depression is wont to manifest itself
with pcculiarand specific force in the cerebr.il masses, owing to
a congenital and frwiuently hereditary tendency in the brain
thus to succumb when oppre.ssed by any escitiui; cause. 2.
That when the cerebral musses are sufferitif; from this condition
of depressed vitality, they lose that static equilibrium of the
nervous enerfrics which we call tone (and which is peculiarly
indicative of healthy vi;;or), and they exiiibit in their functions
the two different degrees of deficient nervous action (coinci-
dently), namely, irritable exces-s of action, and partial para-
lysis; that, in eon.'-equenco, the brain becomes an imperfect
instrument fur the manifestation of mind; and that (as the
manifestations r<f the spiritual beins; are subject to the infirmi-
ties of its instrnment) its operations are distorted cither into
irritable and di.^eased excess, or are more or less suspended
altogether. 3. That thcio two degrees of deficient nervous
energy do not full alike upon all the senta of mental operations,
but thai tho seats of the more elementary faculties (such as

BfmoittoH Intamly, ilt Nat tin ami Trtalmml. London, 1851.

258

niSKASES OF THK NKRV0U8 BTSTEM.

the conception of idens, &c.), maintain generally only the first
condition — namely, that of irritable excess, which is exhibi(x>d
either by excessive rapidity ot" succession of ideas, or undue
impression of single ideas ; while the seats of the less elemen-
tary but hi»;her faculties, such as reason and will, &o., generally
succumb to this second dei;ree — namely, partial suspension of
action. 4. Corroborative of this we find want of vitality and
nervous tone iu those parts of the system of the insane con-
nected with phjsiciil lift!, im the skin, mucous linings and appen-
dages. 5. And lastly, these facts arc supported by the results
of treatment, for that which will at the same time raise de-
pressed vitality, and etjuulize disturbed nervous energy, is found
to be most uwel'u! in ilio treatment of insanity, and this is exor-
cise in the open air, as well as the due empliiyment of other
vital stimuli. — if cnco it \h deduced that iusanity is caused by
loss of nervous tone, and losis of nervous tone by depressed
vitility. Violent symptoms nmy be regarded as attempLson the
part of nature to throw off morbid excess of nervous energy;
consequently the violence is not to be looked on wholly with
fear, but rather with hope, as we know the more acute the
symptoms are, the more hope there is of cure.

The observations of Drs. llucknill and Sankey on the brains
of the insane and the sane give us the following results:
(1.) The ab.sijlutc weight of the brain is increased in insanity,
though the absolute size relatively to the capacity of the cra-
nium is diminished. (2. J The greater heaviness depends upon
increased weight of the cerebellum, compared with the cere-
brum, pons, and medulla oblongata; so that the cerebellum is
heavier in relation to the cerebrum in the insane than in the
Bane. (S.) The increased weight of the cerebellum is found
to be greatest in general paralysis, and least in acute mania ;
the first being a disease of very much longer duration than the
second. (4.) The specific gravity of both the gray and white
portions of the bruin is increased in the insane. (5.) Dr.
Bucknili seems to think tliutlhe most essentia! change consists
in the existence of two kinds of cerebral atrophy, — namely.

INSANITY.

259

•

Jliat wliioh is positivp, nnd that whiuh is iDterstitiiil nr rcliitivo.
Hj' p(i.«itive ntrofiliy he iiulioatos an notual shrinking nf tho
brain ; while by relative atrophy, whieh nmy or may not be co-
existent, he luenns an interstitial ohaniro, wherein the active
cerebral molecules sufl'er diminution, inert materiala being
deposited.

6. The General Treatment. — Supposinj; that the physician
is fortunately consuUt-d when the symptoms nre only threaten-
ing, he may often effect a cure by resting the nervous system,
by takinj; care that there is a due amount of sound sleep, nnd
by attending to the function."* of the skin, liver, kidneys, and
alimentary canal. Whure there is no symptom of active (li.H-
6880 in the head, opium often proves invaluable; or Indian
hiMnp, henbane, hop.«i, or chloroform, niiiy be useful. If the
vit;il powers be depressed, tonics — such us quinine and iron —
must be given. The diet is to be nourishinp, and the amount
of stimulants to be regulated. Change of air and scene may
also be reenni mended.

In examining a person supposed to be insane, the duty of a
medical man resolves itself into two parts :* Iwt, to determine
whether the individual in question be of sound mind ; and,
2d, to give an opinion concerning the treatment required, and
especially concerning the necessity of restraint, its degree, and
nature. The practitioner will have learned from the preceding
observations how to answer the first question. As regards the
second — the medical treatment — it must of course depend
upon the state of the patient ; but it may be positively asserted
that under no circumstjinccs can an antiphlogistic course of
remedies be borne. | Our object clearly must be to restore and

• Oh the hidimliotu of Iiuanily. By Dr. Conolly. London, 1830.

t Ttii? opinion, unfortunntely, will not be acqaiosocil in by all pbysi-
ei&np. One nf the carefnl recent writerci on thii^ subject drawa the follow-
log eonolasion? from his experience : Insanity, in nny form, in not of
iUelf an indication for bloodletting ; on the contrary, it^ existence is of
itself a contro-indicntion ; hence the person who is insane should, other

8«0

DISEASES OF THE NERVOUS SYSTEM.

nininUin the bodilj functions, and to remove any di8urden< in
other parts of the system — as skin diseases, &c , which niny be
connected or cuexistent with the cerebral affection. We may
persevere the more, when we rcnieuiber that many lunatics
have been cured by iniprovinp their general health, even after
Bufferino; for some yenr.i. In an ordinary case of insanity, I
should c.speciiijly lake care that the patient had a nutritious
diet, warm clothing, exercise in the open air, healthy evacua-
tions froin the bowels, and sound sleep at night. I would try
and prevent all bad habits, as onunisiu, &c. ; I should also
endeavor to (jive repose to the nervous system ; and then at
length pently fry to revive the affections, and Rtren<rthen the
bewildered intellect. While following thtji plan noniccbunicai
restraint should on any acconnt be resorted to; and such cheer-
ful oecuputioD and nientitl aujusciucnt should be afforded, as
the lunatic could beneficially enjoy.

From this it will be seen that ^tiniulitnts, tonics, mild wnrm
purgatives, and narcotics — especially opiates — must olYen prove
invaluable remedies. The douche, shower, or simple warm-
bath may often be used, but only according to the ordinary
principles of medicine. The diet of the insane should un-
doubtedly, as a rule, be generous and of the most nourishin);
kind. It not uiit'retjucntly happcn.s that nil food is refused,
especially, perhaps, by those who have morbid ideas on reli;;ious
subjects. Such patients will funcy that they are commanded
to fast, and will perish from inanition rather than disobey the
imaginary precept. In other cases the functions of the stomach

Ibingn bsiog equal, be bled lets than ons not iiuanc : innuiitj may oo-
ezifl with plethora, n tcniloncy to npupleij or paralysis, and aomelimea
•Ihcnio cungpKtion nr inilnmiimtion. which call for th« abstraction of blood;
Iberefore, vene.iecltno in mental disorders should not ba absolutely Aban-
doned, although the caaes requiring it are very rare. Aa a general rule
tajiioil is prefarabia to griural bleeding. Insanity following parturition,
other things being equal, is lu be treated by bleeding Ieit5 fre>|ut«iilly than
that which has it-s origin in other causes. — An Exiimiitatiott of thm Prat'
tin of Blooilltttiii^ in Menial Di$orilfrt. By Pliny Enrle, M.D. New
York. 1854.

INSANITY.

261

■nd bowels are dernnged, and tho refusal is merely due to com-
plete loss of a]>pctite ; the food being eagerly taken when the
intestinal evacuations have become free and healthy. If we
can, therefore, find any physical cause for the abstinence, it
roust, of course, be removed ; but otherwise we may try and
persuade the patient to eat by tempting him with dainties, or
by puttintr food where he can help hiii!.>ielf when unseen, or by
feeding him with a spoon like a child, or we must resort to
forced alimentiilwii to sustain life. This latter process may
be effected by injecting nutritious fluids through Uic misal
passages or by the mouth. If we adopt the first mode, it is
only necessary tu have a funnt.'l with a long flexible tube
attiiched to it; which tube, on being passed through the pos-
terior nares and oesophagus, will convey any liquid by simple
gravitrition. In the second case, while the patient is firmly
held hy two or three attendants, we employ the gag and
Btoroach-pump ; by means of which I have oflen injected mix-
tures of strong beef-tea, milk, cod-liver oil, brandy, and flour.
The u.se of nutrient euemata in these cases is nut advisable.

As regards the moral treatment of insanity, no rules can be
of universal application. I will only aiy, therefore, that it
should be regulated by kindness and a feeling of synipjithy
with misfortune ; und that no harshness or means which induce
fear should be tolerated. The physician must endeavor to
obtain the confidence of his unfortunate patients, by showing
an interest in their well-doing, by quietly listening to tho ro-
citJil of their ailments", by never making a promise without
keeping it, and by allowing as much indulgence as is compati-
ble with the proper treatmctit of their disea.se. Then, if he
have a pleasing and friendly address, with kind but firm man-
oers, he may be sure of maintaining a greater degree of influ-
ence than he can ever acquire by any amount of severity or
violence. It can very rarely, if ever, be at all advantageous
to reason with a lunatic; though, at the same time, it is better
to do so than to treat their observations and complaints with
perfect contempt. Dr. Noble mentions the histories of three

202

DISEASES OF THE NERVOUS SYSTEM.

iomatea of an o^ylutn, eaelr of whom fancied himself the Holy
Ghost. On their being brought together, one was cured of
his delusion ; om he reasoned that there could not be three Uolj
Ghosts. But I cannot 8U|)])t>8c that Dr. Noble rej^rds the
discussion as the agent that effected the cure ; if indeed a cure
was effected, for it is not stated whether there were other de-
lusions, or what wiis the ultiinnte rB.>-ult of the case.

In order to render restraint imperative, I believe a lanstio
should be dangerous either to himself or to others; or seclu-
siiin should bo necessary us part of the cunitive treatment.
A!lhon;rh the (jniet and regular mode ol life led by patients in
woll-orderud ii.Hyiums is often most cfiicaciuus us u remediHl
agent, yet I am also convinced that mittiy institutions contain
hiirmk'sa though incurable lunatic.'*, who wouhl be much hap-
pier and in no degree injured by residence elsewhere; but
who, unfortunately, have relations and friends who will not be
troubled with thciu. Moreover, although very much has been
done within the last few years to improve the appearance and
character of our asylums, nevertheless much remains to be
Bcconijilished. They are not yet properly converted into Hitn-
jjiliils fur the Cure of Iiinaiiify, but still retain to an injurious
degree the look and nature of prisons; while the p:ir.<imonious
way in which some arc furnished, and the especially wretched
appeaniiice of many of the night-cells, are circumstances posi-
tively disgniceful. The days of rotatory chairs, manaclea,
stripes, lieud-shaving, hatha of surprise, prolonged and violent
shower-laths, dark rooms, — in sboit, of puni.«htnent8 of all
kidiis — huve, it is to bo huped, gnne forever; but if any one
doubt.*i that we have yet much to do, let him read the reports
of the Cummissioners in Lunacy.

IX. CEFHALALQIA.

Cephiilalgiu, or headache, is of common occurrence ; since
it is present as a prominent symptom durin<; some part of the

rErnALALniA.

263

progress of most acute, and of mnny chronic diseases. The
puiti or uneasiness is in the head ; and it is to bcdistinpiished
from the suffering due to rheumatism, or ncuruljria, or itiflaiu-
uialion of the scalp, or to sj-philiiic disease of the perieniiitum
' Olid bone.

Three principal varieties of headache majbe noticed. The
first, or phtkork heacliichf, ia connected with fulness of bloodj
the ccrebml tcsscIs become congested; there is a sense of
palliation in the ears; and giddiness on stooping. Persons
who live too freely, who ri«e lute in the morninp, &c., arc liable
to it; also robust, middle-uged men, who " muke blood too
fast;" as well as plethoric jounp: women, with irrepularity of
the catainenia. The second, or bilinuD hraiiiirke, may be
temporary or constant. When temporary, it generally arises
from some error of diet — .some exce.s9 either in food or wine, —
is most severe in (he uioiiiing (m awaking from an iinrofresh-
ing sleep, and passes away as the cause ceases. The constant
sick headache occurs in persons of weak stomach, who are
alnio.st always suffering from indigestion. The stomach and
duodenum arc out of order, as i.s evinced by the eiiated tongue,
the offensive breatli, the flatulence, the low spirit!*, and the
nausea which exists. There is seldom any disposition to
vomiting. The third, or nfrnou* headwhr, is often due to
debility and exhau.stioa. In one variety of this disease — known
as hemii.Tania, or brnw-aijuf — the symptoms assume an inter-
mittent character ; the pain recurring every day or each second
day, with the same degree of regularity as an ague fit. Al-
though this form prevails in damp and marshy districts, yet it
may arise in healthy parts of the country from other causes
than malaria, and especially from constitutional debility.
Weakly women, who exhaust themselves from over-lactation,
&c., are frequently the victitus of a kind of nervous headache
known as megrimt ; which may assume an intermittent charac-
ter like hemicrania. And, lastly, hysterical girl.'j are very lia-
ble to a kind of nervous headache ; which, when confined to a
single spot, ia known as clnvut hystericus, because the pain is

264

DISEA8K8 OF THE. NERVOUS ST8TEM.

said to resemble such as would arise from driving a nail into
the head.

Eleadacbos, of wliatevcr kind, occur more fre()ueatly ia
persons of adult life than in extreme jouth or aJvanecd age;
dwellers in towns suffer more than residents in the country ; *
females more than males ; the nervous and delicate more than
the robust ; the middle and higher classes of society more than
the lower; and lastly, says Dr. VV'rigbt, they " especially affect
persons who neglect (he many little attentions and cares that
our civilized, and therefore in !<ome measure artificial mode of
life requires. I may cspeciuily instance regularity in diet,
carefulness in adapting the clothing to the requirements of
our variable climate, attention to the action of the bowels, and
a sufficient amount of exercise, as essential objects of our
care."*

The indications for treatment arc, to relieve the congestion
of the head and the dyspeptic symptoms, while at the same
time uttempls arc made to give tone and strength to the system.
Mild purgatives, such as the compound rhubarb pill and blue
pill, or the aikalinc decoction of aloes (F. 174, 175, 176, or
179) will frcfjuently be useful. We may also olVen effect a
cure in bilious headaches by pepsiue, ipecacuanha, or rhubarb
(F. 4i)-t, 495), to aid digestion ; in which cases also the
patients must lake daily exercise in the open air, and avoid
too much sleep. In many nervous headaches, stimulant* and
tonics, particularly the nitro-muriatic acid (F. 460, 461), are
to be tried : in bemicrania, quinine or arsenic (F. 55, 68, 70,
72, or 446) will be needed ; while in hysterical women we
uiui't resort to zinc or steel (F. 450, 479, 484, 487, or 490).
Holding the arms high above the bead produces a marked
effect upon the cerebral circulation. Hence this proceeding
will sometimes check troublesome bleeding from the nose;
and I have frequently seen it relieve the severity of that pecu-
liar morning headache, with which some persons constantly

• Unidnrhf. iheir Coufandlhtir Cnrc, p. 13. London, ISfiS.

PISEASKS OF THE SPINAL CORD.

265

nwakr. In iiddition to tht- foro'^ruiti-r wc may oci^asiormlly have
to try cold lotions, eau do Cnlof;ne, &c., to the head ; dry
Clipping or blisteni, or scions to the nape of the neck; the
rpiiKival of decayed teeth or stumps from the mouth; and
change of air. It need hardly be added that in oiynuic head-
aches arising from some cerebral mischief, the disease and not
the symptom must claim the practitioner's attention.

X. DISEASES OF THE SPmAL COED.

Kxperimentand clinical observation ha ve tnii^iht us that the
spinal cord iu eonncctiun with the brain ii^ tlie instrument of
sensation and voluntary iiiutiou to tbe trunk imd exlrumitius.
The continuity of the curd with the ciiccphalon is ulK^lul«ly
essential ; Cor let it be destroyed, and then scn.sation and volun-
tary motion will be abolished iir all those parts of the body
supplied by spinal nerves below the seat of injury. The uciircr
the seat of interruption to the euccphalon, the greater will be
the paralysis and the more rapidly will life be cxtinguLnhcd;
so that if the cord be severed at its junction with the medulla
oblongata (as when ao animal is "pithed"), death will result
immediately. To Dr. Marshall IJall, however, we are mainly
indebted fi>r proving that the spina) curd umy be the iustiti-
meut for the excitatiuM of movements, >inlej)cti<J<Hifi/oi volition
or sensation; either by direct irritation of its substtince, or
through the influence of some stimulus carried to it from a
portion of the trunk or extremities by nerves there distri-
buted.

The nerves which issue from tlic cord have each two roots, —
an anterior purely motor, and a posterior purely sensitive ;
these roots by their union furtning a comp*jund nerve. On
making a transverse section of the cord we liiid it to consist
of gray and white matter. The gray corpuscular matter is
placed in the interior of the cord, in the sh;ipe of two cres-
ccntic masiies; each ma^ts being iu a lateral half of the cord,
each having an anterior and posterior horn, and each being

266

DISEASES OF THE .VCRVOUS 8T8TEM.

joined to the other by a band of mutter called the graj cnm-
missure. From the labors of Sehrowlcr Von der Kulk, it
seems certain that the anterior roots of the spinal nerve!) have
their origin from the gray ganglionic claster of cells of the
anterior born ; the ant-erior medullary fibres of the cord being
the channels through which the influence of the will is con-
veyed from the brain to these ganglionic clusters of plexuses.
The posterior roots have two rootlets, one of which seems to
ascend in the white sulistnncc to the brain, thus forming the
channel of sen.^iitidii; while the other pciietrates the white
substance, and Ki'cnis lo bo lost in the ganglionic cells of the
posterior horn and centre of the gray mutter. These latter
rootlets of the great posterior or scn.sitive roots are thought to
constitute the reflex nerves. Thus the two horns of gray
matter appear to stand in the ctuse.''t relation to motion; the
anterior being the direct sources of motion, while the jwsterior
serve for reflex action and co-ordination. (The cause of the
co-ordinulion of movements is therefore situated in the .spinal
cord, and not in (he cerebellQur.) The roi'dulla oblongata
appears lo be the common central pjint, where reflex action
crosses to either side; and on the irritated state of which gene-
ral spasms — as convulsions and epilepsy — are thought by Van
der Kolk lo depend.

In the hope that these remarks may facilitate the compre-
hension of much that follows, I proceed to the brief conside-
ration of the diseases of the cord seriatim.

1. Spinal Meningitis. — Acute inflammation of the mem-
branes of the cord (sumetimcR termed Ariite Piirali/ti» from
injiammntion of tin mcmlirnnenof the npiiinl cord) may tenni-
nate in resolution, or in the effusion of serum, or in suppuration.
The morbid action when acute may be associated with di.sease
of the cerebellum or of the cerebral membranes; while when
chronic it is mostly found associated with caries of the verte-
bras.

The ti/mptonu which have been described as indicating in-

DISEASES OF THE SPINAL CORD.

267

flnnimation of the meninges of the cord, are — acute puins,
often of a buriiiuji character, cstendinf; along the spine and
stretching into tlie limbs, agpravutcd by motion und pressure,
uud often »iinuliilini; rheuiuutisni ; ri<;idity or teljmic contrac-
tion ol' the niUM'les of the neck and buck, amounting sonietiiueB
to opisthotonos; priralysis of the lower extremities, which fjni-
dually extends upwardn as the efifuHed serum increases in
<|uuntily; a feelin"; of constrictiaa in the neck, buck, an<I
abdomen; sutfocatin*; scnsntiuns; retention of urine; priapisia;
und obstinate con.stipation.

Males appear to sufTer more oflen from spinal meningitis
than females: it is most coniiiion between the second and
seventh year, and then between the twentieth and twenty-fifth
year: esposure to wet and cold in rheumatic subjects seems
to be its most frc(|Uent cause, while mechanical injuries must
rank secimd: the changeK found after death are jrreut conges-
tion, effusion of serum or pus, and perhaps softening of the
cord: and, lastly, the treatment must be that rceominonded in
speaking of inflammation generally, since it is allowed by some
who have resorted to bleeding and mercury, that success has
nut followed the use of these remedies, though they account
for the failure on the ground of the practice not having been
adopted with su65ciciit energy*

C'rri-ljro-iijtiiiiil vfiiiir/iliii arises from the same causes as
inflammation of the membranes of the cord alone. Sometimes
the morbid action is set up in both situations at the same tin)e;
while in other instances the ineitibranes of the brain are tirst
uttackcd, and the disease spreads downwards, or vict; trmt).
Hut it is reuiurkable that cerebro-spinal meningitis occasionally
occurs us an epidemic; the inmates of workhouses being liable
to it.f So also soldiers have suffered from it, when quartered
in ill-ventilnt«d, over-crowded barracks; and when over-

* Di^tows of tfu Spittal Cord and its Memhranes. By Charles Evans
BferiHi, M.D., Ac., p. 45. Loniinn, 1853.

t 8*e an acooimt by Dr. Mayne of nn epidemic which prevailed in the
Iri«h wnrkhouaev, publiflbcd in Ibo Diiilin Qiiailtrl// JuiirHalof McdiniJ
ScttMft, Aug. 1840.

sas

DISEASES OP THE NERVOUS STSTF.M.

worked, and Bopplicd with too little good foot] ami too inach
drink. — To prevent ita 8preadlo<jr, removal from the unhealthy
locality is iibsKiliitely necosiKirj" while proper rcsulations as to
exercisu, veiitiliition, diet, &c., must be enfurcud.

2. Uyelitis. — Myelitis, or inflinnnuilion of the substance of
the spiual cord, i.t not iiiiirkcd by Jitiy very uiiiforai set of
aymptouia; since tbcy will be found to viiry with the severity
of the nttiiok, its duratiuti, »ind tht' portion of the cord affected.

Tracbii);; the iiiflsiiiiiii.ition from above downwards, the fol-
lowing are the chief si/mpfumit. When the rra»i"(i/ portion is
nffectod, deep-seated hojidaehi', (vnvulsive movements of the
liead iind faee, inaiticuliito speech, trismus, difEcult deglutition,
difficult spajimodic breiilhinp:, irrfj:ul;trity in heart's action and
in pulse, with heiiiiplej^ia or other forms of paralysis. As the
f;ilal Bla<^ advances, there is great prostration, feeble pul^e,
increased dyspium, and involuntary escape of the excretions.
Wheo ihc indummutioii utTects the whole thickness of the cord
above the origin of the phrenic nerves, life i.s at once extin-
•lui-ihed by sloppiiiir the action of respir.ition. — Supposing the
inflammation is in the rfrt'/cfr/ portion, dilficuity of deglutition,
iinpos.sibility of raising or supporting the head, acute pain io
the buck of neck, great dyspmca, a son.se of pricking and formi-
cation in the arms and h.inds, and puraly.sis of the up|)er
extremities, form the prominent signs. — In intlammatiun of
the iloriuil region, there ispiiin in the dorsal region, convnisivo
movements of the trunk, ]xir:ilysi.'i of the arms and lower
cxtrcniilies, I'hort and laborious rc-piiatiou, great palpitation,
&c. — When, us is most commonly the case, the lumLar portion
is affected, the pindysis of the lower extremities is more
marked; there is great pain in the abdomen, with a sensation
as of a cord tied tightly round it; convulsions or paralysis;
and pjiralysis of the bladder and sphincter uni, leading to re-
tention followed by incontioeuoe of urine, and involuntary
stools.

The di.scase si'.cms u.^ually to bo cxcitod by cold and damp,

DISEASES OF THE SPINAI, COIID.

269

or by wouiid.s iind ountu^ions; while simielimcB it occurs dur-
injj the profrre^s of fever. The profiitusis is ulwaj-s fjrave;
but there is no rcajion to doubt that mnny cases recover, where
the influtiimntion has only been of short duration, and espe-
cially where only the lower half of the cord has been affected.
It luay, however, terniiiinte f:itully in the acute .stii;re, or nfter-
wurds froru the occurrence of ramollissenient or of suppuration.
II:iiuuHii«8einent is the u)0.st freijuent result ; which cannot be
distiiiguii-hcd from noii-iijf};iiniiiat<iry suftonirifi by the naked
eye. Souietiiues one jiart of the oord is found i<uftened| and
another portion indurated. Occasionally an abscesii has beeo
discovered in the substance of the eord.

The Ireiilmeiil proper in irifluniiimtion of the cord and its
uieuibrancs is the suiue as that previously recommended in
influninmtion of the bruin and its membranes. Great cure
must be tiiken to keep the patient dry iind clean, as well as to
empty the bladder frcijuently with the catheter ; remember-
inj; that iiicnntinencc of urine generally arisos from the blad-
der boin-; over-di.st(Midcd — the urine literjilly overflows. Bed-
soreti will be bc-l girevuiited by placing the patient oti a water-
bed ; or, in the abi^ence oi' this, by the use of the wtl anjaduu
plaster.

3. SpLaal HsBmorrhage. — Apoplexy of the cord, or paraly-
sis from the eDusiun of blood into the spinal canal or into the
subst-ince of the eord, Ih more rare than cerebral hwmorrhai^R.

The CfiifKP* are chieHy blows and falls, over-exertion, acute
inflammation of the cord or metiibranes, fatty de<!;cneration of
the coats of the bloodvessels, and caries or other disease of
the vertebra}. The blood may be poured out citernal to the
dura muter, or between the mcmbnines, or into the "jroy por-
tion of the cord. Where the effusion is abundant, death may
ensue nt once ; but when this docs not happen, a fatal re.«ult
may take place after the lapse of some time, from chronic
softeninp of the cord.

utuint will depend upon the seat of the ruptured

lymjit

depend upon
23»

270

DISEA8K8 OF THK NERVOUS SYSTKM.

vessel. When tlie blooJ is effused between tlie niembrnne.*,
it will neuesiurily gruritatc to the lowest part of the spitml
canal ; ntul la-ia-e will arise paralysis, which jrradunlly ascends.
There will also ijc :icute and sudden piiin in the buck, and
sometinies in the head ; severe coiirulsioDS often set in ; the
breathinjr will he difficult, when there is pressure on the upper
p:irt of the foTi\ ; the heart's actiiin is usually much depressed ;
the skin is pale and cold ; but there i.s no loss of consciousness.
Effutiicin into the substance of the eord produces sudden
paralysis in all parts supplied with nfrvcs below its seal ;
unless the ha!in<irrhii>;e is very sli^'ht, whtu the loss of power
may occur slowly after the lapse of several hours.

The object ul' nur /rMlmnif luust be to chock the effusion
of blood by tjuict, and the application of ice nlong the spine.

4. TumoTS. — Paralysis may arise from the pressure of
tumors upon the cord, producing partial atrophy. The morbid
growths may consist of tubercle, or cancer, or bone, or hydatid
cysts. Exostosis of the odontoid process of the second cer-
vical vertebra has occasionally been found. Sometimes the
tumor has hiiii its ori;:in in syphilitic disease of the verlebrie.

The o^mpi'inis C(nnc on very slowly, paralysis occasionally
not bciniT manifested until sireat pre.isuro is cterted. The
panily«is of inution always precedoa that of sensation. There
is usually pain over the seat of the growth ; cramps, with con-
vulsive movements of the extremities, arc not uncommon ;
and in the event of the di.iea.se beiii'j; due to .wrofula, syphilis,
or cancer, there will be manifestations in the system of the
particular affection.

The trealmriil must be chiefly constitution »1 ; though occa-
sionally counter-irritants to the painful part of the i^pine do
giM)d. Iodide of potassium, cod liver oil, and a nourLsbiug
diet, arc the remedies frutu which most good may be expected.

5. Hydrora:lus. — This is a teroi applied to abnormal col-
lections of fluid within the spinal column. When the fluid

niSKASKS OF TriK SPINAI, conti. 'liV

!ias boon present for some time it produces, by its pressure,
Mlrophy of the cnrd.

iljdruracliis is generally congenital, and associated with
n/iina bijiilit. In such cuscs, one or more tumors containing
fluid are found over the cervieal, dorsal, or lumbar vertcbnc —
genenilly I'im IsittiT — wliii'h eoinuiiinicjite with the niuduila
spiiiidis. The arches and spinous prueesaes of the vcrtcbrseare
wanting in the situation of the tumors.

The tn-fitmriil must consist in improving the general health.
In some instances, reujoval of the fluid by pnnctun.', followed
by pressure judiciously applied, tn;iy be serviceable; but —
as a rule — the less these cases are actively interfered wiih the
better.

6. Concussion. — It is rather remarkable, th.nt while con-
siderable attention has been paid to the subject of concussion
of the brain, very little notice has been bestowed upon the
snnie condition as it affects the spinal marrow. The little
knowledjru which L prisse.s8 on this matter will perhaps be best
conveyed to the render, by a conci.«o reference to two well-
marked cases of concussion of the cord which cunie under my
notice during the year 1860. lu one case, the lady fell while
walking upon some rocks on the Devon.shire coa.«t; in the
other, a jump from a high phaeton was the cause of the acci-
dent. Neither lady lost consciousD&ss in the slightest degree,
both felt n peculiar tingling in the hands and feet called pin<
and needles, and txilh were able to walk sonic little distance
after the shock The first patient did not apply to me till six
weeks after the fall, when she complained of weakness, some
difficulty in pa.ssing urine, a sense of cold and deadness in the
legs, startings at night, with an increasing difficulty in Widk-
ing. Perfect rest in bed for one month, with the daily appli-
cation of the exlr.ict of belladonna down the course of the
spine, effected a cure.

The second patient consulted me on the day following the
mischief, for she was frightened because she felt so sore and

272

DISEASES OF THE NERVOUS SYSTEM.

bruised that she could scarcely move. There was, however,
no runi paralysis. She attributed the puiu tu the jump, though
piirprised at the severe result, iiiasuiuuh as she atijihted safely
upon her feet. She was kept in bed for many days until every
Bytnptotn had vanished ; and no ill consc(|uences eusued oa
lier afforwarda wulkinj; about.

When cases like the foreguinf; are neglected, and when the
suiferers continue to take exercise, there is a fear of chronio
inflammation or 8iifieiiiti>;; of the marrow setting in ; which
conditions arc vcrjt likely to end in incurable paralysis, or even
in death. Mr. Hilton, in his lectures at the Roynl College of
Surgeons in 1800, lueirtioned the case of a jjentlernan who
had a fail upon his back, a few yinrs since, owiiij; to the giving
way of some scaffoldinj;. Directly he fell he experienced the
Fcnsiition of pins and needles in his legs. Having been told,
when a boy, that in the event of an accident of this descrip-
tion, the best plan Wii.s to "run it off," he immediately .«t8rted
away and «|uickiy walked ^ix miles. AYitiiin a very short time
he began to experience spinal tuarrow symptoms, which have
resulted in complete and irretdcdiable piiruplegia. Mr. Hilton
stated his belief, tluiL if the. man had gone houic directly after
receiving the injury, and kept hiiiisclf quiet for a considerable
period, he would have been quite well at this time.

One more example will complete all that need be said on
this subject. The particulars of the case are as follows : A
stout, feeble man, between sixty and .seventy years of age, trod
on a piece of orange peel, and Icll ; the lower part of his sa-
crum striking the pavement with great force. He was taken,
in an insensible condition, to <Mi»ring-crass I]u.spital. wlicro he
soon recovered his mental facultie.'', but both his upper and
lower extremities were niotinnless. On the fourth day he was
conveyed home, and was seen by l>r. C. E. liecves, when it
was noted that his voice was weak and interrupted, breathing
slow, heart's aclion weak, urine scanty, and the extremities
motionless and insunssible. Galvanism and stimulating embro-
cutions were tried, bat the patient was found dead in hU bed

DISEASES OF THE 8PINAI, CORD.

J'i

on ihe twulflh morning. At the necropsy, the cord was de-
ii-ijied of a bluish tinge and pulpy to the touch ; while the
brain presented a similar but lei<s marked appearance. The
Ueurt and Iar(;e bloodvessels cuutaincd librioou!) cluts.

7, Spinal Irritation. — The existence of spinal irritation
as a disliiict and idiopiithie di.ieai^e has been denied by some
writers ; and it is my duty to confcRS thut the greater the at-
tention which I have bestowed ujion (IiIh subject, the »iore
inclined I ain tu believe that there i.n no affeclion dcservinj;
the name.

In former editions of this volume the .symptoms of spiniil
irritation were said to consist of puin siboul the thorax, maiiiiu.Tj,
abdomen, or uterus; this pain huvin;^ some rciuarkable con-
nection with the spine, since, wherever it may be, it i.s in-
creased on pressing certain of the spinous processes of the
vertebrsD, which are also themselves exceedingly tender.
Moreover, thi.>; tenderness is poiuetimes confined to one spot,
sometimes diffused over a large portiou of the spinal column ;
while it is must cuinmon in the lumbar and sacral regions.
The disease would seem to depend (it was observed) upon con-
gestion of the spinal venous plexus, causing pressure upon —
and consct|ueiit irritation of — the origins of the nerves.

Uwing to doubt." which I have fur some time entertained,
I have scrupulously availed myself of every opportunity,
during the la.st thrve years, to carefully examine examples of
so-called " Spinal Irritation," or " Spinal Disorder," and the
result has been this, — that in every instance the .suffering has
appeared to be due to a coinbinatiun of myalgia and hysteria
with constitutional debility. The history has always shown
that the piilicnto, ulniost without exception, were delicate
women; and that prior to the illnes.M for which relief was
sought, they had undergone great fatigue, or had been living
badly, or had indulged in excessive sexual excitement, or had
long sntfcred from a copious Icucurrha'al or uioiistrual dis-
charge. Moreover, lUe scut of the piiina has always oorre-

274

DISEASES or TOE NERVOUS SYSTEM.

Bpondcd with the insertions of iiDportant muscles; there hat
been a luiirkcd freeduiu from sulTuring so long as the recum-
bent posture has been uiaititiiitied ; and more or less weil-
ninrked symptoms of hysteria have coexisted.

The treatment of these cases has served to confirm the .state-
ments just made; for under the influence of rest, belladonna
plasters, nourishing food, eod-li^er oil, and bark or steel, cures
were eflected with coiiipanitive ease. To prevent unjr misun-
derstanding;, it must he mentioned that, with regiird to rent, I
merely mean that for a few weeks the piilient shall retire to
bed at nine or ten o'ehit-k at ni<;ht, and reniuin there until
about the same hour the following morning; and not that she
shall be conflncd to the recumbent posture for months together.
A short time since, I saw a delicate young liidy, who, under
the advice of an irregular practitioner, hiiJ iictually kept her
bed for Gve ycura ; but who, I believe, might have been cured
of her pseudo-spinal disorder in as many weeks by sea-air,
modcnitu exercise, and nourishing diet.

XI. FABAL7SIS,

By j)anilysis, or pttlsy, is meant u total or partiiil loss of
sensibility or motion, or of both, in one or more parts of the
body. All (Hiralytic afl'ections may be divided into two classes:
the first including those in whiuh both motion and sensibility
are affected ; the second, those in which the one or the other
only is lust or diminished. 'J'he former is culled pfr/'nti, the
latter lmp<r/ivt paralysis. Imperfect paralysis is divided into
arinriia — paralysis of motion ; and atnexthexia — paralysis of
sensibility. Again, the pHralysis may be (jenmil or purlinl,
as it affects the whole body or only a portion of it. Partial
paralysis is divided into hemipleijia when it is limited to one
side, anil ]Kir<tp/<-i/i(i when it is confined to the inferior half
of the body. The term loial pnrtilj/tis is u.sed when only a
Kmull portion of the body is affected, as the face, a limb, a

PARAr.VSiS. 2|6

foot, tie. And then there is that peculiar di.-'ciise known ns
toiiithiii pithj/, the prominent sjiiiptotii uf which is a remark-
able degcneralioD and wiistinp of the disuhled muscles.

Paralysis of the eye, or loss of sensibility of the retina to
the rajs of light, is CBlltd timtiumfis ; paralyt^is of the leva-
tor palpebrPB superiorw muwii;, idlowing the upper eyelid to
fall over the eye, pton't p-i/pebrfr ; insensibility to the impres-
sion of sounds (deafness), rophotis ; insensibility to odors
(loss of sineil), tiiiofmin ; loss of taste, mjiusiia.

There are also certain furtus of punilysis arising from the
use of aretallic poisons, as merrurial p'l/ny, and mlumineoT
frntf pn/»i/ ; and, lastly, there is a peculiar affection known as
parali/nm iiijilnnif.

The palsy may bo due to disease of the brain arising from
apoplexy, BbBcessjSofteninsi, indunitiun, renal disease, epilepsy,
vhorea, or the piisun of syphilis ; to disease of the spinal cord,
such as inflammation, atrophy, snlution of continuity, &c. ; to
diseases of the investinf; parts of the bmio or cord, acting by
the pressure they produi;e ; to lesion or compression of a nerve,
by which its conducting power is impaired; to some affection
of the muscle itself, as is probably seen in wasting palsy; to
hysteria ; and to the influence of such poisons as lead, mer-
cury, &o.

1. Oeneral Paralysis. — Ornerat paralysis, or complete loss
of sensation and motion of the whole system, cannot t;ike
place without death immediately resulting; but this term is
usually applied to palsy aflTocting the four extremities, whether
any of the other parts of the body are implicated or not. It
must not be confounded with the general paralysis of the in-
sane. M. Dcfermon* has related a case in which the power
of motion in every part of the body was iost. with the excep-
tion of the uitiscular apparatus of the tongue, and of the organs
of deglutition and re8i>iration ; the sensibility was also wholly

Biillelin da Srimett Medimitt, vol. xiii, p. K.

276

DISEASES OF THE NERVOUS SYSTEM.

di'strojed, except in a small patch on the rifiht cheek, bj
tracing •letters on which the patie-nt's friends were enabled to
foniniunicate with him ; while the intellect was perfect. In
ninat cases the loss of motiuii is more marked than that of
sensibility; the intelligeocc also soon becomes affected.

2. Hemiplegia. — This term is used to denote paralysis of
one side, extending: pcncrally to both the upper and lower
e.ttremitie.«. It is the most common form of palsy; it is coni-
monly spoken of na "a paralytic stroke;" and the left suffers
more frequently than the ripht side. When only one extre-
mity suffers, it is pcncrally the arm. Very rarely the upper
limb of one side and the lower of the opposite are affected, form-
ing what is termed IruvKvene or cmitKai j>al»y. Generally the
facial nerve or portio dura of the seventh pair is not involved
in the paralyziitp le.«ion ; but the fifth nerve is affected, so that
the palsied check drops loosely, while the anple of the mouth
is drawn slightly upwards aitd to the sound side, clearly be-
cause the muscles on that side are no longer counteracted and
balanced by the correspond iirj; muscles of the paralyzed side.
The tonj;uc also is often affected, so that when protruded, ita
point is turned towards the palsied side, owing to the muscles
which protrude tluH organ being powerless on thiit side and in
full vigor on the oilier; so that the sound half of the tongue
is pushed out further than the other half, and consequently it
bends towards the affi'cled side. The articulation is imperfect,
owing to pal.'y of the ninth and fifth nerves ; whiic if tlie third
nerve be involved, the upper eyelid will drop, there will be a
dilated pupil, and a divergent s<|uint. The panil3'sis is always
limited to one-half of the body, the median line being the
boundary. In most cases there is anrosthesia. The mental
faculties are sometimes uninjured, but mure frequently are
irreparably damaged. The memory especially becomes weak-
ened ; at the same time there is a peculiar tendency to shed
tears, and to be much distressed by slight c^iu.ses.

The effect of paralytic disorders upon the memory is often

PARALYSIS.

277

very reinarkuble. Tlipre may be a curinus foruetfulncss and
niisplucemont. of language, so that tlio sufferer cannot find
words to express his ideas, or he substitutes expressions having
no relation with the scnso intended. Sir Henry Flollund refers
to a case of slight paralytic iiffection, in whicli the j)erceptions
from the senses were unimpaired, the memory of persons and
events seemingly correct, the intelligence only .slightly affected,
the bodily functions feeble but not disordered, and yet the
memory of words for speech so nearly gone ihnt the single
monosyllable "yes" nlotic remained as the sole uttemnoe of all
the patient desired to express. Even when a simple negative
was intended, no other word was used.

In paralysis from red softening of the brain, the muscles of
one of the affected limbs are sometimes rigid and contracted ;
owing to irritation of that part of the cord from which the
uerves of the paralyzed member arise, by the propiigmion to it
of excitement from the diseased portion of the brain.

If recovery take place, the symptoms of amendment are first
noticed in the leg. In hopeless cases, the limbs waste; their
iintrition is diminished ; they become atrophied. It is of
practical importflnce to remember that they are colder, and
unable to resist the influence of cold or boat equally with the
sound parts.

Hemiplegia is generally the result of organic lesions of the
brjin ; and most frcrjuently perhaps the lesion is in the corpus
striatum and the optic thahmius. When the intelligence and
memory are affected, we may be sure that the cerebnil hemi-
spheres are involved, either directly in the lesion, or indirectly
by pressure upon them. It iiiu^t be remembered that the
disease is not, as a rule, found on the side of the brain corre-
sponding to the affected half of the body, but on the opposite ;
the cerebral portion of the centre of volition for the left side
of the body being situated on the right side, and rife ffrrdtJ.
The decussation of the fibres of the anterior pymmids at the
junction of llie medulla oblongata and medulla spinalis, ac-
counts for this phenomenon. This form of paralysis may also

278 DISEASES 07 TUE NERVOUS 8Y8TEU,

be due to some lesion of onc-buir of tlio spinal cord, just below
the decussation of the pyramids; and then the palsy will be on
the same side as the disease. Hence the term hemiplegia niaj
signify cerebral paralysis or fpinal paralysis. So also the hemi-
plegia may be transient and caused by a fit of epilepsy ; or it
may follow chorea, and pass away; or an imperfect form may
temporarily occur in nervous women — hysterical hemiplegia —
which may be diagnosed by the way in which they drag the
limb while walking without attempting to lill it, while in true
hemiplegia the patient drags the leg at the same time that he
lifts it from the ground ; or, lastly, there is peripheral hemi-
plcgia, in which the disease creeps from periphery to centre.
In all fonns the paralysis of motion is the prominent symptom;
but sensation is sometimes more or less impaired.

In hemiplegia from disease of the brain, although the patient
cannot by his own will move the palsied limb, yet irritation of
the sole of the foot, as with a feather, will excite active move-
ments; these reflex actions oflcn causing no little astonishment
to the patient. — To distinguish between cerebral and spinal
paralysis is not always easy. According to Marshall Hall the
condition of the irritiibiiity or contractility of the muscular
fibre in the paralytic limbs must be our guide in diagnosis:
since, — 1. In pure cerebral panily.Nis — that in which the in-
fluence of the cerebrum alone is removed — there is augmented
irritability and reflex action. 2. In spinal pnrolysis — that in
which the influence of the spinal marrow is also removed —
there is diminished irritability and reflex action. The galvanic
current is the test of the amount of irritubilily. Dr. Todd,
however, denies the correctness of the.se views, and asserts that
the contractility or irritability of the muscles of paralyzed limbs
beara a direct relation to their nutrition ; that the excitability
of the poralyzcd muscles to galvanism varies with the condition
of their nerves, more than with that of the muscles themselves;
that, in the majority of cases of cerebral palsy, the contractility
or irritability of the paralyzed muscles is less than those of the
sound side, simply because their nutrition is impaired by want

PARALYSIS.

279

of exercise; and, Instly, thnt no diagnostic mark tu distinguish
between cercbrjl and spinal paij<y can Uc bused on any differ-
once in the irritability of the paralyzed nmsclBS, for the
muscles in spinal paralysis exhibit the same states as those in
cerebral paralysis.*

In the trctiimrsit of heniiplejria, even when seen early, it
must not be forgotten that the mischief is done; and we eaii-
not remedy it by taking away blood. Indeed, the patient will
require all the f>ower which he possesses to enable him to re-
cover from the shock to liis system ; and hence depletion will
only do harm. Benefit may, however, be very frequently rea-
sonably expected from cathartics ; particularlj such as jalap
and scanimony, or calomel, or croton oil, or stimulitliiig purga-
tive cnemat^i. Some authors recouinieud bli.-'ters to the scalp
or to the nape of the neck, or the use of a seton. Id all cases
the practitioner should Hex the forearm upon the ann, and the
leg upon the thigh ; taking care to ob.serve if any of the
niu,scles offer resistance to these luovenients. When the
ttiascl&s of the palsied liiub are perfectly flaucid, we may be
sure that the cerebral le.«irjn is of an atrophic nature — proba-
bly white softening due to defective supply of blood ; and con-
iie(|uently that wine and nourishment, ammonia and bark, are
needed. On the contrary when there is resistance, the brain
lesion is of an irritative kind — such as may be produced by an
apoplectic clot which has lacerated the nerrous substance in its
vicinity; and then purgatives, blisters, and iodide of potassium
will be called for.

When the paralysis becomes chronic, stimulants, especially
such as act on the paralyned parts, launt be had recourse to.
Strychnia in small doses (the twentieth or thirtieth part of a
grain thrice daily) may bo cautiously tried, if we can reasona-
bly hope that there is no disease of the brain. Or local
stimulants may be employed: (hua frictions with the hand or
fic«h-brush, nod stimulating lininiontii of turpentine, ammonia,

* MeJieo-Ckinirg-iml TrantticlioHt, vul. ixx, p. 227. London, IB'IT.

280

DISEASES OF THE NERVOUS 8Y8TEM.

tiocture of cantharides, croton oil, &c., have been used with
oocusionul beuefit. Electricity and galvanism have also been
extenHiveljr enipluyt'J; but when there is any structural disor-
ganizatiun thi?y unduubtudly du hunu.

3. Paraplegia. — Paraplegia, or paralysis of the inferior
half of the body, must frequently commences slowly and insi-
diously, witli weakness and numbness of the feet and legs, or
with tijiRling — furmicatwn — of these parts, unattended by
pain. By degrees the weakness increases, until there ia com-
plete toss of sensibility and motion in the lower extremities,
with pumlyBia of the bladder and sphincter ani; the patient
is obliged to remain in the horizontal posture ; sloughs form
on the hips and sacrum ; and these, by their irritation and
exhaustiii<; di.sciinrgcs, accelerate death. If the urine be
allowed to collect in the bladder in any quantity, it will be-
come ropy, fetid, and alkaline; owing probably to the coats
of the bladder becoming diseased and pouring forth unhealthy
mucus, in consequence of the paralysis. Ur. Bence Jones has
proved that the urine when secreted is healthy; but admixture
with the diseased mucus contamioates it, decomposes its urea,
and gives ritic to the formation of carbonate of ammouia, ren-
dering it alkuline.

Although voluntary motion ia completely abolished in the
lower limbs, itivoluntary movements and spasms of the muscles
are not uncommon. Patients arc thus often tormented and
rendered sleepless at night by involuntary movements of the
lower extremities. The cause of this is to be found in some
exacerbation of the primary disease in the marrow; the
excitement being propagated upwards to that portion of the
cord in contact with the brain, as well as downwards below
the lesion. Keflex movements can bo excited much more fre-
quently id (iiiraplcgia than in hemiplegia.

Paraplegia may arise froui injury of the spinal cord or its
membranes; from inflammation, congestion, or hcemorrhage ;
from non-inflammatory soflening; from the pressure of tumors,

PARAI.V818,

281

and alsn from aficclioiis of the bonw iitnl c:irtiliin;c.s uf the
vertebral cciluinu. Most iiuthorities now cleurl}' distiu^iuish
two classes or kinds of pnrajilcftia; viz., thnt which is due to
disease of the spinal curd or its membraucis, and reflex pura-
plegia — i'. e., that produced by au excitation which has reached
the spinal cord fnim a sensitive nerve. In these latter cases
Dr. Brown-Sequard believes that the palsy is accompanied and
perhapA produced by an iosufiScient amount of blood in the
spinal cord. In them the irritation may have its startinji-point
in the viscera, in the skin, the uiucou.s membranes, or the
trunks of nerves; while no direct treatment of the paralysis is
of use, so long as the cause of irritation remains. Moreover,
in reflex paraplegia there is an absence of the .special symptoms
of organic disease of the spine or its contents; while the pa-
ralysis of the lower limbs is incomplete, and comes on slowly
after the existence of disease in the urinary or genital organs,
or in the thoracic or abdominal viscera, &c.

In the Irealment of paraplegia we have to decide whether
there is any congestion or inflummHtion of the spinal cord or
its membranes, or whether there is the very opposite condition.
Dr. Brown-Sequard shows that when the amount of blood is
increased, we find symptoms of irritation of motor nerve-
fibrea — as convulsions, cramps, twitchings, erection of penis;
syniptouis of irritation of .sensitive nerve-fibres — as itching,
pricking pains, abnormal sensatiou of cold or heat, &c.; and
Bymptonis of irritation of vaso-iuotor or nutritive nerve-fibres, —
such as wu-itting of muscles, bed-sores, alkaline urine, and so
on. In attempting to cure these cases our object must be to
diminish the quantity of blood sent to the spinal cord; and for
this purpose it seems no agents are bo efficacious as the ergot
of rye and belladonna, since tliey^ both produce contraction of
the vessels of the cord and its membranes. The ergot should
therefore be given in five or six-grain doses twice » day, while
a large belladonna plaster is applied over the spine. If no
benefit ensue in the course of a few weeks, the iodide of po-
tassium may be given in conjunction with the other medicines.

24*

332

niREASF.S OF THE NERVOUS 8T8TEM.

Cod-liver oil tiibj- also be often beneficiallj addi.cJ tn llic iri'iit-
ineiit. If there be much restleisness, beiibuno, or cotiiuiii, or
Itidiun hemp can be given; btU upiuiu is to be uvoided, as it
produces con;;t>stion of tlie cord. The diet sliouid be peue-
rous; beer or witic often bfiiij; needed. The nutrition of the
liiubs is to be maintiiiried by a {rentlo galvanic current, by the
use of EtiiMuliitiii;; liniments, or by shampooing;.

In parapli'ixia due to diminished nutrition of the cord (as
that caused by white or non-iiiflaiuuiatory softening, und reSes
paraple}j;iu) a directly opposite course is to be pursued. Conse-
quently where we find no sign of irritation or congestion, or of
increase in the vital properties of the cord, we endeavor to
give such food and reiucdies as will improve the quality of the
blood, will (-aii!>c an increased (juantity of it to be sent to the
cord, and will Jiuginent the vitjil properties of this nervous
centre. Strychnine is here the rcinedj, one-twentieth of a
grain being given daily, or one-thirtieth of n grain if combined
with opium. Sulphur baths may also be used; rguinine and
iron will occasionally do good; and the piitiont when in bed
should lie on his buck, with his bead and shoulder.s and lower
extremities elevated, so that the blood may gravitate to the
vessels of the cord. It need only be further added that while
in reflex paralysis we thus try to relieve the palsy, we must aLso
endeavor to remove its external cause; as by the expulsion of
intesiiniil worms, relieving irritability of the urinary or sexual
system, and curing all »kin diseases, &c., &o.

4. Local Paralysis. — Of the different varieties of local

pal.sy, I .shall only mention parn/ffsin of Ihr fme, the effect of
pressure on or injury to the portio dura or facial portion of the
seventh pair of nerves ; a nerve which is very nirely affected by
disease of the brain. As one-half only of the face is usually
palsied — cases of paralysis of the portio dura on both sides are
very uncommon — the appearance i.i remarkably striking; the
features on the paralyzed side being blank, unmeaning, and
Void of all cxpre.Ksiun. The orbicularis palpebrurum musule is

PAnA LYSIS.

2HS

powerleca, and therefore the patient cuiinot clu&e the eyelids.
Moreover he cannot frown on the affected side, the nostril di-
lutes not, the cheek h:inps loose, luid the angle of the luouth
droops. The tifth pair oT nerves is unaffected; for the muscles
of uiaslicjition act properly, and there is no loss of sensibility.
The paralysis i.s ponerully free IVom dunjjer, beinp but rarely
connected with inlracrnniul disease. Exposure to culd is a fre-
quent cause of it; and so is debility froiu any eshausting in-
fluence. In cases where no appreciable cause can be detected,
the mouth !.hoiild be exumined ; so that if there be any decayed
teeth they may be extracted. In children, otitis leudiii;; to
caries of the petrous portion of the temporal bone, not unfrc-
quently produces it. This form of palsy may have a duration
of from ten days to many weeks; if it does not get well, thure
is no fear of its shortening life, unless (here is disease of the
temporal hme; and aperients, tonics, iodide of potassium, and
galvanism are the remedies to be resorted to.

5. Wasting Palsy. — This curious disease is sometimes
described as cnrjiiiuj puhy, or peripheric parnlynin, or lead
piilnff wilhoHl Itoil, or p(irii/y>:ie ntuKitlitire atrophique (Cru-
veilhier), or ntrophie mvscufa're avec tranitjormation tfrait-
teuiie (Duchenne). Dr. W, Roberts, in an excellent essayon the
subject, says that he is inclined to call it idiopnthic deijenera-
tion of thf. voliinlai-y miisrlcf ; but as this name is too cum-
brous, and may not prove correct in the end, ho seems to me
wwely to prefer the more homely name of iVatliiii/ Polsif.

Sj/mploniK — The pathoi;nomonic feature of this disease is
a degeneration and consequent loss of vulume and power of
the voluntary muscles; there bein;; no diminution of the intel-
ligence, or of the sensibility of any part of the body. The
atrophy may affect the upper limbs, or the lower limbs, or
more rarely the voluntary muscles of the entire body — of both
the trunk and the extremitie,s. FibrilUiry tremors ur convul-
sive quiverings of some of the fasciculi which form tlic nuisclu,
can often be noticed by the attendunt, though the patient may

2SJ

DISEASES OF THE NERVOUS BYiTEM.

be i|iiite uncotiRuiuus of their occurrence. Anything which
irritates the fikin will produce these muscular vibnttioiis.
There is weakness that increases daily, though slowly, and
which putients at first describe as unwonted lassitude of the
limbs. The wusliiif^ of the muscles gives rise to a peculiar
withered look in the part afi'ected ; while as the muscular
atrophy is often uncipial on the two sides of the body, distor-
tions arise — the musi-les least disea.^eJ overcoming the resis-
tance uf those most affected. Ta.tile and common sensibility
are usunlly unimpaired ; there is no tremulous agitation as in
paralysis agitims ; occasionally neuralgic or rheumatic pains
are complained of; there is great sensitiveness to cold; the
intellectual powers are undisturbed, and the judgment b sound ;
while the general health is good. In one distressing example
whieli I have seen there was no diminution of sensibility, but
simply a complete inability to move either the upper or lower
extremities, so ihat the patient was obliged to be fed and cur-
ried about iike a t'hild. Doiitli, I believe, occurred from an
attack of bronchitis. This is a very common termination of
these cases; for when the diaphragm and intercoetals become
involved, the thoracic movements are reduced to a slight
motion of the Inwer ribs, so that if any uiul-us be poured out,
it must accumulate and produce autfocatiou, since no efforts
can dislodge it.*

* Few of tbe reported ouei of wuting palsy are more interestiDg than
the one reported by Grareilhier {Archivft Gtntrah$ dt Medeeiiu, oiD-
qaii^me Aerie, tome i, p. 671, Paris, 1B.^3), and I shall therefore give a
cnnilpniied account of it. This case i^ the more deserving of attention,
since from it Cruveilhier Drsl determined the existence of a new fonn of
paralycis, due neither to cerebrospinal disease, nor to metallio poisoning.
The chief ptiints are these : A niountebank, thirty-two years of age,
came under observation in July, IH.Mt, jinRering from atrophic muscular
paralysiii, which hud already become nlnio^t general. In September, 1848.
he paased the night in the open air, on the muddy pavement ; and awak-
ing, found bis right side, on which he hiid slept, quite benumbed. Tba
waniith of a tavern Huun rc.itored both sensation and motion ; but three
weeks afterwards he noticed a weakness of the right hand, he coold not
loke hold of objects, and was henoeforlb nnabla to play the oomet-i-pb-

PARAtYSIS.

285

Pi'Oi/nom'g. — The duration of wasting palsy may be said to
be from nine months to five years; ukbough in one instance

ion. For a year the weakness was oopBaod to the uiumIm of the hand ;
bnt he then parsed another cold wet night in the open uir. und nflerwurda
felt a great weakness in the lower limhs. From this time the inustiular
paralysis progressed rapidly, so that when he entered Gruveilhier's wnrds
in July, 1650, not only were the extremities affooted, but aloo the facial
mu'tcles nud those concerned in articulalion, dcglnlition, and respiraliou.
Still the pntient could dress himself and walk, though with trouble;
while he could nUo feed htmMf, and artitTulnte inlelllgiljly. The mus-
cles were agiUted with u fibrillary quivering nr tremor — a kind of twitch,
such as woald he produced by an aninterrupted succession of mtid elee-
trie shocks. The tactile seniiibility wiir developed to its highenl degree ;
the organs of special sense were remnrkably delicate, the inlcllige*jce was
perfect, and he used thus to describe hb condition : " I itm init ill, but
my strength is gone, and my wenkness increases daily. There is a feeling
of great lassitude in my limbr, which torments me every hour, but ospe-
oially at the time of awaking fmrn sleep."

At the end of 1851, this man could not walk at nil, nor cnuld he change
hil position withunt help. His food was given to him, and be was put to
bed like a Utile child. His saliva could not be swallowed, and rnn from
his mouth ; the buccal portion of the act of deglutition could not be
effected, owing to almost complete paralysis of the tongue ; twice he was
nearly choked by pieces of regetahle lodging in the pharynx ; and his
appetite was vorncions To feed him, the nurse was in the bahlt of
thrusting down the food in a spoon low inta the pharynx . considerable
efforts at swallowing on the spoon and its contents were then made, and
the spoon being withdrawn, repeated attempts at deglutiliun followed.
Id trying to ^wallnw liquids^ the greater part was always returnt^d. The
power of articulation being lost, the wants were made known hy nuds, by
Iha eyes, and by the guttural nasal soand. The re.^piration was very
incomplete ; so that it was certain that the unhappy man, whose intelli-
gence was uuun]ia.ired, was menaced every momont wilh iispb)r.\ia. On
the l&tfa of Jnnunry, IR5.t, he wa? seixcd with the prevailing inQuenia,
and being unable to expectorate the mucus, was one morning found quite
dead.

At the autopsy, it was shown that the ^nnn was quite heaUby, and
weighed 30 ounces 16.S grains avoirdupois. The spinai cord was sound.
and of the usual bulk, consistence, and color. The anterior root$ of the
gpinai jurvtM were remarkably small cumparod with the posterior; for
whereas in health, the posterior or senfiitire roots are to the anterior or
motor OS 3 to 1 in the cervical region. 1^ to 1 in the di»rEal, and 2 to 1
ill tbo lumbar; here the proportion waa as II) to I in the cervical, and 5

286

DISKAAES OF TUE NERVOUS BYTSEM..

(Iciith did Dot occur till after the lapse of more tban twenty
yearn. In 8oinc few instances complete recovery seeiiis to have
taken place ; whilst in a larger number the progress of the ,
disorder has been permanently arrested. When the disease
haa invaded the trunk, the prognosis is most unfavorable; but
as luM<; as it is confined to the extremities, there is hope uf
arresting it. Genera) muiicular atrophy — that of the trunk
and extremities — spares neither children, adults, nor aged
people ; whereas the partial form would appear to be most
common between thirty and fifty years of age. Stales are
much more liable to the disease than females, perhaps owing
to their occupations; it is certainly hereditary; exposure to
wet and cold, or very hard work, are often the assigned caoMS ; J
while Dr. llobcrta hhows tluit when it arises from cold the
atrophy is much more likely to extend to the muscles of the
trunk, than when overwork is the cause.

PiiihijI'tiji/ unit Morliul Anatomy. — We are not in a posi-
tion us yet to decide upon the nature of thi.s disease. Accord-
ing to some authorities it has ita origin in the nervous sjnteta,
the affection of the muscles being secondary. But most ob-
servers sceui to agree that this position is untenable, and that
the disorder consists of a granular and fatty degeneration of
the muscular fibre, similar to what is observed in fatty heart.
Altliougli there is no general depression of the nutritive func-

to 1 ill the ilurtiil and lumbar rrgi'HiK. Moreover, iniiiiy of (be interior
flcrvlcal routR were reduced (o neuriletamu, and presented no tr»ee of
nervunf iiitsue wben exniained with a EenM. The intiMrUs of the pelru noil
thigh hkd eceapod the iilrn|iby : while the elevatom of the lower jnw, the
muBole* of the phnrvox, thoM of the fiupramnd infm-hyoideftn regions, th*
plktytm* un bolh fides, and the lygomntiot hud undergone aimple atrophy
or mnulalion. Utber niuKcles were emnoiated and pale : while mo«t had
Badergooe atrophy with fatly degeneration. Sereral aeemed at Snt
iight to have di!(np[>earcd, ki thin and blender were they. There waa
not a flingle mu»(.'le of (he upper extremities uoalTected, the intrioflio
muwlei of Iho hand being the moiit atrogihied, then those of the shoulder,
then those of Ibe forearm, and orxl of the upper arm. The tongue waa
olutnged into ■ fntly uiiks, in tlin midst of whioh api>rared a number of
Verlioal muscular buudles.

PABAXT8I8.

287

tions, yet there is nn error of nutrition affecting the muscular
fibre, owing to some unknown constitutional peculiarity.

The post- taortc 111 appearances confirm tliese remarks. The
hcnrt, liver, kidneys, and spleen have been always found
healthy; as have a\ao the brain and medulla ohlonj:;ata. la
two-thirds of the reported cases the spinal cord was in a nor-
mal condition, while in three instances there was inflammatory
softening, and in one amyloid degeneration of the posterior
columns. The anl«rior roots of the spinal nerves were dimin-
ished in size in some in-stances, but by no means in all ; though
Buch a change has been carefully looked for, since Cruveilhier
imagined he had discovered the essential nature of the disease
in this alteration.

The affcctod muscles were always wasted, and sometimes
quite annihiluled; they were of a pale red or buff color; while
often to the naked eye they presented evidence of fatty degene-
ration. From the results of the microscopic examinations it
may be said, that the muscular tibrillsB had dcgcnenited into a
granular amorphous substance, or into fat globules ; the empty
sarcolemma or tunic of the elementary tibre having been broken
up,so that only a liltto connective tissue was left. Thedegene-
ration sometimes appeared to be entirely granular and not fatty ;
while in other instances the fat was abundant.

Tientmrni. — It may be instructive to mention that amongst
the remedies which have certainly failed to do good, we niu>t
place strychnia and nux vomica ; sctons, issues, or blisters over
the vertebra; ; and cold baths during the active stage. With
one exception mercury and iwiide of potas-sium have proved
useless; and it is doubtful if there has been greater success
with tonics and cod-liver oil.

Galvanism applied locally to the wasting muscles is said by
Dr. HobertB to be the most effective remedy. Duchenne seems
lo have been particularly successful in the treatment by local-
iied Faradisation (the electricity of the induced or secondary
current in the helix round the magnet, discovered by Fara-
day); but he advises the careful use of this agent, not giving

2fl8

DI8KA8E8 OF THE NERVOUS SYSTEM.

ninrc thnn one uiiiiute to each aSucted muscle, lest it become
fatigued and exhau!ited, and not prolonging each sitting for
L.niore than ten or fifteen minutes. With galvanism there may
'be combined gentle friction.s, occasional warm sulphur baths,
the use of such remedies as will improve the quality of the
blood, and methodical exercise. When the disease has become
stationary, galvanism may be more freely resorted to, and cold
bathing.

6. Mercurial Palsy. — Mercurial pal^, or mercurial tremor,
as it is sometimes termed, consists of a kind of convulsive agita-
tion of the voluntary muscles, which is increased when volition
is brought to beiir upon them. In advanced stages of the dis-
ease, tirticulation, mnsti cation, and locomotion are performed
with difficulty; while the use of the hands is almost entirely lost.
The skin ac(]uires a brown hue, and the teeth turn black.
Workmen exposed to the fumes of mercury, such as gilders of
buttons, ghiss-platers, barometer-makers, &o., are verj' liable
to it.

In the Ircalmcnt of mercurial palsy the patient must be with-
drawn from the injurious atmnsphere. Warm baths, good diet,
sea-air, and iodide of potassium — for reasons to be presently
mentioned — will generally effect a cure.

7. Lead Palsy. — This affection usually follows or accompa-
niea ro/iVrt^i"f/o»Hm, though it may exist independently. The

^poison of lead appears to exert nome peculiar noxious influeoce
over the nerves of the fore-arm and hand ; in consef|uence of
whifli the extensor muscles of the hands and fingers become
panilysied, so that when the arms are stretched out the hands
hang down by their own weight, or, as the patients sny, the
viritls drop. The inferior extremities are very rarely affected.
The sufferers frei|Uont1y experienoe attacks of lead colio. A
characteristic symptom of (he presence of load in the system
is the existence of n blue or purplish line — the sulphuret of
lead — round the edges of the gums, just where they join the

PARALYSIS

289

teeth ; a very important aid to dia-jnosis, for the notice of which
wo are indebted to Dr. Burton. Plumbers, painters, oolor-
grinders, type-fouuders, &c., are the usual sufferers from this
affection.

The question naturally arises, — What is the particular organ
affected in the.se ca-ses? Dr. Todd answers this question by
stating his belief that the muscles and nerves are early affected,
and that subsequently the nerruus centres become implicated..
The muscles being contaminated by the lead, their nerves par-
ticipate in this contamination. The nervous system is there-
fore 6rst affected at the periphery, in the nerves ; and the
poisonous influence continuing, the contamination gradually
advances to the centres). This is proved by the occurrence
first of local paralysis in these cuscs, and subsequently of epi-
leptic convulsions or other symptoms of centric disease. Death
may occur when the system has been long exposed to the influ-
ence of lead ; this termination baing most common in those
addicted to intemperance.

The treatment of lead palsy has been very much facilitated
by the hypothesis promulgated by M. Melaetis, that the effects
of lead and mercury were caused by chemical combination
with the tissues of the body, or by being present in intimate
union with these tissues in some analogous manner. The the-
rapeutical application of the theory necessarily was, as pointed
out by Dr. J. R. Nicholson, that the acttou of the curative
agent must be directed to the conversion of the poisonous
metal into a compound having less affinity fur those tissues,
and therefore readily cliniinated from the body; and it has been
shown that iodide of potassium possesses the requisite condi-
tions to become a curative agent in lead diseases, according to
this theory.

Dr. Nicholson has published a very interesting case, in which
the lead, afler the administration of the iodide of potassium,
could be readily detected in the urine, notwithstanding it could
Dot be found before the commencement of the treatment; but,
though the colic had entirely ceaned, the palsy persisted. Gal-

290

DISEASES OF THE NERVOUS SYSTEM.

Taniam was then used io conjunction with the iodide of potaa*
siuro, and the patient went to hia work, about fifkj dajs after
the commencement of the trentment, without any trace of para-
lysis. From this case it is concluded : First, that the iodide
of potjissium acts as a curative agent in lead-poisoning, by con-
vcrlinf; (he lend into a form which can again be readily taken
up by the blood, and evacuated by one of the natural outlets.
Secondly, (hat (he iodide acts more speedily in conjunction
wi(h galvanism, when employed for the relief of lead paralysis.*
In addition to the iodide of potiis?iuni — gr. v, (hrice daily —
the padent may use wiirm baths or sulphur bjiths (F. l/)9),
galvanism and fri(!(ion to the paralyzed limb, and exorcise in
the fresh air. To prevent this disease, Liebig recommends all
workers in lead to drink daily sulphuric acid leniniiade. This
acts probably by converting the salt of lead, as it enters the
system, into an insoluble sulphate.

8. Paralysis Agpitans, — This disease ia characterized by a

tremulous agitation — a continued shaking — usually commeno-
ing in the hands and arms, or in the head, and gradually
extending over the whole body. Mr. I'arkinson has well defin-
ed the disease thus; "Involuntary tremulous motion, with
lessened muscular power, in parts not in action, and even when
supported, with a propensity to bend the trunk forward, and to
pass from a walking to a running pace ; the senses and intel-
lects being uninjured." The disease progresses slowly, but
when far advanced the a<<itiition is often so violent as to pre-
vent sleep; the patient cannot carry food (o his muutb ; deglu-
tition and mastication are perlormed with difficulty ; the body
is bent forward, and the chin bent on the sternum; the urine
and faeces pass involuntarily ; and coma with slight delirium
closes the scene.

As regards the remedies fur paralysis agitans I can say but
little, since I know of no meoBures likely to do much good.

• Lnttrti, Ulb Ootobvr, 18&4.

EPILEPSY.

291

T ohould, however, trj the effects of pure air, nourishing diet,
baths, ferruginous tonics, and occasionally opiates. A cure has
be«D effected b; the employtneat of the continuoas galvanic
current, such as may be derived from a Palvermacher's chain
buttery of 120 liuks.

XII. EPILEPSY.

Epilepsy is a disease the leadiog symptoms of which are —
sudden lo.ss of consciousness and sensibility, with clonic spasms
of the voluntary muscles, usually fulluwed by cxhausti<M and
coma; the attack recurring at intervals.

Warnlnijt. — There are sometimes, though not in the ma-
jority of cases, premLtiiitory symptoms sufficient to warn the
patient of an approacliiiig seizure. These warnings differ
both in duration and character; in some cases being too short
to allow the sufferer to disiiiount from horseback, or to pet
away from the Gre, or even to lie down ; while in other in-
stances, many minutes, or even hours, elapse between their
occurrence and the attack. Dr. Gregory, of Kilinburgh, was
assured by un epileptic that when a fit wus upproaching, he
fancied he saw a little old woman in a red clonk advance to-
wards him, and strike liicii a blow on the head ; on which he
at once lost nil rocolleetiun and fell down. Spectra! illusions,
headache, sickness, giddiness, dimness of vision, confusion of
thought, a sense of fear and terror, and especially that pecu-
liar sensation known as the aura, rpilepfirri, consulate the most
frequent premonitory symptoms. The epileptic aura is differ-
ently compared by patients to a stream of cold water, or a
current of cold or warm air, or the creeping of an inseot; the
sensation commencing at the extremity of a limb, and gradu-
ally ascending along the skin towards the head ; and when it
slops the paroxysm taking place.

Symiifoms. — The commencement of the seizure is generally
oliardcterized by the utterance of u loud piercing shriek oi

292

DISEASES OF THE NEHV0U8 SYSTEM.

scream, immediately after which the individual falls to the
ground senseless and TioJently convulsed. Hence the disease
has been called by the nilf^r the falling sickntts, or more
vaguely, Gts. During the attnck the convulsive movements
continue violent ; there is gnashing of the teeth, foaming ot
the mouth, and the tongue is thrust forward and oflen severely
bitten ; the eyes are partly open and suffused, the eyeballs
rolling, and the pupils insensible to light; the skin is generally
cold and clammy; there may be involuntary defaecation and
micturition, with vomiting ; the breathing is laborious or
almost suspended ; the face is flushed and turgid ; and death,
in fact, seems about to take place from suffocation, when —
gradually — these alarming phenomena subside, the extremities
of one side are jerked about, «nd shortly afterwards all convul-
sive movements cease ; leaving the epileptic insensible, and
apparently in a sour.d sleep, from which he recovers exhausted
and with a headacho, but without any knowledge of what he
has just gone through.

The average duration of the fit is about five or eight mi-
nutes ; it niny lust Cor half an hour or more. It may also be
very slight or very .severe, coti.stituting the petit mut and the
ifrand mat of the French. The periods at which the seizures
recur arc variable. At tirst there is often an interval of two
or three months, but as the disease progresses the intervals
become shorter, until hardly a day passes without one or more
parci.xysiiis. In ret-i'iil cases, especially, the fits oflen take
plaw ill llic iiiLjht, fitlicr on ju.st going to sleep or on awaking.
The repetition of the seizures has a tendency to impair the
roiTiiory, to produce temporary or permanent paralysis, or to
induce complete mental dcraiigenicnt. As may be imagined,
viirious accidents are likely to occur from the epileptic falling
into the fire, or into water, or upon the angles of lurniture, &o.

Kpilcpsy is often /eii/ii n I ; but the irapofitinn may be de-
tected by observing that the eye." are c!o.sed, the pupils con-
tract to the stimii!us of light, the skin is hot from the neces-
sary exertion, the tongue is not bitten, and neither the urine

EPILEPSY.

298

nor fsBces ore voided. Propositist to apply the actual cnutery,
or to cut off tho hiiir, will of'ieti effect a speedy cure; or we
iDBy bluw some dry snuff up the nostrils with a quill, and
change the fit into one of snecaiing.

Caiiiirs. — The tendt-ncy to epilepsy is often hereditary.
Malformations of the lii-.id are frequent predisposing causes.
It is more common at the date of puberty than at any other
period; while in women at this period it is often accompanied
by 80me derangement of the ciitaiuenia. Debauchery of all
kinds, indulgence iu alcoholic drinks, the practice of mastur-
bation, kc, may give rise to it. Amongst other causes must
be also mentioned fright, blows upon the head, insanity, the
irritation of teething, and the poi.soning of the blood in rheu-
matism, renal disease, &c.

Associated with epilepsy we often find dyspepsia, constipa-
tion, sleeplessness, leucorrhcca in women, involuntary semiiinl
discharges in racn, &c. &c.

Morbid Avatomy and Palkvlogt/. — Uncomplicated epilepsy
is so rarely fatal, that it is difficult to give precise information
as to the appearances most commonly found, or to determine
the value of the variety of lesions discovered. When an
epileptic dies who has only labored under the disease for a
short time, no appreciable lesion of any part of the nervous
system can, as a rule, be discovered. If death occur during a
paroxysDi, the brain is often found more or leas congested, In
oases of long standing, disease of the cerebral bloodvessels,
with softening or induration of the brain, may be found ;
while in such the weight of the brain is usually above tlie
average. Occasionally the bones of the skull are thickened
or otherwise diseased.

Dr. Todd held that the peculiar features of an epileptic
seizure were due to the gradual accumulation of some morbid
material in the blood, until it reached such an amount a» to
act upon the brnin in, so to spcnk, an explosive manner.

Schroeder Van der Kolk concludes from his researches that
the first cause of epilepsy consists in an exalted sensibility and

26*

204

rusKASES OK TIIK NERVOUS SYSTEM.

excitabilitjr of llic medulla oblongata, rendering this part liable
tu discharge its force in involuntary reflex movenicnlg, on the
application of irritants nhich excite it. This irritation may
be external (of the Gftli pair of nerves), or it may be in the
brain, or in the intestines. In children, intestinal worms, or
torpidity of bowels, are common causes; iu adulta, it may be
due to irritation of the intestines, but especially to onanism.
Araenorrhtca, clilorusis, congestion of the uterus, hysteria, &o.,
must also be retiienibered as causes. In the commencement
there is only exalted sensibility, which may be removed and a
cure effected ; but when the disease is of lung continuance,
organic va^uukr diluUition takes place in the medulla, too
much blood is supplied, and the ganglionic groups are too
strongly irritated. Every attack increases the mischief by
promoting the vascular dilatation. Moreover, increased exu-
dation of albumen ensues from the constantly distended ves-
sels ; and the couts of these organs get thickened, the medulla
becomes hardened, and we have fatty degeneration, soften-
ing, &c.

Trealmtnl. — This must have reference to the measures to
be adopted during a lit, and those to be employed in the in-
terval.

During ihf fit — the putieut should be laid on n large bed,
air freely admitted around him, his head ruined, and his neck-
cloth— togLi hor with any tight parts of his dress — loosened.
A piece of eork or sufl wi;>od should, if possible, bo introduced
between his teeth, tn preveot injury to the tongue. Cold
ufTusion to the hciid witl sometimes be useful, especially if the
cuuQteiiance is lur};id and congested. In cases preceded by
the epileptic aura, the application of a ligature Just above the
region from which the sensation start.'i, has been said to pre-
vent the attack. On this principle the testicles have been
removed, or a limb amputated, when the aura has appeared to
proceed from these parts ; and uithuugh success seems some-
times to have followed, yet this practice would hardly be
udiiptod in the present day.

EPILEPSY.

2«5

111 the intervul — we must endeavor to improve the patient's
general health, and especially to give tone and tirmnesa to the
nervous gystem. Dr. Sieveking, l)r. lludcliffe, and in fact,
almost all who have recently paid much attention to this disease,
agree in believing that everything tending to depress the vital
powers does harm. Minenil totiies, e.-'pocially the salts of iron,
sine, and silver, are consequently to be employed (F. 468, 459,
463, 470, 478, 479, 481, 491, 492, &c.). The cold shower-
bath may be especially recommended, if it can be well borne;
otherwise the tepid sponging-buth should be substituted.
Sleeplessness is particularly to be combated. The diet must
be simple but nutritious, avoiding intoxicating drinks. The
patient's habits must also be regulated by such rnlos as common
sense will dictate, — daily exercise, early hours, and attention to
the alvine and urinary sccretiuus being nouessary ; while nientul
excitement or exertion is, on the other hand, especially contra-
indicated.

In some cases, those more particularly which arc dependent
upon the thickening of the cranial bones, iodide of potassium,
or a gentle long-continued course of mercury, docs good. Fo-
ville had great faith in the oil of turpentine in half-drachm
doses, repeated every six hourti; and Dr. Watsoo seems to
think it more useful than any other single drug. Camphor,
valerian, assafoctida, iiaphtha, cajeput oil, aud the various pre-
parations of ether, are often very valuable agents. .The bro-
mide of potassium in (en-grain doses, thrice daily, continued
for a long time, has cured some cases, particularly where there
has been any erotic disposition. The nitrate of silver long
enjoyed great but undeserved reputation ; its tendency to
blacken the skin, moreover, is sufficient to interdict its employ-
ment. Again, the juice of the cotyledon umbilicus has been
of late much vaunted ; my own experience coincides with that
of many pnictitioners who have tried it and found it valueless.
Dr. Marshall Hall recommends strychnia in foni'c not «^'mu/an(
doses (F. 478); while, following a suggestion of Dr. Todd's,
I have m^d the vapur of chloroform, and believe that I have

296

DISEASES OF THE NERVOUS STSTEM.

foand the fits diminish both in severitj and number from its
employment. The truth probably is, however, as Elsqairol
shrewdly remarked, that epileptics improve for a time under
every new plan of treatment. Undoubtedly, hope and confi-
dence are important elements in the treatment of this disease,
and the physician should therefore never appear to despond
nor ullow his patient to do so.

These remarks will hardly be complete without a brief notice
of one or two other points. For eiumplc, Dr. Marshall Hall
entertained stron;.' upinions as to the ufficucy of tracheotomy
in some forms of epilepsy.* Two or three cases have been re-
corded where this practice ha.s been adopted; but probably no
practitioner would now resort to it. — -^gain, caustics to the
larynx have been applied, but without benefit. — Dr. Brown-
S^quard cauterizes the nape of the neck, or the part where the
aurii originates, using the moxa or the red-hot iron ; but I know
not what amount of sui'ce.ss has justified this treatment. — And
lastly, on the principle of attempting to relieve the congestion
of the medulla oblonjirata, Schroeder Van der Kolk employs
setons or issues placed hi^j;h up in the neck; and there can be
no doubt that counter-irritants over the upper cervical vertebrw,
with tonics, and the removal of all external sources of irrita-
tion, will often prove most useful.

XIII. HYSTERIA.

Dr. Copland defines hysteria as — " Nervous disorder often
assuming the uiost varied forms, but commonly presenting a

* Dr. Murtfaftll Hull siit9: "There are two ctaea of eptlepsj in ile dir-
*<tforiiii, in which the propriety and eSicaoy of trscbeotom; sdmitof no
donbt : tlieee are — first, ppiiepFiu laryngen, with ^parmodtc laryngifoiaa,
tbrpstrning the rxlinclicm of Mind : jccond, epilepfin laryngen, with p»-
nlytio larrngiauiU!, ihreuteningtbeextinotinnof Lifu." " The diignosti
mud be eilablirhed by observing the lUte of the larynx, of the neck, of
the fxoc, and uf Ihe ceroltrum. In Ibe absence of Urjrngbma*, the deep
piiipte IJTidit; and tuiuefactiun, and the snbfeqoent deep ooma, Ac., are
equally abfenl, and tmcheotomy of courie hori de pro/ioi."

HYSTERIA.

297

p-iroxysmal chnractor; the attacks usually eon)mencin<r with a
flow of limpid urine, with unensiness or irregular motions and
rumbling Doiscs in the left iliac region, or the sensation of a
ball {(/IfiLvn iiyfffririif) rising upwards to the throat, frequently
attended by n fcelin;; of aulTiwation, and sonietiiiies with con-
vulmons; chiefly affecting feuialea from the period of puberty
to the decline of life, and principally those possessing great
susceptibility of the nervous Bystem, and of mental emotion."*

I shall consider this disease as it occurs in paroxysms, as it
aflfects sensibility, and as it mimics other affections.

Sj/mpfomt. — The symptoms -which characterize the hytleric
parort/tm or fit are, — convulsive movements of the trunk and
limbs; violeut beating of the breasts with the hands clenched,
or tearing of the hair or of the garments ; shrieks and screams,
violent agitation, and the globus hystericus ; the attack ending
with tears, convulsive fits of crying or laughter, and sometimes
with obstinate hiccup. Occa.'iionally, the patient sinks to the
ground insensible and exhausted; remains so for a short time;
and then recovers, tired and crying. The fit is often followed
by the expulsion of a quantity of limpid urine; while occa-
sionally this secretion is passed iuvuluntarily during the out-
break.

The paroxysm differs from epilepsy, inasmuch as the fit is
almost peculiar to women, it continues longer, and there is
seldom loss of consciousness — the patient being aware of all
that is passing around her. The convulsive movements are also
of a different character, much less severe, not more marked on
one side of the body than the other; the respirations are never
suspended ; the tongue is not bitten ; and the attack is not
followed by coma, as epilepsy is.

It has been well pointed out by M. Briquet that hysterical
patients often suffer from hyprnfithefia or increased sensibility
of various tissues. The fleshy pijrtions of the muscles are

* DietioHory of Prarlieal MwUiriiu ; urt. "HysttrU," vol. il, Lon-
aoD, 1844.

298

DISEASES OF THE NERVOUS SYSTEM.

Tcry liable to becoiDc so affected : particularly the muscles of
the frontul and teiuponil regions uf the cranium; those of the
epigastric region, often associnted with dyspepsia; those of the
back, especially on the lower part iwid left side of the verte-
bral column, oflea leading to the erroncoas opinion that there
is spiniil disease; those of the side of the thorax, especially
the left, and likely to be confounded with the suffering of
pleurisy, and with intercostal neuralgia; those of the walls of
the abdomen, which can hardly be mistaken for the pain of
metritis or ovaritis if its superficial chriracter be observed ;
and, lastly, the superficial and perhaps the deep-seated muscles
of the upper or lower extremities. The pain is generally
aggravated by pressure, by movenieiit, by moral emotion, and
by even a mild electric current: it is relieved by resting the
afiected muscles : it varies in intensity from mere uncaMness
causing slight inconveniences, to the most acute suffering de-
stroying all repose and inducing fever and general disturbance;
and it is generally accompanied with weakness and mcntui de-
pression. There is none of the heat, redness, tension, or
pulsation of inflammation ; and the pain may disappear only
Boon to return in an aggravated form, and to prove very re-
belliou.s (u all kinds of treatment.

The opposite condition, ari(f»theila or loss of sensibility, is
a prominent phenomenon in some instances; and it is probable
that nervous women and ro»gnctic somnambulists, whose in-
sensibility is supposed to be n trick, are often merely hyste-
rical women thus affected. The anaesthesia may be only tem-
porary, or it may last for years : the skin is most commonly
affected : the left side of the body suffers more often than the
right,: while the conjunctiva is often insen.sible, especially of
the left eye. The muscles of the extremities may be rendered
BO insensible, that pins may be tbriist into their substance
without caasing the least pain.

Ili/slfria simiifiitfn almont uU iHteatti ; perhaps the favor-
ite maladies itnitated being — suppression of urine, calculus of
the bladder, inQatnni:tti<in of the peritoneum, pleurisy, con-

HY8TKRJA.

299

^
^

sumption, larynjritis, stricture of the oesophagus, aphonia or
loss of voice, pnralysis, and disease of the spine or of one or
more of the joints. The patient deceives herself, and tries by
strung expressions of suffering to mislead others. A practised
eye is seldom, however, imposed upon by such potieuts.
There is a peculiar expression about hysterica! women, impos-
sible almost to define, )'et readily recognized when once it has
been studied ; there ia a fulness of the upper lip, and a ten*
dency to drooping of the upper eyelids ; they answer questions
in an unpleniSiint manner, often only in mono.'yllables ; and
iheir pains are always said to be most acute, and to be increased
by pressure, or almost even by pretended pres-^ure. The cata-
mcnia are generally irregular, and there is frequently profuse
leucorrhooa.

And here the important question may be asked, — Are these
pains and sufferings, described as being so acute, merely
feigned ? Unduublcdly not. Sir Henry Holland has well
observed that the hypochondriac by fixing his coosciousBCss
with morbid intentness on different organs, not merely creates
disordered sensatinn.s in thetu, but even disordered actions.
There may be palpitation of the heart, hurried orehuked respi-
ration, flatulence and other diseases of the stomach, irritation
of the bladder, and vague neuralgic piiins, all arising from this
morbid direction of attention to the organs in question. It
is well known that many of the secretions are immediately
affected by mental emotions ; and the same result.s ensue from
simply sustained attention to the parts concerned in the.se
functions.

Treatment. — During a 6t the patient's dress should be
loosened ; she niu.st be prevented from injuring herself; should
be surrounded by coor air ; smelling-salts may be applied to
the nostrils; and if she can swallow, a draught containing a
drachm of the compound tincture of valerian, or of the fetid
spirit of aniinoiiia, ought to be administered. If the paroxysm
continues, the sudden and free application of cold water to the
head and face will probably cut it short.

300 DIBKA8E8 OF THE NERVOUS SYSTEM.

In the other fonoB of hysteria the general health must be
attended to, the bowels kept freely open, the shower-bath daily
used, and ferruginous tonics administered. In hysterical
epilepsy with disordered uterine functions, Sir Charles Locouk
recoranieiids the prolonged use of the bromide of potassium,
in iivo or ten grnin doses, thrice daily. When the catamenia
are unnatural, the treatment most have reference to the nature
of the particular disorder. Thus, if too abundant, astringents
and the cold hip-hath, to which ulum or bay-salt should be
added, must be employed ; if scanty, they should be encour-
aged by aloetic purgatives, different preparations of iron, and
the warm bath. The compound decoction ofalocsand the com-
pound iron mixture — half an ounce of each — taken thrice
duily, forms an excellent medicine in such coses. In hysteri-
cal aphonia galvanism is often very useful. A mild induced
current of galvanic electricity should be applied by means of
moistened conductors ; the poles being direeUid partially to the
inferior loryngeal nerve, and partially over the crico-thyroid
muscle, since it plays an iiuportant part in the formation of
the voice. In hyperaesthesia of the muscles, hot cataplasms,
iodine paint, warm baths, and a mild electric current, are the
means to bo tried ; while in ansosthesia a cure may of^^en be
effected, by making a stronger current of electricity traverse
the insensible muscles daily for about fifteen minutes at a time.
As in other cases of hysteria, so in these varieties one or other
of Formula) HI, 112, 114, 183, 187, 447, 449, 491, &c.,
will be often found very valuable.

The patient's diet should be regulated ; hot rooms and even-
ing parties are to be proscribed ; stays ought not to be worn ;
and, lastly, it is of the greatest importance that healthy mental
occupation should be found. Indeed %ithout this latter, a
care is not to be expected ; for amongst the most frequctit
causes of hysterical affections we must count the want of proper
employment of the miud and energies.

CATA t.KrSV ECSTASr-

rUOBEA.

301

XIV. CATALEPSY: ECSTASY.

edl

^^ mo

These wonderful diseases are very rare, but they undoubt-
edly do hiippen occasionally. Nervous, hysterical women are
most likely to suffer froin llicm ; tliey are not duncerous.

By a fit oi' catdfrjisi/ is implied a sudden Buppression of con-
iouBoess and Tolitioii ; the patieut remaining during the
-attack in the same po.«ition in which she happens to be at the
commeucetnent, or in which she may bo placed during ita
continuance. The seizure may la,st only a few [niiiutes, or
several hours, or even one or two days. On recovery, which
is generally instantaneous and as if from a deep aleep, there is
no recollection of what has occurred. Very rarely these cases
terminate in apoplexy or insuiiily.

In what is termed eretati/ the state is different. The patient
IB inseusihlo to all external impressions, but is absnrbed in the
contemplation of some imaginary object. The eyes are im-
movably fixed ; but impassioned sentences, fervent prayers,
psalms and hyinna, arc uttered or sung with ^reat expression.

A similar plan of treafmeiit to that recommended in hys-
teria must be relied upon.

XV. CHOREA.

Chorea, or St. Vitus's dance, is characterized by irrej;ular,
tremulous, and often ludicrous actions of the voluntary mus-
cles, especially of those of the face and limbs; there being
incomplete subserviency of the muscles of this class to the
will. The disease has been quaintly designated '* insanity of
the muscles."

Sj/mptotnit. — This disease occurs most frequently in young
girls between the age of six and fifteen ; while it may be either
of a mild or severe type. It begins generally with twitch-
inga of the muscles of the face. By degrees, all or almost all

802

DISEASES or THE NERV0C8 8T8TEM.

the voluntary muscles become affected; the child finds it im-
poesible to keep quiet; there is a constant movement of the
hands and arms, and even of the lees ; and one half of the
body is generally more affected than the other, while in a few
cases the movements are entirely confined to one side, — hemt-
choren. Moreover, the features arc most curiously twisted
and contorted ; the articulation is impeded ; iind all ihc move-
ments arc most severe when the child is conscious of being
watched. If the patient be asked to put out her tongue, she
is unable to do so for some moments ; but at last suddenly
thrusts it out, and an suddenly withdraws it. If she be told
to walk, she advances in a jumping manner, by fits and starts,
dragging her leg rather than lifting it, and alternately halting
and hopping. She cannot even sit still ; her shoulders writhe
about, she picks her dress, and shuffles and scnipcs the floor
with her feet. During sleep these irregular actions usually
cease. When the disease lasts long, the countenance assumes
a vacant appearance bordering on fatuity, and some imbecility
of mind becomes manifest. The functions of the stomach and
bowels are also frequently deranged ; the appetite is irregular;
the abdomen swollen and hard ; and there is often constipa-
tion. The urine is of high specific gravity, especially when
the choreic movement* ore very active ; a condition due,
according to Dr. Todd, to the increased waste of tissue conse-
quent on the disturbed state of the muscles and nerves. Am
the case gradually improves, the specific gravity of the urine
diminishes. Moreover, all the symptoms cease on the terrai-
nntion of the disease; which is scarcely ever fatal, or even
dangerous, unless it merges into organic disease of the Dcrvous
centres, or into epilepsy.

Cnuifi, ffcf. — Chorea may last from one week to several
months ; the average duiiition is probably five or six weeks.
It is often complicated with hysteria ; and the general health
is usually below the normal standnrd. Fright appears to be
its most frequent cause; blows or falls seem sometimes to have
induced it ; the occurrence of the disease from the irritation

CHOREA.

303

of intestinal worms has long buen uciticcd ; it has by some
been attributed to onanism; while I believe that the children
of nervoiia and hysterica! women are more likely to be afflicted
by it than others. Although most common in girls, yet boys
from eight to sixteen years old not unfrequently suffer from it.

Palh'ilwji/. — As tlie appearances found alter death are
usually slight and by no means uuiturm, physicians are not
agreed as to the pathology of choreii. Some observers regard
it as a di.sease, the essence of which is perverted nervous func-
tion. Others believe that the blood is primarily uffectcd.
There seems to be some connection between chorea and rhcu>
nmtisui ; the latter disorder sometime.s preceding the former,
sometimes accompany it. and sometimes fallowing it. Nume-
roas cases have been recorded in which morbid conditions of
the heart and pericardium, of a rheumatic and a non rheuma-
tic character, have given rise to choreic symptoms. In some
instances chiirou would seem to have been connected with
B^mptoms of mental imbecility.

Treatment. — The only plan of treatment f-o be recomnieDded
consists in regulating the bowels, subduing irritation, and
strengthening the 8y.stem. For thi.s purpose, the employment
of cathartics of a stimulating nature is Decessary, such aa
culumel und jahip; or, where worms are suspected, the oil of
turpentine. A combination of tonic or antispasmodic medi-
cines with purgatives, is often found to be serviceable. Tbe
two great remedies, however, are the cold shower or douche
bath, and steel. As regards the former, it should he employed
every morning on the patient's rising; with respect to the
latter, different preparations have been recommended. Per-
haps the best is the carbonate of iron, given in doses varying
from half a drachm to two druehnis, mixed with treacle. The
sulphate, or the ammonio-citmte, or the tincture of the ses-
quichloride of iron may, however, be used almost as advan-
tageously. The oonibiiialion of steel and arsenic (F. 490) is
to be preferred in some cases ; especially in such as are of u
severe and obstinate character. The diet must be nutritious;

304

PI8EASE8 OF tHB NERVOUS SYSTEM.

exercise in the fresh air freely allowed ; and incDtnl eicit€-
tiient guarded against.

The employment of pymnastic exercises has been stroogljr
recommended. In a memoir submitted to the French Aca-
demy of Sciences, M. Blachc states, that he has treated by
these exercises alone, or by these in combination with other
measures, such as sulphur baths, 108 cases — 84 girls, and 24
boys. In 102 the cure was completed, on an average, in 39
days; in the remaining six, in 122 days.

XVI. TETANUS.

The term Tetanus is used to denote a disease the principal
feature of which is, long-continued, painful contraction or
spasm of a certain number of the voluntary muscles. The
rigidity of the mu-scles being continuous, we say that there
ia tonic ipafm or tpaitic coiitrardun ; these terms being em-
ployed in contra-distinction to the clonic upaimi of convul-
sions, in which there is a state of alternate contraction and
relaxation.

The fj/inptomit usually set in suddenly, the muscles of the
jaws and throat being usually the first affected. The patient
complains that he has taken cold, and says that he feels as if
he had got n sore throat and stilf neck ; but the stiffness and
uiieasinei!.>( soon increase, and extend to the root of the tongue,
causing difficulty in .swallowing. The tempoml and masseter
muscles gradually get involved, and trismus— or lofkeitjain —
occurs. When the disease proceed.*, the remaining muscles of
the face, those of the trunk, and, l.i.stly, those of the extremi-
ties, become implicated. The spasm never entirely ceases,
except in .some cusefj during sleep ; but it is aggravated every
f|uarter of an hour or so, the increased cramp lasting for a few
minutes, and then partially subsiding. When the strong
muscles of the buck are most tiflected, they bend the body into
the shape of bd arch, so that the patient rests upon his hend

TETAXtrS.

305

Slid heels, a condition known as opitlhotonot. When, on the
contrary, the body is bfnt forwards by the stronji; contraction
of the oiuscles of the neck and obdoiuen, the affection ig
termed emproslhotonos ; while if the muscles are affected late-
rally, so that the body is curved sideways, it hits been desig-
nated plf-uriiflhotoims, or tetiinui lut'i-a/in.

The suffering caused by the tetanic spasins is absolutely
frightful to contemplate; the face la pale, the brows contracted,
the skin coverinj; the forehead oorrugntcd, the eyes 6xed and
prominent — sonietimea suffused with tears, the nostrils dilated,
the corners of the mouth drawn back, the teeth exposed, and
the features 6xed in a sort of fjrin — the risim nariiimicus. The
respirations arc perfyrined with difficulty and an^juish ; severe
pain is felt at the sternum ; there is great thirst, but the agony
is increased by attempts at deglutition ; the pulse is feeble
and frequent; the skin is< covered with perepiration ; the pa-
tient cannot sleep, or, if lie dozes it is only for u few minutes
at a time ; and yet with alt this suffering, the intellect remains
clear and unaffected. Death at length ends the scene, being
due partly to suffocation, and partly to exhaustion.

There is a peculiar form of thia affection called tn'smitt
naacentium, which occurs in young infants about the second
week after birth, and which is very fatal. It is very rare in
this country ; though some eighty years since, when the Dub-
lin Lying-in Hospital was badly ventilated, it was one of the
most prominent causes of the infantile murtality in that insti-
tution. Tetanus infantum is still common in the West Indies,
where it sometimes seems to rage as an epidemic.

The coKSfs of tetanus are chiefly eipiwure to cold and damp,
and bodily injuries. When due to cold, or when arising spon-
taneously, it is termed idiopnihic ; when the result of wounds,
traumnlic tetanus. In idiopathic tetanus recovery may bo
hoped for; while in the tniuniatiu form almu.^t every case
proves fatal. Taking both varieties into tbe culculiUion, it
may be said that death is most likely to occur between the
third and fifth days of (he disease. The symptoms produced

20*

306

DISKASKS OK THE NERVOUS SYSTEM.

by a poisonous dose of strychnin are very sitniliir to thu.su of
this d)8eii£e. Tetaiiua is occasionnliy connected with or de-
jK'iideut upon some alteration — especially cono:ostion — in the
spinal cord or its mcinbnnies ; but it is generally allowed that
it is often merely a functiunul affection, and by no means ne-
cessarily connected with influniniation of any portion of the
nervous system. Hence in many instances no post-mortem
appearances of any note cnn be discovered.

The treiitmeiit is commonly empirical, and generally — it
must be confessed — useless. There are four remedies on
which, it seems to me, reliance is chiefly to bo placed, — vi«.,
belladonna, chloroform, quinine, and wine. Opium has never
been fijuiid to do iiny >;ood ; and it is now rendered probable
that its use is objectionable, since it produces a state of con-
gestion and polar excitement of the spiniil curd somewhat
similar to that cau.''ed by strychnine. Belladonna may be ap-
plied to the spine locally, swearing the extract well over this
part; while it can also he administered internally, iu doses of
half n grain or one grain with two grains of «iuinine every four
hours. The patient niij;ht also bo kept under the influence
of chloroturm (or very many hours : iiidcLd I would not mind
trying its use for one or luore eolire days, provided no symp-
toms— such as a failing pulse — to forbid it arose during its
operation. Under the iuUuence of this antesthetic the pulse
falls to Ilh natural standard, the respiration becomes easy, and
hH indication of suffering subsides; but as soon as the remedy is
suspi'tiiJed, tlie fatal syinptonia again begin to show themselves.
Witli regard to (|uinitic, twin three to five grains may be given
every four or six hours, either by the mouth or rectum. Con-
sidering that the action of woonint is antagonistic to the effects
of the artificial tctanu.'s of strychnia, it was hoped that this
agent might prove u-'iclnl in tnuunatic and idiopathic tetanus.
It has now been used by inocululion in several cases; but the
result, on the whole, has been unf:ivorable. Mr. Spencer
Wells has suggested that, as the specimens of the cxtruot
brought to this country vary in strength, in future trials it

NELRAI.UIA.

807

Wduld be ns well to use a solution of the active principle of
wnoram — the alkiilciii! eurarina. Further cxperiiiieuts arc
uiidnuhtuclly desirable befiire fjivitig up this drug.

Thero are a few other pnints worthy of recollection. Thus,
if de<,'lutitiuii be diRifult, eiicuiiita luunt be used. I should
also be inclined to try the applieatiim of ice to the spine. Some
practitioners recommend the frequent use of the wanu biith,
while others prefer the cold douche ; the feelin-isof the patient
niii;ht bo consulted as to which he would prefer. A few
authorities h»ve faith in cuniuu when applied locally and
taken internally. Purgatives will generally be necessary; full
dosesof calomel and jalap, repeated until the bowels have been
thoroughly evacuated, being as efficient an any other medicine
of the clas8 of aperients. Bloodlett,ing, mercury, large doses
of assafa?tida, turpentine, digitalis, tobacco, luusk, iron, hydi-o-
cyanic acid, and tlic extract of Indian hemp, have becu re-
peatedly tried, and as often caused disappointment.

XVTI. NEintALGIA.

Introtiuclion. — The pains which occur in the course of
disease may be divided into two varieties: i.e., into those oc-
curring at the scat of niitiehief — ns pain iii the breast from
cancer of the tuaninia, puin in a Joint front intlaniuiation of the
synovial membrane, pain in the scialio nerve from disease of
lie neuritciuiiiii ; and those referred to purls not actually the
eat of morbid action — as pain in the shoulder fmtn disease of
the liver, pain io the little Gneerfrom striking the ulnar nerve
nl the elbow, pain in the knee from di.scasc of the hip, and pain
in the foot from piles, stricture of the urethra, &c.

Neuralgia consists of violent pain in the trunk or brnnch of
a nerve, occurring in paroxy.sms, at regular or irregular inter-
vals : frequently there arc nocturnal e-icacerbations. It may
attack the nerves of the head, trunk, or extremities ; the subcu-
taneous nerves of these parts sutTering the mo.st frequently.
Varietitt. — When the branches of the 6fth pair of nerves

308

niREASEB or THE NEKV0U8 SYSTEM.

are the scat of pain, we call the disease neuralyia faciei or lie
douloureux; when certaiu nerves about the head — hemirraiiiu ;
when the sciatic nerve — H-iutica. Some authuritios consider
that aiiyinii pectoris is a neuralgic affuctiori of some of the
cardiac nerves ; and yatlrudj/nia a similar disease of the nerves
of the stomach.

a. Tic Doufoureux — or facial netiraigia — may affect either
of the three chief branches of the Gfth pair of nerves. When
the pain depciidn upon a tntirbiU condition of the first or
uphthalmie branch, the frontal raiiiiBcation of it — the supra-
orbital nerve — is the most fre(|Uontly attacked ; the suffering
being referred chiofly to the forehead. When the second or
superior maxillary branch is the scat of the complaint, the
infra-orbital nerve is one of the must coniiuonly affected; the
syraptoms uunsisting of excruciating paiu shooting over the
cheek, lower eyelid, alte of the nose, and upper lip. Tic
douloureux of the third or iiir^rinr maxillary branch is gene-
rally confined to the inferior dental nerve, especially to that
portion of it which emerges from the mental foramen and ex-
tends to the lower lip. The pain is referable to the lower lip,
the alveolar process, the teeth, chin, and side of the tongue.

Whichever nerve may suffer, the pain is U!>unliy confined to
one-half of the face. The right infra-orbital nerve is the most
frequent seat of this disease. The pain comes usually very
gradually — perhaps as a momentary twinge ; but soon it in-
creases in severity, gets lancinating and burning, ond often
becomes excessive and intolerable. 1 have seen the most horri-
ble sufferings induced ; nnd until I became aware of the value
of chlui'oform, have often been unable to afford any relief. Not
unfre<(Uetitly the attack is preceded by nausea and derange-
ment of the digestive organ.-*, sometimes by dyspnosa, and ooca-
sionally by slight rigors followed by huat.

Facial neuralgia may arise from many circumstances, as from
decayed teeth — though SirB. Brodie denies this; from disease
of the bones of the face ; or from organic disease of the brain.
Frequently the affection can only be regarded us a product of

NEUBALHIA.

309

hysteria in an hysterical constitation ; sometimes it ia inter-
mittent and periodical, and iippears to be due to the poison of
malaria ; in many cases it seems to be dependent on disordered
digestive organs f while in not a few it cannot be traced to its
real source.

Jn a person liable to nounil<:ia, the paroxysms of sufferini^
are induced by very triflinor cansesj a slight current of air, a
sudden jar or shake, or anything which reminds the patient of
his malady, will suffice to bring them on. The pains often
prevent all attempla even at repose. When the sufferer is
once asleep, however, the re«t is sound and undisturbed; since
the pains — as pointed out by Sir B. Urodic — are suspended
by sleep.

/9. Hemtrrania — is merely headache, affecting one side of
the brow and forehead. It is often attended with sickness,
and frequently results from duhiiity. Occasionally its attacks
are periodical, coining on at a certain hour every day. It liiis
been called Sun-puiit, from the circumstance that at times it
continues only so Ions; as the sun is above the horizon.

j: S'-ialira^-Cimsints of acute pain following; the course of
the great sciatic nerve, and extcridinsr thuretbre from the sciiitiu
notch down the posterior surface of the thigh to the pojilitcal
space, and fret|UCTitly along the nerves of the leg to the font.
It frc<|uently results from pressure upon some part of the nerve,
such B8 may arise from intestinal accumulations; now and tlicn
from iiifliinvniatinn ; Horuetimes from over-fatigue, and exposure
to cold and wet; and occasionally from rheumatism. Puerpe-
ral women — especially those of a rheumatic diathesis — not
nncommonly suffer from sciatica; the nocturnal exacerbations
of pain quite preventing sleep, and exhiiu-stiiig the patient.

Usually one limb only is affected, examples of bilateral
Buffering being rare. The muscles feel stiff, and as if their
action was impeded, so that (he patient liiiip.s along with the
aid of a slick. The duration of sciatica varies from a few
weeks to several months; the middle period of life, from forty
to sixty, is roost obnoxious to it ; and occasionally attacks of it
alternate with other neuralgic affections.

310

DISEASES OF THE NERVOUS SYSTEM.

Treatment. — Ih the treatmeDt of neuralgia, it is obvious
that our first efforts tnust be directed to the removal of the
cause. — The sLnte of the health must be looked to; general
plethora — which very rarely exists in these cases — being
relieved by purging and other lowering means, while consti-
tutiunal debility is to bo corrected by nourishing diet and
ferrui;inous tonics. Dr. Klliotson says, that "in all cases of
neuralgia, whether exquisite or not, unaccompanied by in-
ftauiniatinn, or evident existing cause, iron is the best
remedy;" the stsquioxido may be given in hulf-drachm or
drachm doses two or three times a day, with an occasional
aperient. When there are symptonis of disorder of the di-
gestive organs, purgatives — especially F. 176, 177, 224, 225 —
and antacids will often give relief. Cases associated with
rhcuniutism will derive benefit from iodide of potassium,
guaiacum, colchicuni, and occasionitlly from turpentine, &c. ;
while thuse in which the attacks are periodif will often be
cured by large doses of quinine, or by niitmte do.scs of arsenic
with bark (F. 28, 29, 52, 53, 55, 56, 69, 70, 490, Ac.)-

The efficiency of the vuleriaiiate of aujuionia as a remedy for
neuralgia, bus been proved by many practitioners, though I
must ooufess it has greatly disappointed my expectations.
From oue to three grains of this salt may be given, in an ounce
of infusion of cahmiki, thrice daily. I have greater faith in
the hydrochloratc of ammonia; half a drachm of which should
be given every hour in water, while the paroxysm is on. If
after the fourth dor-e there be no diminution of the buffering,
it will be uscle.'isto persevere. As soon as the puin b relieved,
the dose may be reduced to fifteen grains three times a day.

In the treatment of sciatica, mercury or iodide of potassium
will be needed if there be any symptom.'^ of a syphilitio taint;
purgatives, especially crotoo oil (F. 201, 202j, if we fear the
existence of fsacal accuuiulations; and steel, with ood-liver
oil, if there he general debility. In two or three cases where
I could dulcet no cause for the diseaae, a cure hus been effected
by the sulphate of soda and steel (F. 225), with the use twice
a week of the hot air bath.

NKlTBAtOIA.

311

Certain topicol expedients have been proposed. Division of
the affected nerve is an uni«cientific operation, which can rarely,
if ever, be of any service. Any turaor or foreign body press-
ing upon the nerve must be removed, or any portion of the
necrosed bone that may be the cause of the suffering must bo
taken away. In facial neuralgia, the extraction of a carious
tooth or stump will sunietimes effect a cure; and my friend,
Mr. Hulme, tells me that be has known many instances of this
happy result. Uelladonna, chloroform, opium, and aconite, ap-
plied to the affected part, will often at least palliate the suffer-
ing; while, in some instances, the cuticle may be reinoved by
a blister, and the part dusted over with one or two grains of
morphia mixed with the same quantity of white sugar. Nar-
cotic injections into the areolar tissue find favor with many.
Morphia is, perhaps, the best ajjent to employ (F. 359) ;
while as much relief is given by using this hypodermic method
at a distance from the seat of pain, as by practising it at the
neuralgic part. To inject the solution, a graduated syringe
having a sharp perforated nozzle ought to be used, A small
portion of an ointment, made by mixing one grain of aconitine
with one drachm of lard, may be cautiously smeared over the
track of the painful nerve once or twice a day. So also warm
baths, or hot douches of medicated water, will often be u.«cful.
Where there is no disease of the nervous centres, the use of a
continuous current of galvanic electricity (such as can be ob-
tained from one of Pulvcrmacher's chains) to the affected
nerve, may lead to a cure.

In the majority of cases it will be necessary to resort to the
eropioyment of narcotics and sedatives. When the pain is on,
and when the patient is racked with torture, no agent produces
such instantaneous relief as ether or chloroform (F. 358); the
inhalation of one of which remedies should be permitted until
complete insensibility is produced. The ease induced often
continues long after the patient recovers from the immediate
effects of the anaesthetic.

PART IV.

DISEASES OF THE ORGANS OF RESPI-
RATION AND CIRCULATION.

I. CATARRH.

Catarrh consists of acute inflammation of the mucous nicni-
brniie of sotne part of the air-pa8sat;e8. It is called i-oryzn,
if it aiTect the Schneideriaii tiicnibrnne of the nose ; grnveilo,
if the fronta] sinuses suffer; and bronrhUit, irhen the stress of
the disease falls on the trachea and hronchial tubes.

It is the commonest of diseases. It arises not from mere
cold, but from too sudden a change of temperature, or from
exposure to wet, Ac, when the strength is exhau-sted. Sudden
vicissitudes of temperature are not dangerous; for in the use
of the Turkish bath a cold douche is commonly employed after
leaving the sudatoriuiu, while Dr. Currie and othens have re-
lated many cases of fever, scarlatina, &c., which have been
beneficially treated by cold affu.sion during the hot stage. The
application of cold is dangerous when the heated body, ex-
hausted by exercise, is rapidly paiting with its heat. The
hetitcd body can react upon the cold, and convert it into a
strengthening rather than a depressing agent ; but the body
which is cooling after having been over-warmed is not in a con-
dition to react, and hence the application of cold inoreasca the
depression.

The tyviplomt chiefly consist of lassitude, pains in the limbs,
aching of the back, a sense of tightness across the forehead,

CATAEBH.

313

excpssive discharge from the Qostrils, profuue lachrjmation,
hoarseness, sore throat, furred tongue, nioie or less fevcrish-
iiess, thirst, Ions of Jippctitc, and a (|uick pulse. An erup-
tion of herpes also appiears iipoD the lips, and perhaps iiK»t
frequentl; about the middle of the lower lip. At the end of
about forty-eijrht hours these symptoms begin to subside ; or
(he disease pasw* into ponie more severe afl'ection, as acute
tonsillitis, bronchitis, pneumonia, &c.

Dr. Hyde Salter has sujriiested that the symptoms of catarrh,
depend upin a speeilic animal poison ; and llnit tliey are attri-
butable either to the material presence of tiiis poison circu-
lating in the blood, or to the irritation which it produces in
those organs which are its constituted cliniiM:int.«. The arrest
of the function of the skin from exposure to cold throws back
into the circulation that which ought to have been eliminated
as the cutaneous excretion ; and this, either by itself, or by ulte-
rior changes which it gives rise to iti tlie blood, induces a condi-
tion of toxaemia The vicarious eniunctory for the correction
of this state of blood-poison, by the eliniiniition of the niat«-
rifll for whose excretion the skin has been temporarily rendered
uner|ual by cold, is the respiratory mucous membrane ; and
the principal local symptoms — coryza, tonsillitis, bronchitis —
depend upon the vascular changes in this membrane induced
by this exceptional excretory function, and p<j»<ibly by the irri-
tation of the poison materially present thereat. So long as
the blood is thus contaminated, the fever symptoms persist ;
while its depuration is immediately attended by their abate-
ment.

No one applies to a doctor to cure a cold. Every man acta
as his own physician, and judiciously amuses himself with
slops, putting his feet in hut water, and perhaps by taking a
few doses of James's powder, while the disease runs its course,
and in three or four days exhausts itself. Doubtless tho cure
may sometimes be expedited by a mild aperient, one or two
ten-grain doses of Dover's powder at bed-time, or the use uf
a saline draught (F. 415). A hot-air or vapor bath may ufteD

814 DI8KA8E8 OF LUN08, HEART, ETC.

do good. In some persons, an opiate at bedtime (twenty mi-
nims of the tinctura opii) will cut short a catarrh; and in
others, a good dinner with two or three extra glasses of wine,
will have the same effect. Dr. C. J. B. Williams assures us that
B!iy cold may be cured in forty-eight hours or less, by almost
total abstinence from liquids; but it is a practice which in all
probability very few have adopted, though it was originally
recommended one hundred and ihirty-tive years ago by Dr.
Richard Lower.

II. CHBOinC INFLAMMATION OF THE NOSTRILS,

Chronic inflammation of the nostrils {iiz(rna, rhinorrkcea)
is attended with heat and stiffness of the nose, tumefaction of
the Schneiderian iiienibrnne, and an offensive sanious or maco-
purulent di.scharj;c.

Ctiusfg. — This disease may result from repeated or long-
continued attacks of acute inflammation, or common catarrh ;
being especially apt to do so in such as are of a delicate consti-
tution. It may also be a consequence of the htrumousor gouty
diathesis, when it is generally associated with disordered di-
gestive organs. And again it not uncommimly depends upon
a syphilitic taint. In every case of ozaena the nostrils should
be examined with a probe and an ear speculum, to be certain
that the symptoms are not due to any impediment — as a foreign
body or a polypus — to the free discharge of the nnsiil mucus;
since if (his secretion be allowed to accumulate, it soon putrefies
and excites troublesome inflammation.

Si/mptnm$. — These vary somewhat according to the cause.
Usually they come on insidiously with the indications of an
ordinary cold; there being especially great uneasiness or
"stuffiness" in the nose, owing tfl the thickened mucous mem-
brane impeding the pasciige of the air. A portion of the
8chnctderiau or pituitary metribrane may even swell, so as to
look like a polypus on a superficial examination. There is also

•

■ frontal

CHRONIC INFLAMMATION OF THE NOSTRILS.

SIO

frontal headache, cough, general weakness, and much mcutai
depression ; but the most truublewnie sjuiptuin is a profuse,
fetid, luuco-puruleiit diNcluirge. Sonietiniea this discharge is
quite purulent; mid it is gcDerally tinged with blood if there
be any ulcer on the mucous uiembraue. Large solid flakes of
fibrin or of liurdened mucus occasionally come away. The
smell from thcjie crusts, owing to the rapidity with which they
decompose, is so very offensive and taints the breath to such
an extent, that the patient is unable to go into any society.
He becomes even an object of disgust to himself; and if niedi-
cioe fails to give relief, he gets miserable and desponding, hag
no appetite, loses flesh and strength, and passes wretched nights.
When the diseusc has continued some time the septum of the
nose often gets eattMi through ; or the spongy bones become
implioated, and there is caries or necrosis. This is especially
likely to happen when the system is tainted with the poison of
syphilis.

Occasionally the symptoms in ozaatia arc very slight. The
patient — probably a strumous subject — is merely annoyed by an
uneasy feeling in the nose, and espectiilly by finding that when-
ever he uses his handkerchief he brings away thin mucus
stained with blood, .\dviue is suldom sought until this has
continued some time; and it is then found on examination that
there is a circular hole, perhaps large enough to ndmitagoose-
qnill, in the septum nasi, with ulcerated edges. These cases
are in no way connected with any venereal taint.

Treatmiiit. — This must be local and constitutional. Re-
membering that the fetor of the discharge results, in part at
least, from the decomposition of the retained mucus, we shall
take care to have the nostril frequently and effectually syringed
with warm water; to which a little of Condy's disinfecting
fluid, or a small portion of chloride of zinc (gr. xij to water
Jviij) may often be very advantageously added. I have seen
4paes where a large syringe has had to be used for half an hour
tt a time, in order completely to dislodge the iD.spis,sated
matter; for unless the whole is removed no relief will be given.

816 018EA8CS OF LUNOS, BEABT, KTO.

To moderate it8 secretion Bubsefiuently, the onguentutn hy-
drar^ryri nitrutis mitius .«huuld be applied up the nostril by
means of a caincrs-hiiir pencil every ni;:ht. — In oitarrbnl
ozsena attention is to be paid (fl the digestive organs; and then
such tonics as ijuiiiiiic and iron, the nitru-muriatic acid and
hark, and a nourishing diet, will prove the most appropriate
constitutional remedies.

In stninious cases I have found most benefit from the iodide
of iron and cod-liver oil, tojrether with the injectiim of warm
water, and the inhalalioD of steam medicated with iodine, or
creosote, or turpentine (F. 314, 315, 316). Change of air,
especially to a bracing part of the coast, often does great
good.

The treatment of syphilitic oztena is locally the same as for
the other fonns ; while the conslitutionot remedies are those of
aeumidury 8yphili.s jieiieniliy.

ni. DIPHTHEEIA.

Diphtheria {SetfOi/ui, a skin or luembniiiej may be defined as
an epidemic sore thmat of great severity, doe to tosaBmia;
being attended with much prostration, and characterized by the
exudation of fulse nicmbiunes on the tonsils and adjacent parts.
When it docs not end fatally, it is often followed by an altera-
tion in the voice, partial paralysis of the muscles of deglutition,
weakness of the upper extremities, anwrnia, and impaired
vision.

From the writings of old physicians it is certain that this
disease prevailed extensively at different times in the sixteenth,
seventeenth, and eig)ite<!ntb centuries. In Fniiiccan epidemic
broke out in lUt8, which was described by Hretonueau under
the name of dipbtheritc, in M^moires communicated to the
Aoademie Royale de .Me^dcuirioin 18*21. About the sometime
•Iso some cases .seem to have occurred in Scotland, and a few
in England; but English physicians paid only slight attenlion

DirHTHErilA.

317

to the subject until the outbreak of the epidemic at Boulogne
in Januarj, 18o5. In this country the first cases of the
present epidemic were obserrcd \o the middle of the year
1856 J and it has continued more or less prevalent in different
parts of England until the present time.

Diphtheria and scarlatiua sometimes oocar as epidemics in
the same district ; while oocasiunally they coexist in one indi-
vidual. Hence some havo thought that diphtheria was only
scarlatina without any eruption : and they hnve pointed to the
facts That in modified scarlet fever there is aometiniea an exuda-
tion slightly resembling the diphtheritic membrane, while
albuminuria sometimes is present in both di-scases. Further
investigation shows, however, that those affections are distinct
from each other, though there may be some analogy between
them. Thus, an attack of the cxanlhematous fever, while it
confers immunity to a second attack, doet< not afford any pro-
tection against diphtheria ; a person may suffer from the latter
more than once, the la.st seizure being as violent as the first,
while moreover relapses are not very uncommon ; the larynx
is often affected in diphtheria, never in scarlet fever ; albumi-
nuria occurs only during convalescence from scarlet fever, while
when it takes pluce in the epidemic sore-throat, it may be
found on the first or second day of the disease; and then,
lastly, there is a marked difference in the sequelae of the two
affections.

Si/mptomt. — Diphtheria sets in very gradually, with feelings
of depression and musculiir debility, headache, nausea, alight
diarrhoea, chilliness, and drowsiness ; while before the throat
is actually sore a sense of stiffness in the neck is complained
of. Then the tonsils become inflamed and swollen, and the
glands about the angle of the lower jaw get tender; while, aa
the inflammatory action proceeds, it involves the velum, uvula,
posterior part of the pharynx, &c., and perhiipw causes painful
or difficult deglutition. With regard to the little word " per-
haps " just employed, it is meant that the amount of pain in
thii tliroat is mi criterion as to ihe extent i»f the disease; for

•r,*

318

UJtiFASEB OF LUNUK, HEART, ETC.

in most iiistancos there is less general discoinfort and sufforinp
than in simple acuto tonsillitis, while in many of the fulul
cases there has onlj been a feeling uf uneasiness.

It is probable thut at this stage resolution of the inflammn-
tioD may in scmie iit^tivucca tuke place, and the patient be
soon restored to heallh; but more commonly the chamctcristio
feature of the disen.-e now becomes manifested, and a plastic
fibrinous material is efiused. This exudutiun cumuiences on
the soft pulute, or on unc tonsil, or on the back of the pharynx,
in the form of sinall ash-colori'd spoeks ; these spots by'their
enlargement and cnulesccnoe forming patches of considerable
size. As the {li,«ea>e spreads the false meuibninc increases in
thickness and in ostent, it usnally becomes firmly attached to
the mucous tissue beneath, and if it be forcibly removed a
new patch will be found at the end of a few hours ; but if the
exudation be cast off naturally, then either no new false mem-
brane is formed, or only one which is much more filmy than
the first. The exudation has been compared to wet parch-
ment, or to damp wai^h-loather ; it may .spread forwards to the
check and p:unis, upward.^ into the nares, downwards into the
cesophaj^us, and even throu>^b the glottis into the larynx and
trachea ; when it begins to separate and decompose, the
patient's bri ath is rendered most offensive ; and it is probable
that the briitrticr or blacker its color, and the more dense its
texture, the -ireater is the danger. As the lymphy deposit ta
cast off we may have ulceration, sloufibing, or gangrene of the
mucous coal, or tliis tisi<ue may gradually assume a healthy
appearance. .\nd lastly, true diphtheritic membranes miy
form on abraded cutiuieous surfaces, on the conjunctiva, on
the vaginal mucous coat, or on the lining membrane of the
rectum ; giving rise to a geuorul morbid state very likely to
be misinterpreted, unless the possibility of this oocarrenoe be
remembKicd.

The general symptoms may be rather slight, especially at
first, in oonipjiiison with ihu severe local effects. Th« pros-
tration is usually extreme, and ohen there is considerable rest-

DIPHTHERIA.

319

lessness ; pain luay be almost wuntiiig ; there is onlj modenite
pyrexia, but the skin may be dry aud harsh; the pulse is
Dcither sharp nor hard, but itiureoses in rapidity as the depres-
sion becomes greater ; the tanp;ue is clean or only slightly
furred, the tonsils are much swollen, the saliva perhaps drib-
bles from the month, the breath is fetid, and there is a disia-
dinatiuu to move even to tiike drink or food ; there may be great
dysphagia, ur the throat may be mui'h affected without any
difficulty in swallowing; there are frequently attacks of haemor-
rhage from the noso, throat, or bronchi ; sometimes there is
purpura, now and then an erythematous rasb, sonietiuies
typhoid-looking rose-spots, and ooeasionaliy sudaraina; while
in a few instances there is found, from an early stage, albumi-
nuria with fibrinous casta of the tubes. Death may happen
from hiBiuorrhnge, giingrene, slow exhaustion, or from as-
phyxia, when the larynx and trachea are affected ; the mental
powers generally retaining their full vigor till the last. In
many instances a fatal tcrinin:ttiun bus taken place very sud-
denly ; and, as I believe, from the deposition of fibrin within
the heart or in one of the large vessels, and not from syncope
as has ooninionly been said. — In ca.ses of recovery, the con-
valescence is often very slow. There may be an»;uua for
many weeks; the voice is left iinpiiired, owing to paralysis of
the soft palate ; sometimes the power of deglutition is not
thoroughly regained for severiil months, the difficulty of swal-
lowing liquids espuciiilly remaining; the muscles of the neck
are not unfre()uently paralyzed, so that the head cannot be
pmperly supported, or the mu-scles of the arm may be power-
less, or there may be paraplegia, or very rarely there is hemi-
plegia ; defective vl.'^iun is complained of, owing to loss of
adjusting power, which is to be remedied by the use of a low
convex gla-ss ; and I have seen more than one intense neoral-
gia as a sequela of diphtheria.

Diphtheritic affections sometimes appear sporadically, they
often seem to be endemic, while they are also epidemic Hnd
contagious. BreUmneuu asserts, from the cousiderutiuu of

820

DISEASES OF LUN08, HEART, ETC,

innumerable facts, that those who attend patienta with diph-
theria cannot contract it, unless the diphtheritic secretion, in
the liquid or pulverulent state, is plnced in contact with a
mucous meiubrarie, or a part of the skin denuded of epiderrais.
Diphtheria nttatks both sexes, at all apes, though children
Deem to be most obnoxious to it ; it is probablj most futui to
the poor, or sucb as reside in damp situations and in badly
drained houses ; while spring and autumn appear to be the
seasons when its ravages are greatest.

If the diphtherliiu exudation be examined microscopically,
it will be found to consist of molecular particles, epithelium,
pus cells, and blood corpuscles. Fibrilhe are but very rarely
seen. The oidium albicans may occasionally be detected ;
but the occurrence of this fungus is only exceptional, and when
the membrane has begun to undergo an acid putrefaction. So
also the leptothrix buccalis may be discovered, but it is also
often found in the buccal mucus of healthy persons.

Treatment. — Every one who has seen much of this disease
must feel that remedies of a supporting kind are those which
alone seem likely to be useful. With regard to locat treaf-
ment, it may be said that external applications to the throat
are injurious or useless; leeches and blisters being only power-
ful for mischief, while fomctitatiuns or poultices fail to give
any relief. If the case be seen within a few hours of the com-
mencement of tho symptoms, we may do giwd by painting the
fauces gently with the tincture of the sesquichloride of iron;
or we may employ a gargle of one or two drachms of the tinc-
ture with seven of sweetened water, or one of borax and glyce-
rine (F. 308). l>r. Greenliow very properly remonstrates
•gainst the severe topical applications which have been resorted
to. " I am sure much niisL-liief has been produced by its in-
discriminutu use, c.Hpecially by the fre<|uent tearing away of
the exudation by probangs, or similar contrivancea for the
application of nitrate of silver, or of strong caustic solutions.
Observing that removal of the exudation, and the application
of remedies to the subjacent surface, neither shortened the

DIPHTHERIA.

321

duration nor sensibly modified the progress of the complaint,
but that the false membrane rarely failed to be renewed in a
few hours, I very soon discontinued this roiiirh local medica-
tion to the tender and already enfeebled niueous inenibrane."*

As to the ifenertil rrmetiies, I believe that when the patient
is seen early it may he advantapoous to pive a few dtwes of a
simple saline (F. 41^, 41(j), or perhaps preferably to allow an
alkaline drink (F. 420, 425). But if the patient be deprei»ed,
if there be the least syraptwn of hiemorrhage, or if the urine
contain any albumen, I at once order the tincture of the ses-
quichloridc of iron, ns was first recommended by Dr. Heslop,
of Birrainghani ; and very frecjueutly it has seemed advan-
tnpenus to combine it with quinine ( F. 445). If the formation
of fibrinous clots be feared, ammonia and bark (F. 489), with
or without opium, ought to be prescribed in the place of the
steel. At the same time, strong beef- tea is to be systemati-
cally given, port wine .should be administered, and a raw egg
in milk or brandy-and-watcr is to be ordered twice or thrice
in the twenty-fuur houns. Sometimes iced champagne is very
gr&tefiil to the patient's feelings, frequently a good draught of
bitter ale, oHentiraes simple spring water, or not rarely a tum-
blerful of milk ; either of these drinks being benefiuial if
wished for. When great depression sets in, brandy in often-
repeated doses must be trusted to ; and in such instances I
think it better not to give any other stimulant.

Many physician.^ begin the treatment of every ca.se with an
emetic of ipecacuanha or senega, but I have seen no advan-
tage from this practice, unless any slight croupy .symptoms
have been present. When there is great difficulty in swallow-
ing, we must trust to enemata containing es.senco of beef, port
wine, quinine, and the tincture of the sesquichloride of iron ;
repeating the cl^'ster every four or six hours, according to the
rapidity with which absorption takes place.

• 0» Di'iihtkfna. B; Edvard Hsudlam Orcanbow, M.D., Ac., p. 3dS
LoDduo, 18<0.

322

DISEASES or UiXOS. BEaST, KTC.

As tooa u coDTmloiceace is s*klj established, nothing does
BO moch good as chsoge of sir ; while snj paralytic sjmp-
toms will be best treated by fermgiooas tonics and local Fara-
dixatioo.

IV. CROUP.

Croup (Jrarhralia, trncheitit, or ri/nanrhr triichfalis) va*y
be deSoed as an iDfluainiatory disease of the trachea, or often
of the glottis, larynx, and trachea ; the fever and tnflamma-
tioD being accompanied by the exudation of false menibraoes
upon the aSccted surface.

It is a disease of early life ; most cases of it occurring
during the second year of childhood. It is often complicated
with bronchitis or pneumonia. It may end futally from ex-
haustion, »^ufibcaliun, or the formation of a clot in the heart.

Sj/mptomt. — In the commencement they are those of a
cold; slight fever, cough, hoarseness, drowsiness, suffusion of
the eyes, and running at the nose. In a day or two the pecu-
liar signs of croup begin to show ihenisclves, comuicncing
with an alteration in the character of the cough, which be-
comes attended with a peculiar ringing sound, rendering it
" bras-sy ;" this cough being also followed in a few hours by a
remarkable change in the respiration. The act of inspiration
becomes prolonged, and attended with n characteristic crowing
or piping noise, readily recognized when once it has been
heard. If now the fauces bo examined, the tonsils will be
found etilurged, and of a red color, but less intense than in
tonHillitis ; the uvula ulsu is sometimes slightly swollen. As
the disease advances, the fever increases, the brenlhing be-
comes more hurried and impeded, the cough more frequent ;
the pulse gets very weak and irregular, and the vital power
much depressed ; there is great thirst, and the child is very
irritable and restless; while with features expressive of alarm
ind distress, ho grasps at his neck, or thrusts his fingers into
hi» niiitith, ii.s if to leniove the cau.«e of his sufferings. Bxs-

TROUP.

323

oerbstions alwAjs take place at night, with remissions towards
the morning. Should there now be a tendency towards a re-
gtoratioD to health, the coujrh will lose its peculiar cliinp, and
become moist, whilst the crowing inspirations will almost
oease. On the other hand, when the disease is about to end
fittallj, the drowsiness soon becomes extreme, though the sleep
is uneasy ; the child utarta and wakes in terror; the breathing
becomes gasping and interrupted ; the skin gets cold and
covered with tlainmy sweats; and the child often dies directly
after an in.spti'utiuri, or coma and convulsions ensue, and claso
the scene.

Sometime* this di.scase runs a very rapid cours"^ ; though
usually its duration ranges from four to ten days. Professor
Gblis, of Vienna, relates the case of a healthy little boy, aged
four years, who going into the open air on an extremely cold
day, was attacked with croup, which proved fatal in fourteen
hours.

Diaynosin. — The history of the attack, the hoarseness or
loss of voice, the dry ringing cough, the croupal inspirations,
and the fever, distinguish this disease from every other. It
can indeed only be confounded with true laryngitis : but this
hitter affection occurs in adults, very mrely in children except
as associated with cruup ; it cnusea a fixed burning pain in the
larynx, increased by any examination ; it does nut give rise to
the exudation of false membranes; and — if prolonged — it
ends in suppuration or ulceration. The diagnosis between
croup and laryngismus stridulus is simple ; for in the latter
there is an absence of fever and of the peculiar cough, while
during the intermissions the patient is apparently well.

Polholor/jf. — Supposing death to have occurred nbont the
fourth day of the disease, we shall find the mucous lining of
the windpipe covered with a layer of fal.se membrane. This
layer may be thin, or some lines in thickness; so diffluent that
it may be wiped off, or so consistent that it can only be re-
moved as a cylindrical cast of the tube; either firmly or

324

DISEASES OF LUNOS, HEART, ETC.

looeely adherent; and titnited to the walls of the larynx, or
extending i'rom the glottis do\rn to the minute hronchi.

The inflammation has its 8cat in the muoous Dienibrane; the
vessels of this tissue exuding the alhuniiiious or fibrinoas ma-
terial, which by concretion forms a false membrane. The
breathing is obstructed not only by this croupal production,
but also by spasmodic contractions of the muscles of the
larynx, diutiiiisiiiiig the calibre of the air-tube; while the
irritation produced by partially detached fragments may pro-
duce even fatal spasm.

The mortality from croup is very great, for probably at least
half of the children attjickud die. If we take twelve cases
of death of various diseases daring childhood, we shall find
that about one is due to croup. In a large number of the fatal
oases death seems to take place from asphyxia ; while in some
instances it certainly seems due to a deposit of fibrin in the
heart. After death from acute croup, Dr. Richardson has
more than once found the cavity of the right uuricle filled
with a fibrinous concretion ; which must have been formed
during life, as the masses of fibrin were grooved by the cur-
rents of blood passing over them from the inferior and supe-
rior venaa cavro. In such cases death begins at the heart ;
the dyspnoea being due to the want of blood in the pulmonio
capillaries. The lips arc slightly blue, the body pale, and the
pulse irregular; while the heart-beats are feeble, quick, and
irregular, the sounds muffled, and sometimes there is a bruit.
The respiratory murmur is everywhere audible; and fre<]uently
there are signs of emphysema.

When death in croup is going to happen from suffocation,
the lungs show signs of congestion, but never of emphysema;
while the body is of a dark hue, there are convulsive muscular
movements, the licnrt-sounds arc clear, and the pulse is feeble.

Treatment. — In no disease, perhaps, is it more neoeasary to
be prompt and cautious. Bleeding, tartar emetic, and mer-
cury are the measures on which we are usually taught to rely;
but I cannot help thinking that this treatment is unsound,

TBOIP.

325

f'-nro wc find thiit, however early and perseverinfrlv applied,
j'et the disorder proves fatal. Would it not be better, then,
to try the efiecLs of a difTerent and perhaps nuliior plim ? For
the reasons already stated, I should iiot advigo the abstraction
of blood, nor would I recommend larpe doses of tartar emetic
or mcrmiry. When the disease is seen early, the continuous
application of hot fomentations to the throat will do great
);ood ; but if much benefit is not quickly apparent, emetics
(F. 286, or 287) may also be administered ; while, when the
heat of the body is above the normal stnndard — as ascer-
tained by the thermometer — a warm bath will lessen it. Thus,
it is clear that a patient haviiip a temperature of 104° or 105°
Fahr. must part rapidly with some of this heat if placed in
water warmed only to 96° Fahr.; unless, indeed, as fast as
the heat is piven off it be regenerated.

Supposing that the disease advances notwithstanding these
measures, I resort Ut the use of the iodide of potassium com-
bined with assafostidtt (F. 32), from which I think I have
seen great benefit.

In order to prevent the formation of I'lilse membranes, it is
said that mercurial inunction should be had rocoui'se to from
the oomipcncement of the severe symptoms; half a drachm,
or even a drachm of the ungnontum hydrargyri being gently
rubbed in every four or sii hours. The practitioner must use
his own judgment as to the employment of this agent. No
barm can arise from calomel given at the onset as a purgative,
in doses of two, three, or four grains; but I have no faith
whatever in its power to control inflammation, and believe that
its frequent administration is very injurious. — In the latter
stages of the di.seiise, it will be necessary to support the powers
of life by beef-tea ; and wine, or n few drops of aromatic .spirits
of ammonia, or of brandy, with water, should be fre(|uently
repeated. Ammonia and ether (F. 432) will often give
strength, and act as ii useful stimulant.

Can we do any good by tracheotomy ? This is a question
the consideration of which must force itself upon every one

326

DISEASES OF LUNOS, HEART, ETC.

treating a case of croup. Looking at the pntholngy of the
disease, rememberiDg that the inflauiination generally extends
into the bronchial tubes, that the serioas dyspnoea for the
most part arises from the albuminous exudation obstructing
the trachea and bronchi, and that tracheotomy when performed
in croup has a tendency to induce bronchitis or pneumonia, —
remembering these points, there seems to be inuoli less chance
of a favorable issue than may b« expected from the same
proceeding in laryngitis. Granting this, it must still be
reniciiibcrcd that iiiakiog an opening into the trachea is some-
times the only proceeding that can be of any avail ; while not
only does it directly prolong life by the admission of air, but
it affords time for the disease (o run its course. My colleague
Dr. Conway Evans says — " The operation of tracheotomy for
the relief of croup has been many times performed in this
country, and in at least /eft cases with the most signal succch;
life having been saved when the patient hud been literally
almost at the last gasp."* My friend Mr. Henry Smith is also
a great advocate for this operation ; and he tells me that when
it fails to save life, it ^tili alTurds great temporary relief.

To sum up these remarks, J would say, that if the pre-
dominant symptoms are those of asphyxia — if the air does not
freely enter the luiig.« at ejich inspiration — lracheot*imy is the
remedy ; tliis operation being performed as soon as the false
membranes appear to be causing ob>truction, instead of defer-
ring it as a last resource. The operation should be performed
rslowly and deliberately; chloroform is not to be used; the
external incision is to be large ; and, as Dr. Evans suggests,
before thrusting the scalpel into the trachea, this tube should
be fixed and drawn forwards by means of a book inserted into
it. Afterwards I am convinced that all medicines had better
be abandoned ; due nourishment and stimulants must be
given ; the air of the apartment must be kept warm and moist;

• BiiMiHrgM Mtdioal Jourmtl, vol. t, p. 41ft. MovMnber, IWt.

LARYNOITIS.

327

and the paiient'a neck should be enveloped in a large piece of
muslin, or in a fomentation flannel.

On the other hand, if the sufferer appears to be dying from
Bjnwipe — from Bome obstruction about the heart — then tracho-
otomj will be useless; for there has probably been a deposi-
tion of fibrin in the ri<;ht auricle or ventricle, and we can only
trust tu the adminiiiti'uiiun of uiiuiionia.

V. LARYNGITIS.

Cynanchc larynpea, or laryngitis, is not happily a very
common disease: in the greater proportion of cases in which
it has occurred, it bus proved fatal. Cold and wet are com-
monly the exciting causes of it ; and it — generally speaking —
is peculiar to adults.

The st/nijilomii of acute inflammation of the larynx are often
at first obscure, as the disease may uinke its approach in a very
insidious manner. Generally, however, they are these: Fever,
harsh cough, pain referred to the pomuin Adaini, diflieulty of
breiitliing and of swallowing, excessive anxiety, hoarseness or
even complete loss of voice, and frequent spasmodic exacerbation
of these symptoms, causing the most distressing paroxysms of
threatened suffocation. The inspirations are long, and attended
with a peculiar wheezing sound, as if the air were drawn through
a narrow reed. The face is flushed, the eyes protruded, the
lips swollen, the pulse hard ; and unless relief be afforded, the
distress gets greater and greater. The larynx and trachea
move with great rapidity upwards and downwards, and all the
muscles of respiration are brought into action, so that the chest
heaves violently; the patient tries to got to the open window
to obtain more air; he soon becomes drowsy and delirious; and
then speedily dies suffocated, tiie chink of the rima glottidis
becoming clo.sed from the Jewelling of the mucous meinbmne
lining it, or from the effusion of scrum into the adjacent areolar
ti^8ue.

828

UI8KAKE8 OF t.UNOS, HKART, ETC.

The infiumiuation is oft«o of vnry limited extent : the dnoger
bein^ entirely owin^ to its situation. But this danger can be
averted by surirical treatment ; by makinp an artificial opening
into the trachea, tbrouph whiuh the patient may breathe until
the inflaniinatiun has .subsided. The operation of tracheotouiy
often here uffurds a striking example of the power of our art.
Too loop; a period niust not be allowed to elnp«u before having
recourse to it; since it had belter be performed unnecessarily
than too lale* Indeed when it failif, it is generally because
it is not performed sufficiently early. Mr. Porterf well re-
niark.s that tracheotomy allows tfie orpan in which the diseased
Bcttoii is situated perfect repose; it removes the danger of the
lungs becoming congested and engorged ; it frees the patient
from tho.se terrible paroxysms of spasniodic suffocation ; and in
short it takes the place of all other treatment, which, besides
being injurious from loss of time, it o/len in itself potitietlg
detnmental. He {juotes, also, the opinion of Mr. Lawrence,
that "bleeding, blistering, and the usual means for subduing
iiiflamniation, are here found totally ineERcaoioua." Is it not
then matter for great regret that many still recommend the
free adoption of this antiphlogistic practice, and bid us perse-
vere with it? the u.sual argument really amounting to this,
that becau.so all the cases have not died under this plan, there-
fore there is every ground for encouragement. — After the
operation, the patient's strength niu.st be supported by milk,
good beef-tea, and wine or brandy, if there be — as there usually
ia — much deprciision.

(Edema of ihr i/lottit may sonietiines arise from other causes
besides inflammation, and produce the same effects as laryngitis.
It is often due to boiling water, or the strong mineral acids, or
alkalies taken into the mouth. There seems reason to believe

* See Mr. Ferguason'a Practical Surgtry, 3d cd., p. t41. Loodon,
1862.

t Oifrvaliom u» tlm Surgical Path/Aigyof tht Larynx nnd Trachea,
^. ^ Uublin, 1837.

LARYNGISMUS 8TB1DDLUS.

329

tlmt the poison of erysipelas amy give rise to it. Tracheotomy
is our only resource.

The tarynx may also suffer from chronic disease. Thus
chronic inflammation and ulceration is not unconiinon in cases
of pulmonary consumption ; a species of phthisis beinj;; conse-
quently known as /'hf/iiiis hrymjen. So, ajruin, the niembnine
lininf; the laryngeal cartilai^s often becomes thickened and
ulcenited in seoondury sypliilis. Polypi and warty fjrowths
may also arise from diUbrent parts of thi.s tube, and CiiU.se great
impediment to the entrance and exit of air.* And lastly,
foreign bodie.s — as coins, beana, stones, &c. — are occasionally
accidentally introduced into the windpipe When sufficiently
heavy they full info one of the bronchi — usually the right —
»nd give rise to all the symptoms of obstructed respiration ; or
they may become lodii<"d at any part of the tube. Opening
the trachea is generally the only remedy, so as to allow of the
removal of the subatanee through the wound ; or to permit of
the inversion of the body, and tho.s facilitate the escape
through the glottis of the coin, bean, or whatever the article
may be.

VI. LAEYNQISMUS 8TEIDFLU8.

Laryngismus stridulus, infantile laryngismus, or child-crow-
ing, is a spasmodic disease occurring in infants chiefly during
the period of dentition ; consisting of a temporary, partial, or
complete closure of the rima glottidis, by which the entrance
of air into the lungs is impeded or ."(topped.

Si/mplotnt. — It is unattended by fever, almost its only
symptom being the interruption of the breathing. The child
is suddenly seized with dyspnoea, it struggles and kicks, is
unable to inspire, and seems about to perish from sulToeation.
Presently the spasm gives way, air is drawn in through the

• tiittoirt df* Polyprt Ju Laryni. Par C. H Elirtnann. Strasbourg,
1850.

28»

3S0

DISEASES OF LUNU8, HEABT, ETC.

chink of the ^lott'iH with a shrill whistling or crowing sound,
and the paroxjsm is over; snnetinies to return shortly, or in
B few hours, or not pcrhap? for days.

Paiholoijy. — This affection was carefully investigated by Dr.
Ley, who attributed it to pressure made by enlarged glands in
the neck or clicst upun the recurrent nerve, or upon some part
of the eighth puirof nerves. This pressure subverts the exact
antagonism by which the glottis is automatically and involan-
tarily kept open, and allows its martrins to come together ; thus
occasioning the dy^pntca and peculiar kind of inspiration so
much like that of croup. It was reserved for Dr. Marshall
Hall, however, to give the immediate explanation of the phe-
nomena uf (his disease, by showing that it is to be attributed
to some source of irritation producing reflex spa.sra — to some
excitation of the true spinal or escito-mofory system. It ori'-
yliiiilet, says Dr Marshall Hall, in —

1. a. The Iri/uvinl nerve in teething.

h. The pnriimrM/fiKlrir, in overor improperly fed infants.
c. The f/iijinf iiervft, in constipation, intestinal disorder,
or catharsis.
These (irf through the (nedium of —

2. The xphial miirroic, and —

3. a. The t'v/erior or recurrent laryngeal, the constrictor

of the larynx.
h. The iittrrrontiih and diaphraijmatic, the motors of
respiration.

Trrntmriii — During the parox3-sra this should be the same
as that employed in resuscitating stillborn children. Hot
WAter to the lower parts of the body ; cold affu.Hion to the head
and face; hlappini: the che.st and nates; exposure to a current
of cold air; and artificial respiration, if neces.sary. The vapor
of ether or ammonin may also be applied to the nostrils; and,
as a Inst resource, tnicheotoniv may be performed.

The subsequent remedies must consist of purgatives, anti-
spasmodics, tonics, and, above all, change of air. The diet

DYSPUOSIA CLERICORUM.

331

should be very simple; a child at the breaat should not. be
otherwise fed. Many of the diseases of infaots are caused by
the silly obstinacy of Bc)roe mothers, who are only happy when
overloading the stomachs of their children.

VII, DYSPHONIA CLERICORFM.

Pysphoiiia cluricoruni, or cleriryman's sore throat, is fre-
quently a ncrvou.<i complaint; being unattended, at least in its
early stages, by any organic lesion, but consisting rather of
irritation of the investing membrane of the fauces. Subse-
quently, however, a series of morbid changes takes place.
These are chiefly congestion, inflammation, or relaxation of the
mucous membrane; enlargement of the tonsils; elongation of
the uvula; and irribition, inflammation, mo''bid dep<i.sit, and
ulceration of the mucuu.s follicles. Dr. Horace Green, of New
York, has described this afl'ection when far advanced, as con-
sisting of a diseased condition of the glandular follicles of the
mucous membrane of the throat and windpipe; commencing
usually in the mucous follicles of the isthmus of the fauces
and of the upper portion of the pharyngeal membrane ; and
extending by continuity until the glanduhv of the epiglottis,
larynx, and trachea are extensively involved in the morbid
action. He calls it follicular ditease of the pharyngo-lartpi-
ffeal mrmhrane.

Sj/mpionu. — These consist of an uneasy sensation in the
upper part of the throat, with continued inclination to swallow,
as if there were some obstacle in the oesophagus which could
be removed by deglutition. The patient also makes frcfjucnt
attempts to clear the throat of phlej;m by coughing, hawking,
and spitting ; he will point to the larynx, too, as being the scat
of pain. At the same time the voice undergoes an alteration;
there is loss of power, and hoaisciiess — sometimes complete
aphonia — especially toward.^ the evening. On examining the
thruiit and fauces, we shall Gind these parts presenting an

332

niPEASES OF LUNGS, HEART, ETC.

unlK'altliji, slightly raw. or granular appearance; the inucoos
follicles may be visible, sonictiities filled with a yellowish sub-
sttinee; and a viscid niuco-piirulcnt secretion will be seen
adhering to the pabtc and to the edge of the velum pcndulam
palati.

This sore throat m.iy exist alone, or it may accompany or
follow laryngitis, bronchitis, or phthisis. Clergymen, public
speakers, actors, singers, &a., are tiiuat liable to it.

Treaimml. — In it.s early stages, when merely a nervoiu
affection, the treatment must cmtsist in the use of tooios,
especially iron and quinine; cold shower-bnths or sea-bathiug ;
and temporary change of scene and occupation. When the
disease is further advanced, a eonrbination of internal with
local remedies will be necessary. Iodide of pota.ssinm, iodide
of iron, iodide of zinc, smaU doses of the bichloride of mer-
cury with the tincture and infusion of cinchona, arspnic with
quinine, hydrocyanic acid, ferruginous tonics, and opiates will
prove efficacious ( F. 24, 21), 31, Zi, 70, 445, 448, 461, 486,
&c.).

The local treatment consists in the application of a solution
of nitrate of silver (from two to four scruples to the ounce of
distilled water) to the diseased parts, even to the interior of the
larynx if possible, by means of a whalebone probang about
ten inches long, having a piece of fine sponge, the size of a
pistol-bullet, attached to its extremity. I say, "if possible"
advisedly, because I can scarcely believe that the sponge baa
ever been passed through the true vocal cords, even if it can be
got between the lips of the glottis. However, as the applica-
tion does good, it should be resorted to, even though we know
not how far it reaches; neitlii'r need we try to do more than
sponge the back of the pharynx, the epiglottis, and the margins
of the orifice of the larynx. The best method of using the
uponge is described somewhat thus by Dr. Hughes Bennett:
The patient being seated in a chnir and exposed to a good light,
the practitioner stands on the right side and depresses the
tongue with a spululahcld in the left hand. Holding the pro-

nVSPHONIA CLERiroRUM.

bang with the sponge saturated with the »ulution in the rij;ht
hand, it should be passed carefully over the upper surface of
the spatula cxiiotly in the inedinn plane, until it is above or
imniedtatcly behind the epigloltid. The patient should be now
told to inspire, and us he docs so, the tongue must be dragged
slightly forwards with the spiituln, and the probang thrust
downwards and forwardii by n nioveuient which ciiusei- the
right arm to be elevated, and the band to be brought alniust
in contact with the patient's tiice. The operation of course
reijuires dexterity, since the rima glottidis is narrow, and unless
the sponge comes fairly down upon it, the aperture is readily
missed. The passage of the sponge into the proper channel
may be determined by the senstition of overcoming a ooiistric-
tioQ, which is experienced when it is momentarily embraced
by the riuia, as well as by the spasm and harsh expimtion
which it occasions.* The application will be required to be
made about every other day for two or three weeks.

When the tonsils remain enlarged and indurated — as they
often do after this disease, an well as after tonsillitis — various
astringent gurgles and inhalations, preparations of iodine, and
solid nitrate uf silver have been employed. Nut urilre<|uently
permanent and cifectual relief will only be obtained by the ex-
cision of one or both of these glands. iMr. Harvey has con-
demned this practice, and has stated that removal of the ton-
sils interferes with the development of the genital organs. I
have seen, however, so much benefit from the operation, with-
out any bad re-sulls, that 1 eaiinut but doubt the correctness
of Mr. Harvey's views.

* The mioUke of trustiog to these »enaat!oiu it well illustrated in the
Report of the Cdiumission of the New York Acuilomy of Medioioe, ap-
pointed to inquire into this subject: "We witnesaed in cues II and 21
(he fallacy of Dr Horace Oreen'e opinion an to the iinaoen of his experi-
ment, though based on so large an experience. Id both instauoes, whiitt
positive that he had successfully passed the instrument (an elastiu tulio)
inlo the tracbeu, i/tr jtatirnl vumited t/truii^h the tu^Ct and thu* demuu-
sttated his error."

834

DISEASES OF LUNGS, HEABT, ETC.

VIII. BRONCHITIS.

Infltiraniiition of the bronchial tubes ia one of the most
common of the pulmonary diseases which come under the
notice of ihe practitioner. Broneliitis nmy be acute or chronic ;
and one or both lunj^s may be affected or only a portion of the
lun^ — usually the upper lobes.

liay-a.slhuiu will also be tncluiicd in this section, as its
proininciii .symptoms are often of a bronchial character.

1. Acute Bronchitis. — This is a dangerous disorder, more
especially on account of the frajuency with whiub the inflnm-
matory ac'tion spread.s to the vesicular toxture of the lungs.

Si/inpioms. — The chief symptoms consist of fever, a sense
of tightness or coDstriction about the cheat, harried respira-
tion with wlieezinj;, severe cough, and expectoration — at first
of a viscid glairy mucus — which subsequently becomes puru-
lent. The pulse is frequent and often weak; the tongue fool;
and there i.^i headache, hissitude, sickness, and great anxiety.

Iiijiiimmntion of I he lary.r tintl metliiim-xizfil tnlten is at-
tended by less severe eyraptoms, and is less destructive to life
than grnerat anil riipillnri/ bronchitis, in which uU the ramifi-
cations of the bronchi are affected. This latter form of the
disease is chiefly seen in the very young and old, being rare
in adults; while it is readily reengniKcd by its tendency to
produce asphyxia, by the paroxysmal attackii of dyspnoea or
orlhopnoia, the congestion of the surface of the body, the
perpetual cough, and the extreme general restlessnes!*. The
patient is obliged to sit up in bed ; the urine is scanty, deep-
oulored, of high specific gravity, and sometimes contains a
little albumen ; the pulse is regular but feeble, and from 1*20
to 150; the prostration rapidly inureases, and we may have
anasarca of the Feet and legs ; while in fatal cases there will
soon be somnolence, inuttcring delirium, coma, and death.

It sometimes happens in the progress of a case of bronchitis,

BROSrHITlS.

335

that one or more of the tubes becomes cimltoi] up with the
viscid phlegm ; and we have, as the result, ptilmonnry ro/-
lop»e, a portion of the lung being emptied uf air. Thus, sup-
posing a plug to form in one of the bronchi, the lung beyond
it in expiration soon forces out the air bj the side of the foreign
body ; but each inspiration draws the obnoxious substance to-
wards a narrower part of the tube, which it seems effectually
to cork up. The consequence is, that the collapsed portion of
the pulmonary tissue becomes condensed ; this condensation
at one lime having beeu considered as due to inilainniation,
whence it was termed tubular pneumonia. One frequent re-
sult uf the collapse is the production of vesicular emphysema;
80 that the loss of function in the airless part of the lung is
compensated for by an increase of volume in the nou-obstructed
portion.

On practising atiirvjiaiinn in the early stage of acute bron-
chitis, two liry sounds will generally be heard — viz., rhonvhut
and sibilut ; both of which indicate that the nirtuhes are
partially narrowed — that the mucous membrane lining tbem is
indeed dry and tunrid. Rhonohus in itself need give us no
anxiety, as it belongs entirely to the larger division of the
bronchia] tubes; sibilus, on the contrary, bespeaks more
danger, since it denotes that the smaller air-luhos and vesicles
are affected. After a time, the infiamed mucous membrane
begins to pour out fluid — a viscid, transparent, tenacious mu-
cus is exhaled ; this constitutes the second stage of the in-
flammation. Two very different sounds to those just noticed
are then to be detected — vis., fart/r crrpita/ioH and small cre-
pitation— often cjiUcd the moi«t sounds. As the air passes
through the bronchial tubes it gets mixed, as it were, with
the mucous secretion, so that numerous air-bubbles keep form-
ing and bursting. When this ocoure in the larger branches,
it gives rise to large crepitation ; when in smaller, to small
crepitation. We have thnreforo rhonchus and targe crcpitu-
lion as, respectively, the dry and moift sounds of the larger
air-passages; sibilus and small crepitation as those of the

38«

niREASES or LUNOS, HEART. ETC.

snittller branches. On practicing pemiMion, no approciuble
alteration in the resonnnce of the chest will usually be dis-
coverable. If the lunpp, however, are acutely cmphy.ienia-
toiw, there will be increased resonance ; while if there be
collapse of a large portion of the lung from the obstruction
produced by pressure of an cnliirged bronchial pland upon a
tube, or from the choking up nf the latter with inspissated
mucus, the percussion note will he dull.

Prrtijnosit. — If relief be not aflbrded by copious expecto-
ration, or by remedies, the disea.se assumes n more dangerous
character, the strength becomes much reduced, signs of great
pulmonary conjrestion ensue, and symptmimof partial asphyxia
follow, soon ending in death. In favorable cases, however,
the affcclion begins to decline between the fourth and eighth
day, and shortly either entirely subsides, or paases into the
chn)nic form. From three-fourths to one-half of those at-
tacked with enpillury bnmchitis die between the sixth and
tenlh days of the di-seuse.

Treatment. — After a brisk purgative, a saline mixture con-
taining ipecacuanha or sifuills (F. 415); or, if there be any
depression, a stimulating expectorant (F. 289, 293) must be
ordered. Gentle counter-irritation to the front of the chest,
by dry-cupping, turpentine stupes, or sinapisms, will also be
valuable. Should the phleirm appear to accumulate in the
bronchial tubes, an emetic ( F. 280, 283, 286) will readily re-
n)ove it. When Physician to the Fnrringdon Dispensary,
where the patients were very poor, I was in the ejn.«tant habit
of successfully treating acute bronchitis from the coiun)encc-
nient with stimulating eipeetoranti? — F. 293 was a favorite
fnrin of prescription — good bccf-toa, the inhalation of the steam
of hot water, and connter-irritatinn by means of rubefacient
liniments or tupentine stupes. Opium, cautiously given, often
does much good ; though it is not to be employed if there are
any indications that the blnod is ni>( properly aerated — if the
complexion he du.«ky or bluish.

BRONCUITIS.

337

2. Chronic Bronchitis. — Chronic inflanimation of the bron-
chial tubes is very cotonion in advancud life. The slighter
forma are indicated only by habitual cough, some shortness of
breath, and copious expectoration; these .>iymptoni8 beinj;
always aggravated by exposure to cold and wet. The majority
of coses of winter cough in old people are examples of bron-
chial iuflainmutioo of a low lingering kind. It may arise
idiopathically, or it may follow an acute attack.

There is a peculiar and severe form of this disorder, how-
ever, occurring in old people, which deserves notice. It has
been described aa peripneumonia noiha (bastard peripiicu-
niony), or catarrhui $enifls, or luhacute Lronchilit ; and it
really consists of a subacute attack of general or capillary in-
flammation of the tubes. In these cases there is often only
the appearance of a violent catarrh, with excessive secretion of
puriform mucus; the symptoms being entirely relieved by
remedies which cause a free and copious expectoration. In
other cases, however, the feverish and catarrhal symptoms are
at first very moderate, and even slight ; but after a few days
these symptoms suddenly become considerable, there is the
orthopnoea and tendency to asphyxia already noticed, great
prostration soon sets in, and a fatal event oocurs so quickly,
that it is often unexpected. Capillury bronchitis sometimes
proves fotal by the accumulated mucus, which the putiuut has
not the power to expel, causing suffocation.

Platdc bronrJiitis is a rare form of bronchia! disease, char-
acterized by the formation of solid or tubular concretions of
exudation-matter within the bronchial tube::, and which runs
its course very slowly. The chief symptotn is the occasional
oxpectonition of casta of the tulxjs; very little suScring being
ftuscd by the bringing up of small fragments, while the
^Ittpectoration of casts of notable size is usually preceded by
dyspnoea, dry cough, and sometimes haemoptysis. Cases of
plastic bronchitis not uncommonly last for years ; the patients
having acute seizures, attended with the peculiar expectora-
tion every few weeks. Medical treatment seems to have no

388

DISEASES OF LUNGS, HEART, ETC.

pcnnnncnt effect upon this disease; but I believe that the pro-
longed use of the sesquicarbouate of ammonia will prove more
iisefu! than any other drufr. Over-active remedies, especially
of an alterative or depressing nature, will only be prodaclive
of great mischief.

There are various forms of mechant'ral bronchiti't, caused
by the inhalation of different particles of matter vrhich irritate
the tubes. We thus Lave the grinder's rot, or knife-grind-
er's disease ; carbonaceous bronchitis, or black phthisis, in
miners, from the inhalation of the lamp smoke, and the inspi-
ration of the carbonic acid gas formed in the pits; and cotton
pneumonia, or cotton phthisis, amongst the operatives in cotton,
mills.

Bronchitis occurring secondarily in blood-diseases is not no-
common, though often very troublesome. Thus we may have
gutiti/ or rkeumatic bronchitis, only to be cured by the relief
of the conMitutional disorder. So again, persons poisoned to
the second, or tertiory degree, by syphilis, are apt to suffer
from tj/philitic bronchi'ti* ; giving rise to excessive muco-puru-
lent expectoration, night sweats, great debility, and wasting.
Iodine inhalations are useful in these cases, in conjunction
with anti-syphilitic remedies. It shonld he remembered that
occasionally the bronchitis assumes the acute I'urm.

Severe examples* of chronic bronchitis, wiib abundant expec-
toration, are apt to be misUiken for cases of phthisis ; especially
if there be also dilatulion of the bronchi. Professed cousuDip-
tion-curers often cummil, such ;in error of diagnosis, and then
vaunt their very ordinary us estriiordinury cures,

The frcatment of chronic bronchitis must depend very uuob
upon the age and conEtitutiuD of the patient. The eases wfaioh
have fallen under my own observntiuu have been most bene-
fited by various siiinulating expectorants (P. 288, 2i)0, 292,
294, 299, 300) ; by tonics (F. 442, 469, 482) ; by cod-
liver oil ; good nouridiing food ; and wine, or some other
stimulant When t)ie disease is due to the poison of syphilis,
it will be most readily cured by the iodide of potassium and

BRONCHITIS.

339

Pluinmer'g pill. If the patient be gouty or rhcnmatic, col-
chicum and iodide of potassium often work wonders. Sup-
posing there be any difficulty in throwinj; off the roucopuru-
lent i<ecretion, we shall do most good with ammoniH, squilla,
chloric ether, and sulphuric or nitric ether. Sometimes an
emetic of sulphate of zinc does good in these canes, but we
mast take care that it does not cause much dopression.

The inhalation of simple vapor is often useful. Counter-
irritation by sinapisms, turpentine stupes, or rubefacient lini-
ments, will give great relief; bliiiters frequently do good. Pa-
tients often subsequently derive advantage from covering the
chest with a large emplastrum ferri.

3. Hay-Astlima. — This peculiar disease (hnif-anlhrna, Aoy-
Jevfr, or Slimmer rnlnrrli ) might perhaps be best described as
a severe catarrh frequently having asthmatic symptoms super-
added. The conjunctival, nasal, fauciiil, and bronchial mucous
membranes, are all affected ; so that the patient has all the
suffering often experienced from an aggravated common cold.
There is headache, suffusion of the eyes, sneezing, irritiUion
of the nose and fauces, and dry harassing cough. Then at
intervals there may be paroxysmal attacks of asthma; the
dyspnoea being sometimes so urgent, that the patient has all
the distressing sensations of impending suffocation.

Hay-asthma is not a common disorder. It may arise from
the inhalation of the aroma of spring grass and hay {Aiiiho-
xanthum odoratum) ; or from the pcrfumo of the Nardiit
ifricla when in flower, a grass which is abundant in many graz-
ing fields, for cattle will not eat it; or from exposure to the
emanations of iptrncuiinha ptju-der.

If the disease be allnwcd to run its course without medical
treatment, it will probably have a duration of three or four
weeks. It may, however, usually be out short by removal
from the cause ; sometimes residence at the sea-side being
effectual. In two or three instaoces the susceptibility to the
diaease has been destroyed by the use of quinine and iron, or

340

uisEASKs or Luiras, heart, etc.

of arsenic, or of niix vomica. During tbe attack, antispiw-
modics {F. 113, lift, 120) give most relief; while a trial of
creasote inlialiitions f F. 316) once or twice daily, ns recom-
mended by Dr. Wwlshe, may bo resorted to. To cure the
a-sthnialic paroxysm, no agent is so valuable as tobacco; for
directly the nausea and collppsc caused by fmoking set in, the
sense of sufTocatiun will pass ofiF, and the patient be enabled to
forget his sufferings in sleep.

IX. IHFLXTENZA.

InflaenzB, or epidemic catarrhal fever, or in France " h

grippe," is an epidemic disorder attended with great depres-
sion, ohilliiii's.s, running from the eyes and nose, frontal bead-
ache, cough, reslloiisness. and fever.

Infloenwi ari.=es at various poriod.>f from some peculiar con-
dition or pontamin:ition i)f the atmosphere. The first visita-
tion of it in this country, nf which we have a tnjstworthy de-
scription, is that (>r IftlO. The puisonou.s influence, whatever
its nature may be, wings its way with greater celerity than the
speed of human intercourse, while its progress seems uninflu-
enced by the .oeasoii of the year; it is said to travel from east
to west, and it .seldom stays in one district more than six or
seven weeks. Some visitations have proved more severe than
others; one in \7)<2, which extended over the whole of Hurope,
was very fatal. l)r. Southwood Smith says that when the
influenza broke out in London in 1H47, it spread in a single
day over every part of the metropolis, and afi'ectcd upwardit of
600,000 persons.

Si/mptomt. — The chief symptoms of this mysterious affec-
tion are heat and drynu^s of skin, urgent frontal headache,
coryza, sneesing, tciidtTiiess of the fauces, hoarseness, harass-
ing cuugh, shortness of breath, pains iu the back and limbs,
perverted taste, and disorders of the stomach ; together with
all the signs of nervous and muscular prostration, such as an

INFLUENZA.

341

ancomtnon degree of languor, debility, and dejection of spirits.
Occasionally the danger is much increased by the getting in of
acute bronchitis, or even of inflammntion of the lungs. The
suddenness and rapidity with which the attack occurs is very
remarkable. It is more fatal to elderly than toother persons ;
in favorable cases it runs its course in about a week, often ter-
minating in an attack of diarrhneii, and merely leaving great
feebleness.

Diai/nonit. — Influenza differs from a common cold in its
greater severity, and cspeeiaily in the amount uf prostration
which it gives rise to. Between the reception of the poison
and the appearance of the symptoms, there is a period of in-
cubation ; but as to the duration of this we know nothing,
since in some wctl-obiierved cases it baa appeared to bo only
ten or twelve hours, while in other instances it has been as
many days. The deaths amungst persons under forty years of
age were very small indeed, in all the epidemics; but fre-
quently, amongst the aged, the mortality has been large.

Treatment. — About the treatment there can be no mistake.
The patient rau.st be kept in bed, and barley-water and nourish-
ing broths administered. If tho catarrhal symptoms are
argent ten grains of Dover's powder may be given at night ;
or a mixture may be ordered containing a little nitric ether
and opium (F. 415, 417). A sinapism applied to the che.tt,
together with the inhalation of the steam of hot water, may
be necessary. A vapor or hot-air bath would probably give
great relief When prostration is the predominant symptom,
stimulants are to be freely rcwrtcd to; such as wine, ammonia,
or even brandy. The subsequent debility will be the soonest
removed by tonics, especially by quinine and iron (F. 443,
450, 458, 471, or 486); and by a few days' holiday in the
country.

29«

842

DiBCASKR nr t.uNas, rkart, RTr.

X. HOOPING-COUGH.

PertasRis, or hooping-cough, is ao infoctiona disease; rarely
occarring more than once in the same individual; attended
with slight fever, and vomiting; and aocompanied at first by
cntarrh, and suhseqiu-ntly by a peculiar cough, which occurs
in paroxysms at uncertain intervuls Its duration varies from
two or three weeks to as many months. It is especially a
disease of childhood.

Sifviptoms. — Iloopinp-couph appears to depend upon some
peculiar poi.wn wliieh affects and irritates the pneumogastric
or vngua nerve. In the commencement (after a latent period
nf perhaps six days) it produees a simple febrile stage of eight,
ten, or twenty dn)s' duration ; which is sometimes accompa-
nied, but generally followed, by violent paroxysms of coughing.
The little patient is never confined to his bod ; but he is rest-
less from the coryza, oppression of the chest, and hcjit of the
skin. As tho fever begins to remit, at about the end of ten
days, the cough assiinies its peculiar shrill sound or hoop.
Prior to the corameiieeniciit of each paroxysm the child has a
kind of warning, and he runs to his nurse for protection. The
series of coughs or expiratory efforts are so powerful, and
expel the nir so largely from the lungs, that the patient seems
on the point of beiiig suffocated ; until a long-protracted in-
spiratory act follows, the rush of air through the contracted
glottis cau.sing the characteristic crowing or hooping noiso.
As Pr. Todd remarks, it i.s the signal of the child's safety.
Directly the tit, which bears some analogy to laryngismus stri-
dolua, is over, the child regains his courage, soon appears well,
and reiurns to bin ainuticments ; while even if it end in an
att.iek iif vomiting, the patient has a craving (or food directly
afterward", and wants something to eat. The frequency with
which the paroxysin-i of cough recur varies : there may be
only two or three in the day, or as many in an hour.

The dnralion nf hooping-cough is very variable, some oases

HoopiNa-couriH

S43

being susceptible of cure in a fortnight or three weeks, while
others continue trmiblesorae for sevi-nil months. Wlien the
disease conies on in the autunimtl ur winter months, I believe
it to be more obstinate than when it sets in during the spring
or summer.

Complirtifi'Jin, d-r. — The poison of hooping-cough may co-
exist with other poisons, as with those of small-pox, measles,
&c. Dr. Gibb has pointed out that in many cnses, the urine
is saccharine — perlustal ghicomtria — the quantity of sugar
being usually small, and oflcn consisting of a mere trace. —
Hooping-cough may also be complicated with bronchitis, pneu-
monia, disordered bowels, or some head affection. Dr. Graily
Hewitt states that this disease, when it dpstr^ya life, generally
does BO, not by causing pneumonia an has been thought, but by
inducing cat.arrhal inflammation of the bronchial tubes, attended
with cullapst! of a pnrtion of the lungs. This airless state of
a part of the lung has been found to arise in young children
from other causes besides hooping-cough ; and also, according
to Dr. Gairdncr, in u(iult.«, as has been already mentioned in
the section on brnncbitis. It has been variously designated
as di'tDeminaleii lubular pneumonia, marginal pneumonia,
' tiimificaHon, or pulmonary r.olUipie ; while, when there is
the same condition from congenital non-expansion of the air-
cells, it is known as alelectatit of the lungs. The margins of
the lungs and the vesicles most distant from the roots are the
parts which ore most likely to undergo this change, when it
arises from disease; while the air-ct-Us in the neighborhood of
the affected portion become emphysematous. Pulmonary col-
lapse is not by any means necessarily fatal unless it is exten-
sive, or is badly treated by lowering measures : it being a con-
dition which especially calls for the free employment of stimu-
lants and strong liquid nourishment.

Trealmrnl. — In the treatment of this disease our object
must be to keep it simple — to prevent other affections from
complicating it. In uiild cases very little management is re-
quired : the patient should be warmly clothed, kept iu-doors,

8(4

DISEASES op LUNOS, HEART, ETC.

fed with iiprht nourishing food, and allowed to drink freely of
some uiuci!!ir;inous fluid. No medicine need be administered
internally ; but the spine may be nibhed every night with the
linimentum opii, or with a mixture of erjual parts of tincture
of belladonna, glycerine, and camphor liniment.

With regard to the more severe forms of the disease, eme-
tics (F. 287) are often very beneficial, especially if their um
be followed by mild sedative expectorants, such as the tincture
of squills and compound tincture of camphor; or by a mix-
ture of animoniii, s((uills, and senega (F. 291). As in all
diseases, bkioJlclting has been recommended by some phy-
sicians; but I think it is impossible not to sec that this affec-
tion, instead of being an influiiiuuitory, is rather a spasmodic
complaint; und that, consequently, on this ground alone it
may be po.sitively ati.°ertcd that antiphlogistic measures are to
be discarded. The patient must be kept from cold air, in an
npartnuvit having a temperature of about 66° or 68'^ Fahr. ;
he ought to be clothed in flannel; the general nutrition should
be maintitined by food easily (o be digested; the chest should
be sponged, back or front, once or twice a day with cold water;
and embrocations containing sedatives may be aflerwnrds used
to the same part. The best drugs are those known as anti-
spasmodics, such as morphia, opium, henbane, conium, belU-
donna, hydrocyanic acid, assufujtida, camphor, chloric ether,
and chloroform. It need hardly be mentioned that the greatest
caution will be neccs.sary in the use of these remedies, that
they should be given in minute da<!es, and that their effects
should be narrowly watrhed. A favorite prescription in my
own practice is one containing ammonia, chloric ether, hydro-
cyanic acid, and morphia; the doses being of course exactly
proportioned to the patient's age and strength.

Dr. Fuller speaks very highly of the use of sulphate of
lino and belladonna (F. 118); under the influence of which
remedies, given in increasing and large doses, he says the
hoop rarely lasts more than twenty-one days, while it sooie-
times subsides in ten. In out-patient hospital practice I have

ASTHMA.

ni5

been disappointed with this treatment ; but there are many
reasons why too much reliance should not be placed upon re-
sultfi thus obtained.

Dr. Gibb also states that nitric acid (F. 117) is a specifio,
but I have not Toand it so. — In many instances great bendfit
will be produced by sponfrinp the fauces and glottis with a strong
solution of nitrate of silver, 9i to 5j. — Where the secretion
from the bronchial tubes is excessive, it should be checked by
wtringents; as, for example, by alum, sulphate of zinc, small
doees of sulphuric acid and infusion of bark, or gallic acid.
When the case becomes chronic, a care may oflen be effected
by ferruginous tonics and change of air, — by removal t« the
sea-side.

XI. ASTHMA.

Asthma may be defined as essentially a nervous disease; the
phenomena which it presents being dependent upon tonic con-
traction of the circular muscular fibres of the bronchial tubes.
The paroxy.sm may bo induced by direct or reflex mechiini.^m, —
or in other words, the stimulus to eontnictiun may be centnil,
in the medulla oblongata; or it maybe in the puliuonary or
gastric portion of the pneumop;a.strit', or in some other portion
of the nervous sy.stem besides the vagus, and being transmitted
to the medulla oblongata by incident, may be thence reflected
by motor filaments.

Si/mpiomx. — A fit of asthma is either preceded by headache
Dod sleepiness, or by various digestive or other diifturbances, or
it occurs suddenly without any warning. The patient awakes
two or three hours after midnight with a sensation of suffoca-
tion or constriction about the chest; the dyspnoea gradually
increasing until a fearful and m'lat painful struggle for breath
sets in. Various postures are u-ssuuted to facilitate the attempt
at emptying and filling the lung»; the patient stands erect, or
leans his head forwnrds on his hands on some piece of furni-
ture, or rushes to the open window, at which he will reuiuia

346

DISEASES OF MJN08, HEART, ETC.

almost for hours gaaping for air. The chest is distended to ita
utmost limit, inspiration and expiration are performed with the
greatest difficulty, and there is evidently some serious obstruc-
tion to the entrance and exit of air. If vse auscult the thorax
DO respiratory murmur is audible; but we hear sibilant rhonchi,
loud wheezing, or shrill whiittlings, fur inasmuch as the varying
oatibre of the tubet^, due to tbc muscular contraction, causes
the air in them to be thrown into vibrations, so we of course
huvo mu.sical sounds of greater or lesser intensity according to
the size of the constricted bronchi. The pulse is small and
feeble; the eyes flaring;; the countenance anxious; while the
skin is cold and clammy from the deficient oxygenation, or it
may be bathed in a hot sweat owing to the fatigue produced by
the respiratory efforts. The patient's whole appearance is most
distressing, so much so that he seems sometimes to be dying;
while he is either irritable at his prolonged suffering, or he
looks beseechingly at the attendant for relief from his misery.
Then, after n certain lapse of time, comes a remission. Cough
ensues, and with the cough expectoration of little pellets of
mucus; and soon the paroxysm ceases, to allow the sufferer to
full into tbc long-desired sleep.

During the interval which elapses between one asthniatio
paroxysm and the next, the patient very often enjoys good
health, and has his breathing <|uict and free. Most asthmatics
are thin and rouud-shouldcred, they have an anxious appear-
ance of countenance, the cheeks are hollow, the voice is rather
hoarse, and there is a slight cough. The length of the interval
Turies greatly in different casus; but not utif'rci^ueutly the
attacks are periodic, whether the time of recurrence be once
in the twenty-four hours, or once a week, or onco a month, or
once in twelve mouths. In one of the most troublesome c«s<>s
(though there was no organic disease) which have come under
my notice, the paroxysm always came on every morning at 1
o'clock A.M. ; the dyspnosi continuing just as regularly for two
hours. Thinking that this periodicity might be due to some
particuhir stage in the function of digestion, the patient wu

ASTUMA.

317

Rdvised to discontinue taking supper, but no alteration was
induced in the disease. — With another asthmatic, habit has
something to do with the attacks. Thus, he is generally well
in I^ndon, yet beinp fond of Britjliton tries to stay there some
weeks in each year. Hut if, on the first night of sleeping away
from town he experience an attack, a paroxysm is sure to recur
nightly, until he is compelled to return; whereas if this night
be safely passed over, he may continue his sea-side residence
for weeks without any fear. Dr. Salter mentions several simi-
lar cases; while this gentleman also points out the capricious-
neas of asthma, one patient being better in a crowded city than
in the country, another being bcneGtcd by a bracing air and
injured by a relaxing climate, a third preferring the winter
uiunths to the autumnal, while again there are other instances
where it is just the reverse of all thi.s.

Asthma is more common in men than in women ; it is o(^n
hereditary; and it may set in at any tinrcof life, though most
common at the middle period. It miiy be uncomplicated, —
that is to say, in all other respects the suflerer is perfectly
healthy, there being no lesion of the brain, lungs, heart, sto-
mach, or other organs; or it maybe con)plicated with, or
indeed symptomatic of, some disorder, such as chronic bronchi-
tb, heart disease, morbid state of the brain, &c. — The first
form is sometimes known as idiopathic or sjjasmodic, the
second as symptomatic or ori/anic asthma.

(Jautei. — The fact that the ICTidency to asthma may be he-
reditary has just been mentioned; but it uiustbe remembered
that often no influence of this kind can be discovered. Again,
this disease may sometimes be owing to some organic disease
within the chest, while frequently no such cause can be de-
tected.

The paroxysm may be directly due to an irritant inspired
into the air-passages, such as dust, cold air, certain vapors, and
emanations from hay, ipecacuanha, or mustard. The influence
of particular atuiuspheric or climatic conditions is well known;
though we are unable to explain why one asthmatic should be

348

DIASEASES OF LUNOS, HEART, ETC.

unable to sleep in a smoky, dirty city, while another can live
nowhere else. Improper food, or an excessive quantity, or
meals taken at certain particular times — «■;)■< I"'* suppers —
may originate a fit. So, again, the cause may be some irrita-
tion applied to parts of the body remote from the chest, aa in
a patient of Dr. Chuwne's, where the application of cold to the
instep at once induced the fit. And, lastly, mental emotion —
fear, anger, &o. — may originate it.

Proffnorit. — Spasmodic asthma very rarely, if ever, directly
destroys life; and even many who are subject to it live to a
good old age, perhaps because they are obliged to take great
care of themselvc!). Moreover, a complete cure occasionally
takes place ; though, as a rule, when an attack has once
occurred, there arc sure to be repetitions of it.

But the disease is nevertheless a very serious one, because of
the morbid pulmonary and cardiac conditions which it some-
times induces. The chief of these are congestion of the lung,
emphysema, and tiypurtrophy and dilatation of the right Hide
of the heart ; and when these conditions have become estab-
lished the asthmatic has but a poor time of it. Indeed, his
life is gradually rendered more and more uiisurable by cough,
abundant expoctonition, orthopnuea, venous regurgitation, oode-
ina, and cyanosis; until at length the circulation of venous
blood produces coma and death.

Treatment. — Under this head must be considered the mea-
sures necessary to relieve the paroxysm, and those which may
be employed in the hope of preventing or delaying its recar-
rencc.

During the parozyim we most first try and remove the
oaose; as by giving an emetic when the stomach contains an
undigested meal, or adiiiini.'tlcring an enema if a loaded rectum
Meras to be the source of the irritation, Then our efforts must
be directed towards relaxing the bronchial spasm, and fbr this
purpose we resort to the use of sedatives. — Tobacco may be
employed as a depressant or as a sedative, and in either way it
often does good. To those who are anaooustoraed to aaokiag,

ASTHMA.

849

^
^

8 pipe of I^atukia (which is quite strong enough for the pur-
pi>»e) soon produces exhaustion ; while directly the feeling of
nausea nnJ collapse comes on, the attjick of asithnin ceases. As
a sedative, tobacco is more uncertain, though it is often useful
if taken when a fit seeras impendinjr. — VMornfitrm is invalu-
able in many in.stances, while in others' it does hann ; and such
is also the case with the vapor of mi/jihun'c ethrr (F. 358).
The latter possesses this advantage, that with proper directions
it may be intrusted to the patient's wife or nurse for lulujinis-
tration, after it has been found to have a favorable effect. It
is seldom necessary to produce complete insensibility, and when
there is any bluenc8,s of the surface it i.s never advisable to do
go — Stramonium acts like a charm with »ome asthmatics, a
few whiffs of a pipe filled with it, or of a cigar, giving relief;
but in other cases it is often worthless. Care must be taken
to get the drug good, and it may be reiuenibcred that the seeds
are much more powerful than the leaves and stalk cut up. —
Nitre-paper fumes— the fumes of burning filtering or blotting
paper, which has been soaked in a satunited solution of nitrate
of potash and dried — ogives much relief in many cases of un-
complicated asthma. — And, lastly, there are instances where
relief is soonest obtained from a tlimulanl, as very strong
coffee; or from an emetiv, as a scruple of sulphate of zinc or
powdered ipecacuanha, even where the paroxysm is not due to
any gastric derangement.

Our treafment in ihr interval must be directed to improving
the general heallh by tonics, a regular mode of life, and the
use of the cold shower or sponge bath ; to laying down rules as
to diet, so as to obviate attacks of dyspepsia ; to so ordering the
times of the various meals that the process of digestion may
be finished before bed-time ; and to choosiing a climate, the
opposite to that in which the fits come on — as London air for
those who are worst in the country, and the reverse. The
inhalation of oxygen gas, may (as suggested by Dr. Salter) do
good in some instances; and, perhaps, the respiration of com-
pressed air (as long since recommended by Sir John Sinclair

350

DISEASES or LCXGS, OEAKT. CTC.

i othen) may, perlMpe, give relief in siuikr caaes, since it
the tjattm mo exeesi of oxj^n. As wgfda blisters
to the cpine or nucha, strjchnia, and galvanisni, it need oid^
be aaid that the great theoretical objections to these agenia
hatre not been OTercome, as far as I know, bj any pnetieat|
experience of their utility, although they are not aofreqneBtly
recommended.

Xn. EMPHTSEMA.

Tlie diseases of the lung thus deoominaied are of two kinds.
One consists essentially of enlargement of the air-cells, atrophy
of their walls, and obliteration of their resseb; this is called
vencuiar or piilmmiary empliyscma. When, on the other
hand, there is infiltration of the air into the interlubolar
areolar tissue, or into the sub-plenral areolar tissues, the
disease is known as interlobular emphysema. Ik)th forms
give rise to habitual (shortness of breath, with occa^iuoal serere
paroxysms of dyspnoea, resembling asthma; while they ore at
all times very distressing complaints, and quite unfit the suf-
ferer for any active occupation.

Vesicular emphi/iema may affect one lung, or both, or a
part of each — especially the anterior edges. According to Dr.
(.iuirdner, it is essentially a compensatory dilatation of the air-
ccllif, implying that a portion of the lung is non-expansible ;
hence the foundation of the disease may be bronchitis, asthma,
&c. Some diticu!<sion has arisen as to whether the extra sttaia
upon the cells occurs from the pressure of the air during inspi-
ration or cxpirutimi ; tind it seems probable that although a
certain amount of dilatation may be determined by inspiration,
yet — ss Dr. Jenner has shown — the most efficient cause is the
pressure of the air contained in the lung brought to bear upon
the inner surface of the air-ceils by the expiratory efforts.

The prominent symptom of emphysema is dyspnooo, which
is niuclv increased upon any exertion. There is also cough,
oxpeotoration of frothy sputa, a dusky appearance of Uie counte-

EMPHTREMA.

351

nance, weakness of the voice, a stooping: gait, loss of flesh and
strength, constipution, a weak and slow pulse, and a diminished
frequency of the respirations. — The physical signs of this dis-
ease consist of unnatural cleameas and resonance on percussion ;
while only a very indiHtiuct vesicular murmur is heard on
auscuilatiiin. The heart's sounds are merely feebly heard;
while if only one lung be affected there will be cardiac dis-
placement to the opposite side, or if both be involved we shall
have displacement downwards and to the right. The diseased
side of the thorax is also more prutninent and rounder than
the healthy one. Thus, as regards percussion and auscultation,
emphysema affords results the reverse of other affections : the
disease consisting, as it were, of a superabundance of air whinh
dues not pass away, there is more resonance, but less sound in
the air-passage — less respiratory murmur. It can only be con-
founded with pneumothorax ; but it may be distinguished by
renicinbcriag that this latter disease only affects one side of
the chest, that the percussion note is much more tympanitic,
and that the site over which ttie resoaance is obtained Is much
more extensive than in cmphyi^cina.

As regards treatment, we can only attempt to give relief by
rest, warm clothing, attention to the general health, and by
the occasional use of anodynes and aiiti.ipa.'rimodics (F. 107,
111, 115, 36H, or 383). Stniiuonium may also be smoked;
or the camphor cigarettes of M. Kaspail might bo tried. Ooca-
Biooally the vapor of chloroform is of great temporary service.
A wann climate is often very beneficial to sufTerfrs from this
affection ; the dyspnoea being always most urgent in cold
weather. If Dr. Jenner's theory be correct, we must — as
he shows — luodenite the violence of the expiratory actions in
persons disposed to emphysema ; and not allow them to follow
occupations — .such as carrying or pushing heavy weights —
which necessitate expiratory efforts with a closed glottis.

Interlobuliir emphysemn, or the collection of air in the
areolar tissue between the lobules and in the interspaces
between the cells, is generally produced by the sudden rupture

852

r>I8r.ASE8 07 LUN06, HEART, ETC.

of air-cells frum some violent strain or effort. Hence it may
be caused by straining efforts at stool, by the expulsive pains
of parturition, by violent fits of coughing, and soon.

It is not to be diagnosed by any certain signs during life ; it
is very rarely as^sociated with vesicular emphysema ; and when
very extensive, it may at once give rise to fatal asphyxia.

Xra. PLEimiSY.

Pleuritis, or pleurisy, are terms applied to inflammation of
the pleura — the serous membrane investing the lungs and
lining the cavity of the thorox. The disease may run an aoute
or a chronic course; while one side only is usually affected,
though occasionally we have double pleurisy.

Si/mploni>. — This disorder is ushered in with chilliness or
slight rigors, fallowed by fever, and an acute lancinating pain
in the side, called a stitch ; which pain is commonly seated
below the nipple, over the antero-latcral attachment of the dia>
phragm. It is aggravated by the expansion of the lung in
inepiration, by coughing, by lying on the affected side, and by
prc.iaure. I'here is also a short harsh cough, the skin is hot
and dry, (hu cheeks are flushed, the pulse is hard and quick,
the recpirutiuiis are slightly iiicrensed in frequency, there is
anxiety and rctitlessuess, and the urine is scanty and high-co-
lored. If we listen to the painful part of the chest at this
period, we shall hear the dry inflnmcd uieinbrune — the pulmo-
nary and costal pleura; — rubbing iigaitist each other, and pro-
ducing a/riclioii soiinii ; or if the hand be placed on the cor-
reiiponding part of the thomx, this rubbing may also be felt.
Hut the sound soon ceases ; either the inflammation terminates
in regolution, and the iwo surfaces of the pleura regain their
iiiitural iiii.ti.stiire and siuouthiiuss ; or, the roughened and in-
tlanicd surfaces get adhciunt; or they become separated by
the effusion of scrum, niid a luiid ot dropsy results, known as
UVl>KuTHuitAX. If the pleuri.ty has been severe, the effu-

PLEURISY.

353

ftion becomes excessive (it may vnry from a very few ounces
to several pints); and the liiiid accuinuluting in the tiiic of
the pleura compresses the yielding lunp, suspends its func-
tions, displaces the heart, and somewhat distends the thoracic
parietes.

When the pleuritic inflanimatiun ends in suppuration, and
the pus accumuhit«j? in the cavity of the chest, we have what
is coiled empyema ; a ternii nation which is much more fre(|uent
in men than in women. Pome practitioners speak of true and
false empyema ; the first form being that in which the pus is
secreted by the pleura ; while the second is that in which the
pus finds its way into the cavity of the thorax from the rup-
ture of an abscess of the lunt;. Occa.fiomilly ulceration takes
place in the costal pleura and gradually extends through the
muscles, or a portion of ihc rib becomes carious, and an aper-
ture is formed exteruully ; ihroujih which channel (jmrietal
Jinhifa) pus continues to be dischartred for some time in oases
of chronic pleurisy. On the other hand, the pulmonary pleura
may be perforated, and an opening take place into the air-
tubes ; a condition which, when it fails to close after the
evacuation of the fluid by the bronclii, is known as bronchial
Jidtu/u.

Whetlier the mutter effused consist of serum, or of pus, we
shall find, on iistening to the chest, that the respiratory mur-
mur la diminished in proportion to the quantity of fluid thrown
out. Where this is excessive and the lung is compressed
backwards — (l;iltened almost against the spinal column — no
vesicular breathing at alt wilt be heard, but instead we shall
detect the air pa.ssing into the larger bronchial tubes, the con-
densed lung and the layer of fluid acting as conductors of
sound; we then say that hroitchial resptrti/ion, and bronihial
voice or hronchnphony, exist. The bronchophony may he
accompanied by a tremulous noise, resembling the bleating of
a goat ; it is then termed mjojikony. If the lung be completely
compressed, so that no air can enter even the bronchial tubes,
then no sounds of any kind will be heunl; but on the he:il(liy

MO*

354

DISEASES or LUNGS, BEART, ETC.

side the respiration will be more distinct than natural — will be
puerile. There will also be dulness on percussion all over the
affected side, if the pleura be full of fluid; if it be only par-
lialiy filled, we can judge of the i{aantity by placing the
patient in different attitudes; for since the fluid will gravitate
to the most dependent part of the cavity, so it will carry the
dull sound with it. We shall also often be able to judge of
the amount of the effusion by the dyjipncea which the patient
suffci-s from ; since this will, of course, be most urgent when
the lung is most compressed. At the same time, also, the
sufferer is commonly unable any longer to lie on the sound
side ; clearly because the movements of the healthy lung would
be impeded by the superincumbent weight of the dropsical
pleura. The pain, moreover, no longer prevents his lying on
the diseased side. If we measure the two sides of the chest,
the side containing the effusion will be found the largest j we
must remember, however, that in many persons the right half
of the chcsl is naturally rather larger than the left. In mak-
ing ail ocular examination of the affected side, it will be found
enlarged; the iiilc'rcustal muscles will be inactive, and bulging
if the .secretion be oupious ; there is marked fulness of the
infra-clavieular regiuii ; and the shoulder is depressed. From
some inexplicable cause, pleuritic effusion occurs most fre-
quently on the left side.

After a time the .symptoms often begin to decrease, and
absorption of the effaced fluid fortunately commences. Sup-
posing the lung to be bound down by adhesions, it will out
expand in proportion to the absorption of the fluid ; the affected
Hide will tlii::ii !>hrink inwards, and instead of any longer re-
maining larger than the sound side, will become smaller.

In one furin of the disease known as latent pleurity there
may be neither pain, cough, nor dy.spncea, and yet effusion may
go on until one side of the chest becomes filled with fluid, as
shown by the phy.sical signs.

Dia<f7wsi». — The distinction between pleurisy and pleuro-
dynia (pain in the muMles of the thorax) ia rendered so easy

PLEURISY.

355

by attention to the symptoms, that nothing more need be
said. Malifriiant disi-ase of the lunp or pleura is mure iikidy
than any other affection to be mistaken for empyema ; since in
both nf these instances there has genendly been pleurisy, in
both there may be displacement of the heart, dulness on per-
cussion, absence of respiratory nmrmtir, inability to lie on the
sound side, and ojdematous enlargement of the affected side.
Again, empyema of the ri^ht pleura is not always easily diaj^-
nosed from enlar^'ement of the liver; but the difBculty will lie
lessened by noticing that in the latter there is no intercostiil
paralysis, there ia resonance on percussing the middle and
upper parts of the chest, the foree of the raspiratory murmur
in the postero-inferior portion of the chest is much greater
than the dulness would lead as to anticipate, and the heart
is displaced upwards instead of laterally.

(JaunKK. — The most common cause.«i of pleurisy are exposure
to cold and wet In cancer of the female breast pleurisy
often occurs secondarily, either from the irritation of the pleura
by a. deposit of cancer beneath it ; or in some instances proba-
bly— as Dr. Walshe sucgests — by the sub-inflamroatory action
on the confines of the diseased gland extending through the
intervening tissues to the pleura. During the progress of con-
tinued fever, and of Bright's disease, an attack may set in.
And, lastly, inechauieul injuries will excite iiilfamniation of
the pleura. Thus the jagged enda of a fractured rib often
-give rise to it ; while if they also wound the pulmonary pleura,
ur will escape front the lung into the pleural cavity.

The presence of air in the pleura may also be due to other
circumstances than the injury produced by a broken rib.
Thus it may arise from an exteriial wound ; or from ulcenition
owing to the extension of a tubercular cavity, When the
pleura contains air alone, we say there is pxeumothohax ;
when, aa generally happens, there is a liquid with the air,
we call the disease pseumothurax with effusion. The
physical signs of pneumothorax are great resonance on pcr-
cUMtion, with indistincttiess of the respiratory murmur uu

856

niSEASKB OF LUNOS, HEART, ETC.

otucultation. The piilicnt's breathing, cough, and voice, givn
rioo to a ringing nietalliu noise liite that produced by blowing
obliquely into an empty flask, and hence called timphortc
risimaiice. When ttiere is also lii)uid with the air, wo obtain
in addition — on practising sacoussioD — a sound known as me-
tii//ic tiiihlinij ; which results from a drop of fluid falling from
the uppar part of the cavity and causing a little »plash.

i'rijynotU. — Simple unilateral pleurisy always terminates
favorably. Even when it is bilatenil, or when it occurs during
the progress of some chronic ailment — as IJright's disease,
tuberculosis, cancer, &c. — it is not often the immediate oaiue
of death.

Trr.utment. — The indications in the treatment of pleuriHj
are first to subdue the inflammation ; and, secondly, to pro-
uiote the removal of its products. As, probably, the more the
patient is lowered, the more severe will be the results of the
iiiflunimution, I would advise the practitioner not to resort to
general bleeding; but rather to trust to the administration of
diaphoretics (F. 257, 25S), with opium to relieve the pain,
and poppy-head fonientations sedulously applied to the in-
flamed side. When the pain is very severe, the removal of
three or four ounces of blood by cupping will possibly give
relief sooner than any other proceeding, by unloading the con-
gested vessels. iJut even before taking away this small quan-
tity it will be better to try the effect of the fomontationa,
together with the application uf the extract of belladonna ; •
proceeding which 1 constantly resort to with the greatest ad-
vantage. If the prauiiticiner have faith in the powers of mer-
cury to control infliniimatioD, be may administer calomel and
opium; though it is very doubtful if the calomel can exercise
any beneficial influence. The bowels should be kept open by
purgatives, if necessary; the diet should consist of gniel,
arrowroot, milk, and broths; and cooling refreshing drinks are
to be freely allowed.

If these means prove insufficient and effusion takes plaoe,
We must then endeavor to promote absorption. The patient

PLEURISY.

357

ought to be kept on a moderate diet, free rrom stimulants ; a
BQCcession of blisters uhouid be applied to the diseased side ;
BDd pur;5itivcs and diuretics are to bo administered. The
iodide of potassium (F. 27, 30) will often be useful; or a
combination of squills, digitalis, and blue pill (F. 60) has
been highly refoiuTuended Very often, however, mercury in
any shape does harm ; and especially if the effusion be due
to chronic pleurisy. In such cases the compound tincture of
iodine, or the iodide of iron, or cod-liver oil, are much more
likely to forward our views.

When the foregoing remedies fail, tapping the thorax so as
to let the fluid out has been resorted to, and on many occa-
sions with success. The opinions of pliysicians vary as to the
propriety of performing this operation.* My own feeling is,
that as a general rule it oujfht not to be performed unless the
effusion is excessive; nor until proper attempts to procure ab-
wrption have been adopted. At the sitnie time it is by no
means to be tried as a last resource; for if deferred too long,
irremediable mischief tiikes place in the lung. Thus, ibo

* The appoKitt ws; in which the ftimc plan of troatraeDt is regnrdrd
by difTerent practitioners is well illostraCer] hy the views entertaiopd nn
this operation. Drs. Hughes and Addison were both physicians nt the ,
same time to Ouy's Hospital. The former [Giti/'i Iloipilal Sffiorit,
Second Series, Vol. U, p. 48, London, 1844), speaks in high terms of
the good which be hn.^ seen effected by tapping the chest in numeroos
cftHS, and the facility with which it may be performed. The latter gen-
tleman {Ijiiierl, Nov. ITtb, 185J), soys that he believes, from the oume-
rons cases seen every year At Guy's Hospital, timt paracentesis thoracis
is one of the worst and moat deceiving operations in general prnt-tice. A
■arous cavity, he thinks, is almost invariably changed into a cavity pour-
ing out purulent matter by the first operation : ami the thick, leather-
like, false membranes lining the pleura soon make the operation one nf
very great difficulty and danger. Nature herself, if assisted by proper
remedies, will often remove serous effusions from the pleura; but if once
interlerod with by instrumental assistance, the amount of pus separated
from the system is almost increditjle, and beyoml her power to get rid of.
Crises are mentioned of twelve and fourteen pint" of purulent mtiller
druwn from the chest, but its prodttction in very pus^ihly due to the first
opening made in the pleura.

858

DISEAflES OF LnPfOS, HEART, ETC.

pulmonary tissue becomes carnified, and deprived forever of
its power of expanding; ; while the pleura continues to secrete
fluid, and bunds are formed between the pulmonary and ooetal
portions, which lead to future contractions of the chest.
When it is decided to resort to paracentesis, it will be as well
to commence by making an exploratory puncture with n
grooved needle ; if fluid iRsue, a trocar and canula may then
be introduced. The best position for the puncture is probably
the intercostal space between the fifth and sixth true ribs, at
— or soiiiewliat posterior t« — their angles; provided, of course,
that the lun>r is not fixed to this part by adhesions, and that
nu pijod reason exists for selecting a different spot. It will
probably be better to remove all the fluid : if serum come
out, the orifice should be closed and healed ; if pus, the aper-
ture may be enlarged and kept open by a piece of catheter, or
an India-rubber drainage tube. The admission of air through
the eunulu into the pleura does no harm, for it becomes spon-
taueously removed in a few hours.

In some examples of pneumothorax, where the dyspnoea
has been very urgent, it h;iR been found necessary to puncture
the pleural cavity with a grooved needle, to let the air out.
Such cases, however, are very rare.

XIV. PNEUMONIA.

Pneumonia, or acute inflauiraatioD of the substance of the
lunfis, is a serious dise.ise, conwnoniy ushered in by general
febrile disturbance. At the end of from one to three days
there are rigors ; which are soon followed by nausea, cough,
pain in (he side, distressed brcBthing, a pulse reaching to 140
or even ItiO bent.s in the minute, burning heat of skin, thirst,
loss of appetite, prostration, headache, and sometimes transient
delirium.

Each case of pneumonia may be said to oousist of three
degrees or stages — viz., first, that of engorgement; secondly,

PNKUMONIA.

359

thnt of r<?d hepati^ition ; and, thirdly, that nf gray hcpntizn-
lion, or punileiit inliltration. In each sta>.'C' there is, spoakiiig
suiiiiiiurilv, fever; more or lesa paiti in some part of the chest
— most severe at the comnicDecnicnt ; accclenited and op-
pressed breathing ; great depression, with occasionally deli-
rium ; cou>:h ; and expectoration of viscid, rust-colored sputa,
which unite into a mass so tenacious, that even inversion of
the vessel containing them will not detach them. If thew
sputA be minutely examined, they will he found to consist
chiefly of mucus, epithelium, exudation matter, blood-ccUa, and
oil-globules ; while the presence of sugar may gometimee be
detected by Trommer'a test, and there is also an excess of
chloride of sodium. Moreover, as the blood contains an excess
of Clbrin, coaguln may form in the right side of the heart or
in the pulmonary arteries, and give rise to urgent dyspnoea or
even to sudden death.

In ihrjimt utai/e, or thai of emjori/emrnt, the substance of
the lung becomes loaded with blood or bloody serum. It is
of B dark red color externally ; on cutting into it, a quantity
of red, frothy serum cscapeH ; while its appearance somewhat
resembles the spleen, its elasticity and sponginoss being dimi-
nished, though it will still float in water. If we listen to the
chest when the lung is in this condition, we shall hear very
fine crepitation ; a .sound which is known as minute n-rpiiii-
tion, or crepitant rhonchiis. If a kick of one's hair be rubbed
between the finger and thumb close to the ear, a sound will
be jiroduced nearly resembling it. The natural respiratory or
vesicular murmur is still heard mingled with this minute cre-
pitation, especially at first; as the inflamuuHion advances,
however, the healthy sound is quite dit-placorl by the morbid
one. Percussion also, at first, affords the natural resonance,
which gradually becomes obscured.

If the inflamniatiiin proceed, it ptisses into the teconri itai/r,
or that of hcpatizaiinn ; in which the spongy character of the
lung is quite lost, and it becomes hard and solid, resembling
the cut surface of the liver, whence it is said to be heputizud.

360 DISEASES OF LUNOS, BEART, ETC.

If WO now practise auscultation, neither the minute crepita-
tion nor the vesicular murmur are any longer perceptible.
HrtmcJitiphony, however, often exists, more pnrticularljr if the
iiiflaiuiimtioii bo sealed near the upper pnrt or in the vicinity
of the root of the lungs ; it is accompimied also by bronchial
retpiriiti'on, thme sounds beinp conducted by the solidiBed
lung. The sound on percussion is dull over the whole of tbe
affected part.

Advancing still furlher, we now have ihe third ttage of
pneumonia, or Ihal of ijray hepatization, or purulent infiltra-
tion ; which consists of diffu.sed suppuration of the pulmonary
tissue, parts of the lung rcni:iiiiinrr.deri!>c and inipernieuble. In
many instances there is no true suppuration, the appearance of
such a coiiditiou being simulated by liquefied exudation matter.
Circuuiacribed abscess of the lung is very uncommon; but dif-
fused suppuration is said to be a frequent consequence of
inflammation of the pulmonary tissue. There are no physical
signs by which this stage can be diagnosed, utitil part of the
lung breaks down and the pus is expectorated; large yurgling
crepiliilion will then be heard.

If the inHammation subside before the stage of purulent
infiltration, as it fortunately often does, then the hepatized
condition may remain permanent, or may gradually cease. In
the latter case we shall find the air slowly re-entering the lung;
as will be indicated by a return of the minute crepitation,
mingled with — and subsequently superseded by — the healthy
vesicular murmur.

When the urine of a healthy person is treated with nitrate
of silver,* after being acidulated with nitric acid, the copious
procipitato of chloride of silver which is thrown down shows
the presence of a considerable quantity of chlorides. In pneu-

* Nitrit« of filrer, wlded to bcntthy arine, throws domi a wbitiib pn-
oipitate, which conriBtj of chloride sod pboBphateofailTer. A little nitric
acid will diasolTs the phoepbatc, learing tbe inrolable chloride. Tbeohlo-
ride of silver isresdllv soluble in a little ammonia. Nearly all thocblorina
eontiiinrd in the nrine occur* there a« chloride of TCdiiim

PNEUMONIA.

361

aotiia, n normni nniount of the clilorides may be found for the
first day or two; but the qiiantitj- gradually diniini^ihes as the
inflainniatioQ advances, until — when hepatization is perfect^
they have entirely disappeared. As the hepatization recedes,
80 the chlorides reappear; continuing tti increase as convale-
scence favorably progresses. Dr. Ri'dtcnlKichcr further ob-
served that the more intense the inflamniation, the greater was
the diminution in the chlorides ; while the rapidity or 8lownei>8
of their decrease or increase was in cnnstant relation to the nipid
or slow course of the disease. Dr. Beale, in confirming the im-
portant views of Redt«nbachcr, says, " There is reason to believe
that the absence of the chloride of sodium frtmi the urine dur-
ing the stage of hepiitization, depends upon a determination of
this salt to the inflamed lung ; and that when resolution occurs,
this force of attraction ceases, and whatever salt has been re-
tained in the lung is reabsorbed, and appears in the urine in
the usual way."* It must be remembered, however, as Dr.
Beale points out, that a deficiency of chloride of sodium, or its
total absence from the urine, is not peculiar to cases of pneu-
monia, nor even to acute iuflamuiations generally; but as far
as my own investigations have gone, it seems more constantly
wanting in the di.seaae under consideration, than in any other.

Occfl.?ional!y, in depressed constitution,*, acute inflammation
of the lung terminates in diffused or in ririirmsirifjrd gnn-
yretie. The characteristic symptoms of such km occurrence
are an intolerably fetid state of the breath, resembling the
odor which proceeds from external gangrenous parts, together
with dyspnoea and very great prostration. Unless the morti-
fied portion be small, death will in all probability result.

Chronic pneumonia may occur as a sequel of the acute dis-
ease ; giving rise to persistent consolidation of a portion of the
pulmonary tissue, which maybe mistaken for solidiflcation, the
result of tubercular deposit. This error is the more likely to
be made, since the general symptoms are partly those of phtbi-

* Mrdico'Cltirurgieai Ttantaction*, vol. xxxt, p. STS. LoD<lon, IBSS.

862

DISKASES OF I.VXae,.BKABT. ETC.

•is; aoch u weakoea, ciiiBriatioii, cough, m wotmt of opprtiMWi

within the che«t, aliaciu of feverisbnew, and ion of appetite.
Iodide of potaieiuni and barls, or iodide of iron, or amniunia
and bark, with cod-liver oil or gljfcerioe. and ^ood diet, are the
remedies to be trusted to.

Pneanionia may affect one lung or both ; or, technically
speaking, way be double or single. The right lung gaffers
from inflammntion nearly twice as often as the left ; about once
in eight cades both are affected. The lower lobes are more
obnoxious to inflammation than the upper. The average dura-
tion of the disesKC, when uncomplicated, is about fourteen days,
when (ioniplicated, about twenty-one days. In fatal cases death
occurs between the sixth and the twentieth days. PoeumoDia
destroyed life in 26,486 cases, in England, during the year
1858; the mortality being greatest in the winter quarters.

Pneumonia without brunvhitis is probably never seeo. It
may occur with or without pleurisy; when the pneumonia
forms the chief diseosc, the double affection is termed pleuro-
pneumonia ; when the pleurisy predominates, it is sometimes
called jmeumo-jilrurifis.

The iredtmeiit of pneumonia remains to be considered;
though, after what has been said in speaking of the remedies
for inflammation, only a few remarks are called for. Bleeding,
tartar eiuutic, und luercury, are the agents on which we have
been mainly taught to rely; but these remedies will, I feel
uonvinued, do great barm if applied to the treatment of pneu-
monia in the present day. It is the more necessary to insist
upon tiiJH point, beciiuse some of our text-books still advocate
depletion. In recomuiending the adoption of a very simple
Hoe of practice, I am only doing that which my experience
has tnught me is much the best, not only for the ultimate safety
of the patient, but even fur diminishing tlie duration of the
disease, I ara quite alive to the argument that whereas oor
anoostors bled too much, wc may fall into the opposite error,
and bleed too little ; but whatever may be said upon this head,
it oao only be replied, that the practitioner is advised not to

PNEUMONIA.

363

bive recourse to aTittphlo<riHttc remedies in the treatment of
pneumonia, because I believe the recoveries from this disease
to be much more numerous without them.

When the case is first seen, attention must be paid to the
bowels, a dose of castor-tiil being given if necessary. The
most perfect quiet in bed is then to be enjoined, thenirof the
sick-room being kept nioi.Kt by the evaporation of boiling water,
while the temperature is not allowed to fall below 60° Fahr.
From half an ounce to six or eight drachms of the lifjuor am-
monise acetatis may be given every two, three, or four hours,
according to the action of the skin, with or without a few mi-
nims of wine of colcliieuni; while smalt doses of opium are
also to be administered, if there be pnin or restlessness. The
Tapor of ehlornfurni may occasionally be used to relieve the
cough and dy-spnoen ; but I have had no experience in the
treatment by full inhnlutions repeated every three or four
hours. When the patient's constitution is feeble, a draught
containing an excess of ammonia, according to F. 259, is to be
ordered. At the same time, poppy-head fomentations are di-
rected to be properly used over the' affected side ; or if the
pain be bad, recourse may be had to turpentine stupes night
and morning. All that is necessary besides is a light diet with
a free supply of cold water; together with strong beef-tea and
wine as soon as there are any indications of greater weakness
than the patient can support. When the crisis occurs by
sweating or by diarrhoea, care mtist be taken not to check it
unnecessarily; while during convalescence few tonics will be
more useful than ammonia and bark (F. 488).

Should the inflammation end in ;/rrn;/rene, stimulants and
tonics will be especially needed. Wlieii the odor of the breath
is very oflfensivc, F. 100 may be prescribed. Dr. Skoda, of
pVienna, has publi.«hed several cases in which the symptoms
ave way on the use of tcrebin thin rite vapors, and the free
exhibition of quinine. The inhalations are made by pouring
oil of turpentine on boiling water; the vapor being inspired
for about fifteen minutes every two or three hours. Urandy,

864

DISEASES UV LUNOS, HKART, ETC.

and nourighment in as large quantities as can be borne, will
be required.

XV. PHTHISIS.

Tubcrcutiir phthisis, or palmonary consumption, is a oon-
(•tilutioriuj (iif'cu.'-e uiauifesting itself chiefly by certain changes
in the lungs.

Phthisis may be acute or chronic. The arute form is very
rare : it coimncnceH .suddenly with shivering, fever, pain, cough,
and dyspnoea ; soon there is huclic fever, profuse sweating, and
diurrhccu; nnd deuth may hitppon from exhaustion within as
few a nninber of weeks un I'rum three to twelve from the com-
uienoeuienl of the disease. Acute puliiioiiary consumption
may occur us the sole morbid state ; or it may sot in during
the progress of otironic phthisis; or it may prove the termina-
tion of some chiunic ninlady, as was the ca»e in a lady long
under my care with pelvic abscess. — Chronir phthisis is that
variety which is ordinarily met with ; the symptoms, diagnosis,
&c., of which will presently be detailed.

Pathuliitf)/. — The origin and formation of tubercle has already
been considered in the section on Tuberculusis. It is only
necessary to mention, therefore, that in phthisis the tubercular
deposit takes place in the ureoiur tiNsue between the air-cells,
in the air-cells thctiiselveB, and in the smaller bronchial tubes
communicaliii^ with tliera ; and that wherever a speck of this
matter is depo.-it('d from the blood, it continues to increase by
constant addition. In its hard state it is ciilled crude luberole.
Af\cr a time, inflauimation arises in the pulmonary subsUinea
surrounding the deposit, suppuration occurs, the tubercular
matter softens and breaks down, and at length is gradually
expelled through the bronchi, tniuheu, and mouth, leaving
cavities or excavatiuna behind, of variotis sizes. Sometimes
the cavities close and heal ; more fretjuently tubercular matter
contioues to be deposited on their sides, and in other parts uf

PHTHISIS.

365

the lunp*. until these organs become diseased to an extent in-
compatible with the continuance of life.

St/mploms. — The general symptnins of phthifitaare gradually
increasing cough, hajuioptysit?, debility, expecUirntion, dyspepsia
in some form or other, acceleration of the pulse, pyrexia, slight
dyspocea, Iosa of flesh, hoarseness, sweating, ami diarrhrea. A
mark at the reflected edge of the guius, usually deeper in color
than the adjoining surface, and producing a festooned appear-
ance by the accuracy with which it corresponds to the curve of
the gingival border, has been observed to be very frequently
present in these cases.* Sometimes, especially in males, fistula
in ano is one of the earliest symptoms. The disease ordinarily
sets in with a short dry cough, which the patient often refers
to the trachea. It is doubtless due to tubercular deposit irri-
tating the bronchial membrane; it may continue souie time
without being aggravated, or without the supervention of any
other symptom. Occasionally there is hjcnioptysis : which,
recurring at variable iutervulg, gives the patient the first un-
mistakable intimation of the disease. The haemorrhage may
be so considerable as to kill directly or mdirerlli/. Dr. Walshc
States that hi.s analyzed series of ISl cases of phthisis furnishes
but two examples of such mode of death. In one, death was
direct from n.^phyxia, owing to the plugging of the trachea and
bronchi with blood ; in the other, it occurred from exhaustion
at the end of five days.f The patient complains also of
languor ; slight exertion — ascending a hill or going up stairs —
canses fatigue, hurries the breathing, and often gives rise to
palpitation ; the uterine funcfiona are more or leKs disturbed
in women ; and the liver becomes congested and tender.
When this state has lasted for some time, during which the

* CKuieal LMturn on Ptilmotiory Comumplion, by Theophilni
ThomiMoa, M.D., F.R.S., lus London. 1864.

t On Di$eaMrt of the Ltingtj Jlrnrt, and Aorta, 2d edit., p. 606.
LondoD, 1864.

31*

8(i«

mSKASEH (IF l.t-NUB, HEART. ETC.

cough and expectoration* have been increaRing, hectic fever
appears. The debility i|uickly ;iets more luurked ; ihe counte-
nance becomes lVe<iueiitly flushi'd ; chilliness is complained of
in tht! evening, while un awaking in the morning the body ia
fiiund bathed in a profuse sweat ; and there ia loss of appetite,
with thirHt, &c. Moreover, in women, there is a total oessu-
tion of the cataineniii ; n very discouraging indication of want
of vititl power. The patient now rapidly li«es flo.'^h ; diarrhoea
— either due to disordered secretions, or to ulcerations of the
nacous incnibrtine of the ileum and colon — often sets in and
increases the debility; the urine is soiuetiuies found to contain
nlbuuicn, and occasionally minute quuntities of sugar; the
lower extremities fret]uently become painful and oedematoua;
and death soon ends the scene, the mental faculties remaining
clear until the last few hours.

Dtii</iiits>ii. — The attempt has been made by Dr. E. Smith
to show thiit before the deposition of tubercle in the lungs,
there is an abnormal physical condition of these organs and
of the bodv generally which nianifesbt itself by certain indica-
tions. The physical si^'ns of this so-called pre.liiltercular slate,

• " The micrascupicttl elements af phthisical sputa'* — MiysDr. Wal»he —
"arererjrnDincnuii. Fir^t, epithelium Irssellnted, I'jlindrical, and oiliateil
frnm l-be broiu'hiiil tuhev ,- iialivAry fluid, anclepilbeliuai from the month.
Seoondlj, bluoiT-dialu (even when no reddish tint exists to the niilced eye),
tneliinic celln and molcctiles, molecular fat, oil globules, an<l valine mfttt«r,
erystalline and amorphouti. Thir<ily, exudutioD-matter in patches, exndjt-
tion-cell? and ptia.cellf. Fourthly, frngmentii of pnlmonnry 6bre, eapilUry
TeMel And nerve. Fifthly, darli molecular matter, Hduhte ueitber in ether
nor in hydroeblorid acid, and probably tuberculous, — and, in very rara
citMS, cells po'seseing the charaoteri originally assigned by M Leber! to
t/tate of tubercle : I have — at least occasionally — seen, in the opoqae buff-
cnlored etrin of comparatively clear apata, cells non-nucleated and mora
angular in ontlinc than tho^e of exudation-mutter. .Sixthly, the vibrio
lineola, and mycodermatous entophyte;. Now, the presence of fmgroenl*
of Uatne indicates breakage of the lung-substance, and may furnish it*
•■rliest evidence. The existence of tubercle-cells, if certain, is, of coarte,
distinctive of phthisical disease. Otherwise, the character* enumeratad
have uo precise di:\|rno«tio signification." — On tht Diteawoflkt LuHgt,
All Mlit., p. iir. [.ondon, 18A0.

PIITMIBIS

!ire verj sii<;lit sub-claviculur dulness, diitiiiiislied ve«ieular
murmur, less forcible and deep inspiration, and fluttenin<; of
llie apices of the lutip;s. If there are also syuipt-ODis of dys-
pepsia present, with loss of weight, it seems to me that the
evidence is in favor of tubercle having been actually deposited,
rather ihan ih.it it is about to irivude the lun]*s.

Many authors havo divided the course of phthisis into three
stages; a plan which is convenient, to say the least. During
the Jirst — that in which tubercles become developed in the
lungs — neither the local nor the general symptoms warrant us
in positively announcing the presence of any other affection
than severe catarrh. If the tubercles be deposited, however,
in considerable quantity, the infra- and supra-clavicular regions
will be fldtteoed ; the sound oti poicussinn will be dull, or it
may be morbidly resonant if the deposit extend from the costal
surface directly to the trachea or large bronchi ; there will be
harsh or tubnhir iii«.piratinn, the act of expiration will be pro-
longed— from inipiiiruient of the elasticity of the lungs — and
dronvhial re»pira1ion and bronclwphony yi'iW be heard. In the
tfcond stage, the tubercles increase both in number and size,
80 as to compress and obstruct the substance of the lung, and
iK'casion dyi^pnoea; while they also begin to soften and dis-
integrate. There is marked depression of the infra- and supra-
claviouiar regions; the resonance on percussion is increased;
while large crrpili/twii will be distinct, and in the sound lung
purrilr brenfhinif. In the ?/mV(/ stage, the softened tubercles
are eliminated ; they make an opening for themselves through
Bome of the Kurrouiiding or involved bronchi, and being thus
evacuated, they give rise to the formation of cavities. Aus-
cultation now elicits a peculiar sound, called guryling, caused
by the bubbling of air with the pus or mucus contained in the
cavity, (rurgling, it must be remembered, may also arise from
that rare disease, circumscribed abscess of the lung, as well as
from the mixture of air with liquid in a dilated bronchus
affected with chronic inflainmatiou. When the cavity contains
nil liquid, we hear cauernoui rfxpimlioit ; if it bo large.

8C>8

DISEASES OF LUNQS. HEART. ETC.

amphoric resonnncf nnd pertoriloquy will also be distinpiish-
able. Nutwithstatuliiior the existeuce of one Inrge or of
numerous emull cavities, pcrcussioD almost invariably affords a
dull sound, owing to the liiyer of lung forrninp the wall of the
cavity being dense and solid.

The spirometer is an instruiucnt for measuring the volume
of air expired from the lungs; and as this volume is always
diminished in each stage of phthisis, we have a valuable aid
to diagnosis, fur which we are indebt«d to Dr. Hutchinson.
The quantity of air expired after the most complete inspiration
is termed by this gentleman the vital volume, or the vital
rapacity. Now the vital fupacity always increases with sta-
ture ; it will also be slightly affeeted by weight, but not suffi-
ciently, as a rule, to interfere with the correctness of the fol-
lowing tabic, which is intended to show the capacity in health
and in the three stages of phthisis :*

(hp«ctlv

Oi/)'in7y in

BagltL

(MBtaUA.

PhMtiM p)d manatu.

lit SUgF.

2dSU««-

Sd8t«c>.

In.

Ft.

Id.

rnb. In.

Oiib In.

Cub. In.

Cob. In.

1 .

.. 174

117 .

»9 ..

2 .

. . 182 . .

122 .

. . loa . .

B«

3 .

. . 190

. 127 .

. . 108 . .

4 .

. . 198 .

. 13S .

.. 113 ..

b .

. . 206

138 .

.. 117 ..

8 .

..214 .

143 .

.. 122 ..

100

7 .

..222 .

149 .

.. 127 ..

104

8 .

.. 230 .

IM .

.. 131 ..

108

e .

.. 238 .

159 .

.. 136 ..

112

10 .

. . 24« .

165 .

. . 140 . .

116

11 .

. . 254

170 .

. . 146 . .

119

0 .

. . 282 . .

. 176 .

. . 149 . .

133

* When th« vital cafiaoity i< to be tested, the patient should toosao bU
vest, ttnnd perfectly erect, take as deep an inspiration u possible, tnd
then place the mouth-piece of the spirometer between his lips. Tha
observer having opened the lap, the patient empties bis lungs, making
the deepest possible expiration, at the termination of which the operator
turns off the tap, thus oon&ning the air in the receiver. The receiver is
then to be lightly depressed until the surface of the spirit in a bent tube
on the outside of the instrument are on a level with aaoh other, when
the rilal oapaoily may he read off from the scale.

KUTHISIS.

3fi9

This table reads thus: A man between 5 ft. 7 io. and 5 Ft.
8 in. should breuthe in health 230 cubio inches ; in the first
stage of consumption this will be reduced to 154 ; in the se-
cond, to 131 ; and in the third, to 108 cubic inches.

Another very early, and therefore highly iniportant, sign of
pulmonary consumption in (omt nf writjht. -A slow and gra-
dual loi^s is more serious (ban a rapid and rc>:ular diminution
in weight ; a iteailj/ lost nlica^i precedes titbercuhtU. Dr.
Hutchinson, from an examination of 2650 healthy men at the
middle period of life, has deduced the foilowiug table :

fTrifflil iHcrmttd

KMd

Halnrt.

jr«m WrifM.

hyt frr

cent.

rt.

in.

tbi.

lb*.

St.

Ibn.

Ibil.

nr 120 .

. . 9

2 or 128

•• 126 .

. . 9

9 ■

• 135

•• 1.13 .

. . !0

2 •

' 143

" 139 .

.. in

• 149

•' 142 .

. . HI

12 •

• 152

•' 145 .

. . 11

1 •

' 155

" 14fi .

.. 11

4 '

• 158

" 165 .

.. 11

12 '

' 16«

" 182 .

.. 12

5 '

• ITS

•' 1B9

.. 12

■ 181

•■ 174 .

. . 13

4 ■

inn

" 178 .

. . 13

8 '

• i9n

This reads: A man of 5 ft. 8 in. should weigh 11 st. I
lb. or 15.5 lb. (14 lb. ::= 1 stone); he may exceed this by 7
per cent., ands*") attain 11 st. 12 lb., or 166 lb., without affect-
ing his vital capacity ; beyond this weight his respiration be-
comes diminished.

Cttunfn, (Cv. — Phthisis may be inherited or it niiiy be ac-
quired ; it is not conUigious. Of 1000 cases collected by Dr.
Cotton, at the Consumption Hospital, 367 were hereditarily
predisposed; 582 were ninlcs, and 418 females. The lelt
lung suffers more frequently than the right; in Dr. Cotton's
eases the left lung was affected in 455, the right in 384, and
both in 161. The apices and posterior parts of the upper

370

msE^swB or Luxes. bkast, nc.

Mici of the Inngs are onliiMnlj the ntadooa in vhich the
depuMt firat ukes pUc«. In aonie few instances, howcTer, the '
derelopmeot of tabereles begins mt the bane of the Inng, and
gradually extends upwards. As these eases sometimes manifest
the physical si'nu of pneumonia, especially persistent minotc
crepitation, thcjr hare not unfreqaentiy been erroneooslj
ti«ated. To avoid this mistake it is only necessary to obserre
that the general symptoms are not those of inflammation, bat
of depression.

No period of life is exempt from this scourge. I hare
already shown that in. the year 1858, considerably more than
oue-fourth of the whole number of deaths in England were
due lo consumption and other diseases of the respiratory
organs. Insufficient and bad food, impure air, the dirty dost
suspended in the atmosphere which the people of London hare
to breathe, confinement, deficiency of light, and immoderate
indulgence of the senHual passions, may be regarded as fre-
rjucnt causes. Its ordinary darattoo varies from about six to
twenty-four months ; it very rarely proves fatal in less than
three months, unless indirectly from severe pueamonia or
pleurisy.

Treutmenl. — This resolves itself into that necessary for the
prevention of phthi.«is, and that to be adopted to stay its course
when it has mice developed itself. As regards prevention, I
need oisly refer to the observations which have been made in
the section on Tuberculosis.

When the disease is present — when the tubercles have
hocimio developed in the lunp?, we must endeavor to improve
the ijentrnl nuln'liun, by uttention to the quantity and quality
of the food, by enjoining residence in a healthy climate, by
order! nf; exercise in the open nir, by Inking caro that the
patient never sits or sleeps in a vitiated atmosphere, by advis-
ing warm clothing, and by the administration of cod-liver oil.
The pntiont's system should in no case be lowered ; and eveo
during the temporary exacerbations of fever which occur in the

PHTHISIS.

371

pni^rcps of every case, it will only be nece&aary to substitute
wilitiea uiid diuretics in the place of the tuoics, for a day or
two, to speedily j^ive relief.

As regards the (lift in phthisis, only the most nutritious
food should be allowed; an animni diet being absolutely neces-
sary, 80 lonp as the powers of the stomach and aSiiuentary
canal are suffitMcntly strong to digest and assimilate it. VVlien
the strength of the digestive organs fails, pepsine — in doses
of pr. XV — with the two principsU daily meals, should be or-
dered. Slilk and cream are very nutritiuus, and so are raw
eggs (F. 5, 16). A small allowance of brandy, or a moderate
quantity of wine, or of good bitter ale, or Scotch ale, or of
Ouinneas's stout, may always be advantageously permitted.
Too long an int«rvnl should nob elapse between each meal.

Chavyr. of air and sfene is an important element in the
treatment ; though it must be remembered that this change is
to be resorted to only in the early stages, for it is cruel to send
patients away merely for them to die. When softening of
the tubercles has begun, it will generally be too late to expect
niuvh benefit; and cerlainly nought but mischief can ensue
from depriving a sufi'erer of the eomforts of home when exten-
sive cavities have formed. Phthisical subjects sometimes ima-
gine that change of climate is the remedy, iirstead of being
only one of the steps which favor the accomplishment of a cure.
Conset]uontly such persons on leaving home should be cau-
tioned to act with prudence; to avoid high living and over
excitement; to take open-air exercise in moderation, and not
to walk up high bills exposed to the sun's glare; to attend to
the skin, and the proper action of the bowels; to keep regular
and early hours, always being in-doors between sunset and
sunrise. Moreover, they are not to give up the use of such
drugs as steel, cod-liver oil, bark, &o., if these have been
found beneficial at home.

Torquii^, the Undfrrliff of the h!c of Wiij/if, and Ilaitinijn,
are places in our own countr}' admirably adapted for the win-
ter residence of many consumptive invalids. liut a more

STi

D1SE.\SE8 or LI' SOS, OKAST, STC.

pletc change of diante i* oftaa wiahed for bj the pa-
tient, Bod then we nnj send him to the eoatfa of France or
to some part of Italy. One of the most sheltered winter
Btadons in the south of Europe is Jienione, a sma]! town sita-
ated at the foot of the Maritime Alps, twelve miles east of
Nice, on the road to Genoa. The bay, in the centre of which
the town is placed, is completelj protected from the north,
northwest, and northeast winds bj the moaotains; while,
owing to the absence of fogs, the slight amount of rain, and
the power of the sun, the climate is very pleasant during the
winter months. For the sake of those who are not over-bur-
dened with wealth, it may be as well to remember that Nice
and Meotone are both extravagant places, while S'ttt Remo is
luuch cheaper, and the air is juift as good daring the winter.
Some physicians strongly recommend Funrhul, the chief town
of the island of Madeira. The invalid who leaves thu coun-
try about the middle of October, can reach Madeira in from
ten to fourteen daj-s ; where he will find himself in a tropical
climate, with an unclouded sky, a glowing sun, a deep blue
sea, a luxuriant and varied foliage, and beautiful hills which
were formerly covered with vines. Dr. Francis speaks very
highly of Malaga, which, indeed, seems to be the El Dorado
of climates; for he asserts that there is no place in Spain, nor
in the whole of Europe, as far as onr present information
goes, that possesses a climate at once so mild and equable,
with so little variation from day to day. Without venturing
in any way to dispute the absolute correctness of Dr. Francis's
views, I yet think it rip;lit to suggest that they are not to ho
adopted without further inquiry. And, la.stly, there is Alffiert;
which can be reached in less than seven days from London,
by way of Folkestone, Purls, Lyons, and Marseilles, and thence
by steamer in forty-eight hours. Speaking of the city of Al-
giers, Dr. Mitchell says that with difficulty, if at all, will the
European traveller find a spot on earth where natural beauties
80 combine with those of uiuu'b creation to please and interest
hire. One of the long sides of the oblong of which *' the

PHTHISIS.

373

Place du Gouverneiiient" is foriued, is open to the sea, and
commands a view of the bay, the harbor, the site of the an-
cient Rusginium, the peaks of the distant Atlas, and the ver-
dure of the Sahel slopes. The *' Place" itself is filled with a
strange mixture of all races ; the Ar|}b, the Moor, the tar-
baned Jew of Africa, the Maltese fisherman, the Spanish
fruit-seller, the veiled women of Moslem, the picturesque
Jewess, the prettj Spaniard, &c. &c. The invalid will find
objects of interest without seeking them, and will be grati-
fied and aam.scd merely by wandering in the open air. The
mean annual temperature is about &}° Fahr. The mean tetu-
perature for each season is, — Winter, 62.13 ; Spring, 61.04 ;
Summer, 75.09 ; and Autumo, 78.26. The mean annual
temperature more nearly approaches that of Malta than of any
other of the more ordinary resorts of the invalid. It exceeds
it, however, by 2° ; while it exceeds Malaf;;a by 3°, Madeira
by 4°, Rome by 9°, Nice by 10°, and Pau by 13°. The mean
annual temperature of Cairo, however, is 3° higher, yet its
winter is 4° colder than that of Algiers. Compared with
other points on the Mediterranean, Algiers has a warmer and
a less varying climate than Marseilles, Nice, Genoa, and Na-
ples ; while it more nearly apprt)aches, but is still superior to
Malta, Corfu, and Gibraltar. Dr. Mitchell also quotes the
opinions of M. Odrultz, which are to the following e9°ect :
1st, The climate of Algiers is opposed to the generation as
well as to the evolution of tubercle in the lungs : 2d, This
morbid production is observed but very exceptionally among
the indigenous population : 3d, Europeans who do not bring
the germ of the disease to Algiers, almost never become phthi-
sical : 4th, Those who do bring not only a predisposition, but
actually crude tubercle, in greater or less quantity, in the
lung, are often cured; or, in the worst cases, the progress is
extremely slow : 5th, When the tubercle is softened, the cli-
iuat« is no longer favorable.

With respect to druyi, there are certain agents which must
be especially mentioned. Cod-liver oil is a most valuable

374

DISEASES OP tFXOS, HEART. ETC.

remedy; it nourishes the body; diminishes the coa<rh, expeo-
tonition, and night-sweats; and, there is eyery reason to be-
lieve, checks the fresh exudation of toberculur matter. In
the beginning, a teaspoonfiil should be pven twice or thrice
daily, and gradually increased tu a tablespoonfol four or five
times a day; remembering that it will be more easily digested
if taken directly after the meals. If there be much acidity
of stomach, the oil may be combined with liquor potassie ; or
if it produce nausea, a drop of creasotc can be added to each
dose. Where the stomach will not tolerate this spent, ene-
mata containinn; it may be tried ; or it may be introduced into
the system by inunction (F. 326), and by applying lint satu-
rated with it to the chest. Inunction with the best sperm oil
has also proved very useful in my hands. Glyterine is pro-
bably inferior in its effects to cod-liver oil; but it may at times,
and in particular cases, be found very efficacious. The dose
varies from one to four teaspoonfuls two or three limes a day;
and it may either be given with some bitter infusion, or with
the symp of iodide of iron, or with tincture of sesquichloride
of iron, &c. (F. 458).

The vnriotts preparations of tVon (F. 44.'>, 448, 450, 456,
473, 486, &c.) are very useful in many cases; especially
during the first stage of the disease, pnivided there be neither
hsamoptysis nor pulmonary congestion. I<nline and its com-
pounds— cppecially the iodide of potassium — hove been highly
praised ; the iodide of iron is the best preparation, though I
have but little faith in it. Bark is an excellent tonic, and I
have frerjuently seen much good from giving one drachm of
the compound tincture three or four times in the twenty-four
honre. Liquor potasKv is often beneficial in the early periods,
particularly when combined with bark (F. 464). When the
cough is severe, small doses of opium or morphia, frequently
repeated, give relief; when there is troublesome haemoptysis,
the oil of ttirpntlinr — m. x, every hour — often checks it, or
ammonio-mitpfiale of iron (F. 149), or </allic arid (V. 182)
may be tried ; when the heart's action is irritable, it may be

CANCER or THE LUNG.

S75

coDtrolled by hi/ihor.i/anic acid with or without small doses of
digitalis: if the night-sweats weaken and annoy tlie patient,
they may often be checked by i/ullie acid, or by tlie mineral
acids with bark, or especially by the oxide o/ zinc in four or
five grain doses at bcdtiiue: while the diarrhosa, when ur<;ent,
must be stopped by cutfchu, loifworxl, compound kino poicder,
the enema opii of the London Fharmacopceia, or by F. 122,
128, 124, 141, 360, 362, &c.

Counter-irritation to the chest by dry-cupping, or the use
of the croton oil liniment (F. 254), or a succession of suiuil
blisters, or frequent sinapisms, or turpentine stupes, and par-
ticularly by the iodine paint (F. 25-), often gives relief. —
Pyro-acetic spirit or naphtha, administered by the stomach or
by inhalation, has been hij^hly but undeservedly praised, since
it more frequently does harm than good : Dr. J. F. Churchill
regards phosphorus, in certain combinations, as a specific, but
the physicians who have employed the bypophosphites of soda
and of liiuo according to his directions have only been disap-
pointed : while, lastly, nought but mischief can result from
the use of arsenic, oxalic acid, phosphate of lime, oxygon gas,
daily emetics, frecjucnt small bleedings, antimony, mercury,
eolchicum, and a host of similar and dissimilar remedies.

XVI. CANCER OF THE LITNO.

PuknoDary cancer, most commonly of the enccphaloid kind,
is a rare disease; it may occur as a primary infiltration, or a.«
a secondary nodular deposit. It is generally associated with
mediastinal cancer.

When the disease occurs ^ri'/Huri'/y, the symptoms will vary
with the extent of the disease : there will, however, often be
found — flattening of the affected side, impairment of the respi-
ratory movements, and dulness on percussion. Moreover, pain,
emaciation, night-sweats, failure of the powers of life, dyspnueu,
cough, purulent expectoration — often mixed with blood, and

376

ntSEABES OF LUNOS, HEART, ETC.

of a dark color — and sometimes foBtor of the breath, will be
present : chronic bronchitis also frequently complicates the
disease. — In iecondary emirer the symptoms are very obscure ;
indeed dyspnoea is often the only indication afforded during
life. Both lungs are usually affected. Cancer and tubercle
but rarely coexist. Dr. Walshe states that the nienn duration
of cancer of the lung may be estimated at Vi.'Z mouths ; the
greatest 27 months, the least 3.5 months.

As regards the treatment we can only attempt to relieve
the symptoms as they arise; while we try to support the
strength by nourishing food, ood-liver oil, and stimulants, as
long as possible.

XVII. PERICAEDITIS.

Pericarditis, or inflammation of the external fibro-serous
covering of the heart, is a local disease, occurring moat
frequently in connection with some special disorder of the
system.

P(itholo(/ff and Morbid Anatomy. — The inflammation may
end in resolution. More commonly there is effusion of serum,
the (juantity varying from a few ounces to three or four pints.
Lymph may also be eitravasated with or without the serum.
This lymph may form a false membrane, covering the heart
and lining the pericardial use; the thickness of the exudation
being viirioblc, but usually measuring some two or three lines,
while it oft<;n presents a peculiar irregular or honeycomb
appvurancc. And, then, in cases occurring in depressed
constitutions, the inflammatory action is very likely to end in
the formation of pus; such instances usually ending fatally.

In severe cases, the muscular walls of the heart are very
often involved in the morbid action. So also endocarditis
frequently arises during the course of rheumatic pericarditis.
White patches of lowly-organized fibrin may be found afker
death, efi°uscd either into or upon the (issue of the pericardium,

PERICARDITTS.

877

especially that part covering the ripht side of the heart. They
are of no iuiportnnco, and are probnhly due to the friction
arising from tlic cardiac movements.

The S8C of the pericardium is sometimes obliterated from
adhesion of its free surface; a condition which generally arises
from inflammation of a chronic rather than of an acute charac-
ter, occurriDg for the most part in strumous subjects. Oeca-
sionally there are only partial adhesions, obliterating the sao
in parte; in such instances, the adhesions being most common
at the base. Obliterated pericardium is not unfrequently
found with a healthy condition of the heart, but when there is
an alteration in the muscular structure, the left side of the
heart is by far the most frequently affected ; the cavities being
generally dilated, with hypertrophy of the walls. In a, less
number of eiamplcs of adherent pericardium, however, the
heart has been found partially or entirely atrophied ; this con-
dition probably ciristing when the adhesions have been so thick
as to compress the organ. La.stly, together with the adhesions
there may be fatty degeneration of the heart's texture.

Ctiufen. — It frequently arises from acute rheumatism, frora
the contaniinuted slate of the blood produced by renal disease,
from damp and cold, and from mechanical injuries. In acute
rheumatism, probably one case in nine or ten will be compli-
cated with pericarditis : in Hrigbt's di.sease the proportion will
possibly be only one in fifteen or twenty. The tendency to
cardiac complication in rheumatism diminishes with increase
of age after fifteen. — Dr. Ormerod reduces all cases of peri-
carditis to two classes: 1. Ilhcumalic pericarditis; 2. Non-
rheumatic pericarditis. In the first, the disease is always well
marked, it is associated with affections of the joints, women
appear rather riwre subject to it than men, it is most common
iu the youug and delicate, and it is rarely directly fotal : in
the second, the inflammation occurs at a later perind of life, is
moat common in men, occurs most frequently in bad constitu-
tions, and is very often the cause of death. Moreover, non-
rheumatic pericarditis may be due to some I' cal irriiDiiuii, as

•i2*

ZiS

niSKASKB OF LUNOS, HEART, ETC.

cancer, tubercle, &c. ; or it may arise from some constitutional
cause, as disease of the kidney, pleurisy, pneumonia, pyaemia,
or one of the eruptive fevers.

Symplomi. — There is considerable difference in tbe nature
and de(;ree of the symptoms; for while sometimes they are so
gliitht that the diBeusu escupes detection durini; life, in other
cases they are stroof^ly marked. When there is merely a
Bli((ht exudutioD of fibrin, or when the serum thrown out has
been mpidly iibsorbed and adhesions early effected, the patient
may simply experience a feeling of fever and oppression; but
when there is obundant effu.nion pressing upon the heart and
embarrassing its uiuveiuentH, or when there is coexistent
myocarditis, then both the local and general symptoms are
much more decided. Thus in these hitter instances, there may
be high fever ; pnin referred to the region of the heart, often
darting throuu;h to the left scapula, upwards to the lefl clavicle
and shoulder, and down the arm j violent palpitation, the
motions of the heart being tumultuous, and perceptible at a
distance from the patient ; irregularity of the pulse ; hurried
respiration ; ineajuicity of lying on the lefl side; strong pulsa-
tion of the carotids; anxiety of countenance; difficulty in
swallowing ; and frequently, noises in the ears, giddiness, and
epistaiis. As the disease advances, there is extreme debility,
cough, suffocative paroxysms, occasionally a tendency to
syncope, and cEdcmn of the face and extremities; the heart's
action also becomes much weaker, the impulse irregular and
trembling, and the sounds weakened and altered in character.
In very severe cases indications of disturbance of the nervous
centres frcfjuontly show themselves ; especially great restless-
ness, disttirtion uf the features, tetanic spasms, and furious
delirium.

The uncertuiiity uf the general symptoms of pericarditis
makes it ail the more necessary that in every instance where
the occurrence of thi.s di.«Bse is feared, the physical signs
which indicate its commencement should be carefully watched
fur. On practising auscultation, we ahull find — in the earliest

PERICARDITIS.

879

1^68 — increased intensity of the natural sounds; if endocnr-
ditis coexists, as it so frequently does, a loud systolic bellow*-
mvrmur will also be heard. Very early, too, a distinct ttlfcmtite
ruhbiuij or a to-nnd-fro goitnd, as Dr. Watson terms it, will be
audible. The bellows-sound indicates fibrinous deposits in the
texture as well as on the surface of the valves, from influmuia-
tion of the internal raerabrane of the heart — the endocardium
— and it generally continues for life. The to-and-fro sound is
indicative of inflainiuation of the pericardium, and it commonly
ceases in a few days when either adhesion between the two
surfaces of the membrane takes place, or when effusion hap-
pens. The pericardial friction-sound may so closely Biraulate
valvular murmur that it is sometimes difficult to distin^ish
between the two ; while it is probable that a full development
of the friction-sound can only take place when both divisions
of the pericardium are the seat of plastic exudation.

When serou.H effusion occurs, there will be a feebleness and
deficiency of tone and force in the heart's sounds, probably
owing to the dcadenint; influence of the fluid surrounding the
heart. There is also increased dulnesa on percussion in the
cardiac region ; the dulness extending; upwards to the level of
the secoud rib or clavicle, though but little below the healthy
limits downwards; while the dull region may also change its
extent from day to day. Hypertrophy of the heart, as well as
serous effusion, may produce precordial bulging ; though there
may be a large qunntity of fluid poured out without this bulg-
ing being present. In hypertrophy of the heart, the percuMion
dulness is extended in all directions, and is stationary. ]n
cases of effusion, al8<i, it has been specially insisted upon that
an undulalory or vermicular movement accompanies the cardiac
impulse ; but this motion has also been seen where no serous
effusion existed, in enlargement of the heart, and in adherent
pericardium. If the fluid does not become absorbed, we .say
that hi/tiro-pcn'tttr'fiiim exists; a drnpsieal afTtetion which
usually proves fatal — Only when the friction-sound is loud,

DISEASES OF LCNOB, HEART, ETC.

will it be Bcnsiblc to tbe touch; since a more powerful rubbing
18 needed to produce a tactile than an audible phenomenon.

If we classify the physical signs of pericarditis, they will bo
as follows : 1. Sensations of friction communicated to the hand.
2. Friction-sou nda: the "attrition murmurs" of Hope. 3.
Extension of dulness over the heart, resulting from liquid effu-
giun. 4. Friction signs, attended with — or preceded by —
viilvular luurniurs. 6. Signs of eccentric pressure analogoua
to those of etnpyctna. 6. Signs of excitement of the heart.
7. Signs of weukness or paralysis of the heart.

Prognosis. — Pericarditis — especially the rheumatic variety —
is not so much to bo feared for its immediate danger, as for
tbe traces of permanent injury which it leaves behind. The
endocarditis which so freijuently accompanies it, especially pro-
duces mischief to the valves of the heart. Hence an individual,
after apparent recovery, seldom becomes as strong as he was be-
fore the attack ; he suffers oocusiunally from cough and shortness
of breath, and from palpitations of the heart on moderate ez-
ertioo. Sometimes the syniploiiis reniuin latent for a few years;
that is to say, they are not appreciable to the patient, who flat-
ters himself that he is free from all traces of his attack. But
after a time — much siiorter in those who have to work hard for
their daily bread, than in the well-to-do members of society —
the health begins to fail; the weakness, difficulty of breathing,
and palpitations return ; dropsical symptoms set in ; or perhaps
an attack of inflammation takes place, and proves fatal.

Treatment. — In do disease was the lancet used with a more
unsparing hand only a few years since, than in inflammation of
the pericardium. More extended experience has proved to us,
however, that this heroic and sure method — as it was deemed —
of extinguii-liing the morbid action, is not only uncertain, but
often very dangerous. Dr. Murkhunr well says, — " Experience
has also shown us that venesection has no direetti/ beneficial
influence over pericarditis; and that large bleedings are preju-
dicial, and therefore inadmissible in this disease. Nevertheless,
tluit small bleedings are often of very great service in rrlirvini/

PEK10ARDITI8.

381

Ihe eongntion of the heart ari'l lunijt, which so often arise as
consequences of and coineidently with the pericarditis, is, I
think, an undoubted fact."* — Then we were also taught the
great importance of rapidly getting the sj'stem under the influ-
ence of mercury after bleeding; but the observations which
have already been made (p. 91) upon this head, render further
remarks unnecessary.

The treatment which I adopt ia that practised by many for
the relief of acute rheumatism : the three principal remedies
being the bicarbonate of potash in half-drachm doses every two
or three hours, opium in sufficient quantities to relieve pain and
restlessness, and the vapor bath. From these agents I believe
that I have seen the greatest benefit ; and certainly in no in-
stance have they been prejudicial. They give great relief to
the patient's sufferings, without inducing debility; and they in
no way complicate the symptoms. The quantity of opium
which will bo needed, will vary with the severity of the suf-
fering; but usually full do.«es — one grain every three or four
hours — will be wanted. Sometimes a single vapor bath suffices:
in other cases, it is nece.'isary to repeat it daily, for three or four
times. Alkaline drinks (F. 420, 421, 425) will alsodogtwd.

In most cases it will be necessary to administer a few doses
of some purgative: the neutral salts (F. Iti9, 184, 185) will
generally agree well. — At first the nourishment should be light,
consisting of gruel, arrowroot, milk, and mutton broth. Di-
rectly the strength begins to fail, however, the diet must be
made more strengthening; and soup, strung beef- tea, and wine
freely allowed. I>r. Stokes states that he is convinced patients
are often lost from want of stimulation at the proper time ; and
he directs us to give support directly the pulse becomes feeble
or intermittent, or the jugular veins become turgid, or pallor
and coldness of the surface set in, or a tendency to faint upon
exertion is manifested. "It nmy be laid down us a general
principle that there is no local inflammation whatever, the mere

* On Dtuatf of the Heart, ^, Snond sditton, p. 4i. Lundus, 1880.

382

DISEASES or LCNQS, HEART, ETC.

existence of which should prevent the ose of wine, if oircain-
stances require it. In two cases especially, namely, cerebritis
and pericarditis, we find the greatest timidity in practice with
respect to the use of wins. Yet even in the first case it may
be required; and in the second its employment js imperative,
when, as too often happens, exce.<<sive depletion has been r»-
siirted to."* — Ab.solute repose of body and mind in all caaesia
important.

When the effusion into the pericardium is abundant, a large
blister should be applied over the praecordia; or a sucoessioo
of blisters may be necessary. The iodide of potassium (F. 27,
31, 3(>) has been advantageously administered to promote ab-
sorption. It has been proposed — as a forlorn hope — in obsti-
nate hydro-pericardium, to remove the fluid by the introduction
of a trocar and canula. M. Aran, Physician to the Hopital
8t. Antoioe, Paris, relates a case of pericarditis with oopioos
effusion in a young man aged 23, which he treated by an in-
jection of iodine. The pericardium was punctured from below
upwards, with a capillary trocar, in the fifth intercostal space,
a little below the spot where the dulncsson percussion was well
marked: about '28 ounces of a transparent reddish serum were
removed. A mixture formed of four drachms of tincture of
iodine, fifteen grains of iodide of potassium, and an ounce and
a half of water, was then injected without causing any pain:
a draohiu or two was allowed to escape before closing the wound.
The fluid having reaccumulated, the operation wai performed a
second time with a stronger injection, formed of equal parts
(f^Jtij) of tincture of iodine and water, with one drachm of
iodide of potassium. The treatment was successful.

XVIII. EUDOCAEDITIS.

Endocarditis, or inflammation of the membrane which lines
the interior of the heart and its valves, is of great interest to

• Tki DiiviMsq/'lIu Hmrinnllki AoHit.f B8. Dublin, ISM.

ENDOCARniTIS.

383

lis as fMitholopists mid physicians, owing to the severe organio
diseases which spring fruin it.

Inflatiiiiuition of the endiwardium is most frequently associ-
ated with acute rheumatism. Dr. Hope was of opinion that
endocarditis more fretjueDtly occurs without pericarditis, than
the latter without the former. Dr. Stokes has come to a dif-
ferent conclusion, and he places these diseases in the following
order of frequency : 1. Acute pericarditis with endocarditis ;
'2. Acute pcrii-arditi.s without endocarditis ; and 3. Endocar-
ditis without pericarditis. It is certain, however, that enc/n-
pericarditis is more frequently met with than simple endo-
carditis.

Sj/mptomt. — In very severe instances it chiefly gives rise
to a sense of oppression and uneasiness at the prsecordial re-
gion ; the patient prefers to lie on his back, and he is restless
and anxious; there is fever, with a small, feeble, and inter-
mittent pulse; while there may be also cold sweats, oppressive
dyspnoea, jactitation, and syncope. When the inflammation
is only of limited extent, or when it assumes a chronic form,
the synipt'Oms are much milder and more obscure; so that it
not very un frequently occurs during the progress of rhenmatio
fever without being recognized, though its power is manifested
by the changes left after apparent recovery. Endocarditis of
the left is much more cunimon than of the right side of the
heart; while that part of the membrane which covers the
valves and lines the orifices is most prone to become affected.
The disease is seldom directly fatal ; its remote effects being
those so much to be dreaded.

Dingnosis. — If we apply the Jiand to the chest in simple
endocarditis, the action of the heart may appear to be violent;
while sometimes a vibratory thrill will be felt. Percussion, it
is said, oRen discovers an augmented extent of dulnesa in the
prsBcordial region ; this dulness being distinguished from that
caused by pericardial effusion, by the beat of the heart appear-
ing superficial instead of remote and distinct. But it is very
doubtful if simple endocarditis ever gives rise to so much

381

DISEASES OF LUNOS, BEART, ETC.

tumefaction or congestion of the walls of the heart, as to pro-
duce BD increased degree or extent of dulness. Auscultation
alone gives us any reliable infonuation. If we listen to the
heart's action we shall usually detect a soft bellows-murmur,
the iroet constant atid churacteriftic of the phenomena of en-
docarditis. If during the progress of an attack of rheuma-
tism we find a murmur where none existed before, we can
hardly be wrong in diagnosing endocarditis. The mnrmurs
of purely acute endocarditis are thus arranged in order of
frequency by Dr. Walshe : Aortic obstructive ; mitral regurgi-
tant; aortic regurgitant ; aortic obstructive and mitral regur-
gitant together ; aortic obstructive and regurgitant together.
Pulmonary systolic and diastolic murmurs are infinitely rare.
Dr. Walshe has never observed acute obstructive mitral mur-
mur, nor acute regurgitant tricuspid murmur.

For the further consideration of the physical signs, see the
section on Disease* of (he Valves of the Heart.

Terminations. — The terminations of acute endocarditis are
permanent volvular disease, followed by implication of the
heart's substance, and all their combined consequences. Per-
sistent valvular disease leads to dilatation of the cavities; the
system loses tone, and the blood becomes impoverished ; and
after a variable interval dropsy sets in. Thenceforth the pro-
gress towards a fatal termination is rapid, life rarely being pro-
longed beyond fifteen months after the occurrence of dropsy.

When fibrinous deposits have taken place upon the valves,
portions of them may become detached and circulate with the
systeoiio blood until they become arrested in some artery where
they act as a plug, and cut off the supply of blood to the part.
Temporary paralysis is not very rare in heurt disease, and may
thus arise ; the power being restored if the collateral circula-
tion is able afterwards to afford a due supply of blood, or if
the mass of fibrin should soften and break up so that the ves-
sel again becomes permeable.

Treatment. — This must be the same as that recommended
for pericarditis.

MYOCARDITIB.

385

XIX. MYOCARDITIS.

Myocarditis, rarditis, or iuflaniination of the muscular sub-
stance of the heart, seldom oceurs ss a difttinet affection ;
beinjr generally, if not always, combined with pericarditis, or
endocarditis, or with both. The morbid action, it is probable,
extends from the investing or the lining membrane to the
muscular substance ; thousrh our present knowledge will not
justify our denying that the starting-point of the iuRamtuation
may be in the muscular fibres themselves. The walls of the
left ventricle seem to suffer more fref|uently than other parta
of the heart. The results of myocarditis are indui-.uion of
the rau.'wjular structure from the depu.sit of I3 uiph ; the fnrnia-
lion of abMces-ses ; aneurisiual dilatation of the walls of the
heart, and, perhaps, rupture.

An instructive cxanipJc of inflammation of the muscular
substance of the heart has been recorded by Mr. Salter,* in
which the disease ran its course in seven weeks. It com-
menced with an acute pain in the left side of the che.st, which
came on when the patient was walking, liist<:d a short time,
and recurred about a week afterwards, whilst he was usiog
the same exerci.se ; it subsequently became very IVeijuent, and
was induced by the slightest exertion. When Mr. >Sjilter first
saw bim, about a week before his death, there was orthopnnea,
and an uneasy sensation or dull pain referred to the stomach
and middle of the sfernutn. VeniBsettioti, caloniol and opiuui,
and counter-irritation were the means adopted to stay the
disease ; but they were unavailing, and death took place. At
the pott-mor/em exaoiination the pericardium was found in-
flamed, especially its diaphragtnatic portion ; its vessels were
distended, and spnts of ecchyniosis were discovered beneath
the serous membrane. The substance of the heart was mode-
rately firm ; but the left ventricle hud almost entirely lost the

* Mttlito-Ckirurgifal Trinuaetiom, vol. uii, r- 72. London, 18.19.

386 DISEASES OF LDN08, EIKART, ETC.

color of muscle, pns could be scraped from its snrface, and in
some parts there were smull cuTitiea in the muscular substance
containing pus.

TUere seemg to be some reason for believing that the mnaoles
of the heart ma; occusiotinlly be affected with rhenroatic ill'
flanininlion, causing sudden paralysis of the organ and death.
This occurrence may explnin tliose cases of acute rheumatism,
where patient.s have been Middenly seized with severe pain in
the cardiac region, suffocative dyspnoea, insensibility, convul-
sions, and dentb ; and where afterwards no appearances have
been detncted on a careful examination of the body to account
for the abrupt invasion of the fatal symptoms. It must not
be overlooked, however, that possibly in some of these cases
the fiitiil event may have been due to the formation of a oo*-
gulum in one of the large arteries.

XX. VALVULAE DISEASES OF THE HEAHT.

A f<>w words on the heart's sounds may not be out of place,
before speaking of the valvular diseases of this organ. On
practising auscultation over the cardiac region we can detect
two sounds, very tjuickly following each other. These sounds
•re succeeded by nn appreciable period of silence. If the
time occupied by the sounds and the pause be divided into
fifths, we shall find the first sound occupying two-fifths, the
second sound rather more than one-fifth, and the pause rather
less than two-fifths. The Jint ntniiii/ — sometimes called the
systolic or inferior sound of the heart — should be listened to
lover the apex : it is coincident with the systole of the ventri-
cles, pulso of the arteries, diastole of the auricles, and impulse
of the apex against the thoracic parietes. The »econd tound
—-often termed the diastolic or superior sound — is best heard
about the middle of the sternum : it is syncbronous with the
passive flow of bluod from the auricles into the ventricles, the
diastole of the ventricles, and the retrocession of the apox.

VALVCLAE DISEASES OF THE HEART.

3!«7

All physiologists agree in regsrding the second sound of the
heart as due to the tension of the Eemilunar valves of the aorta
and pulmonary artery; but the cause of the first sound is still
a matter of uncertainty. Dr. Hulford believes that he has
solved this quteslio vi'jcuta ; for this physiciiin states that his
esperiments demonstrate the fuel thut both sounds "depend
open the same cause, which is simply the vibration of the
valves, produced by the backward pressure of the blood, first
against the auriculo-ventricular, and secondly against the vea-
triculo-arterial valves." Now this explanation is not altogether
satisfsotory; and the experiment by which he supports it —
viz., exposino; the heart of a livinfr animal, and arresting
the flow of blood through it — is liable to mislead the student.
For it is clear that if the ciroulation through the heart be
arrested, none of the supposed causes of the first sound can
act : there can then be no rush of b1<x)d through the arterial
orifices, no impulse against the thoracic walls, no bruit tnuseu-
laire. Hence it seems better, in the present state of our
knowledge, to regard the heart's first sound as really a com-
pound sound. In other wordn, thouph it may be chiefly due
to the tension uf the auriculo-ventricular valves, yet that there
are other causes which aid in iits production. These are the
impulse of the heart's apex npainst the thoracic walls, the
muscular bruit, and the sudden dilatatioa of the aorta and
pulmonary artery.

Cnuit'g and Effect* of Valvular Di$ea»e. — Most of the
alterations in the internal lining membrane of the heart result
from inflammation, which gives rise to a deposit of lymph upon
or beneath the serous membrane. The valves thus lose their
thinness and tran^)arency ; they become thick, puckered up,
and adherent to each other or to the opposite walls of the
cbaonel. Independently oF inflammation, the valves may
become covered with warty vegetations or excrescences, or
they may be converted into bone, or they may be the seat of
atheromatous or other deposits.

The ifftcli arc twofold : either to coDtraot and narrow the

388

DISEASES up LUNOK. HEART. KTP.

orifice and so obstruct the passage of the bluod — vnlvulitr
ebitruclion ; or by thickening and shortening the valves, to
make the orifice more or less patent, nnd hence permit of
regurgitation of blood — valvular innuffirfrnrt/, regurgitant
di»ea*e of vahitt, &c There may be only valvular obetnic-
tion or TalvQlnr insufficiency in any given case ; but often
these condition!- coexist.

Diagnoti*. — In the diagnonis of these diseases attention
must be directe<l, firstly, to the physical !<ipn8; and secondly,
to the chief physiotnjxical or functional symptoms.

1. The Fhysicul SijL'ns. — The natural sounds of the heart
■re liable to be modified or charvj;ed by disease, causing either
sound or both to be ncccuin|janicJ or to be supplanted by a
noise wliich hiis been aptly eompiired to the blowing of a pair
of bellows; hcnco it is termed by us a irllowi-murviitr, and
by the French a btiiil fie noiijfflft. A bellows-ronrninr may b«s
harsh, or rou^h, nr rocjiiip, or whi.-itling, or musical, but these
modificutioiis are nf little importance : of whatever nature, it
ts caused cither by the presence of obstructions which impede
the free flow of bloud tbroujih the heart and its great vessels —
producin<r an onjnnic murmur; or by a supposed peculiar
condition of the blood — giving rise to an inorganie, or fane-
tianiil, or hitmic niurniur. When the valves of the heart are
affected so that tlicy act ineffectively, an organic bellows-
marmur rcsult.s.*

* la the Mirly «tkgp of phthiaU, a marmar may aometime* be dateoted
ander the left clnvicle, uwing perhaps to the preaaure of the tuberolu
upon the left unbdlnrntn iirtorj , while not uncomnioDljr, from some unex*
plained eaufe, a ryrtolic tiellow.i-rnund \f hoard in the second left inter-
ooatal apace orer the [lulrannary artery, the heart and the pnlmnnary
artery tfeing quite heulthy. Moreover, diaplncement of the heart, owing
to the preasare of (ileuriiic efToaioD, aacito^, Ac., may give ri^e ti> a loud
mnrmar which diKS not ilifmjipear nnlil the organ ia reatored to its natural
prmition, by the removal of the fluid . though it muat be confeased that a
hruit under tbeac oirouni^tance^ ia n rare event, for I have frequently
liiuked in vain fur it when the heart htia been pushed cunaiderably np<
warda by the presence of an ovarian tumor.

VALVULAR DISEASES OF THE UEABT.

389

The loudness and distinctness of organic murmurs is not
proportionate to the extent of disease causing them, for
sometimes a very gtunll vegetation on one of the valves will
produce a very loud murmur. Dr. C. J. B. Williams had a
man, thirty years old, under his care, in vrlnim there was a
very loud murmur followitiff the second sound; which, thouph
most distinct in tho midsternuro, was also heard in every part
of the chest, in tho arteries of the neck, and even slightly in
the radial. The man caujiht typhus fever and died ; and at
the pont-mnrtem e.\amiaation it was found that the valves were
all healthy except the aortic, and in the.se the only change was
that one uf them had the free marj^iu neatly retroverted, so aa
to leave a small smooth chink for regur<^itation. The ventricles
were alfio moderately enlarf;cj and thickened.

The lining membrane, valves, and orifices of the left side of
the heart arc much more fre(|ucntly diseased than those of the
right J so much so, (hat it is a!ui«sta<|ucstion whether disease of
the tricuspid or puliiionury valves can be accurately diagno.sed.
" Practically, in at least nineteen out of twenty cases," says
Dr. Harvey, " the fjuestions to be determined are, whether it
be the mitral or the aortic valve that is diiteased, or both ; and
whether the disease be of the nature of valvular obstruction,
or of valvular insufficiency, or both."* Diseases of the left
side chiefly aSect tho arterial pulse, giving rise to irregularity
and inequality ; those uf the right side affect the venous circu-
lation, causing regurgitation into the jugular vein.s — a condition
known as the venous pulse. Dropsy is more often connected
with disease of the rifrht than the left oavities.

Disease of the seynitunar vi/ves of the aorta is not uncom-
mon. If the affected valves diminish the aortic orifice during
systole — or contraction — so as to prevent the blood from freely
flowing out of the ventricle, a systolic bellows-sound will result,
which will be best heard at the base of the heart, along the

* Nottt on Chronic Htart Dueatt — Mediokl AMooiatioo Journal,
Sept. 1st, 1854.

ssa

UISEASES or LUNU8, HEART, ETC.

course of the thuracic aorta, up towards the right clavicle, and
creo in the cnrotids; the sound diminishing ua the stethoRcope
is moved towards the apex of the heart. If the valvcfs cloee
iuiperfcctly, pcrinittiiio; reflux of blood frum the aorta, the
morbid soiitid will be diastolic — will accompany the dilatation
of the ventricle. Tlio pulse of aortic regurgitunt disease is
peculiar, being genenilly sudden and sharp, and without any
prolonged swell of the artery; Dr. Hope ealKs it a jerking
pulse. The t-huH, >ecuud sound of the heart will also bo
mufiled and indistinct. Sometimes we have both these con-
ditions of the acirtic valves in the same case ; a double bruit or
bellows-snunil will then be produced.

The mill-Ill f«/vr, which guards the left auriculo-ventricular
orifice, may beciiniG thickened or ossified ; the effect of which
is to prevent its closing the auricular orifice during systole, as
well as to hinder its lying flat against the walls of the ventricle
80 as to allow the bluod to pass freely out during the diastole.
In such cuT'c^ tliu oritice is almost rendered a permanent oval
slit. A double bruit may perhaps be delected; the first, sys-
tolic, caused by tho regurgitation of the blood from the ven-
tricle into the auricle; the second, diastolic, and due to the
inipedi incut to the passage of the biuod from the auricle to tho
ventricle: it is but rarely heard, however. The murmur or niur-
inurfi will be best distinguished towards the apex of the heart
on the left. The pulso will be irregular. Palpation alsoof^en
discovers a purring thrill Mitral regurgitont is the ulost com-
mon of all the valvular lesions ; while next we must rank aortic
eonatrielivc, then aoriio regurgitant, then mitral constrictive,
and lastly in the same order diseases of the tricuspid and pul-
monary valves. In valvular lesion due to rheumatism, the mitral
and aortic valves are very oflei] affected together.

Dr. Harvey thu.s briefly tabulates the signs of the disease of
the aortic and mitral valves:

Hruit : If tytlolir, and loudest at
ifet»« = Aortic ultfinniion.
Ai>ez^ '•IrrB.AU iumjffii-iett'y

VALVULAR DIHEA8KS OF THK riKART

:i91

= Aortic disease.

= Mitral disease.

Bruit: If liiiuluUc, and loudest at
iJc;/w== Aortic insujffirienry.
Apex = 51 ITRAL obtlruction.

Pulse: If reyular.
Full, or strong,
Jorking, resilient,

Pulsk: If irrrijular.
Intermittent, unequal,
Soft, snmll, weak,

The semil'initr viloes of the piilmonari/ itrterj/ are very
rarely diseased ; so rarely, that any organic alteration in them
is a patholo>;ic!il curiosity. When, however, a bellowH-inurmur
can be traced from the middle of the left edge of the steniuin
up towards the left clavicle, and when this raurmor cannot be
heard in tlie subclavian or carotid arteries, we may a.ssnnie that
it originates at the orifice of the pulmonary artery. The pulse
will be unaltered.

The frnutpid vtihv, iiuardinj; the ri^ht uuriouln-ventricu-
lar opening, is also but seldom found otherwise than healthy.
When diseai-ed, the arterial pulse will be unaffoeted; but there
will be turgcscence, with pulsation of the jugular veins at
every ventricular systole. A bcllows-uinrmur will be heard
over the central and lower part of the sternum, extending
downwards to the epigastriutu, inaudible in the aorta and its
branches.

To determine the systolic or diastolic character of a iiiurniur,
the puLse at the wrist must be carefully noted during ausculta-
tion; if systolic, the bruit must of course be synchronous with
the pulse, and if muni audible at the apex, is indicative of mi-
tral disease; if dinstulie, not synehroiious with the pulse, and
most audible over the centre of the sternum and along the
course of the aorta, it is indicative of aortic disea.se.

2. Physiological and Functional Symptoms. — The following
are the chief:

a. Difficulty of breathing, varying from the slightest dys-
pnoea to the most severe orthopnea ; much increased on ascend-

8»2

DISEASES OF LtlNOS, HEART, FTC.

ing a height or making any exertion, h. Palpitation and
irregttlur action of the heart, with the sounds and munuurs
discoverable by auscultiifion, &c. c. Irregular pulse. In mi-
tral disease the pulse is generuUy soft and irregular; in aortic
hard, jerking, but regular, d. Congestion of the lungs; bron-
chitis; pneuiuonia; pulmonary hemorrhage, with or without
pulmoniiry apoplo.xy; the.se gyinpUjiiis being most urgent in
mitral disease, e. Haiuiorrhages from the nose, bronchial
tubes, or raucous membrane nf the stomach. /. Qidema of
the lower and !<(iiiieiiiiie8 of the upper extremities and face;
hydnitliorax; and ascites. Dropsy is more coin luon in disease
of the right cavities of the heart than in affections of the left.
g. Cephnlulgiu, tinnitus auriutu, vertigo, syncope, cerebral con-
gestion, and cerebral haemorrhage, must urgent in aortic dis-
ease, h. Broken rest, with st-artings during sleep, and frightful
dreams, t. Enlargement of the liver and spleen, with disor-
der of the digestive orgjins generally, j. A peculiar appear-
ance of the countenance, wherein the faoe is pufied, the cheeks
flushed and of a purple hue, the lips congested, and the eyes
bright.

As time advances, the heart disease sometimes becomes more
aggravated. In such cases the patient then gets weak, and
suflFers immediately from over-exertion, mental emotion, im-
proper food, or exposure to wet and cold; and subsequently
death ensues, either suddenly from syncope, or gradually from
the progress of one ur other of the secondary affections. The
latter tertiiinutiun is decidedly the most common.

Proynotii. — The danger of structural cardiac disease will
be ill proportion to the extent to which the change impairs the
power of the heart in carrying on the circulation; as well aa
partly in proportion to the degree to which the blood is dete-
riorated in (jiiality. 80 long as the nutuiul sounds are distinct
and the impulse does not extend far beyond its natural limits,
there is no present danger — provided there be no great amount
of anxniia — however loud or harsh the accompanying murmurs
may be; and even if the general symptoms be distreming, we

VAI.VII.AK IHHKASES OF TlIK HKAflT

'W\

miiv pntertiiin very snnjjuino expectiitions of rclicviiip fliem to
FiK'h an extent tli:it niodt^ratf. health may be ri'>;aiiied. Whether
the iniprovenuMit will persist for any lenjjth of time, will of
course depend upon whether the viilvulur lesion becomes sta-
tionary or agiiravuted ; fur it may so increase, from many eauHes,
aa to develop dnn^rerous diswrder. But if the history of the
case is not that of a sudden or recent attack, and if the phy-
sical signs do not i;row more marked in the course of a few
weeks, a fiivoralile prosrnosis may be given, and hopes encour-
aged of some years of comfort.

On the contrary, if the natural sounds are indistinct or
nearly superseded by abnormal murmurs, (hen it must be in-
ferred that the iieart's power for action is much impaired, and
that there is serious ground for alarm. In such cases, too,
the genend symptoms u.sually plainly indicate that the chief
organ of the circulation is fnilinff in its work; for there ii
irregular action, distressing palpitations, frequent attacks of
syncope, dropsy, and congestions of internal orgiin.sand tis.iues.
Thase cases are especially dangerous where the valvular lesion
is due to some violent exertion ; or where the structural change
has been aggravated by a sudden increase of endocarditis or of
fatty degeneration and consequent softening. When to the
above symptoms there is superadded a thin watery stirte of the
blood, the cause for nlami ia proportionately increased; as is
also the case when the blood ia poisoned by urea, bile, lithio
acid, &c.

TVcotmeiit. — In the treatment of the valvular diseases of the
heart, three indications have gencrnlly to be followed : Ist, To
abate inordinate action of the heart by sedatives — as digitalis,
hydrocyimtc acid, aconite, belladonna, conium, henbane, hop,
and morphia; though these remedies, and especially the last,
must be employed with great caution, for where there is a fee-
ble pulse, dyspnoea, and difficult expectoration, a dose of opium
may but materially hasten death. 2d, To ward off or gradu-
ally relieve the results of the cardiac disease, .such as pulmo-
nary congestion, pneumonia, hnamurrhage, congestion uf lltu

894 DISEASES OF LCNOS, HEART, ETC.

liver nnd kidneys, dropsy, &c., by a nutritious diet, and by
maintaining the various secreting or>;ans in a healthy slate;
saline purgatives and diuretics being very valuable. When
the dropsicul efiu.'jion is great in these instances, much benefit
is often derived from mercury; diuretics which had previously
been useless, often causinir an astmii.'iliin'; flow of urine directly
the pums pet touched. Thi.M latter eftoet is frequently obtained
with difficulty when the obstruction to the circulation is great.
In anasarca of the lower extremities, small incisions along the
legs give great relief, by allowing the serum to drain off; the
uneoinfortablo feeling caused by the flow of fluid being best
mitigated by wrapping the limbs in soft chamois leather. And
then, 3d, We must endeavor to give strength and tone to the
heart, so as to as.sist it to do its work, by nourishing food,
perhaps cod-liver oil, a duly regulated supply of stimulants,
breathing pure air, warm clothing, early hours, cold or tepid
salt-water sponge baths, avoidance of all bodily and mental
excitement, and by the adniinistratioD of tonics, especially
the various preparations of steel.

XXI. HYPERTROPHY OF THE HEART.

The heart is stated roughly to be about the same size as the
closed fist ; its mean weight being between eight and ten
ounces.* The muscular walls of one or more of the cavities of
the heart may become thickened without any diminution in ,
the size of the chamber; this is called simple hj/perlrop/iy.
Or, as moat frequently happens, the walls may bo thickened

* The weight uf the beultbjr heart in pertona from twenty to Ony-five
years of age nverages, in malea, 9 ot. 8 dr., and in females 8 oi. 13 dr.
Eatimatet of Ibia deaoription are of onurae, to a certain extent, arbitrary ;
for aa tbe heart ta foand, in aume ea»a, to be oonaiderubly above its ordi-
nary weight, without tbe proportiun of its walla and cavitiea being mate-
rially altered, or the organ being otberwiae diaeaaed, it ia not caay to aay
■t what point itoeaaeato be healthy. — Dr. PeMOok: Edinburgh Moiuklg
JoKiiuil, Sept 18^4.

HYPERTROPHY OF THK H15ABT.

33.7

and the chamber become larger than natural; this is eccentric
hi/fir.rlrnphi/, or hypertrophy in'th dilatation. On the other
hund, the iniTUHKe in thickDefis may be accoinpunied with
diniinutiun in the size of the cavity; this is known aa coitcm-
tric hypertrophy, and is now believed only to occur as a con-
genital malformation, and never as the conseqaence of disease.

The cnuw of the hypertrophy is usually some obstruction
either in the flow of blood through the heart, or to the free
play of this organ ; hence it is frequently a provision of Nature
to countcrbulatice the impediment. The heart is stimulated to
extra esertion, and in consequence receives an extra supply of
nutritive niutcrials, by which its muscular structure is strength-
ened. The left ventricle is more frequently found hyper-
trophied than the ri^riit, and much more so than the auricles.
In a heart which weighed five pounds, the walls of the left
ventricle had acquired a thickness of two inches. Hypertro-
phy with diliitation of the right ventricle is commonly due to
some chronic disease of the lungs obstmcting the circulation.

The symptoms will depend upon the extent of the hypertro-
phy ; frequently they consist of palpitjition, dyspna^n, difficulty
of walking quickly, uncasine.'*s and pain in the cardiac region,
beadaohe, and frequent attacks of vertigo. If we listen to
the heart's movements, we shall find the systolic sound less
distinct than in health ; but we shall also feel that the extent
of the pulsation beyond the prsecordial region, and especially
the degree of impulse against the walls of the chest, are both
much increased. Moreover, when there is valvular disease,
the morbid sounds indicative of such will be present.

The trtattncnt must consist in keeping the patient as quiet
as possible, and in prescribing for his symptoms. If there be
much debility, steel, bark, or the mineral acids { F. 443, 445,
449, 458, 471, 488, 496) may be given; if the heart's im-
pulse be very g:reat, aconite or digitalis (F. 373, 374, 380,
381) may be occasionally, but cautiously, tried; when the
dyspnea is urgent, stimuluuts, especially ammonia and sul-
phuric ether (F. 120), may be bad recourse to. Dr. Hope

398

DISEASES OF LliNOS, HEART, ETC.

observes that the art of treating hypertrophy conaiste in keep-
ing the patient rather low, and the circulation tranquil, abort

of producing anfcmia or debility.

Simple Hypertrophy of the Left Ventricle with no Ob*
Btruetion to the Flow of Blood. — Thi.f condition is raa-. On
auaculting the heart the systolic sound is less loud and clear
than natural, but no bellow.s-n]urmur is heard. On placing
the hand over the precordial refrioii, the impulse of the heart
will be found increased.

In many cases of chronic Bright's disease, there is found
liyportiophy of the heart — especially of the left ventricle —
without any disease of the valves or lar-'c bloodve.'«el8 existing
to impede the flow of blood, and thus to expluin the increased
bulk of the muscular walls. In these cases it issupposed that
the blood is impeded in its passupc through the minute sys-
temic vessels owing to its contamination by excremcntitious
materials in consequence of the renal degeneration ; and hence
the loft ventricle has to make extmordinnry efl^orts to propel
the blood, and of course acquires increased hulk and strength.

Hypertrophy of Left Ventricle with Valvular Dis-
ease.— This is the most common furin uf hyportniphy. The
chief causes are — " Defective aortic valves, permitting regur-
gitation of the blond into the left ventricle during its diastole;
constriction of the aortic orifice, impeding the free passage of
the blood from the left ventricle during its systole; deficiency
of the aortic valves, a.ssoeiatcd with con.sfriction of the aortic
orifice ; defective mitral vulves, permitting regurgitation of the
blood from the left ventricle into the left auricle; — all these
abnormal conditions occasion impediments to the circulation
of the blood through the heart, and their immediate efiFlBota
are, for the most part, communicated directly to the left side,
and indirectly to the right side of the heart."* As the hyper-

• Dr. Markham. Opiiieii., p. lij.

ATROPHY OF THE HEART.

397

tnipliy in these cases is an endeavor — so to speak — towards
lieiiltb, the increased power compensatina; for the obstruction
to the finw of blond caused by the vaWulnr disease, we must
not unnecessarily interfere with the sytnptouis.

Dilatation of the Heart. — Thismny occur under three cir-
cumstiince.i. First, there may be, as has been just shown,
hypertrophy with dilatation ; this condition being known as
inlive diliitntwn, when the dilatation predominates over the
hypertrophy. Secondly, we have simple ili/nintioii, where
the thickness of the walls is normal. And thirdly, there is
pitfxive liihitalion, the walls being thinned. This la.-it is the
only state which demands a few words. It is often combined
with degeneration of the niusctilar fibres, both ventricles are
usually aflected, and the attenuation may be so extreme that
the walls are found quite collapsed after death. Passive dila-
tation may be due to some exhausting di.scase, or to iiiflamnia-
tion of the endocardium, or perhaps to pericardial adhesion ;
it causes the heart's impulse to bo feeble, the apex beat to be
almost invisible, and the sounds to be transmitted to only a
short distance ; while the patient gets weak and irritable, he
suffers from asthmatic paroxysms, palpitation is often distress-
ing, attacks of syncope are not uncommon, and there is ana-
sarca fcllnwed by ascites. Antispasmodics and tonics are the
only remedies which afford temporary relief.

XXII. ATROPHY OF THE HEART.

There are two forms of atrophy of the heart. One, in which
the organ simply wastes and dwindles in all its parts ; the
other, in which the texture of the muscle suffers a sort of con-
version info fat — becomes affected with fatty degenemtion.

Simple atrophy occurs in connection with many exhausting
diseases, — as cancer, tuberculosis, diabetes, dtc. The whole
organ diminishes in size ; so that after death it may be found

398

DISEASES OF LUN08, HEART. ETC.

to weigh about five ounces instead of nine. Minutely exam-
ined, the mu.scu!ar fibres are found pale and soft, but other-
wise healthy. The treatment uiu.iit be that which is demanded
by the constitutional aifeotion, of which the atrophy is merely
one gyniptoin.

Fitllji ileijmrrntion of the heart is a most interesting dis-
ease, which has been already incidentally noticed (p. 124),
The student who wishes to study the subject thoroughly luay
be especially referred to the writings of Dr. Richard Quain,
Ormerod, Paget, Barlow, Wilks, and Virchow.

This disease occurs under two circumstances; either alone,
or in conjunction with futty disease of the other organs, as the
kidneys, liver, cornea, &e. Its dunjnoth is beset with diffi-
culties, and when existing alone it is frequently not suspected
until after death, and after a microscopic examination of some
of the muscular fibres of the heart. The most prominent
tymploms are feeble action of the heart, remarkably slow pulse
— soractimos as low as fifty or forty-five, general debility, tmn-
sient attacks of giddiness or faintness, and a feeling of ner-
vous exhaustion, loss of tone, &o. The sounds of the heart
arc weak; and in advanced cases there are attacks of dyspncea,
with mony ur all of the symptoms which prevail in angina
pectoris. When in addition there is well-marked arcus senilis
— due, an Mr. Canton has shown, to fatty degeneration of the
edge of the cornea — the diagnoxis may perhaps be facilitated;
though in many cases of arcus senilis the heart is quite healthy,
while the latter is often affected with fatty degeneration with-
out the arcus being present. This disease seems to occur
rather more frequently in men than in women : it may take
place at all ages, though it happens principally at advanced
periods of life: nil classes of society may suffer from it; it
may exist singly or with other cardiac diseases : and it is not
an uncommon cause of sudden death.

" On opening a heart thus affected," says Dr. Ormerod,
" the interior of the vciitncles appears to be mottled over with
buff-colored spots of a singular zigzag form. The same may

ATRdPIIY <IF THK HEART.

ann

be noticed beneath the periciirdiurn also; and in extreme cases
the same appearance is found, on section, to pervade tiie whole
thickness of tlie wuIIh of the ventricle and of the carnesB
columnae." On microscopically exaniinin<: these spots, their
nature is revealed; they are not deposits, but degenerated mus-
cular fibres. Instead of seeing transverse stri:e and nuclei, the
evidences of a healthy state, little can be distinguished but
a congeries of oil-globules. The muscular fibres are also found
to be short and brittle ; and Dr. Quain has pointed out that
the coronary arteries are often obstructed. Mr. I'agct well
remarks that " the principal characters which all these cases
seem to present is, that they who labor under this disease are
fit enough for all the ordinary events of cairn and Cjuiet life,
but are wholly unable to resist the storm of a sickness, an ac-
cident, or an operation." From the foregoing it will appear
that the pro(/iioiiis is always unfavorable. Dilatation, ruplure,
and ancurisin of the heart are prominent changes most fre-
quently found in connection with this affection.

Sometinie^ the fat which is norninlly deposited npon the

heart is increased on and amongst the niusewlar fibres to a

,.|QOrbid extent ; and we thcu speak of the condition wbicb

Bults as /altjf growth. This may happen alone, or in con-
junction with general obesity ; or it may be associated with
fatty degeneration. It is ptissiblo that the arcus senilis much
more frequently accompanies these cases of fatty growth than
those of futty degeneration. The syiuptoms of fatty growth,
when it exists alone, are those of a heart impeded in, the per-
formance of its functions.

In the present state of our knowledge, the treatment of a case
of suspected fatty disease of the heart resolves itself chiefly
JDto preventing further degeneration of tissue. The means
to adopt therefore are — good nourishing food, attention to the
digestive organs, pure air, early hours, gentle exercise, the
avoidance of everything which enn hurry the circulation, and
the use of ferruginous tonics. Soda-water will prove useful
aa a drink ; a little brandy or sherry may be given with it.

400

DISEASES OP Ll'NilC HUART, ETC.

The patient should use daily a snlt-water sponging bxth. Some
authors object to the use of fat meats, of niilit, and indeed nf
all ulea;:itious foods. But it is ditBcult to understand the
ground on wiiich these restrictions are recommended ; since
the disease is a dej^oiiertition of tissue, t-aused by debility or
a wearing-out of the fninie, rather than by an excess of power.
Hence I believe that cod-liver oil, cream, and milk, may gene-
rally be given with great advantage.

XXni. CYANOSIS.

Cyanosis (xumni^, blue, and vuvo;, disease), morbus caeru-
leus, or blue diso-ise, are terms applied to a condition charac-
terized by blue or purplish discoloration of the skin ; arising
generaHy in connection with some malformation of the heart.

The ch'mi' malformations are — permanence of the foramen
ovale, allowiiip; a passage of the blood between the two auri-
cles; abnormal aperture* in some part of the septum of the
auricles or of the ventricles ; orir:iD of the aorta and pulmo-
nary artery from a single ventricle; transposition of the origins
of the larije vessels from the heart, the aoitsi arising from the
right and the pulmonary artery from the left ventricle ; ex-
treme contniction of the pulmonary artery ; or, lastly, con-
tinued p:itcscencc of the duetus arteriosus, permitting a mix-
ture of the bloods of the aortJi and the pulmonary artery.

Three explanations have been given as to the immediate
cause of the discoloration of the surface in these eases of mal-
fornialion. Thus, some pathologists refer it .solely to general
venous congestion ; others regard the intermixture of the two
currents of blood as the cause; while a third class believe that
it is partly due to eonsrestion of the veiunis .system, and partly
to the intermingling of the venou.s with the arterial blood.
The truth is probably this, — that the discoloration is owing to
systemic venous congestion, but that it may be nggravoted by
certain malformations. On the other hypothesis it seems iiii-

ROPTPTIE OF THE HEART.

401

possible to explain the admitted facts, that maHormations per-
mitting the free ndmixture of arterial and rcnous blood may
exist without givin<5 rise to cyanosis ; while the latter is some-
times found where no such admixture could have taken place.
The cause of the general renou.<; congestion is some obstruc-
tion to the flow of blood through the lungs or from or into
the right ventricle ; such obstruction frequently consisting ia
a contraction of the pulmonary artery or its orifice.

In addition to the discoloration of the skin, the patients
who survive their birth suffer from coldness of the body, pal-
pitation, fits of dyspnoea, syncope on the least excitement, con-
gestion of internal organs, and dropsical effusions. The dis-
coloration is geueruUy increased by aught which excites the
heart's action ; while if there is no valvular lesion the sounds
of the heart will be found normal. In some few cases the
symptoms of cyanosis are not manifested until many months
after birth. Infants affected with the disease generally die at
a very early age; but, occasionally, they live on even to the
adult period.

The trratmevi must be simply palliative, the organic cause
being irremediable. A very nourishing diet, warm clothing,
the avoidance of fatigue or undue mental excitement, and re-
sidence in a pure miJd air, will give the sufferers from cyano-
sia every chauue of life which oau be afforded them.

XXIV. SUPTUaE OF THE HEAET.

Rupture of the heart may occur .spontaneously from previous
disease, or it may be cau.sed by external violence. Rupture
from disease is much more frci|uent on the left than on the
right aide of the organ ; whereas, when it occurs from exter-
oal violence we find just the reverse. The laceration most
commonly has its seat in the vetitricles, and in that of the lefl
lide when disease is its source. Rupture of the valves or
their tendons is generally the consequence of a prior attack

34»

4132

nTHEASRS OF LrNCK, ORART. KTr.

of eadocanlitis ; whereas laoention of the niOMulM' vail i>f
the heart most freqaently is symptomatic of fattj dcgeDemlion.
The rupture takes place as fre<|nently at the apex as at the
base ; the immediate cau.«e Ls asually some suddeo strain or
emotion ; it occurs more frequeotl; in males than females ;
and its occarreiice is rare aniil after the fiftieth or sixtieth
jear.

Where death is not the immcdiute result of this accident, the
symptoms which indicate its occurrence are great orthopnuM,
intense prustniliun, syncope, and convulsions. la laceration
of the valves, of the chordse tendineie, or uf the mnsoali
papillares, there is sudden great oppression about the praa-
oordia, together with n loud endocardial bruit.

In the majority of cases, rupture of the heart kills instanta-
neously ; not 80 much, however, as a rule, by the loss of blood,
•8 by the embarraf>sinent to the play of the heart or lungs
which arises from the extravasation. In more than one
instance the patient has been known to survive some hount,
or eyen days, the wound having become plugged by coagala,
so that the cxtruvasntion of blood into the pericardium took
place slowly and gradually.

XXV. ANGINA PECTORIS.

This is a pRroxjsmal <lisca.se, first described by Dr. Heberden
in 1768, who called \ttt dwiriier of the breast ; remarking that
" the sunt nf it and the scn.?e of slranglinp iind anxiety with
which it is attended, may make it not improperly be called
iingina peclorit," ft is not of very frequent occurrence.

The Bj/mpinmii consist of paroxysms o( intense pain about
the pnocordial rc^'ion, aecompiinicd with a feeling of suffooa-
tion,and a fearful sense of impending death. The pain io the
breast is variously described by sulTcrers as lancinating, burn-
ing, or oonstrictive ; and it utten seems to radiate from the
centre of the Ht«rnum to the neck, or to the bauk, or to the

AXniNA PECTORIS.

4'^.3

k'fl slioulder iinJ arm. If the paroxysm eoiue on while the
p;itii;nt is wulkinj;, iiiniu'dinte rest is necessary, the atiauish is
80 extreme for the time. During the attack (he pulse is sluir
and feeble, the breulhiiig short and hurried, the countenance
pale and anxious, the surface of tlic body cold and perhiips
covered with a clammy sweat, while the consciousness is un-
impaired. As the attack passes off, the patient regains his
usual health, aud perhaps appears perfectly well.

The duration of the seizure rarely exceeds a few minutes,
thoufi^h it may lust for lialf an hour, or an hour, or even longer.
The attacks occur at uncertain intervals of weeks or months;
but in confirmed cases the periods of recurrence ajiproxiraate
more and more with each successive paroxysm. The seizure
may oome on at any lime, not only when the patient is walkinr;,
but even when in bed. The pairi is nxjst severe, and is attended
with a fceli(i<: as if life were about to cease ; and in some oases
the paroxysm has at once proved fatal.

It necessjirily follows from the foreiroin<i, that the prw/zion'ir
is very unfavorable; for if death do not occur in the first or
second seizure, it generally does so in sotno subsequent attack.
The disea.'<o occurs most frei|uently in advanced life, and is much
more common in ineu than in wi)iio:'n. Inscntie few instances
it has secTued to h;ivc .some connection with fjoul ; and I have
read of gout and angina pectoris allernatinp with each other
in the same iudividuul. But I apprehend this only happens
in gouty subject.* who have a weakened lieart, either from
attenuation or iVmn fatty degeneration.

With regard to the patholoiji/ of angina pectoris, it may be
said that our improved nieuns of observation have rendered it
almost certain that this disease is always associated with suuie
important organic cjirdiac affection. In many instances fatty
degeneration of the muscular fibres of the heart has been
found; a condition wliich, sometimes at least, seems to be con-
nected with partial obstruction of the coronary arteries.

Sir John Forbes, in an essay published in 1S33, before the
value of the microscope was appreciated, collected the histories

404

DI8EASEB OF I.UNOa. HEART, ETC.

of forty-five cases of angina pectoris, in which the boilv wxs
examined after death. In two of the ca-'^es there was disease
of the liver only; in four there was nothing morbid except an
excessive coating of fat about the heart; while in the remain-
ing thirty-nine there was found organic disease of the heart or
great vessels. Of these latter ca^es, in ten there was organic
disease of the heart alone; in three of the aorta alone ; in one
of the coronary arteries alone. But there was ossification, or
cartilajrinous thickening of the coronary arteries, combined
with other disca.se, in sixteen inistances ; and there was disease
of the valves of the heart in sixteen cases likewise. The aorta
wos diseased in twenty-four cases, and in twelve there was pre-
ternafura! softness of the heart.

The trfntmenl during a paroxy.sm consists in the adminis-
tration of stinuilant*, as ammonia, wine, and brandy; and of
antispasmodics, such as ether, opium, chloroform, hydrooyanio
acid, &c. 1 have found Formula 107 cxcocdinirly valuable.
The patient should keep the medicine by him, in order that it
may be taken on the least threatening of an attiick. Sinapisms,
turpentine stupes, and hot fomentations, will help to relieve the
suffering.

The return of the seizure is to be guarded against by im-
proving the general health ; by great attention to diet; by the
occasional use of well-selected tonics ; and by the avoidance of
stimulants, strong exercise, walking soon after meals, and all
mental excitement. A belladonna plaster worn constantly over
the prmcordial region may do good.

XXVI. CARDIAC ANEURISM.

Aneurism uf the heart was formerly said to occur in two
forms. Either wa a simple dilatation of the wall of a ventricle,
forming the improperly called passive aneurism of Corvisart;
or as a pouched fulness arising abruptly from the yentriolc,
constituting a tumor on the heart's surface. The latter is the

CARIUAC ANELKISM.

4(1'.

only disease to which the desi<:niition of cardiac aneurism (or
partial dilatation) should bo applied In it the tuiiror may
vary in size from that of a small filbert to a growth the size of
the fist ; the sac is found to contain layers of fibrin or laminated
coapula uf blood, espeeiully when its mouth is constricted, like
arterial aneurisms; while it generally has its seat in the left
ventricle, much more nirely in the led or right auricle, but
never in the right voiitriele.

According to Rukitaiiskv there are two distinct kinds of
cardiac aneurism. The first or acute variety depends upon a
laceration of the endocardium and muscular tissue, through
which the bkwd passes and graduidly makes a pouch ; while
ill this pouch libriii is deposited, its entrance presenting a
fringed margin of encJocardium with vegetations attached.
The second or chronic form is the result of some inflammatory
condition of the muscular fibre, or of the investing or lining
membrane of the heart. The walls of the sac consist of the
endocardial and pericardial meinbranes unbroken, while the
muscular fibre seetns to be replaced by a fibroid tissue. Either
kind gives rise to symptoms which are uncertain and obscure.
Often the passage of the blood into the sac has caused a murmur,
but this has been mistaken and thought to be due to some
valvular lesion. Death usually takes pliice suddenly from rup-
ture into the pericardium, or into the plenra — if the free
surfaces of the pericardium be adherent, as they often are in
these cases.

The coroniiry tirlerien may be diseased. Aneurisuial dila-
tation and rupture of these vessels is not a fretjuent event. In
the inst.anees which have been recorded there hiive been no
symptoms during life to allow of a correct diagiuisis; while
death has occurred suddenly, the pericardium being afterwards
found filled with blood,

PART V.

DISEASES OF THE ORGANS OF
DIGESTION.

I. INFLAMMATION OF THE TONGUE.

Glossitis, or inflanuuntion of tUe substance of the tongue,
ia generally mot with nm an accompaiiiinent of other diseases,
mthcr thiiQ as an idiopathic nffcetion. When it Arises idio-
pathically, fjlossitis iiives rise to fever, tuental depression, and
general weakness. In all cases the local symptoms are the
same, coosistiug chiefly of pain, heat, and swelling; the tongae
is found of a deeper red color than usual; and occasionnily
the swelling proceeds to such hm extent that the cavity of the
mouth is not lar^e enough to contaiti tlie organ, and it projects
beyond the teeth. This condition, which often occurs very
rapidly — sometimes in a few huure — is attended with urgent
dyspnwa and requires prompt treatment. Active purgative*
should be administered by means of enomata ; the vapor of ho^
water can be applied to the tongue itself; pencilling the orgtt^
with nitrate of .silver may reduce the swelling; and if neo^^
sary, incisions must be made to relieve the congestion, or t^^ x
out the pus if the tuorbid action has gone on to supr'>
If suffocation be threatened, owing to the eiiliirgcnv
root of the tongue, tracheotntny ouirht t<> be perfffl
Benjamin Bell saved a patient's lifn by this
case of glossitis produced by mercury.

INFLAMMATION OP THE TONOUE.

407

Thcre are severnl varieties of vlcem of the lovijiu, mo8t of
tlicra beiog very painful, and difficult to heal. When they
are the result of simple inflanintotioD they are usually small,
superficial, without definite shape, and very sensitive ; they
are seated about the tip or near the fraanum rather than at the
sides of the orpin ; and they are to bn cured by mild diet,
purging, the application of sulphute of copper, and the remo-
val of the tartar from any teeth which maybe irritatinj; them.
Ulcere occurring after ptyalisra are easily distinguished by the
accompanying affection of the gums and fcctor of the breath ;
they will be most readily healed by the adniinistratien of saline
purgatives, and the use of a gargle formed of two grains of
sulphate of copper to each ounce of water. Syphilitic ulcers
are generally superficial, attended with siinilur disease of the
lips or other secondary symptoms, appear at the sides of the
tongue, are very sore, arc very intractable, and are best treated
by calomel and opium every night, or by tiie inunction of mer-
cury together with the application of nitrate of silver. The
deep syphilitic ulcers usually commence as inelastic indura-
tions, which slough in the centre ; the sores then become deep
and excavated, the edges ragged and sloughy or thickened
and hard; their most frequent seat is the upper and back part
of the tongue ; they are accompanied by other tertiary symp-
toms ; and they are generally cured — at least for a time — by
iodide of potassium and the fref|uent use of a gargle of one
drachm of the dilute nitric acid to eight ounces of water. The
remaining forms of ulcerations are either strumous, tubercu-
lous, or cancerous; they occur for the most part with other
symptoms of these affections ; and they retjuire the general
[constitutional treatment proper for each affection, espeuiallj

!-liver oil.

Vrtiiked louijiie is sometimes a troublesome and inre(ent«

eating and speaking very painful. Wkace

Bo conditJiBSfiL the system, or do dnmage-

iry ' ^unt for iv, I ha:tm t&mad m

) act veij

408

DISEASES OF THE ORGANS OF DIGESTION.

ludide of potussium nrith 8tcel or rarsapanlla (F. 31, 3tt, 38)
may likewise be administered, if local remedies fail to effect a
cure. The clefts or fi.ssures may be a couple of lines in depth,
and so numerous thut they form an irrcsalar scries of grooves.

The surface of the tongue occasionally presents palchet of
bfildnest — that is to say, one or more smooth, oval, g:los8y
pntches. There is no ulceration or fissure, and the remainder
of the surface of the orgjin is healthy. This appcannce is
oonibiDed in many ciiscs with psoriasis palmaris ; and is proba-
bly very often indicative of a syphilitic taint, when it will
require a prolonged course of the bichloride of mercury (F.
24) for its cuie.

Warts and ivmlylomnfa are not uncommoD diseases of the
mucous membrane of the tongue ; the former merely requiring
excision, while the latter demand anti-ayphilitic medicines.
And lastly, papillari/ patches are sometimes met with ; or,
in other words, wc find large spots of the mucous and submu-
cous tissue thickened, tough, brawny, coarsely papillary, and
perhaps fissured. These patches produce an unpleasant feel-
ing, with thickness of speech ; they must not bo mistaken for
cancer; and they may generally be cured by the administra-
tion of the iodide of potassium. When much induration is
present, coiiiura, in large doses, appears to be an efiBcaoious
remedy in producing softening.

II. INFLAMMATION OF THE MOTITH.

Stomatitis, or inflammation of the mouth, is a commoD dis-
ease in young children. It may occur in three forms — t. «.,
according as the prineipal seat of the morbid action is in the
mucous follicles of the mouth, the substance of the gum, or
the tissues of the cheek.

1. Follicular Stomatitis. — Inflammation of the mucous
follicles of the mouth — the aphthous stomatitis of some an-

■I

INFLAMMATION OF THE MOITII.

409

thors — is tlie mildest form of stomatitis. It uia; be idio-
pathic, or it may occur as a sequela of some of the eruptive
fevers — as measles, Jtc. The attention is first directed to the
child's uiouth by observing that a dilficulty seems to be expe-
rienced in 8uckin<;, that there is a more free secretion of saliva
then usual, and tliiit the submaxillary ginnds are tumid and
tender. The patient is also restless and feverish, has but
little appetite, seems to experience pain in deglutition, and
frequently suffers from diarrhoea with very offensive evacua-
tions. On eiauiiiiutioii, numerous bniall vesicles are found
about the inside of the mouth, on the tongue, and ou the
fauces ; which vesicles by bursting, form tittle ulcerations
covered with a dirty white or yellowish slough. These uicera-
tioDS sometimes remain separate and sometimea coalesce, form-
ing a sore of considerable extent ; to either case, as they heul,
fresh vesicles appear, which again degenerate, and so the mor-
bid action may continue fur some weeks. When follicular
stomatitis occurs as a concomitant or secjucla of measles, it may
become associated with diphtheria and produce an alarming
malady.

In most cases very simple treatment, such as that presently
to be recom mended in thrush, suffices to effect a cure.

2. TTlcerative Stomatitis, or Noma. — This disease attacks
tbe gums ; the ulceration sometimes progressing to such an
extent as to destroy these parts and denude the teeth. In all
cages it produces heat of the mouth, an increased (low of saliva,
offensive breath, swelling of the upper lip, and enlargement
with tenderness of the submaxillary glands; while on looking
into the mouth we shall see that the gums are swollen, red or
violet-colored, readily bleeding to the touch, and covered with
a layer of pulpy grayish matter. If the disease be allowed to
creep on unchecked, the gums will get destroyed by the ul-
ceration, and the teeth become exposed and loosened until
they tall out ; the morbid action also spreads to the inside of
the checks, which become covered with irregular sloughing

410 DISEASES or THK ORGANS OF DIOESTION.

ulcerations, and the tongue assumes a swollen and sodden ap-
pearance. Ulcerotive stomatitia is not uncommon ; it occura
for the must part in weakly children who have been badlj
nourished, and exposed to cold and diiinp.

The treatment of this disease \a not difficult, inasmuch as
we possess in the chlorate of potash a remedy which may
almost be deemed a specific* Five prains of this salt may be
piven every luur or six hours to an infant one year old, in a
little supar and water. When the ulcerations have healed,
bark or quinine should be administered.

3, Gangrenous Stomatitis. — Gangrenous stomatitis, or con-
crum oris, or sloughing phagcdeena of the mouth, is a much
more furmiduble affection than either of the foregoing. It
occurs in children of debilitated habits, between the ages of
two years and five. The si/mptomt are generally these : The
child is out of health, and evidently weak; and on one cheek
is a hard indulcnt swelling. On exuuiiuiiig the cavity of the
mouth, a whiii.sh or ash-colored eschar is seen in the centre of
the check; which gradually increases until the slough baa
spread over the whole of the interior of the cheek, lips, and
gums, The saliva is copious, and horribly fetid. There is
great constitutional disturbance, and the disease frequently
ends fatally. — It has often been unjustly attributed to the ac-
tion of mercury; it may oceur when not a particle of thid
medicine has been given.

The treatment must consist in the application of the nitrate
of silver — in some instances, of the strong nitric acid — to the

* From th« cffectf of thii agent in nuinrroDsoa««aMr. HutcbinsoDcon-
oludttB; 1. Tliat chlorate of potm^h ('OMefSet ft peculiar influenoe over sli
iDflammatory nSections of the mouth, the v^philitie perhaps excepted. 3.
That it pos»i>e!i a peculiar indueDce o>er infliimmalionii atteoded with
phagednoa or itloughing. on whatever part of the body vituated. He ra-
GotnmendR fire grnios aa a fair ordinary dope for infante of one year, whit*
for thoae older it nhould be proportionntely increased — a scrnple or half B
draobm being the quactitj for an adult. — Mtdiail Timu and Gutltt,
Aagut 23d, 1866.

INFLAMMATION OF THE PAROTID.

411

slough; in frequently gjrin^ing the mouth with solutions of
chloride of zinc or of chlorinated soda (F. 104, 313); and in
the free adniinistratit.m of strong beef-ten, wine, or brandy, and
the chlorate of potush in decoction of bark.

ni. APHTHAE OF THE MOUTH.

Aphthna consists of small round white specks or patches,
scattered over the tontjue and lining membrane of the mouth.
They form a special disease in infancy — the thrush ; in adult
age they are apt to arise in the course of other diseases, when
they are often the harbingers of death. In at least some forms
of this disease, microscopical parasitic plants — the Lfptothrix
bncralix and the Oufiiim (il/n'canr: — are developed in large
quantity; and are, in fact, the cause of the peculiar appear-
ance presented by the di.seose. The treatment of the thrush
consists in the u.so of mild alteratives and tonics, and the ap-
plication of borax and glycerine (F. 321, 322) to the aphthous
parts.

Dr. Jenner states that in cases attended with the formation
of parasitic plants, the application of a solution of sulphite of
soda (5j to water gj ) suffices to remove the disease from the
uiucouB membrane of the mouth in twenty-four hours. The
aeoretious of the mouth being acid, the salt is decomposed, and
sulphurous acid is set free, which at once destroys the parasite.

IV. INFLAMMATION OF THE PAROTID,

Cynanche parotidsea, or parotitis, or the mumps, is a specific
contagious inflammatory affection of the salivary glands, and
of the parotid gland espeeinlly. It first manifests itself by
slight febrile disturbance, with tumefaction and soreness in one
or both parotid regions; the swelling extending fnmi beneath
the ear, along the neck to the chin, and involving the sub-

412

DI8EA>^E8 llF TlIE ORGANS OP DlflRHTroX.

masitlary fclands. The disease reaches its height in four dajrs,
and then declines. Occasionally, during or after the decline,
the testicles or niamni^ bfcome pninfiil and swollen.

When orchili.ihas occurred during tlie prevalence of inumpe
it hafl iisuallj been considered as the result of metastasis. In
nn epidemic of catarrhal fever, however, described by M. Des-
biirrcaux-lk'rnard, of Toulouse, to which the prevalence of
mumps imparted a peculiar character, this explanation could
hiirdly be adopted; inasmuch as in several patients the affec-
tion of the testis appeared at once, without any preliminary
affection of the parntid whatever. It cauio on during the ca-
tarrhal feverj the piiin, however, being only slight, and the
tumefaction xssoming a globular form. Individuals of all ages
were attacked, and .neveral of those were patients in the boepi-
tal, suffering or convalescent from various serious di.seases.

The treiitmrnt — when any is necessary — ooniiistd in the
employment of gentle laxatives, mild diaphoretics, and hot
fomentations, or merely flauuelj to the throat.

V. INFLAMMATION OP THE TONSILS.

Cynanche tonsillaris, or tonsillitis, or quinsy, or eoramon ia-
flammatory sore throat, uiiinilcsts itself by smart fever, redness
and swelling of (he fauces and tonsils, and difficulty of deglu-
tition ; togethei' with — in severe cases — pain shooting from the
throat to the Ciir, along the course of the Eustachian tube.
Dyspnoea is but rarely prt'scnt. Under ordinary eircumf.tancc6,
the inQnmmatioo runs a certain course, and terminates by reso-
lution in a few days, merely leaving the tonsils enlarged ; when
violent and prolonged, however, it frof|ueiitlj leads to suppura-
tion in one or both toucils. Rigors often announce the sup-
puration; and the pain is very severe until the abscess bursts,
or is opened artificiaSly.

The principal exciting cause of quinsy is cold. The liability
to it is increuBcd, during the youthful period of life, by repeti-

DISEASES OF THE (ESOPHAOtlS.

418

tions of the attacks. It is doubtful whether it be contagious
or not; but most practitioners assert that it is not.

The Irfatmeiit required is usually very simple. A few dases
of some cooling miline purpative, and hot fomentations or
linseed meal poultices to the throat, will often be all that is
necessary. The steam of poppy-water applied to the fauces
gives g;reat relief; and I have frequently found benefit from
opiate gargles (F. 311). Blistering the outside of the throat,
or the application of stimulating embrocations — as the com-
pound camphor liniment — has seldom done any good in my
hands; and I much prefer using freely the extract of bella-
donna, and applying a large poultice over it. Guaiacom in
large doses has been recommended as a specific in quinsy, but
I have never found it of much service.

When the inflammation has gone on to suppuration, it will
generally be necwwary to open the abscess. In doing this care
mu.st be t^kcn to puncture the tonsil in a direc-tion inwards;
for it has on several occasions happened that an awkward and
unskilful operator has, by inattention to this rule, wounded the
internal carotid artery. Should sueh iin accident happen, a
strong solution of the perchlorideof iron must be quickly and
freely applied to the wound; this excellent styptic having
arrested the hromorrhnge in a case, where — had it failed — a
ligature would have been placed on the trunk of the common
carotid artery.

Permfinettl eulargemttnt and xnihtration of the tontih may
result from acute inflammation, or this state may como on
slowly in strumous children and weakly young women. Por-
tions of the glands must be excised, if the applications which
have been recommended (p. 383) fail to effect a cure.

VI. DISEASES OF THE OESOPHAGUS.

The oesophagus is not often subject to disease. Occasion-
ally, however, this canal becomes the seat of cancer, or of

3-1 •

414

DISEASES OF THE GROANS OP DIOKSTION.

inflammatinn, leading to stricture. The latter may also result
from simple spasnicxlic contraction, but then it is only tempo-
rary ; or from the pressure of aneurisnial or other tumors ; or
from destruction of the mucous membrane and the effusion of
a fibrinouH material into the submucous areolar tissae, the
consequence of swallowing the strong niincral acids or eaustio
alkalies. I have seen only one insturicc in which inflamma-
tion and ulceration occurred, followed by stricture, without
any appreciable cause.

Disciise of the pharynx and oesopha^s is attended by one
prominent symptom — dysphafiia. Difficulty in swallowing
may likewi.se arise from ton.sillitis and diphtheria ; from ery-
sipelatous or other inflammation of the areolar tissue of the
neck, or retro-ph!iryn<;eal absee.=.s ; from panilysis of the mus-
cles of deglutition ; from malignant, ajphiiitic, and tuber-
cular ulcenitiotis about the epi|^Iuttis ; and rarely from disease
of the laryngeal earti Sages.

Simple tik-craliiiii u/ the ampkngu* is a peculiar disease,
the patholngy of which is obscure. The chief symptoms are
difficulty ill swiiUowing, sonietiuies so great that deglutition
is impiisailjle ; pain at the epigastrium, or at the top of the
ftternum, or between the shoulders; with a frequent sense of
nausea, emnciotion, and debility, and considerable mental dis-
tress. Nut unfrcquentiy the ulceration extends into the
tntchea ; while it has also been ktiuwn to progrcas until it has
made a communication between thea-sophagus and one of the
bronchi — especially the left, or between the cesuphagus and
either the pleura, pfrifardiuin, or aoita. The remedies which
are chiefly u.seful in these cases of ulccrnliuii are tonics, iodide
of potassium, eod-livor oil, a very nourishing diet, and sea-air.
I have no doubt that life might have been saved in some of
the recorded cases by the formation of a gjistrie fistuli* in the
manner presently to be described.

Ciincer it/ the crKiiphni/nii may occur at any one part of the
tube, or lhrou;;li its whole length and circuinfcrenee. Th"!
diacusc may be of the scirrhous, or medullary, or epithelial va-

DT8EABE8 OF THE (EBOPnAOUS.

415

riety ; the latter pmbably boing the most common. When it
occurs as a priinary disorder, distant organs arc but rarely im-
plicated in the ciincerouB affectiim, possibly, because of the
rapidity with which it destroys life. It gives rise to obslruc-
tiou, so that after a time not a purticle of nourishment can bo
passed into the stomach ; while ju.st above the constriction
there often is formed a pouch where food accumulates until it
is rejected. There is also considerable pain in the canal, or
in the buck, or in the shuuldcrH ; hiccup is not uncommon ;
there is eouietimes h«5inorrhage, occa.sionally fiital through ex-
tensioD of the ulceration into enlarged veins ; the patient
wastes rapidly and to a wonderful extent; while the cancerous
cachexia becomes plainly established. Death may occur from
inanition ; or from the ulceration involving iniportjint parts ;
or from destructive inflammation of the lung, owing to the
iniplieation of one of the pncumogastric nerves. We can
only hope to give temporary relief by the use of opium and
nutrient enemuta.

Simple stricture of thf cemphagut is generally an afler-con-
sequence of the attempt to swallow some corrosive poisim.
Dr. Basham has recorded* a very interesting example, which
will show the coarse of these cases. A young woman, twenty-
two years of age, accidentally swallowed a very small quantity
of soop-lees (a caustic solution o\' impure carbonate of soda).
When admitted into the Westminster Hospital, five days after
the accident, she was suffering chiefly from vomiting; which
was relieved by culouicl and opium, oleaginous hixatives and
demulcents, milk and farinaceous diet, and by a blister to the
throat and the upper part of the sternum. An awophugua
tube passed easily. Ten days after her admission she was dis-
charged app:ircniiy well. At the end of eleven months she
was again adtniitcd, suffering from urgent dysphagia. 8he
appeared hulf-starved, and stated that for many weeks she had
taken no solid food ; and that lately the difficulty of swallow-

* Mniieo-Chii-urgieal TratuaelioHt, vol. xxxiii, ;> W London, 1850.

416 DISKASeS OF THE OROANS OF DIOEBTION.

in;; had become 80 great thnt she could hardly get down liquid
nourighmcnt. A small gum-elustic catheter, No. 8, wa« passed
with a little difficulty; and beef-lea was injected into the sto-
miich, to the great relief of the patient. This plan of treat-
ment was continued, a larger tube being gradually used;
while in a little more than twenty days she was so much im-
proved that she wa.s able to swallow freely, and was therefore
made an out-patient. She neglected to attend, however, and
consequently eighteen days afterwards was readmitted with
her former symptoms aggravated. The same treatment was
again successfully resorted to, and she was kept under longer
observation by employing her as an hospital nurse. She was
afterwards lost sight of for a time; but in about eight months
— or twenty-six from the accident — she again, for the fourth
time, applied, and was admitted. Only the smallest bougies
could now be passed; nutritious enemata were employed ; bat
in ft few days she died, literally of starvation.

In the inaniigement of these cases we can only trust to the
repeated use of bougies, to prevent the stricture from closing.
One lady under my care derived relief from constantly wear-
ing a gum-clastic catheter of a large size; through which she
injected her fuod and medicines. In passing any instrument
great caution is to be exercised; for in one instance it is said
that an eminent surgeon forced a tube through the stricture
into the thoracic cavity, and injected half a pint of beef-tea
into the pleura. With regard to hopeless examples, it has
been suggested to make an incision into the stomach, lai^
enough to enable us to introduce food ; and in one instance of
niulignant stricture of the ocsnphngus gnstrntomy has b«ea
actually performed, the patient dying forty-five hours after-
wards. Although 1 should be averse to sanctioning such an
operation in a case of cancer, yet it would be a ditfercnt mat-
ter in an instance of incurable simple stricture; for the well-
known case of Alexis St. Martin (not to mention soveral others
of a similar kind) seems to show that such treatment might
be successful. I would, however, saggest that instead of

DYSPEPSIA.

417

rankinp s coninmnicBlion between the stomach und external
snrface hy the knife, a stronp caustic — r. ;)., pntiissa fusa —
should be empioj'ed ; throu<;h the agency of which we could
gradually excite inflammation, adliesion, and ulcenition. The
feasibility of such a proceeding seems to be pruTed by a c«8e
recorded by Dr. Murchison.* In this instance ft woman pro-
duced a large openinj; through the ubdutninal parietes into the
Btomafh by tneanH of long-continued pressure with a penny-
piece. The ulcerative process wa.s completed, .so that food
escaped, on the 2d of March, 1854 ; yet the patient was* in
tolerable health, with the fistula large enough to admit three
Bngers, in June, ]So8.

The ccajphagua may, like the urethra and bronchial tubes,
suffer from upasmodic stricture. Young hysterical women are
often affected with it ; the principal symptoms consisting of
difficulty in swallowing, an occasional sense of fulness and
choking, with unsemia, &c. Spasmodic cannot be confounded
with organic or permanent stricture, because the dysphagia is
only temporary, a bougie passes with very little or no diffi-
culty, and the symptoms are aggravated when the patient's
attention is directed to them. Moreover, it may generally be
readily relieved by antispasmodics (F. 101), 111, 114, or 120),
by the daily use of the cold shower-balh, and by the cure of
any geucral or uterine disorder which may be present.

VII, DYSPEPSIA.

Dyspepsia, or Indigestion, is one of the most common diseases
we have to treat. Anything which interferes with the healthy
action of the stomach and intestiricn may give rise to it.

There is a yastric and inltitiniil digestion. The first occu-
pies on an average from two to three hours; and it essentially
consists of an exposure of the food to the solvent powers of the

* Mtdiro-ChtrHrgirut Trantadioiu, toI. xll, p. 14. LoDdon, 18S8,

418

DISEASES OF THE ORGANS OF DIUESTION.

gastric juice. This fluid consists of water, holdinj; in solation
hydrochloric and perhaps lactic acid, most of the salts which
are fuund in the litjuor sanj^uinis, and an ulhuminous matter
absolutelj necessary to the solvent powers of the juice — whence
it is named "pepsine," or "ferment substance." Moreover it
is always diluted with saliva ; soinetiiues there is an admixture
of bilo. The object uf the pastvic juice is to render soluble
the ulbutuen, fibrin, casein, &c. (the ulbuminoid mutters), sub-
mitted to the stomach; and this it effects by converting them
into a new or^nic, non-congulabic substance, which has been
called "peptone." Of this peptone, part is probably at once
absorbed ; while the remainder, with the fnlty substances of the
food, pa.sse» onwards into the duodenum, &c., to be acted upon
by the biliary, pancreatic, and inte.'-tinal .secretions. The con-
version of starch into sugar is commenced in the mouth, by the
power of the secretion of the several salivary glands; bat
whether it is completed in the stomach, or whether its conver-
sioD there is delayed, to bo again renewed in the duodenum,
is uncertain, According to M. Lucien Corvisart the pancreas
is to be regarded as a supplementary organ to the stomach; so
that those matters which escape gastric digestion become quickfy
act«d upon in the duodenum by the pancreatic juice. The
quantity of the pancreatic juice secreted in the twenty-four
hours has been estimated at seven or eight ounces avoirdupois;
but though it is so uiuch less than the gastric juice, yetitsfer-
nientivo matter is said to be ten times more eflfective. It of
course follows from this that wo may have a duodenal dyspep-
sia, caused by vitiation of the pancreatic juice, just as we may
have gastric dyspepsia.

Cauiiet. — The most frequent causes of dy.'ipepaia are the tiae
of food in too large a quantity, or of an improper nature; or
the imperfect mastication of it from carelessness, or owing to
the pain of bad teeth, &c. Dr. Beaumont clearly proved, in
his well-known experiments on Alexis St. Martin, that spiritu-
ous liquors were most injurious to the stomach; heiice persona
in the liubit uf using theio of^en suffer from indigestion. An-

DYSPEPSIA.

419

I
i

Other cnuse is an error frequently coimnitted, of not allowing
a 8u(S(.'ient interval between the ineals, to pcnnit of the sto-
mach diiing its wurk ond rcstirin;: for Aberncthy's rule, that
six haul's at least should intervene bctwceri each meal, cannot
be long broken with impunity. Want of bodily exercise, ex-
cessive labor, undue intellectual exertion, mental anxiety, gene-
ral debility, immoderate smoking, and snufflukin^' are fruitful
sources of this aifeetioD; while of course disease of the sto-
lUBch, liver, or pancreas will alw give rise to it. So also morbid
states of the brain, lung, liver, or uterus may, by reflex action,
produce functional gastric disorder, attended with most trou-
blesome vomiting. Again, when the blood is rendered impure
from any morbid poison in the sy,stem, as that of fever, cholera,
&c., we have indigestion; while it is common in Bright's dis-
ease, when the blood is contamicatcd with retained urea, owing
to the imperfect action of the kidneys.

Sj/'ii]il(>m!. — The symptoms of that functional derangement
of the stomach which is coiuiuonly known as indigestion, vary
very much in nature and severity j one individual suffering se-
verely when his dinner "disagrees" with liini, while another
has merely slight depres.-<ion. Uut in the chronic cases for
which advice is sought, there is commonly anorexia or loss of
appetite; a sensation of pain, weight, and J'ulness at the epi-
gastrium; fiatulence, or the undue collection of gas in the
intestinul canal ; nausea and vomiting, costiveness alternating
with diarrhcea, furred tongue, and foulness of breath ; palpita-
tion of the heart; pain in the loins, and aching of the limbs;
with dull headache, and hypoehoiidriasis. Occasionally the
patient comphiins of (/tintrafi/ia, cardial'jia, or hearl-Liirn ; of
gattrodjfiiia or cramp in the stomach; oi ot pjfroris or waler-
hrafh, which consists in the frequent eructation of a thin,
watery, acid, or tasteless fluid. I'yrosis occurs more frequently
in women than men; is not uncommon in advanced life; and
often exists in connection with some derangement of the nerv-
ous or uterine system, or — in souio in»tanoe» — with organic
disease of the stomach, pancreas, or liver.

420

DISEASES OF THE nRGANS OV DIGESTION.

The consequences of $hw dit/estion from a scanty secretion
of the pii'tric juice, are — a feeling of fuloess and distension in
the left hypnchondrium and ot the pit of the stomach af^r
taking food; flatulence, sour fetid eructations, constipation, a I
coated tongue, aud loss of appetite; palpitation of the heart,
irregularity of the pulse, hendacbe and occasionBlly dimness of
vision J with distressing mental depression. When the stomach
becomes greatly distended with gas, oppression of the breath-
ing is often produced, owing to the descent of the diaphragm
being impeded. The low spirits induced by gastric irritation
may vary from slight dejection and ill-humor to the most ex- ,
trcme mclaucholy ; sometimcH inducing even a disposition to
suicide. The patient misconceives every act of friendship,
and exaggerates slight ailments into heavy grievances

DhijnoMs. — The difficulty of diagnosing correctly the vari-
ous morbid affections of the stomach is by no means slight;
since not only are wu for the most part ignorant of any direct
means of ascertiiining the physical condition of this viscos
during life, but the proaiioent symptoms of many of its dif-
ferent diseases are almost identically the same. Thus we lind
pain and turfritsu at the epiijastrium not only common to most
of the organic afTections of the stomach — as to cancer, simple
ulcer, and inflammation of the mucous membrane; but also
to many of the merely functional derangements, being gene-
rally present in the synipotlietic vomiting of phthisis and in
that of many diseases of distant organs. The diagnosis may,
however, be assisted by remembering that when the pain de-
pends upon org-anio disehse, it is generally most severe soon
after taking fond, especially if this be heavy and indigestible;
while, when it is due to functional disorder only, it is often re-
lieved by food. This last fact has been explained on the sup-
pasition that the uneasiness is mninly due to an unhealthy
coiiditioti of the gastric secretions; wliich of course act the
less vioictitly the more they are diluted. In ulcer of the sto-
mach, pain is usually cousU-intly present, being merely aggra-
vated by food ; in cancer, it is of a dull aching character, is

DYSPEPSIA.

421

most ncute after nie;tls, and continues severe while the ?tomnch
iii full; while the pnin of simple indigestion — the remorse of a
goilty stomach, as it has been facetiously called — onlj requires
BbRtinence for its complete alleviation.

Another important ."ytnptnm — rovtilin;/ — mny be produced
by a greater number of cirfumstant-es than (hose which give
rise to pi:in : as, for e.tample, by organic disease of the sto-
mach ; by mechanical ob.strucf ion of any part of the alimenlnry
canal ; by irritation in distant or<ran!<, a.s the brnin, uterus, &c. ;
and by uimbid .states of the blood. When due to organic dis-
ease, it generally coexists with pain ; and it may be diminished
by eating very light food, by taking but little at a time, by
counter-irritation to the epigastrium, and often by bismuth.
In the vomiting from mechanical obstruction of any part of
the aliincnlary canal, we learn much by noting the time of its
occurrenee, the nature of the vomited matters, and the extent
and urgency of the general symptoms. Thus in stricture of
the pylorus, the vomiting only takes place when the stomach
is full and distended, so that the matters brought up are large
in rjuantity. When the constriction is in the small or large in-
testines, the contents of the bowel are returned into the stomach
by a process hereafter to be described, and then rejected. In
the sickness from irritation in a distant organ, or in that caused
by an unhealthy state of the blood, there is usually a constant
and very depressing feeling of nausea, but no pain ; flatulence
is also often complained of, and there is commonly disordered
action of the bowels.

This leads me to speak of a third general symptom of func-
tional and organic diseases of the stomach, which is often very
nnnoyinp, and not always easily relieved — viz., flatulence, or
the undue collection of gas in the intestinal canal. It may
arise from one or more of the following causes — /. e., from air
Bwalifiwed, from gas generated by decompo.«ition of the contents
of the stomach or bowels, or froui gas secreted by the mucous
membninc of the intestinal canal. In the fir.st instance, the
air is thrown up by eructation, and is nearly odorless and

422

DISEASES OF THE ORGANS OF DIOF.STION.

tasteless ; in the second the gnses are passed upwards or down-
wards, arc verj fetid, and often accompanied bj nausea, grip-
ing sensations, tenesmus, &c. ; while in the third case the fiaa
is generally' expelled per anum, and has the odor of healthy
fieces.

The subject of hsemorrhape in connection with disease of the
stomach hiis already (p. 79) been treated of. Pyrosis or water-
brush, voracious appetite, depraved appetite, sick-headache, &c.,
arc oil symptoms of different varieties of dyspepsia, dependent
upon various causes, and re(|uiring special treatment.

Trutlmeiit. — Abernethy u.scd to say that no person could be
persuaded to pay due attention to his di|iestive organs until
death, or the dread of duath, was starinf; him in the face.
Without cither subscriliiiig to, or dcnjinji the truth of this
dogma, it is certainly fortunate, that of all the organs of the
body, the stomach is that on which we can exert the most
powerful action, both indirectly and directly. Daily observa-
tion has taught us all how thoroughly digestion is improved
by those means which invigorate the system generally; as by
rest and early hours, relaxation from severe studies or from
the harassing cares and anxieties of business, change of air,
sea-bathing, cold or tepid sponging, horse exercise, the disuse
of tobacco and of alcnluilic stimulants where these have been
too freely indulged in, and so on.

The rn/ii/alion nf lh« dirt alone will often effect a eure;
while in no case need we expect to give any relief unless we
can persuade the dyspeptic to pny attention to the quantity and
nature of his food. Supposing that the physician hns to deal
with a severe case, it is fortunate that he cau give the stomach
a complete rest for twelve or twenty-four hours; or even for a
longer time by resorting to nutrient enetnata. Then merely
the plainest fimd should be allowed, and only small quantities
ought to be taken at a meal : milk and lime-water, gruel, sago,
and arrowroot will all be useful. As wo find these articles
can be assimilated without causing any pnin or unensiness, we
uiay increase the diet: and white tish, poultry, and mutton can

DYSPEPSIA.

428

be ordered. Stale, or unfermented, or aerated bread may be
eaten ; but ve^tables, pastry, cheese, beer, port wine, and
undiluted spirits sliuuld be Turbiddcn. If any .«ttniulunt be
needed, a little dry sherry or pale brandy and water wiii prove
the least injuriouit, and in some iostanceis will be even bene-
ficial. Coffee (not chicory) tiiken upon an empty stomach
often acts as a valuable stimulant ; but swallowed soon af\er a
meal it merely serves to hinder digestion, and to make a, simple
dinner disatiree. Lastly, the dyspeptic ishould keep (juict for
some little time after takinjj: food, so as not to divert from the
stouiach the nervous force reipiired for dif^estion.

With regard to mrdiciiien, several are useful. Perhaps the
first which ouglit to be mentioned is pepsine, the di<i;e.slive
priuciple of the ^.stric juice ; soiuctimcs valu;ible when there
is an imperfect performance of the functions of the stouiach,
and especially when this is indicated by disturbance followinj;
the u.«o of uiiiiiiul food. It should be given in doses of fifteen
grains with the two chief meals of the day ; in some instances
an advantage seems to be gained by the simultaneous use of a
amall additional f|U!intity of lactic acid. When the pepsine
alone fails to relieve the pain of indigestion, about the one-
seventh of a grain of the hydrochlorate of morphia should be
combined with each dose ; or when great atony prevaiis, the
one-twenty-fourth of a grain of strychnia may be employed in
the same way.* There are also other agents which increase
the gastric secretions, such as the nitro-niuriatic acid, rhubarb,
ipecacuanha, and ginger ; the first being often especially useful,

For the introduciioa of pep»tne iuto prnctiee we are obioQy indobted
iK. Corvlnart, iiod to Dr. Ballard for promulgating thin pbjaioian'i
Mrs iu this country. — Fepsme ia prepared by treating the maoouii mem-
brane of the rennet bng — the fourlli utiiraacb of the ruminants — with dit-
tilled water, precipitating the pepnino by acetate of load, and decomposing
tbii precipitate by sulphuretted hydrogen. The solution of nearly pure
pepsiue thuf4 oblniued, is evaporated to the con.^istence of a syrnp, and
then mixed with tttarch in iueb proportion that fifteen grains of the
mixture ehull be capable of digesting (out of the atomach) one drachm of
diicd Sbrio.

424

mSEAHES OR THB 0R0AN8 OF DIOBHTION.

when given in snuill duses well diluted (P. 457, 460, 461).
If we wich to restniin undue gecretinn, we re*)rt to small dosua
of sulphuric acid, bisitiuth, eoniuni, belladonna, opiaiu, or
liydrocyiiTiio acid; if to relieve puin and vomitiiifi we may use
ice, Hiorpliia, and carbonic acid — by menus of effervescing
draufihts; wliilc if there be an excessive secretion of acid we
order alkalies. — In an acute attack of pastrfjdynia caused by
thf stomach being londod with unhealthy aeid .secretions, we
niii.st eirdeavor to ffva relief by producing; vomiting. For this
[purpose the free adiuini^tration of warm water will usually
suffice, or if it fail, tickling the fauces will make it aot.
Afterwards one or two doses of a mi.xture containing soda,
morphia, and liydrooyanic acid (F. 96) maybe advuatugeously
ordered. Alkalies are not to be persistently given, however,
beciuiiie there is a greater secretion of gastric acid than is
proper; since they will only tend to keep up the niisohief by
stimulating the mucous metubninc of the stomach to a still
greater secretion, so that there will .still be a surplus of free
acid over the amount neutraliijed. — Where there is no great
irritability of the stomach, one or other of the vegetable tonics
will ol'len prove invaluable, and recourse may be had either to
gentian, calumba, (luassia, or bark. Saliein (F. 46fi) is espe-
cially worth trying in many instances, often agreeing well
where quinine cannot be tolerated. If aperients are needed,
only those of a mild nature ought (o be prescribed ; such as
gray powder and compound rhubarb pill, taraxacum, nitrio
acid and senna, ipecacuanha and rhubarb, magnesia, or simple
eneraata, &c. (F. 174, 11^), ISO, 192, 197, 212, 220, 221,
239). Finally, to make the cure complete, and to prevent —
as far as drugs will do so — a relapse, mild preparations of steel
(F. 450, 409, 484) are to be ordered ; while it may be noted
that fretjuently I have liitind bejietit from combining pepsino
with the reduced iron (V. WS). Where there is any suspi-
cion that the digestion is still torpid from want of tone, nothing
will prove of greater service thuu (juiuiiie aud ipecacuanha
(F. 494).

OASTRlTlfi.

425

With repird to the u!>o of wine and well-diluted spirits to
prevent dyspepsia, it may be said that they are often very
beneficial. It is no doubt true thnt the stomach which re-
quires stimulants to enable it to act efficiently, can hardly be
said to be in a healthy state; but, at the same time, we must
remember that the baiile of life is not wuped without much
wear and tear, without aliiiust overwhelming anxieties and
sickening dtsappotntnients, and that the digestive organs arc
the first to Hynipathize with the depre.ssions of the mind, no
less than with the fatigues of the body.

VIII. GASTRITIS.

Under this heading several important affections of the sto-
mach, more or less closely connected with the inflammatory
process, have to be considered. The well-directed labors of
many eminent physicians, both abroad and at home, during
the past few years, have done much to improve our knowledge
of these obscure but very important diseases.

1. Acute Gastritis. — .\cute inflammation of the mucous
membrane of the stomach is a disease which in all probability
never arises idiopathically. It is, however, a frequent result
of poisoning by any of the irritants — as by the mineral acids,
caustic alkalies, arsenic, &c. ; and it someliiues occurs from
swallowing boiling water, or large (|uantities of mustard to
produce vomiting, or excessive doses of tartar emetic.

Si/mploms. — In gastritis produced by irritant poisoning we
shall find an increasing burning pain in the epigastrium, ag-
gravated by the slightest pressure ; constant distressing nau-
sea, soon followed by violent retellings, with accelerated pulse
and breathing; and great thirst, with an unremitting desire
for cold drinks, which are vomited as soon as taken. Very
shortly there sets in eitrenie prostration ; denoted particularly
by faintness, feebleness of the pulse, great pallor, cold cluniiuy

426

DISEASES OF THE OR(JANB OF DI0E8TTON.

extremities, and intense anxiety of countenance. VVheu the
inflammntion continues, the tonfrue becomes red, glazed, and
fniDdlhod, unless it has been injured by the action of the poi-
Bon ; the bowelH are cniistipafcd ; the urine is scanty and liigh-
colored ; there is great restiesiiness and hiccup; and the pros-
tration increases, till death liikcs place from exhaustion. These
syinptums are nut present io all cases : the imnifidiute effecta of
severe injury to the stomach bcitij; soinetinics comparatively
slitrht. Wheti the Kddystone Liiihthouse was destroyed by
fire in llf)^, one of the keepers was burnt by the fall of the
molten lead. The man asserted that some of the metnl had
passed down his throat; but as he had gone through much
fatigue after the accident, and h;id begun to nincnd at the sixth
day, his stateuient was not credited. However, on the ele-
venth day, he rapidly grew worse and died ; when, on examin-
ing the body, a piece of lead, weighing more than seven
ounces, wa.>i removed from the stomach.

Morbid Aiifiiomi/. — The tnurbid appearances usually found
are intense dark redness, softening, sloughing, and — when one
of the powerful cscharotics has been taken — perforation. —
RedtiesR alone is by nu means evidence of the previous exist-
ence of infltiuimation, since it may be produced after death by
gravitation of the blood to the most dependent parts ; when
dentil occur.-*, Uk>, from any cause during the process of diges-
tion the st<jmach will be found red. — So also with soRening
and perforation, we mu.-it remember that these may occur from
the po.st-mortem action of the gastric juice — from the sto-
mach actually digesting its own tissues — as was lirst pointed
out by John Hunter. Cadaveric iu)/lrniiiif nf llie stomach is
not uncommonly fijiind when death has occurred suddenly
from an accident, soon lifter a meal, and when the body has
been kept in a warm situation. Its most frequent site is the
fundus and cardiac end of the viscus; and it is perhaps most
often met with in young subjects, and after death from phthi-
sis, or severe cerebral disease, giving rise to great exhaustion.
Some interesting experiments have been made by Bernard,

GASTRITIS.

427

Hnrley, Piivy, nnd others, upon this power of (he gastric juite.
Throiifrh a fistulous opening in tlie stomach of a tlo<;;, Dr.
Puvy iivltodufod (Jurinfi the procc<« of di<;pstion the hind leg
of a living frog and the ear of a live rabbit. In both caBes
the parts underwent dijrestion after two or three hours. Hence
Dr. Pavy argues, that the capability of resisting their own
digestive powers, passessed by the wall* of the stomach during
life, and which ceases with death, is not due, as Hunter
thought, to the vitnl force with which they are endowed, but
to the gastric epithelium and luucus being constantly repro-
duced as soon as digested.

Treatment. — The treatment of acute gastrili-s will, in a
fP'eat measure, bo the same, whatever ni.iy be its cjiusc. In
most cases I should rely on purgative eneinata at the unset;
afterwards trusting to opium, and the sucking of Wenhuiu
Ijake ice — which will freijuently relieve the vomiting, as well
as lessen the inflummation ; and pcrh:ip» at the same time
allowing barley-water, milk, cold arrowroot, or gruel. It will
be better to nourish the patient, however, by nutritious ene-
ninta (F. "20, *21, 22) than hy food given by the mouth. In
some iiislances fomentations npplied to the epigastrium give
much relief Whm any of the corrosive poisons have been
taken, emetics will very rarely be necessary, since the former
agents themselves induce severe vomiting ; while the stomach-
pump should never he used. During convalescence great care
will beref|uired in regulating the diet; farinaceous substances
and iirolhs being chiefly allowed, aud only in small (luantitics
at a time.

2. Chronit; Gastritis. — This form of inflammation is al-
most as common as the preceding variety is rare. It is fortu-
nately a mild disorder, unless of long duration; when it may
produce thickening and iuduration of the coats of the sto-
mach, narrowing of the pylorus, or ulceration perhaps going
on to perfunition.

The minus are numerous. There is no doubt that it may

428

DISEASES OF THE OROAXS OF DIGESTION.

b« brought on by excess in eating or drinking ; for Dr. Beau-
mont Trequently witnessed this result in Alexis St. Martin,
who, in consequence of a frun-shot wound, had s permanent
fi>tuluu8 openini; through the abdominal parictes into the sto-
mach, thus affordint; an opportunity of watching the process
of digestion. Under the continued use of improper food, the
iufiuiiiiiiiition always became aggravated ; whereas under the
influence of low diet and coolinn; drinks the stomach rapidly
recovered. Acute or chronic alcoholism is one of its most
eoiniiion sources. On the other h;tnd, long-continued absti-
ncDce is a cause of chronic ga.siriti» ; as has been proved ia
experiments upon dogs and other animals when deprived of
food. So also this disease sometimes arises during the pro-
gress of infliimination and febrile disease.", particularly some of
the cxantliemata — as scarlatina ; small ijuaruities of arsenic,
in whatever way they may be introduced into the system, will
produce it; sonietiinos the poison of g<mt in the bloud seems
to give rise to it ; and, la.'itiy, it may be due to some narrow-
ing of the pylorus impeding the passage of food into the intes-
tines.

The chief tympiomn are anorexia, tenderness at the epigas-
trium and stenium, pain and vomiting alter meals, slowneas of
digestion, cnirapn, acid or watery eructations, disordered bowels,
and a furred tongue. In women there often coexists some
organic or functional disease of the ovarii'S or uterus.

Under the injluence of this form of inllammation. Dr. Beau-
mont noticed, in the ca.sc of Alexis St. Martin, that the gas-
tric mucous meuihranc lost its healthy pale pink color, and
assumed a somewhat livid redness. Patches of the membrane
wore also marked with extravasated grumnus blood; some-
times layers of false membrane were partially formed; while
neither gastric juice nor mucus was secreted. This active
congestion of the stomach from infiammation, differs from that
piiiuice form which arises from some obstruction to the circu-
liiiion, impeding the return of blood from the stomach towards
the heart. Pas.^ivc congestion of the stomach, leading per-

OASTRITIS.

429

haps to severe h^mntemesis, is most frcfjiiently due to some
cause whieh prevents the free fluw of bloo'l tliruiisih the liver
— as ''liob-iinil" or gin-drinker's liver. OrfTiUiiu aflVctinns of
the heart and lungs not unfreiiucntly keep the stuuiucli in a
state of congestion.

In the trratmeitt, attention must be paid to the rules laid
down in the remarks on Llyspep-nia. In niat)y caces removal
of the cause, low diet, and cold water will thoroughly cure the
disease.

3. Oastric Catarrh. — Catarrhal affections of the sloninoh,
like those of other mucous menibraTies, present themselves
under two or three different forms. When slight they are
u.'fually .spoken of as "bilious attacks;" the syuiptuuia being
little more ihaii those of simple iudigestion, such aa a furred
tongue, oppression at the epigastrium, vomiting of bile, giddi-
ness, and "sick headache." If the mucous membrane could
be seen in these cases, it would be found congested, ojdemu-
tous, aud perhaps marked here and there with patches of
ecchyuiosis. In the ireatuient of these ca.se.« nothing mow is
necessary than a purgative pill of colocynth or aloes at bed-
time, followed by a seidlitz powder or bottle of soda water
early on the following morning. A meagre diet and plenty
of cold water for the succeeding twelve hours will complete
the cure.

Chronic catarrh or mucous flux may succeed a bilious attack,
or it wilt occasionally arise as a separate nfrecliun, It oflfn
OMsists with chronic bronchitis, hooping-cough, phthisis, anil
emphysema of the lungs. If the patient vomits, a quantity of
glairy enucuj is brought up, to the great relief for the time of
the symptoms. There is congestion of the oapillary gastrio
vessels, with an excessive secretion of tenaciuu.'; mucus. The
symptouis depend upon the extent to which the walls of the
stoinitch are covered with viscid mucus, being only well-
marked when the greater part is coated. There is then evi-
dence of a want of nutiition, a feeling of faintness and epigas-

430

DISEASES OF TIIK OROANS OF DIORSTION.

■

trie pain when the sbomoch is empty, a craving for food but
an iiinbility to take more than a very little when it is sopplied,
and a sense of oppression ufter editing whii-h only vomiting
relieves. Flutulcnce, aci3 eructalions, heartburn, pyrosis, con-
stipation, thirst, vomiting of glairy fluid on awaking in the
morning, weakness, coldness of the extremities, &c., are often
connected with pustric flux. The most useful remedies for
restoring the stomach to its natural uonditlon are those which
restrain the secretion of mucus ; such as the sulphite of soda
(F. G3), bismuth (F. 123, 145), kino and logwood (F. 141),
and occasionally the iron alum ( F. 149). If there be much
constipation, I think a dose of live grains of calomel is one of
the best purgatives. Of course attention must bo paid to the
diet; and it will usually be better for two or three days to
keep the patient almost entirely upon milk rendered alkaline
by admixture with lime-water, allowing small quaolities at
short intervals. Then arrowroot made with milk, bread-and-
milk, and an egg lightly poached with stale bread and fresh
butter may be permitted; followed after a short time by white
fish, poultry, mutton, sherry and water, &c.

The more severe examples of gnstric catarrh produce symp-
toms which are oflen regarded as inSamnuttory ; and hence
they are often spoken of as " gastric fevers." In them the
skin i.s hut and dry, the pulse is quick and full, there is vomit-
ing and epigastric pain, with urine scHiity and loaded with
lithates. Superticial ulceration sometimes results, especially
when the catarrh is due to long-continued congestive disease
of the portal system. The chief remedies are rest, low diet,
demulcent drinks, aperients, and effervescing salines. At the
commencement, if there be a sense of nauseik without vomit-
ing, an emetic of ipecacuanha will give relief. The epigastric
tenderne.ss may be best relieved by hot fomeatations, or poul-
tices, or even turpeutine stupes.

4. Indiira.tion of the Pylorus. — Induration or fibroid infil-
tnitiou ut' the pylorus ajipears to consist in the abnormal du-

OA8THITI8.

431

velitprannt of fibrous tiwue in the submucous areolar mem-
bratif abuut tlie [ijloric portion of tiic sloiiiach. It may ocour
as ihu result of chronic inflammalion, ur perhaps frotu the
hcalinp and contraction of an ulcer, or from irritation caused
bj the habitual use of raw spirits. Tlie appvarance of the dis-
eased strueture to the naked oje somewhat resembles seirrhus,
so that by some, this disease has been erroneously regarded as
malignant; but tuiuutely examined it is found to be composed
of tissues resetublint; those of a simple fibroid tumor, and not
to consist of the copious cell-growth characteristic of cancer.
The walls of the pylorus may be only slightly thickened ; or
they may be converted into fibro-cartilaginous tissue, with
such contraction of the opening that hardly a quill will pass.
In proportion to the amount of obstruction there will be found
dilatation of the stomach, with hypertrophy of its muscular
coat.

Althoufih the pyloric region is by far the most frequent
seat of the fibrous deposit, yet the whole of the viscus may be
affected. In such a case the necropsy shows a large stomiich,
of an opaque pearly-white appearance, of increased weightnnd
density, of a gristly feel, and having its coats greatly thick-
ened. This condition may exist without giving rise to any
symptoms of imparlance, except in cases where there is con-
striction of the pyloric valve. Fibroid {vjillriidon appears to
be a good natue fur it, unless the reader should prefer the
designation suggwted by Dr. Brinton, — cirrhotic inflamma-
tion, or plastic linitis.

The symptonrs of fibroid infiltration of the pylorus are in
some respects like those produced by malignant disease affect-
ing this part. There is eniacintion and proprcssive debility,
pjrrosis, acid eructations, and constipation. Although the
appetite is commonly ravenous, great moderation is obliged to
be adhered to owing to the severe sufTering which a hearty
meal induces. Vomiting takes place three or four hours after
a meal, especially dinner, the matters brought up being partly
digested, mixed with water, often yeasty-looking, and pcihapa

432 nisEASEs of tiik ouoans of ninESTioN.

containing sarcinse or {oriilas. Sometimes Uie siekness only
occurs at intervals of a few days ; while if (here be much
hypertrophy the contents of the stoninch are ejected with con-
siderable force. As the patient praduiilly wastes, so the thick-
ened pyloric tissues can be felt, like » tumor, perhaps the size
of a small oranpre, throu{;h the abdominal parictes ; the swell-
ing only being painful when there is any ulceration. After a
time the feet and le^ get cedematous, the temper beoomei
very irritjible, the .«leep is disturbed, diarrhoea often inter-
venes, and death uliiniately occurs from inanition. In many
instances, however, by strict attention to the diet, life may
be proloncjed for several years.

The treatment must consist in nllowinp only simple soft
food, — such as milk, cream, raw eggs beaten op in sherry-and-
watcr, stronjr beef-tea, and soups. Cod-liver oil often proves
very useful. When there is any temporary exacerbation of
the symptoms, the stomach should bo rested for a day or two,
and nutrient eneniata resorted to. The patient should be
warmly clothed ; an elastic abdominal belt gives agreeable sup-
port; while pain may often be relieved by the application of a
well-spread belladonna plaster.

8. Dilatation of the Stomaoli — Dilatntion of the stomach
is a curious disease, to which attention has lately been di-
rected. The enlargement is due generally to some affection
of the pyloric orifice ; which, causing contraction, prevents the
food from readily passing into the duodenum. Hence, the
stomach slowly and gradually dilates; until at last it comes to
occupy almost the whole of the abdmniiial cavity, giving rise
to appciirances as if a large tumor were present. These ap-
pparanca« are the more deceitful when the stomach is full,
because fluctuation may then be present; when this viscus is
empty, there will be a tympanitic sound on pereussiou.

The patient suffers severely from cardialgia, gastrodynia,
pyrosis, flatus, constipation, and sometimes from vomiting. In
two instances which I have »cen the appetite was voracioua tu

GASTRITIS.

433

a marked degree ; but whether this was partly the cause or
the consequence of the dilatation can only be a matter of spe-
culation. In favor, however, of its havinj: been the cause it
may be mentioned, that in one instance the symptoms during
life were those of torpid digestion, with such luent.-il depres-
Bion that suicide was at length committed; while at the exa-
mination after death, no reason for the dilatation could bo de-
tected. Where there is sickness, the vomited matters are
frequently very large in quantity, they rapidly ferment, are
intensely acid, and often resemble yeast in appearance ; while
they arc found, when microscopically examined, to contaia
large quantities of those vegetable parasites first described by
Goodsir, the ISarciiia: vtiitn'ciili, together generally with the
yeast fungus — Torulae terevitlix. Dr. Todd discovered the
sarcinsc in ulceration of the stomach with contraction of the
pylorus, and he suggested that these vegetable organisms re-
sult from the long detention of food in the stomach. There
is but little doubt that this explanation is correct; but it is
also probable that the intensely acid fluid in which the sarcinse
are found may itself irritate and close the pylorus spasruodi-
cally. In such cases, consefjuently, if wc check the formation
of these growths we shall cure the disease. Thanks to Dr.
Jenner and Professor Graham, we are enabled readily to ae-
complish this latter object by tho administration of the sul-
phite of potash, or by the sulphite of soda ; which latter (F.
63) is perhaps preferable, since it is a more stable salt, and is
less liable to bo decomposed by keeping than the sulphite of
potash, The beneficial action of cither of these salts depends
upon their being decomposed in the stomach by the acids
generated therein, sulphurous acid gas being liberated, which
quite destroys the fungi. Dr. T. K. Chambers prefers tho
hyposulphite of soda, in doses of gr. v to xx, thrice daily.
The patient's diet should be regulated, and it will be better
for him to be allowed the unferroented in the place of the
commoD bread.

434

DISEASES OF THE OBOA^B OF DIGESTION.

IX. ULCER OF THE STOMACH.

Thiii is an interesting and not uncommon disease, rariously
spoken of by authors as the nmple, chronic, or per/orating
ulcer of the stomach.

The putiuilogy, syuiptoms, and treatment of this affection
have been especially investigated by Dr. Brinton ; and from
his valuable monograph many of my observations are taken.*

Among the 4000 CMses of different diseases which formerly
came under Dr. Brintun's caro nnnually at the Royal Free
Hospital, he calcui;ited that there were at least 40 examples
of ulcer of the stomach. The ulcer is mure frequent in the
female than the male, in the proportion of nearly two to one.
It is specially a disease uf middle and advancing life, hardly
ever occurring before puberty; it is more frequent in the poor
than in the rich. The ulcer is rarely smaller than a fourponny
piece, or larger than a crown piece; its shiipe is usually cir-
cular or slightly oval ; it is niuoh more frequently found on
the po.«terior surface, the lesser curvature, ur the pyloric pouch,
than on the anterior surface, the greater curvature, or the car-
diac extremity ; and two or more ulcers arc fre({uently present
in the same .stomach. About half the instances of this disease
undergo what is probably a spontaneous cure : iu exceptional
cases the ulcer has been fatal in ten days, generally by per-
forntion ; sometimes by exhaustion, caused or hastened by
vomiting, and very rarely by haemorrhage. In the majority
of fatal instances, a period of several weeks or months pre-
cedes death. Perlbration, however, is an exceptional occur-
rence in gastric ulcer ; when it occurs, the ulcer has commonly
been found on the anterior surface of the stomach. When
perforation does take piaee, the contents uf the stomach are
generally poured into the abdominal cavity, where they giro
rise to fatal peritonitis. But in some very few instances the

• On Ulcer oftkt StomaeA. LondoD, 1867.

ULCER OF THE STOMACn.

486

effusion — owing to the presence of adhesions, &c. — is coii6ned
to the neijrhborhood of the perforated spot ; so that circum-
scribed peritonitis is set up, suppuration takes place, and a
kind of chronic abscess is formed. This may prove fatal in
many ways, as, e.tj., by discharfrint; its contents through the
diaphragm into the thonijt ; or, more fortunately, it may open
externally through the abdominal walls. In the latter case a
gastric fistula is e.^tablished ; which may either remain open,
like that of Alexis St. Martin, or will i^radnally close and
permit of complete recovery. Dr. Briuton conjectures that of
every 100 ulcers of the stomach, 50 may cicatrisEC, 13i perfo-
rate its walls, 3i corrode its larnc vessels, and 2 or 3 kill by
the sheer exhaustion and inanition they involve. There is
still a proportion of about 30 ulcers in every 100 left quite
unaccounted for.

The symptoms are liable to some variety, and hence the dis-
crepancies which are to be found in the descriptions of dilTer-
ent observer. The most constant i=ymptotn is pain in the back
over the lower dorsal vertebiie, and in the epii^a-strinm. With
respect to the latter, it is often referred to a small spot just
below the cnsiform cartilage, it is frequently described as dull
and sickening, and it is increased by food. Somctiraea the
pain is associated with violent pulsations; and in some few
young women it has apparently been increased by the access
of menstruation. There is occasionally eructation of a sour
fluid, and at times nausea and vomiting. The patient gene-
rally loses flesh, but otherwise the constitutional symptoms are
slight; with this exception, that in young females amcnoiTheea
is often produced, especially in those cases wliere there is
copious hffimorrhnge from the ulcer. After the disease has
continued a longer or a shorter period, perforation may occur;
or failing this, there may be a severe attack of hicraorrbage.
But in favorjble cases the ulcer gradually heals, the pains di-
tnintsh, and the patient completely recovers.

Supposing perforation to result, the symptoms will be so
severe that the nature of the case cannot be mistaken. There

436

UISEASES OF TUK ORaANS OF DIGESTION.

is violent pain, beginning in the epigastrium bat soon spretd
ing over the whole belly; the abdomen becomes swollen and
tympanitic ; the patient assumes that position which most re-
luxes the abdomin:il muscles; and there is great anxiety, with
rapidly increasing prostraliDn. Moreover, these indications of
the giving' way of the coats of the stomach usually occur uftera
full meal, and perhiips from some sudden exertion, as that pro-
duced by vomiting, coughing, sneezing, &c. Alter an interval,
a state uf iiliiiost pninlcss collapse sets in; and death usually
occurs within thirty-six hours from the time of rupture.

Per/(jnilinf/ ulcer of the dtioiie/iuni presents many of the
symptoms of nn ulcer in the stomach, but in a mitigated form.
Consequently fatal perfonition ocoasion.tlly takes place sud-
denly, whtMi the patient has previously made but little com-
plaint. A curious observation bus been mode by Mr. Curling,
that a sloughing ulccrsnmetimes forms in the upper part of the
duodcniiiti within a few days after asevereburn, and doubtless
in cdiiseijueiico of it: but further investigation is rcijuired to
confirm the slotemcnt. The ulcer may destroy life by hseinor-
rhage or by perfurution.

In the ircaimeiii uf ulcer of the stomach we have chiefly to
support the system, and to facilitate the cicatriztttioD of the
ulcer. When the piiiti is very severe, hot fomentations, sina-
pisms, and turiieiiliiic stupes applied over ibe epigastrium,
give relief: in obsliimte vomiting, or in ha'morrliage, the ap-
plication of ice is more advisable. Upium may often be ad-
ministered with very great advantage, either alone in the form
of the extract, or conibitrcd with heiibiinc, Indian hemp, Sic. :
bismuth is also a good sedative, and may be given in ten-grain
doses, thrice daily, mixed with five or ten grains of compound
kino powder: when there is much flatulent nausea, Dr. Brinton
recuniiiieiids the iodide of potassium with calunibii (F. 42):
when there is troublesome vomiting, bydroeyanio acid in na
effervescing draught (F. 430, 43») gives relief: and when
there is but iitllo pain or nausea some mild preparaliun of steel
(F. 450, 469, 484) will prove very valuable, or, if the patient

CANCER OF THE STOMACH.

437

can bear it, quinine and iron (P. 445, 440) may be ordered.
Supposing that aperients are needed during the progress of
the case, small doses of castor oil will be most efficacious.

Any of the fureffoing remedies, however, will bo almost
worse than useless, unless great attention is paid to the nature
of the food, and the quantity taken at each meal. In the
commencement it will better merely to allow fiirinacenus sub-
stances— as a little oatmeal or arrowroot — with niitk ; taking
care that only a smnll quantity be used ot a time. Cold n)ilk,
mixed wifb one-fourth of lime-water to prevent its coagulating
in the stomach, may be taken in small quantities at a time to
the extent of four or five pints in the twenty-four hours. It
is probable that milk thus rendered alkaline is digested in the
intestines; bo that its administration really rests the stomach.
Should this even be rejected by the stomach, that viscus ought
to be allowed a complete rest, nourishment and medicine being
administered by enemata. Then, as the symptoms decrease,
more strengthening diet may be gradually permitted, until the
patient can enjny white fii^b, light puddings, poultry, &e.
During the whole progress of the case tea, coffee, sugar, beer
and other alcoholic stimulants, should be forbidden ; but if the
latter be called for by the wants of the system, only a little
weak brandy and water may be ordered. And lastly, after a
cure has been effected the patient must be warned that a
careful avoidance of errors in diet, of pressure over the epi-
gastrium, as well as of violent exercise, will bo neecs.sary for
many moTiihs. A single exce.ss, several weeks after recovery,
has brought back all the painful symptoms, and again placed
the sufferer's life in considerable jeopardy.

X. CANCER OF THE STOMACH.

The stomach may suffer from scirrhus, tucdullary, or colloid
cancer; the affection is generally piinmrj/. Of 9118 cases of
death from cancer, in Paris, from 1830 to 1840, the diseas-)

37*

438

DISEASES OF TUE ORGANS OF DIGESTION.

was seated in the uterus in 2906 cnscs, in the stomach in
2y03, and in the breast in 11-19. The pyloric aperture is the
part most fre(|ueiitly attacked, next the cardiac orifice, and
then the space aloii^ the !<maltcr curvature. "Soinetitucs the
cancer, at tho time of dcatli, is of amall extent; but occasion-
ally, and especially in colluid cancer, tho di.'ioase spreads, until
the greater portion, or even the whole of the stouiach, is in-
volved."* When the diaeaso causes obstroction or narrowing
of tho pyloric oriQee, the stomach generully becomes greatly
diluted. Gastric cancer is more common in men than in
women, and is rare before the age of forty. Very few cases
survive two years from the first appearance of the symptoms:
in scirrhus — the most common variety of {;a.<itric cancer — life
may rarely be prolon<;ed for three years, wiiile in cnccphuloid
and colloid, death often takes place within twelve months.

The K_i/mj)lomg YiiW vary with the situation of the disease:
when it is in — or near — tho cardiac orifice, there will be
merely pain and some difficulty in passing food into the
stomach ; if in the pylorus, pain and sickness, when, a few
hours after eating — digestion being completed — the chyme
has to pass into the duodenum ; while, when the lesser curva-
ture is the sent of the affection, the suffering will often be very
slight.

Speaking generally, the principal iiyniptoms may be do-
scribed thu.s : pain in the epig;i»trium, of a burning, lancina-
ting, or gnawing character, augmented after eating, and often
increased by pressure; eructations of fetid air; frequent
nausea and vomiting, at first of ingesta and glairy mucus, sub-
^ec]uc^tly of a bloody sanious fluid, and sometimes of dark
grumous matter having a coffee-grounds appearance; const!-
pntioN ; and extreme and ificren.-ing emaciation and debility.
Occasionally n pulsating tumor is felt in the epigastrium when
the cancerous muss lies over the aorta ; or a tumor may be
detected io some part of the epigastric, umbilical, or hypo-

* On J}iita$a of ihs Slopuicll. Br Dr. Genrg« I1u<ld. LntiJon, 18S5,

lANCEIl OF THE STOMACH.

43l>

cbondriac repions so placed ns not to receive any impulse from
the aorta. And then, in ahnost all cases, the countenance
tfill present the peculiar cnehcctie hue and expression so cha-
racteristic of the cancerous diathesis.

In niali(;nant as well as in t'iniple ulceration of the stomoch
prrforaliim may take place, with escape of the contents of this
viscu.s — fortunately not always into the peritoneum. Com-
munications ore this way sonietiines formed between the
Btomnch and the outside of the flbdomcn; or between the
stomach and colon; or between the stomach and duodenum;
or even between the stomach and the pleural cavities, lungs,
or pericardium. Gcmfrwoli'c Ji*lulie are much more common
than i/af/milu'Mlentil ; while they have genorally for their
cause walignant rather than simple ulceration. In gastro-
colic Cstula, moreover, the stomach and colon are not always
found thftcly adbercnt; hut a cavity may intervene, as if a
mass of cancerous or tuberculous matter had connected the
two, and had been j^radually huHowed out. The symptoms pro-
duced by sueh a fistula are chiefly fa5cal Touiitinj:, and the
expulsion of undigested food with the stools; owing of course
to the pa.«.sage of the contents of the colon into the stomach,
and of the gastric matters directly into the birgc intestine.
When these effects follow upon the symptoms of malignant or
simple gastric ulcer, the diagnosis cannot be a matter of much
difficulty.

The trrafmrnt of cancer of the stomach can only be pallia-
tive; for the disea-^e makes continual progress, and ropidly
exhausts the powers of life. Opium, administered cither by
the mouth or rectum, will be necessary; it should be given
in free and repeated doses lo subdue the pain. When the
vomiting is very severe, nourishment niu.st be given by means
of cncmata ; where it can be borne, however, a uiilk diet with
three or four raw egfis in the twenty-four hours will bo service-
able. In some instances, perhaps, it may be ndv-intiigcous to
lessen the work of the stomach by the administration of pcp-
aine; but I have not had the opportunity of testing this

440

DISEASES OF THE 0H0AN8 OF DIGESTION.

opinion Cod-liver oil is occasionallj easily digested. If the
eructations are very fetid a litllo wood-charcoal will do j;ood.
The extract of belladonna, or a piece of lint soaked in hot
tincture of opium, applied to the epigastric rcjrion, will o)\en
prove grateful to the patient's feelings; or a small blister uiaj
even be raised, and its raw surface aRerwards dusted with a
little morphia — one or two grains.

XI. ENTEEITI8.

Enteritis, or inflammation of the small intestines, Tsries
much in severity; being sometimes so slight as hardly to at-
tract notice, but often so severe as to threaten — or even rapidly
destroy — life.

The intestine is very seldom affect«d throughout its whole
extent ; but I know of no signs by which we can localize the
morbid action, and assert thnt it is only in the duodenum, or
in the jejunum, or in the ileum. So also the iullammation
may aifcct all the coats of the intestine or only the mucous
lining; the latter being a not uncommon disease of child-
hood, particularly during the progress of dentition.

Si/mpfoms. — Enteritis is generally preceded by rigors, hot
skin, thirst, with hard and frequent pulse. The patient then
begins to complain of severe pain in the abdomen, especiftlly
around the umbilicu."?, and of di.strcssing nausea and vomiting;
while he lies on his back with his knees drawn up so as to
relax the parietes of the abdomen. Very C|uickly these symp-
toms are fallowed by great restlessness, high fever, prostration
of strength, anxiety of countenance, obstinate costiveness, and
— in severe C9i?es — delirium. As regards the pain, it must be
remembered that it is increased by the slightest pressure; ia
colic, on the contrary, pres.sure gives relief. The raittera
vomited are usually highly ofTctisivc, and are somotimes ster-
coroceous. Thi; pulse i.s at lirst full and hard, but it soon be-
comes wiry and almost imperceptible.

ENTEnnis.

4-U

Muco-Enteritis, or itifltitiiruatioii of the lining membrane of
the intestine, sometimes occurs in younp children from six to
eight montlis old. The child is hot and restless in the enrly
stflsrcs, ntid suffers from thirst; the tongue is drj, or covered
with a brownish crust; there is fretjuent screaming; disturbed
sleep; vomiting; pain in the abdomen, increased on pressure;
and irregularity of the bowels — in s«:)nio cases diarrhooaj tiic
ficces being green and offensive and often discharged with con-
Biderable force. Thus far the disease docs not differ much
from a sharp attack of diarrhoea. Severe constitutional symp-
toms, however, soon set id : sacb as great febrile oppression,
thirst, vomiting, dryness of the tongue, watery diarrhoea, &c. ;
followed by rapid iind unexpected exhaustion, or sometimes by
coma, with a peculiar pule, waxen appearance of the body.
These .symptoms mny come on before the disease has lasted
any considerable time, and whilst it can scarcely be distin-
guished from the ordinary bowel complaiiit.s of children. It
should be observed that an erythematous redness is generally
observed nround the anus.

Paihvlwjif. — Idiopathic enteritis is rare, the infliimination
being generally due to souie constitutional cause ; and hence
we may hove a tubercular form, a typhoid variety, &c. When
in6aroed, the intestinal mucous membrane will be found of a
deep venous red color, exceedingly congested and covered with
an excesn of mucus. If the morbid action be confined to the
duodenum the affection is known as ihioJenith. Sometimes
numerous ulcers are found scattered through the whole of the
small intestines, especially when there has been long-protracted
diarrhoea. In typhoid fever the solilarj' glands stud Peyer's
patches in the lower part of the ileum, and sumetinies in the
cxcum and ascending colon, are chiefly affected ; the ulcera-
tion occasionally progressing to such an extent as to cause
perforation.

A thickened btnte of the coats of the intestines frequently
results from inflammalion of u chronic or subacute kind. An
irritable luucoua membrane accompanies this condition; whilst

442

DISEASK8 OP THE ORGANS Or DI0E8TI0N-

the peristaltic movements are impeded by the deposit of esu-
datorj matter in the intestinal walls. Hence, it results, that
the characteristic symptoniB are attacks of diarrhoea — or even
mild dysentery — alternating with constipation and retention
of aoybata ; together with slight tenderness on pressure, and a
feeling uf resisUnce on practising pnlpatiun over the affected
parts. Friction with iodine ointment, a nourishing but un-
Btiniuluting diet, and regulation of the bowels by astringents
or by mild alterative aperients — according a.s diarrhoea or con-
stipation cxi.sts — will often remove the deposit. Thickening
from maligtiant disease can scarcely be confounded with that
from simple influmniutory action if the constitutional symptoms
be fairly taken into consideration ; and if it be iilso remem-
bered that the deposit in the former always assumes a nodu-
lated form rather than a continuous thickening.

Diaijvimt. — Enteritis may be mistaken for hernia, or for
obstruction of the bowels from some internal cause. A care-
ful examination of those regions at which intestinal protrusion
may take place, should be made ; and the history of the case
must be well considered In mechanical obslrnction the symp-
toms come on slowly, the pain is fixed, and there have often
been previous attacks of constipation ; while in intussuscep-
tion there is sudden pain like that of colic, with the discharge
of a bloody mucus.

Kritcritig from chronic poisoning is not to be ea.<=ily detected
from iiiflnninintion due to natural disease. But in the former
the vomiting is most urgent., the stomach rejects everything,
there is diiirihoea after taking food, and the puin is less severe.
Where there is the least doubt, however, all the excreta should
be analysed.

Hysterical tympanitis, peritonitis, cerchral disco.«e, suppres-
sion of urine — inducing sicknt«8 and constipation — have been
mistaken for enteritis, though it seems difficult to imagine
how such errors could be cmnmittcd.

Trtntment. — Opium freely administered is invaluable; hot
fomentations sedulously applied to the abdomen will also give

INFLAMMATION OF THE CiCCUM.

448

great relief. Perfect quiet in bed must be enjoined. All
purcatives are to be rigidly avoided ; but attempts mny be
made to empty the lower parts of the intestinal canal by sim-
ple cneniata, especially by warm water thrown up in large
quantity, gradually and slowly, by means of a, lonp flexible
tube, OS the tube of the stomach-pump. After the inflamma-
tion has ceased, mild aperients, such as castor oil, may be pre-
Bcribed ; followed by vegetable tonics, especially the infusion
of bark. In strumous subjects, cod-liver oil, or glycerine and
Bteel wine, do good service. The diet should be very simple,
and ought to. consist chiefly of demulcent drinks, broth or
beef-tea, and farinaceous foods with milk. Ice or cold water
may be freely allowed. When there is a disposition to col-
lapse, stimulants must be resorted to.

In children the same kind of treatment ought to be pursued,
though opium must be given to them with caution. The warm
bath, and hot fomentations or linseed-meal poultices to the ab-
domen, will give relief. If the child is at the breast, no other
food should be allowed; otherwise the diet must be very mild,
con.sisting chiefly of milk with a little broth, and nicely flavored
mucilaginous drinks. The hydrargyrum cum cretii is often
given to children, directly an inflammatory disorder is diag-
nosed. I have seen it administered in muco-enterttis, and
invariably it has aggravated the symptoms.

Xn. INFLAMUATION OF THE CAECUM.

The caecum or its appendir — situated in the right ilino
fossa, and covered by peritoneum only anteriorly and laterally
— may be seriously diseased without any other part of the in-
testines being involved. Thus, severe colic and even fatal
ileus may arise from the lodgniput in this portion of the ali-
mentary canal of hard fsecal matter, skins or stones of fruit,
biliary and intestinal concretions, balls of lumbrici and asca-
rides, &c. Sometimes the intestinal matters accumulate to such

444

DISEASES OF THE ORGANS OF DIOEftTION.

an extent as to produce a large tumor; ond mnn^ arc the
cases where patients hnrc recovered upon passing an immense
quantity of feces, after a careless practiiioner has diagnosed
absce^ or cancer of the kidney. When any of the morbid
matters get impacted in the vermiform appendix of the oseeum,
dangerous inflamniation ciidin°; in nbscciss is very likely to
arise; while, as we shall presently see, the persistence of
disease in the appctidix may form the starting-point of the
morbid process in the cfccum itself.

The iiiflaunnntory process may affect only the vascular mu-
cous surface, or all the coats of the caecum; in either case,
the affection being termed trecilis or li/phlUig, or lyphlo-enle-
ritit. So we may merely have injiummiilion of ihe appendix
caeci, which is attended with more acute syuiptonis than giu)ple
typhlitis. Or the abundant areolar tissue which connects the
cecum to the psoas and iliac muscles may be especially iu-
volved, and then perityphlitis is the mther pedantic name ap-
plied to the disorder.

Whether it be true or not that an important part of the pro-
cess of digestion is carried on in the caacnni, it cannot be de-
nied that irritation and perhaps the suspension of the functious
of this part by disease soon gives rise to prominent ni/niplomt.
Thus, there is always more or less general constitutional dis-
turbance, slight fever, nausea, and often constipation; together
with fulness and tenderness in the right iliac region, the pain
being rendered exquisite by pressure upon the csecum or the
parts in its immediate vicinity. The patient lies on his right
side, with the trunk bent and the knees drawn up, so as to
relax the tissues about the seat of infiammation. The pulse
is not quickened to the same extent, nor is the countenance as
anxious as in peritonitis or enteritis. Supposing the disease
to progress, the peritonea! surface of the caeeura becomes in-
volved, the appendix gets inflamed, and we soon have evidence
of the exititeuco of general peritonitis ; while the areolar tis-
sue may also be affected, and suppuration and abscess result.
The latter may open externally, nr into the intestinal canal,

INFLAMMATION OF THE C-llCrM.

445

and the patient recorer: but ("omotinics the matter is dis-
charged into the cnvity of the peritoneum, causing great suf-
fering, and in a fuw hours death.

If the inflammation begins in the appendix from constitu-
tional causes or owinj; to the escape into this part of morbid
matters, the symptoms are generally very acute; consisting
especially of excruciating tormina, violent sickness, pain in
right testicle and thigh, and obstruction of the bowels. Gan-
grene of the affected part, with general peritoniti.i, frequently
ensue and pmve fatal. In tuberculous typhlitis ulceration
occurs more frerjucntty in the appendix than in the caecum
itself.

The early symptoms of perityphlitis are severe pains shoot-
ing from the right iliac region, diarrhoea and tenesmus, nausea,
fever, &c. The parts around the scat of inflammation become
swollen, and unless resolution takes place suppuration occurs.
Frequently the abscess opens into the cavity of the Cfficum,
and with care the patient recovers.

Occasionally the physician meets with cases of chronic in-
flammation of the Cixcura, in which the symptoms come on
very slowly, with failing health, weakness and lo.ss of flesh,
colicky pains in tlio right iliac region, flatulence and anorexia,
and alternately diarrhcta with constipation. Frequently the
mucous coat of the bowel ulcerates, and then there are nu-
merous mucous discharges with attacks of hiemorrhage ; the
loss of blood at times being considerable. If there be much
thickening of the walls of the cajcum and tumefaction, the
case might be mistaken for an aneurism of the iliac artery.
If death occur, it is generally from exhou.stion ; while at the
nccrop.sy the intestinal coats arc found considerubly thickened,
inflamed, and ulcerated. Very rarely is there perforation.

The (i-fatment of all affections of the ca3cum re<iuire8 con-
siderable caution. I have had to watch a few cases where no
little mischief has arisen from the abuse of purgatives; and in
one particular instance had it been necessary fur mc to state the
cause of death, I could hardly have conscientiously given any

446 DISEASES OF THE 0RQAN8 OF DI0E8TI0N.

Other certificate than — "coropouod colocynth pills." Generally
speaking, anodyne fomentatiuoB or poultices will require to bo
assiduously applied, while opium is pjivcn internally. This
kttor remedy must be used so as to keep the patient free from
pain; and its inflacnce should be maintained for several days.
Effervescing drinks, lemonade, and ice will be useful in reliev-
ing the nausea ; while if it appear necessary to obtain an action
from the bowels, castor-oil enemata may be employed. In chro-
nic cases I have seen most good from simple nourishing food,
warm bathinp, sedative liniments (F. S'iG, ^30, 346) used night
and morninr;, the administration uf cod-liver oil, and the employ-
ment of small doses of the mineral itfids with bark (F. 460, 471).
If an abscess point esterually, It should be opened.

XIII. DYSENTERY.

Dysentery consists chiefly in inflamniation and ulceration of
the mucoua membrane — occasionally also of the other tissues —
of the colon, especially perhaps of the lower part of this gut
and the rectum ; being attended with considerable febrile dis-
turbance, and soon giving rise to great prostration. It has been
sometimes termed colilig. Cases, however, are occasionally se«n
in which the ulceration does not stop at the ilio-caocal valve,
but extends for nmny inches up the small intestines.

Ciiuiff, dr. — Severe dysentery is now a comparatively rare
disorder in this country, either as an idiopathic affection, or as
a complication of some other disease. It appears, however,
occasionally to prevail as an epidemic in our prisons, or in
unhealthy localities. In tropical regions it is at times very
prevalent, and is often particularly fatal to our soldiers and
sailors. Dy.setitery has been ascribed to wet and cold, to con-
tagion, to malaria, polluted water, bad or salt food, to detention
in crowded barracks or transport ships, to insufficient clothing
and bedding, to retained excretions, to drastic purgatives, &o.
All cachectic states of the system predispose to it, in thoae

DTBENTERT.

447

countries where paludal fevers are rife. Moreover, intermit-
tent or remitlent fcvera and dysentery often coexist, or they
succeed each other in the same individual. Whether malaria
is an exciting cause of dysentery, as it is of paludal fevers, is
uncertain.

Sj/nipt'ims. — At the commencement, there is uneasiness and
pain in the abdomen, of a pripinp; character {torminii), with a
frequent inclination to po to stool, which is followed by relief.
As the disease becomes developed, and ulceration or sioufihing
commences, the desire to go to stool is more frequent, and the
eane which succeeds more transient: the evacuations are thin,
mucous, and bloody ; and frequently mixed with small, hard,
separate lumps of faeces, termed tri/htihi. The .scanty evacu-
ations soon produce distress rather than relief; the patient is
constantly tormented with tenesmus and gripintr; the stools
become fetid, dark-colored, and mixed with shreds of lymph;
and the bladder sympathizes with the rectum, causing frctjuent
micturition. The urine also is high-colored, and produces
scalding when pH.«8ed : sometimes there is strangury. — In all
cases there is more or less fever and constitutional disturbance;
the tongue is furred, and the papillas prominent; pulse quick
and small; skin harsh, hot, and dry; thirst urgent, with no
appetite; dyspnoea; and great prostration. In fatal cases, the
abdomen becomes tense, full, and tender, e.ipecially on pres-
sore; the pulse gets weaker; the tongue dry, red, glazed, and
aphthous; there is wakefulness, or short di.sturbed snatches of
elecp ; the evacuations are extremely offensive and watery;
hiccup comes on, with great exhaustion and emaciation ; and
death soon follows.

Termlii>iii(9is. — Dysenteric inflammation, whco violent, may
end in perforation of the bowel and fatal peritonitis; or in rup-
ture and fffical absce.'s; or in ichorrhajniia and abscess of the
liver; or in healing of the ulcerations, with sub»Cf|uent trouble-
some constipation from the contraction of the cicatrices ; or in
fatal exiiau.stiun, particularly where the mucous membrane bus
become sphacelated. — Whuu the disease becomes chronic it is

44S

DISEASES OF THE OBOANS OF DIGESTION.

must iatrncUiblc : there is usually atrophy of the mueoos mem-
brane, with degeneration of the glands; while the patient
wastes awuy, the skin becomes dry and scaly, there is improve-
ment one day with a relapse the next, the toncue is florid and
glazed, the discharges are most offensive, and the pain, &c.,
exhausts the patient so that death is looked forward to as a
welcome source of relief.

The immediate mortality from this disease, in hot climates,
varies from five to ten per cent. According to many observers,
where it does not at once destroy life, it leads (when once
fairly impressed on the system) to so much suffering and slow
exhaustion, that life is ultimately destroyed by it.

Palholmj)/. — By many good observers this disease is thought
to commence as an affection of the tubular and solitary glands
of the large gut, which get enlarged and filled with a jeily-liko
substance. After a time the glands rupture and an ulcer is
formed, and this happening in several parts large patches are
produced by the ulcerations running into each olhcr; while
the intervening mucous membrane gets infliimed and pulpy,
secretes a large quantity of mucus, and readily bleeds under
the influence of any irritation. After death the most extensive
ulcerations are found ; with perhaps portions of the mucous
coat in a sloughy or gangrenous condition.

Rnkitansky states that the dysenteric process is divisible into
four degrees or stages, ranging from inflanim.ition and soAening
of the mucous lining of the colon to complete mortification.
Dr. Piirkes considers that ulceration is always present, and th.it
the solitary glands are much affected. Dr. Hnbcrshon thinks
it probable that the diseased condition is closely allied to that
of the pharynx in dipihtheria; and that in severe examples,
the membrane rapidly sloughs, without antecedent ulceration,

Trenlmrni. — Bloodletting, both by the lancet and by leeches
applied in the Inick of the colon, is usually recommended, and
is, I believe, still practi.scd by many. In the dysentery of this
climate, it is worste than unnbves.sary to bleed; and this must
be the case in all countries when the morbid action has ad-

nYSENTERY.

449

vancedso far that there is ulceration or gangrene of the aficctcd
tissues.

Ill the early stages our object ought to he to sootfie the in-
flamed membrane, and to remove all sources of irritation.
Hence denmlccnt drinks must be freely given ; and the diet is
to he free from stimulnnts, and of the lij:hte,st kind, — farinace-
ous food, milk, and thin broths. The warm bath may be fre-
quenilyemployedwith great advantage; while the wet compress,
fomentations, and hot ponllioes always give great relief. When
we fear il e lodgment of scybala, a few doses of castor oil may
be given, the action of which should be aided by enemata of
gruel. The bowels having been acted on, no drug appears to
exert so good an etfect as ipecacuanha. This agent seldom
produces nauuea and vomiting, when given in dysentery; but
it is bencficiai by causing an increa.«ed seurution of mucus, and
by restoring the deranged capillary circulation to its normal
state. From three to six graiii.s may be given every four, six,
or eight hours, until unmistakable evidence of amendment is
afforded. If there be much pain, opium must be combined
with the ipecacuanha; while, in exceptional eases, it may bo
advisable to give small doses of blue pill with it. While the
opium does good by keeping the patient in a state of ease, and
by diminishing the peristaltic movcnietits of the bowel, it also
does harm by checking secretion ; and therefore it is not to be
employed uuneces-sariiy, or without caution. If it produce
constipation, recourse must bo had to castor oil.

When the dysenteric inflammation has reached an advanced
stage — when there is disorgiini/.ation of tissue — then there are
still two fHjints to be uimud at — viz., to support the general
strength, while the diseased structures are to be kept as quiet
as possible. Under the.«e circumstance.^, tonics, astringents,
and opiates are to be the tools with which we work. Where
the patient is weak and antemic, we may try salicin, quinine,
bark, ur some mild preparation of stcei : when the dejections
are abundant, frothy, and sanguineous, we are to use bismuth,
gallic acid, kino, logwood, and sulphate of copper; while in

3fl*

450

DISEASES OF THE 0R0AN8 OF DIGESTION.

both olaweii, but chieflj in the last, opiates by the month, or
often preferably by the rectum, will be invniunbie. The diet
oupht to bo generous; milk, raw epcs, animal food, ripe grapes,
and perhaps stimulants being necessary.

In chronic dysentery the patient niu.«>t seek relief in a mild,
dry, equable climate. If unable to do so, he should be treated
according to the principles just inculcated. The remedy which
eecnis to have had the most salutary eifeet in the chronic dys-
entery from wiiich our soldiers suffered in the Crimea, was
morphia. One grain of the hydrochloratc was given twice or
three times a day, with some aromatic spirits of ammonia and
nitric ether.

XIV. DIARRHOEA.

In most works on practical medicine many varieties of diur-
rho?a arc described, eucIiiik the fseculcnt, the bilious, the mucous
or catarrhal, the dysenteric, &c. These .subdivisions are, how-
ever, quite unneces.sary. . It would seem much better to apply
the term (liarrhccn to all examples of simple purging; that is
to ssy, to all cases in which the alvino evacuations are frequent,
loose, or liquid, without any coexistent inflammation of the in-
testines.

C'liuffn. — The causes of diarrhoea are numerous; the most
commcm being over-feeding, or the use of improper food, or
exbaustiuii iMinserjuent upon sturvatiun, or the drinking of foul
water, or iirhaling the fumes from decaying animal or vege-
table matter, or great mental emotion, or exposure to damp and
cold or to too great heat. From the latter cause relaxation of
the bowels is couiuion during the summer months; hence it
has been termed pummer or English cholera. Diarrhoea is
often al.KO a symptom of many diseases, as of phthisis, typhoid
fever, &c.

Si/m]ili>m$. — In addition to the purging there is generally
some degree of nausea, a furred tongue, foulness of the breath,
flatulence, griping pains, acid eructations, and tenesmus. Mure-

DIAnBIKEA.

451

over, the stools are unheulthj ; either consistin': of liquid faeces,
or of a watery fajoulent mucus, or of a tiiin frothy soruai, or
of n pale yeast-lilte matter. In severe summer or Enjilish
cholera the evacuations are often composed chiefly of bile, the
paios in the nbdomen are violent, there are cramps io the legs,
and the depression is often crcat.

The way in which haaniorrhago occiii-s, the blood being
passed by the rectum, has already (p. 79) been noticed. The
reader may, however, be reminded that blood sometimes ap-
pears in the sstools from en-iorgcnicnt of the portal system
causing congcxtioD of the whole mucous linti),i;of (he alimen-
tary tract, owing to disease of the lunps, heart, or liver, ob-
structing the circulation; from ulceration — either nimple or
niatifrnant — of the stomach; from disease of the intestinal
glands, as in typhoid fever, and sometimes io phthisis; from
ulceration about the colon or n:ctuni, as in dysentery; and
liislly from the giving way of one or more of tiie hicniorrhoidal
veins, as in instances of piles. When the blood is mixed with
faecal matter and intestinal mucus, the case may be mistaken
for simple diurrhcea, unless the practitioner cxamino the stciols
himself, as he ought to do in — at least — every serious case.

Prorf)io$U, <f-c. — This is always favorable, except in the di-
arrhoea of young children, or of old people with enfeebled
fi-ames, or of some exhausting dii^ease. — It UTU>t be reiiiem-
bcred, that in examples of fiecal accumulation there is con-
stantly tenesmus with the frecjuent passage of snml I rjuantities
of lir|uid fa;c(s. I have seen more than one inslance where
the patient's life has been endangered by recourse being had
to chalk mixture and opium, when the removal of the mass by
enematn and the scoop ought to have been adopted — Agaiti,
cases in whic-h the power of the sphincter ani becomes diini-
nbhed, either from paralysis or from very great prostration,
are soniutimes mistaken for diarrhoea. When the rectum is
irritable and the sphincter weak, nialtei-s which wnuld other-
wise remain some houis and accumulate puss away at once:
but of course no benefit will arise from treating such cases as

452

DISEASES riF THE ORGANS OF UIOEUTION.

ditirrboea. The recumbent posture, fcrruginona tonics, and
good diet raa; more probably effect a cure.

Treatment. — This will of course depend upon the cause.
When the purging arises from the presence of some offending
matter in the intestinal canal, the expulsion of such matter
must be aided by adiiiinisteriuj!; a dose of rhubarb or of castor
oil, conibining a few drops of the tincture of opium with the
draught if there bo mueh pain. If no such cause exist, we
may endeavor to relieve the symptoms by opium, or by calomel
and opium, or by the chalk mixture with ci\tcchu, Ike , or by
the pulvis creta) compositus cum opio of the Phar. Lond., or
by lof^wood, sulphuric ncid, kitiu, or Dover's powder, according
to F. 122, 1'23, 1*24, l.S.i, 136, 1.38, 141, 145, 147, and 364.
The enema npii of the Phar. lx)nd , or a suppository of opium
(F. 386) will uften give great relief. Ipecaouwnha is especi-
ally usefiil in the dinrrhcea of children, or in that of ndulta
when due to tnflamnifltory congestion of the mucous membrane
of the intestine (F. 36t), 385). Attention must invuriubly be
paid to the diet; emollient drinks, liquid nourishment, and
custard or baked rice puddings only being allowed for a few
days after the attack.

XV. EPIDEMIC CHOLERA.

Chulcra is probably the most fatal disease known in the an-
nuls of medicine. It is variou.ily spoken of as Sfa/iiptnnt, or
Afititir, or Alijide Chulvra ; this latter term having reference
to that diminution of animal beat which is one of the signs
of this disorder.

It is generally believed that cholera is of Eastern origin,
that it first made its appearance in India in 1817, and was
imported into England in 1831. We are just as ignorant of
the rcB.son of its origin, as we are unable to explain why it
should have nigcd in this country in 183 1-32, 1848-49,
1853-54, and not during the intervening years. All that our

KPIDEMIC CHOJ.ERA.

453

experience has taught us is this : thnt cholera attacks the poor
in a much larger proportion than the rich; and thiit as we
remove destitution, HIth, foul nir, and the causes of disease
generally, so we destroy the agencies through which this for-
midable malady operates.*

The first two epidemics of this disease in En<;land {1831-
32, 1848-49) were the most severe; and each continued fifteen
months. They began in October, spread gradually, increased,
and then as sprinp; advanced gradually subsided, to burst oat
afresh with the hot weuthcr. It is worthy of notice, that in
both epidemics the cholera entered England after the wheat
harvest was over, at lite close of tlie hot season ; iind that it
was most fatal durinj^ and after the wheat harvest of the fol-
lowing year. In 1848-49 there were 53,'i93 deaths from this
disease in England alone, not including 18,887 from diarrhoea.

In l85i there were 32 deaths from cholera in the metropolis
between the conitnencement of Fehruary and the end of July;
in August, 48 deaths; in September, 99; in October, 293;
in November, 318 ; and in December, only 62. During the
eatly part of 1854, cholera had nearly disappflured : so that
until the 1st of July only 10 fatal cases occurred. But it now
again became epidemic, and between the Ist and 22d of July,
(he mortality was 38 ; during the week ending 29th July,
there were 133 fatal cases; and it then rapidly increased, until

* As Mnmplos oT tbe eiTrotj of orsr-crowding, the following are n-
lected from n number of similar CKKes ; Within the walls at an eBtablinb-
menl for paiiptT children at Tooting, there were crowded 1395 children.
Liitle more thun 100 cubic feet of brenlhing space waa allowed for each
child : nl though n« we know SOI) io the emalleit amount which can be glTen
cotnpnliblc with fnfety. One night — during the epitlcmio of 1853-54 —
cholera Dtlnckedf3-1 of tfae»< children : 500 were attncked in nil, and within
a week IftO perif*h«>d..— In the workhouse of Tnuntoi] there were 276 in-
mate*. In sotne of the rooms the breathing space was not more than 68
cubic feet for cnch person. Cholera swept away 60 of these iobabitanis
in les< than a week. In the county jnil o! the same town, the breathing
space allowed to each prisoner ranges from 810 to 935 cubic feet. While
the poor were being destroyed in the workhouse in this wholesale manner,
not a single case of cholera or ofdiarrbaia occurred among the prisoaera.

454

niSEASES op THE ORGANS OP DIOESTION.

in the week cndinp; 9th September there were 2050 deaths
from cholera, and 276 from diarrhoea. Having now attained
its maximum, the ufTection sluwlj declined, but did not en-
tirely cease until the end of December; the total mortality
from it in the metropolis in 1854 bein^ 10,690.

The estimate has been made by Dr. William Farr, that little
lens than five millions of the people of the United Kingdom
were attacked by cholera or diarrhoea in the epidemics of 1848
-45) and 1853-54 ; and that a fjuarterof a million of these ao
attacked died.

Sympfomii. — The cholera usually manifests itself in three
Binges. In the first, there is diarrhusa and vomiting, which
are considered by Dr. Stevens as efforts of nature to expel the
morbid poison from the blood and from the body ; in the second
stage, there are in addition, cramps, spasms, coldness of the
body, and sinking of the pulse ; while in the third and last
stage, there is collapse.

Considered somewhat nioro in detail, the chief symptoms
may be described as copious vomiting, with purging of a pecu-
liar flocculent rice-water kind of fluid ; severe cramps in the
lower extremities and abdomen, rendering the muscles as hard
as wood, or drawing them into knots, as it were ; sometimes,
in the early stage, albuminuria, followed by complete suppres-
sion of urine; thirst, usually very urgent; diminished circu-
lation and impeded respiration, cau.sing iiiten.se prostration,
with icy coldness of the surface of the body, the tongue, and
even the breath ; lividity or bluoncss of the lips, nod the skin
gciieraUy; alter-ition of the voice, which becomes whispering
and unnuturul ; togetlier with shrinking and piauhiog of the
face, and indeed of the whole body. Notwithstanding the
diminution of temperature, however, the jiatieut probably
conipluitis of oppression ; while he often prefers to lie unco-
vered. Moreover, the sharp pinched appearunoe of the fea-
tures, the muddy-looking complexion, and the sinking of the
eye with flattening of the curuea are so characteristic that the
expression they give rise to is known as ihe/aciei choleriticti.

EPIDEMIC CHOLERA.

455

Then there soon follows a graJual lessening of the breathing;
a diminution, or Dbsolule disappearance of tbe pulec ; and, at
length, a complete arrest of the circuhiiion. In all cases the
intellect remains clear until the last ; the suiTerer being sonie-
tinies hopeful, eomctiiuea quite callous to his fate. Death
generally take^ place in from three to eighteen Uuurs. Pa-
tients who survive beyond this period frequently show signs of
amendment, and eoinetiues rapidly get well. But otlen the
improvement is transient, and they subsequently die p<jisoned
by their own secretions — by the continuance of the suppres-
sion of urine ; death being preceded by headache, drowsi-
ness, tonic or clonic spas-nif, vomiting, slertor, and coma. In
more favorable cases a ruild febrile exacerbation follows, which
subsides gradually in a few days ; or this consecutive fever
may be of a more severe type, and the patient may sink into
a low typhoid condition, from which, under proper treatment,
however, he nlowly recovers. The attack is sometimes pre-
ceded by slight diarrhoea, but mure frequently comes on sud-
denly without any warning.

If wo examine the stools in cholera we shall find that they
consist of an abundance of water, a large quantity of epithe-
lium, a little albumen, a trace of biliary matter, and a large
amount of salt.s, but particularly of chloride of sodium.

PolholiMji/. — The only explanation which can be given of
the cause of cholera is, that it ia due to some maleriei morbi
— a septic agent, the existence, increase, power, and trans-
mission of which from place to place is favored by some par-
ticular stale of ihe atmosphere associated probably with a high
temperature. The action of the poison is undoubtedly encou-
raged by filth of all kinds. As far as I can glean from the
recorded evidence — and I have carefully studied the subject —
it certainly appears to me to be, to a certain degree, conta-
gious: in other words, 1 believe that human intercourse has a
share in propag:tting the disease, though it is not the only
means of effecting its diffusion. We must remember, how-
ever, that cholera, like other contagious disordere, can only be

456

DISEASES or THE ORGANS OF DIGESTION.

taken by a person predisposed to disease : we may indeed
compare a contagious or infections disorder to a seed, which,
unless put into a fit soil, undergoes no change — does not grow
or take root.

Whether the cholera poison {cliolerirti) enters the blood
thmugh the skin, through the lungs — which is probably the
case — or through the alimentary canal, as Dr. Snow believed,
is a question which cannot be said to have been satisFactorily
solved. But on examining the evidence adduced to prove
the hitter hypothesis, Dr. Baly came to the conclusion that no
sufficient reasons have been found for adopting the theory that
the poifon is swallowed with the food or drink, i.s reproduced
in the alimentary canal, and being discharged with the excre-
tions propagates the disease by finding access io the satoe way
to the etoiuachs of others.

When an epidemic of cholera is prevalent there are certain
conditions which render individuals liable to the disease.
These ■prrdifpnsiritj caimts are undoubtedly the use of bad,
uowholesomc food ; such as etalc meat or fish, shell-fi^h, high
game, bad vegetables, unripe fruit, impure water, &a. The
effect of exhalations from badly-constructed sewers is highly
injurious; the influence of noxious trades and nuisances is
powerful ; while intemperance, uneleanliness, vitiated damp
air, are all prolific predisposing cau.'cs. So again, anything
which lowers the vital powers will predispose ; as great fatigue,
too long abstinence from food, diarrhoea, &c. Hence, in cho-
lera-times, it is most important to reside in a well-ventilated
house, in an elevated, airy, dry, locality; to live by rule; to
strictly avoid the use of purgative tuedtcines; and to be most
careful to check any tendency to looseness of the bowels by
the recumbent position, and by chnlk mixture, opiates, and
aromatics, since such looseness causes dcbilit}', and thus pre-
disposes a person to receive the choleraic poison, I do Dot
believe, however, that common diarrhoea can produce the spe-
ciGc poison of cholera, as some imagine, any more than it can
give rise to the poison of small-pnx or measles.

EniiEMir CHOLERA.

457

Morhiif Analovii/. — Post- mortem examinations have thrown
but little lif^ht on this disease. As one of the foei of the mor-
bid action, we naturally look first to the pistro-ititestinal mu-
cous membrane ; but beyond distension of the follicles with
8cruin, an oedematous condition of the mucous lininjr, patches
of venous congestion, and here and there rupture of the ves-
Beh producinc; eccbymosis, we find nothing. Tlio symptoms,
moreover, indicate great exhau8tion of the abdominal gan-
glionic nervous centres, while there La also a ninrked loss of
tone in the capillary circulation. May not these eflects be
due to the altered condition of the blood? This fluid i.s usu-
ally of a tarry appearance and consi.stence, the proportion of
water being much diminished, the amount of Bbrin being un-
affected, and the corpuscles increitsed ; while the Bcrum is rich
in albumen, it contains a slight excess of urea, and though its
salts collectively are perhaps diminished, yet the potash and
phosphates are increased. The brain, heart, lungs, and liver
are usually found healthy; Dr. Ayre's statement that the latter
organ is always congested, having been contradicted by other
observers. The kidneys are sometimes discovered gorged
with venous blood.

The bodies after death arc found much shrunken, and of a
dusky or livid color; while u.'iually putrefaction is more de-
layed than usual. A'ery remarkable contractions of the vol-
untary muscles arc sometimes noticed shortly after death from
this disease. In the Chokrn Gazette for 1832, it is men-
tioned that in India the dead bodies of the soldiers were so
violently convulsed, that their coniraJes, "in order to calm
the timid, bound the limbs to the hed-frnme." Another re-
markable circumstance is, tliut the temperature of the body
often rises after death from cholera ; the increase of heat being
maintained for nuiny hours. This rise of temperature some-
times hiippctrs together with the muscular contractions, but
0^60 also without.

Trraimriii, — Every article of the Materia Medica has been
tried in this disease ; large doses of enlnmel, opium, bnindy,

458

DISEAf^ES OF THE ORGANS OF DI0E8TI0N.

Bulphuric acid, cajepul uil, custor oil, crotoD oil, creasote, cblo
rorurm, sugnr, sulpbur, ncctatc of lead, logwood, emeticii, osy-
gen gas, hot-air bath$, Ten£escction,&c., having been the favor-
ite remedies. Direotlj' a case recovers, the sanguine practi-
tioner imagines that he has cured it, and immediately sets
goose-quill to paper to record his success. The consequence
is, that the tiiedical journals — and even the daily ptipers — ia
cholera times, are filled with letters and comiuunicatious renora-
menditig the most opposite and useless remedial agents ; these
epistles not only frequently serving to show the weakness and
credulity of the writers, but also tcoding to bring discredit on
the niediciil pruft's^ion gcnenilly.

Mercury litis buen hi}j:hly praised by some practitioners, and
espcciully by Dr. Ayre; whu shows that of 725 une(|uivocal cases
treated with it, ;>C0 recovered. But it bus been pointed put
by l)rs. Ualy and Gull, in thdr Report un Cholera to the CoU
h'ge of I'hysicianH, that under opposite plans of treatment, the
recoveries even in severe ca.ses averai;ed from 45 to 55 per
cent., according tti the period of the epidemic, Cousei|Ucntly,
the farts adduced by Dr. Ayre are nut worth much. Again,
Dr. (Jeorge Johnson has strongly advocated the use of castor
oil. The Medical Council of the Board of Health, after inves-
tigating several cases treated by (his agent, report, on 20fh
September, 1854, " From the above abstract, the details of
which have been carefully investigated by the Committee, it
appears that, in 89 cases of cholera, treated by 14 different
practitioners, with castor oil, on the plan reeoniiuended by Dr.
Johnson, 68 were fitiil ; recovery having occurred only in 15
cases, while G remaining cases arc still under treatment."

The only plan of treatment really deserving of notice, since
it is the only one ba^cd upon a scieutiiio foundation, is that
by salines, as 8ug>.'estcd by Dr. Stevens; a plan, no doubt,
which will often fait, but which will succeed much more fre-
quently than any other. The following is an outline of it, ss
most succes.'-Cully used on a large scale, in the prison of Cold-

F.I'IUKMIC CHOLERA.

469

bath Fields, in 1832.* Pntients presenting the premonitory
syniptiuus — diarrhcea and vomiting — were removed iutu an
oK^ervntion ward, where an even temperature was constuntly
niiilntaitted. A Seidlitz powder was iniuiedioteiy adminis-
tered ; if sinking wn.s felt without puruirij;, three or four toa-
spoonfuls of Epsom sahs were added to the powder. On these
ajjents aetinj;, plenty of thin beut-ti'a, weH-.«en«)ned with salt,
was given ; if there vins any paiih, u sinHpisni was applied to
the gastric recion ; and thirst was relieved with seltzer, soda, or
pure water ni/ lihiliim. Most of the fsses were thus cured.
If, however, cramps, coldness, or sinking of the pulse came
on, the patients wtTo considered as cholera cases in the second
degree. The fdllowini^ was then aduiiniiitcrcd about every
half-hour : Sodii chloridii 9j, Sodse carbonatis 5^1 Potassae
chloratis gr. vij, dissulved in wutor. If there was much irri-
tability of stomach, a larjxe sinapism was applied; if much
heat or burning pain, an additional quantity of carbonate of
soda was added to the mixture. In cases in the stage of col-
lapse, a strong solution of the same salts, di.'solved in hot
water (100° Fahr.), was thrown into the bowels, and repeated
every two or three hours. Sinapisms were also applied to the
stomach, between the shoulders, &c. ; and in the cold stage,
frictions with warm towels were used. A- pure air for the pa-
tient to breathe was considered of the greatest importance.

In addition to the above, I would try the effect of placing
the sufferer in a tepid hip bath, and then pourinn; cold water
over the bead, back, and chest. Directly afterwards the pa-
tient should be removed to bed, between warm blauketa;
while if this cold affusion were followed by amendment, it
ought to be repeated every sis or four hours. In mild cases,
the " wct-sbeet envelope" will favor reaction ; but it has only
proved mischievous in severe instances. When the vomiting
is severe, or the thirst insatiable, nothing gives more relief
than permitting Wenham Lake ice to be continually sucked.

• On Ahalie CAoltra, Iff. B; Dr. William St«T»iu. London, I8SS.

400

DISEASES OF TIIK (iBtlANS OF DIflESTIOX.

The greatest coutiua will subsiuqneDtly be required for ronny
days tin to diet ; not a few deaths having occurred fmni the
too early use of aniuial food. As a rule, brotbs and farina-
ceous substances only should be allowed, without any solids
whatever, until the renal secretion has beeo fully re-estab-
lished, and all the symptoms have vanished.

XVI. COLIC.

Colic is eharacteriied by severe twisting pain in the belly,
especially about the uiiibilicus, occurring in paroxysms. There
m no iuflawmatory action, and the pain is relieved by pressure;
it is accompanied by constipation, and often by vomiting: and
thert! is neither fever, nor (juickness of pulse, nor depressing
anxiety as in enteritis.

Attacks of colic may arise from indif^estion accompanied
with flatulence; the suffering; being severe until vomiting, or
eructation, or expulsion of the wind by the anus gives relief.
A second common cause is the presence in the bowel of mor-
bid secretions, or of retained cxcremeotitious matters; easily
cured, as is also the first kind, by hut brandy and water, and
a dose or two of castor oil. — Then we may have to treat ner-
TOtu or spasmodic colic, such as occurs from frigbt, oold, bys-
teria, ^out, kc. ; and which demands the use of Hntispaaniodics,
like ether, chloroform, and opium. — While, fourthly, we may
have colic from lead.

Zjtad Colic — or (Juliia Piclonuvi, so called from its former
frequency among the Pictoncs or inhabitants of I'oictou — hns
superadded to the symptoms already mentioned, an intense
griudinir or twisting sensation around the navel, with retrac-
tion of the abdoniimil integuments towards the spine, and pain
ill the back. We are indebted to the Into Dr. Hurton for
pointing out a pathognomonic symptom of the presence of lead
in the system, namely, the existence of a blue line around the
edges of the gums. Painters most frequently suffer from this

CONSTIPATION.

461

disense, in this country : they often have several attacks before
the muscles of the arms become affected with parulysis, causing
drop wriu. Sleeping in a recently painted room, drinkins;
fluids which have been kept in leaden vessels, taking snuff
adulterated with load, &c., are not unfrequent causes of this
affection.

In the treatment of lend colic, our fii-st object must be to
get the bowels to act. This may generally be best accom-
plished by administering a large dose of calomel and jahip (F.
191) : two or three hours subsequently placing the pjitienl in
a warm bath, and injecting part of the water into the bowels.
Should these means fail, an ounce of castor oil must be ^iven;
or a full dose of sulphate of magnesia with sulphuric acid (F.
170).' Opium will afterwards be necessary to remove all the
pain ; only farinncc'ius food should be allowed; and the patient
should be purged fur a few days by the sulphate of niagncsiii
(F. 178), administered every morning. The application of
elcetricily by induction — Faradization — is somctiuies an ex-
cellent palliative; giving relief to the pain more speedily than
any other remedy. If the praelitioiier be afraid of the elec-
tricity at first intcnsifjing the suffering, ibo patient may be
put under the influence of chloroform. When the attack bus
been relieved, and the bowels have been freely acted upon, the
iodide of pota.ssium should bo administered (F. 27, 30) ; and
& hot sulphur bath (F. 159) may be ordered. Benefit will be
derived from frequently repeating the latter.

XVIL CONSTIPATIOH.

Constipation may arise during the progress of any aoate or
chronic disease, or it may happen as an idiopathic affection.
In cither case too much importance is usually attached to its
occurrence, and consequently it is often treated with unneces-
sary activity.

There is some variation io dilTcreDt individuals with regard
3a»

462

DISEASES OF THE OROANS OF DICIESTIOV.

to the frequency wilb which the bawela net during health.
As a rule, most people have an evncuotion every day ; but
sonic ptrsoiia hubilually go to stool twice in the twenty-four
bourH, while uthcra only have an operation every sccuud or
third day. The most important eunsc(|uences which result
from habitu;il costiveness (by which term is meant, a depar-
ture from the standard natural to each individual) are irrila-
tiuii of the ^uNtru-intcsliiml mucous uembmne, and perhaps
the reabsorptiiin of excremenlilioua mailers. The functions
of the stomach, liver, pancreas, i&c., are im[>crfcctly performed ;
and hence complaint is made of a sense of oppression, mental
and bodily; ibe iiilcHeetual faculties are dulled, ihe complexion
gets sallow and pasty, the skin is dry, the urine is scanty, and
such motions as conic away are pale, clay-like, and very oifen-
Bive. In obstinate cases the sufferer may lose all power of
exertion, he may have frequent attacks of headache, lits of
palpitation of the heart are not uocummon, neuralgic pains
torment him, and be perhaps becomes a contirmed hypochon-
driac.

A torpid condition of the colon, leading to insufficient cou-
traction of this gut, is the common cause of the retention and
nccuiimlution of iaeail matter. It occurs in old people, in
individuals weakened by exhausting disease, in chlorotic fe-
males, in the votaries of fashion accustomed to indolent and
luxurious habits, in those who neglect to attend to the calls
of nature, as well as in such us are engai^ed in sedentary occu-
pations. Ill addition to constipation there is defective appetite,
slow di^cstiun, a pale sodden tongue indented at its edges,
flatulence, fetid breath, a dingy complexion with dark Hues
under the eyelids, and low spirits. The uccuniulatiuii of faecal
matter may be so excessive that an abdominal tumor is pro-
duced ; which will perhaps give rise to jaundice by its pres-
sure on the biliary duct, or to u?dcma by impeding the flow of
blood through the inferior vena cava. Cases have been ob-
served in which the abdomen has been enormously distended,
where a motion has not been passed for ten or twelve weekn,

CONSTIPATION.

463

k
^

and where the contents of tlie rectum huve had to be scooped
awaj to procure room Cor the use of cneniata. Again, it is
sometimes argued that an accuinulatiun cannot have taken
place, becau;3C the patient is toriucntcd with teucsinus, and as
he sajs with diarrhoea. But the fact is, that when the de-
scending colon and rectum beconie blocked up, small quanti-
ties of faseal matter may fl<iw through a channel formed in the
mass, or they may pass between the substance and the walls
of the bowel, and so lead to deception. I have seen several
such cases, occurring in delicate females during the period of
pregnancy.

In attempting to cure habitual costiveoess, the grand aim
of the praclilioner must hi; to do away with the use of purga-
tive drugH. This cannot U!«ually be elTeeted at one rude blow ;
but it ie posiiible at once to substitute simple aperients for the
various patent niediciiies, the mischievous blue pills, and the
nauseous black draughts, with which the public are so fond of
tormenting themselves. The remedies that muy for u time
be employed, ut properly reguluted intervals, are castor oil,
olive oil, rhubarb, magnesia, sulphate of sodu, small du!<es of
aloes, inspis.satcd ox-gall, taraxacum, and Scidlitz powders (F.
174, 175, 176, 179, 182, 183, 185, IStf, 192,2(15, 206, 207,
208, &c.) An imitation of the Cheltenham or Carlsbad waters
(F. 224, 225) will ollen prove useful : or simple electuaries
(F. 238, 239, 240) may be tried : or fref|uently it will be
much better if the piitient caa be persuaded to trust to eneniatu
of soap and water, of salt and barley-water, or ol castor oil (F.
232, 233). To restore tone to the colon, tonics are invalu-
able; and hence many of the prescriptions just recommended
contain these agents in combination with purgatives. But
afler ten or fourteen days the aperient medicines must be
gradually discuutinued and tonics alone trusted to; the best
drugs of the latter nature being quinine, sulphate of zino,
nitro-iuuriatic acid, extract of uux vomica, pepsine, and cod-
liver oil (F. 216, 223, 446, 401, 481, 483, 481, 494, und
408).

tlISEA£Eft or TBK ORGANS OP DIGESTIOX.

None of the fore^inp remedies will prove of pcrmnnent
service unless attention be paid to the diet. It is of the
greatest importance that the food be wholesoue and digrati-
ble; a variety of dishes being only injarions when lht>y lead
the patient to eat to excess. Ve';t'tabica are often obji'Ction-
able, more especially if they produce flatulence ; while the
necessity for them, until the function of digestion is healthily
performed, may often be obviated by the use of ripe fruiti in
the morning. Brown bread, containing the bran, can often
be Rubstitnted for the fine bread usually consumed ; bat for
the stomach to be able to utilize that outer covering of the
wheat, rich in gluten and fatty matter, it mu.tt be strong
enough to digest it properly. The aerated loaf is generally to
be preferred either to brown or the common white broad, since
it is certainly more easily assimilated.

Daily exercise in the open air, either on foot or on horse-
back, stands foremost amongst the remedies for constipation.
Gencnil indolence, with too much sleep, must be avoided.
There are very few cases of costiveness with dyspepsia, arising
from sedentary pursuits, that may not bo cured by the sufferer
retiring to bed ut eleven o'clock, and drinking a tumblerful of
spring water; ri.«ing at .«even o'clock and taking a bottle of
soda-water, then walkitig for three-quarters of an hour, and
afterwords breakfasting upon weak tea with plenty of milk,
and meat, bread, kc. In the hepatic sluggii-hness of old ago,
nothing is more beneficial than a daily walk, or even than a
ride in an open carriage.

There are, in conclusion, one or two .suggestions which may
bo advantageously remembered. Thus, it is very necessary
that the bowels should be solicited to act at a regular hour
everyday; soon after breakfast being perhaps the best time.
A sponge or shower hath every morning gives tone to the ali-
mentary eanul. In sonic instauces, where the liver is congested
or the secretion of intestinal ntuous deficient, marked benefit
arises from wearing the " wet compress" at night; this appli-
cation merely consisting of two or three folds of thin flannel

oussTuicTioN (pk the UUWEr.S.

406

or calico, wrun^ out in t<!pifl water, liiid upon the abdomen,
and covered with gullapcrfliu <pr oil-silk. And luBt!}', in the
csases cspceially of children and old jieDple, gentle kneading of
the abdominal muscles, or frietiou with .«onie stimulating lini-
ment, will produce a daily evacuation ; these means being
generally preferable tu the employment of galvanism.

XVin. OBSTRUCTION OF THE BOWELS.

Intestinal obstruction is a fearful disorder which may ari.-^e
from several conditions. Before mentioning these, it may be
remarked that when there is obstruction with freeal vomiting
the disease is often called the Ileus (eikim, I twist or contract);
while it is also known as the Iliac passion, Volvulus, and Co-
liqiie lie Miseriion/e. The most frequent cause perhaps of an
ubstriiction to the passage of the fjcces through a part of the
intestinal tube ia stranj^ulatcd hernia ; so that consequently in
every case of ob.stiuate constipation the practitioner should
make a careful examination of those parts of the abdomen,
thigh, and hip, and — in women — of the vagina, at which the
intestine may protrude.

Pulholoijy, itr. — Dr. Haven has collected, from various
sources, the histories of 2.'i8 cases of intestinal obstruction ;
which — without including examples of inguinal, femoral, or
umbilical hernia — he has thus tabulated :*

Three divisions of the causes of intestinal obstruction are
made, viz. :
1. Intermiiral, or those originating in and implicating thu

mucous and muscular coats of the intestinal walls :
a. Cancerous stricture.
h. Non-cancerous stricture, comprising —

1. Contractions of cicatrices following ulceration.

2. Contractions of walls of intestine from inflamma-
tion, non-cancerous deposit, or injury.

* American Jaurnal of tht Mtdioal Stiinctt, vol. Ivl. Pbilulelphla,
IS56.

40G

DISEASES OF THE OROANS OF DIOEHTIOK.

e. Inta^snsception.

d. Intussusception associated with poljpi.
2. Eriramurnl, or those causes acting from without, or affect-
ing the serous covering :

a. Bands and adhasions from effusion of lymph.
6. Twists or displacements.

c. Divorticula.

d. External tumors or abscesses.

e. Mcsocolic and mesenteric hernia.

f. Dinphrasiniiitic hcroiu.
y. Oiiicntiil hernia.

h. Obtunitor hernia.
8. Ill tram II ntf, or obstructions produced bj the lodgment of

foreign substunccs :

u. Foreign bodies, hardened fieccs, concretions having
for tiieir nuclei gall-stones, &o.

In the first class, the largo intestine is affected more than
twice as frequently as the small ; in the second ulass, the re-
verse happens. The average duration of the attack of ob-
struction is shorter in the first class than in the second ; on
the whole, the avenige u about three weeks. Sir Astley
Cooper mentions three other causes of obstruction, viz., — her-
nia at the ischiatic notch, at the foramen Winslowii, and peri-
neal hernia, but none of these causes existed in either of the
258 cases.

In 1(59 examples of intestinal obstruction collected by Mr.
Phillips* — 09 were instmccs of invagination or intussuscep-
tion ; 60 of Ktnuigulaiion by the constriction of b.inds, adhe-
sions, and abnonnal openings; 19 were caused by disease of
the coats of the bowel ; II by impaction of hardened faeces,
or concretions ; and 16 were due to the pressure of tumors
external to the bowel.

When the strangulation is due to bands or twista, the lower
part of the Ileum is the most frequent seat of the mischief.

* Mtdi4so-ChiniTgital Trantaetiom, vol. xxii. London, 1848.

OBSTHUCTIOX or THE BOWELS.

467

Tn intussusception — that conciitioD where one part of the bowel
is drawn inlo another portion, just as the finger of a plove is
pulled within itself — the passage gets completely obstructed
by the congestion, effusion, and inSaniioation which result.
Most fre([uently the intussusception is single : the traction is
usually from above downwards, — that is to say, the upper sc;;-
ment of the bowel is drawn into the lower: in probably half
the cases, the ileum and ciecum are protruded into the colon :
it IB most common in children : while, in addition to the sick-
ness, constipation, sudden violent pain, &c., there is often a
discharge of blood and mucus per anura. In a Dumber of in-
stances the iiifiummatory action ends in ^ngreiie, and many
inches of the included splmeelated bowel may coiuo away by
the rectum, leaving the canal of the gut free; so that a cure
will often ensue if care be taken not to disturb the adhesions.
With ref^ard to cancerous stricture, the si^uioid flexure of tiie
colon and less frequently the rectum are the parts usually
affected j the general symptoms of malignant disease being
superadded to the sijins of occlusion of the intestinal tube.

Si/tr>i>fo}ii!< — The principal symptoms arc constant vomiting,
which is at first simple, — consisting of the coutonts of the
stomach and mucus, but which in a few days becomes sterco-
raceous or faecal ; pain varying in decree, often very severe ;
gradually increasing tympanitis, with violent borborygmi,
unless the obstruction be high up; severe hiccup, particularly
in strangulation of the upper part of the small intestine; great
mental depression ; and the pathognotuoniu symptom, — consti-
pation, Very careful palpation will often detect, at an early
period, a feeling of increased fulne.«s just above the obstruc-
tion; while percussion elicits diminished resonance, more
marked at this point than elsewhere. In almost all instances,
the prostration sets in early ; acute peritonitis is not very un-
common ; and gangrene is most frcunent in intussusception
and obturator hernia. The lower the obstruction is situated
the less urgent will be the vomiting; if, for instance, it is in
the duodenum, the vomiting will be incessant from the begin-

468

DISEASES OF THE OROAN8 OF PIOESTIOJ*.

(lin;: ; if in the colon, it may be absent for some tiiuc. It
inifiht be thought that the ilio-ca;caI vahe would prevent the
return of the contents of the colon into the ileum ; the pre-
liminary dilatation, however, renders this valve quite patulous.
AVhcn urine is freely secreted, the obstruction cannot be very
high up, since absorption is only p,irtially checked. The
urine, however, may be scanty when the seat of occlusion is
low down, if there be copious vomiting of fluids; or, if there
be present much fever.

From the time of Galen the occurrence of fjecal vomiting
has been explained on the supposition that it was effected by an
antiperistaltic movement of the intestinal canal. Dr. Briulon,
however, has shown conclusively that the natural pcrislaltio
action of the bowel above the occluded point is not reversed;
but that the intestinal contents are pradvially propelled until
stopped at the obstructed point. Here they accumulate so as
to distend the canal with a lif{uid mass; and then a double
current is formed, one at the surface or periphery of the tube
having; the direction of the peristalsis itself, and one in its
centre or axis having exactly the reverse course.

When the obstruction is in some part of the upper tract of
the small intestine, and our treatment fails to remove it, death
usually occurs in a period varying from five to ten days ; while
occlusion of the colon, from being attended with much less pain
and distress, may not prove fatal for several weeks. Moreover
it mu.st be remembered that in cases apparently t|uite hopeless,
a spontaneous cure sometimes takes place even at ihe lastj
moment; so that the more protracted the duration of the dis-
ease, the greater is the cliunco of recovery.

Trealmeiit. — In the monajrenient of cases of obstruction of
the bowels, there is at first a period when the diagnasis can
only be doubtful. At this early stage purgatives may be re-
sorted to, though they need never be of a violent or drastic
nature. An ounce of castor oil may be given: or preferably
on enema (F. 233, 236, 237 ) may be tried, the patient being
directed lo retain it for an hour or two, if possible. But'J

OBSTRUCTION OP THE BOWELS.

469

directly the practitioner \b coDTtnced that there is sonie me-
chanical obstruction to the passage of the fasces, all remedies
of this class must be withheld, since they are positively mis-
chievous.

Under these circumstances the increase in the severity of
the symptoms is to be retarded by attention to the nourishment
of the patient, and by alleviating pain. As regards the first
point, it is certain that the more freely food and fluid;) ore
partaken of, the greater will be the distension, torment, and
danger. It is absolutely necessary therefore that the sufferer
exercise great self-deniul; and tliat instead of attempting to
quench his thirst with copious draughts, he be content to
alleviate it by sucking ice and frozen milk, as well as by fre-
quently washing out his mouth with cold water. To support
the strength, .<<mall quantities of extract of beef, or soup tliick-
ened with flour and eggs {F. 1, 2, 3, 5), may be given ; a little
tea with cream is often refreshing ; while brnndy-and-water will
form the best stimulant. If the vomiting be severe, food by
the mouth uiuist be stopped, and nutrient enemata (F. 20, 21)
trusted to. — The second indication is to be carried out by the
administration of opium ; which is invaluable in these cases,
since it relieves or removes pain, cheeks spasm and contrac-
tion, diminishes the peristaltic action of tlic bowels, and sup-
ports life by le-sseuing waste of tissue. Large quantities will
usually be needed; and no preparation is better than the
watery extract, given at first in grain doses every four, six, or
eight hours. Relief will also be afibrdcd by the assiduous
employment of sedative fomentations.

But are there do direct means which may be tried in order
to overcome the obstruction ? There are two: a surgical ope-
ration, and the injection of large quantities of fluid with ma-
nipulation of the intestines by pressure upon them throuuh the
abdominal walls. The want of success which has attended the
operation of gastrotoniy has been so universal, that many excel-
lent surgeons now consider it unjustifiable; arguing, that while
on the one hand this proceeding has almost always proved fatal,

470

DISEASES OF THE OROANS OF DIOESTION.

on tLo other, many denperate cases which have been let alone

have ended favorably, recovery setting in at the last moment.
Allowing the great force of these objections, it still seems to
me that there are a few — perhaps exceptional — instances where
8ur<;ical interference may be the means of prolonging life,
when all else seems to have failed. Thus, if we can be certain
that the obstruction is due to malignant disease or to some
tumor in the sii;moid flexure of the colon or rectum, opening
the c'olun in the left loin (Aniussat's operation), and forming
an arttScial anus, may be the means of relieving much suffering
and prolonging life. So also in cases where the obstacle is in
the tran8ver!<e portion of the colon, the same proceeding may
be resorted to in the tight loin. Again, if by a careful and
searching examination we can come to the conclusion that the
occlusion is in the small intestine, and is caused by a diver-
ticulum, or by a constricting band of organized lymph round
the bowel, it is the duty of the surgeon to perform gastrotomy.
On the contrary, in the case of intramural obstructions, of in-
tussusception, of stricture from the contraction of cicatrices, of
obstruction complicated With enteritis or peritonitis, in neither
of these instances has any operation the least chance of Stto-
cess. — The use of large cncmut-n, with manipulation, remains
to be mentioned. And first it must be rensarkcd, that though
this proceeding is here spoken of at the end of this section, it
ia really to be practised at a very early stage, and certainly
before there is any fear th.it the tissues have become gangre-
nous. Supposing that ordinary injections have failed in their
object, the patient sliould be placed on his back, with the pelvis
considerably elevated while the shoulders are depressed. A
long stomaeh-punip tube is then to be ciirefully passed as high
as it will go ; (he anus is to be compressed around the tube by
pressure with the hand and napkins; and warm water is to be
slowly injected, as much as possible being thrown up, until
there is distension of the bowel. As the fluid is allowed to
come away the surgeon is to press with the flat of bis hands
upon the abdomen so as to move the coils of the intestine upon

INTESTINAL WORMS.

471

one aaotber, and to press ihem upwards against the dinphrogm.
Tins proeeedinj^ may be adopted more than once; and in many
cases it will be advantageous to have the patient under the in-
fluence of chloroform while practising it.

Inasmuch os I should never resort to the use of crude
mercury in doses of one or two pounds, or of smull shot, or of
tobacco injections, these agents need not be noticed, except to
mention that they have each been reco id mended.

XIX. INTESTINAL WORMS.

There ere five entozou — ^k-u;, within, and 'wov, an animal
— occasionally found inhabiting the intestinal canal; of which
three possess an alimentary tube, and are therefore cjitled
hollow worms, or VotMmintha — xtnkiti;, hollow, and ikniv^, a
worm — and two which have no abdominal cavity, and are
hence termed solid worms, or Slcrelmintha — ute/jsot, and

In the first class we have, —

1. The Tricocephalus ditpar, or long thread-wonn, is
usually found in the cascum and large intestines, measuring
about two inches in length, and having a very slender body.
It is said to be often present in considerable numbers, even
in the intestines of healthy persons, but this statement is pro-
bably incorrect. During life these worms give rise to no spe-
cial .'ymptoms.

2. The Asrarit lumbn'coii/eii, or large round-worm, is found
in the small intestines, especially of ill-fed children. It some-
what resembles in size the common earth-worm, varies in length
from six to nine inches, is of a light yellow color, is unisexual,
and the female is larger than the male. Although the habitat
of this worm is the small iiitcstinctt, yet it may pass upwards
into the stomach or downwards into the colon; and conse-
quently be vomited in the one case, or evacuated with the
Bt^ls in the other. Sometimes these worms are very utimer-

472

DISEASES OF THE ORGANS OF DIUE8TI0X.

Otis; than Dr. Hooper has recorded bo instance in which a
girl voided upwards of 200 iu one week. The syrnptoitis which
they give rise to are thirst, disturbed sleep with grinding of'
the teeth, moroeenesa with low spirits, 'pallid countenance,
fetid breath, swelled belly, emaciated extremities, depraved
appetite, slimy stools, itching of the nose, tenesmus, and irri-
tation of the anus.

3. The .4w«rM UCT-micu/ari'*, or small thread-worra, is found
in thu rectum, and perhaps about the sigmoid flexure of the
colon ; and is the smallest of the intestinal worms, avenigtDg
usually about u quarter of an inch in length, while the female
is longer than the male. It gives rise to intolerable itching
and irritation about the anus, tenesmus, depraved appetite,
picking of the nose, offensive breath, and disturbed sleep.

In the second class we find —

1. The Tifiiia tuliiim, or common tape-worm of this conn-
try. This parasite consist.* of a number of segments; it exists
in the small intestines; and it varies in length from five to
fifteen yards, and in breadth from two lines — at its narrowest
part — to four or five at its central or broadest portion. The
head of this parasite — more properly, its root — is small and
flattened, having in its centre a projecting pnpilla, armed with
a double circle of hooks, around which are four suckers or
mouths, by whit-li the worm attaches itself to the mucous coat
of the bowel. The generative apparatus consists of a ramified
canal or ovarium containing the ova, and of a minute sper-
matic duet, buth occupying the centre of each joint or seg>
ment. It is probably nourished by imbibition through its tis-
sues, just a.s algte imbibe nourishment from the sea-water in
which they float. The researches of Kuchenmeister have
shown that the taenia soliuui is the same parasite as the cys-
ticercus cellulosse of the sheep, pig, &o., though in a different
stage of dcveloptneot. The symptoms which arise from the
presence of the tape-worm are not very striking, its existence
being goncntlly unsuspected until single joints are pa.s8ed in
the stools. In many coses, however, there is a continual crav-

INTESTINAL WORMS.

478

ing for food, debility, pain in the stomach, emaciation, and
itching; ahuut the nose and anus.

2. The Bofkrioffpftiiliiii fulim, or hroad tape-worm, is almost
peculiar to the inhabitants of Switzerland, Russia, and Poland.
It differs from the common tjipeworm in having its segments
of a greater breadth than lensth. The extreme fertility of
the bothrioccphalus latua may be imagined by considering that
each foot of the well-developed worm contains 150 segments
or joints, each joint possessing its own ovary and male organs.
Hence each joint i.s fertile; and as each ovary would produce
8000 ova, it may be calculated that ten feet of such a worm
would produce 12,000,000 of ova. These parasites are very
rarely met with in this country, but they are .so occasionally.
Professor Owen, cianiiuing tlie collection of a worm doctor in
Long Acre, found three specimens; two had come from per-
Bons who had been in Switzerland, but of the third nothing
was known.

Si/Jiiploms. — The most common eymptoms produced by in-
testinal worms are — colicky pains and swelling of the abdomen;
picking of the noso; itching of the rectum and fundament;
foulness of the breath; irregularity of the bowels; grinding
of the teeth at night; a frequent feeling of malaise; and vo-
racious or impaired appetite. The most conclusive sign ia the
pas-sage of some of the worms or of joints of them in the fteces;
and indeed without this, the other symptoms are bat of little
value.

When intestinal worms produce much irritation, the ner-
vous system may become affected by reflex action ; and hence
convulsions or epileptic attacli.s are not uiifrequenily the result.

Kuchenmeister mentions, without confirming the observa-
tion, that Dr. Ficinus of Stolberg, regards habitual cephalea
in the crown of the head as dependent upon tape-worm. lie
found this symptom almost always accompaied with this para-
site, although only so in women.

Treatment. — Wo have several remedies fur ihc round and
tape-worms, such an the oil of turpentine, scammony and jalap,

40«

474

DISEASES OF TBE OROAXS OF DIOESTIOX.

eomponnd jalap powder with calomel, tbe bark of the pome-
granate root, karoala or rotllere tinctoria, the konsso, and the
oil of male fern. I am in tbe habit of trusting to the latter;
which may be employed in full doses even for children three
or foar years old, and which I thus administer. On the first
morning I commence with a dose of castor oil, or a Seidlitx
p<jwder; and during the day keep the patient on very low
diet, only allowing a little good beef-tea. At night the pur-
gative is repeated, and thus the worm or worms get thoroughly
uncovered by the removal of the contents of the alimentary
canal ; and hence receive the full benefit of to them poisonous
du«e of oil of mule fern, which is taken tbe first thing on the
following morniDg, according to F. 231. By this means, per-
haps twice repeated, I HclJuni fail to remove tbe whole worm,
including the head, — To prevent its re-formation, tonics should
be given, espcciully the mincrtil acids in iiifusiun of quassia.
The patients should also be directed to take plenty of salt with
their food ; and to have the latter well cooked.

The ascarides may generally be killed by enemata of infu-
sion of qua8.sia, or of common suit, or of lime-water, or of fif-
teen minims of sulphuric ether in an ounce uf water, or of the
tincture uf the pe.'<iiuichloride of iron — in the proportion of half
an ounce to half a pint of water. It is often difficult to effect
a thorough cure in the case of patients tormented with ascari-
dos. The worms may be apparently quite destroyed, and for
a lime there is a cessation of annoyance; but again and again
they return, until the sufferer gires up all treatment iu dis-
gust.

XX. PERFORATION OF THE BOWEL.

The intestine may be perforated owing to disease in tho
coats of the bowel, or frnin the extension of ulceration affecting
adjjiceiit organs. The first class of cases has been already
treated of; and it has been shown huw perforation may take
place in ferer, inflammation of the ctecum, dysentery, cancer,

PERFORATION OF THE BOWEL.

475

&c. The eecoiid division remains to be considered — viz.,
where the perfurulion occurs fr<ini wiilinut inwai-ds.

Iliftlntiil ditf,<i!te and nlnress of ike tin r not nnfrerjucntij
end b)' perforating the bowel ; when hjdatids or pus, iis the
case muy bo, will either be vomited or passed away in the
stoold. The .'iyniptoTns of hepatic disetu»o, the slow growth of
hydatid tumors, the occurrence of local peritonitis, and the
character of the discharge, will render the diagnosis of these
oases comparatively easy — In the same way abieesset of the
S2>leen ami IciJnei/ may opea into the bowel.

Calculi from the ijaU-hladtler sometimes enter the bowel
by direct ulceration through the apposed coats of the reservoir
for the bile and the duodeuuiu. This has generaily been the
e: Be in those instances where an impacted gull-stone hiis pro-
duced obstruction of the bowels; the concretion having been
too large to pass down the cystic duct.

Oviiririn ••yaiit have often emptied themselves by a commu-
nication lakin>; place between them and the csecum, colon, and
rectum. The subsidence of the tumor, together with the pas-
sage of the cystic fluid per anum, will point to the true nature
of this occurrence. Many examples of 'Utni-iilfrinf. /(clution
could be referred to, where the sao containing the foetus has
formed a communication with the cavity of the rectuoi. As
the fcetus deconiposcs, its soft parts and bones aro gradually
voided per anum ; while with care the mother will gradually
recover. Indeed, one or two rare instances are known in
which extra-uterine pregnancy has twice occurred in the same
woman, with this same fuvonible result. Ovarian nbsrest
as well as alacesn the reiulc of pelvic nlfulilif, may open iivto
the rectum. In both instances /tefal abucesi almost invaria-
bly results, owing to some portion of the contents of the bowel
passing into the purulent cyst. The suppurative process is
thus kept up ; so that these abscesses burrow in all directions,
opening into the bladder, vagina, groin, and perhaps again
into the rectum. The wife of a medical man was long under
uiy care with such ao abscess ; there being at one time three

476

DISEASES OF THE ORGANS OF DIOESTIOX.

separnte openings in the groin from which pas, urine, and
liquid fseees used to be diselinrjreJ. Thw practitioner may try
to eflfect a cure with strengthening food, tonics, opiates to re-
lieve pain and diarrhoea, cod-liver oil, sea air, and carefully
adapted pressure ; but usually his efforts will fail, and the pa-
tient will gmduully sink.

Siippuriition in the abdominal pariefet, the oonsequeace
of inflainniatiun cxcitx;J by falls, blows, &c., often siiuulates
deep-seated disease. Tbe abscess may open externally, or into
the peritoneal cavity, or into sonic part of the intestinal canal.
When the purulent collection tends towards the surface, the
diagnosis is not difficult; but when the matter burrows among
the muscles, and is confined beneath the fasciu of the abdomi-
nal wall, the case is very likely to be mistaken for peritonitis,
malignant disease of some internal organ, or for some affection
of the coscuin, liver, kidney, spleen, &.e. It is important that
the true nature of the case should he detected as soon as possi-
ble; since all risk is avoided by making an early opening, so
that the contents of the abscess may be discharged externally.

PART VI.

DISEASES OF THE LIVER, PANCREAS,
AND SPLEEN.

I. CONGESTION OF THE LIVER.

The hepatic rircululion is affected bj so many diifcrent
agencies that hj'perasmia, congestion, or the undue accutuula-
tion o}' blood in the capillary vessels of the liver is a morbid
condition frequently met with. Moreover, it is the initiative
step in almost all the structural diseases of thia organ.

The simplest form of this condition Is that wliich results
from some obstruction to the circulation of tlie blood, Cbrough
the hepatic and the portal veins — passive congation. Exam-
ples of this variety are met with in cases of valvular disease of
the heart — as in instances of iiiitral obstruction and mitral
insuffieiency, and more particularly where there is incompe-
tence of the tricuspid valves ; in those morbid states of the
laogs which impede the pas-tage of the blood through the pul-
monary artery — as emphysema, collapse, &c. ; as well as io
Buch affections as diminish the size of the thoracic cavity.
Violent exercise, particularly soon after meals, causes tempo-
rary enfjoryement of the liver; to which is probiibly due that
stitch in the side which compels the sufferer to rest. Under
the influence of congestion the liver is found after death en-
larged in every direction, with its capsule tightened or dis-
tended, and its parenchyma tough. On making a section of
the gland, dark red patches may be seen, consisting of the

47S

DISEASES OF MVER, PANCREAS. SPLEEN.

gorged hepatic veins ; around whtcli are lighter-colored parts,
corresponding to the delicate branches of the portal vein.
During life, obstructive hjporseniia of the liver ia attended
with a sense of constriction and weight in the right hypochon-
drium ; there is often .slight jaundice, nausea, and dyspepsia;
the urine i.'? scanty, high-colored, and frequently contains bile
pigment, with traces of albumen ; while the bowels are con-
fined, and the hiBmorrhoidal veins probably enlarged. In
hcallh, percuiiijion affords b dull i^ouiid from the sixth right
rib down to the costal margiii ; whereas, in the stute under
consideration the area of the dulness is more or less increased.
Palpation, too, will detect the increase in size. Moreover,
there will also be present the symptoms of tlie primary cardiao
or pulmonary disease, which 6ubsci|uently often ends by pro-
ducing general dropsy, &c. Our treatment can only bo pallia-
tive ; in the early stages saline purgatives (F. 1G9, 181, 219,
225), acting well by causing a drain from the portal system.
At a later period, the use of mild aperients must be combined
with ammonia, ether, &c., (F. 175, 192, 193.)

Passive congestion usually leads to a diminished excretion
of bile; the secreting cells remaining active, but the passage
of the bile from the tubules and through the small gall-dacta
being delayed, owing to the compression which is exerted by
the loaded bloodvessels. The ducts consequently become
gorged with bile — hiliart/ comjrition. Supposing this condi-
tion to be kept up for any length of time, tho cells of the
gorged lobules get impaired and their power of reproduction
diminished; since not only is their nutrition interfered with,
but they atrophy when their functions are not duly called into
play, Just as all tissues do.

In active congestion the capillaries of the hepatic artery are
chiefly involved ; serious structural changes arising in propor-
tion to its intensity and the frequency of its recurrence. This
state is brought about by causes which increase the functional
activity of the gland. The chief of these are, — the pre-
Bcoce of uorbid matters iu the blood ; the suppression of

CONGESTION OF THE LIVER.

479

habitual discharpes — as of a haBmorrhoidal flux, or of the
OHtanienia at the critical period of life ; a loop residence in hot
climates, particularly in marshy districts; derann;ed nervous
influence, an instance of which may be seen in hyperieuiia
from mental excitement ; and probably atony of the blood-
vessels, owing to disease of their coats. The liver always con-
tains more blood, and its secreting cells are more active during
the process of digestion, than at other times ; heocc, escessire
eating and drinking, irritating articles of food, alcoholic drinks,
&c., win unduly stimulate the gland. Strong, healthy indi-
viduals, who take plenty of exercise, may counteract the evil
effects which flow from a too rich and abundant diet ; while
those of sedentary habits are sure to suffer. The cure of the.se
cases is to be effected by the removal of the cause; by the
use of horse-exercise, walking, &c.; by the employment of
laxatives containing rhubarb, aloes, and sulphate of soda (F.
173, 174, 179, 224); by recourse, when necessary, to the
mineral acids (F. 460, 401); and by the adoption of a simple
diet, consisting chiefly offish, rice, fresh vegetables, &c.

Extravasated masses of blood — apopltjtt/ of the liver — are
sometimes found in the hepatic tissue or beneath its capsule,
as the result of great conge.<ition induced generally by morbid
changes in the blood. These cases of heraorrhage may be
met with in scurvy, in purpura, in ichorrhroraia, and espe-
cially in the malarious fevers of tropical climates. The ex-
travasations are often numerous ; the blood may be found in
masses varying in size from a pea to a hen's egg, or it may
be infiltrated through the parenchyma, converting the tissue
into a pulpy mass; and the effusions are probably directly due
to some disease of the coats of the vessels— such as fatty
degeneration, leading to rupture.

The effusion of serum into the subst-anoe of the liver —
hepatic oedema — is said by Dr. W. Thomson* to have been
oilen observed, uncombincd with marks of acute inflamma-

• A Sftltm of Praetieai Mtdirint, toI. It, p. 180. London. 13«l>.

480 riSEASES OF UVER, PANCREAS, 8PLBBN.

tion. It cannot be a common condition, however, since verj
few authorities make any nienliun of it. In a case of fatal
remittent fever reported by Dr. Morehe;id, the liver was found
of a dark olive color, reaching two inches below the right
ribs, and touching the point of the eighth left rib. It weighed
41bs. 4oz., wiiile on cutting and pressing it, six ounces of
scrum freely oozed from the surfaces. The parenchyma broke
down rendtly under the finger; and the incised surfaces pre
sented a dark olive color, with brown intermixture, but not
the mottled redness of congestion.

II. INFLAMMATION OF THE LIVER.

The inflammatory diseases of the liver, though often met

with in temperate climates, are particularly common in tropi-
cal regions. In describing thum, I shall speak dr:<t of hepa-
titis, or inflummation of the peritoneal investment of the liver,
or of the substance of the gland, or of both combined : se-
condly, of cirrhosis, or that slow form of iiiflnmiiiatory action
which afTecIs the fibrous and areolar tissues of the portal ca-
nals : thirdly, of inflammation of the veins : and fourthly, of
inflammation of the gall-bladder and gall-ducts.

1. Hepatitis. — The term hepatitis .seems better than that of
suppurative inflammation, as proposed by Dr. Budd, inasmuch
as the morbid action does not necessarily end in suppuration
and abscess. However the name is not very important, pro-
vided the nature of the affection be understood.

Patlioloijy. — In a few casea the capsule of the liver becomes
inflamed with very slight implication of the peripheral tissue of
the glaod ; the morbid action either terminating in resolution,
or leaving behind it opacity and thickening of the membrane,
with adhesion between the apposed peritoneal surfaces.

But most commonly the substance of the liver is the seat
of the inflammation, and then a series of changes takes plaoe

INFLAMMATION OP THE LIVER.

481

which hiivo been so clearly described by Dr. Morehead that I
shall give a condensed account of that which he has sketched
from actual observation.* In the first stage of parenchyma-
tous hepatitis there is vascular turgescence ; and could the
gland be examined, the pathologist would find the structure
redder and softer than natural, while blood would ooze freely
from it when cut. At this period resolution may lake place ;
but if the inflammation proceeds, then interstitial exudation
of coapulablc lymph soon follows in different parts of the
organ, inflammation of the entire substance being very rare.
When the lymph maintains the liquid form in which it is
exuded, there is hope of complete recovery by reabsorption
aud resolution. Supposing, however, that it coagulates in the
interstices of the parenchyma, then one of three courses may
follow : cither the Itrjuid parts may be absorbed, and the solid
lymph become organized into fibrous tissue ; or the exuded
lymph, inBtt.'ad of becoming organized, may re-lir(uefy, be ab-
sorbed, and disappear; or the lymph changes into pus, the
tissues where it has been deposited soften, liquefy, and dis-
appear, and the whole is more or less circuuisoribed by mem-
brane of low organization, — in short, hepatic abscess has
formed. Then more lymph exudes from the inner surface
of the investing membnine, and degenerates into pus; the sac
becomes distended, the bulk of the liver increuBed, and tume-
faction takes place ; adhesion of apposing serous surfaces fol-
lows ; and the circumscribing wall becoming thin on one side
by the li*|ucryinp process, pointing and rupture succeed. This
is just what happens in an ordinary phlegmonous abscess : the
central parts of the lymph — those most remote from the living
tissues — change into pus ; while the peripheral portions — those
adjacent to the living sfructures — get organized into mem-
brane. In the liver the abscesses are seldom single, but souic-
Umes several small ones coalesce. If diffuse suppuration of

* Clinieal Rtuarrhu oh Diuatt in India.
3»n. London, 18A0.

SMond Edition, p. 327 to

482

DISEASES OF LIVER, PANCREAS, SPLEEN.

the liver ever happen, it must be very rarej since Dr. 3Iore-
head asserts that he has no knowledge of it.

Causei. — Europeims resident in tropical climates, wh'j live
too freely, Eoem liable to suffer from hepatitis. The morbid
action may be induced by some mechanical injury; though it
is seldum that thi.s Ig a cause. The disease is sometimes due
to suppurative inflammation of some vein, contaminating the
blood by pus. Ulceration of the intestines, of the stomach, of
the pall-bladder or gall-ducts, are all causes of sappunitive
hepatitis; atid perhaps a hut climate alone, by deranging the
functions of the gland, may give rise to it, as may also marsh
fevers. Spirit-drinking often produces adhesive inflammation
and induration of the liver; but not the suppurative form.

Sym-plamf.. — At the onset there is tenderness over the gland,
which is most marked when the peritoneal investment is af-
fected. Then, as tlie morbid action progresses, we find high
fever, with hot skin, thirst, and scanty urine, the fever some-
times assuming a typhoid character; fulness of the right hypo-
chondrium from enlargement of the gland, with increased dul-
ne8S on gentle percussion ; pain — more or less severe — in the
region of the liver, increased on pre.ssure, deep inspiration, or
cough; inability to lie on the left side ; occasionally a yellow
tinge of the conjunctiva, but mroly complete jaundice ; dys-
pnosa ; sympathetic cough and vomiting; and (ruublesonie hic-
cup. When the pain is of a sharp, lancinating character, it is
supposed to indicate inflammation of the serous covering of
the gland; when dull and tensive, the parenchyma is the part
affected. Again, when llie convex surface of the organ is the
seat of the inflaramation, the chest symptoms will predomi-
nate; when the concave, the stomach derangements will be
the most marked. It is well known that in hepatic affections,
the right clavicle and shoulder become the seals of gnawing
and aching sytnpathetic pains; sometimes also^probably whea
the left lobo of the liver .suffers — pfin is referred to the left
shoulder. Accurding to Anncsley, pain in the right shoulder
u a aure indication that the disease is in the right lobe. An-

INFLAMMATION OF TIIF. MVER.

483

dntl has noticed that in some cases the only pain has been in
the head; which has been Eufficiently intense, constant, and
long continued, to attract exclusively the patient's attention.

The formation of hepatic abscess is chiefly »i{;nalized by the
occurrence of chills — perhaps of distinct rijcors, hectic fever,
pnin, u reeling of weight in the repioii of the liver, and a dry
cough. The physicol signs of eiilargeiiient of the gland will
be pre-^cnt; and while the hectic fever iiicrease.H, the patient
eiuaciatee, there is increasing prostration, and either diarrhoea
or dysentery sets in.

Terminatwnii. — ^The tuo.<t favorable termination of hepatitis
is of course by resolution. When this happens the pain and
fever gradually abate, and the patient is soon well. — The io-
flamniation may, however, as has been shoivn, go on perhaps
to diffused suppuration ; but much more frequently to the for-
mation of circumscribed abscesses, or even to gangrene.

Abscesses of the liver souietiuies attain a preat size; and,
in extreme cases, have contained several pinta of pus. — Hepatic
absoesses may undergo a spontaneous cure from absorption of
the liquor puris, and degeneration of the pus corpuscles. They
may burst into the peritoneum, and give rise to fatal peritoni-
tis. In a few instances they appear to have opened into the
biliary ducts, so that their contents have passed into the duo-
denum. Most frequently, however, when the matter gets near
the surface of the gland, adhesive inflammation is set up in
the portion of peritoneum immediately above it, and lymph is
poured out, which glues the organ to adjacent parts — to the
abdominal parietes, the diaphragm, stomach, or some part of
the int«stines; the pus being then discharged externally, or
into the lung, or pleura, or stomach, &c.

Hepatic suppuration and dysentery often occur together.
We are indebted to Dr. George Budd* for proving — contrary
to the opinion formerly entertained — that the dysentery is the
primary disorder, the abscess the secondary; the latter being

• On Difaitt oftht Liver. Third Edition. London, t8S7.

484

niSEASES or UVER. PANCREAS. SPLEEN.

caused by the fetid gaseous and liquid cnnrent« of the Inrpe
intestine, or by the pus resulting fmin its ulceration being «b-
eorbcd and conveyed iiutuediately to the liver. Abscess of
this gland niny also oceur from other causes besides those
already mentioned, the most cuinmun being ulceration of the
rectum, bladder, va>,'ina, &c.

Very rarely the inflaniuiiitiun terminates in gangrene, or
gangrene niHy follow sufipuration. In one of the patients of
the Dread nou<;lit Hospital Ship, luortitication resulted from
opening an akscess.

Treatmeiil. — Various observers have recognized that the
strength of tlio piUient requires to be supported in this disease,
rather than to be lowered by bleeding and the administration
of mercury. The latter remedy is, however, still used very
indiscriminately; and Dr. Abercrombie's observation remains
true, that mercury is employed "with very undefined notions
as to a certain speciQo influence, which it is believed to exert
over all the morbid conditions of this organ. If the liver is
supposed to be in a state of torpor, mercury is given to excite
it; and if it is in a state of acute iuflummation, mercury is
given to moderate the circulation, and reduce its action."*
In all canes it appears that active trrntmeiit is contra-indicated ;
but it is especially so, when we infer that suppuration has
taken place.

Purgatives in the early stages appear to be useful by in-
creasing the circulation through the portal capillaries, and thus
diminishing congestion in the capillaries of the hepatic artery.
If there be a suspicion of portal stagnation — as is indicated
by a yellow-coated tongue, scanty alvine discharges, a dimi-
nished secretion of urine, and a dingy state of the skin — then
Dr. Morehead recommends smuU doses of blue pill with ipeca-
cuanha, or the extract of taraxacum with an alkali, and the
external application of nitro-inuriatio acid. Opium will often

* Palhologieal atui Praeticai Rtuareka oh Diuasu of tkt Stomarii,
4«., p. SCO. Edinburgh, 1828.

INFLAMMATION OF THE LIVER.

485

be necessary ; the diet must be restricted; and tbc patient must
be confined to the recumbent posture.

When the inflammation has pone on to the formation oF pus,
then nourishing food, with tonics — such a.'i f|uinine and iron,
the uitro-uiuriatic acid and bark, ke. — will be necessary; the
bowel.<f must be rei^ulatcd by rhubarb, or by rhubarb and aloes;
and wine must be allowed in proportion t*) the weakness of the
patient. — If, after a time, we can be i|ut(e sure that the sur-
fuco of the abscess is adherent to the abdominal parictes, we
may — after making an exploratory puncture with a grooved
needle — open it with the knife, or — what is better — may punc-
ture it with a trocar; but great jud^!;ment and caution must
be exercised. On the whole. Dr. Budd seems to be in favor
of allowing the abscess to burst of itself; and I suppo.% that
Mr. Waring is of the (.Bmc opinion, for in the summary which
this gentleman has published of eighty-one cases operated on,
there are only fifteen recoveries, while he fears that even this
proportion is too favorable, owing to the nou-publiuatiuu of
unsuccessful cases.

2. Cirrhosis. — This disease consists of chronic inflamma-
tion of the areolar tissue of the portal canals, followed by the
exudation of lymph. Slowly the lymph becomes organized
into contractile fibrous tissue ; and hence results a diminution
in the calibre of the branches of the portal vein, as well as
of the hepatic artery and duct. From this, atrophy of the
lobular structure of the liver ensues. The diminished flow of
blood through the portal vein favors congestion of the capil-
laries of the gastrie and intestinal mucous membrane, whence
arise baBmorrhages ; whilst it also produces engorgement of
the capillaries of the peritoneum, and hence ascites.

On slicing the gland, it is found hard and tough; while
the new fibrous tissue is seen to form thin lines between irre-
gular masses of lobuJes. At the parts on the surface oorro-
aponding to these lines, the capsule is drawn in, so that the
surface has a "bob-nailed" appearance; the tissue of the liver

41*

486

DISEASES or LIVKK, PANCREAS, SPLEEN.

is also paler than nuturul, owing to the presence uf this Gbrooa
tissue, and it is often yellowish from accumulation of biliary
matter in the cells. Hunce, a section of the liver has the
grsyish-jellow color of impure beeswax; and this disease has,
in conMequence, been called by the French rirr/ton'n*

Citux'ii. — The mo.xt common cause of cirrhosis is spirit-
drinking; which has led English practitioners to call it the
gin-drinker's lircr. When alcohol has been introduced into
the system in the ordinary way by the stotnaub, analyses show*
that a greater proportion of it is present in the liver than in
any other organ of the body. Next to the liver, the brain at-
tracts to itself the largest f|uantity ; though recent researches,
already alluded to (p. 242), show that when alcohol is intro-
duced by injection into the veins, then the proportion is greater
in the nervous centres than in the liver.

It is worthy nf notice, that the alcohol taken in wine and
beer is not as destructive as thut taken in the form of ardent
spirits. Dr. Paris explains this by supposing that in the first
case the alcohol is not only more intimately mixed with water,
but that it exists in combination with its extractive matter;
and consequently that it is incapable of exerting its fall efifecta
before it becomes altered in its properties, or, in other words,
partially digested. A hot climate increases the vicious effects
of alcohol.

Sj/ntpfotng. — These are generally few and obscure, until the
effused fibrin has caused impediment to the flow of the portal
blood, and to the secretion and escape of bile. Slight enlarge-
ment of the liver is present in the early stages ; but as the
fibrous tissue contracts and the lobules atrophy, the size of the
pliind becomes diminished. Then pain in the right hypo-
chondriura, indigestion, occasionnl feverishness, dry and rough
skin, and an unhealthy sallow look, are the nioet prominent
symptoms. When relief hjui been obtained by the use of
purgatives and an absteuiious diet, the patient fancies himself

• See th« worki of Horehexl and Badd, alreadjr quot«d fVom.

tNFT.AMMATION OF THE I.IVEB.

487

well, and pursues his usual occupations ; though at the same
time he Sods that he pets gradually weaker and thinner, and
that his complexion remains sallow. At the end of some
months, or perhaps years, the increasing contraction of the
effused lymph greatly obstructs the circuIatioD through the
portal vessels : an exudation of scrum takes place from the
extreme branches of the veins converging to foriii the vena
portaj; and hence the belly becomes enlarged by dropsical
effusion, which gradually increases so as to cause great disten-
sion. The veins on the surface of the abdomen enliirge —
showing that the current of the portal blood is seriously
impeded; and occasionally hsemurrhiige from the distended
portal By.stera gives rise to an effusion of dark blood into the
stomach and int«8tine.s. In a few rare instances the attack
of haeniorrhuge has constituted almost the first symptom of
cirrhosis; bo that death may really occur from this cause, if
the loss of blood be great, in the midst of apparent health.
When ascites has once occurred, it continues, increases, and
in some twelve months or bo the patient dies from exhaustion.
Treatment. — At the commencement of the disease, Dr.
Budd states that most benefit will be derived from cupping or
leeches over the liver ; from Ewline purgatives, such as the
sulphate of magnesia, or bitartrate of potash; from a regulated
and rutiier low diet; and from the avoidance of all alcoholic
drinks. If the patient will not bear the loss of any blood,
repeated blisters — we are told — may be employed ; and con-
sidering that gin-drinkers are the la-tt class of people likely to
derive benefit from bleeding, I think that blisters and dry
cupping will bo always preferable to leeches and scarifications.
Iodide of potassium, inunction with the iodine ointment, and
such remedies as aid the eliminating function of the liver will
do good. Hence taraxacum, nitro-muriatio acid, and the hy-
drochloratc of ammonia are favorite medicines. — If there be
hiEmorrhage, such astringents as gallic acid, or nitric acid,
must bo employed. — When ascites has taken place, mild
diuretics, purgatives, tonics, and sedatives are the agents with

488 DISEASES OF LIVER, PANCREAS, SPLEEN.

which we may hope to palliate the symptoms and to prolong
life for a short time ; but if there be urgent dyspnoea or gene-
ral distress from the dropsy, the fluid must be removed by

tappiiip.

3. Inflammation of the Veins of the Liver, — This oondi-
tion is not often met with. Whetbur there be portal or heputio
phlebitis, the morbid actiun will commonly give rise to fever,
puin in the riglit bypochondrium, nausea and constipation, '
hiccup, jaundice, Bliivering, &c. The inBammation may end
in resolution, or in the effusion of coagulable lymph which
blocks up the vessel, or in suppuration. The latter event
usually leads to a fatal termination.

4. Inflammation of the Gall-Bladder and Biliary Ducts,
— Inflammation of the mucous membrane of the biliary ducts
and of the gall-bladder gives rise to symptoms of very variable
severity. The gall-bladder, cystic, and common ducts are more
obnoxious to this morbid actiun than the hepatic ducts; since
they are more likely to be irritated by gall-stones and unhealthy
conditions of the bile. When there is merely catarrhal inflam-
mation, we 6nd slight tenderness, fever, and jaundice — if the
mucus secreted be sufficiently vi.scid and abundant to choke up
many of the ducts; the symptoms ending in slight diarrhcea
M.s soon as the pent-up bite finds its way into the duodenum.
Supposing, from any cause, the bile is unduly retained in its
natural reservoir, it may decompose and give rise to much
irritation and inflammation; which processes are very likely
to end in suppuration and ulceration. The inflammation rosy
be conlined to the gall-bladder, or it may eitend from it to the
ducts. Ulceration of these parts may also arise from the irri-
tation of biliary calculi, from defective nutrition of the system,
sod it has beon found by several observers after death from
remittent fever. The iurmediate consequences may be perfo-
ration and fatal peritonitis; or, if adhesive influmniation have
previously occurred, abscess may result and open into the bowel

snppnEssioN OF functions of thk i.ivkr.

4S9

or externally ; or closure of the cystic duct may follow, render-
ing the tpll-bladder useless and causing the bile to flow con-
tinuously into the duodenum ; or we may have closure of the
common duct, which ends in gradual destruction of the proper
cells of the liver.

ni. SUPPRESSION OF THE FTTNCTIONS OF THE
LIVER.

The secretion of the bile may be suspended ((irholin) from
acute atrophy, as well as from cirrhosis, fatty iief;ei>eration, &c.
This subject has already (p. 44) been generally treated of; but
its importance is such that it requires further consideration.

1. Acute Atrophy of the Liver. — Acute or yellow atrophy
of the liver (aometinies spoken of as arule maitini/, toflenivg
of the liver, diffused hfpatilis or fatal jaundice') is a most in-
teresting disease ; consiBting in a rapid and complete destruc-
tion of the hepatic cells through every part of the gland, owing
perhaps to impaired nutrition.

C'awiet. — Women are more obnoxious to this very rare dis-
ease than men. Pregnancy seems to predispose to it ; and it
has happened more frequently between the third and seventh
months of gestation, than at other periods. It would appear
to be most common between the age of seventeen and thirty.

Among the alleged exciting causes it is necessary to mention
grief or anxiety, sudden alarm, and fits of pa.ssion : venereal
excesses, syphilis, and the excessive use of mercury ; drunken-
ness with dissolute habits : the influence of malaria ; and the
poison of typhus.

iSi/mjitomg. — There may be a preliminary stage, in which
complaint is chiefly made of headache, deprc8.>iion, irregularity
of the bowels, tenderness of the abdomen, and after a time
jaundice. These precursory symptoms may last a few days or
upwards of three weeks; or they may be altogether absent.

490

D18EABE8 OF 1.1 VKU. I'ANCBKAS, aPT.EKX,

The syitiptonis which directly arise from acute atrophy of the
liver are jaundice, smuetiiiies with tho formation of peteehiaB
and large ecchymoses; vomiting, at first of the contents of the
stomach and mucus, and then of a matter like coffee-grounds
owint; lo the presence of altered blood ; with especially, abnor-
mal conditions of the nervous system — at first of noisy deliriam
and convulsions, followed by stupor and deep coma. The pulse
is at the onset slow; but us the cerebral disturbance is mani-
fested it rises in frequency to about 120, becoming slow again
as stupor sets in, and getting frequent and small as the fatal
terminatinn approaches. The tongue and teeth are coated
with black sordes; the abdomen is often tender; the extent
of hepatic dulness rapidly diminishes, while that of the spleen
increases ; there is constipation, with hard clay-colored stools,
and subsequently evacuations which are black from the pre-
sence of blood; while the urine is loaded with bile pigment,
and perhaps is albuminous. Then the jaundice increases;
and there are hemorrhages from the nose, stomach, bowels,
bronchi, &C.

This disease usually ends fatally within a week from the
appearance of the acute symptoms; while sometimes death
occurs at the end of eighteen or twenty-four hours. It is
doubtful whether recovery ever takes place ; but at all events
cases in which the termination is favorable are very rare.

Patholtyif, ctr, — Examinations after death reveal a oon-
Biderable diminution in the size of the liver, the reductioa
being often to the extent of one-half or even two-thirds of the
normal volume. The capsule is found opaque and puckered,
while the parenchyma is flabby and shrunken ; the cut surface
presents a dark-yellow hue, the outline of the lubulea is invisi-
ble, and the bloodvessels are almost empty; while under the
microscope either no hepatic cells can be detected but only
brown granules of biliary niatftT with oil globules, or isolated
cells loaded with fat or pigiiK'nt are discovered. The gall-
bladder is usually empty, and the bile-ducts are free from any
obstruction. In most of the recorded cases, the spleen haa

SUPPRESSION OF FUNCTIONS OF THE LIVER.

491

been congested and enlarged. Soiuetiincs the glandular epU
thcliutn of the kidney has been found in a state of fatty de-

ncrulion.
I " Acute atrophy of the liver," Hays Frerichs, " belongs to
those obscure processes, ns to the nature of which various opi-
nions may be advanced, without it being possible for any one of
them to obtain a general acknowledgment. The fact of the
disappearance in a few days of one-half or one-third part of
the original volume of n large ginnd abounding in blood, with-
out any alteration in the bloodvessels leading to it, has a com-
plete analogy in no other disease."* Rokitansky and others
have referred the destruction of the hepatic cells to the action
of the bile — to a bilious liquefaction. Bab I looks upon the
disease as analogous to typhus. While again, it has been
regarded as a diffused inflammation, the destruction of the
cells by a. fatty degeneration arising from an acute exudation
process.

As no morbid appearances are found in the brain or i)a
lueiubranes to explain the nervous symptoms, they must be
referred to changes in the blood. Frerichs attributes the
cause of the blood-intoxication to the complete arrest of the
hepatic functions from the destruction of the secreting cells,
and to the derangementof tlie renal secretion so that the elimi-
nation of urea is stopped. The former of these causes in-
cludes not only the absorption of bite, and the rctentiori in the
blood of the suLf-tances from which this secretion is formed,
"but also the cessation of the powerful influenec which the
liver exerts over the processes of metamorphosis of nintter, and
the simultaneoas passage of the disintegrated glandular sub-
stance into the blood."

Treatment. — Our ignorance of the nature of this disease, no
less than its severity and rapid progress, render the treatment
empirical and ahnoat useless. The favorite remedies are at

* A Clinical Treatite on Ditta4ft of iht Livrr. Translktcd by Cbarlei
MarohisoD, M.D., rol. i, p. 227. New Sydenham Society. London, I860.

492

DISEASES OF LIVER, PANCREAS, SPLEEN.

first draatic purgatives, then the mineral acids, and subse-
quentlj diffasible stimulants as depression sets in. Ice way
be freely given to check the vomiting. Where the dia^osis
is doubtful, and especially where the distinction between acute
atrophy and bilious fever remaiDS uncertain, FrcrichB reooni-
inends large doses of quinine dissolved in acids,

2. Acholia from other Canses. — Blood poisoning may
arise from all the diseases which produce complete disorgani-
Mtion of the liver ; and may be attended with jaundioe,
hmniorrhages, delirium, cointt, &o. On the other band, these
symptoms may be absent ; fur it is certain from the ezperi-
ments which disease is constantly perfonning, as it were, for
our instruction, that the constituents of the bile may be re-
tuiiied ill the blood without marked injury.

The chief diseases which ultimntely may lead to destructioa
of the glandular epithelium, and consc(|Uout!y to complete
arrest of the functions of the liver, are — cirrhosis, fatty dege-
neration, extensive cancer, and those aiTections wliicb produce
an impermeable state of the ductus communis choledochua, of
the hepatic duct. In these cases it not uncommonly happens
that severe indications of cerebral disturbance, i|uickly ending
in fatal coma, are suddenly .supei'added to those morbid symp-
toms which may have been lung present.

3. Chronic Atrophy of the Liver. — This disease is in no
way connected with acute atrophy. It results from all thoRe
conditions which tend to arrest the capillary circulation
through the gland, and hence to Ic^cn its nutrition.

The rnvtfs which diminish the size and functional activity
of the liver are chiefly, long-continued compression of the
organ ; such as may arise from tight lacing, extensive pleuri-
tic effusion, great hypertrophy of the heart, constant disten-
sion of the ascending and transverse colon, chronic peritonitis,
&c. The various forms of adhesive inflammation, either uf
the capsule or parenchyma, occlusion of the hepatic capillarieo,

SUPPRESSION or FUNCTIONS OF THE LIVER.

493

»
N

obliteration of the trunk of the portal vein, the develupment
of new growths, the cicatrization of abscesses, &c., will also all
tend to produce more or less extensive atrophy.

The nymptomi which ensue from an habitual defective secre-
tion of bile are developed slowly and insidiously. Id the com-
mencemeDt there is usually imperfect performance of the func-
tion of digestion, flatulence, alternately diarrhoea and consti-
pation, pale-colored stools, a dry sallow state of skin, and a
falling off in flesh and .strength. Then pcrcu.s.sion shows that
the dimensions of the liver are gradually lessening, so that
sometimes there is scarcely any appreciable dulness. Of course,
the digestive derangements lead to increasing debility ; the
patient, in the course of many nionlh.s, becomes very anajniic,
and much wasted ; and frequently general dropsy sets in, which
soon ends the suffering.

A carefully directed plan of treatment when early com-
menced, may do much to prolong life. The diet must be light
but nourishing; being free from rich dishes, sugar, and fer-
mented drinks. Warm clothing ought to bo used, and over-
fatigue carefully guarded against. To aid digestion recourse
may bo had to pcpsine ; or to what baa answered better in my
hands, a daily dinner-pill made of one grain of ipecacuanha
with three of rhubarb. To combat the aiisemia in these cases,
it appears to mo more adviji.ible to trust to bark and the mi-
neral acids, rather than to ferruginous tonics; for the latter
havo sometimes seemed to give rise to hepatic congestion, and
to have increased the mischief This remark does not bold
good, however, with regard to the waters of the various chaly-
beate springs, which may often be used with much advantage.
When dropsy has set in, diuretics are to be resorted to ; the
patients being generally too weak to bear the employment
of drastic purgatives. If the ascitic fluid be excessive, tem-
porary relief must be afforded by paracentegis.

A'i

404

DISEASES OF LIVER, PANCREAS, SPLEEK.

IV. DEQENEEATI0N8 OF THE LIVER.

1. Fatty Degeneration. — Ttie hepatic cells in their Dormal
state always contain a certain imount of oil. But in fattj/
liver, or /a/ti/ Jegenrralton of the liver, the quantity is very
much increased ; so that the cells may be seen, on a micro-
scopic exaiiiiiiation, to be gorged tritb oil-globules, quite
obscurino; the nuclei. This condition is of frequent ocour-
renue in pulmonary consuniptiun, as well as in fatty degenera-
tion of other iuiport.int organs — like the kidneys, &c. Per-
sons who live too freely, who indulge in alcoholic drinks,
and who lead indolent lives, frequently suffer from it. It has
also been met with in instances of constitutional syphilis ; as
well 08 after death from some acute diseases, such as typhus,
STnall-pox, erysipelas, &c. If we wished to produce a fatty
liver, wo could hardly follow a better example than that of
the poulterers of Strasburgh, who keep their geese in small
cages, deprived of exercise, in a heated atuoephere, and with
a large supply of food.

It is probable that the accumulation of fat takes place only
in the secreting cells; there being nodepoeitin the intercellu-
lar spaces. Frerichs reminds us that appearances are not unfre-
qacntly in faror of a deposition in the intercellular spaces,
inasmuch as in preparing sections for microscopic examination
a number of cells become destroyed, and their fatty contents
escaping, they appear to lie external to the cells. Unless the
quantity of oil be considerable, it is often impossible to say that
there is fatty degeneration without a minute examination. la
the case of excessive degeneration, however, the gland is found
of a dull yellow color; it may be increased in breadth but di-
minished in thickness, and it is generally soft and flabby. The
weight of the liver may remain unaffected, or it may be slightly
increased, or it may bo much diminished. The cut surface
usually presents a reticulated appearance; there being reddish-
brown rings corre.oponding to the hepatic veins, around yellow

DEGENERATIONS OF THE LIVEB.

495

patches which correspond to the periphery of the lobuleM, the
region of the portal vein. This nutmeg-like appearance i.s not
characteristic of futtj degeneration, however, since it may oc-
cur in hepatic congestion, &c.

Unless there be considerable accumalation of fat in the he-
patic cells, the functions are not deranged ; and there is neither
pain, jaundice, nor dropsy. If the cells be much loaded, they
may impede the circulation of blood in the capillaries, as well
88 obstruct the excretion of hile. Under these circumstances
gastric catarrh, indigestion, diarrbcea, anaemia, htemorrhoids,
and ascites may result ; but very seldom are there these serious
symptoms.

The treatment of these cases scarcely requires consideration,
inasmuch as it is comparatively of little importance when this
condition occurs in phthisis, syphilis, &c. But if it should be
diagnosed as the sole affection of the system, its euro ought to
be attempted; while, as we have merely to free the hepatic cells
of their excess of fat, the minute elements of the liver not
being disorganized, there is every reason to hope for success.
The most important remedy is the regulation of the diet; alco-
holic drinks, sugar, amylaceous matters, and fat being inter-
dicted. A large proportion of vegetable food may be allowed,
especially fresh fruits, &c. Torpidity of the bowels is to be
overcome by aloea, rhubarb, or sulphate of soda ; or by the use
of the waters of Karlsbad, Kissingen, &c. The two remedies
which then appear to promise moat favorably are the hydro-
oblorate of ammonia, and the liquor potassae (F. 85, 464); but
should they appear to induce debility, or to destroy the powers
of the stomach, they must be exchanged fur bitter vegetable
Bnbstanoes.

2. Amyloid Degeneration.— Tbis structural disease of the
liver does nut demand much attention in this place, since its
pathology has already (p. 127) been treated of with perhaps as
much latitude as the present extent of our knowledge will
allow.

496

niaEASEB OF LIVER, PANCREAS, SPLEEN.

Tbc iiuportunt condition known aa amyloid dcgcnenitioa (the
Koxy, ii/l/iiminovn, lar<fareous, or trrofulou$ liver) may coexist
with futty liver, or it louy alone be present. In it, the glandu-
lar structure of the organ is converted into a dense material ;
and hence results destruction of the gland-cells, with abolition
of their functions. The liver is found after death much in-
creased in weight and size, so that, instead of weighing from
three to four pounds, avoirdupois, it may average eight or nine;
its substance is tough, and somewhat resembles yellow wax;
and the cut surface presents only faint traces of lobules. Mi-
nutely examined, the cells are found compressed, irregular in
form, and with their nuclei aynphied.

This peculiar state of the liver occurs in phthisis much more
fref|uently than fatty liver does, with which moreover it has
been often confounded. But it is perhiips rmist commonly found
in young persons who have long suffered from scrofulous cariea
of the bones J whence it was at one time thought to be pecu-
liar to this disease. The infiltration takes place insidiously,
the first indication of its existence being the increased size of the
gland. Then the circulation gets impeded, as well as the escape
of bile from the ducts; so that the superficial veins of the ab-
domen enlarge, a small quantity of fluid collects in the perito-
neum, and the skin and conjunctivaj become of a yellow tinge.

The spleen and kidneys arc likewise often involved in the
morbid process. The renal affection, however, is more serious
and fatal than the hepatic ; while its existence is rendered cer-
tain by the presence of albumen in the urine, together with
waxy-looking casts of the secreting tubules. On the subject
of treatment it need only be remarked that disappointment baa
hitherto followed all attempts at cure. The general health must
be attended to; and the system supported by nourishing food.

3. The Pigment Liver. — After death from severe inter-
mittent, remittent, or continued fevers, the liver is sometimes
found to present a blackish or chocolate color ; brown insulated
figures being observed upon a dark ground. The cause, &o.,

DEOENKRATIONS Of THE LIVER.

497

of lliis change of color has been particularly eiatuined by
Frerichs ; who says that it is due to the accumulation of pig-
ment matter in the vascular apparatus of the gland. In fine
sections of the hardened ti.s.sue, accumulations of pigment are
to he seen in the capillary network of the portal and hepatic
veins; while the branches of the hepatic artery also contain
quantities of black coloring matter. The same melanotic mat-
ter may often also he found in the parenchyma of the spleen ;
while the kidneys, brain, and other organs are le.ss constantly
implicated. The pigment is carried to the tissues by the blood ;
and if this fluid be minutely examined, it will be seen to con-
tain .small granular masses, together with nucleated pigment
cells having black granules in their interior. — It is generally
believed that the melanotic matter is formed in the spleen ;
owing to stagnation of the blood in the venous sinuses, arising
from the intense congestions which affect this organ in all ma-
larious fevers.

The chief consequence of this pigment formation is an im-
pediment to the circulation of the blood through the liver; so
that tlic gland at first becomes congested, and subsequently
atrophied. The non-arrest of particles of the pigment as they
circulate through the liver and lungs, allows them to be carried
to the brain ; in the narrow capillaries of which they accumu-
late, where they may subsequently induce severe cerebral dis-
turbance.

The occurrence of this condition shows how necessary it ia
to cure all diseases dependent upon mar.sh miasmata as quickly
as possible; lest the capillaries of the liver get loaded with
melanotic matter, leading to their destruction, and of course
to atrophy of the gland. When the latter is established — as
indicated by gastric outarrh, diarrhoea, and ascites — it wilt be
too late to hope for benefit from the use of quinine, &a.

42»

498

U18KA8E8 OF UV£B, PANCREAS, SPLEEN.

V. CAlfCER OF THE LIVER.

Every variety of canoor, except perhaps gelatiniform or col-
loid cancer, has been met with in the liver. Medullnry or
soft cancer is probably more comraun than the scirrhous or hard
kind.

Si/mptomt. — When a liver contains numerou.s masses of
cancer, we shall find (in addition to the gcnerul indications of
malignant disease) that it is generally much enlarged, extend-
ing far below the false rihs, even to the brim of the pelvis.
These nodulous msisses do not give rise to inHamniation of the
heputic tissue ; but when superHcial, they often cause peritonitis,
which is generally very partial, and of the adhesive kind, so
that afler death the tumors are found adherent to the dia-
phragm or to the abduuiinnl walls. The remaining symptoms
are very obscure; loss of flesh and strengtli, constant diffused
pain and tenderness, disorder of the digestive organs, and great
irritability with mental depression, being generally the most
proroinont. Jaundice occurs more frequently than ascites;
while in about one-fifth of all the oases both these conditions
may be combined. The duration of hepatic cancer is usually
short; life sometimes closing within six months from the first
appearance of the symptoms, while it is seldom prolonged for
two years.

Where the disease presses upon the common duct so as to
render it impermeable, the gall-bladder may become greatly
distended; in one instance it having acquired the size of the
fojtal head.

Vaittes. — Malignant disease of the liver is often a secondary
affection ; that is to .say, it results from the transfer of caocer-
cells by lymphatics and veins from the brca.st, stomach, kidney,
&c. WhoiT primary, it does not occur before the age of thirty-
five; while though it frecjuently spreads to contiguous organs,
it only rarely contaminates remote structures.

Treatment. — Our remedies can only be palliative. Relief

nTDATII) TUMOnS OF THE UVER.

499

to the pain must be piven by sedatives — especialiy by opium,
coiiium, and bellsiloiina ; while the digestive organs should
be strengthened by mild tonics, and a light nourishing diet.

VI. HYDATID TUMORS OF THE LITER.

Hydatid tumors oi'cur in the liver more frequently than in
any other orgiin; but they are occasionally met with in the
spleen, omentum, muaoles of the heart, brain, kidneya, tungs,
and bones — particularly the tibia. These growths consist of
a sac, lined by a thin bladder or cyst, and filled with u limpid,
colorless fiuid; floating in whieh liquid, numerous small cysts,
similar to the cyst lining the sac, and varying in size from a
pea to a pigeon's egg, are usually found. To these cysts or
bladders Laenncc gave the name of Acephalocyst — a bladder
without a head. The acephalocyst lining the sac is composed
of finely laminated, friable coats, about the firmness of coagu-
lated albumen. Sometimes it eontuius no floating hydatids,
or very few; in other cases it is literally crammed with them;
and these again, it is said, may contain another generation.
To distinguish these different kinds, as well as to mark the
mode of their increase, luituralists have divided these produc-
tions into two species: Ist, the acephnloryttis endogena of
Kuhn — likewi.sc called mrinlin, vfl pr')lij'rrii by Cruveilhier,
the piU-btjx hi/iliitid of Hunter — which is the kind most com-
monly developed in the human subject, and in which the
fissiparous process of generation takes place usually from the
internal surface of the parent cyst, the progeny being some-
times successively included; and, 2d, the ai-pphnforyMis exo-
<jena of Kuhn — eremila, vd ntfrids of Cruveilhier — which
develops its progeny generally from the external surface, and
is found in the ox and other domestic animals. The true
nature of these acephalocyst^ has long been a subject of in-
vestigation. M. Livois seems, however, to have settled the
question by his discovery that they are the dwelling-place of

500

SISKAJKS or LIVER, PANCREAS, 8FLEEN.

those minute animalcules, to which Iludolpbi gave the name
echiiioroci:ug, from the cylinder of houks surrounding the
head. M. Livois stales that echinococci exist in all accpha-
locysts, and this observation has been in a great measure con-
firmed by Dr. Budd and other observers. When an acepha-
loeyst is opened, its inner surface is seen to be studded with
numerous white opaque particles, which are found bj the
microscope to be distinct echinococci.

The echiiiococcus hominif is a transparent, colorless, oval-
shaped animalcule, displaying an apparatus of suctorial promi-
nences and hooklcta at the cephalic extremity, and measuring
about the one two-hundredth of an inch in length, and rather
less in breadth. In structure the animal is a mere integu-
ment, one-half — the head and neck — being susceptible of re-
tractiuD into the other half. The head is u flat disc at the
extremity of the neck, having imbedded in its substance an
apparatus of small htioks, thirty-four in number, di.sposed in a
circle. Immediately behind the head are four rounded sucto-
rial processes, beyond which follows the body, while at the
extremity of this is a short peduncle by which the animal at-
taches itself to the wall of the acephalocyst. When the ani-
mal is viewed with its head retracted within its body, the circle
of hooks is seen through the transparent integument appear-
ing like a ring in the centre of the body.*

Si/mptoma. — When a hydatid tumor forms in the liver, its
growth is generally slow. It gives rise to little inconvenience
beyond a sensation of weight, so that its presence is often not
suspected until it is found after death. When the tumor is
of a large size, it may then be easily felt ; sometimes it com-
presses the portal vein or vena cava, causing ascites andcedema
of the legs. It may burst into the peritoneum — producing
fatal peritonitis, or into the lung, or into the hepatic duct —
whence its contents may pass through the common duct into

* Erasniut Wilton on tb« Echioomccaa Hominu. Mtdico-Chirurgieol
Trantadioiit, yoX.xxtiii. London, 1845.

HYDATID TUMORS OF THE LIVER.

501

the Juodenutn, or into the intestines, or through the sbdomi-
mii wall ; in the three hitter cases, the contents will often be
entirely tlischarfjed, and the wic ultimately closing up, will
leave the patient well. When the tunjor opens into the lung,
the patient becomes so worn out with constant expectoration
of hydatids and purilbriu matter, and the constitutional dis-
turbance is so severe, that he <renerally sinks under it.

Sometimes a hydatid tumor ^ets woll without opening ;
namely, by the secretion of a thick, piitty-iiko matter within
its sac, owing either to the destruction, or at all events causing
the destruction of the hydatids.

Diaifuoni'i. — When a large hydatid tumor occupies the right
hypoohondrium, it need not necessarily be situated in the
liver; for it may have its origin in the omentum, or in the
right kidney. One of the largest tumors of this kind that I
ever saw was diagnosed during life as arising from the liver;
but it was found after death to be seated in the omentum. In
the same way, when the tumor fills the left half of the abdo-
men chiefly, it will often bo difficult to say whether it is con-
nected with the spleen, omentum, or left kidney.

Treatment. — Two agents, iodide of potassium and common
salt, are supposed to possess the power of stopping the growth
of these tumors. Confirmatory evidence is still required, how-
ever, to prove conclusively the value of these remedies; thongh
it is very probable that the first agent, in five-grain doses thrice
daily, may sometimes cause absorption of the fluid of hydatids
and thus lead to their destruction. When we can be certain
in our diagnosis, and are sure that the tumor is adherent to
the abdominal wall, we may effect a cure by puncturing the
sac. It is needless to say that the greatest caution will be
necessary in performing this operation ; while it ought not to
be resorted to until the medical treatment has failed to effect
any good.

502

DISEASES OF MVER, PANCREAS. SPt.EEX.

VII. JATTBTDICE.

Iclerun, Morbut Rri/iut, or Jaundice, is rather a sign of
some affection of the liver or of the blood, thin k separate

disease.

Cautet. — The way in which jaundice is produced has Jong
enpiped the attention of pathologists; and even now further
observutions and experinienta are needed to solve manj of the
difficulties surrounding this question. According to Dr. Bodd
it may be set up in two ways : Ist, by some racohanical impe-
diment to the flow of bile into the duodenum, and the conse-
quent ab.sorption of the retained bile ; and 2d, by defective
action on the part of the secreting substance of the liver, in
consequence of which the secretion, or the elimination of bile
is arrested. With regard to the first point there is no dispute,
and it is allowed that the greatest number of cases of jaundice
are due to the reabsorption of secreted bile. But as to the
second hypothesis Frericha argues that, if it be true, the bili-
ary acids and bile-pigment ought to accumulate in the blood
in cases of granular liver, just as urea accumulates in granu-
lar degeneration of the kidneys. Yet all attempts to detect
traces of the essential elements of the bile in the blood gene-
rally, and in that of the portal vein in particular, have failed;
neither the coloring matter, nor the acids of the bile having
been found. Moreover, Moleschott kept some frogs alive for
several weeks after depriving them of their livers; but no trace
of the elements of bile could be detected in the blood, lymph,
urine, or muscular tissue. Frericbs therefore suggests thai
thase cases of jaundice which occur without any mechanical
obstruction to the e.xcretory ducts of the liver (such as the
jaundice of pytemia, typhus, and snake-bites) arc due to an
arrested consumption of the biliary acids which have been re-
ab.sorbed into tlie blood, either from the inte.stine, or directly
from the liver. He endcuvors to show, that even in health,
all the bile formed io the liver docs not pass into the dnots,

JAUNDICE.

503

but that a portion of it enters the hepntic veins along with
the sugar. The biliary acids thus entering the blood, or which
are reabsorbed from the intestine, arc i$uppuscd to undergo
certain changes from oxidation ; which may thus account for
the quantity of taurine which has been found in the healthy
lung, and for pigments which are nnturnlly voided in the urine.
When, however, anything interferes with these normal meta-
morphoses in the blood, it is thought that (he complete change
of the colorless bile into urinary pigments is arrested, and that
the intermediate substance — bile-pigment — is formed in the
blood, 80 as to color the various tissues and secretions. There
are objections to this theory; but for these, &c., the reader
must refer to the work of Frerichs, as well as to the admira-
ble introduction with which Dr. Murchisun has prefaced hia
translation.

To return to the more frequent cause of jaundice, it must
be noticed that the most common impediment to the flow of
bile in the duodenum, is the impaction of & gali-stone in the
ductus communis cholcdochua. (J a 11 -.stones consist of inspis-
sated bile, and chiefly perhaps of chotestcrine — a peculiar Bub-
stance, that exists in a state of solution in healthy bile, but
which, under certain circumstances, becomes relea.«ed from its
solvent, and assumes the natural crystalline form. In all cases
the nucleus of the concretion consists of a small piece of solid
biliary matter, or of inspissated bile cemented by mucus. As
many as 3000 gall-stones have been counted in a single blad-
der. Sedentary occupations and free living tend to their for-
mation. When the obstructing stone or stones have passed
into the duodenum, they are voided with the foices, and the
cause of the jaundice being removed, the skin gradually as-
sumes its natural color. The other causes of jaundice from
obstructed gall-ducts are — cancer of the liver or pancreas,
closure of the ducts from adhesive inflammation of the liver,
from spasm of the ducts, and from constipation, (he loaded
intestine pressing upon the ductj and so impeding the flow
of bile.

504

DISEASES OF LIVER, PANCREAS, SPLKEiT.

St/mptom». — The skin and conjunctivsa are of a yellow
color; the urino has the hue of saffron, it gives a yellow stain
to linen dipped into it, while on a few drops of nitric acid
being added to it on a white plate, there is a rapid dovelop-
nient of pale green, violet, pink, and red tints; and the faeces
are whitish, or of a light clay appearance. A peculiar itching
of the skin is occasionally complained of; there may be ex-
haustion, drowsiness, giddiness, and peevishness; a bitter taste
is sometimes experienced ; the pulse is often slow ; while the
function of digestion is uninterfcrcd with, except as regards
fatty articles of food. In some exceptional instances, the cor-
nea, or the aqueous and vitreous humors have become jaun-
diced, and then all objects appear of a yellow hue.

When the disorder is of long continuance, there may be
stupor, delirium, and other indications of cerebral derange-
ment; the patient also becomes weak and thin from mal-oa-
trition ; and frequently there appears to be a tendency to
hsemorrhace — as cpistaxis, bleeding from the gums, purpura,
&c. — Supposing there is obstruction from a gall-stone, the
most acute suffering is induced; the pains being paroxysmal,
and often attended with vomiting and hiccup. Should the
concretion not pass through the duct, fatal exhaustion maj
set in.

TVralment. — The selection of remedies must of course be
guided by the cause. When the jaundice iw due to some ob-
struction, hot poultices, anodyne fomenlRlious, warm baths,
saline purgatives, and low diet will be called for; while daring
the passage of a gall-stone sedatives will be nece.ssary, either
alone or combined with draught.s of hot water containing plenty
of the bicarbonate of soda. With regard to opium, the prac-
titioner should he careful lest he give an overdose, as he is not
unlikely to do in his anxiety to relievo the patient's torture ;
for it must be remembered that nliirniing narcotism ban fol-
lowed the employment of large doses, when the pain which
has appeared to deuiand them has suddenly ceased from the
passage of the calculus. If the safTcring bo very severe, the

DISEASES r>r TBE PANCREAS.

506

inhalation of chloroform or ether is sometimes to be preferred
to the administration of large quantities of uarootics bj the
mouth.

In other cases of jaundice, as we shall be merely working
in the dark, it will he better to rest contented with resorting
to gentle saline purgatives, diaphoretics, baths, rest, and regu-
lated diet.

VUr. DISEASES OF THE PAITCllEAS.

We know so little of these diseases, and they are so rare,
that I shall do little more than enumerate them.

The morbid conditions of the paiicreos which may be met
with are — congestion, li^'pertrophyjinflttmrnatiuii, suppuration,
induration, softening, fatty degeneratiun, cystic tumors, hy-
datid cysts, and cancer. Calculous concretions — composed of
carbonate or phosphate of lime — are not uncommonly found
in the pancreatic duct or its branches: they arc usually of a
white color, of variable size — ranging from a pea to a walnut,
and they exist either singly or in numbers up to fifteen or
twenty. These various affections are generally accompanied
by enlargement of the gliind; and they often give rise to paio
in the epigastrium with fulness or hnrdness, nausea and vomit-
ing, loss of appetite, inodorous eructations, mental depression,
and emaciation. In some cases the vomiting has been very
obstinate ; the matters ejected being large iti quantity, thin,
ropy, and with a slightly sour or saltish flavor. Fatty stools
have also been noticed in connection with acriain diseases of
the pancreas, but whether due to the puncrciitic disease or not
is at present uncertain. It is, however, highly probable that
they are a sign of derangement of the functions of this gland;
whose office — according to Bernard — is to assist digestion and
the absorption of fatty matters.

The treatment of supposed ponoreatio disease can only be
conducted on general principles ; that is to say, by chiefly al-
leviating the most prominent symptoms.

506

DISEASES or LITER, PAXCBZAS, BPIXZ9.

a. DISEASES OF THE SFIEEIT.

The spleen may goffer from congestion, inflamination, aofl-
eoinp, 8nppuralion, and gangrene; from tabcrcular, or from
malignant disease; from 6briooiM deposit<; — tbe remains pro-
bably of exlravasated blood; from the formation of seroos and
hydatid cysts in it ; and also from simple enlargement.

Enlargement of the spleen is readily diagnosed by the sitaa-
tiun uf the tumor in the left bypochondrium, by its general
appearance and shape, and by the history of the case. It re-
sults mo!<t commonly from intermittent fever or ague; bat as
B rule only after several attacks. P»ticnts affected with tumid
spleen can sometimes be readily recognized by their peculiar
sallow and unhealthy aspect, by the dingy appearance of the
conjunctivic, and the anaemic appearancu of the gums and oral
mucous membrane. They are also not anfrcqnently liable to
haemorrhage from various parta of the body; there is deranged
digestion, irregularity of the bowels, and dark-colored offen-
sive motions; there is mnscaliir dubilicy; and we often find a
general unhealthy stale of the system, with a tendency to
sloughing sores from slight cau-scs. In protracted cases, gene-
ral dropsy may set in. When the blood is much altered from
its natural condition, as it often is with splenic cachexia, we
may detect a systolic cardiac bruit : but abnormal prsecordial
dulness with cardiac murmur may likewise arise from an en-
larged spleen displacing the heart upwards, and preventing
the free descent of the diaphragm and full cspansioo of the*
left lung.

In many splenic nffectiona the disease seems to have won-
derfully little effect on the general health; a feature which
lends support to the physiological doctrine that this glaud is
not a very important one.* In some few cases which have

* Dr. Cri^p regardi the ppleen «« "compjiratirply nn anftnportant
orgun in the imtmnl ecoDom;;" and ronridsra "that one of ila olBees if
thst of affording an adsiiaata lapply of blood to ilia itoiDMb and livar.

DISEASES OF THE SPLEEN.

50/

been under my core, the en]ar{»emeiit has been so prcat that
the jilaud h;is occupied (he entire left half of the abdomen :
nnd in these (general debility has been tlie prominent synipfora.
Tlic strueturo of the spleen may not be otherwise than healthy
in these instances of entariiciuent ; or the tissues may be in-
durated and the capsule thickened; or there may be numcroua
cysts scattered throughout the gland.

When the enlargement is the result of ague, purgatives with
bark or quinine will be necessary. In other cases steel, or
the bromide of potassium may prove the moet efficacious reme-
dies. Mercury in any form is injurious; and so is depletion.
Under all cireuinstances, the general health must be supported
by good nourishing food; and by cheerful mental occupation,
with residence in a dry and bracing locality.

and to aet u ft rraerroir for tbt bloud whan the balanae of the gtntnkl
eirenlalioD ia dcrsugsd :'° while another ofBcs i< " to secrete an albuml-
noni fluiil, wbicli performs some part in the process of sangaiSoation."
The result of Mr. Oraj's invesUgoIions would lead bim lu eonolode that
(he fanction i>f (he spleen " is (o regulnte (he quantt(j and (he quality
of (he blood." — See the Treatises of Dr. Crisp and Ur. Gray, Uutht
Btruelvre and Uttoflkf Spleen. Loadoo, 1854-55.

PART VII.

DISEASES OF THE PERITONEUM,
OVARIAN DROPSY. Etc.

I. INFLAMMATION OF THE PERITONEUM.

The peritoncQin or serous membrane lining the abdominal
and pelvic cavitica and investing the viscera, majr suffer from
acute or chronic inflammation.

1. Acnte Feritonitis. — All serous membranes become vas-
cular and of n bripht-red color under the influence of the in-
flammatory process ; a Jorge number of small scarlet patches
at first appearing, which gradually coalesce and spread until
perhaps the whole tissue presents the chanicteristic hue. The
morbid action may end in resolution, merely Iciving the peri-
toneum opaque and thickened ; or if it proceed beyond a certain
stage there will be cff'usion of serum — perhaps to fuch an es-
tcDt a« to produce itiflamraatory drop«y, or coogulable lymph
may he poured out, euusinu; adhesion between the apposed
surfaces of the metiibraue. In extreme cases suppuration and
ulceration take place ; and sometimes the lar^e or small inteft-
tines have been perforated. — Tliose parts of the peritoneum
covering the stomach, omentum, mesentery, and bladder ap-
pear less apt to become inflamed than the portions over Che
convex surfaces of the liver and spleen, the iliao foasee, and
the small intestines.

The earliest ntfinplom in many instances is pain ; which b

INFLAMMATION OF THE PERITONEUM.

509

at first confined to parts, but

soon extendB over the whole
abdomnn, is increased on pressure, and is attended with ht^h
fever. It is sometimes preceded by cbilliiieiw and rigors, with
a feeling of weakness; in other cases it cornea on abruptly,
with acute distre.ss in some part of the abdomen, frequently
in the hypogastric or one of tho iliac regions. The pain is
generally very exquisitely severe, it causes much depros.'ion,
and it is aggravated by any movement which calls the abdomi-
nal muscles into action, or by pressure — even tlie weight of the
bedclothes being insupportable: the patient consequently lies
quiet on his back, with his knees bent, and legs drawn up.
The abdomen is tense, hot, and frequently tympanitic; the
bowels are constipated, and there is often nausea and votoiting;
the skin is very hot and dry ; the pulse is rapid and weak, the
respirations are hurried, there may be hiccup, and the tongue
is furred ; while the countenance is expressive of suffering, and
great anxiety. After a time the belly ceases to be tympanitic,
but remains somewhat enlarged from the effusion of ses-um.
When a fat^l termination is approaching, the abdomen oileo
becomes much distended, the pulse gets very feeble and quick
— 140 or upwards — the countenance assumes a gha.^tly expres-
eioD, a cold dummy sweat covers the body, and death occura
from exhaustion within eight or ten days from the beginning
of the symptoms.

The principal <:ausee of peritonitis are cold and damp, me-
chanical violence, perforation of the stomach or intestines, the
bursting of hepatic abscess, &c. It may also arise from in-
flammation of the inleslines; from diseases of the ovaries;
and from the contamination of the blood by morbid poisons —
especially perhaps by that of erysipelas.

That fearful malady of women recovering from child-bearing,
termed Pl'ehperal Fever, is very generally accompanied by
peritonitis ; or pcrha|>s it may be more precise to say that id
the most common form of this disease tho force of ihe poison
seems to be expended upon the peritoneum. It u.sually comes
on about the third day after labor, but sometimes not until the

43»

510

DIKKA8ES or THE PERITONEUM.

fifth, with one or more rigors followed by fever. The inflnm-
DiatioD commences in the uterine portion of the periloneam,
and sprends rapidly over the whole of its surface ; while in ita
gyinptoins it does not differ from common acute peritonitis.
It seems to result from contamination or poisoning of the
blood, citlier by putrefaction of part of the placenta left in the
uterus, or by the absorption of some of the products of inflam-
lUDtion, or by contagion. There is, unfortunately, no doubt
that this disease may be carried by a third person from one
lying-in woman to another (see p. 48); hence a practitioner
when he has attended a patient with puerperal fever, is bound,
I believe, to di^cuntinuc for a time his attendance upon cases
of labor. Chanpinj; his clothes, washing his hands with a
solution of chlorine or of cyanide of potassium, wearing oil-
silk gloves, will not — it is to be feared — prevent him from
carrying the poison of this malignant disease about him; and
I should therefore recommend, that he absent himself from the
lying-in room for at least fourteen days from the last day of his
exposure to the fever. In proof of the justice of these re-
marks it may bo mentioned, as noticed by Dr. Armstrong, that
in an epidemic of this disease whieh occurred in Sunderland
in 181;-], fiirfy-three women suffered; of these, forty were at-
tended in tlioir labors by one sur<^con and his assistant.

In the tic'iimett! of acute (as well as of puerperal) peritonitis,
the patient's diet must at first be restricted to milk and water,
arrowroot, and beef-tea ; allowing plenty of diluents, such as
iced water, tea, barluy water, &c. Then we have one remedy
which i.s invaluable, and that is opium. This drug should be
given in grain doses ovory three or four hours until the pain
is thoroughly relieved ; and I believe that by it alone we may
save tho palient's life. Sedative fomentations properly and
sedulously applied also give great relief; or covering the ab-
domen with a mixture of four parta of extract of poppies to
one of extract of belladonna, and then fomenting will prove
very serviceable. As I have adopted this plan of treatment
in all my cases for the last few years, and am fully convinced

INFLAMMATION OF THE PERITONKUM. 611

of its value, I trust that it will be fairly tried without inflict-
ing general blcedinj?, antimony, or mercury on the sufferer.
Even leeches are quite unnecessary, if the fomentation flan-
nels be applied loaded with steam, and if they are changed
every fifteen or twenty minutes. Linsoed-meal poultices, made
thick enough to retain their heat for three or four hours, may
be advanta,>;eou.sly substituted for the fomentations as soon aa
the patient can bear their weight without inconvenience. In
all instances purgatives by the mouth du harm; but if there
be evidence lo show that the large intestine is oppressed with
fajcal matter, the latter should be removed by one or two
enemnta. — Directly great exhaustion sets in stimulants must
be given ; no agent of this class being better than brundy.
Essence of beef, quinine, and aninioniu are also often invalu-
able in staying that prostration which, uules5 properly treated,
80on ends in fatal collapse.

2. Clironic Peritonitis. — This is sometimes the sequel of
acute, but more frequently an independent affection.

M. Louis is of opinion that this disease, when not following
acute inflauimiUion, is always couiplicated with tubercles. Dr.
Hodgkiu* says — " My own inspections would lead me also to
the conclu.sion that chronic peritonitis is very frequently con-
joined with tubercles; yet this concurrence has not been so
uniformly ^uppo^ted by cases observed in this country, as it
has been by Ijouis' eases. That i'orin of peritonitis which is
accompanied by oopious effusion, and which might easily be
regarded as a.scitcs, occurs without any appearance of tuber-
cles. The same may be said of other cases in which the con-
crete product of inflammation had been more considerable."

Young children, especially such as manifest the strumous
diathesis, are very often affected with lubfrcular perilonitit.
It is by no means confined to them, however, for it is not un-

• L»e(urt$ OH Morbid AtuUomy of Straus and MueoHi Memhrniui
vol. 1, p. U9, LondoD, 1S36.

512

DISEASES OF THE PEDITONECM.

frequently met with in adults between 18 and 25 years of
age ; particularly in those who, being hereditarily predisposed
to phthisis, have led iiis>^ipatcd lives, or have been exposed to
great hardships with insufficient food. In examining the
peritoneum after death it» substance may be found studded
with miliary tubercles; or there may bo a more abundant
tubercular deposit, which with lymph plues the coils of intes-
tines together, while it covers the liver and spleen with thick
cheesy nreiubnincs. Suiuetinies one or more of the masses of
tubercle in their c>oftcnirig give rise to ulceration and perfora*
tion of the intestinal coats; a fsecal abscess alone resulting,
since effusion of the contents of the bowel is prevented by the
adhesions which have previously formed. In the same way
diSerent portions of intestine may communicate by fistu-
lous openin','8 without even fspcul abscess resulting. I have
also seen the faical abscess lead to perforatioti of the abdomi-
nal parietes — an artificial anus.

The fi/mpioms of chronic peritonitis are somewhat obscure,
the abdominal pain being usually slight. There are often
attacks of colic, while at other times there may be fever with
diarrhcea. Generally treatment gives relief for a time; but
after a few weeks the abdomen again geU tender, there is
more obstinate diurihou with nausea, while the patient wastes
rapidly and becomes very anaemic. After a time, effusion of
fluid takes place, the abdomen enlarge.'), and fluctuation is felt.
With tubercular peritonitis there is often combined disease of
the mesenteric glands, phthisis, &c.

The frraimml must consist in attention to the bowels ; in
allowing a uiild but nutritious diet, with plenty of milk, raw
eggs, and Liebig's beef-tea (F. 2); and in employing blisters
or Btimulatiiig liniments to the abdomen. The application of
iodine paint and the iodine ointment may also be recom-
mended. I think I have seen benefit likewise from the inter-
na! use of iodine — particularly the iodide of iron, from bark
with sedatives, and from cud-liver oil. These cases are, it
need scarcely be added, very unpromising.

ASCITES,

61S

II. ASCITES.

Ascites, or dropsy of the peritoneum, may arise from chronic
peritonitis; from cirrhosis, cancer, obliteration of the portal
vein, and scrofulous disease of the liver, causing; obstruction
to the free passage of the blood through the system of the
vena portJE ; from Bright's disease of the kidney ; from disease
of the heart, or of the aurla ; from disease and eolurgcmeDt of
the spleen ; from mulif^nant affections of the oracntum ; and
from a few other more simple disorders. Cirrhosis and renal
disease arc, however, the most cuuimon causes.

Sympfoms. — The appearance of the patient is often charao-
terislic. The upper part of the body may be wasted, the fea-
tures pinched, and the countenance anxious, while the abdomen
is greatly enlarged. On examining the latter it ia not only found
distended, but the integuments have a shining appearance,
while the superficial Teins are dilated, Commonly there is
anasarca — infiltration of limpid serum into the areolar tissue —
with the ascites ; in most cases the former being confined to
the lower extremities, though the face and arms may also be
affected, particularly in examples of renal dropsy. The tis-
sues affected with anasarca " pit," on applyinj; pressure. The
urine is usually scanty, and often loaded with lithutes; while
in ascites from cirrhosis it generally contains bile, and in that
from renal disease there is albumen.

Proijnosu. — This is always unfavorable in ascites from or-
ganic disease. When it is merely due to the action of cold
causing congestion of the kidneys, or to functional derange-
ment of the heart, or to an aniBtuic state of the blood, the
danger is comparatively slight.

Diaijnosh. — The extent of the abdominal enlargement will
of course depend upon the quantity of liquid present, but the
distension will always be uniform; fluctuation will gcncmlly
be distinct ; and there will, in most cases, be resonance over
the higher parts of the belly on percmwion, owing to the ilout-

514

DISEASES or THE PERITONEUM.

ingof the intestines, thus — as a rule — prominently distinguLsh-
inr; ascites from ovarian dropsy. I say, in most cases, fur the

distension tiiny be so great tliut the bremlth of the mesentery
may be insufficient to allow tlie intestines to reach the surfuce
of the fluid ; dulncs.s will then, of coarse, resalt. Again,
there is occasiomilly — though very rarely — resonance on per-
cussion in ov:iriiin dropsy. This may happen after tapping,
from the cyst filling with air; or it may occur from a coiiimn-
nication forming between (he cyst and the intestine, and so
allowing of the escape of flatus from the latter into the former.
I have noticed, however, that ordinarily where there is any
real difiiculty in the diagnosis of ascites and ovarian dropsy,
the mere fact of difficulty may be taken as presumptive evi-
dence in favor of tbe case being one of ascites. Ovarian
dropsy very rarely simulntcs ascites. In both di.<iense8 there
'will be dyspnoen, which vill be urgent in proportion to the
distenxion. The r|uuniity of the effusion is sometimes re-
markably large. A lew years since I was obliged — owiog to
the severe orthopnoea which existed — to tap a patient in the
Hospital for Women .suffering from a.scites; when 460 ounces
of a clear, urinuus-louking fluid, loaded with albumen, were
removed, the whole of which hud been secreted in rather less
than one mouth.

Tnolment, — Attempts roust be made to procure obsorption
of the fluid ; hence diuretics, drastic purgatives, and perhaps
mercurials arc t-o be carefully employed. One or other of F.
28, 60, 188, 190, 204, 266, 268, 272, 276, 278, Ac., may be
advantageously tried. The muriate of ammonia, either singly
or with taraxacum (F. 84, 85), has been found useful in Ger-
many. I have seen bencflt also from the iodide of potassium,
combined with the aranioiiio-citrate of iron (F, 29, 38), when
there has been great debility. As a rule, in ascites dependent
upon renal disea.se, diuretics do htirin ; and we had better trust
to purgatives, with frequent hut air or vapor baths.

When the distension gives rise to much distress, we mast
resort to parocentcsis. The patient ought to lie upon the left

OVARIAN DROPST.

51S

side, along the ed<!e of the bod ; and the trocar and cnnula
shuuld be introduced tuidwny between the umbilicus aud
pubcs. Tiie horizontal position is preferable, since it is the
tuost coTnfortabk' to the patient, no pressure is required upon
the abdomen, and especially because syncope is much less
likely to follow the evacuation of the fluid. After the opera-
tion I tightly buiidiige the abdomen, and generally contiMue
the use of compression for two or three weeks, or even longer
where it seems to be beneficial; while at the same time iodide
of polai»sium is given, and occasioniilly alterative doses of mer-
cury. In spite of all treatment, however, the fluid i.s usuully—
but by no means always — re-secreted; and in such cases the
disease ultimately proves fatal.

III. OVAKIAN DROPSY.

The most frequent disease of the ovarium is encysted or — u
it is termed — ovarian drup«y ; which consists in the conversion
of this origan, or of parts of it, into cysts, generally perhaps by
enlargement of one or more of the Grauttan vesic-les. Under
the same name, simple serous cyst.s formed in the broad liga-
ments, and drop.sy of the Fallopian tubes arising from closure
of tlieir extremities, have been included.

It would be quite out of place to treat of this disease at any
length in this work ; to consider it fully, a Buiull volume would
bo required. I shall therefore merely make a few general
observations.

Ad ovarian cyst may be single or multilocular ; that is to
say, it may consist of one sac only, or it may be made up of a
variable number of small cysts. All ovarian tumors run their
course much more rapidly thai is generally sup(K>scd ; and 1
believe that the greater number of cases prove fatal within four
years from the first appearance of the symptoms. Cases of
fibrous tumors of the uterus, which often exist for years with-
out any suffering, are repeatedly uiistaken fur ovarian tumors.

6ir>

ItlSEASKS or THE PEniTONErM.

Mr. Paget hns remarked that ovarinn cysts are the onlj unex-
ceptional instances of the transformation of innocent into ma-
h'gnant tunrors. Adhesions often form between these tuinors
and the peritoneum; but I beliove that they may be distin-
guished by every physician possessing the taclut erudilui.

Married women are more liable to this disease than the sin-
gle; while in a large number of instances it is found that the
sufferers have never been pregnant. — With regard to the ovary
most liable to be affected, it seems that if we look to the re-
cords of 500 cases of ovarian tumors, examined only during
life, wc !<hall tind the disease said to be seated in the right
gland in ubout 'IbQ cases, in the left in some 170, and in both
in 80. But if we take only those cti.scs where the opinion has
been verified by operation or post-mortem investigation, then
the numbers become much more equal, though there is still a
slight preponderance in favor of the right side.

The fi/mploms produced by an ovarian tumor in its early
stages are usually so slight, that the disease escJtpes detection
until the patient finds her abdomen rapidly enlarging; while
even then, so little pain or annoyance docs she experience, that
the increase in size is often attributed to pregnancy, or to the
growth of fat. It is only in exceptional instances that the
tumor, while small enough to remain in the pelvic cavity, gives
rise to irritation of the rectum or bladder, or to a sense of
weight and opprcision, or to pain and nun)bne.ss extending
down the thigh of the affected side; these symptoms being
much more characteristic of ovaritis, and even of fibrous ta-
mors of the uterus. Pain in the back — an annoying aching
and wcnkne.s.s about the sacrum — is not uiifroquently complained
of; but women so constantly suffer from this, that they hardly
think of seeking advice for it. Moreover in most cases men-
struation continues regular; though in others the flow maybe
entirely suppressed, or it may appear irregularly, or it may be
scanty or profuse.

When (he tumor has attained such a size as to attract atten-
tion— which, strange as it may appear, may not be until it it

OVARIAN UK0P8T.

517

US large os a child's head — then pain or tenderoesa begina to
be com plained of; the menstrual function gets disordered or
suppressed, the patient loses fiesh, and the tumor by its pres-
sure interferes with the functions of the abdominal viscera.
Constipation, indigestion, diminished secretion of urine, with
frequent micturition, are amongst the chief complaints; while
there is loss of appetite, reittlesstjcss at night, djfspncca, dimi-
nution of strength, and in fact a sense of progreiisive general
decay. On examining the abdomen, it is found moro or less
completely occupied by the morbid growth ; the enlargement
being smooth and rounded without any prominences where the
dbeaae is of the unilocular variety, but often very uneven in
the multilocular form. Pressure with the hnnd communicates
a sensation of great resistance; fiuutuntion varies in distinct-
ness, according to the number of cpts and tbeir size; while
percussion elicits a dull sound over the whole tumor, except in
thoee rare instances where a coil of intestine posses in front of
it, or where the soo has emptied itself into the bowel and got
filled with flatus. — In not a few cases the tumor gives rise to
ascites; but almost always, after a time, the lower part of the
abdomen, the vulva, with the thighs and legs become cedemat-
ous. Then the suffering rapidly increases, and the tumor
greatly impedes the patient's movements; the nights are
wretched, the sleep being imperfect and unrcfrcshing, while
the attacks of dyspnoea prevent the woman from lying down;
there is sometimes suppre^ion of urine, followed by headache,
stupor, and coma ; or great prostration sets in, which soon ends
in death.

As regards the treatment of ovarian tumors, nothing can be
more absurd and reprehensible than the practice which some
gentlcmeu adopt of administering hyjragugue cathartics, diu-
retics, emetics, mercurials, iodine, iodide of potassium, liquor
potasste, bromide of potassium, muriate of lime, &c. Kquallj
injurious are the local applications which the same practitioners
employ, such as leeches, blisters, iodine ointment, friction with
stimulating liniments, electricity, &o. It is only necessary to

518

DISEASES OF THE PERITOXEVM.

examine a Binf;1e OTarian tamor, to see that such agents cannot
by any possibility do pood; and consequcnily, as they are of t
very powerl'ul nature, they must be productive of harm. That
such is really the case, I know too well ; and I am led tospenk
thus plainly, from the painful examples which h.-ivc come un-
der my notice, at the Hospital for Women and elsewhere, of
health entirely ruined, and death hastened, by violent medical
trcatuieht. — The only way in which relief or cure can b« effect-
ed is by paracentesis, fulluwed by careful pressure and the
admioistration of iodide of potassium ; or by paracentesis und
leaving an elastic catheter in the wound to withdraw the flaid
as it is re-secreted, a proceeding by no means free from danger;
or by ovariotomy. — The injection of ovarian cysts with the
tincture of iodine has been lately much practised ; but in most
of the cases in which I have tried it, no permanent good has
resulted, white in the hands of some physicians it hns caused
death. The ooly instances in which it is available are the
unilocular tumors, or just those that may be often cured by
tapping and pressure. If it be resorted to, the cyst must be
emptied; and a mixture made of two scruples of iodine, one
drachm of iodide of potassium, and two ounces of water, in-
jected and left in the cyst, care being taken that none of it
escapes into the peritoneal cavity. Nature sometimes effect*
a cure by rupture of the cyst, with extrusion of its contents
into the intestine or vagina, or into the sac of the peritoneum,
whence it is removed by absorption. I have never seen a case
where the fluid has been disehurgod through the Fallopian
tube ; and I believe that in all probability the examples which
have been recorded of this occurrence have been instances of
dropsy of thi.s canul owing to inflammation combined with ob-
literation of its oriSces.

My first rule in these cases is this: when the tumnr is not
increiuing in size, h not nflccttng the patient's health, and is
nnproductivcof any unpleasant symptoms beyond those result-
ing from its weight, I do nothing at all, merely directing the
patient to see me in the event of any change. These oases are

■

TABEU MEHENTERICA.

519

unfortunately very rare. In deciding between paracentesis and
ovariolomy, repird must bo bad to the patient's health, consti-
tution, a}^e, the condition and nature of the tumor, the pre-
sence or absence of ndhesions, &c. Where there is any hope
of cure from piinicetitesi.H, it is of course to be resorted to, in
proferonce to removal of the tumor; but in certain cases, and
eBpecinliy in the multilocular tumors, ovariotomy is the only
prooeedin;; which offers a reasouiible chance of reseuin;; the
patient from an early and painfal death. That it will often
succeed is quite certain ; and indeed the more my ospericDc«
increase.0 with repird tu this operation, the greater is my con-
victioD of its value in properly selected instances.*

IV. TABES MESENTERICA.

Tabes Mesenterica is the name given to a tubercular or
strumous dofroncration of the mesenteric glands. It might
be tcriued abdominal phthisi.s.

The tubercular matter becomes cSused into the j;;lBnds them-
•elves, entirely destroyinji their structure, and of course pre-
ventir)!! the piissa<:e of the chyle thrim>:h the laetc:)l,M which
traverse them. The glands are found enlarj^ed, and affected
in different degrees; in some the abnormal product beino;
touffh and almost fibrous, in others degeneration having so far
advanced that it is soft and pulpy, while in a third cla-ss there
is only a calcareous deposit, the albuminous portion having
been absorbed. — Mesenteric disease particularly affects infanta
and young children.

* For further obsenratioiut on the treatment of ovarian tamors, see Dr.
Druitt't Siirgeou't VadnMrrnm, eighth edition ; Mr. Spenuer Wellt'i
Catft of Ovariotomy, repriat«<l from the DtthUn Qttarterly Joiirnnt,
1859; Mr. Bukcr Brown'n Sitrgint/ Tiimtaesof Women, seeonil edition [
and paper* by the author in Laucet, I8tb September and 2Ut November,
1B52: and in Mediral Timtiaiul Gazellt for 1863, vol. vi, pagea 10, 3»2,
and .'>2S.

620

DISEASES OF THE PERITONEUM.

The tymplom* consist of pain in the b«vrel8, more or lesa
constant, Bometimes severe, caasinp; the child to keep his legs
drawn up towards his belly. The lips are of a deep red color,
and the angles of the mouth arc covered with small ulcers, or
the whole lip is fissured. The bowels are variable, though
generally rclased ; the motions are often unhealthy, and ex-
tremely fetid. The abdomen is swolleo and tense; while the
other parts of the body waste away, owing to the obstruction
of the chyle ducts, until an extreme degree of emaciation
exists. There is great pallor and general debility, the weak-
ness increasing rapidly. Symptoms of pulmonary consumption
may supervene, or the brain may become implicated, or the
child may die worn out by the abdominal disease. Recovery
does sometimes occur, however, when treatment is resorted to
before the functioos of the glands are much impeded. In
these favorable cases the period of convalescence will be very
slow, and great caution must be employed to prevent any re-

The diaynosiit is not always very easy, and there are two
or three disorders with which this disease may be confounded.
Thus strumous infants not un frequently suffer from very obsti-
nate diarrhoea, as a sccjucla of some exhausting disease; or ft
looseness couies ou owing to insufficient nourishment, or to
being kept in a daiup otfcnsive atmosphere, &c. The evaoua-
tions from the bowels may be very nutuerous, consisting of
greenish mucus, with undigested food. The countenance be-
comes anxious and aged; the skin is harsh, the breath offen-
sive, the tongue dry and aphthous, and the stomach irritable;
while the little patient is restless and very fretful. If removal
of the cause, and the use of such remedies as milk and lime-
water, logwood and opium, ipecacuanha and catechu, port
wine or brandy, &e., fail to efTi^ct a cure, extreme exhaustion
sets in which soon ends fatally. After death the mucous
membrane of the alimentary canal will be found quite norma],
while the mesenteric glands may be merely swollen uud con-

TABK8 MESENTERirA.

521

eested — probiiblj as a consequence of the irritation, but per-
haps being the cause.

Agnin, hjdroccplialus in its early stages somewhat resembles
Btruinous disease of the abdomen. But in the fornter the
cerebrsil oppression is "greater, sickness is more constant, the
mind is duller, there is strabismus, and the abdomen is flat
rather than distended.

Strumous peritoniti.s is hardly to bo distinguished from the
disease under consideration, with which indeed it is often
combined. Fortunately the distinction is unimport^int.

The treatment must consist in the use of mild nourishing
food adapted to the child's age and strength; a.-sscs' milk, soda-
water with niitk, and farinaceous preparations being very use-
ful. P'ort wim; and beef-tea arc valuable agents. Cod-liver
oil will be of much use in many cases; especially when given
with tonics, and sometimes with small doses of iodide of po-
tassium and the ammonio-citrute of iron (F. "29, 33, 3J, 39,
or 41, reduced in strength according to the patient's age). In
some instJinces benefit scenis to have been derived from altera-
tive doses of hydrargyrum cum ereta combined with Dover's
powder, or with the compound chalk powder with opium of
the Pilar. Lond. Astringents to check thediarrhica, frictions
over the abdomen with the common soup or opiate liniments,
and the employment of a flannel bandage round the body may
frequently be necessary. Change of air, especially to the sea-
side, will often work wonders; and should bo advised at an
early stage of the disease.

44*

PART VIII.

DISEASES OF THE KIDNEYS, SUPRA
RENAL CAPSULES, AND BLADDER.

L INFLAMMATION OF THE KIDNEY.

Nephrftis, nr inflammation of the subBtance of the kidnej,
niaj arise without any appreciable cause, or from cold, from
the formation of calculous matter, from rurious mechanical
injuries, or from the administration of cantharides or oil of
turpuiitine. It is a very rare disease. As in inflammation of
other organs so in the kidney the morbid action may end in
resolation, or it will go on to suppuration ; in the latter case
■variable siied abscesses resulling, which sometimes cause en-
tire destruction of the gland. In most examples of nephritis,
the mucous niembraiie linin>; the pelvis and tubuli b involved
in the disease; inflammation of this tissue being known afl

The nt/mptomt of nephritis are chiefly these : Neuralgic
puins in the loins — especially in the region of the kidney; the
pain sometimes extending along the ureter to the neck of the
bladder, or to the groin, scrotum, or testicle, and being in-
creased by pressure or by exorcise. There is often also numb-
ness of the thigh ; and, in men, retraction of the testicle, with
frequent micturition. The nufTeriiig from congestion and in-
flammation mu.tt not be confounded with that which arises
from BOiao irritation of the kidney — nrphrahjia — such as is
caused by the passage of a small calculuH from the pelvis of

ACUTE DESQUAMATIVE NEPHRITIS.

523

the kidney along the ureter to the bladder, and which is gene-
rully much more severe but of shorter dumtiun. In addition
to the foregoing symptoms there is, in nephritis, much cou-
Btitutlonol disturbance, fever, nuuHen and vomiting, with ^reiit
thirst; pulse hard, frequent, and full ; constipution and tym-
panitis ; while though the desire to pass urine is frequent nnd
urgent, yet the secretion is scanty, high-colored, and often
contains hlood, or sometimes pus.

When the inflammation terminates in resolutioa, the patient
appears to get well ; but the gland is often left somewhat in-
durated, and thus perhaps is kid the foundation for future
disease. When abscesses form, they lead frequently to ulce-
ration, the formation of renal fistulas, and the establishment
of a purulent discharge ; these consequences being accompa-
nied by hectic fever, which moat times ends fatally. In more
favorable cases, however, the pus passes out by the natural
passages, and is found in the urine. Sometimes the disease
causes death at an earlier stage, by inducing coma; owing to
the retention of urea in the blood, and its conversion perhaps
into carbonate of ammonia (p. 41 ). In other examples, again,
typhoid symptoms appear early, and the patient ginks from
pure exhaustion.

The treatment must consist in the use of warm fomenta-
tions, the vapor or hot-air bath, mild purgatives, and diapho-
retics— especially those containing opium, such as Dover's
powder. Our objoct, indeed, must bo to rest the inflamed
gland, and to get its work done by the skin and mucous mem-
brane of the bowels.

n. ACUTE DESaUAMATIVE NEPHRITIS.

This renal affection has ita origin from many causes, as in-
temperance, starvation, wet and cold, and the cholera-poison,
&c. ; but especially is it often due to scarlet fever.

Puthulitijy. — Acute desquamative nephritis (acute iDflttiu-

DISEASES OF THK KIDNEYS AND BLADDER.

niatory dropsj) consists essentially of disease of the epithelial
or pland ciOls lininp; the convoluted urinireroas tubes, induced
by their haviii;; t/) eliminate rroni the blood some mutter which
is not naturally excreted by the kidneys. The cells, having
their functions thus niudified, suffer ehanpes as regards their
nutrition ; and in eoiist'(.|uence they rapidly des<|uanaate, and
tendto check secretion by luechanicidly obstructing the tubes.
While the srlaiid-eolls are undcrcoing these changes, the cir-
culation through the vessels of the Malpighian tuft also be-
comes impeded ; so that an effuMon of scrum and Bbrin tukea
pliico into the cavity of the tubes. The scrum which escapes
from the congested Malpighiun capillaries mingles with the
urine and renders this fluid albuminous ; while the fibrinous
material solidifies, entangles in its substance the cast-off epi-
thelial cell'*, and escaping with the urine is detected in this
secretion in the shape of epithelial tube-casts. If any of the
walls of the vessels give way, as they will do under the in-
fluence of the preasure to which they are exposed, blood cor-
puscles will also be found entangled in the casts, while the
urine will present a durkcolorcd sediment,

In the event of (he disea.se terminating falAlly, both kid-
neys will bo found aflccled, increased in size and weight, and
marked with irregular extra-vascular patches. Minutely px-
amined, the convoluted tubes of the cortical portion of the
kidney are seen to be crow<led willi desijuaniated epithelial
cells, some tubes being more distended than others. The
straight tubes of the medullary cones are comparatively unaf-
fected. The Malpighian bodies are found engorged.

Sj/mpl'jtnf — As a general rule, the disease is ushered in
with rigors and chilliness; these symptoms being soon followed
by feverish reaction, hendaohe, restlessness, pain and tender-
ness in the loins, and often vomiting. The dropsy, which it
gives rise to, is an early symptom ; the face first becomes
puffy, followed by general swelling of the areolar tissue through-
out the body, and by effusion of fluid into one or more of the
kcrous cavities. At the same time there is a frequent desire

ACDTK DESQUAMATIVE NEPHRITIS.

625

to pass urine ; which is scanty, of b dark smokj color, and on
being tested by heat and nitric acid is found to be highly al-
burainous. Examined microscopically, it is seen to contain
niDHses of coagulated fibrin, epithelial casts and cells, bloud
corpuscles, and occasionally crystals of lithio acid. The epi-
thelial casts and cells sometimes inclose a small quantity of
fatty matter; but this oircuntstance need not lead to an unfa-
vorable prognosis unless a large proportion of the cells are
seen distended with oil, when it must be feared that the kid-
ney is passing into a state of fatty degeneration.

The earliest sign of improvement is a disappearance of the
dropsy, and an increase in the quantity of urine secreted. It
is not uncommon for a patient during convalescence from this
disease, to pass from four to six pints of urine during the
twenty-four hours ; the natural quantity averaging only from
two to two and a half or three pints.

It is very curious that acute desquamative nephritis from
scarlatina is more frequent after a mild than after a severe
attack, owing probably to the want of caution which is ollen
observed in such cases during the period of desquamation.
The patient gets exposed to cold, and iuimcdiiitely the escape
of the fever-poison through the pores of the skin is checked ;
and, as a consequence, is directed to the kidneys in larger
quantities than they can bear. It usually commences about
the twenty-second day from the setting in of the fever.

Difignoitis. — The preceding observations leave nothing to
be noticed under this head, except as to the analysis of the
urine for albumen.

When examining the urine for albumen, two tests must be
employed, — heat and nitric acid. On applying heat, 140° to
167° Fuhr , to albuminous urine in a clean test-tube, the albu-
men coagulates and produces a cloud varying in density. This
only takes place, however, when the urine is acid; fur alkaline
urine may be loaded with albumen, and yet heat will produce
no deposit. In such a case the secretion must be rcmlered
acid by the addition of nitric acid until the deposit is thrown

526

DI8EA8E8 OF THE KIDNEYS AND BLADDER.

dnwn ; hent bein^ then opplied to mnke mire that the precipi-
tate remains unchanged. It will not do merely to add a, drop
or two of nuid und then apply hcut, for under these circuin-
etanees the urine may he louded with albumen and yet no do-
pasit be tbnued ; a circumstance that Dr. Hence Jones has
suppoitcd to be due tu the formutiun nf a nitrate of albumen,
which is wluble in a weak and even boiling solution of nitric
ncid, but i.H in.>iolublo in a more ocid mixture. Moreover, heat
alotre niu.«t not be trusted to in any case, since it renders the
urine cloudy when there is an excess of earthy phosphates;
this cloud being dissolved by nitric acid, while the albuminous
di'[iii8it continues permanent. Again, nitric acid alone may
give rise to turbidity, owing to the decomposition of the urates
held in solution, and the precipitation of amorphous uric acid;
the latter being dccuuiposed, and the urine rendered clear,
thoujrh of a brown tint, on using heat.

ProijHosii. — This may generally be favorable. The chief
points to be feared are the occurrence of uncroia, and subse-
quently of Bonie permanent structural disease of the kidney
setting in. Cure must be taken not to discontinue treatment
until the urine is found by ohemical and microscopical exami-
nation to be quite heiilthy.

Treatment. — In seeking to euro acute inflammation of the
kidney, we have to remember — as Dr. George Johnson remarks
— "that there has been, first, a morbid condition of the blood,
which has excited disease in the kidney, and that, as a second-
ary consequence of the renal disease, the blood has becoma
contaminated by the retention in it of urea and other oxcre-
mentitinus matters."* Our double object must therefore be
to rest the kidney, while we purify the blood by means of the
other excretory orpins. To carry thi.'? pliiti into practice, the
patient must re^t in bed, in a moderately warm room, and be
placed on low diet; he may be allowed plenty of .simple drink
— water or barley-water; and in order to get the skin and

• On Dimint oflht Kidney, p. 12A. London, 1853.

CHRONir PEPQTAMATIVE N'KrHRITIS.

S27

hrvwels to act freely, the h(»t-air bath or hot-wntcr hath must
be used once dnily for three or four timcH, diaphoretic medi-
cines (F. 256,257, 261) administered, witli saline or other
purgatives (F. 169, 178, 181, 203 ). In many instances, ola-
tcrium (F. 188), given so as to produce free purging, is very
beneficial ; but for children I usually prefer the compound
jalap powder, in doses varying from ijr. xv to 9ij. Powerful
diuretics should never be hud recourse to in this disease; since
in the early stages they do great mischief, while in the latter
they are unnecessary. When the dropsy has been removed,
and the urine is getting into a natural cuniiitiun, the patient
may be allowed to leave his room, and to have plain nourish-
ing food. No medicine will then prove so bcnc&cial as steel,
and often the tincture of the Hesquiehloride of iron acts very
benetieially. Spirits and beer ishould be avoided, and wine
ought only to be given if it seems to be really required. The
patient will have to clothe warmly, wearing flannel next the
bkiu; while he must long avoid exposure to cold and damp.

III. CHEONIC DESaUAMATIVE NEPHRITIS.

For our knowledge of this disease we are entirely indebted
to the able researches of Dr. George Johnson ; the following
remarks are consef[Hently a mere epitome of his ob.servations.*

Chronic de.snuamative iiepliritis is cliarncterixed by a long-
continued shedding of epithelium, which appears in the urine
in a more or less disintegrated state. The lubes gradually lose
their epithelial lining, and subscijuently become atrophied or
filled with a new material ; or they may continue to be
nourished, secrete serum into their cavities^, nud so at length
get dilated into cysts. Meanwhile the renal bloodvessels un-
dergo changes, and the kidney becomes wasted and indurated.
The urine is, fur the most part, albuminous ; it is usually

♦ Opus jam citnt.. p. 168. Alao, Medico-Chirurgirtil Trtinf-irtion$y
vol, xxz, p. I6& I/ondon, 1847.

528

DISEASES OF THE KIDNEYS AND BLADDER.

greater in quantity and of a less density than in health, vary-
ing from 1005 to 1015. If we examine it luicruscopically,
we shall Gad abundant amorphous granular matters, either
scattered or in the form of cylinders, which have evidently
come fi-om the renal tubes, and which are known as yranular
epithelial ca»ls. The disease is frequently a conse<|ueDce of
chronic gout — Dr. Todd used to speak of it as the goutjf kidney
— or of some allied disorder of the general health ; while it
may happen as a result of acute desquamative nephritis. In
some instances it comes on so insidiously, that unless the urine
be examined it may escape detection, until perhaps the patient
is seized with a fatal attack of suppreMsioD of urine.

This disease produces great changes in the blood, and many
and various coiistitutiunal disiorders consequeot upou theM
changes ; amongst which the most frequent are anasarca,
dropsy of one or more serous cavities, intiaiDuiation of the
serous membranes, liypcrtropby of the heart, with or without
disease of the valves, and, lastly, either structural cfaaoges, or
great functional disturbance of the nervous centres.

To speak rather more in detail, chronic nephritis may exist
for some time without producing any marked «ytnj9fom«; or
the renal disease may be masked by the progress of some pre-
existcnt and causative malady. Thus I have seen instances
of chronic gout where the disease of the kidney has become
far advanced without having manifested itself by any special
signs: and hence in all such cases the urine should be fre-
quently tested. — In many ca.ses, however, this form of nephri-
tis is attended with failing health and strength; the skin is
harsh, dry, and sallow; the appetite is variable, sometimea
bad, at other times voracious; there may be dyspepsia, diar-
rhoea, rheumatic pains, or some pulmonary derangement; and
in several instances there have been frequent attacks of hasmor-
rhage from the nose. The patient loses ficsh, but this may be
concealed by the snosarcuus swelling of the body; though
drop!>y is by do means a constant feature of this affoction. In-
deed, many cases prove fatal without the occurrence of dropsy

CHRONIC DESQUAMATIVE NKPHRITrS.

529

in any form ; while in others there may be merely a puffiness
about the face and eyelids, with slight swelling oF the ankles.
The urine is pnssed more fret[ueBtly than in health, and espe-
cially has the patient to rise once or oFtenor in the night to
empty the bladder. On testing the urine it may be found of
normal color, reaction, BpcciSo gravity, and free from any
blood ; while if the disease be in an early stage there may be
no albumen. But in all instances, if the secretion be allowed
to stand, and the sediment be minutely examined, the micro-
gcopist will detect a granular material, in small masses and
oylindere; which consist of disintegrated epithelium from the
basement membrane of the tubes, washed out with the urine.
As the disorder advances the epithelium becomes shed more
abundantly, and the urine gets albuminous.

This affection often makes but slow progress, and when it
happens as a .secondary disorder, the cure or retardation of the
latter, will have a very beneficial influence upon it. But
when it gradually advances, complications ari.se j the heart or
lungs get diseased, the nervous centres becouie implicated, and
convulsions or coma set in. Of cour.'se the prognosis must be
partly regulated by the mode of living which the patient
adopts.

The treatment, for the most part, resolves itself into the
adoption of means for the removal of the morbid state of the
blood and constitution generally ; of which the renal affection
is only a result and a manifestation. When the disease is the
consequence of gout, we must regulate the diet — disallowing
sugar and all fermented liquors, attend to the various excre-
tory functions, and employ such remedies as are indicated by
the paticjit's general condition and state of health. Great
benefit will always be derived from keeping the skin warm,
and from the occasional use of the warm water, air, or vapor
bath; diaphoretic medicines (F. 255, 257) are also useful.
Gentle aperients ; dry cupping over the loins frequently re-
peated, or counter-irritation to the same part by siuapisma,
tartar emetic ointment, or ammonia linimenta; quinine, iron,

530

DISEASES or THE KIDNET8 A.XD BI.ADDEB.

and Other tonics — these are all remedies which oAen aSbrd con-
siderable relief. Mercurials, and especially all dinretic medi-
cioes, are strictly to be avoided. In cases attended with dropty,
we may use those purgatives which produce copious watery
stools, such as elateriuni, gamboge, jalap, &c. (F. 180, 188,
189, 204). Sometimes there is spontaneous diarrl.oea; which
b not to be checked, unless it produces exhaustion. — When
there is much depression we must avoid drastic purgatives,
and simply get the skin to act freely by diaphoretics, and espe-
cially by the use of the hot-air bath, repeated every night, or
on alternate nights. In these cases too the diet ought to be
generous, and a small quantity of wine may often be allowed
with advantage. Change of air, particularly a sea-voyage,
often proves very valuable.

IV. FATTY DEGENEEATIOU OF THE KIDNEY.

In 1827, Dr. Brightfirst pointed out the frequent connection
of anasarca and other drop.'>icul aficetions with a peculiar dis-
ease of the kidneyRj the prominent character of which is the
appearance of albumen in the urine, and the deposition of a
peculiar granular matter in the substance of the renal gland,
together with the gradual atrophy of its cortical and tubular
structure. Hence this affection is commonly known as Briyhft
diteate, or as t/riinular i/iyenerali'on of the kidney. By some
pathologists the term Brii/hCt disease is applied to all renal
disorders, attended with albuminuria; these gentlemen holding
that this affection is one morbid process, which runs through
various stages. The itivestigntions of Br. George Johnson
seem clearly to have proved the incorrectness of this view, and
to have shown that there are at least two or three great classes
of renal di.<ioaBe. In the following reamrks I have again to
avail myself of this gentleman's labors.

Fatty degeneration of the kidney may bo the consequence
of acute desquamative nephritis } or it may arise from scrofula.

FATTY DEOENERATION OF THE KIDNEY.

531

bad living, constint exposure to wet and cold, intempcranoe,
&o. Hence the renal tcxtural changes are but the espresaion
of that which no doubt primarily is a blood disease.

The appearances in the urine which chiiractcrize this disease
are — a scanty secretion, which is hig;h!jr albuminous, and of
low specific gravity; it is generally, in the early stages, free
from sediment; and, when examined by the ruicroscope, is
found to contain neither renal epithelium, nor casts of tubes,
or, if any, only small waxy cast.s. Aftor a period, variable in
different cases, while the general characters of the urine re-
roain unaltered, there appears a light, cloudy sediment, which
is usually found to contain some of the small waxy casts,
in which are entangled one or more globular or oval cells,
inclosing a. considernble number of oil-globules; several of the
cells being completely 61Icd with oil, and presenting the ap-
pearance of dark opaque masses. Some of the casta have
adhering to their surface many small oil-globules, which have
probably escaped from ruptured cells; while numerous cells
containing oil, together with detached oil-globules, are scat-
tered over the field of the microscope.

When the urine is of a nntura! color, highly albuminous,
Md presents numerous oily casts and celts, the prognmit is
most unfavorable. Dr. Johnson says that these appearances
indicate as serious and intriictuble a malady as tubercular
disease of the lung. He has examined the urine in a Iarp>e
number of these cases, and in no one instance did he find that
this secretion regained its normal condition, or ceased to be
albuminous. The patient's life may be prolonged by careful
management, but he cannot hope to be cured.

The chief rymptomi produced by this disease are — gradually
increasing debility; inflammation of the serous membra -les ;
anasarca of the limbs, with dropsy of the different cavities;
and ultimately coma, which soon ends in death.

In the trfittmenf, we can do little more than relieve symp-
toms. The diet should be regulated; and abstinence from
intoxicating drinks, starch, sugar, and perhaps fatty articles

532

DISEASES OF THE KIDNEYS AND BLADiiKR.

of food, iosigtcd upon. In other respects, the rules laid down
ia the preceding section must be uttended to.

V. AMYLOID DEGENERATIOlf OF THE ZIDIIET.

To Bajr much upon this subject would only be to repeat in a
weariBonie luaniier the remarks which have already (p. 127)
been made. Suffice it therefore to notice that waxy, larda-
ceous, or amyloid degeneration of the kidney probably never
exists alone, for it i.s a constitutional affection ; that the effect
of it is to render the kidney iiicllicient as an excreting organ,
and ultimately useless; that it causes the urine to be albumi-
nous, while there may sometimes be found waxy casts of the
tubes but no roiial ipiiheliura; and that the victims of it pre-
sent all those marked symptoms which arc usually set down as
due to Bright's disease.

Profeasor Virchnw states that a large proportion of the casM
of Bright's disease, and especially of the chronic ones, are
assignable to this change. The changes which the kidney
undergoes cannot he distinguished immediately with the naked
eye; so that not until iodine tuts been employed, cun it be said
what the disease rctilly is. If a solution of iodine be applied
to the anaiinio cortical substance, a number of red points
appear, corresponding to the glomeruli, and sometimes fine
streaks also, which are the nffcrcnt arteries; and next to this,
when the disease is very severe, red parallel lines are also seen
within the medullary cones, lying very close to one another.
These are all arteries.

VI. GRAVEL.

Gravel may be defined as the discharge of gritty powder or
sand, or of small calculi, with the urine; occasioning pain and |
irritation in the kidneys, ureters, bladder, and urethra.

OKAVEL.

688

When a patient osperiences " a fit of the gravel," tbe sufFer-
ing is most severe; especially during the passage of the calculus
down the ureter. As soon as this substance reaches the hlad-
der, however, all pain ceases ; and if it be true, as some phi-
losopher has observed, thiit the height of happiness is sudden
relief from suffering, the patient is indeed happy. When
there is merely gritty matter or sand, do pain whatever may
be experienced.

The most common forms of gravel are — the urates of lime,
potash, and soda, with smuil quantities of ammonia : it is often
called lithate or unite of ammonia, but Dr. Has.sull has clearly
proved tliat the (juantity uf :ininioiiia present is always very
small, and is probably only derived from the decomposition of
urea. Second in frequency we find lilhic or uric acid, or red
sand. Then a deposit, consisting mainly of the triple phos-
photc of ammonia and magnesia, mixed with amorphous phos-
phate of lime. Next, a deposit of oxalate of lime. And,
lastly, one of cystic oxide.

Urinary calculi are composed of either urate of soda, am-
monia, and lime; or of uric acid; cystic oxide or cystine;
carbonate of lime; oxalate of lime; triple pho.'iphate of am-
monia and magnesia ; phosphate of lime; or of silica.

The trfalment will vary with the species of gravel. In the
lithic-acid diathesis, a vegetable diet, avoidance of alcoholic
drinks, the free use of simple diluents, gentle exercise, atten-
tion to the bowels, and the use of alkaline aerated waters — as
those of Vichy or Carlsbad — will be beneficial. Alkalies often
give relief, and none can be employed so advantageously as
the salts of potass ; since soda often combines with the lithio
acid, and forms a hard, insoluble salt, while magnesia in large
doses is very apt to cause intestinal concretions. The bicar-
bonate of potass may be freely given, without any of these dis-
advantages ; the liijuor potasste in largo doses (^ss- in water
^ij) is also an agent poBscs.sing valuable properties, which ap-
pear to have been generally overlooked.

lo the phoephatic diathesis a directly opposite oouree of
45*

631

DISEASES OF THE KIDNEYS AND BLADDER.

treatment will he necessary. The diet ought to be generoos,
a moderate allutrance of wioe must be allowed, and tonics —
such as bark, iron, and the mineral acids, especially the nitro-
muriatit — should be admiiii^terbd. Opium is also a valuable
drug in these cases; aud complete meDtal relaxation must be
insisted on.

In the oxalic-acid diathesis, all articles of food containing
this agent — such as the common garden rhubarb — must be
avoided ; saccbai ine substances should also be disallowed. The
nitro-niuriiitic acid will genenilly prove useful (F. 4G0, 461);
and tepid or cold bathing, change of air, &o., should be re-
commended.

The sulTuring caused by the passage of a calculus down the
ureter will be most readily relieved by the warm bath, by the
free use of emollient diluents — especially by barley-water con-
taining a couple of drachms of spiritus cetheris nitrici, and by
full doses of opium. The subsequent passage of the stone
from the bladder will bo facilitated by introducing a lai^
silver catheter with an open extremity, and washing out this
viscus wilb warm wiiter. When too large to be thus got rid of,
surgical interfereuce — lilhotrity or lithotomy — will be required.

VII, DIABETES MELLITU8.

Some little confusion hiw occa.sionally arisen from the de-
scription in text-books of two kinds of diabetes, — diabetex mfl-
Hint and t/i'iltrle.1 iusipiiliig. The two diseases have no con-
nection with each other. In the so-called diabetes insipidus
or chronic diuretit, a large quantity of pale watery urine is
passed. It is of low speciiic gravity ; while if the whole
amount excreted in the twenty-four hnui-s be quantitatively
examined, it will usually be found that the total solid content*
are not above the healthy average. In this condition there is
generally greiit thirst, and it is probably owing to the quantity

DIABETES MKLLTTU8.

536

of fluid taken to satisfy this craving that so niucb water is re-
moved by tlie kidneys.

Ditiltntex mellitus, melituri'n, or </liniaiiria, is a complicated
form of disease characterized by the secretion of a large quan-
tity of urine containins: sug-ar.

Si/mjif'ima. — The early iiidicntions of this disease are not
generally well-marked, compliiiiit being merely niadeof mn/aise
and a sense of fevcrishness. Then it is noticed that larpe quan-
tities of urine are passed, having a faint odor somewhat like
that of apples. Owing to the quantity of water thus got rid
of by the kidneys, it can be readily imagined that the mo.st
prominent effects will soon be greiit dryness and harshness of
the skin ; together with hardness of the fseces and constipa-
tion, and urgent constant thirst which it is difficult to allay.
After a time the general health begins to give way, and there
is a loss of all sexual power. Then follow such gyuiptoniH as
pain in the loins; coldness of the extremities, with burning
pain in the hands und feet ; great emaciation and debility, with
a rapid diminution in weight; a chloroform-like smell of the
breath; spongine.s.s of the gums ; mental depression ; together
with a constant feeling of linking at the stomach, inducing a
voracious appetite. Thi.n disorder commonly progresses slowly
and insidiously, and often ends in— or becoiiics associated with
— pulinnnary consumption. It almost always proves fatal.

There would appear to be sonic causal connection between
diabetes and cataract. At all events when the former has ex-
isted soiue time the latter may occur ; the catamctous condition
being symmetrically developed in both eyes. The cataracts
are of the boI'i kitid ; aud in the c&ses which have been seen
there has been no reason to suspect further disease of the eye-
ball.

J'iithufoi/i/. — For remarks upon this head the reader is re-
ferred to Part I, p. 37. It may be again mentioned, however,
that this disease is only here considered for the sake of conve-
nience ; since diabetes is no more a disease of the kidneys than
of the liver, skin, or intestines. In examples of it, sugar may

536

DISEASES 07 THE KIDNET8 AND BLA0D8B.

be detected in the blood, sweat, tears, saliva, and fasces, as well
08 in the urine.

Diagnosis. — Diabetic urine has a sweetish taste and odor,
is geneniliyof a pale color, and is secreted in very large quan-
tities. In health the nvorajie quantity of urine passed by an
adult in the twenty-four hours may be said to be two and a half
or three pints; while in the disorder under consideration this
quantity may be increased to 6fteen, twenty, or even thirty
pints. Ihc specific gravity is also very high, varying from
1030 to 1050; the more aggravated the disease, the greater
being the density.

It was at one time thought that certain forms of vegetable
fungi or torute were developed only in saccharine urine. Dr.
Bence Jones and others have proved, however, the incorrect-
nes.s of this view ; these observers having taught us that though
toruljB are often formed in acid diabetic urine, yet that they are
not peculiar to it, being especially frequent in acid albuminous
urine, or even in healthy acid urine after exposure to the air.
Dr. Hassull* has shown that the so-called tonila cerevisia* is
identical with the penicillum glaucuui, the fungus which im-
parts the mildewed appearance so coinmon in decaying vegeta-
ble and aninia! substances; while he has also labored to prove
that a characteristic species of fungus, identical with the yeast
plant, is developed in saccharine urine, and in this urine only,
when it is acid, is freely exposed to the air, and is kept at a
moderate temperature. The presence of this sugar-fungus in-
dicates the vinous fermentation, its development being accom-
panied by the disengagement of carbonic acid and the forma-
tion of alcohol. The penicillum glaucum smd the yeast-fungus
not unfrcqucntly exist together in diubctic urine; but the lat-
ter— it mu.st be remembered — is alone peculiar to it, and may
be found when the quantity of sugar is too small for detection
by the potash and copper tests. ,

* MtJieo-Chirur^tat Trautaeli4im, vol. xxzTi,p. 23. London, 1BS8.

DIABETES MKLLITU8.

537

Several tests have been proposed fur the detection of sugar
in urine. Thus wc have, —

Mtwre's Test. — Add to the suspected urine, in a test-tube,
about half its vulanie of liquor potussae, and boil the mixture
pently for a few tuiiiut(.'!<. If supar be present, the liquid will
assume a dark bruvvn tint If, on the contrary, the urine be
healthy, it will only be very slifrhtly darkened.

Care must be taken — as Dr. Owen Rees has pointed out —
that the liquor potassa^docs not contain Icud, as it ofteti will if
it has been kept in a while "[lass bottle. When itdocsso, the
sulphur in the urine produces a dark color with the lead, which
mipht lead to an incorrect dinfrnosis. The test solution should
be kept in a green glass bottle, free frnm lead,

Troiuiner's Test. — A little of the suspected urine is to be
placed in a test-tube, and a drop or two of a solution of sul-
phate of copper added, so as to pive the mixture a slight blue
tint, A solution of potash u now added, in quantity equal to
about half the volume of urine employed : this will throw
down 11 pale blue procipitat* of hydrated oxide of copper,
which, if there be atiy su>;ar, will immediately rcdissolve, form-
ing a purpli.sh-blue solution. The mixture is then to be gradu-
ally heated t<i the boiling point; when, if sugar be present, a
yellowish-brown precipitate of suboxide of copper will be de-
posited. If there is no sugar, a black precipitate of the com-
mon oxide of copper will be thrown down. This test is deli-
cate, and will delect very small quantities of sugar.

Fermentation Test. — Mix a few drops of fresh yeast, or a
little of the dried German yeast, with the suspected urine, and
then fill a test-tube with the mixture. Put some of the urine
also into a saucer, and then invert the tube aud stjmd it up-
right in this vessel, taking care that the tube is full and free
from bubbles of air; set aside io a warm place, having a tem-
perature of about 80° Fahr., for some eight or twelve hours.
If sugar be present, it begins very shortly to undergo the vin-
ous fermentation, by which it becomes converted into carbonic
acid and alcohol ; which change will be recognised by the bub-

DISEASES OF THE KIDNET6 AND BLAODKK.

bles of carbnnio acid canstng gentle effervescence, and after-
wards collecting ill the upper part of the tube. If the arine
is free from su-rar, no pas will be formed.

Treatment — Our knowledfre of the actual nature of this dis-
ease beitif? fuulty, preat benefit cannot bo expected from the
treatment; thouph it is surpri^^ing how much improvement dia-
betics odcn manifest, for a time, from a well-conducted course
of remedies. The first point is to regulate the diet ; which
should be nutntiuu.s, and as free as pos.sible from all saccharine
or amyluceous materials. Of all kinds, animal food is the best;
and the patient may take his choice of different sorts of meat,
poultry, frame, fish, and epgs. Cabbage, cauliflower, broccoli,
spinach, water-cresses, and celery may also be allowed; but
fiuit, and espficially potatoes — which contain a large quantity
of starch — must be forbidden. Patient." would be much better
without bread; when used, care should be taken that it is well
fermented and stale, and it will be better toasted. The bran
loaf (F. 9) recommended by Dr. Camplin, ha« often very salu-
tary effects, when taken continuously; and to abstinence from
starch as it exists in ordinary bread, and the employment of
this substitute, Dr. C. believes that he owes his own life. The
thirst will be best appeased by a drink contiiining the diluted
phosphoric acid, as recommended by Dr. Paris (F. 424); or
by Bordeaux wines and Vioby water when wine is notcontra-
indieatod. Weak beef-tea, or niuttonbrolh, will also of\ea
allay thirst better than other kindsof drink. Heer, raw spirits,
and tea should be avoided ; but the latter is less injurious thau
coffee. Weak brandy and water, or claret, may sometimes be
allowed ; and in many cases the stronger wines will be needed
by the system. The clothing must be warm, the whole body
being covered with flannel or chamois leather : for cold and
dauip are especially to be avoided.

Amongst the inedieinul remedies opium is the most import-
ant, since under its use the patient is not ou)y cumlbrted, but
his symptoms are mitigated, and the specitio gravity of the
nrioe lowered ; it may be advantageously given io the form of

CANCER OF THE KIDNET.

5891

Dover's powder. The hot-vapor bath will often excite the skin
to HClion, when other means full, and thus be productive of
mnch comfort; and so also with the warm-water bath. The
Ealt tepid buth (F. 101) should be tried. The citrate of am-
monia or jiotash with steel (F. 484) often proves very valuable :
it should be taken for two or three weeks at a time, then dis-
continued, and recommenced according to the general strength.
In some cases quinine proves useful, cspeciolly when combined
with opium — one grain of each three or four times a day.
Cod-liver oil frequently does good. Creasote (F. 47) has also
been thought bcncHeial, e.'*pecia!ly by Dr. Watson, who believes
that it tends to check the conversion of the food into sugar.

Since the last edition of this work was published, M. Fiorry
has treated several cases of glucosuria by the administration
of large cjuaiitities of sugar; at the same time insuring absti-
neuce to a great extent from all fluids. The remedy is given
in the form of half a pound of treacle or honey daily, or some-
times from seven to ten ounces of the best white sugar has
been taken in the same time. Of ten cases thus treated in
this country, the sugar was injurious in six, while it seems to
have been decidedly beneSciul in four ; for io these laet the
quantity of urine secreted was lessened and its specific gravity
lowered, the fikin lost its bartih dry state^ and the palieuttt ia-
creased in weight.

VIII. CANCER OF THE KIDNEY.

Cancer is probably the rarest form of renal disease. Dr.
Walshe has collected forty cases of cancer of the kidney from
different sources. In thirty-one of these, pure cnceplialoid —
or one of its varieties — was the species of cancer observed,
while there were only five casca of scirrhus. The disease
affected both organs sixteen times, the right alone thirteen
tiroes, the left alone six. Cancerous degeneration, like many
other forms of renal disease, commences usually in the corti-

540

PISKASES OF THE KIDNEYS AND BLADDER.

cal substance, and thence extends to the medallarj cones nnd
to the walls of the pelvis and ureters.

In one case of renal cancer about which I was consulted by
Dr. Greenfaalprh, the gland was enlarged to such an extent,
that it .'■innilated in nianj respects a si)lid nvarinn tumor, and
had indeed been diagnosed as such. When I saw the patient
she was pregnant ; consequently — as only an incomplete ex-
amination could be made — no positive opinion was given,
though I was certainly inclined to regnrd the tumor as ovarian.
AAer death the right kidney was found to be the seat of dis-
ease, and was enlarged at least to the extent of two adult
heads.

Dr. Owen Rces states that the following are the chief points
to be noticed in the diai/nosis of malignant disease of the kid-
ney from calculus ; 1. In nuiligriant disease the blood is gene-
rally passed in larger rjuaiitity than in calculus of the kidney.
2. There is more freciuont tendency to nausea on tliyht orca-
tion than in calculous disease. 3, Microscopical examination
of the urine will freijuently show pus or mucus in excess, if
there be calculus; wliercas in malignant disease this sign doea
not BO frequently exist. 4. The appearance of thoee suffering
from malignant disease of the kidney is nearly always indica-
tive of a state of ansemin more or less advanced. 5. In cal-
culus, hteaiaturiu generally follows upon some unwonted exer-
tion. 6. Careful examination of the abdomen will frequently
lead to (he detection of tumor, if there be malignant di.sease
of the kidney.

If the urine be microscopically cxnmincd either in malig-
nant di.»ease of the kidney or bladder it will generally be found
to contain cancer-ceils; together with fibres of connective tis-
sue, blood-corpuscles, &c. In renal calculus the epithelium
of the pelvis of the kidney is sometimes rapidly exfoliated ;
while as these cells are of a caudate and irregular form Ihej.
are very likely to be mistaken for cancer-ceils. The general^
symptoms will, however, aid the diagnosis ; for, in advanced
renal cancer there is usually pain in one or both loins, attaok

DISEASE OF THE SUPRA-RENAL CAPSULES.

641

of nausea and vorniting ar« frequent, the malignant cacbexia
is present, and the enlarged gland can be felt.

In the treatment we can only do pood by supporting the
patient's strength, and by relieviug pain with opium or other
sedatives.

IX. DISEASE OF THE SUPEA-REITAL CAFSTILES.

The supra-renal capsules have long been objects of great
interest to the anatomist and phjsiolugist ; for, though they
probably perform some ioiportatit office in the animul economy,
yet at present that office has been but vaguely guessed at.
Hence, we must be content for the time with believing that
they serve in some way to minister to the elaboration of the
blood, in common probably with the spleen, thyoiu.'), nnd thy-
roid glands ; though the exact nature of their functions, or
the manner in which they perform them, cannot even be sur-
mised. All that we know is, that the size of the capsules
depends upon the age : since they are larger than the kidneys
in the embryo, about an equal size in very young children, and
only about the twentieth part as large in the adult.

The obscurity which surrounds these organs has not been
dispelled by the discovery of Ur. Addison, that certain exam-
ples of severe anaemia, with a peculiar discoloration of the
skin, arc due to — or at least accompanied by — disease of these
capsules.* Dr. Addison having observed that cases of anseraia
occasionally came under his care, generally terminating fatally,
and presenting certain prominent characteristics, such as pal-
lor, faintness on the least exertion, great debility, loss of appe-
tite, sickness, emaciation, and a peculiar discoloration of the
skin ; and finding that no adequate cause — as, e. g., loss of
blood, diarrhoea, chlorosis, purpura, or renal, splenic, strumous,

* On Disease of ifu Supra-Renal Captulet.
M.D., Ac. London, 18ii.

By Tbomu Addiion,

542

DISEASES OF THK KIDNEYS AND BLADDER.

or malignant disease — could be discovered, for these important
symptoms, he gradually seems to have imagined that the fault
existed in the supra-renal cap-tulea ; and the more numeroiu
the cases he examined, the stronger his convictions grew.

As in most cases of antcinia, so in the present form, the
disorder commences almost imperceptibly with symptoms of
failing health and dobility; the patient becomes languid and
weak, the pulse feeble, the appetite impiiired, the stomach
irritable, the whites of the eyes pearly, and the body ema-
ciated; while occasionally there is urgent gastric dbturbance
with vomiting, and sometimes indications of disturbed cerebral
circulation. With all or most of those symptoms, for which
no adequate cau.se can be found, Dr. Addison thought that a
gradual discoloration took place in the skin ; roost marked
usually about the fiice, neck, superior extremities, penis, scro-
tum, the flexures of the axitlro, and around the navel. The
skin, in the eases which formed the basis of the ob.servations,
was seen to be of a dingy or smoky hue, the depth of color
being variable; sometimes slightly marked, and occasionally —
as in one instance — "so universally and so deeply darkened,
that, but for the features, the patient might have been mi»>
taken for a mulatto," — fp. 5). It is worthy of remark that
the discoloration gradually appeared to increase; becoming
more marked as the other symptoms acquired greater promi-
nence, and as the disorder approached to its fatal termination.
In only one of Dr. Addison's recorded cases does the blood
seem to have been examined microscopically; on which occa-
sion a considerable excess of while corposclea — leucocyth»-
mia — was found to exist.

Since the publication of Dr. Addison's researches, cases of
rennl-capsular disease have been recorded where there has not
existed any discoloration of the skin during life. It is now
said, therefore, thut the discoloration occurs only in very
chronic cases ; while the most reniurkable symptom is the ex-
treme prostration of all muscular power. But again, it is cer-
tain that there may be the most extensive pigment-deposit ta

IRRITABILITY OF TDK BLADDER.

543

the rete mncoRnni of the skin, without the slightest trace of
disease bcin<r found after denth in tho siipni-reiiul cjipsules. A
mao died io University Culk'ite Hospital in the wiuterof 185S,
whose skin had been gmdually darkening for a few months
previously ; the " bronzed" condition being most marked on
his admission. It was supposed to be an excellent esuiuple
of morbus Addisonii ; till the scnipel and microscope proved
thnt there was no trace of disease in either cap.sule. Uluinen-
biich has quoted from Kouinrc the cane of a French peasant,
whose abdoiuen became entirely bluck durinjiench pregnancy;
while Camper mentions the case of a lady who bei^in to get
brown as soon as she became pregnant, and before the termi-
nation was as black as a negress. After delivery the color
gradually di.sappcared. I have also a patient whose skin be-
comes of a notably darker color during each menstrual period ;
though at other times it is darker than it was two years ago,
since which time she has gradually been becoming anEemic.

In the present state of our knowledge, it seems to roe that
we are not justified in accepting or rejecting Dr. Addison's
hypothesis. A large number of cases must be examined
before we can say that the association insisted upon between a
certain set of symptoms and supra-renal capsular disease has
been only accidenljil.

The Ireatmenl of this affection is particularly unsatisfactory,
almost all the examples having terminated fatally. Until our
pathology becomes more perfect, we can do little more than
attempt to remedy the prominent symptom, — prostnilion ; for
which purpose the various preparations of steel should be tried,
combined with the most nourishing kinds of food.

X. IRRITABILITY OF THE BLADDER,

Irritability of the bladder is said to exist when an indivi-
dual is troubled with a frequent desire to pass urine. It may
aritie from organic disease of the kidneys, bladder, prostate

544

DIt3EA8ES OF THE KIDNEYS AND BLADDER.

gland, or urethra; or it mnj be due to the pressure of the en-
Inrged uterus during pregnancy, or to the pressure of foreign
bodieB in the bladder, or to the irritntion of htetnorrhoids ; or
it may be — as it generally is — merely functional, i. «., depen-
dent on some temporary derunpernent of the digestive organs,
kidneys, or bladder, or on sonic constitutional nervous uffectioD.

iij/r>ij>lumi. — The desire to micturate comes on suddenly
and very fiequentlj, so that in many cases a patient has to
pass urine every thirty or forty minutes. There is gencmlly
an inability to resist the desire ; but if this can be checked,
uneasiness and pain are induced by doing so. The urine is
seldom increased in (juantily, except in hysterical subjects;
in the latter the increase is ollcn considerable, and the secre-
tion is pale and very watery, the proportion of solid constitu-
ents remaining as in health. After this alfcction has lasted
some time, the bladder often diminishes very much in size;
so that instead of being able to contain from fifteen to twenty
ounces of urine, as in health, it cannot hold more than two or
three ounces.

In all cases the urine should be examined. When it ia
found prctcrnuturally acid or alkaline; loaded with lithatee,
or pho.>^phates, or oxalates ; or when it contains pus, albumen,
sugar, or any other morbid secretion, we must trace the dis-
ease to its origin; since the irritability of the bladder is a
nicresynjptoui of some severe constitutional derangement, or of
dangerous organic disease.

Trratment. — In simple irritability of the bladder, not of
long duration, attention to regimen generally, the avoidance
of all Ktiuiulatiiig drinks, and tepid snit-water baths, will often
effect a cure. The dilute nitro-muriatic acid in decoction of
pareira bniva is very useful when the urino is alkaline or only
slightly acid ; when the secretion ia abnormally acid, small
doses of liquor potassaj in infusion of buuhu do great good (F.
95, 269). Opiate suppositories at bed-time, or five or ten
griios of the extract of henbane in a pill, will lessen the irrit»-
bility, and allow of a good night's rest.

SPASM OF THE BLADDEB.

545

Ferniginous tonics should be ordered where there is general
debility, or when the irriUtbility comes on in youiifr women at
the catamcnial periods. In n lew obstinate cases the tincture
of cantharides, with or without the tincture of the sesquichlu-
ride of iron, has relieved all the symptotus after other means
have failed.

XI. SFASH OF TH£ BLADDER.

Like other muscular organs, the bladder is subject to spaa-
mudic atUicks of pain.

Si/mploms. — The patient complains of severe pain at the
lower part of the abdomen, and along the urethra to tiie ex-
tremity of the penis. The urine may be passed involuntarily,
but generally it is retained ; there being a constant desire to
micturate without the power to do so. Frequently, also, there
is tenesmus.

When the spasm has been of long continuance, death has
resulted, with all the isyniptonis of suppre-ssion of the urine.
Id these cases the vesical extremities of the ureters have been
found spasmodii'ally closed, while the tubes themselves have
been diluted by the accutnuluted urine, the increased dilata-
tion sometimes exteuding to tlie pelvis of the kidneys. Care
must be taken not to confound spasm with infiainmation of the
bladder ; in the latter the pain is constant, lancinating, and
thrubbing; while there is also general fever, and great dis-
turbance.

Camet. — Stone in the bladder is one of the most frequent
causes of the violent paroxysms of . spasm; the malignant vesi-
cal tuuiors also produce them ; and they are not uncommon in
diseases of the rectum and uterus. Dr. Prout says that spasm
of the bladder may arise from the presence of nbnorraully acid
urine, as in gout; or from an abscess of tlie kidney ; or from
ulceration or other or(;anio diseases of the bladder, prostate
gland, &c. ; or from the use of irritating diuretics, as canthari-

40"

DISEASES OF THE KIDN'ETS AND BLADDEB.

des; from excesitive venery ; from hysteria ; and from disor-
ders of Lhe intestinal canal, e&peciully, perhap, from the irri-
tation of ascarides.

Treitlnirnt. — Two indications present themselveB — vi»., the
immediate relief of tlie spasm, and the removal of the caase.
Tlie Brs-t will be best accomplished by the hot bath, or by fo-
mentations until a bnth can be obtained, and by the adminis-
tration of a full do.=e of opium either by the mouth or by the
rectum. The removal of the cause is more difficult. Where
the patient is (;outy and the urine loaded with lilhatea, ool-
chtcuiu will do much good; and at the same time attempts
may be tuade to induce an attack of yioxit in the foot, by the
application of si napisms, or by the use of stimulating pedilavia.
In abscess of the kidney, the symptoms must be palliated as
they arise, and the strenjith kept up by mild nourishing food,
change of air, &c. When a cnleuius is present, the physician
can only give temporary relief until a surgeon takes the ocoes-
sary steps to crush or extract the stone. Supposing the spasm
to be due to sympathy with a contiguous organ the disease of
which cannot be removed, frequently repeated doses of the
tinotura ferri se-stjuichloridi often prove of great service. Cam-
phor mixed with a linsocd poultice and applied to the perineum,
is also said to be rrer[ucntly serviceable; but the quickest re-
lief will be obtained from an opiate enema.

In every case the diet is to bo retrulated. Simple nourishing
food, an avoidiince of ail stimulant,*, and a free supply of mild
mucilaginous drinks should be ordered. The patient also
ought to wear flannel neit to the skin, to protect himself from
sudden chaugcs of temperature; and should avoid all violent
exercise.

Xn. PARALYSIS OF THE BLADDER.

The muscular ooat of the bladder may become paralyzed
from some influence confined to this viseus ; or from diseue

PARALT8I8 OP THE BLADDER.

547

of the nervous centres, inducing loss of rouscnlnr power in
other parte of the body ; or from constitutioual debilitj arimng
from any cause.

Symptonu. — Unlike the rectum, the bladder retains its con-
tents when paralyzed: this phenomenon being due to some
peculiarity in the neck of the bladder not possessed by the
rectum. The sphincter vesicae consists only of pale musculiir
fibres mixed with elastic tissue placed round the nock iif the
bladder; the clastic ti.ssue modil'ying materially the action of
the muscle. "The same loss of power," says Mr. Coulson,
" which allows the escape of fajcal niiitter through the paralyzed
sphincter ani, does not affect to a similar de{;ree the sphincter
vesicae, whose elasticity inherent in the tissue itself, and not
dependent upon nervous iuflueace, retains closed the vesical
oritice when the rest of the organ is paralyzed."*

When the bladder geta over-distended, the urine dribbles
away by the urethra; the resistance to its escape at the neck
of the bluddcr being overcome when the walls are incapable
of further dilatation. Hence incontinence of urine is often a
symptom of retention ; of which fact the following is a good
illustration ; Hr. Ijawrcnce was one day sent fur to see a case of
supposed irritability uf the bladder. The medical practitioner
iu attendance stated that he had been doing all in his power
to nllay the irritability, but that his efforts were unavailing;
for the urine passed off as f|uickly \\s it entered the bladder.
On examination Mr. Lawrence felt the fundus of the bladder
forced up some way above the umbilicus : he introduced a
catheter, and hvc pints of urine were withdrawn. The fact
was that the bladder had been allowed to become distended
for about five days; and the consequence of this was that the
patient never afterwards recovered the natural power of emp-
tying this viscus.

Id must cases of panilysis of the bladder, the urine is found

• Oh Diaeattt of tht BUddv and Prottatt Gland, 6tb cdiUon, p. SB.
LoDdoo, 18&7.

54«

DISEASES OF THE KIDNEYS AND BLADDER.

loaded with mucus of a most offensive aramoniacal odor, of an
alkaline reaction, and loaded with phosphates — the ueutnil
triple phosphate of magnesia and ammonia. It is highly pro-
bable that the urine when secreted is of acid reaction ; bat on
flowing into the bladder it becomes mixed with a greater or
smaller quantity of urine which has been retained a suEBuient
time to become decomposed, and hence the fresh' secretion ia
contaujinated. In injuries of the spinal cord the vital power
of the walls uf the bladder is so lowered that the urine readily
becomes decomposed. The urea is converted into carbonate
of auimania, the ammoniacul urine inflames the vesical mucous
membrane, and the latter secretes a quantity of viscid ropy
mucus. If the pnticnt survive, the inflammation may extend
to all the coats of the bladder.

One of the earliest symptoms of paralysis of the bladder \a
pain at the neck of this viscus and in the f;laQS penis; but
after a time, little or no uneasiness is complained of, and as
the bladder loses its Bensilility even the desire to void urine
is not expcricDccd. The constitutional disturbance is usually
severe; the pulse becomes quick and feeble, the tongue furred,
the appetite fails, the nights are restless, there is great mental
depression, and the vitJi! powers become greatly lowered. Fre-
quently the patient sinks into a state of stupor, and dies from
exhaustion.

Causes. — Tlie paralysis may bo due to over-dilatation of the
muscular coat of the bladder. Thus, a person from some
cause — as being in the company of ladies, or from being shut
up in a railway carriage — is unable to micturate when he feels
the desire ; on afterwards attempting to do so, be finds that
he has lo.st the power.

It may also be a consequence of apoplexy, or of injuries to
the head, or of injuries or diseases of the spine.

It is, generally speaking, a disorder of old age, and seems
particularly to attack gouty and rheumatic persons. Not un-
commonly it is connected with disease of the neck of the

PARAtVSIH liF I'lie DLADDER.

549

bladder; or with enlargement of the middle lobe of tbe pro-
state gland.

Women who have had large families, and especially such as
have experienced severe labors, sometimes suffer from paralysis
of the neck of the bladder; so that they are either unable to
retain the urine at all, or it eoines away involuntarily on
laughinn;, coughing, or making any sudden exertion. Time,
astringent vaginal injections, cold hip-batha, and ferruginous
tonics often effect a cure.

Treatment. — Where the paralysis depends upon over-disten-
tion of the bladder, the catheter must be introduced; but care
must be taken not to withdraw the fluid too rapidly, since
rapid coilapse, followed by death, has occurred from the too
Buddcn abstraction of a large quantify of urine. When the
paralysis continues, the patient should bo taught to introduce
the catheter for himself, using as large a one as the passage
will allow; and especially should he be cautioned always to
withdraw every drop of urine, since that which is retained
may, aller a time, become decomposed, and not only contami-
nate the fresh secretion as it flows from the ureters, but also
give rise to most serious changes in the mucous and other
coats of the bladder. The instrument should be passed about
every six hours. — To restore the contractile power of the
bladder various remedies have been recommended. In recent
cases iho u.se of the catheter occasionally suffices to givetone to
the vesical walls; sometimes cold water injections — as recom-
mended by M. Civiale — are beneficial; and good results are,
in many instances, to be obtained from small doses — the one-
twelfth of a grain twice daily — of strychnine, or from the use
of the ergot of rye. Galvanism, cold douche and hip-baths,
blisters over the lower port of the spine, and aloetic purgatives,
are also remedies that may be often resorted to with advan-
tage-

When there is disease of the brain or spinal cord, we can
celdom hope to do much good beyond taking care that the

550

DISEASES OF THE KIONBTB AND BLADDER.

bladder does not become distended; at the same time attempt-
ing, as far as possible, to combat the symptoms as they arise.

Xni. IFFLAMUATION OF THE BLADDER.

Acute inflammation of the bladder is a »'verc disease, which
occurs under a variety of circumstances. Tlie morbid action
is frenerally confined to a portion of the mucous surface, the
neck and bus-fund being the parts most frequently affected ;
but in severe cases the vrholc bladder and all its coats ara
attacked. It may arise as an idiopathic affection : in the
great majority of cases, however, it supervenes on long-exist-
ing chrouic inflammation ; or it is caused by the extension of
inflammutiou from some of the pelvic viscera; or it is produced
by external violence, as by wounds, ke.; or it is due tu the
irritation of some foreign body, as a calculus.

Si/inplf>m». — The symptoms of acute cystitis are : pain over
the bladder, boat of the urethra, a constant desire to pass urine,
which is voided in very small quantities, high fever, nausea,
mental depression, and general constitutional disturbance.
The bladder can often be felt, on making pressure over the
lower part of the abdomen, as a small, rounded, tender tumor.
The pain is usually very severe, extending along the perineum
and urethra, and down the thighs; while it is much increased
by pressure upon the lower part of the abdomen, or by ex-
amining the posterior wall of the bladder through the rectum.
Moreover, it diminishes in severity directly the bladder is
emptied ; but as soon as a small quantity of urine collects, the
pain rccotiimcnces, becoming more and more severe, until the
desire to micturate is rendered so irresistible, that the patient
feels compelled to respond to it. Frequently, the irritation
extends to the rectum, and the sufferer is annoyed with
tenesmus.

Unless the progress of the inflammation be controlled in the
course of two or three days, the pain becomes unbearable, the

INFLAMMATION OF THE BLADDER.

551

calls to micturate are constant, the urine is expelled in drops,
nnd the vails of the bladder lose their power, so that an accu-
niulatinn uf urine takes place ; while, at the same time, the
constitutional disturbance rapidlj increases, great prostration
ensues, cold clammy sweats cover the body, the pulse becomes
very feeble, low muttering delirium sets in, and death relieves
the sufferings about the sovcDth or eighth day. In lcs.s violent
cases, resolution sometimes takes place, and the patient re-
covers; or the inflammation — if limited in extent — ends in
softening of the mucous membrane and ulceration, and gives
rise to much pain and disturbance subsequently.

Treatment. — The remedies mainly to be relied upon are
those which have been recommended in the inflammatory
affection.s of other organs; especially opium, hot fomentations,
and warm baths. The mildest apcricnt.'s ought to be employed
to keep the bowels open : a catheter must be used frequently
if there are any symptoms of retention of urine, but not with-
out: and the diet shouldbe very light, with only a small r|uaa-
tity of fluids. In short, our object must be to keep the bladder
as quiet as possible.

PART IX.
DISEASES OF THE SKIN.

The early writers on skin diseases seprated the study of
these aficctions from general patholofry, and thereby commit-
ted DO small amount of mischief. For medical men having
thus been led to regard these disorders as something special,
took but little pains to acquire any accurate knowledge of
tbem ; so that frum inexperience they were led to believe that
cutaneous affections were multitudinous in their nature, very
confused in their respective appearances, and particularly re-
bellious to treatment. It is only during the last few years
that more enlightened opinions have prevailed, and that prac-
titioners have found that these diseases are as easy to diagnose
and to treat as any which couie under observation.

Although the division of cutaneous affections into Orders or
Classes assists very materially to simplify their diagnosis and
management, yet the student must not always expect to find
these disorders existing in one simple form. On the contrary,
we quite as frequently find two or three in combination as not;
the coexistence of lichen and eczema, or of impetigo and eczema
being just as common as simple eczema, impetigo, &c. So
again, one source of irritation may produce a different eruption
in different individuals; as, «. g., with the Acarus Scabiei,
which may give rise to a vesicular, pustular, or papular rash,
according to some peculiarity existing in the supporter of this
parasite.

The classification which it is proposed to adopt in these

DISEASES OF THE SKIN.

553

pages, is that of Willan, considerably modified. There are cer-
tuiDly much more ambitious and extensive arrangements to be
found in our various systematic treatises; but I believe that of
Willaa to be the clearest, most simple, and to have fewer faults
than aDj proposed since its time. The classes are as follow :

Orher 1. Exaiilhemata. — Erythema; roseola; urticaria.

Order 2. T'e*iVu/<r.— Sudamina; herpes; eczema.

Orders. Bulla. — Pemphigus; rupia.

Order 4. Puftula:. — Ecthyoia ; impetigo.

Order 5. Paranilid. — Tinea tonsurans; tinea favosa; tinea
decalvans; tinea sycosis; plica polonica; chlo-
asma ; scabies.

Ohder 6. Papuliv. — Lichen ; prurigo.

Order 7. Sguamce. — Lepra; psoriasis; pityriasis; ichthyo-
eis.

Order 8. rMtercu^a.— Elephantiasis ; molluscam ; acne;
lupus; framboesia; keloid.

In attempting to cure diseases of the skin, we have to resort
to constitutional and local remedies ; the former being, as a
rule, by far the most important. Speaking penenilly, our ob-
ject must be to eliminnte from the system the morbid matter
upon which the eruption depends, and this wo can best do by
the proper use of purgatives, and often of diaj>horetic8. Tlieii
we have to try and aller the constitutional stutc which led to
the formation of the poison, and so restore the healthy tone of
the body ; a proceeding which will be best effected by the care-
ful use of such medicines as the mineral acids, the alkalies
with vegetable bittern, iodine, arsenic, phosphorus, quinine,
steel, bichloride of mercury and bark, &o. The local remedies
— amongst which are included baths — are of considerable use
in assisting the radical cure of the disease, as well as in mode-
rating irritation and pain ; while in the class of Parasitic dis-
orders they can often be alone trusted to for giving permanent
relief.

554

mSKASES op THK SKIN.

The diet may altrajB be nourishiDg and sufficient in quantity
to satisfy the patient's demands. Cocoa or chucolate, milk,
sherry and soda-WBt«r, or claret ; white fish, nintton, beef,
chicken, and ^pinie ; together with fresh vepetables, bread ond
butter, mid lij;ht suet puddings, are all unobjectionable articles
of diet. On the eoiitnirj, it will be advisable to forbid ten
and coffee, but especially the latter: as well as beer, raw spirits,
sugar, pastry, most salt meats, and indigestible fruits. The
patient ought also to avoid wearing flannel next to any of
that part of the skin whieb is affected. lie must wash with
warm sofl water, using a thick downy towel ; resorting to oat-
meal, or starch, or arrowroot, or glycerine in the place of soap
when the eraplion is at all irritable. To clean the scalp notfaing
is more cflScacious than the yolk of an egg and warm water ;
though in the piiru.silic afiections soap may oflcn be freely em-
ployed.

When the skin of a nursing woman begin.s to present any
eruption indicative of n cachectic state of constitution — e. <j.,
ecthyma, rupia, pemphigus, &c. — she ought ut once to wean
her infant; while no female with elephantiasis, lupus, or nny
one of the fypbiliiic cutaneous disorders, should be allowed to
Buckle her child for a single day.

ORDER I, EXANTHEMATA.

The oxanthcuiata consist of variously formed ^superficial
reddish pnti'hes, varying in intensity and size, disappearing
under pressure, and terminating in resolution or deaquauialioD.
They are frequently complioated with gastro-intestinol irrita-
tion or influmination, and sometimes with cerebral or pulmo-
nary diseanes. This order includes erythema, roseola, and
urticaria. By many dermatologists, erysipelas, measles, and
Rcarliitina are regarded as esanthciDntous diseases ; but such
un nmngement .seems to have imly the iiuc.itionable advantage
of making the class as comprehensive as possible.

EXANTHEMATA.

555

1. Erythema, — Er^tliem!!, TiiSaminatory blush, or Efflore-
scence cutanfe, is a non-contafjious affection ; characterized by
Blit;ht superficial red patches, irregularly circumscribed, of va-
riable forra and extent, and most frequently seen on the face,
chest, and extremities. Its duration varies from a week to a
fortnight : it is seldom preceded or accompanied by febrile
symptoma ; it causes but flight heat, and no pain ; and the
prt^nosis is always favorable. Several varieties are usually
enumerated, the chief beiiij; — erythfrna fugnx, so named from
its fleeting nature, and which is generally due to some deranpe-
nicnt of the alimentary canal. Then there is erythema ceile-
mntonum, which is developed oil the lower extremities when
they become ana.^arcous ; givin': rise to the formation of blis-
ters that burst and discharge (quantities of scrum, and causing
ulcers which may eud in mortitication when severe. Dot the
most curious species of this disorder is that known as erythema
nodoiiim ; iu which the eruption is confined to the fore part of
the leg, taking the form of one or more large oval patches run-
ning parallel to the tibia, and rising into painful protuberances,
much resembling nodes. It occurs commonly in children and
young women when badly nourished or overworked.

The treatment is very simple if the cause can be removed,
A few do8e« of some mild saline aperient ( F. 182, 186, 197);
warm water or vapor baths; liglit diet; and tonics — especially
ijuiuine, or the compound tincture of bark, or the mineral
acids — are sufficient lor the cure of most forms of this afl'eo-
li(m. Any derangements of the digestive, urinary, or uterine
i'unctions which may be present, must be remedied.

2. Boseola. — ^Thia disease (^known as Rose rash, False
measles) is a non-contagious intianimationof the skin; charac-
terized by transient patches of redness, of small size and irre-
gular form, distributed over more or less of the surface of the
body. The ernption, ut tir.st bri^-htly red, gr.idually subsides
into a deep ruseate liue, and slowly disappears. It is accom-
panied by slight fever, and it lias a duration of froin one to

556

DISKABKB OF TtlK SKIN.

Beven days. There is one form of this affection which fro-
qnentlj affects adulu, especially females, in the summer; it itt
called roseola ctstiva. Women of an irritable system, with
irregularity of the uterine irinctions, are mostly attacked ; the
disorder is preceded by chills and smart fever; when the erup-
tion appears the fauces often become affected ; while the rash
and general symptoms disappear on the fifth day.

Bat little Irratmnil is usually necessary for the cure of this
rosy eruption. Mild alteratives, laxatives, and Ionics, may in
some cases be required.

3. ITrticaria, or Hettle-rash. — This ia o non-con tngtotu
exanthcmatous eruption ; characterized by long prominent
patches or wheals, cither red or white, of irregular shape, of
uncertain durution, and accompanied by intense heat, a burn-
ing and tingling in the affected spots, nnd great itching.

There are twn varieties : one iu which the disease is acute,
running a short, rapid course ; another in which it is chronic,
very obstinate, and cither persistent or intermittent. Both
forms attack individuals of all ages and constitutions. The
chronic intermittent variety is the urticaria evanida of Willau ;
it sometimes lasts for months, or even years.

Urticaria is caused by certtiin derungenients of the di^sUve
organs, arising from the use of particular articles of diet, such
as shell-fish of different kinds, cucumbers, mushrooms, bitter
almonds; certain nicdiciiies, as turpentine and balsam of co-
paiba, &c. It is also seen occusiunally in connection with
uterine irritation; or mental anxiety, over-fatigue, rheumatism,
dentition, &c., may induce it. Patients are occasionally mot
with whose cutaneous nerves are so susceptible that slight
pressure with the finger will produce a patch of urticaria.

The treatment of acute urticaria must consist in the admi-
nistration of emetics and purgative."*, where the disease do-
peiids upon stumiicli dcrungenieiit. In the chronic form, a aim*
plo diet, without wine, beer, or spirits, must be rigidly adhered '
to; while laxatives, antacids, and warm or tepid baths, arc tho

VKSICUL*.

557

chief remedies. Strel (F. 450, 469, 484) will somelitnes
cflFc'ct a euro. The irri»alion niuy be relieved by the common
lead lotion, or by n aoliition of the bichloride of mercury (F.
329, 349), frefjuently npplicd.

ORDER II. VESICULAE.

A vesicle is a slight elevation of the epidermis, cont.iinin<;
a serous fluid — generally transparent, but ocoamoDnlly opaque
or 8cro-purulent. The fluid may become absorbed ; or it may
bo effused upon the surface, causing excoriation and small thin
incnislution.a. Vesicular eruptions arc occasionally preceded
by fever, but often appear imperceptibly; they pive rise to a
peculiar appeiirnnce, as if dmps of water had been sciittered
over the surf';ice of the skin ; they may appear upon any part
of the body; and they are not unfrwiucnlly more troublesome
to euro than would be anticipated from their apparently slight
nature. In this order we find three affection.^, — sudamina,
herpes, and ocisema. Varicella, vncciniu, and .scabies are often
also included ; but the first two may bo (nuch more appropri-
ately placed among the eruptive fevers, while the third is a
parasitic disease.

1. Sudamina. — In the profrress of many acute and chronic
diseases attended with sweating, crops of .small tran.sparent
vesicles make their appearance. Thus, in acute rheumatism,
typhoid fever, &c., sudamiua are frcr^uentiy found upon the
trunk and extremities ; especially in the latter stages of those
affections.

Some authors speak of Miliaria as a distinct fever, arising;
from constitutional causes, and differing from sudamina pro-
duced by copious sweatinpr. The distinction — if it exist — is
unimportant, since the vesicles in both cases resemble each
other, and disappear spontaneously without requiring any truut-

47»

558

DISEASES or THE SKIN.

mcnt. Miliiirj ernptions have occasionally been epidemic, and
then they have been attended with considerable danj^er.

2. Herpes. — Herpes, or tetter, is a transient non-contagi-
ous affection, consisting of clusters of vesicles upon inflamed
patches of irrfgular size and form.

Tbc eruption runs a definite course, rarely continuing for
more thuii two or three weeks; while it is not usually severe,
nor is it accompanied by any constitutional symptoms. Care
must be taken not to mistake its nature, since hrrpt* preputi-
nlit has been actively treated for syphilis, and hrrpes cireina-
lu$ — when occurring on the scalp — as tinea tonsurans, or ring-
worm. A singular species of this disease is Iierpet zoster, or
zona, or the sh lixjles, in which the inflamed patches with their
clustered vesicles are arranged in the form of a band, encircling
half the circumference of the body. Id nineteen cases oat of
twenty the tone will be found to occupy the right side of the
body.

Very little is necessary in the way of treatment beyond at-
tention to the bowels, and roguhition of the diet. The local
irritation may be relieved by the oppliciition of zinc ointment,
or the diacctatc of lead cerate of the I'hnrmacopceia.

3. Eczema. — Eczema, humid tetter, or running sc&il, is a
noD-contiigtous disease ; consisting of an eruption of small vesi-
cles on various parts of the skin, closely crowded together, and
oilen running into each other, so as to form, on being ruptured,
superficial racist excoriations. The heat and inflammation of
the affecli^d part, the irritation produced by the scabs or crusts,
and the pain of the fiery red or raw surface which results, all
tend to produce considerable fever and restlessness. There are
several species of this disease. When the eruption consists of
minute vesicles on different parts of the skin, without any
inflammation, it is called eczema timplex; when the akia
is inflamed, nnd there is heat and swelling, ecxema ruhrum.
Ek'zema inipcii'i/inode* is a severe degree of eczema rubrum.

BULLAE.

650

Whuii arising, as it sometimes docs, from great heat, especi-
ally from the heat of the sun, it is called eczema Kolare ; when
as a result of the use of mercury, eczema mercvriale. In in-
fants at the breast, and in children during dentition, this dis-
ease— eczema in/<uiti7r — is often very severe, and may extend
over the whole body ; becoming complicated with erythema,
impetigo, pityria.-is, and in fact with almost every eruption that
the skin seems liable to.

All the varieties of eczema are often obstinate, and resist the
power of medicines. Mild local applications, such as thiu gruel,
barley-wafer, or linen rags dipped in w.irm water and covered
with oiled silk, are useful. I have found glycerine, or a lotion
of glycerine and water in equal parts, very beneficial. The
carron oil (F. 327) has been recommended. The general treat-
ment must consist in the use of warm or tepid baths, saline
laxatives, slightly acidulated drinks, opiates to relieve the irri-
tation, sarsaparilla, the mineral acids, &c. In severe or chronic
eases the iodide of potJissiura, or the li(|Uor potassa; arsenitis,
should be tried (F. 27, 31, 68, 71).

In eczema infantile the child must be purged by a few doses
of calomel ; the local distress is to be relieved by the free ap-
plication of zinc ointment, or the use of Mr. Erasmus Wilson's
bcnzoated oxide of zinc ointment; and the blood is to be re-
stored to its healthy condition by the employment of Fowler's
solution (one minim may be given to an infant one month old,
thrice daily) in a little steel wine and syrup.

ORDER III. BULLAE.

As a general rule, bullas differ from vesiculie merely in being
larger; and hence it is alimiat unnecessary to separate them
into two orders. Bulla: consist of round superficial tumors or
blebs, caused by effusion of scrum beneath the epidermis; the
bladders bursting after a few days, while their contents form

5(50

DISEASES OP TDE SKIN.

thickish crusts. Pemphigus and rupia are the two eruptions
which are classed under this denomination.

1. PempMgiis. — This affection ia characterized by the ap-
pearance of hiT'^e bullii3, two ur three inches in diameter, upon
one or more regions of the body. The eruptiou b fjenerally
preceded for twenty-four or forty-eight hours by sliiirht general
indispoaitirin, fever, and itchincnf the skin ; small red circular
patches then form, gradually increase in extent, and become
covered with bulhe, which either fade away on attaining their
full M7.C, or burst, and are replaced by thin brownish -colored
iiicrustaticins. The duration of this disease is usually from one
to three weeks, although it occasionally becomes chronic and
is prnlonped for months.

Ponipholyx is nicrply a variety nf pemphigus, unattended
with fever, and running it-s course in eight or ten d.iys; it b
very nire, — A kind of artificial ponipholyx may be produced
by tlio application of cfintharido.s. I remember a young wuniun
in King's Cullege llospitiil who deceived me for a short linie
by rubbing powdered catilharidcs into various parts of her per-
son, and thus raising numerous small blisters. Particles of the
fly were detected with a lens.

Tonic and alter.itivc medicines, with generous diet and fresh
air, appear to be the remedies called for (F. 24, 31, 38f 78,
84j. In any obstinate coses arsenic will certainly effect a oare.

2. Rapia. — Rupia may be considered as a modificatioa of
pemphigus occurring in persons of debilitated constitutions,
and especially in those whose systems have been contaminated
with the poi,son of syphilis. It is characterized by the erup-
tion of small flattened bulljB, containing at first serous fluid,
which soon becomes purulent ur .«anguin<ilent, and concret«eor
dries into dark, black, rough scabs. The margins nf the sur-
rounding skin inflame, more sorum is poured out, and thus the
incrustation increases in circumference and thickness nntil it
somewhat resembles the shell of one of the mollusoa. When

pusTri,i«.

the onista fall off they leave circulur ulcere, of various sizes,
indisposed to heal, and which often only cicatrize after iho Inpse
of many weeks. The lower extremities are most frequently
affected. Its duration varies from two or three weeks to seve-
ral months.

Warm baths, generous diet, wine, bark, and other tonio
medicines, followed by change of air, will form the treatmml
to be pursued. In syphilitic rupia, iodide of potassium (F.
28, 36) will generally effect a cure.

ORDEE IV. PUSTULAE.

The pustular affections of the skin are characterized by the
formation, between the cuticle and cutis vera, of small tumors
containing purulent fluid, called pustules. The pustules are
sometimes scattered irrcpularly, sometimes united into eluHters;
they are succeeded by scabs, and frci|Uontly by permanent cica-
trices. The diseases of this class are — ecthyma and impetigo.
Small-pox is often ranged with the pustular dii^eases.

1. Ecthyma. — Ecthyma is an acute inflammation of the
skin ; characterized by large, round, prominent pustules, oc-
curring upon any part of the body. Tlie pustules are usually
distinct, seated upon a hard inflamed ba.sc, and terminate in
thick dark-colored scabs. The latter leave superficial ulcers,
followed by cicatrices. Ecthyma will often occur spontane-
ously; or it may result from some irritant applied to the skin.
Thus it is easily produced by croton-oil liniment, or by tartar-
emetic ointment. When arising without any apparent cause,
young persons appear to be nio.it obnoxious to it, especially in
the spring and summer. The eruption may bo very partial, or
it may almost cover the body, and it may continue troublesome
for some weeks.

The IrealmenI must oonsist in the use of gentle laxatives,
with alteratives, slightly acid drinks, and spare diet. Water-

562

DISEASES OF THE SKIN.

dres^injn;, or the lotio plurabi, or the angaentnm zinci, msj be

applied to the pustules.

2. Impetigo. — Impetigo is a severe Don-contagious inflam-
nintion of the skio; chiiracterized by an eruption of small
hoint!<pheroidal or flattened pustules, most frecjuentlj grouped
in clusters, and forming thick, rough, yellowish scabs or in-
crustations. From beneath the incrustations a discharge
takes place ; the crusts become thicker and larger ; and fall
off, leaving a raw surface. The mode of distribution of the
pustules has caused a divigii.m of the disease into two varie-
ties,— impftliji) figurata and impntiyoipiina. The 6r8t occurs
generally on the face, especially on the cheeks; it is attended
with constitutional Jiaturbiince; and as the pustules burst and
form scabs, the heat and itching become intolerable. Id chil-
dren, the inipetif;inous eruption sometimes covers the face like
a mask, and is called cruxta lactea. The second form merely
differs from the first, inasmuch as the pustules are more scat-
tered, being sometimes distributed over an entire limb, or
even over the whole body.

When there is much inflammatory action, the patient ought
to be kept very quiet, on a liglit diet, and with a free supply
of diluents. The bowcl.s must be acted upon by saline purga-
tives. The best local applications are lotions containing the
oxide of zinc, or hydrocyanic acid (F. 324, 3:?2, 342, 353);
dusting the affected part with the o.\ide of zinc is otlcn very
useful. Vapor or warm water baths arc always beneficial.
The constitutional treatment muxt con.sist in attention to diet,
mild laxatives, alkalies, and tonics (F. 94, 97, 99, 438, 450,
47G, 484, 490, &c ).

ORDER V. PARA8ITICI.

The order Parasitici must be divided into two groups; ac-
cording as the parasite belongs to the vegetable or animal king-

PARASmCT.

563

dom. Thf cutaneous aflections dependine; on a parasitic plant
are — Tinea totisuranp, Tinea favosa, Tinea decnlvans, Tinea
sycosig, Plica Pokmica, and CliluaBnia; while the disease pro-
duced by a parasitic insect is Scabies. All are contagious.

1. Tinea Tonstiraiis. — This is a chronic contagions disease,
known by the decnldrixalion and brittleness of the affected
hairs, the scaly eruption, and the roundness of the diseased
patches. It is called pnrrigo scutulatu by liuteman and Wil-
lan, herpes tonsurans by Ilebra, herpes circinatus by Erich-
sen, trichosis furfuracea by Erasmus Wil.son, and vulgarly
ringworm. The parasite is the Tricophylon toniuran$, the
spores of which infiltrate the texture nf each hair.

Ringworm occurs not only on tbe scalp but on other parts
of the body, as the neck, trunk, &o. In children it affects
the scalp ; in young adults it attacks the general surfnce. It
is a local disease juat as scabies is. Mr. Enisinu.s Wilson
maintains that ringwonu is a constitutional affection due to
poverty of blood, that it is not contagious, that there is no
veget.ablc growth within the substance of the hair, and that it
is one of the most friTjuent of the diseases affecting the sculp;
on all of which (loint.s, 1 believe, be is at variance with almost
every physician who has had favorable opportunities of watch-
ing this disease.

2. Tinea Favosa. — A parasitic disease which most com-
monly affects the scalp, in the form of small cup-shaped, dry,
yellow crusts, each containing a Imir in its centre, and some-
what resembling a piece of honeycomb. In cases of long
standing, the disease will be found on parts of the trunk as
well as on the scalp, inoculation with the spores having taken
place. The synonymes for this disease are honeycomb ring-
worm, favus, tinea lupinosa, and porrigo favosa. The crypto-
ganiic pnra.site ciiuBing it is the A</ioriuH Sc/ionlrivit.

3. Tinea Becalvans. — The third variety of these diseasen is

564

DISEASES OF TUE SKIN.

easily diagnosed. The hair falls off one or more circular or
oval spots ; leaving perfectly smooth bald pjitches, which rary
in size, sonietiiues extending over the entire sculp. This
affection is usually known as porrigo decalvans, or alopecia
circumscripta. The parasitic fungus ia the Mkrotporon Au-
douini.

4. Tinea SyoosiB. — The last species of tinea is obaraoter-
iiscd by inflaiumatioQ of the iiuir-fuUicles, causing successive
eruptions of siuall acuminated pustules. It b met with most
frequently upon the chin and other parts occupied by the
beard ; it seldum occurs on the scalp, and rarely affects women.
It is called menlagra by Willan and Bateman, and sycosis by
Cazenave. The parasite is the Microsporon menlayrophjftc*.

Treatpient. — This is the same in all the varieties of tinea ;
and consists in attention to cleanliness, removal of the hairs
with the scissors or extraction of them by the forceps (epila-
tion), separation of scabs or incrustatioDS by poultices, improve- I
ment of the general health, and the destruction of the parasi-
tic phint. By the latter proceeding, the disease will in all
cases be cured. It may be effected by the application of bqI-
phurouii aciil lotion (F. 3.30) ; or by the use of creasotc ointment.
Ill ringworm, the strong acetic acid is a good application.

8. Plica Polonica. — Plica Poloiiica, or trichoeis plica, ia
little kniiwn in this country; but it is probable that this Po-
lish di.scase is somewhat analogous to our ringworm. It ia
chamcterized by tenderness and infliimnmtion of the scalp;
the hairs become swollen and imperfectly formed; and the
buir-follicles secrete a large quantity of viscid rcddish-noloredj
fluid, which glues the hairs together, uniting them into n msfli,l
It is caused by two parasitic plants — the TrithojihjfloH
turaiiK and Trichophyton itporuloiile$. As regards the treat-
ment of this disease little is known, but it is usually recom-
mended that the diseased hairs should not be cut. I should
be strongly inclined to advise gentle douches of warm-water

PARABITICI.

565

dally ; great cleanliness ; with the constant use of the sulphu-
rous acid lotion, so bencGcial in analogous diseases.

6. Chloasma. — Chloasma, pityriasis versicolor, or liver-
spot, makes its appearance generally on the front of the chest
or abdomen, in the form of small spots of a dull reddish color,
which gradually increase in size, and assume a yellow tint. It
may last from a few days to many months or years. It is con-
tagious. According to Eichstedt, this disease is caused by a
cryptogamic plant,- — the Microtporon furfur. It may be
cured by the use of the sulphurous acid lotion ; or by the lini-
ment of bichloride of mercury in water (gr. ij to 5J), applied
night and morning. Mr. Startin considers that it is apt to
return, if an arsenical course be omitted ; hence in obstinate
cases this remedy may be resorted to (P. G8, 7'2). I have,
however, cured many cases by the mercurial liniment alone,
continuing its use for a short time ofler the disappearance of
the eruption.

7. Scabies. — Scabies, or psora, or the itch, is a troublesome
disease, attended with great itching, the irritation being in-
creased by warmth. It commences aa a vesicular eruption ; the
vesicles becoming raptured, and excoriations being produced by
the scratching with the nails which is being constantly resorted
to. This affection may attack every part of the body, though
it most frequently occurs io the flexures of the joints, espe-
cially on the fingers. It is often stated that scabies is never
seen on the face; but this opinion is probably incorrect, for I
am told that at the Hospital for Skin Discuses coses of its
occurrence in this region are not uncommon.

The cause of the disease is an insect called the Acarut
Kabiei, which is to be found about a line from, but not in,
each vesicle. It must be killed by the free application of the
simple sulphur ointment, or the use of sulphur baths; and
thus this loathsome affection will be cured. The contaminated
clothes should be afterwards destroyed; or if it is desirable to

566

OI8BA8K8 OF THE SKIR.

keep them, thej must be well fumigated with salpburous acid
gns, which may be procured bj igniting a mg dipped in melted
sulphur.

ORDER VI. PAPTTIAE.

A papula or pimple is a small, solid, acuminated elevation
of the cuticle, resembling an enlarged papilla of the skin,
generally tcrrainating io resolution or in slight dcs<juamation,
but sometimes in ulceration of its summit. Papular eruptions
arc usually preceded by itching; they are rarely accompanied
by fever; arc slowly formed; are not contagious; may be de-
veloped on any part of the body; and they vary in their dura-
tion from a week to several mouths. Lichen and prurigo are
the diseases of this class.

1. Lichen. — This is a papular afTection readily recognixed
by the minute, hard, red elevations of the akin which it pre-
sents, together with the annoying pruritus. There are three
forms :

Lichen timplex, in which the eruption consists of small
agglomerated papulae, rarely larger than a millet seed.

Lichen tlmphulus, or red-gum, tooth-rash, &o., which gene-
rally attacks infants at the breast, and is characterized by ao
cniplion of minute, hard, sometimes slightly red pimples,
attended with itclili)g, and appearing upon part or the whole
surface of the body.

And Lit:hrn agriuf, in which the pnpulas are more inflamed,
and developed on an erythematous surface, which appears hot
and painfully distondcd. In a short time the inBammation
diminishes, and the papula; become covered with a furfura-
ceous desquamation ; or their points are scratched off, the skin
around them becomes fissured into deep and painful cracks,
and a soro-purulcnt fluid exudes, forming thin, scily crusts.
The itching, tingling, and smarting is often very intense;
there is usually fever, nausea, headache, rigors, and other

PAVVLX.

BVtnptoDig of constitational di.sturbancc; and though in mild
cases the symptoms may subside and the eruption die away in
about fourteen days, yet in severe varieties the diHease is fre-
quontlj prolonged for several months.

The cniptiou in lichen agrius is oilen partial; being most
common on the hands and arms, the groins and legs, the chest,
&o. On the hands it constitutes the baker's, washerwoman's,
grocer's, and bricklayer's itch.

The treatment is simple ; for tepid baths, mild laxatives, an
unstimulating diet, and acidulous drinks, will euro most forms
of lichen. The irritation will be best relieved by a weak lo-
tion of the liquor pluwbi diacetatis, to which a little hydro-
cyanic acid may be added ; or by a lotion consisting of two
ounces of glycerine, sis grains of bichloride of mercury, twenty
or thirty drops of chloroform, and six onuces of water.

2. Prorig'O. — Prurigo — itching — is a cutaneous disease
characterized by an eruption of small papuiao or pimples, of
the natural color of the skin. It is a chronic affection, lasting
for months or years, and causing great discomfort, not to say
misery. Patients afflicted with it scratch and tear themselves
constjintly til! the blood flows, their sufferings being aggravated
by warmth. Willan describes three varieties: pruriyo milit,
pritrii/o formk-aitt, and pruriyo neniHt. The first is the
mildest form; in the second, the itching is combined with a
scDsution like the creeping of ants or the stinging of insects;
while the third occui% in old persons, and is the most obsti-
nate, often continuing for the rest of the patient's iife.

Diagnonh. — The itching arising from prurigo must not be
confounded with that caused by insects. I may here men-
tion that the human body is infested with four kinds of lice,
viis., the Pediculus venlimciili, or rlolka hjtin' ; the Pidicului
capitis, or Iieail loune, whicii lives in the hair; the Ptdiculum
corporis, which is larger and flatter than the head louse, and
which adheres to the smooth parts of the body ; and the Pn/i-
culm pubi*, or crab lonae, wliicli infests the hair of the pubes.

568

DISEASES or TBB StUK.

Thej are all destroyed bj mercnrial ointment, or bj dvtin^
the part« with calomel, or by washing them with a strong io-
fiision of tobacco.

In some Tery rare instances there appears to be a constito-
tional condition faTorin<; the development of pediculi; and the
statements of old authors, " that divers persons hare come to
their ends, being devoured by lice," are not so very improbuble.
Dr. Whitehead relates an instance, which I shall here abbre-
viate, in confirmation of this statement:* R. S. set. forty-
three, a farmer, strong, of sanguine complexion, contracted a
virulent form of syphilis in April, 1840, for which he was
chiefly treated with ioduretted sarsaparilla. Seven months
afterwards he suffered severely from secondary symptoms;
when he was placed on a course of mercurial medicine and
was salivated, with great relief to his disease. At the end of
1841 he again sought advice, stating that for several weeks
past he had been annoyed by the presence of lice about his
person, chiefly on the trunk; he was scrupulously clean in his
habits, and had never before been troubled with these vermin.
None were found about the head : what little hair he had was
clean, fine, and silky. The vermin no increased in number,
and produced such mental distress, that fears began to be
entertained for the integrity of his intellect. On ctaniining
his skin, a multitude of irritable-looking points were detected
on the front and sides of the chest, from which the nits could
be detached by lateral pressure. At this period the genen-
tion of them was so considerable, that the flannel vest put on
clean in the morning whs crowded with them by the end of
twenty-four hours. For some time remedies were unavailing:
sulphur, oxymariate of mercury, white precipitate, and belle-
bore were freely tried with little or only temporary benefit.
At length, by mere chance, a mixture of iodide of potasaium'

• On tK» Tratunimion from ParfHl lo Offipring of MOM Ftrmt ^
Diieatr, aiul nf Morbid Tainti and TehdeHcitt, Mcood edition, p. ITS.
London, 1857.

SQUAMA.

569

and pmssic acid in full doses was given; and in a few da^B,
after taking sixteen or eighteen doeea, the onre was pcrma-

nentlj/ cumpleted.

TVealmetit. — ^lo attempting; the cure of prurigo, alkaline,
sulphur, coniura, orcasoto (P. 155, 15G, 157, 159), or even
plain water baths, should be used daily; the temperature ought
not to exceed 70° Fahr. The local applications which give
the most relief are vinepar, liuie-water, a weak solution of
bichloride of mercury, a dilute solution of crcasote, a lotion
containing prussio acid, an ointment containing a small quan-
tity of aconitina, tar ointment, &c.

The general treatment must consist in the use of a light and
cooling regimen; the avoidance of stimulating food or drink;
and the employment of laxatives, sarsapurillu, acid tonics, and
even the liquor potassas arsenitis (F. 30, 56, 175, 185, 484,
490, kc).

Dr. Howling, of Kentucky, says, in a letter to Dr. Watson,
that he has cured numerous cases of obstinate prurigo senilis
thus: " I direct that the affected part.s be sponged for a minute
or 80 with good apple vinegar, and then be allowed time to dry.
After this they are to be nmeared over with citrine ointment
(uniinfntumhi/f1raT(j!/ri nilralix). Tlie applications are to be
made twice a day. The cure is usually effected in a week."

ORDER VII. SQUAMAE.

The term squamae is applied to the scales of degenerated,
thickened, dry epidermis which cover minute papular eleva-
tions of the skin ; these scales or particles of scurf being readily
detached, though they are reproduced by successive desquama-
tions for a long time. The scales or scurf are the result of a
morbid secretion of the epidermis. Their formation gives rise
to but slight constitutional disturbance, and to mere local heat
and itching; while none of the squamous diseases are conta-
gious, though they are very chronic in their duration. T.iepra,

48*

570

DISEASES OF TQE SKIN.

psoriast!!, pityriasis, and ichthyosis are the disorders included
in this order.

1. Lepra. — Lepra, or lepra vulgaris, is perhaps the most
obstinate and troublesome of aU curable outanoous disoases.
It is a non-contagiuus chronic eruption ; consisting of red,
scaly, circular patches, of various dimensions, scattered over
different parts of the body, but more frequently found in the
neifrhborhoud of the juints, especially near the knee and elbow.
By dcfrrces the putches increase in size and number, and ex-
tend aloni; the extreiuitics to the trunk.

When the patches are small, white, and of long standing,
the disease is termed kpra alphoidet ; when copper-oolored,
and the result of syphilis, fyphilitic lepra.

In the treutviftil, all local npplications, with the exception of
alkaline baths, or the simple warm bath, are useless. Liquor
po1aR.srt3, in half-drachm or drachm doses, thrice daily, is often
bonetieial ; or the liijuor potassae arsenitis, or the triple com-
pound of iodine, arsenic, and mercury, known as Donovan's
solution (F. G7, 70, 72, 73), may be cautiously given with the
greatest advantage. Where tbe.se remedies fail, the decoction
of dulcamara, or decoction of sarsaparilla and bichloride of
mercury, tar capsules, tincture of cantharides, or the iodide of
potassium, may be tried. Mercury will generally cure the
syphilitic form. The Ilarrowgate waters have been recom-
mended. At the same time, the diet must be very simple,
and all stimulating food or drink avoided. During an arseni-
cal coarse, acids, fruits, and most vegetables should bo ab-
stained from.

2. FsoriaBis, — Psoriasis, psora leprosn, or dry tett«r, u a '
chronic noii-cuiiUL'ious inflammation of the derma; character*
ited by the (Icvolopment of patches of various extent and form,
which arc slightly raised above the level of the skin, covered
by thin whitish scales of altered epiderma, and accompanied
by rhagades or fissures of the skin. The eruption msj be

SQUAMA.

571

local, or it may be difTuscd over the whole body. The local
vnrieties consist of — psoriasis palpcbrnrum, psuriusis lubiulis,
psoriasis preputialis, psoriasis scrwtaiis, psoriasis pulmaris, and
psoriasis nn^uinuni. The general varieties are — psoriasis yul-
garis, psoriasis pymta, and psoriasis invcrata.

Psoriasis is closely allied to lepra in its appearance and
genera] pathology ; in the former disease, the pntches are
irre{!;ular, and not depressed in the centre; in the latter, they
are circular, and depressed in the centre, with elevated mar-
gins. Biith nifeciions arc somotinies hereditary, and both re-
quire the same treatment.

3. Pityriasis. — Pityriasis, or dandruff, is a chronic inflam-
mation of the skin, attended with redness and itching, and
characterized by the production of minute white scales or scurf
in great quantity. It may attack any region, but the scalp
and parts covered with hair we the most common seats of it.
The desquamation takes place copiously and incessantly. It
is often very rebellious to treatment, and may be prolonged for
months; in which cases it gives rise to much annoyance, with
slight constitutional disturbance.

Some tonic infusion, an occasional purgative, and the use
of sedative or alkaline lotions to the affected part, are the
measures to be employed. Occasionally the ungueiitum hy-
drargyri nitratis mitiua does much good, applied daily. Gly-
cerine is an excellent local palliative, When the head is the
part affected, the hair should he cutoff close to the scalp, with
a pair of scissors. Great cleanliaess is, of course, essential.

4. Ichthyosis. — Ichthyusis, the fish-skin disease, is charac-
terized by the development, upon one or more parts of the
integuments, of thick, hard, dry, iuibrieatod scales of a dirty
gray color; these scales resting upon an uuinflamed surface.
It is unattended by heat, pain, or itching. The scales, or
shagrecQ-liko flakes, when shed have souietiuiens been found

672

DISEASES OP THE SKIN.

to lucasure threc-quart«r8 of an inch in thickness. Ichthjacwi
is 8aid to be a congenital disease, and to last during life.

Simple warm and alkaline baths may be employed ns pallio-
tives ; no other /rea/mcnt seems to be of any use. Donovan's
triple solution (F. 67) might be tried.

ORDEE VTII. TUBERCXTLA.

The diseases belonging to this order — Elephantiasis, mollus-
cum, acne, lupuR, framboj-sia, and keloid — are characterised
by the formation of small hard tumors or tubercles, more or
less prominent, circumi^cribcd in form, and persistent. The
tutiinrs may become ulcerated at the summit, or they may
terminate in suppuration. Tubercular diseases are slowly
developed, are very chronic, are almost peculiar to tropical
regions, and their symptoms ar« so characteristic thai thuir
diagnosis is easy.

1. Elephantiasis. — There are two species of this disease ;
viz., Elephantiasis Gncoorum, and Elephantiasis Arabicum.

Etfphantiatis Grcrrorvm is a terrible and dangerous dis-
ease; noncontagious, hereditary, and generally incumblc. It
is characterized by the appearance of patches of a purplish
color J which are succeeded by elevated tumors, having the
same lint, being irregular in sh.ipe and size, soft, smooth and
insensible to the touch, and which generally — after a certain
time — become the seat of unhealthy ulceration. It is not met
with in temperate climates ; but there i.s found to be disposi-
tion to it as we approach the polar regions on the one hand,
and the tropics on the other. Males suffer from it more than
females. It is designated by the Jews luarnnlh.

I-]/rph<inlunis Arahinim is characterized by great swelling
and induration of the skin and of the subjacent areolar and
adipose tissues, producing marked deformity. It frequently
attacks the lower extremities, causing swelling so great ihnt

TtTBEUCTJLA.

578

the limb becomes double ita natural size. There is also hard-
ness, severe pain, thickening, and an appearance resembling —
it is fancifully said — the log of an elepliant. It is uncuninjon
in Europe, occurring principally in the West Indies. Ele-
phantiasis generally continues for life ; it causes alarming con-
stitutional disturbance, is neither contagious nor hereditary,
and attacks males and females, rich and poor, indiscriminately.

2. MoUnscQin. — This affection — bo called from the simi-
larity of the tubercles characterizing it to the eminences grow-

% ing on the bark of the maple tree — consists in the presence of
small tumors ; these varying in size from a pea to a pigeon's
egg, being occasionally of a brown color, while sometimes they
are found growing from a broad base, and sometimes from a
narrow peduncle. There are two forms, one contagious, the
other not. Oontagious niolluscum is a very rare, severe, and
chronic affection : Bateman saw two ciises only. Non-conta-
gious niolluscum is less severe, and does not produce so muoh
irritation as the opposite kind ; while after a time the tumors
neither grow nor alter, but remain stationary for life.

3. Acne. — Acne, or gutta rosacea, or copper-nose, is a chronic
pu.stular affection ; characterized by small pustules with deep
red bases. These pustules, after suppurating and bursting,
leave behind them small hard red tumors, the seat of which
appears to be the sebaceous follicles of the skin.

Willati describes three varieties of this disease, — acne sim-
plex, acne indurata, and acne rosacea; the eharaeteristio dis-
tinctions of which are indicated by their names. Aone sim-
plex and acne iudurata arc most common about the period of
puberty, appear on the forehead or sides of the cheeks, are
very protracted in their duration, and often leave indelible
cicatrices. Acne rosacea attacks the nose, is often connected
with some stomach or liver disease, and is mostly seen in per-
sons of advanced years, especially if they have been hons vi-
vantt, &c. In the treatmeiU of all the forms, the diet must

6T4

DISEASES OP THE BKI».

be restricted, stimulants of all kinds abstained from, aod mild
laxatives occasional! j employed. The iodide of salptiar oint-
ment sometimes does good ia acne indurata; and so does
warm bathing.

4. LnpoB. — Lupus is a most formidable affection. Dr. Bur-
gess, in his excellent translation of Cazenave, says that it com-
mences with purple and red spots, or more frequently livid
indolent tubercles, the chief character of which is their ten-
dency to end in destructive ulceration of the surrounding parts.
There arc two varieties of this disease, lupiu nan txeilent, and ^
lupiu exedem — or noli me tangere. In the ^r$t there ia no
ulceration, yet the tubercles leave deep cicatrized pits behind
them ; when it spreads rapidly and superficially, the skin is
left crossed by white scar-like ridges and bands. The teamd
is very destructive ; it attacks the nose more frequently than
any other region of the body, though why it does so is un-
known. The extent of parts which it destroys varies ; some-
tiaies the whole nose being eaten away, somedmes only the
point.

A prolonged course of the liquor hydriodatis arsenici et hy-
drargyn, or of the liquor potassie arsenitis, or of the bromide
of mercury, or of iodide of potassium in decoction of saraa-
parilla, is necessary in both varieties (F. 25, 34, 36, 67, TO,
75, 77). At the same time, cod-liver oil and a very nourish-
ing diet ought to be given.

As a local remedy in lupus non exedcus, Mr. Wilson recom-
mends the occasional sppliaition of the acetum canthnridis,
made with strong acetic acid. In lupus exeJens, chloride of
zinc, or potassa fusa, or nitric acid, may perhaps be used to
destroy the ulcerated surface, and to excite the capillaries to
a more healthy action.

5. Framboesia. — Fnnnbocsia, or pinn, or yaws, is a disorder
rarely iiict with in Huropo, but is (.'oiiimon in Africa, Amerioa,
nod the Wt5st Indies. Without any precursory symptoms.

THBERCtJ LA-

STS

parts of the skin — especially about the face, scalp, axillae, or
genital organs — are found covered with small Juskjr-red spots,
which gradually become converted into larger tubercles, iso-
lated at their summits but collected together at their bases,
and often resembling raspberries or mulberries in their color
and form. The tubercles are generally hard, covered with
dry scales, and are sometimes inflamed. If the iufiamniBtion
spreads, ulceration sooa sets in, and a yellow sanioas discharge
results, which forms scabs around the tumors. The disease
continues for years, or even for life.

6. Keloid. — Keloid, cheloidea, or cancroide, was first de-
scribed by Alibert under the above names; owing to the dis-
ease presenting a flattish raised patch of integument resembling
the shell of a tortoise. This aifcclion forms small, flat, painful
tumors, one or more inches in diameter, raised a few lines
above the level of the skin, having irregular forms with slight
depressions in their centres, and being covered with wrinkled
epidermis. Sometimes the excrescence resembles a cicatrix
left by a burn ; white, though soft on the surface, it commu-
nicates a sense of density and resistance on pressure. There
may be only one tumor, while occasionally there are several.
The disease is developed slowly, rarely ends in ulceration,
sometimes disappears spontaneously merely leaving a cicatrix,
is usually found on the chest between the mamraie, and is very
uncommon. It has no analogy with cancer. Arsenic (F, 68,
72, 73) seems to be the only remedy which exerts any bene-
ficial eifect upon it.

PART X.
DISEASES OF THE EYE.

I. MPAIEED VISION.

The conditions to be noticed in this section are of much
importance, for, though thej may be unattended with anj
diaease of the delicate structures of the eye, yet they often
give rise to much annoynacc and anxiety. Before speaking
of them, however, I would draw attention to one affection,
which is frequently a source of very unnecessary disquietude
— viz., the floating specks known as mutca; iv/litanlrit. Ac-
cording to Mackenzie, the muscsD are the effect of shadows
thrown on the retina by minute bodies moving close in front
of it. They are mostly of no consequence ; and, though
doubtless sometimes the forerunners of serious disease, yet
generally they are quite compatible with enduring good sight.
These floatiny fdameiUi must not be confounded with the_^x«l
$pf)tt tnet with in disease. The latter are always of great sig-
nificance, since they arc caused by i-solated patches of the
retina being insensible to light — a condition which osnallj
precedes more serious and extensive loss of power.

1. Myopia. — When the distance at which ordinary type
can be easiily read is much less than twelve inches, the visioD
is said to be myopic. Myopia, or near or short sight, most
frequently arises from too great a convexity of the cornea,
or of the crystalline lens, or both. An undue density of any

IMPArRED VISION.

577

or of all the refractive media maj also cause it. The raya of
light from objects at the usual distance are brought to a focus
before they reach the retina, iiisteud of being concentrated
upon it. Myopia is usually congenital ; it may, however, be
gradually or even suddenly induced. It occurs most frequently
ID the hijiher ranks of life. In confirmed cases, double con-
cave glasses or spectacles must be worn ; single eye-glasses are
bad. The greater the degree of sliort-si<rhtedness, the greater
must be the concavity of the plnsses. The gla.sses had better
not be worn eonstnntly, but only when especially required.

In many cases of short-sightedness the iris is either proter-
natunilly contracted, or it possesses an unusual degree of irri-
tability. This occurs especially in individual.^ of a very ner-
vous temperament Exposure to a bright light aggravates
this condition. Snow-blindness is chiefly due to it; consisting,
in a great measure, of excessive contraction of the pupil.
Agents which cause dilatation of the iris — us belladonna — give
relief.

2. Presbyopia. — One of the earliest indications of advan-
cing years is an alteration in the refractive powers of the eyes,
producing presbyopia, or long-sightedness. Mr. White Cooper
enumerates the following structural changes in the eye as
giving rise to this state: I. A flattening of the cornea, from
a diminution in the bulk cither of the aqueous or vitreous
humors, or of both, the result of defective eecretion. 2. An
alteration in the consistence and diminufinn in the convexity
of the crystalline lens. 3. Diminished density of the various
humors. 4. Diminished curvature of the retina, which —
existing while the vertical diameter of the globe remains about
the same — prevents the refracted rays that enter the flattened
cornea from forming a picture upon the retina. Whichever
of these changes may exist, the effect is to cause the converg-
ing rays of light to bo brought to a focus at a point beyond
the retina, and so to produce an imperfect and confused pic-
ture. Distant objects, however, are still seen di?tinctly, since

Tm m.

tW imtaAffity or iW

the

S. Asthenopia. — Awthfitwpk, ot wetkaeas of Twoa, is a
comnoa afleetioa ; opeciallj anwep die poor and iU-fed work-
people of Urge cttiea, wIm lead tedenlarj Kree. Ckildrra who
an eooined too cloaelj to tkeir booka also suffer from it. The
Rofferer u able to read di&tiiictlj or to work for a short time,
but at the end of au hoor, or eren sooner, the vision becomes
confuHcd, the words run into each other, musc^ volilaotes ai«
perceived, and the ejes ache or get very tired. If the cyca
be rented for a time, then the patient can ;;o on again, until
the inmc Kymptotns recur. The Irntlmmt is Bucb as cotnmoa
a*DW dictate* : that is to f>nj, tonics, good nourishing food,
relaxalion from toil, bathing the ejes with cold water, and
flXoroiM in the open air.

4. Color SUndness. — The inabilitj to discriniinRto between
certain colors (^t'hromalo ptetiilopni'i, Wilson, ^/rl/tK-Aromoty,
Dixon ) is a defect which is quite compatible with perfect Tision
in uthur reHpccts.

It hns been shown b; Dr. 0. Wilson that color-blindness
may exist in thrrc forms: 1. Innbilily to discern anj color,
properly »o culled, so (hat black and while — i. e., lijjht and
•bade, arc the only variations of tint perceived. '2. Inabilitjp

INFLAMMATION OP TlIK CONJUNCTIVA.

579

to discriminate between the nicer shades of the more compo-
fiitc colors, as browns, prays, and neutral tints. 3. Inability
to diBtingnish between the primary colors, red, blue, and yel-
low, or between these and the secondary and tertiary colors,
such as fcrecn, purjile, orange, and brown.

The deVect u{ion which the false perception of colors is due,
consists probably of some peculiar organization of the retina
and that part of the brnin which is essential to vision. It is
generally coiijienital, but ca.ses are known where it has been
induced by disease or injury; and it is incurable. Care should
be taken that railway servants are not afflicted with color-
blindness, since the mistake in tbe nature of a signal might
lead to a serious accident.

11. INFLAMMATION OF THE CONJUNCTIVA.

Conjunctivitia, or inflammation of tbe mucous membrane of
the eye, or ophthalniia, is a common affection. Some authors
divide the uphthaluiiic into several classes; but for all practical
purposes it will suffice for the surgeon to remember the varie-
ties to bo presently mentioned.

During violent Hts of coughing, vomiting, &c., blood some-
times gets extravasiatod beneath the conjunctiva, owing to the
rupture of a small vessel. Whether the patch of ecrhi/moii't
be small, or so abundant as almoift to conceal the sclerotic, ab-
sorption soon takes place. If the piitient be ansious for some
iipplicution, a piece of linen dipped in cold water containing a
few drops of tincture of arnica, may be laid over the eye.

Kffusion of serum iiitd tlic areolar ti.s.suc between the eon-
junctiva and sclerotic is called chrmusi't. When the oedema
is abundant, the conjunctiva becomes quite elevated, so that
the cornea looks as if it were sunk in a deep depression. The
swelling subsides as the dii^ease which causes the pressure on
tbe conjunctival veins disappears.

5R0

DI8EASKS or THE ETK.

1. Catarrhal Ophthalmia. — This affection is a mild form
of iDfiaintiiution of the coiijutictivn und Meibomian ri)lliole<;
and is the most common of nil diseases of the eye, being
caused by exposure (o cold and wet, vicissitudes of tcinpeni-
tore, &c. The pain in catarrhal or simple ophthalmia is slight;
the patient cciiiplaiuing most of Btilfncss and dryness, aod of
a feeling of pricking or roughness of the eye, na if sand or
broken glass was under the upper eyelid. This sensation is
caused by the ruhbinfr of the sensitive eyelids over the enlarged
vessels of the sclerotic conjunctiva. These vessels are seen to
be of a bright scarlet color, and irregularly arranged; differing
thus from the appearance of the ves.scls in sclerotitis, in which
they ore of a pink huCj and disposied straight and regularly,
like radii in a circle. The natural secretion from the con-
junctiva and Meibomian follicles is increased in quantity, and
oflen becomes piirit'orni.

Catarrhal oplilhuliuia yields readily to simple treatment;
and often terminates favorably, without the employment of
any remedies at all. At the outset, the patient may be purged
with calomel and jiilap, or with a do.se or two of some milder
aperient (F. 178). If the general health be bad, stimulants or
tonics will bo needed, with beer or wine, and meat; if the
patient be plethoric, the purgatives should be continued for
two or three days, while the diet is restricted. The affected
eye can be rested by wearing a shade over it, while it will give
relief to batho it several times in the day with warm water.
Astringent applications aro rarely needed; but occasionally
the ose of a drop or two of the vinum opii or of a solution of
nitrate of silver {gr. ij to 5J) may cut short an attack. When
the discharge is abundant, the edges of the eyelids should bo
well smcjired with some simple ointment at night, to prevent
their adhering in the morning.

2. FDmlent Ophthalmia. — This is the same disease as the
foregoing, only much more severe, and consequently of a mora
deKtructive tendency. There are three kitids of pnrulcnt

INFLAMMATION OF THK CONJUNCTIVA.

581

ophthalmia; vi/., purulent ophthalraia of adults, or contagious
ophthalmia, or Kgjplian ophthiilinia ; gonorrhoea! ophthalmia;
and the purulent ophthnliiiiH of iufants.

In purulent ophthalmia of adults, the inflammation is very
intense, runs a rapid coui'se, is attended with violent pnin, and
leads to the tbruiatton of large quantities of thick, yellow, puru-
lent matter. At the same time, the eyelids swell so that they
cannot be separated sufficiently to expose the cornea, there is
chemosis, the discharf^c adheres to the eyelashes in thick drops,
and the patient complains of pain in the eje and forehead.
There is generally much constitutional disturbance, fever, and
prostration. Where the disease does not yield, the iiiflamnm-
tion increases, attacks the cornea, and occasionally the internal
toxtares of the eye ; extensive sloughing takes place, and when
the sufferings terminate, it is found that the sight is com-
pletely lost. — This affection is contagious, is frequently epi-
demic, and is common in hut climates. Military life appears
especially to predispuae to it. Both eyes are often affecfed,
and sometimes simuUnncnasly.

Gonorrhaal ophthnlmia differs from the foregoing in a few
points only. Thus, it is the most severe disease of the two;
it is rarely limited to one eye, but one organ is usually attacked
two or three days before the other; and it is caused by contact
of the gonorrhoeal— or even leucorrhoeal — discharge with the
conjunctiva. It frequently ends in sloughing of tire cornea.

Th^ purxtkiit ophlhrilmiti of in/antu, or uphlhalmia neoiiti-
torum, generally commences about the third day aflcr birth,
with inflammation of that part of the conjunctiva lining the
palpebraa. The edges of the eyelids adhere, and on separating
them a drop of thick white fluid escapes. As the inflamma-
tion extends to the conjunctiva covering the eyeball, the eye-
lids swell, the purulent discharge increases, and the child be-
comes very feeble, rcj^tless, and fretful. The disease may
remain in this state lor eight or nine days ; if not then re-
lieved, ulceration of the cornea occurs, and those destructive
consequences ensue which have been already referred to. Both

4»»

bH'Ji

DISEASES (IF THE ETE.

cyps commonly Buffer, either at the same time, or witliin in
iiilervui of a few diiy?. The discharge is contagious.

In the liciilmcnl of the purulent ophthalmia of adults and
of gonorrhiEul ophthalmia, there is fortunately no need for the
violent measures formerly in vogue. The result to be dreaded
in these nffections is ulceration and sloughing; morbid pro-
cesses which are more likely to be encouraged by bleeding,
antimony, mercury, and starvation, than by any other ag«nt«
with which I :im acquainted. At the commencement, when
the tongue i.s thickly coated, an active purgative may be pre-
scribed ; and tlien if the pulse be feeble and the patient de-
prosed, ammonia and bark, or (juinine, is to be given. A
mutton chnp, with beer or wine, fur dinner, is to be allowed;
the riuaotity of .stimulants being regulated by the sufferer's
condition and general habits. If the patient be restless and
irritable, five grains of extract of henbane may be given at bed-
time, or two drachms of the compound tincture of camphor
with some ether. With regard to local remedies, it will bo
found bencGcial to inject a solution of alum (gr. vj or viij to
,5j) under the eyelids every hour; or a solution of nitrate of
silver (gr. ij tu 3j) may be employed, in the same way, about
every eight hours. If there be any ulceration of the cornea,
it may sonictimes be checked by the early application of the
solid nitrate of silver. The pain arising from the application
must be relieved by warm narcotic fomentations, and opinin.
To provent the lids from adhering, the edges should be smeared
at niglil with the uiigucntuin hydrargyri nitrati.s niitius.

To cure the purulrnt nphthnbnia of in/anlt, it will be ne-
cessary to keep the child's bowels freely open by castor oil,
magnesia, or a few grains of gray powder with magnesia, or
Dover's powder (F. 44, 45), according to the strength of th«
patient and the degree of restlessness. The mother's milk
should be exuiuincd, so that if it be poor or deficient in quan-
tity (he child may be nourished with cow's milk, or by a healthy
Wet-nurse; while very often the youngest infant will be bene-
fited by having a teaspoonful of port wine three or four times

INFI^AMMATION OF THE CONJUNCTIVA. 5S3

in the twenty-four houro. — The eye must be frequently bathed
with tepid water, and a rolution ol" alum (gr. v to 3j) injected
between and beneath the lids twice or thrice in the twenty-four
hours. Occasionally a lotion of sulphate of zino (gr. ij to 3j)
applied thrice daily, will be more e£BcDoiou8 than the alum.

3. Stmmous Ophthalmia. — This form of Ophthalmia is a
disease of scrofulous and other children, occurring generally
between the period of weaning and the ninth or tenth year.
Its principal ttftnptomi are slight conjunctival and sclerotic
redness, with the formation of little phlyctcnulfp. or pustules,
sometimes of ulcers, on the cornea; a copious lachrymal secre-
tion, with irritability of the nasal and buccal mucous mem-
branes; great intolerance of light (photojihohia') with spasmo-
dic contraction of the eyelids ; and swelling of the lips, erup-
tions behind the ears, and disordered intestinal secretions.
Both eyes are usually affected. The hot tears flowing over the
cheek often produce an eruption resembling crusta lactea.

The trr.atment of these tedious cases must be chiefly consti-
tutional. In addition to good nourishing food, warm clothing,
and fresh air, it will be found that mild laxatives, cod-liver oil,
and tonics are nece.Hsary; of the latter, steel, and especially
quinine are the best (F. 453). Warm fomentations give great
relief; while wearing a green shade will also bo useful. When
the most acute symptoms have subsided, local stimuluDts,8uch
as the viiium opii, or the solution of sulphate of zinc (gr. ij
to Sj) may be employed. Benefit is often derived from small
blisters on the temples, or behind the ears, or to the nape of
the neck.

4. Granular Conjunctiva. — In this disease, the conjunc-
tiva— particularly the palpebral portion — is found red, uneven,
and granular. It may follow obstinate ophthiilraia. The so-
called "granulations" conststuf the inflamed mucous follicles
and pupillte ; and when they give rise to much irritation, opa-
city of the cornea sometimes results.

5»4

DISEASES OF THE EYE.

In most cases the constitutional powers are depressed, and
tonics with good diet will be required. I have on several oc-
casions seen arsenic with steel (F. 490) prove very efficacious.
Mr. Dixon states that he has known much benefit ensue from
appljing the undiluted liquor potassae to the palpebral granu-
lations. The fluid is to be dabbed upon the everted lids, at
intervals of a few days. It appears to act by saponifying and
dissolving away the hypertropbied tissue.

III. INFLAMMATION OF THE SCLEEOTIO.

I. Rhenmatic Ophthalmia. — Hheumatic Ophthalmia or
Sclerotitis idiopnthica, may be defined as inflamniution of tho
sclerotic or firm fibrous tis.sue of the eye, excited by cold.
When severe, the morbid action sometimes involves the iris
and cornea ; though the sclerotic may be alone affected.

The iij/mjilomi consist of bright redness of the eye, the
turgid vessels being arranged in a radiated or zonular form,
and being evidently beneath the conjunctiva; of severe pulsat-
ing pain round the orbit, in the eyebrow, and over the temple,
always most severe during the night; of dimness of vision,
from hiizincw of ihc cornea and contraction of the pupil ; and
of a variable amount of general constitutional disturbance.
There is no chemoais, neither docs the access of light prove
Tery distressing.

Iq the treatmrnt of these cases it will generally be found
that warm baths with alkaline purgatives will give great relief.
Aller the bowels have been freely acted upon, the administra-
tion of calomel and opium is generally advised ; but, withia
the scope of my experience, iodide of potassium (F. 31) has
proved very much more serviceable. This agent may also be
advantageously combined with culchicum (F. 35); or in some
cases the latter drug may Imj given alone. Blisters behind the
curs, or a large one to the nape of the neck, will occasionally
perhaps do good. Collyria have but little power over thia

PISEASES OF TUE CORNEA.

585

disease. Durinf! the progress of the ca."*, the pupil of the
affected eye must be kept dilated, by placins: a drop of a solu-
tioD of atropine in it (F. 354); or by smearing the extract bel-
ladonna, made semi-fluid by admixture with distilled water,
round the orbit.

2. Catarrho-Rheumatic Ophthalmia. — This affeotion ia
by no means uncomiuoti. It i.s ubaracterized by a combination
of the Hymptoms of conjunctivitis and sclerotitis. Thus, there
is a feeling of sand between the eyeball and eyelids, severe
circiimorbital pain, the peculiar redness of both affections,
chemosis, intolerance of lipht, epiphora, &c. When the in-
flammation runs on unchecked for eight or nine days, ulcera-
tion of the cornea, and the deposition of pus between its lamellte
— constituting the appearance called oni/x — is to bo feared; at
the same time, the iris becomes sluggish in its movements and
altered in color, and lyuiph is effused into the pupil, Bometimes
quite closing it.

The treatment which I have seen most effectual has been
the administration of iodide of potassium and bark, opiates to
relieve the pain, and the free use of sedative fomentations.

rV. DISEASES OF THE COEITEA.

1. Conical Cornea, — In this affection the cornea is found
exceedingly convex, giving a peculiar sparkling or brillinnt
appearance to the eye. Both eyes are usuolly affected, though
often unequally. The oon8W[uence is an almost total depriva-
tion of vision. The causes of this deformity are not known. In
the few cases which have been examined after death, the apex
of the cornea has been found thinner than natural. All kinds
of treatment have been fruitlessly recommended ; but the
patient's vision may sometimes be partly assisted by a deeply
concave glass, or by the use of a black plate with a transverse

5S6

UIAEASKB or THE GTE.

slit along its middle, fixed in the speotaclo franie with or with-
out the glass.

2. Inflammation of the Cornea. — Infiamination of the
tissue of the cornea {Keralili$ or Comeitis) renders this po>
lished transparent structure hazy, dina, and rough. The sur-
rounding sclerotic is vascular, and gooae of the veins of the
conjunctiva are nUo enlarged. There is often great intolerance
of tight. One or both eyes may be aifected ; and sometimes,
especially in strumous children, one eye is attacked just as the
other is getting well. The morbid action is occasionally vety
chronic, lasting for months, and leaving the cornea pcrius-
nently cloudy.

Inflammation of the cornea sometimes ends in suppuration,
and pus gets infiltrated amoug the fibres of this membrane.
Softening generally takes place posteriorly, and the pus makes
its way into the anterior chamber, to the bott<.>m of which it
sinks ; where it as,«uraes a cre.scentio form, which is termed
ht/pupyrm. When an opening occurs anteriorly, a perforating
ulcer of tlic cornea is produced through which the iris pro-
trudes— »taphi/h)ma triih'*.

The treatment roust be constitutional. On esaminiog the
sufferers from corneitis, they will be found to be delicate and
often strumous. Hence, furruginous tonics, bark, cod-liver oil,
good diet with plenty of inilk, &c., are the remedies to trust
to. Blisters the size of a florin, applied behind the ears or to
the t«mp]es, are often of signal service. When suppuratioa
occurs, stimulants nod tonics are still to be persevered with,
while anodyne fomentations may be continuously applied.

3. Opacity of the Cornea. — This condition may result from
inflammation, giving ri.se to the effusion of fibrin into the sub-
stance of the cornea, or between it and the conjunctiva ; or it
may be the cx)n8ccjuence of a cicatrix following an ulcer.

When the opacity is cloudy and diffused, as from keratitis,
the appearance is culled a tiebit/ii ; whereas a limited white

DTeEAscs OP Ttre ntre.

patch, such as results from a cicatrix, is known hj the terms
atliutfo and lemoma. The use of acetate of lead oollyria,
when there has been an abrasion of the cornea or conjunctiva,
baa led to the formation of a permanent white deposit. Tbia
may sometimes be geutlj scraped away.

V. DISEASES OF THE IRIS.

I. Inflammation of the Iris. — Iritis is a most interesting

disease to the physician and to the pathologist. Suspended —
like a curtain with a circular aperture near its centre — between
the cornea and erj'stalline lens, and bathed on both sides by
the aqueous humor, the iris serves to regulate the quantity of
light admitted to the retina. By it, the cavity containing the
aqueous humor is divided into an anterior and a posterior
chamber. The iri-s is composed of delicate bundles of fibrous
tissue, of circular and radiating involuntiiry muscular fibres,
and of pigment cells. Sometimes it is absent, or only present
in a rudimentjiry form, a condition known as Irideremia. In
Albitioc.s the iris is of u ro.se color, and the pupils present a
deep red appearance, owing to the absence of pigment in the
choroid and uvea.

Si/m]itijmi. — Inflammation of the iris seldom exists alone,
the sclerotic and deep-seated textures of the eye being gene-
rally also involved. Hence, Dr. Jacob has objected to the use
of the term Iritis; since he thinks its employment " has the
effect of directing the practitioner's attention to the iris, which
bears a great deal of inflammation without destruction to the
organ, and withdrawing it from the retina, which bears very
little without permanent injury to vision.''

In the first stage of the morbid action, the iris presents a
confu.sed appearance, owing to its fibrous texture becoming in-
distinct; while it loses its contractile power, and undergoes a
change in color. The sclerotic is also vascular. In the next
stage, fibrin is effused oti the surface of the irii^, and in the

•588

DlfEA8E« OF THE KTB.

anterior chamber. While, if the iDSammation proceeds, the
pupil may be closed, or its margin become adherent to the
capsule of the lens ; or the cornea may be rendered opaque ;
or there may be permanent opacity of the lens or its capsule.

The important symptoms of iritis are thus clearly enume-
rated by Dr. Mackenzie: 1. Zonular sclerotitis ; fine hair-like
vessels, running; in radii towards the edge of the cornea. 2.
Discoloration of the iris. If naturally blue, it becomes green-
ish; if dark colored, reddish. This is the result of incrcsBed
vascularity, or of efiusion of lymph into its Bubstanoe, or oa
its posterior surface. 3. Contraction, irregularity, and immo-
bility of the pupil. 4. Effusion of coagulabic lymph into the
pupil and posterior chamber, and occasionally into the anterior
chamber. 5. Adhesions uf the iris, and especially of its pn-
pillary edge, to the capsule of the lens; in some rare cases, to
the cornea. 6. Tubercles, pustules, or small abscesses of the
iris. 7. Dimness of sight, and sutuetimes total blindness. 8.
Pain in the eye, and nocturnul circuuiorbital pain.

It must nut be supposed that in every case all the foregoin;;
syinptuius will be met wiih, but rather that a certain number
of them will bo found sufficient to render the diagnosis cer-
tain. The constitutional disturbance is well marked, though
it is not generally severe.

If the iuSamuintinn be not checked, it creeps on, iorolres
tho choroid coat uiid retina, and, spoiling the delicate textaro
of the latter, completely destroys the sight forever.

Cau»e$. — The chief causes of this affection are — esposure
to cold and wet, giving rise to rheumatic or idiop.'itbic iritis ;
syphilis and gouorrhx'a, causing syphilitic iritis; injuries and
wounds, producing traumatic iritis; and certain conditions of
the constitution, especially the scrofulous, rheumatic, and
gouty.

Iritis arising as one of the secondary effects of syphilis, ia
perhaps tho most coniniou. It is usually attended with the
other effects of constitutional syphilis, such aj; copper-colorod
eruptions, nodes, pains in the bone« especially severe at night,

INFLAMMATION OF THE IRIS.

589

and ulcemtion of tbe throat. Without laying too much stress
upon the local peculinritics of syphilitic iritis, it may be men-
tioned that, Dt 6r^t, the redness is much less severe than in
the rhenmatio form ; that the iris often assumes a rusty color,
especially near its pupillary edge ; and that the pupil is apt to
be displaced, and to be drawn upwards towards the root of the
nose.

Treafmenl. — Mercury, bloodletting, and belladonna are the
three supports on whioh we arc taught to rely ; and so strongly
have these remedies boon reeomniended, that it will bo diffi-
cult to persuade many practitioners of their inutility. But
that the first two agents may be often advantageously llispensed
with, is — I think — proved by the sixty-four cases of Pr. W,
H. Williams ; all of which were cured by sustaining the ge-
neral health, relieving pain with narcotics, and'keeping the
pupil dilated by belladonna.*

In the treatment of inflammation of (he iria our object must
be to check the flow of blood towards the part, to arrest the
efTa.sion of fibrin, and to procure the Bb.«orption of that which
has been poured out. To gain these ends it is advisable that
the patient be kept quiet, preferably indoors, and with the
eye protected from the light ; that sedative fomentations be
applied, if the eye is morbidly sensitive ; that the bowels be
kept regular by mercurial purgatives, or enemata ; that opium
be given to relieve the pain ; and that the diet be plain but
nourishing, and free from stimulants. Iodide of p<^>tasstura
(F. 27, 35) is often of great value, especially in rheumatic
and strumous iritis ; while in that dependent upon the
poison of syphilis, mercury (F. 26, 43) will sometimes prove
more useful, though it is not to be given to the extent of pro-
ducing salivation. If there bo depression, ammonia and bark,
or quinine, may be advantageously given. When thecircuni-
orbital pain is intense, it is said that relief may be speedily
afforded by mixing three grains of powdered opium with ten

* 8n lh« Remark! on Inflammation, p. S2.
50

or THK m.

of Bereorial otntaeBt, mod well raMiiag tlie
tile temple. Moreorer, it is nsaAlljr leeomaead^d that, dnriag
tbe treatment, from the commencenieiit to the temiiwtMO,
the popil be kept dilated, in order to prerent die iria fipom
foraiog adhesioni with the capsole of the CTjstalliBe leoa.
Thia ma^ be dooe by belladonna, or bj m airfittioa of MttOfiam
( P. 354). No astringent or other colljris ahoold be emploj«d.
Oil of torpentine haa long been recommended in iritia where
the nae of mercury is contra-indicated. Mr. Gathrie speaks
favorably of its effects in some few instances (F. 64). Should
the practitioner be unwilling to tnut too much to Natare, fie
can try in effects.

8. Inflammation of the Iris and Cornea. — This affection
is sometimes very ubstinaic in delicate children. It was be-
licTcd until recently, that a serous membrane or capsule co-
vered the posterior surface of the cornea, both surfaces of the
iris, and the front of the capsule of the lens; while the disease
under consideration was .«uppoecd to consist of inflamiuation
of this membrane, and hence was named " aquo-uapeulitis."

The syniptomg run a chronic course ; and consist chiefly of
intolerance of light, Tascularily of the sclerotic, huiness of the
cornea, and slight change in the color of the iris. The gene-
ral health is always bad. Mr. Hutchinson believes this dis-
ease to be always the result of inherited syphilis.

The treatment must consist in the use of mild alterative*,
tonics, and good diet. Tincture of iodine carefully applied to
the skin of the eyelids will often relieve the intolerance of
light.

3. Mydriasis. — Sometimes from the paralysis of the third
nerve or motor oculi, the long-continued use of belladonna,
and other causes — the iris loses its power, so that the popil
remains dilntcd. This condition — mydriaiit — must not bo
cuni'uuiidt'J with imiiiubility of the pupil owing to disease of
the retina, from which it uiny bo distinguished by a simple

lOrLAMMATION OP THB CHOROID. 591

esperiment practised by ophtbalinic surgeons. These gentle-
men direct the patient to supply the want of a contructod iris
by looking throuf;h a large piii-bolc in a card held close to the
eye. If the case be one of mydriasis, be will see perfectly ;
where, if the retina be diseased, the aperture will be nearly or
quite useless. In mydriasis, tonics whiuk specially net upon
the nervous system, as zinc, nux vomica, &o. (F. 483, 491),
will often prove useful.

VI. INFLAMMATION OF THE CHOROID.

Choroiditis is rarely or never seen alone, since the inflam-
mation rapidly spreads to the neighboring textures of the eye,
producing disorganization, &o., by which it is recognized rather
than by any syisiptouis of vascular excitement.

The pathognomonic symptom is the formation of a blue
sone, of variable breudtli and completeness round the cornea ;
this being produced by thinning of the sclerotic, and followed
by the protrusion of small dark-blue humors. Tbe pupil is
frequently displaced, contracted or dilated, and immovable ;
tbe cornea often becomes in parts opaque. There is generally
considerable puiti, intolerance of light, and diiuocss of vision ;
the con.stitutional symptoms arc slight. The disease is fol-
lowed by enlargement of the globe of the ey^e, and sometimes
by suppuration and the formation of fungous growths ; the
Bight is often lost, or at least much impaired.

The trerifment consists in the use of mercury, first as a pur-
gative, and afterwards as an alterative. The warm bath,
counter-irritiition to the temples and behind the cars by means
of the tartar enietic ointment, and the adniitii.stration of the
liquor putassie arseiiitis (F- 68, 72) are the remedies usually
rcooutmcDdcd.

692

DISEASES OF THE EYZ.

VII. INFLAMMATION OF THE RETINA.

Retinitis usually occurs as a sympathetic aiTectioa in the
course of other uphthalruisa. As a simple idiopathic inflamma-
tion it is exceedin<;ly rare.

It is characterized bj acute deep-seated pain in the eyeball,
extenditij; to the temples and forehead ; great intolerance of
light ; diminution or loss of the power of vision ; and frequent
BCDsatioDS of flashes of light. The pupil is found contracted,
the iris loses its brilliancy and becomes motionless, and there
is vascularity of the .sclerotic. The constitutional disturbance
is severe. High fever and delirium are often present.

When the acute symptoms have subsided, the ophthalmo-
scope iihows that the vessels of the retina are congested and
varicose ; that the transparency of the retina is impaired ;
while extravasations of blood may often bo seen, owing to
rupture of one or more of the vessels.

It is generally caused by exposure to vivid light — large
fires, furnaces, &c. Reflected light appears very injurious to
the retina ; hence the pernicious effects of the glare from
snow, or from the burning sands of tropical climates.

Perfect rest in a darkened room; the application of cold
lotions or of hot fomentations, according to the patient's feel-
ings; mild purgatives; sedatives to relieve pain; and a simple
diet, are the means upon which we must roly.

VIII. CATAEACT.

Cataract ooDsiats of an opacity of the crystalline lens, or of
its capsule, or of both ; the effect being to intercept the njt
of light on their way to the retina. Three varieties of catamot
arc recognized, according to the situation of the opacity — via.,
the lenticular, capsular, and capsulii-lcnticular.

Hard or lenticular cataract of old people, is the most common

OLAUOOMA.

58S

form of this disease. It is met with in old persons, between
fifty and seventy years of apo; it causes objects to appear as
if obscured by a thick cloud or gauzu ; while it allows the
Tision to be most clear when tho pupil is dilated, os by the
use of atropine or belladonna, or by the light beirij; dull and
subdued. In advanced cases vision is reduced simply to the
perception of light from darkness. Commonly one eye is first
affected, and then the other. The tnovenrcnts of the iris aro
. natural; and when the pupil is dilated by belladonna, the

^ft cataractous opacity can bo di.^tinctly seen with a convex frla.ss
^^ of about one inch focus. In commencing cataract, lenticular
opacities not otherwise perceptible may bo seen with the
ophthalmoscope as black lines or marks upon a red back-
ground.

Soft or lenticular cataract of young people, may occur at
any time of life. Congenital cataract is always of thi.s kind.
It is due to a dittintognition of the whole substance of the lens,
which becomes opaque and swollen. The symptoms are much
the same as of the hard kind, except perhaps that vi.siun is
usually more imperfect.
H Capsular cataract may result from chronic inflammation.

^^ ' The opacity is of a dead white color; and commonly aflects
part or the whole of the anterior wall of the cap.sule, or, in

■ rare cases, it may perhaps be confined to the posterior portion.
Opacity of the cap.sule always leads to opacity of the lens,
BO that capsulo-lenticular cataract m common.

The tn'iilment of all forma of cataract, wlicthcr by extrac-
tion, by di.sptiicement or couching, or by inducing solution or
^M absorption, falls to the province of the surgeon.

■ The t(

IX. OLAUCOUA.

The terra "Glaucoma" is need in the present day to imply
a form of blindness attended with disorganization of the various
tissues of the eyeball.

60»

594

DISEASES or THE KTE.

Mr. Hulke slates (hat the symptoms are the cunsequences of
excessive intra-ocular pressure, this being dne to an incrcMe
in the quantity and (iniiiiess of the vitreous humor, (rlnacoma
is peculiar to niidiile lile and old nge ; while its occurrence is
sometimes foreshadowed by quickly increasing presbyopia.

The disease may be arute; when the glaucomatous changes
take place very rapidly, and quickly end in loss of vision. The
Dttuuk perhaps commences suddenly in the night, with severe
throbbing pain in one eye and temple. The pain continues,
and the tullowing morning the sclerotic is found discolored
and congested. The iris then become.s of a dusky hue, and
motionless; the cornea geL<i dim; the pupil is widely dilated,
and sometimes of an irregular oval shape; and the eyeball is
felt to be uiinatumlly hard. Sometimes complaint is made of
^bright flashes of light darting before the eye; and occasionally
there is slight temporary improvement, though blindness sab-
scquently results. Both eyes are affected, but the disease
usually commericcs in one a few days before the other.

In chronic glaucoma there are the same siymptoms, but they
come on very insidiously, and arc attended with ranch leas
pain. The morbid changes are spread over many months ;
and their sequence, according to Mr. Dixon, seems to be aa
follows. First, in the retina and choroid; going on, perhaps,
to serous effusion between these two coats, which causes •
bulging forwards of the lens and iris, by pressing from behind
upon the vitreous body. Then, congestion and inflammation
of the iris and cornea; and, lost of ull, opacity of the lens, a;3
a consequence of its deranged nutrition.

The ophthalmoscope usually shows the presence of extrava-
sations of blood in (he retina and choroid ; serous effusion be-
tween the retina and choroid, the retina appearing as if raised
into folds; small clots in the vitreous humor; and an excava-
tion of the optic nerve entranoe, with pulsation of the arterU
centralis retina).

As regards the treatment of these cases, it is only neoesBaty
to say that bleeding, blistering, and the administration of

AMAtTHOSlS.

596

mercury have invariably Hone great harm. All that the phy-
sician can do is to attend to the generaUhealth. Whether
the surgeon can reduce the excessive tension of the oyebiiil,
in acute eases, by irideelomy or any other operation seems at
present to be a disputed point.

I
I

X. AMAUROSIS.

The term amaurosis — from a/iaopAu, to obscure or darken —
is used to express partial or complete loss of vision arising from
defective nervous function.

Piilhofo</i/. — The transparent tissues and humors of the eye
may all be heulthyj but the nervous matter which should re-
ceive and convey impresstuiis, and render them perceptible to
the mind, is nffectcd. As Dr. Mackenzie says, if the retina
be incapable of receiving with correctness impressions of ex-
ternal objects through the medium of light; if the optio nerve
be unable to convey to the scnsorium the impressions made
upon the retina; or if the brain be incapable of receiving the
impressions conveyed by the optio nerve, the individual must
be affected with an obscurity in vision, or suffer a total depri-
vation of sight, according to the degree of inability in these
several pjirts to execute their functions. Even when he goes
no further than this, the pathologist must see the necessity of
distinguishing different cases of amaurasis according as the
retitia, the optic nerve, or the brain is the part first and prin-
cipally aifected. Now the affections of either of these three
parts which may cause amaurosis are pressure and striielural
chani/e, such as inflanimatiun, suppuration, induration, ramol-
lissement, hypertrophy, atrophy, ifcc. It must be remembered,
however, that rejiex amnurosis may certainly be produced by
remote causes. Thus, it may arise from the presence of worms
in the intestines, the intestinal irritation being sufficient, in an
extreme caae, to excite a morbid condition of some part of the
optic apparatus through reflex action. So, again, the irrita-

596

DI8EAS88 or TDK EYE.

tion of teething maj prodaoe temporary amaurosis in the same
manner.

Si/mptoms. — In examining an amaurotic patient, the first
points that attract attention are his gait and expression of
countenance. He walks with an air of uncertainty, and hLi
eyes, instead of being directed towards surrounding objects,
have an unmeaning look — appear to be staring at nothing. In
incomplete amaurosis, the movements of the iris arc sluggish
and the pupil is dilntcd; in total blindness, the pupil is greatly
dilated and (he irin immovable. When both eyes arc affected,
they arc often unnaturally prominent and of an unhealthy
color; the sclerotica being frequently of a yellowish hue, and
covered with varicose vessels.

In the commencement, the failure of sight is only expe-
rienced occasionally, as after long-continued exertion of the
eyes, reading by candlelight, &o. Sometimes it begins with
indi.stinct vii<ion, or amblyopia ; or objects appear double,
diplopia; or only one-half of an object may be seen, hemiopiu.
At the same time there is frequently headache, and ocular
spectra become visible, the patient complaining of miucie
volitantes.

There is one other peculiar form of partial blindness which
demands notice, viz., that in which the patient can only see in
broad dnylight, being quite blind during the remainder of the
twenty-four hours. This complaint — termed hemeralopia — is
usually met with in persons who have been exposed to the
strong glaring light of the tropics.

Treatment. — It is diffifult to lay down rules for the treat-
ment of this disease, for since the causes upon which it de-
pends arc various and opposite, so must the means of care be
numerous and unsatisfactory. In all instances, however, at-
tention should first be directed to the general health. Each
case is then to be studied in all its bearings, especially with
reference to the cause of the affection. Wbco it manifoHtly
results from the reflected irritation of worms, decayed teeth,
tic,, the treatment is obvious ; when from inflnmmatiun, strict

AMAUROSIS.

59/

quiet, warm baths, and low diet may be necessary; when from
vascular exhaustion or nervous debility, the preparations of
iron, bark, good diet, sea air, and cold bathing are indicated.
Strychnia has been particularly recommended, and probably in
some few examples it may stimulate the optic nerve into action.
Electricity acts, I suppose, in the same way. Both remedies
require caution in their use, however, for if improperly em-
ployed they do much mischief. Counter-irritants behind the
ears, or to the nape of the neck, or to the shaven scalp, are
spoken highly of by some authorities. Dr. Priohard recom-
mends an issue to be made by dividing the scalp with a bis-
toury from the summit of the forehead to the occiput, and
filling the spaoe with peas. I have seen this cruel practice
resorted to by physicians on several occasions, but I cannot
remember that benefit was derived in a single instanoe.

PART XI.

DISEASES OF THE EAR.

I. OTALGIA.

Otalgia, or earache, may be n/mplomalie of iDflammatioD
of the ear, or of the presence of foreign bodies in the external
meatus, or of tonsillitis, or of disorder of the primer- via:, or of
rheumatism of the head, &c. ; or it may be idiopathic, that ia
to say, true ncoralrpa of the auditory nerves. In tlie latter
case, the suffering is most severe on its invasion, and unlike
the pain in otitis, docs not inerease in severity, is unattended
by fever, and often disappears suddenly. Nervous otalpa may
be connected with imperfect performance of the functions of
the stomach or liver; or it may arise from some uterine de-
rangement ; or it may occur in the early stape of utero-gest«- ,
tion ; or it may be due to a carious tenth ; or it may alternata
with sciatica, tic-douloureui, &c. If the pain is very severe,
it frequently shoots through the nervous filaments distributed
over the same side of the face and head, caa^ing much suffer-
ing and restleasnesa.

When the affection is symptomatic, the treatment must bo {
directed to the primary disease; when idiopathic, mild porg«- ■
lives, a blister behind the affected ear, or the application of
ohlorofurm or the tincture of aconite, will be useful. Any
carious teeth must be extracted or stopped.

Noises in the cars (tinnitus aurium), deafnes.^, confusion ia

OTORRHCEA.

509

the head, &c., soraetimcs arise from an accumulation of ecru-
mm in the external meatus. The wax must be removed by
thoroughly syrinpinj; the ear with warm water. I have seen
a patient actively treated for incipient cerebral disease — such
was the diagnosis of the practitioner in attendance — merely
because he happened to be Buffering from deafness and singing
in the ears, owing to the pressure of a mass of hard wax on the
membrano of the tympanum.

n. OTOERHOEA.

Otorrhoea — a purulent or muco-purulcnt discharge from the
ear — is, properly speaking, only a symptom of certain diseases
of this organ ; nr^ of cntarrliul inflaninisition, polypus, granula-
tions on the surface of the meitibrnna t-yrapatii, tfec. It occurs
very frequently, however, without any appreciable cau.se, in
young children, about the time of dentition ; or on the sub-
sidence of any of the exanthemata, especially in strumous
subjects. Even in adult.? it occasionally seems to be due to
a depressed condition of system. The secretion is generally
offensive; and when it has existed for any length of time, it is
often tinged with bloud.

Commonly, under appropriate management, the discharge
ceases in a short period ; but occasionally it becomes chronic,
in which case it may continue fur years, destroying in the
course of time the menibrana tympnni, the ossicula auditus,
and producing caries oF the bony walls of the meatus and
tympanueu. The di.<iease may even extend to the cells of the
mastoid process uf the temporal bone; or in the opposite direc-
tion along the petrous portion of the same bone, until the
brain and its membranes becouiing involved in the unhealthy
action, rigors, fever, and marked cerebral symptoms show
themselves, and the case ultimately terminates in convulsions,
coma, and death. Cases of phlebitis with pleurisy and pneu-

600

DISEASES OF TQE EAR.

monia have also been Found — and not very ancommonlj — to
result from caries of the mastoid celia.

The first step in the treatment must be to gently syringe
and then carefully examine the meatus auditorius cxternus.
If the discharge be not severe, and no cause, aa polypus, &«.,
be found to accuunt for it, a cure may often bo effected by
daily dropping into the ear a solution of alum, zinc, or tannin,
of the same strength as the various collyria (F. 356). When
these means fail, the i-urface of the canal should be painted
with a solution of nitrate of silver (gr. vj ad sj), by means of
a camel 'g-hair pencil; which application must be repeated every
second day, the ear being Irecjuently syringed in the interval
with tepid water by means of an elastic bottle. The local
employment of glycerine, aa recommended by Mr. Thomas
Wakley, will also be bcneScial after the use of the astringents.
Where the patient's general health is bad, ferruginous tonics
and change of air will be necessary ; while in the scrofulous
cases, iodine, cod-liver oil, &c., should be tried.

in. HfTLAMMATION OF THE EXTEHNAL MEATUS.

The sensitive dermis of the external meatus may become
inflamed from the introduction of irritating matters, from an
accumulation of wax, or from cold, &c.

The $ymploms of this disease (often spoken of as external
olilit) are a feeling of tension and fulness in the meatus, fol-
lowed by more or less pain, tinnitus aurium, and dulness of
hearing. There is irritability with restlcs-sness, and often
fever ; while not uufrequently the cervical glands are en-
larged. On examination the lining membrane of the meatus
is found red and swollen. During the course of a day or ao,
a copious secretion of mucus takes place ; which ia sometimes !
viscid, sometimes thin and very abundant. In the great ma-
jority of oases the patient now gets well ; but very rarely it
bna happened that the morbid action has extended to the

DISEASES OP THE MEMBRANA TYMPANl. 601

bone, and even to tho membranes of the brain. In other
instances the inflamnialion becomes chronic; and then ihe
dermis renmins more or less tumid, the epithelium is thrown
off in scales, which accumulate and obstruct the canal, there is
diminished power tif hearing, ^reat itching is complained of,
and the patient's hcnlth is found depressed.

The treatmrnt consists in the use of fomentations and poul-
tices, with frequent bathing of the ear to remove the irritating
dischar);e. If there be much pain and swellin)f, the applica-
tion of a couple of leeches to the margin of the meatus will
relieve the congestion. When the inflamiuutory symptoms
terminate in chronic irritation, the collection of epidermis
roust be removed by syringing in warm water, after which
mild astringent injections are generally useful; while some-
limes the cure is hastened by the application of small blisters
over the mastoid procei<8. The •jeiienil heiilth should be im-
proved; sea air, a nourishing diet with plenty of milk, steel
wine, bark, cod-liver oil, &c., being valuable remedies when
properly applied in these cases.

IV. DISEASES OF THE MEMBRANA TTMPANI.

The meuibranu tympani is a nearly oval, semi-transparent,
elastic structure, which separates the external meatus Crom tho
cavity of the tynnKinuni. Its use is generally supposed to bo
for the reception of the sonorous undulutiuns from the air of
the meatus, and the transmission of them by the chain of bones
to the lalyrintli. By its tension, also, it lessens or modifies
the effect of loud vibrations.

Tho mcmbrana tympani may suffor from acute or chronio
inflammation (the myringitit of Wilde), the consequence of
cold, or of irritating matters kept in contact with it, or of the
extension of disease from the walls of the meatus. The symp-
toms consist chiefiy of piiin, itching, a feeling of discomfort in
the affect-ed side of the head, and slight deafness; while on

602

DISEASES OF THE KAB.

examinatiun the membrane is seen to be opaque, and traversed
by distended vessels. The treatment is the same as that jaHt
reconiiuciided fur inflammation of the external meatatt.

When the inflammatory action continues uucoutrolled by
remedies, it sometimes tertninntea in ulceration; this luttor
notion, in rare instaiict's, goitis on to the extent of producing
fjerforution. The management of lliese cases will be refurred
to iD the Dest seotion.

And, lastly, I dulness of hearing may result from reluxntion
of the membrana tympani ; a condition, the existence of wliich
has been doubted by some writers on aural disenso. Mr. Tojrti-
bee, however, assertfl that no affection of the ear can be more
distinctly diagnosed; and he attributes its occurrence either to
an ordinary cold producing hypertrophy of the mucous coat
of the mcriibrane, or to inflnmuiation of the fibrous layers.
The result of these causes is that the membrane loses its natu-
ral de^zree of resiliency and becomes flaccid, so as to fall in-
wards and approach closer to the promontory than is natural.
If the mucous coat be thickened, counter-irritation over the
mastoid process is culled for; if the fibrous layers are inflamed,
leeches to the margin of the meatus are recommended; while
if the laminte be weakened, an injection of nitrate of silver
may give them tone.

V. INFLAMMATIOir OF THE CAVITY OF THE
TYMPANUM.

Inflammation of the mucous and fibrous tissues of the tym-
panic cavity — sometimes called internal otitis — is a severe
disease ; rendcn-d perhaps more serious by its being u.suallj
combined with influuimation of the internal oont of the mem-
brana tynipant.

This is rather a common disorder in youth, and mnny cases
of children's earache causing miserable nights are really ex-
amples of it. When it takes pkicc in adults it proves » more

INFLAMMATION OF TIIK TVMPANUM.

60S

formidable affection, and give« rise to great suffering for the
time. Cold, tho pui.«on of rliuunintisiii or gout, scarlet fever,
and the struiuuus constitution, arc it.s mast common causes.

The first fymptnm is perhaps uneasiness in the ear on blow-
ing the nose or on swallowin<£, which soon becomes continuous.
Then there may be violent headache; followed hy intense,
acute, gniduuUy increasing pain in the ear, and loud or beat-
ing noiws. After a short time, a sense of bursting or disten-
sion in the ear is experienced ; with more or* less deafness.
The eyes become injected, the countenance is anxious, the
skin is hot, pulse frp<[iient, and the functions of thi> kidneys
and bowels uro disonlyrud. Delirium is often present, or — in
children — convulsions. In all eases there is great depression,
and a foreboding of some heavy caluniity. Facial paruly.sis,
caused by the inflnnimation extending to the bony cunal in
which the pnrtio dura passes round the tympanum, may occur ;
but power will be regained as the morbid action subsides.
The disease terminates in one of three ways ; either by resolu-
tion, or by siippunition, the pent-up pus bursting through the
memlirana tyiupani, and so discharging itself; or by the in-
fiummatory process spreading through the mastoid cells inter-
nally, or by the bony meatus tu the pcrlusteuiu covering the
mastoid process externally.

It bos. been already mentioned that perforation of the uicm-
brutia tynipsini may lake place owing to the eileasion of ulcera-
tion from without inwards. In the disorder under considera-
tion, the reverse happens, the morbid action progressing. from
within outwards. This latter is the most frequent cau.se of
the formation of an orifice ; though fortunately in the ma-
jority of these cases the opcuing closes spontaneously in the
course of a week or two.

The Irealmeiil luust be conducted with caution. The bow-
els should be kept optsn, the action of the skin promoted, and
the patient kept in bed in a quiet room. If there be much
fever, sulines may be administered ; while if the disease appear
to be due to rheumatism or gout, iodide of potassium and col-

604

DISEASKS OP TOE EAR.

chicum (F. 35) will be called for. The vapor of boiling
water, anodyne fomentations, and hot poultices will be found
soothing. Opium or morphia will eenenilly be needed, and
ought to be given in sufficient dose.s to relieve the pain.
Should the suffering continue severe, blisters to the miutoid
process may be tried.

In the event of the opening in the membmna tympani
failing to heal, the diminution in the power of hearing which
ari.scs must subsequently be remedied by the application of a
thin layer of cotton wool, moistened with glycerine, as ad-
vised by Mr. Yearsley ; or by the use of an artificial mem-
brane made of vulcanized india-rubber, as recommended by
Mr. Toy ti Lee.

VI. DISEASES OF THE EUSTACHIAN TUBE.

The Eustachian tube, or canal by which the tympanum
communicates with the pharynx, is about two inches long,
and is composed jiartly of bone, partly of fibro-cartihiginous
tissue. Its use is to afford an ciilranco for uir into the tyni-
panutn, and an exit for mucus from this cavity ; while, ac-
cording to many phy-tiiilogints, its guttural orifice always re-
mains open, 80 thst air can flow continuously through its chan-
nel. Mr. Toynbce, however, has attempted to prove that^
" in the sUite of repose, the faucial orifice is always shut; that
the means by which it is opened uro the muiiclos of the polate ;
and that it is opened during the act of deglutition."* He
adduces the results of several experiments in support of hia
view, and they certainly seem to confirm its oorrectneas.

But although the Eustachian tube may be commonly closed,
except during the act of deglutition, yet it is certain that its
permanent obstruction produces an exhaustion of the air in the
tympanic cavity ; and consequently there results a preasara

• TAn Dit4tt*u aflht Ear, p. 190. LondoB, IMO.

DISEASES OF THE EUSTACHIAN TUBE.

C05

inwardii of the Diembruna tjnipani, a forcing together of the
chain of bones, pressure on the contents of the labyrinth, and
deafness. The conditions which give rise to obstruction are
as follow : A thickenin<r of the mucous membrane of the
fauciul orifice, such as often coexists with chronic enlargement
of the tonsils ; a collection of mucus, or a stricture of the mid-
dle part of the tube ; and a thickening of the mucous mem-
brane, or a deposit of fibrin al tho lyinpanic openinj;.

A simple mode of ascertaining wlit'tlicr the Eustachian tube
is pervious, without having recourse to the somewhat dungcr-
0U8 catheter, hn.s been described by Mr. Toynbce. The en-
trance of air into the tympanum during the act of deglutition,
can be distinctly heard by means of the Otoscope, — an elastic
tube ab<iut eighteen inches long, having its endy tipped with
ivory. One end being iiiserleJ into the ear of ihu patient, and
the other into that of the surgeon, the patient is directed to
swallow a little saliva, the niouib and the tmse being closed.
If the tube be pervious, at tho itionjent the patient has a sen-
sation of fulness in the ear, the pr.ictitioner will detect a faint
crackling sound, produced by a slight movement of the mem-
brana tympani. Where the mucous membrane of the tympa-
num is thickened, a gentle flapping sound will be heard instc.id
of the faint crackling. If the otoscope fail to reveal any sound
during deglutition, if no sound be heard when a forcible at-
tempt at expiration is made with the mouth and nose, tightly
closed, and if no other cause can be found for the duluess of
hearing, then it may be presumed that the tube is obstructed.

In attempting to cure these ob.ntructions most good will
usually be derived fmm attention to the general health, A
nourishing diet, warm clothing, exercise in the open air, and
sea-bathing will be invaluable. The best medicines are cod-
liver oil, iodide of iron, iodide of potassium and bark, and per-
haps in some cases the bichloride of mercury in small doses.
If the tonsils are enlarged, or the faucial mucous membrane
swollen, the solid nitrate of silver should be applied; or these

6l»

600

DISEASES OF THE EAR.

pnrt,^ nmy be pponfrpd daily with the compoiin<l tincture of
iudine. Only after ihe failure of those measures, and \rhen the
tonsils are much enlarged, may a portion of them be excised.

VII. RHEUMATIC. GOUTY, AND NERVOUS
DEAFNESS.

These forms of deafness have been particularly investigntcd
by Mr. Harvey; and from his valuable writings many of the
fuUowing observations have been derived.*

Rhrumalltm of tlir Ear or ila Appeniiayei seldom occurs as
a primary disease, being most frequently met with after the
sabsidenco of rheumutic inflatnmDtion of the joints. Any part i
of the fibrous .^'tructure of the ear may be attacked, — either the
cartilage of the anrielc, the periosteum, the mcmbrana tympani,
or the neurilcnima of the nerves distributed to the cavity of the
tympanum and to the canals in the petrous portion of the tem-
poral bone. The local syinptoma will be those of inflammatioo
from other causes, but the diagnosis is to be determined by the
general hi.story of the patient's health. The soalp, temple,
mastoid process, jaw, and teeth on the affected side are yerjr
tender; there is usually distressing heavy tinnitus; and there
are often ni<.'litly exacerbations, with acid perspirations. An
acute nttauk of rheuniatio disease may destroy the organ of
hearing by producing periosteal influniniation and caries; or
the active stage may subside, and an obstinate otorrhoea result,
which sometimes leads to exfoliation of a portion of the bone.
Tn the treatment of these cases I should look for greater good
from the use of the alkaline salts, iodide of potassium, opiatM,
hot bathing, and fomentations, than from mercury or depletioD.
When there has been great teiiderncw over the mii.stoid proeen,
Mr. lliiivey has seen oonsidernble relief afforded by making aa

On R/teuniiifitm, Gout, ntij^ Nturalf^ir lUmiitrh* ; tu rrltnioH I0
^OuMt, lVu,,r> ill Ihe luir, Ift. Thiril Eilitiun. LuiidoD, I»'in

RHEUMATIC. OOUTY, AND NERVOUS DEAFNESS. HOT

incision over this part down to the bone, so as to free the tense
and inflamed periosteum.

Gout affevtinij tJie Slrurtura: of the Ear is a common cause
of deafness. The ear is seldom attacked, however, until the
suiiiller joints have been frequentlj invaded, thus giving une-
quivocal evidence of the f^nuty constitution ; while the deafness
is generally preceded by severe headaches. When the inflam-
mation seizes upon the externa! ear, the symptouis usually set
in after midnight, with a tearing or twistinji; pain, burning heat,
beating noises or singins; in the car, and swelling with redness.
Not uncuiiiinonly the dinca-KC afTects the middle car, and here
(the struetare consisting of minute articulations of hone) wo
have an instance of gout attacking the smaller joints. After
death full evidence of the gouty action is discovered, in the
form of concretions and deposits of urate of soda, analogous to
those seen in the joints of the toes and fingers. The pain in
these cases i.s very acute j while sometimes there is loss of con-
sciousness, delirium, and even convulsions. The remedies to
be resorted to must bo of the same nature as those reqnired in
gout atticking other parts of the hodj. If the inElaroniation,
however, apjicar to he due to metastasis, muistard pediluvia or
other local stiniulant-s ou;j;ht to bo freely applied to the joints
usually affected with gout, in order to recall the disease from
the more important organ.

Somewhat analogous to amaurosis is the disorder generally
known as jiervoits dea/iicim. In these cases there is dulnessof
hearing owing to some lesion of the nervous system ; whether
this lesion be seated in the nervous tis-sue expanded in the
labyrinth, at the origin or in the course of the seventh pair,
or in the brain itself. In some of these casea no relief can
be given ; as in senile deafness, arising from the insensibility
which occurs in the nervous tissue from old age. With regard
to other cases, we must trust chiefly to the alleviation of the
prominent symptoms; usually endeavoring to give tone to the
nervous system.

PART XII.
f^EASES OF THE BLOODVESSELS.

I, A0ETITI8.

Aortitis, or acute inflammntion of the aorta, is a very
rare aflfectiou. It is probubly a blood disease, bein^ perhaps
allied to rheutiiatisiu, like pericarditis and endocarditis.

Tlie »i/mploin» uru so obscure, that uortitis is seldom ding-
nosed. Ill the recorded cases there seems principally to have
been great general uneasiness, rigors ibllowed by fever, orthop-
nea with a rre(|UL'nt sense of suffocation, pain atid violent pul-
sation of the vessel, and great palpitation of the heart. In a
very interesting case reported by Dr. Purks,* a loud, rough,
Bystolic bruit, due to the pawasie of the blood over a surface
roughened by a deposit of lymph, was hoard from the third dor-
sal vertebra down into the luntbar region ; while the pulse was
irregular and snialf, though this arose from the aortic orifice
of the heart being diseased. The pulse is often unatTccted.

The appcaruncus found after death are great vascularity,
with a thickened pulpy suite of the inner and middle coats of
the artery. Ijyniph is .sonietirucs detected effused on the in-
ternal tunic.

Should the existence of aortitis be suspected, warm baths,
dry cupping over the spine, counter-irritation by means of
blisters, and the administration of iodide of potassium and

• Mtnlieal Tivut. London, Frbruary, 23d, )SJO.

ANEURISM or THE AORTA.

iidf)

opium, are the meaiiurca to be resorted to. Colchioum niaj
pprhapA do good ; while ether may be tried to relieve the

orthopnom.

II. AORTIC PITLSATIOIf.

Aortic pulsation is a peculiar fiiDctional affection, charac-
terized by violent throbbing, usually most observable in the
abdominal portion of the vessel. It causes annoyance rather
than pain ; but nt times produces sickne.'ss and syncope. The
pulsation may frc(|iifntly, in thin .subjects, be seen at the epi-
pistrium, nnd wmietinies at the umbilicus. On applying the
hand, a jerking, quick, strong, forward impulse is felt; while
au-scultfllion often di.«covers a bellows-murnuir, especially if
anffiuiia coexists. The diagnosis between functional and ancu-
rismal puLsation is somewhat difficult. I have found this pul-
sation not uncommon in cases of utcriue disease. It has also
been frequently noticed in hypochondriacs, in those whose di-
gestive organs are deranged, in gouty patients, in cblorotio fe-
males, &c.

The trmtmrnt must be directed to the removal of the cause.
In a case which was under my care during the year 1853, in
the Hospital for Women, the pulsation produced so much sick-
nes.s and distress, that it was frpc|ucntly necessary to control
it by the application of ice to the abdomen, and by the admin-
istration of morphia. Hohnbaum, who suffered for some years
from this disease in connection with dyspepsia, .says that he
derived most relief from the u.sc of the aperient waters of
Carlsbad, change of air, and complete relaxation from his pro-
fessional duties.

III. ANEUBISM OF THE AORTA.

Three forms of aneurism are usually described. True
aneurism, io which all the coats of the artery dilate and uuito

610

DISKASE8 OF THE BLOUU VESSELS.

in lorininp the wnlls of the pouch ; falte aneiirUm, in which
the inner unij middle arterial tunics being ruptured, the wulla
arc formed by the cellular coat and conli<;iiou9 parts ; and
mixrd fir rouseciitirr fti/Ke ancurium, in whii'h the three coata
having; at first dilated, the inuernnd middle ones subsequently
rupture as the disleiision increases. When the two inner
tunics are ruptured, and the blood forces its way between them
Bnd the outer coat by a kind of false passage, so as to form a
spreading diifused tumor, the cose is known as a diuecUny
aueurinm.

Aneurism is more conituon in men than in women. Thus,
according to the Rpgistrar-Gotierara Returns, there were in
England in 18<')8, '2i>i> dcathh from aneurism in males, and 92
in females.

Aortic aneurism is a disease of advanced periods of life
rather than of youth ; it often result.'^ from atheromatous or
calcareous deposits, or fium fatty dogcTieration of the coats of
the vessel ; when the tumor is !<miill, its existence frequently
goes undetected; and death generally results from rupture of
the sao, or it may also occur suddenly without any rupture, or
it may t^iku place gradually from exhaustion caused by the
long-continued suffering.

1. Aneurism of the Thoracic Aorta. — This is chiefly met
with in the ascending portion, or in the arch.

The general ni/m/ifomn are very obscure, partly in conse-
quence of their similarity to those arising from disease of the
heart. Supptosing the ancurismal tumor is large and pulsating,
and rises out of the chest, producing protrusion or absorption
of the sternum and ribs, then the diagnasis is altogether as
easy as it was before difficult. When the sac presses upon the
trachea, there will be dyspncea and cough ; when on the recur-
rent laryngeal nerves, aphonia with troublesome cough, and
pain which comes o(i in paroxysms j when on the (esophagus,
dyspliiigia and syniptouis of stricture; and whcu on the thj-

ANF.l'RI8M OF THE AORTA.

611

racic duct, inanitinn and engorgement of the absorbent veraels
and gliinds.

When a cervical or thoracic aneurism presses backwards
deeply towards the vertebral column, it may give rise — as Dr.
W. T. fJnirdner first pointed out — to permanent contraction
of the pupil of the affected side. This contraction is prfjbably
due to irritation of the gynipathetic. As a sign of aneurism
its value is diminished by ihc circumstance, that probably any
tumor which extend? in a .Muiitar direction and gives rise to
the necessary pressure, will have the same effect. Dr. Ku.ss-
maul has proved that obstructing the flow of blood through
the carotid artery, produces a contracted pupil ; but this
contraction only lasts for a short time, and is followed by
dilatation.

Aortic aneurism is sometimes accompanied by a bellows-
sound, somotiines not. In false aneurism there is generally a
murmur both with the entrance and exit of biood into the sac ;
or there may be one lond, prolonged, rasping bruit, from the
passage of the blood over the roughened inuer surface of the
vessel. In true aneurism, or mere dilatation of a part of the
wall of the artery, murmurs are seldom audible. A small
but free opening; from the canal of the artery into the aneuri.'t-
mal sac, and a rou^^hencd state of the arterial tunics from de-
Bueration or from atheromatous deposit, arc, however, two
conditions which will give rise to a bruit. In both forms,
when a murmur e.ti»ts, a peculiar thrilling or purring tremor
will be felt ou applying the baud over the sternum.

The aneurism may prove fatal by bursting into the trachea,
or into one of the bronchial tubes. It is curious that occasion-
ally aneurismal patients expectorate blood, to the extent of many
ounces, for weeks or months before death. Dr. Gairdnor ha-s
directed the attention of the profe8.sion to a case in which the
first gush of blood took place four years and eight months
before the patient's death, blood being also expectorated in
varying quantities at diflcrent times during this period.

In many cases of aortic aneurism there is a destructive in-

612

DISEASES OF THE BI^OODVESSELS.

fiamraation of the long, owing either to compression of the pul-
monary vessels cutting off the supply of blood, or perhaps to
pressure on the pncuniogastric nerve diminishing the nervous
force and consequently interrupting the nutrition of the af-
fected lung.

The treatment of these cases is the same as that required
in aneurism of the abdominal aorta.

2. Aneoritm of the Abdominal Aorta. — The aneurism
often fiives rise to acute pain in the lumbar region, occasion-
ally filiootin;^ into either hypoclinudriuui, and downwards into
the Ibigbs and scrotum : uunstipution uugnivates the pain,
while lying on the face often gives remarkable relief. By
eareful examination, a tumor may generally be felt, which
communicates a constant and powerful pulsation to the hand.
On applying the stethoscope, a short, loud, abrupt bcllow»-
eound will be heard.

In t!ie <.!wtjiio*i» uf aneurism it must be remembered .that
simple or malignunt tumors having their seat over the artery,
receive pulsation from it. Moreover, if such growths cause
much proti.sure upon the aorta they may produce a murmur ;
if they press upon the trachea and ecsophagus, there will be
djrspncea and dysphagia ; while in cither case we shall find
dulness on percussion. Our diagnosis must bo made by a con-
sideration uf the history ; by noticing that aneuri.sms pulsate
from the first, while tumors only appear to do so when thej
acquire some si/.c ; by remembering that tumors are hard and
firm from the cninmencciucnt, whereas aneurisms only become
so Hubdcquenliy; and by observing that gentle continued pres-
sure will often diminish the size of an aneurism.

The treatment of aortic aneurism — whether thoracic or ab-
dominal— must consist in the avoidance of all bodily and men-
tal excitement ; in the use of a generous reparative diet, free
from Btimulante of every kind ; and in attention to the diges-
tive, secreting, and excreting functions.

The method of cure proposed by Valsalva and Albertiut,

PHLZBinS.

613

and which has been since often adopted until the present time,
consisted in bleodinp; the patient frequently, ami keeping him
npoD the lowest possible diet eumputible with the sustenance
of life. By this means it was thought that the force and ve-
locity of the blood would be diminished, and that coagulation
would take place in the aneurism. Since, however, the coagu-
lation of fibrin seems to be impeded by diminishing its rjuan-
tity, and as the rapidity of the circulation and the throbbing
of the arteries are increased by depletion, Valsalva's method
would seem to produce effects the very opposite to those wished
for; and such is the fact. Dr. Copland says be has seen oases
" in which aneurismal tumors had existed for some time with-
out any increase, so long as the patient avoided any marked
vascular excitement and continued his accustomed diet ; but
when repeated depletions and vegetable or low diet were
adopted, great augmentation of the tumor, and fatal results
soon followed."

In advanced and aggravated cases wo can only endeavor to
palliate the various symptoms as they arise. Thus, the pain
and depression will always be moderated by opium, which ia
an invaluable drug; the harassing cough may generally be re-
lieved by sedatives and expectorants ; the dropsy by small
doses of mercury, digitalis, squills, and other diuretics; while
the heart's action may be regulated and moderated by assafoe-
tida, camphor, digitalis in small doses, but particularly by aco-
nite. In all cases, experience no less than common sense
teaches us to avoid loo debilitating a plan of treatment. This is
especially proved by the fact, that of all the diseases which
accompany aneurism, tuberculosis is the most common.

IV. PHLEBITIS.

Phlebitis, or inflammation of the veins, depends upon, or
is generally accompanied by dtsea.se of the blood. Mr. Henry
Lee has clearly shown that the lining membrane of veins has

614

DISEASES OF THK BLOODVESSELS.

a very slight tendency to inflammBtion ; and that when ia-
flanied it does nut exude lymph as a serous membrane does.
Indeed it is now well known, from recent experiment and ob-
servation, that the doctrines of the effusion of lymph from the
lining membrane of veins, and the formation of pas by the
same, are quite untenable. As Virchow has proved, the his-
tory of the iiftections of veins to which the term phlebiti.s has
been hitherto applied, is really the history of the coagula
(thrombi) formed within thcni, and of the metamorphosea
through which these coagula pa.«s.

Symplomt. — The signs of phlebitis are — pain, which is in-
creased 00 pressure, swelling, t-tiffness, and redness in the
course of the vessel, generally spreading upwards towards the
heart. When suppuration results, it is usually accompanied
or perhaps preceded by rigors and flying pains in various ports
of the body. The constitutional disturbance is always great.
The result of the adiiii.\turc of pus or other morbid fluids with '
blood is to cause the hitter to coagulate; in this way a vein
sometimes becomes filled with a coagulum, when, if the mor-
bid mutter is of such a nature that it ought to be eliminated,
the areolar tissue around inflames, suppuration and abscess
follow, the coats of the vein ulcerate, and the conUiined clot
is discharged by meang of the abscess. On the other hand,
if the poison does not produce coagulation, it mises with the
circulating blood, affects the whole system, and is subsequently
deposited in distant parts, as in the lungs, liver, spleen, eye,
joints, areolar tissue, &o., giving rise to very serious conse-
quences.

Trtaiment. — This consists in rest, fomentations and poul-
tices, and purgatives. When the system is low, stimulants
and tonics will be necessary ; especially good boef-tea, port
wine or brandy, and opiates to relieve the restlessness.

Ttn-BOMASTA DOt.EN8.

filS

V. PHLEGMASIA D0LEN8.

Plitegmasia doleiis may be defined as a brawny, non-oedoraa-
tous, puinrul swcHiiii: uf one or both luwer extremities, attended
with depression of the vital powers. It probably depends upon
the coagulation oi blood within the internal or external iliac
aud femoral veins, owing to the reception within these vessels
of some poisonous fiuid. The disease conimeDces for the most
part — especially in puerperal women — in the uterine branches
of the hypos^astrio veins. It has been termed ob.«tructive
phlebitis. It is most likely tbat the lymphatics are also in-
volved in the morbid action, and that they become obstVucted.

I'hlefimasia dolcns in very common after parturition, especi-
ally in women who have been much weakened by flooding, or
other causes. The left leg is said to be more freijuetitly at-
■ tacked than the right.

Si/mpt07n». — It commencea generally, in from one to five
weeks after labor, with fever, headache, thirst, nausea, and
pain. At the end of twcnty-fuur or tliirty-.six hours, there is
HWcllint:, and lass of motor power of one of the lower extremi-
ties— rarely both limbs are aftected — the swelling beginning
at the upper part of the thigh, and gradually extending down-
wards. The limb is unnaturally hot, tender, not wdeniutous,
but swollen sometimes to twice its natural size j it is of a pale
white color, and is tense and elastic; while it has also a glazed
or shining appearance The acute stage generally lasts about
fourteen or twenty-one days, but the limb often remains swollen
and feeble, or almost useless, for many weeks or even months.

Patholnijy. — Dr. Mackenzie rejecta the opinion that this
di.sease arises from phlebitis, but believes that it is due to a
vitiated state of the blood, giving rise to irritation of the
nerves, muscles, lyniphaticj*, lining membrane of veins, and
areolar tissue of the limb; owing to which there results the
tense ela.stic swelling, pain, loss of the power of motion, affec-
tion of the lymphatics, and obstructed condition of the veins,

616

DIBEAci^S OF THE BtOODVESSELS.

constituting the pathognomonic Rymptoms. Hence, this gen-
tleninn asserts that phlegmusia Uulens is a blood disease, the
affection of the veins being of secondary importance, since it
is merely an effect of the disorder.* Dr. Robert Lee — in a
paper published in the same volume as Dr. Mackenzie's —
gives the results of his last twenty-four years' experience.
Hia oases, he says, "prove in the most conclusive manner that
inflammation of the iliac and femoTBl veins is the proximate
oauso of the disease; and that in puerperal women, the inflam-
mation commences in the uterine branches of the hypogastric
veins. It has likewise been demonstrated by morbid anatomy,
that phlegmasia dolens is a disease which may take place in
women who have never been pregnant, and in the male sex,
and that, under all circumstances, the proximate cause is the
same."

The latest writer on this diseftse is Dr. Tilbury Fox, whoee
essay is well deserving of careful study.f I can only give
this gentleman's conclusions, which are as follow: In phleg-
masia dolens both veins and tyraphutics are obstructed. The
obstruction may either be due simply to extrin.^ic pressure; or
to influiiitnatory change* in the coats of the vessels leading to
coagultition (this depends upon virus action), which except
during epidemics of puerperal fever is not so common as i*
supposed. It being generally admitted that rapid ingress of
abnormal fluid suddenly, ntid in large amount, will cause in-
stantaneous coagulattun of blood; and it being also allowed
that large drains from the system are followed by rapid and
compensatory absorption ; — there is good reasons for believing
that these conditions arc amply fulfilled, in conjunction with
the presence of wound (facilitating absorption) in a great many
cases, prior to the occurrence of phlegmasia dolens, and that
the latter is frequently thus evolved. These different modes
of erolution may be more or less conjoined.

• MttlirvChirurgical Tratuactioiu, Tol. xxzri, p. 149. London, 1853.
t TiUMtactioiu ofthf Obttelrical Soeitljfof London. Vol. il, p. JOl.
I^ndoo, 1861.

PHLECMAHIA DOI.KNS. 017

Treatment. — Dr. David Davis, who paid much attention to
this affection, recommended the local abstmction of blood by
leeches, the application of blisters, evaporating lotions, free
and constant exposure to the action of the atmosphere, and
the internal exhibition of digitalis and blue pill. — Dr. R. Lee
seems to place most reliance on the repeated application of
leeches above and below Poupart's ligament. — In the cases
which have been under my own observation, I have generally
at first employed warm fomentations, perfect rest, simple diet,
and opiates to relieve the pain. The patients have invariably
been in a feeble state of health, and consequently such reme-
dies as venesection, leeches, calomel, and digitalis have not
been thought of. Subsequently, great benefit has seemed to
accrue from attempts to improve the condition of the blood ;
as by the use of wine, brandy, ammonia and bark, &c.

Blisters, stimulating liniments, and bandages to the limb,
are useful when all the acute symptoms have subsided; at
which stage I have seen much good from the employment of
the iodide of iron, glycerine or cod liver oil, and change of
residence to the sea-side.

62»

APPENDIX OF FOUMUL^.

Id prewribini; n medicine, ntlenliim mast b« pnid to the Tollowlng
potnti: Age, Sex, Temi>erament, Ilivbit, Cunciitiun o[ System, Cliuiste,
and Season of the Year. Tbe suoceeJing IVirratilie are for Adults, eioepl
when the contrary ia stated. The dosea may, boweTer, be redueed by
Bttention to thii table :

For an adnlt, suppose the dose to b«
Under 1 year, will reiiuire only

•• 2

.. 3

.. 4

•' 7

" 14 " "

" 20 " "

1 or Sj.

1-1 2th or gr. t.

l-8th or gr. riisa.

l-(Jth orgr. X.

I-4th or gr. XT.

l-3d oraj.

1-bair or 3s8.

2-3dii or 9ij.

Aboya 21, the full doee.

" 05, the dose must be diminbhed in the inrerse gradation of the
above.

Children bear as large ilosea of mercury as adalts : but they are much
more snaoaptible to the influence of opiates. Consequently, opium must
be given in very minute doses to them. Fem&lea, also, require smaller
quantities of [wwerful mediaines than mitles.

Tbe skill of the pfaysictan is shown by tbe administration of the proper
remedy at the pri>[i«r time. A druggist's apprentice can tell what agents
will purge, vumit, or sweat ; but a man must be practically conrersant
with di-ease to be able properly to apply his therapeutical ruources to
the exigenciea of any particular case.

Tbe practitioner will do well to bear in mind the following rales : I.
Wfaen a disease is pro|;ressing fariirably towards recovery, do not inter-
fere with the efforts of Nature fay the administration of drugs. — 2 When
drugs are needed, other things being equal, employ the remedy wbioh
will be tbe lea.<t distreiisiDg at the time, and subsequently the least inju-
rious to the constitution. — 3. Put the medicine in that form in which it
ean be most easily taken. When possible — especially with children —
cover the disagreeable taste of the draught by syrups, Ac. — 1. Attend to

620

APPENniX OF pnnMHL-«.

the coodition umlrr wliicb Ihi- patient will be ut the (wrloil or the msili-
cine's action ; t. ^., it will be worse than awleu to give a aailoriBe to an
indiridunl obliged to be in the open air soon nfter taking it. — j. Be care-
ful that the variouv agenta in the prescription are not incompatible with
each other, unlesii it be desired to Tortn some new or particnlnr compound.
Chemical iaoompatibility, however, Is by do means synonymous with
therapeutic inertness ; for expericnoe tells ns that certain unchemical
cnm|>ouo(l9 — bichloride of mercury and tincture of bark, gallio acid and
tincture of opium, calomel and l^ver^s powder, Ac — are all valuable
prepariitioii^ in curing; disi^nses. — fl. Remember that if a disease be incu-
rable, it mny »till ndmit of great alleviation. Hence it is cruel to give
np any case; iillbough, at the same time, the patient is not to be deceired
by false promises. — 7. Xever order, or sanction the use of a quack medi-
cine; I*, f , one, the composition of which is kept a secret. — H. White it
Is allowed that many of the following formulae may often be employed
unaltered with great adv.intagc, yet it is not supposed that they will
usually be prescribed with servile exactness ; for it must never be for-
g</tlen tliut all medicines of any power have to be adapted to the rei|uire-
ments of the special case under treatment. It has been quaintly but
truly observed, that a bundle of ready-mndc receipts in the hands of the
routine practitioner, is but a well-equippi^d quiver on the back of an un-
skilful archer.

For the sake of convenience, the formal^ have been arranged in twenty
classes, running thus:

PAGC
1. Aliment 831

2. Alteratives and Resolvenls,

3. Antacids, ....

4. Antiseptics,

b. Antispnsmodics, .

6. Astringents,

7. Uaths, ....

8. Cntbarlics and Anthelmintics,
ft. Caustics and Counter-irritants,

10. Diiiphnretios,

11. Diuretics, ....

12. Emetics and Expectorants, .
1.3. Emmenagogues, .

14. Qftrgles and Inhalations,

lb. Lotions, Liniments, and Cullyria

Id. Narcotics and Sedatives,

17. Ointments, ....

IK. llefrigerants and 8a1ines,

19. Stimulants,

JO. Tonics

MS
fi33
fi:<4
6H&
037
A4)
043
AS3
d&3
66i
«&«
Oil)

enu
ti«i

l>0&

«n9

071
073
I1T4

ALIMENTS.

G21

I. ALIMENTS.

Formula 1. Extract of Beef .

Take ane pound of ruinpMeak, mince it like ttau^age^mest, and mix it
with one pint of cuM water. Place it in a pot at the side of the fire, to
heat very filowlj. It maj stjind two or three hours before it ia allowed to
simmer, and then let it boil gently for fifteen minates. Skim and senre.

3. hiehig''$ Suup for Invalidt,

Take \ 11^. of newly killed beef nr fowl, chop it fine, add 5xij of distilled
water, four dr(>pj< of pure tnuriatio acid, 34 to 57 ^rs. of common salt, and
itir well together. After an hour the whole ii to be thrown on a conical
hair yiere, and the fluid allowed to pa?^ through without any pressure.
The first thick portions which pass are to be returned to the ttieve, until
the fluid runs through quite clear. On the flesh residue in the sieve pour
slowly Svj of distilled water, and tei it run through. Tbere will be thus
obtained about sixteen fluid (>nnoei> of cold juice (cold extract of flesh),
of ft red color, and po^senaing a ploajiant taste of soup ; of which a wioe-
glo^^ful may be taken at pleasure. It mu!*t not be wanned (at lea«t, not
to greater extent than can be effected by partially flUing a bottle with ii,
and standing this in hot water)^ since it is rendered muddy by heat, and
deposits a thick coagulum of albumen and the coloring matter of blood.
Very valuable in cases of conti tnted fever, in dysentery^ aiirl iwleed in all
di*eases attended trilh great prostration and weakness of tite Uigeatiif9
organs. When the flavor is thoiiglu disagreeable, it may be conctaletl hy
the addition of spice, or of a fcineglassful of claret to each teaeupfnl of

3. Essence of Betf.

Take a pound of lean beef, free from skin and fat; ohop it up; put it
into a large earthen jar with cover ; cement the edges with flour paste ;
tie tt up tightly in a oloth ; plunge it into n saucepan and let It boil for
two hour^; pour ofi"the liquid eP5cnce from the coagulated muscle; let it
■tand till cold ; and skim ofl* the fat. — Dn. DnriTT. In hucnse Debility.

4. Extract of liullocL's Blood.

This somewhat norel remedy is beginning to be pretty much used bj
Oerman physioianf!. It is prepared, according to Maulhner> process, by
■training the blood of the ox through a fine sieve, and drying and powder*
ing the residue. Of this medicine Dr. Horing gives from ten to thirty
grains in the twenty-four hours, according to the age of the patient. Ue
relates the pnrticulars of three ca^es in which he adminifitered it : the first,
a case of curvature of the lower part of the ttpinal column, with loss of
power of limbs ; the second and third, oases of tubercuIof<is, occurring In
a child ogrd threo and a man aged forty. The treatment was successful
in eTery case, the onrrature being arrested in th« first, and the cough and

022

APPENDIX OF FORMULA.

emuiktion gnatly improrcd in the wsond uid third. — Wurttmi. Corr.
Bl. 32, I8i3.

5. Egs^if Crnam, and KxJraet of Beef*
Wub a quarter of n poand uf (be belt pearl rago until the water poured
from it ii olear. Then etevr the lago in * pint nt witter nntil it in qnit«
tender and rery thick: mix with it it pint of good boiling oreani and the
jrolks of six fre«h eggs, and mingle the whole carefully with two quarti of
good beef-tea, which should bo boiling. Serre. ThU iwiiritJtiuf irolk
it very useful in mttntf en*e* of lingering eoniUiUtetnee nfter acute tiitfiUM.

0. Mutton or Veul Broth.

Take of miillnn or veal four jKiunds; cold water three quarts; a little
nit ; and riue four os. Siiomer for four hours, boil for a few minotei,
■train and serre.

7. Gruel and Beef-Tea.

Take two tablespoonfuls of oatmeal with three of cold water, and mix
them thuroughly. Then add a pint of strong boiling beef-tea (or milk);
boil for llvo minutes, stirring Wf;ll to prevent the oatmeal from burning ;
and strain through a hair sieve. — An erttllent simple restorative during
coHvnUiccnce from netite JiSMse before solid fooil am be taken,

8. Tapioca and Cod Liver.

Boll a quarter of a pound of tapioea till tender, in two quarte of water ;
drain it tn ii cnlleniler. then put it back in the pnn ; season with a tittle
aalt and pepper, acid half n ]iint nf milk, and put over one pound of fresh
cod liver cut in eight pieces. Set the pnn near the fire to simmer slowly
for half an hour, or n little more, till the liver is quite cooked. Press
on it with a spoon, so Ojt to get as muob oil into the tapioca as possible.
After taking away the liver, mix the tapioca. If too thick, add a little
milk, then boil it a few minutes ; stir round, add a little salt and pepper,
and servo. — Alexis Sotkr. Tapioas thus eauttJ is nourishing and
eiisily digested.

9. The Binn Ijoaf.

The formula used by Mr. CaMplin, in Diabetes, is as follows ; Take a
nfflcient quantity (say two or three quarts) of wheiit bran, boil it in two
■neeesaiTe waters for ten minutes, each time straining it through a sieve,
then wash it well with cold water (on the sieve), until the water runs at
perfectly clear ; squeete the bran in a cloth as dry as you can, then spread
it thinly un a disb, and pince it in a slow oven — if put in at night let it
remain until the morning, when, if perfectly dry and crisp, it will he St
for grindini;. The bran thus prepnred must be ground in a One mill, and
sifted through a wire sieve of sulllcient fineness to require the use of •
brush to pass it through ; that which does not pass through at first masi
be ground and sifted again, until the whole is soft and fine.

Take of this bran-powder three ounces troy, three fresh eggs, one van**

ALIMENTS. 623

■od a half of bntter, rather Icra than half a pint of milk ; mix the eg^s
with part of the mills, and warm the butter with the other portion ; then
■tir the whole well together, adding a little nutmeg and ginger, or any
other agreeable spice. Immediately before putting into the oven, stir in
flrst thirty-five grains of sesquicarbonate of soda, and then three drachma
of dilate hydrocblorio acid. The loaf thus prepared should be baked in a
baain (previously well buttered) for about an hour or rather more.

Biscuits may be prepared as above, omitting the soda and hydrochloric
aoid, and part of the milk, and making them of proper coneiatence for
moulding into shape.

If properly baked, the loaves or biscuits will keep several days, but
should always be kept in a dry place, and not be prepared in too large
quantities at a time.

10. White Wine Whty.
To half a pint of hot milk, add one wineglai>«ful of sherry or Madeira ;
then boil, until the card separates, and strain through muslin. Sweeten
with refined sugar.

11. Caudle.
Beat up one egg with a wineglossful of sherry, and add it to half a pint
of fine hot grnel. Flavor with sugar, nutmeg, and lemon-peel, hi in-
tomnia with debility.

12. Frrrngiiioui Chocolate.

Spanish chocolate 16 ox.; carbonate of iron half an ounce. Divide into
one ounce cakes. One to be dissolved in half a pint of milk, and taken
night and morning. /» aniemia, amenorrhaa, ifC.

13. Lime-water and Mill.

3. Liqnoris calcis, Lactis, Su Sig. Mi«ce. Thit compound leill some-
timre be relainetl when all other food it ejected. As a variety, milk and
uidn-tcnter, in ei/tial proportions, may also be ordered.

14. Artificial Ass's Milk.
Take half an ounce of gelatine, and dissolve it in a pint of hot barley
water.- Then add an oance of refined sugar, and pour into the mixture a
pint of good new cow's milk.

15. Artificial Goat's Milk.
Chop an ounce of suet very fine, tie it lightly in a muslin bag, and boil
it slowly in a quart of new milk. Sweeten with white sugar. An excel-
lent aliment in some eases of tubes mrsenterica, ifC.

18. Milk, Flour, and Steel.
Beat up carefully one tablespoonful of fiour, one raw egg, and about a
rcruple of the carbonate of iron, with half a pint of new milk ; flavor with

624

APPENDIX OF FOBMUr,^.

nutmeg and whiU sngsr. To be taken for lunch with a bi«onit. I» tk»
early $Ui^et of tubereti/oth, the ant/tar tuis found this mij:ittre very
valuable.

17. BrnU Jelly.
Take a qnnntit; of the xafl pjirt of a loaf, break it up, cover it wilti
boiling water, and allov it to sonk for some bonrt ; tbe water^^ontaining
all the noxious matters with which the bread may be adulterated — is then
to be strained off conipletelj, and fresh water added ; place tbe mixture on
tbe Are and allow it to boil for some time until it becomes smooth ; tba
water is then to be pressed out, and the bread un cooling will form a Ibiok
jelly. Mix a portion of this with sugared milk and water, for use aa it ii
wanted. Ds. OauBCBiLL. A goo<l food for iufantt at the time of wean-
ing, i/c-

JS. A Nnlritiotu Demiilcenl Drink.

Mix together half a pint of Mistura Acaciss, Mistura Amygdalae, and
pure milk ; sweeten with sugar-candy or honey ; and add one large table-
spoonful of any liqueur. Allow tbe whole to be taken during the day.
Thii drink it very giatefnl in caets of tonsillilii^ ttlcerijtinn of the fiha-
ryfiT, ife. ; also in some ctitrs of itebitity with irritability of the etomacA,
and a tendency to diurrhaa.

19. Indian Sareaparilla and Barley-water.
H. Syrupi ]{rmidcsml (Phar. Dub.), .^ij ; Deoocti Hordei Compostti,
tx. Fiat Misturn, cujussuuiantur cochlcnria ampla duo interdiim. Ah
agreeable demulcent anil diaphoretic Mixture^ partieviariy ttuful in in-
Jtammationt of the mucous memhranee.

20. Ah Excellent Nutritious Etuma.
This enema may be made by mixing together (nm four to twelre onneea
of very strong bref-ten, half an ounce of melted butter, and half an ounce
of brandy or one ounce nf port wine. It may he administered twice or
thrice in the course of the twenty-four hours, in cases of acute gastritis,
caroiaoma of the itomacb, iui., where it is necesmry to rest this visciu.

21. Cod- Liver Oil Enema.

Take four ounces of essence of beef, two ounces of port wine, half aa
ounce of cream, an ounce nf cod-liver oil, and twenty drops of laudanum.
Administer this enema every eight hours,

22. Quinine and Beef Enema.
Take one tablespoonful of brandy, six grains of disulphate of quinine,
two tablesponnfuls of cream, and from four to eight ounces of strong beef
tea. The latter should be made without any salt or spice. — This enemk
may be administered every six or eight hours. If the rectum is very ir>
rilnble. from twenty to thirty minims of Ilattley's Liquor ttpii Sedativna
fnay he ndvantagenusly added.

ALTERATtVES AITD BtSOtVEKTS.

625

n. AXTERATIVES AKC RESOLVENTS.

S3. Compound Calomel Pilt.
n. PilnliB Hyrlrarg^ri Cblorid! ComposiUc, gr. r ; Extracti Opii, gr.
M. Fikt pilal*, otnni o<ict« gumenda, Tel nooU maneque. In Hitoril»n
dtpendntt oh a vtntrtal taint.

24. Sartoparilia and Corrosive SuhiimoU.
H. Liqnoris Uydrarg;ri Bichloridi, 3j ; Extracti Same Liqaidi, Jj ;
Deoooti Sarae Oumpotiti, Sin. Hiaoe, fiat baiutaa, ter die samendas.

J5. Bromidf of Afereurif and Sarsaparilla.
R. Hjdrargyri Bromidi, gr. ■» ; Decooti Saren Compoaiti, Jin. Miioe.
Ter die samendas. In syphilitic lepra and secondary fyphilitic trnptiont.

26. Calomel and Opium.
4. Hydrargyri Ohloridi, gr. ij ; Pulverii Opii, gr. i ; Confeelionis
RoBie, q. B. nt fiat pUala, quarUL quiii|Ue hordsumenda. AManalteratitje,
tc'Asn ire with to get the syatem ijnicUy under the tnjiuence of mercury. -

27. Iodide of Potaesium Mizlure.
If. Patassil lodidi, 3j ,' Tincturic Serpentarise, Siij ; Aqaie Destillata,
SrJ. Misce. 8umat Sj t«r die. A valuable formula, in chronio rheH-
malim; at well at in catet of lead and mercurial }>oiioning.

28. Iodide of Potattivm and Liquor Potasta.
4. Potassii lodidi, Sj ; Liqnoria Polamne, Sij; Tinetarte Opii, 3n; In-
fari Quasriv, 3rj. Misce. Sumat ij ter die. In chronic rhenmaliim
vith coptout teeretion of lil/iatrt.

39. Iodide of Polotiinm, Steel, arid Cod-Liver Oil.

H. Potanii lodidi, gr. xxiv; Ferri Ammonio-Citralis, Sj ^ Olei Men-
thie Piperita, "Ix ; Olei Morrhua), Srj. Miace, Oopiat Sss bia die post
oibam.

30. Iodide of Potattium, and Epaom Salle, li«.

It. Potossii lodidi, gr. xij ; Vini Colohici. Siss ; Tlnctnrte Hyoaoyami,
Sj ; Hagnesiap Sulpbatis, Jus ; MisturtcGanipborte adJrj. Miace. Doaia,
pars sexta ter die. In some iiutaneee of gout with fever and conttipation,
and in chronic pleurity with ^ution, the author hat found this mixture
valuable.

31. Iodide of Potateium and Rhubarb.

IV. Potassii lodidi, 3ij ; Tinct. Rhei Comp., Svj ; Syrupi Sarste ad Siij.
Uiaoe. Signetnr — " A small teaipaonfal tbree timet a day in two table-
apoonfalfi of water." In folJiruiar inflammation of the pharyngo-lnryn-
geal memhrane, ^.

626

APPENDIX OF FORMDL^.

33. Iodide of Polauium and Aita/atiJa,
^. Poteraii Iadi<li, f^r. tJ ; Tinotum HyoKysmi, "Iz ; Tinolars Ana-
fcetidcD, Sin." ; Dvcocti Senrgv *d )ig«. Mince. Capiat ooohlears pwiroai
4t& ((U&que hort. For a child ahoiU tiro ymri old, tiiff'eriiig /mm C'Owp.
Also in toms com* of ittfitniiU pnenmonia.

33. Iodide of Iron and Gfj/eerine,
R. P«rri lodidi, gr. iv — gr. lij ; Olyoerinic, Sj — Jij. MiMe. V\m%
miatnra, cujut cspint partem quartam ter in die, ex ojritbo pnrro aqnas.
Ih tubtrcu/ont, tcrofitlii, ^., tckrre the ^ttunark itfitl not toitrate cod'
liver oil.

34. Iodide of Potauivm and Glyerrint.
^. Polaraii,Iodidi, sij ; aijcerinn Pane, 8yrapi Limoni, Si Sin. Fiat
mistara, onjas capiat cochleare parrum ter die ante cibum. In comj of
tuierrulosis, if<.

35. Iodide of Potojsittm and Coiekirum.

. H. Potanii lodidi, gr. ij i Tini Colobici, nvxr ; Tinctane HyoKjami,
^x; Inrufl Quaasin, SJ. Miace, flat baiutaa, ter die eumendua. In
ehranio gout.

S6, Sartaparilla and Iodide of Pottuhum.
tk. Decocti Saniv Compoaiti, Clj ; Pdtatsii lodidi, 9j. Miaee. 8aa*l
poeulnm (uociaa quatuor) bia terra indiea. In gonorrkaal rktumatitm,
Moondary tfpkiliM, eertain $kin diMOMt, (fC

37. Iodine and Sariapariila.
B. Liquorit Potaaii lodidi Componii, 3j — ]aa ; Dceoeti Saras Compo-
aitt, SJRi Miaee, fial hauatoa, I«t die enmeDdna. A uttful mtnh ^JM-
kihtttng iodine in tonu forme of bronehocfie, iff.

38. Iodide of Potauinm and SteeJ.
B. Potaaaii lodidi, gr. xij , Ferri AmmoBio-Citratia Sa> — -J ; Tioetara
HTOMTami, 5j ; MiatnrB Camphor*, Sij. Miaoe. Samat 9j ter di*. /■
tamt ^ dtiility, wKne iodine it rtquind.

39. Steel and Iodine.

K. Tinclnr* Ferri Seaqaichloridi, TiDctor* lodinii Compodta, U <%s :
Aqaa, Sj. Miace, fiat hanKtus ter die >aaienda«. In in^trcmUti*, mmm-
ttrie diteatt, i/t.

40. Stml and lodint.

H. Syropi Ferri lodidi, S«e: lalaai Calambaa, Sj. Mtam, flat baBa4a%
Ik 4i* luaaiidaa. /» atrataiaiM ^ediont, ekronie fJunwteitttm, tfC

AtTiniATIVBS AND BKSOT.VKNTS. fi27

41. lodidtof Potauium aiut Sttti./or ChiUrem.
R. PoUssii lodidi, gr. i^ j Ferri Ammonio-Citrktii, 9j; S^rapi Papa-
veri», Sij { lafuvi Qaanise, Siij. Migrc. Sum&t Ssa Ur di«. /» laiet
imsjutUerica, Krofnia^ i^r.

42. lodidt of Potassium ami Catumba,
R. Pot««ii lodidi, gr. j ; PolMca) Bicarbonstia, gr. XT ; Tinctnm
Anraotii, Sm ; Inrnii Calumbii<, SvijM. Misco. Horft mouDdL poit eibum
nmitur. Prrscribed with ththf$t tffert in thtflatHUnt dytptpsiaof gat'
trie ulcer. — Dr. Bbiktox.

43. Mirrvry, Chalk, and Dover's Powder.
H. Hydrargfri cam Crelft, Palrerig Ipecsouknhie Compoaili, H gr. t.
Miaoe, 6at palvia, omniboa MXti« horia aumandoi. In dfUHterf.

44. Ah Alterative aftd Purgative for Children.
4. BodiD Seaquicarbonatie, Hydrargyri cum Cretl, uu gr. ij ; Hagneaia
Carbonatia, gr. iij. Miac«, Sat palvii, omni Docte eumeDdui.

45. A Mercurial for Children.
li. Hydrargyri cum Creti, gr. ij ; Pulreria IpecacuaDbie Oompoaiti,
gr. aa. Mtsce, fiat palrla, omoibu.s ^extia horia auraendua. In iujiamma-
tioH of the serous memiranes in children from six to twelve months old
/n younger infants, the quantity bf eompouad ipeeaeuanha powder must
hedimiiusked.

46. Phosphoric Acid aiui Orange.

li. Acidi Phoapborioi Diluli, Siaa ; Acidi HyJrooblorici Diluti 3j j
Tinotam Aurantii, ad Siaa. Miave. Capiat oovhleare pnrvum bis die, in
quoWs robiciito grato. In mucous urine with copious deposit of phos-
phates.

47. Creosote Pills.

^. Crsaaotl, nvx — zx; Pulveria Olycyrrbiiae, 3J ; Mucilagioia Aoacin,
quantum auSoiat ut flaot pilule xx. Suioat pilulaa dna^ t«r di«. In
someform-tof neuralgia, chronic bronchitis, and vomiting when uneon-
tterted with iujlammation or organic disease, as seti-sieknsss, \c. After
taking creosote for a short time, the urine oceasioimlly assumes a dirty or
brownish-black color. Inunction with tar gives rise to the same effect.
Under 'these eireumstanees, ereasote has heen obtained from the urine by
distiUalioH.

48. Quim'ns and Ipeeaeuanha.

H. Quinus Diaulphatia, gr. viij; Pulreria Ipeoacuanhn, gr. xxir ; Pnl-
Teria Ipeoacuaobni Compoaiti, Saa : Mucilaginia Acacia;, cjuaotum aufficit,
at Sunt pilulaa •edeoim. Somat piinlee daic terti& qu&que borlt. /» dys-
entery oceurring in tropical regions.

Omauitmm tat aim lam UgU^
tt.Qwtmm

gr. Ilj. MlM*. Ui tU»U, *»r «• Milt

M. HarmpmU* Mtjtmm.
». Nyra^ Ktnm, ttj , BxtrMti ^oadca, SQ; On«cU Smw GmikmIU,
l«j. Ml«n. Oaptat ly bit •it*.

57, Anihon^ WAilt't Gout Pill.
H. Il;i|r>r|)rri I'hlorlill. RilrKoti C'olobioi Actliet, Extrseti AIom Pa-
tlAoNll l'iilv«rU (|>«>i>na>nhai, tt gr.J. If imc, flat pilaU qasrtt qalqa*
limft >iiMii'iiilii.

ALTERATIVBB AND RESOLVENTS. 629

58. ColeAieum and Blue Pill.
9. BztrMti Colohioi Aoetioi, gr.j ; Piluln Hydrvgyri, gr. iy. Hisec,
flkt pilnla, omiii noets lomcndk. Z» gmit vritk defieitttt aetioH o/ tht
Uv4r.

&9. Colekieum and Morphia.
4. Potaoas Biearbonatis, Siss ; Tini Colehiei, Sj — 3^ ; Liqooria Hor-
phin Hydroohloratia, in; Hiatara Camphors, Syj. Miam. Capiat tj,
omnibaa seztis horil. In tome forms of goiU, lolure the eorutittUional
power* are strong.

AO. Mercury, S^uillt, and Digitali:
Q>. Pilalas Hydrargyri, gr. i^ ; Palveris Scillas, gr. in ; Pulrtria Digi-
talia, gr. aa. Hisoe, fiat pilala, bia rel ter die aamends. Dr. Bi.illie.^
Recommended at an alterative and diuretic.

81. Bichloride of Merettry and Opium.
9. Hydrargyri Biohloridi, gr. y ; Polvarii Opii, gr. T — ^riij ; Palvcria
Oaaiaoi, Saa. Hiaoe. Fiant pilalas, zvj. Capiat j ter die. In tome forme
of eonttitutional lyphilit.

82. Oxide of Silver.
^. Argenti Ozydi, gr. aa — j ; Confectionia Opii, gr. iij. Miaee, flat pi-
lala, ter die aumenda. Of doubtful efficacy in dytpepiia, pyrotie, hamop-
tytit, menorrhagia, IfC.

83. Sulphite of Soda.
9. Sodga Sniphitia, Ss»— j j Infaai Qaaaeia, Siaa. Miaoe, flat hanatna,
ter die aamendna. Db. Jciririii. — In diteatet of the ttomach, accompanied
iy the formation of the eareina ventrieuli. The patient thould eat unfer-
mented bread urhile tajcing thit medicine.

84. Turpentine Mixture.
9. Olei Terebinthinaa Beotiflcati, Sj ; Vitelli Unina Ovi ; tere aimnl,
et adde gradatim Miaturas Amygdala, Sir ; Syrapi Aorantii, iij ; Tino-
tnrea LaTaadalte Compoaitaa, Siv ; Olei Cinnamomi, gattaa ir. Hiaee. 8a-
mat oooblearia magna ij ter die, Cabxicbabl. — Recommended in iritie,
wheie use of mercury it contra-indicated.

8S. Turpentine and Ether.
9. SpiritOa .fitheria Gompoaiti, S^ ; Olei Terebinthinas, 3ira ; Hiatara»
AoaeiiB, Svj. Hiaee. Bignetar — "One-aizth part three timea a day."
To prevnu the formation of gall-etoaee, or to aid in diiiolving them.
The utility of this mixture it doubtful.

53*

033

APPENDIX <iF FIlBMirLifE.

flfl. Tiirytntimf and Syrup.
ft. 01«i Tercbinthinie, Si» — 3i!j ; Syrapi Aurantii, Srj ; Hiatarni Aoa-
eiie, ad ITJ. Mirro. Signelur — "One-iixth pnrt eroryfour or «iz houra."
Useful in tome forme of httmatemfsis, /nrmnptytix, epittiixis, purjrttru
kamorrhaeica, (ft. he rfftcts muel if wauhnl, so thit it miiy h* liitooH-
tinvvi directly any unpluttnut results — such as strangury or severe vo-
miting;— arise. — If the symptoms are very urgent the first dose of the Sur-
fentint may consist ofiW — Srj, heatru up u*ith mucilttge ; the Mwcetding
doses fteittg aecording to the formula. In some aises the turpentine may
iie ojlvantogeously given ivilh gallic aeid^ or the tincture of the sesquichto-
ride of iron, or with the compound infusion of roses, or with the dilute
nitric aciil. A drop of aeasote with each dose ptalerialiy leeseiu i$4 tiH-
tleuey to tause nausea.

67. Donovan^ s Triple Solution.
H. Liquoris Hjilriodntiii AncDici et Hydrsrgyri, ^xx — 3«k ; Tinctnrie
ZiDgiberin, 3j ; Aqiie, 5j. Misos, fiat haUKlus, bis die taniendni. ITse-
ful in lepra, psoriiieie^ ifc. It should be taken with the meals.

68. Arsenical Mixture,
ffi. Liquori« PoUwir Aracoitia, T^lr ; Tinotura> Hyosoyami, ttIxt ; In-
ftiii Qaawiic, Sj. Misce. Ter di« rameDdua. To ke taken at mual-times.
Very useful in many ohstirutte rutaneous diseases. In ague the t/uaniity
of arsenic mail he doubled. Under any circumstanres, the dost skosUd it
dimiitishrd dirretly the syslom appears at all affected.

69. Arsenical Mixture with Colehtmm.
R. I.iqnnris PoUaaia ArMoitig, lUiij ; Liqnoria Potasaa,

Vini Colchici, TIt ; Aqnoi, y.
forms of chronic rheumatism.

Hi!0«. Ter die sumendua.

"Ix — XX ;
/h some

70. Quinine and Arsenic.
I(. Quinic Diiulphatic, 5j ; Liquoria PotasNB Araenitia, Sij ; Aoidi Sul-
phurid Dilnti, Sj : TiDFtnm Cinohonis Cumpoaitw, STrufii Zingiberis, UK
Sij. Miare. Capiat oochleare parram bia terre die, post cibum. In se-
vere neuralgia, chorea, chronic rhcumaliem, and iulermiltmi fever. Th»
action of this remnty must be airrfully watched.

71. Iodide of Arsenic,
ft. Liqnoria Potnaaai Araenitia, Saa ; Liquuria Pota.'.«ii lodidi ComposiU,
Iriij." Miace. Hignrtar — " One.eigbth part three timea a day, Just aftar
Bea'a." Vuluoblt in tomt inveterate cnlaneous diseatet, as Inpne, Itprm^
ftsoritisis, ^.

ALTERATIVES AND RESOLVENTS. 631

72. Chloridt of Arteuie.
9. Liquoria Arseniei Chloridi, Sj ; Tinotam Hyoaoyami, Sin ; Higtura
Cunphorc, Stj. Hiace. DoaU, pars aexta ter di«, port eibum. Tkit it
Utt likely to ditorder the ttomach and bowels than tht liquor pota$$a aree-
nitii. Jh ague the dote may be repeated every Jive or $ix hotirt.

73. Arsmiate of Soda.

H. Arwniatis Sods, gr. j ; Aqae Drstillatae, Sj ; Hisce. Samal gutta),
x^ , ad zzr io die. /» peoriatis, ehrome eezema, ife.

74. Iodide of Mercury.

^. Hydrargyri lodidi, gr. zij ; Laotnoarii, 9ij. Misee. Divide into
xxiv pills, and order one to be taken three or four times in the day. Tlit
iodide of mercury will cure »ome of the pnetular and tvbereitlar dieeatet of
the elein, at well at certain secondary venereal ulctrationt, when all other
meontfail.

75. Biniodide of Mercury.

^. Hydrargyri Biniodidi, gr. ij ; Extract! Oentianee, 8ij. Misoe. Di-
Tide into pills x^ : and order one to be taken twice a day. A eonple of
oances of the Componnd Decoction of Sarsaparilla may be taken with
each dose, or an ounce of the Mistura Gaaiaci. Uteful in the tame catet
at demand) the iodide of mercury. The biniodide, however, it lets likely
to cattle gastric irritation.

70. Biniodide of Mercury and Conium.
^. Hydrargyri Biniodidi, gr. ir ; Horphiae Hydroohloratis, gr. ig ;
Extract! Gonii, Sj ; PaWeris Zingiberis, 9j ; Olycerinae, quantum auffioit.
Divide in pilulas duodeoim asqnales. Capiat unam noote maneque. In
tome tubercular and uleeroui affeetiont of the tkin.

77. Biniodide of Mercury in Solution.
^. Hydrargyri Biniodidi, gr. iij; Potassii lodidi, 3i — $\j; Spiritfli
Vini Rectificati, Sj ; Syrupi Zingiberis, Siv ; Aquas Deatillatie, Siaa.
Hiace. Signetnr — " Thirty dropa three times a day in a wineglasaful of
water." Hb. Lamoston P^nnxRsays — and I confirm the remark — that
this remedy, used in eonjunetion with the mercurial vapor bath, produeei
excellent retultt in tome obstinate forms of tubereitlar disease of the tkin ;
at well as in secondary venereal ulcerations, proving intractable after the
employment of other remedies.

78. Iodide of Sodium.
H. Sodii lodidi, Sj ; Decocti Sarsas Compodtl, StI^. Misoe. Flat
mistura, onjns capiat partem quartam ter in die. Dr. OAMBiiitiiti, of
BoLOGRA, has recommended the iodide of sodium as an anti-syphilitic in
rases where the iodide of potassium cannot be borne. It will alto tome-
timet tueettd in Meeting a curt after the latter has failed to do any good.

682

APPENDIX or FORMDLiC.

79. Ptiefooti attii lodidf of ArttnU.

H. SangointritD Canadensit, gr. xij ; Arsenioi lodidi, gr. y ; Eztranti
Conii, 3^. Miwe eeounduro nrtom. et diride in pilulM xxiv, qoarum
capiat aoam t«r in die. Said to bf henejieial in eatu of card noma.

80. Woody Nightihade and Mtreury.
^. D««ooti DulcamariB, Sj — Sij ; Liquoris Hjdrargjri Biohloridi, 9|j.
Micce. Flat bauitns, t«r die Bumeodai. This decottion it alteralio* ia
itt action. It it utrful in tomt formt of ekronic rhsumatitm, and in
tome catet of conttilutional ttfphiUt.

81. Chloride of Brominm.
H. Bromidi Chloridi, gutt«iij — i» ; PotveriaOlycyrrhiase, Sj. HiteeM-
ennduDi artem. et diride in pilulat viginti. Capiat aoam bis larre die.
Recommendfd by LA.^DOLri, in caiictr.

82. Terehhridt of Gold.
9. Sodii AurO'tercbloridi, gr. y, aolre in aqna destillatc, q. •. ; Ez-
tracti Aconiti, gr. v; Extracti Dulcamane, Sbb -, Althea radicisto palver«,
q. t. Miroe. Divide in pilala« xl quarnm capiat anam ter in di*.
Grotireb. — Said to ie very effieaciout in venereal ektn affeetione.

83. Nitrate of Silver.
Vr. Argenti Nitratir, gr. j ; Mice Panin, qnantum plaeeat, nt fiat pilula,
bia die Biinienda. To be taken on an empty ttomneh^ for aftout ten dayt,
in eatei of idiopathic janndiee ehiejly dependent upon gitstro-dnodemal
dttturtattee rather than on diteute of the liver.

84. Hydrxtehlurate of Ammonia.
B. AmmoniK B;drochlorati«, Sin; Byrupt Hemideimi (Phar. Dub).,
Saa ; Aqute, Sviisa. Misoe. Capiat ooohlearia ampta duo nxti« horla.
In tome forpit of chronic rhettmntitm.

85. Mtitiate of Ammonia and Taraxaenm.
K. Ammonia) Hydroohloratit, 3j ; Extraoti Taraiaci, Su ; Miftnra
Gantiana! Comporitie, Sj. Mince, fiat haaitus, ter die lumendna. I»
aome eaeet of atcttes dependent on eirrhotit, in jamtdice, dimintthed i#-
trttitn of bile, ^.

88. Chlorate of Potaih.
B. Potaaaae Cbloratis, Sij ; Hiatune Camphoric, ]vj. Miaee. Capiat
^ ter die. In infiammatory affeeliom of the vuntth.

87. Chlorate of Potaih and Barl.
9. Potaiaa Chloratia, Siaa : TinolunB Cinohonm Compoaitaa. Sfj ,' Infoai
OinohoDte, ad Svj. Hiao*. Capiat nnciam anam bit terTa die.

ANTACIDS. 633

in. ANTACIDS.

88. Magneiia and Opium.
^. Hagnesio) GBrbonatig, Sj j Tinotura Opii, Sj ; Spiritfis iEtheria Com-
poiiti, Siu ; Aqaw Mentha! Bativae, Svj. Hisoe. Sam»( ooohlearw duo,
dnm flatui infeatat.

89. Magnesia and Soda.
9. Hagncaiae Carbonatia, SodK Carbonatia, Sfi sj ; Infaai Scrpentartae,
IJ. Miaoe. Bia terve die aamendua. /n chronic urticaria.

to. Ammonia and Chiretta.
^. AmmoniiD Seaqaicarbonatia, gr. T ; Tinotaraa Aarantii, Sj ; Infaai
Chirettffi, Srij. Hisce. Fiat liaaatua, mane meridieqae aamendua. A
UMfvl draught in dytpeptiu, vith acid cructationt and debility.

91. Bismuth PoKdert.
9. Bismatbi Nitratia, Hagneais Carbonatia, i& gr. X. Miaoe, fiat palria,
ter die aamendua. Vary useful inpyrosis, gaslrodynia, (fc.

92. CAott Mixture and Sops.
IV. Tinoturae Lupuli, Svj ; Tinoturie Cardamomi Compoaitae, Sir ; Tint
Opii, Saa — 3j ; Miatara) Gretas ad Srj. Miaoe. Capiat aemiuneiam quarts
qnftqne horft. In diarrhaa due to acidity of the prima via.

93. Potash and Ammonia.
H. Potaaaae Bioarbonatia, Sij; SpiritOa Ammonias Aromatioi, Si^i
Tineturai) Lupuli, Saa ; Infuai Lapnli, Srij. Miaoe. Capiat Sj ter die.
In atrdialgia.

94. Ammonia, Potash, and Bark.

9. Ammonias Seaquioarbonatia, Sj ; Potaaaae Cbloratis, sy ; Eztraoti
Opii, gr. Tj; Deoooti Cinchonae, Szy. Miaoe. Capiat ij ter die. Indt-
bility tnth acid secretions.

95. Liguor Potassa and Buchu. •

^. Liquoria Potaaaae, '"It — z; Tinotane Hyoaoyami, lUxx; Infaai
Buobn, Siaa. Miaoe, flat hanatua, ter die aumendaa. In catarrhus vesica.

96. Soda, Morphia, and Hydrocyanic Acid.
9. Sodae Bioarbonatia, gr. zt ; Liquoria Morphias Hydroohloratia, fix ;
Aoldi Hjrdrocyanioi Dilati, flT; Miataraa Camphora, Sj. Miaoe, flat
faanataa, atatim aamendua. In gastrodynia, ifC,, after the stomach has
brcn emptied hy an rmetic.

6S4

APPENDIX OF FOBMI'LiB.

97. Polaih anit AIm$.
t(. Potusa Bioarbon»ti«, Iss,- Tincturie Annntii, Siij; D«eooti Alom
Compostti, STtij. Miaee. Capiat ooohlearia tria magna omni man«. In
eJkronie gout.

98. Biearbuntjte of Potaak.
9. Potann Biearbonalis, Sm ; Aqate, Sim. Miaoa, flat liaustaa, m-
oondil qa&qoe horft aumendui. Db. Garboo uaet this draught in aU
COM* of atvtt rh^unuititiH, continuiti^ it urUii the joitUs artfrufnmk
paiH. It gAurally rentUri the uritu alkalitu in twtiuy-four honrt.

99. Polath and Limt-irater.
Vi. Liqnorii PotauK, i^Lzt — Jm; LiquorisCalcia, Siu. Hiaoe. To 6t
tatm in doubU the fHanlity ofhttf-tia, or milk, two or thrtt timtt daily.

IV. ANTISEPTICS.

100. SoliitioH of ChlorituUnd Soda.
Vi. Liqnoria BodB> Chlorinalar, Siij ; TinctnriB Opii, Sn; Miatane 0am-
phorae, Sviij. Hiaoe. Capiat 3j ler die. In gangrentof the luug, low
Jevfr, ^. It twt onJjf rtiieve* thtfator, hut acts oa an atterativt, ^. If
necettary, the opium ahouid be omittMl.

101. ClJorine OoM.
Aa a rumigaling agent, antiaeptio, and diaiafeciant, chlorine staada
nnrivalled. The ingrcdieDle Tor producing it should be contained in
aaucers placed in the higher parte of the room, oa the goa which is devel-
oped will deacend hy ite denaity, and .^oon beeuine mixed with the aar-
roandiug air. Dr. Faraday adopted the following method at the Milbank
Penitentiary: One part of common aalt woa intimfttely mixed with one
part of the block or binoxide of man^nneae, nnd placed in a ahallow
earthen pan ; two pnrta of oil of vitriol previoaaly diluted with two parte
by meaaare of water, were then poured over it, and the whole atirred with
a (tick. Chlorine eontinaed to be liberated from Ihie mixture for four
daya. A more aimple method of canaiog a rapid evolution of eblorine
gaa ia by placing aome chloride of lime in a aaucer, and pouring over it
a amill portion ofdilnte hydrocblnrio acid, or a aolntion of common aalt.

102. To prepare Chlorine for Internal AdminiatratioH.
Put eight graina of chlorate of potoaa in a atrong pint bottle, and pour
npon them one drachm of atrong bydroehloric acid. Cloae the mouth of
Ibe battle until the violent action ocaaea, when add one oonoe of wat«r,
and agitate well ; add another ounce, again shake, and continue tbia pro-
ceaa until the bottle ia full. Saa or Sj may be taken frequently according
U> Ibe age. An adult may use the whole pint in one day.

AMTT8PA6MODI0B.

esft

103. PmmongaHaU of Potash.
The periDSDRaDBtc of potwih U an excellent dininreotant : and Is the
banis orCondy> Antiieptic Flaid. Half a drachm to two or three drachma
of this fluid in one pint of water may be applied to all kind* of aappara-
iing eores. I have frei^nently used it with great benefit to destroy the
horribly offeosive odor of a malij^nant ulcer, or for the same purpose in
suppnmting scalds and burns. The solniion should be made only of snoh
a strength, as to be home without any pain or eren uneasiness. A piece
of lint saturated with the lotion is to be laid over the sore; and a layer
of ootton-wool applied over the whole. The solution (Sy to water Oj)
may be likewise employed as an injection in cancer of the uterus.

10*. Uhloruie of Zint.
This substance ia a most powerful caustic, which has long been ased to
destroy cancerous and other growths. It has been ndministered inter-
nally— dose gr. j, largely diluted — but without any benefit. It forms,
however, a valuable disinfectant gargle — gr. x to water Sviij, or in still
larger proportions it is a most efficacious antiseptic. Sir W. Burnett'*
Disinfecting Fluid consists of gr. xxr of this »alt to water 3j. For use,
about one ounce of this solution is added to two pints of water. To dis-
infect a sick-room a piece of Bannel three or four feet square is to be
moistened with a solution thus made, and frequently waved through the
air. Some of it should also be sprinkled upon the bare floor, ai well aa
placed in the olose-stoole and bed-pans.

)0&. Chloride of Lime.
V,. Calois Chloridl, 3j : 8aeohnri AIbi, Siv ; Amyli, Sj ; Olei Menthas
Piperitie, 3J ; Pulveris Tragacnnthfe Compositi, 5ij ; Aquie Mentha Pi-
perita), quantum sufficit, nt flat mossnla. Thii man ii to it divided into
ioz9nge* of twenty grains ear-h. One may he taken frequently to remove
fator oftke krealk, whether duf to mercury or other eaueet.

106. Bark and Camphor.
H. SpiritOs Camphorac, ^Ixx ; SpiritasVini Rectificati, Sj ; Infusi Cin-
ohona; ad Siss. Misce, fiat haustus. To he token every tix or tight houre
hy a nervout attendant in a tick-room. Its efficacy may be ittenattd iy
the occaeional addition of a glati of port vine.

V. ANTISPASMODICS.

107. Suiphnric Ethrr and Opium,
■(. SpirilOa .£theris Compositi, 5gs ; Liquoris Opii .Sedativi, flxx;
Tincturte Castorei, Rxv i Aqun Menthaa Piperilaa ad Siu- Mifoe, fiat
haoilos, pro re nalA aumendua.

APPENDIX OF POBMDL-«.

108. SiUphurir Ether and Ammonia.

K. Spiritfls jittberia Com{)Oiiiti, Siss ; SpiritOs Ammoniir Aromatioi,

3j ; MiDlara Gsmpborn, liij. Misce. Sumat Sj omni quadrante bora

dooeo dolor exulavertt. In tptumodie dis*a9fs, tiif A tu angina ptetorit, ^

109. Cnrmiiuuirfj and Etkfr.
H. Spiritflg .£tbsri8 Composili, 3ij : TiDctonu Cardamom! CompoBilw,
Siv ; SpiritOs Aniai, Sri ; OIci Carui, Tllxij ; Sjrnpi Zingiberi«, Siv ; Mif-
tane Camphone, Sij ; Aquts Mentbas Piperita, jiv. Miroe. Sumat
ooehlearia g ampla, urgente flatu.

110. Ammonia and Pi-usfic Arid.
9. BpiritOi Ammonitp AromaticT, ^xv ; Acidi H;dro«yaiiioi Dilati,
"liy i Tinotura! Cardamomi Coiupositio, Sj ; Syrnpi Croci, Sj ; Aqnie
Carui, ij. Miaoe, fial bnuatus, bis t«rTe, die someodus, urgeotc flatu
aut languore. In dyipeptia or debility, with irritakh itomafh.

111. A$tafirtida and Mutt,
ti. TiDctarn) AKsafcEtidie, Sij ; Tinoturie Castorei, Tinotane Moschi,
Su Sj ; Tincturic Opii, Sss. Misce. Sumat ^xxz «x Aqum MeotbiB
Piperits, Sj, spouudis horis. In hysterical paroxytm.

112. Auaftitida and Ammonia.

I(. TinoturK Aarafcvlidic, Sij ; Ammonie SeKqaicarbonatie, Sj ; Aqna
Pulegii, Siv. Fiat mistara, dr quit capiat cochleare unnm rel eooblearia
duo in langnoribas.

113. Chloroform and Ammonia.

1. Chlororormylii, i^x ; Spiritaa Ammonin Aromatioi, Sas ; Hagna-
siie Carbonntie, sj ; Aquie Destillat«i>, lias. Miwe, fiat houatus, atatim
aamendua. In tevpre eo/ir. The patient ehonld be cautioned thai th*
draught mil it very hot to tht mouth and throat.

114. Valerian Draught.
9. SpirltOa Ammoniaa Foptidi, lUxr; Tioctunp Talerlana, Sh; laAul
ValeriaoB, 1^. Miace, Sat baaatas, pro re natl aumeodiia. In hylm

115. Lobelia, Ether, ^.
^. TiDctnraa Lobelim il^tbereie, Sij ; Vini Ipecacuanbn, Sias ; Hiatiua
Ammoniaci, Ivj. Mirce. Capiat Sj omniboa sextia boria. In the dyt-
pnaa of aithma, urhen thtre it vetieular emphytema.

US. Ammottia and Opium.

R. SpiritOs Ammonia Foetidf, Sm ; Tinotarai! Opii, tru ; Mi*tar» Cud-
phora, ^. Hiioe.

ASTRINQENTS. 637

117. Nitric Add Mixture.
9. Aoldi mtrioi IHlati, Szij ; Tinotnne Cardamomi Oompoatte, SifJ ;
8ynipi Simpliou, Si^n ; Aqan, Sj. Miaee. Bumat Sj — fj Moandtqatqiw
hori. Db. Qibb Hate* that nitric acid ii a tpeeifie in ihs trtatmtnt of
kooping-amgh, curing the diuate in from tvn to fifteen dayi. He re-
eommendt thie formula.

118. Sulphate of Zinc and Belladonna.
9. Zinei Solphatia, gr. tiij ; Eztraoti BelladonntB, gr. ij ; Aqua, Xiv.
Mine. Capiat unoiam dimidiam quater in die. Dr. Fdlliii. For a
child above three yean of age teith hooping-cough. Every other day the
ttrength of the mixture may be augmented in the proportion of one dote.
The bdladonna may be thus gradually inereaeed to doeee of five grain*
toithout anymitchief.

119. Valerianate of Quinine.

9. Qainte Talerianatis, gr. zg ; Extract! Gentians, 9^. Fiant pilnln
duodeoim, qnanm capiat anam ter in die. Deaarentar pilula. in hye-
teria and analogous nervotu disorders.

120. Valerian and Astafatida.

^. Tinctarn Valerianie Compciito, Tinctarte Asaafoetida, Si 3\j ; Mia-
tnraa Camphone, Sraa. Miace. Bomat qnartam partem qaarti qotqne
hort. In hysteria, flatulent colic, and similar eases.

121. Tincture of Sumbul.

K. Sambnlii Radioia, Sir ; Spiritfls .Stberia Compoaiti, Sir. Macerate

in a atoppered bottle for aeren daya, and then filter. Doaa itxz — Saa.
In hysteria, nervotu paine, IfC.

YL ASTBIHOENTS.

122. Rhatany Mixture.

I>. Infnai Eramerio, Sviij ; Tinotarae Opii, Sj. Fiat miatnra, e^joa
anmantar cocblearia tria magna poat aingnlaa liqnidaa dejeotionei. A
useful attrittgent in common diarrhaa.

123. Bismuth Mixture.

^. Biamathi Nitratia, SJ ; Hiatnrae Aoacin, Svj. Hiace, fiat miatnra.
Sumat Sj ter die. Recommended by Ds. Tbbofhilds Tbok psoti as very
useful in checking the diarrhata of phthisis.

688

APPENDIX OF FORMULA.

124. Cattein. Opium, atul Chalk.
if. TioetonB Oat«cba ComporiUe, 3iij ; Confeetionii Aromatiei, Siw;
Tlnetanp Opii, Sa« — j ; Mittanc Cretae, Srj. MUoe. Citpiat >J po<t «iD-
gulu liqaidu «des. Very effiraeiout in cMeeting timpti dinrrhaa. In
tome insranrfis a dou of eattor oil (Sm) thouU ht givtn fonr kourt btfhr0
cammenciHg this mixture.

125. Tairin'n and JVitrie Add.
H. Aeidi TaoDici, 5m ; Aeidi Nitrici Dilatl, SJ ; Tinctartp Lnpnli, Sfj;
Infusi Oenti&nic, ad Svj. M. Signetar — " One-eixtb part three time« a
dlty. " To restrain iecrriion in chronic broiiehiat catarrh, in phthisis
when the cavities are large and tht wall* throw out eontiderahle quanti*
tie* of purulent matter, in nervout dehility, and in mot eates where ii»
astringent it required. When n feri-uginotu tonic u irtdicated, the aSove
mixture may he given night and morning, and mme preparation of etui
in the middle of the day.

ISO. Snlphurie Aeid and Opium,
n. Acidi Sutpburici Diluli, Sij ; Tinctara Opil, 3m ;
Ivj. Misoe. Sutnat Sj tor die.

Infiui Qauila,

127. Seejuichtariile of Iron and Columha.
H. Tinotnne Ferri Seaquichloridi, iHjcr; Infaai Calnmba, ^.
Fi»t hsnttiu, quLrta qatque hort lamendat.

Misee.

128. Oil of Tiirprnliiie.
If. OI«i Terebiutbina>, ^Uz ; Mitturte Amygdalie, Sj. Hisot, flat baiu-
tni, omni hor& sumenduii. In levere hamoptyeie, eepeeially in urtaJk
eoehtdie tndividualt.

m. Soda and Turpentine.

H. Macilaginiii Acaciie, .^ ; 8odflB SesquicarboDatU, gr. x ; Olei Tere-
binlfainn, "Ixv ^ Aqnn DetUUaUe, 3j. Misce, fiat banjtua, t«r die (a-
mendus. In paseive hamatemetit.

B. Aeid! Qaltioi,
mendai.

130. Gallie Aeid.
gr. X — XT. Ex aqut Jin, qaartt qulqne hart ni-

ls 1. Gallie Add and Morphia.
B. Acidi Qalliri, gr. viij ; Morphia Rydroehloratia, gr. i ; CoDfee-
tionia Bone, qnantntn saffloil nt Bant pilaln Aam, hort decabitna anmendi*.
TV) cheek the night-ett-eate in phlhine.

ASTRINQENT8. 639

133. GaUte Acid and Opium.
9. Aoidi Oallioi, gr. zij ; Palreria Opii, gr. i. Hiaoe, flat palrii, om-
nibas Mxtii boris snmendus. A vaitiaiU attringtnt in hmnmrhag* from
tkt luMgi, ttomaek, kidney $, or uterui.

133. Cinnamon and Sulphuric Aeid.
9. Tinetatw Cinnunomi Compoate, Stj ; Aoidi Sulphnrioi Dilati, Sy.
IfiiM. Sanut gntU* zzz leonndll qn&qne hort ex oyatho aqnn. A vry
utfful aMtringtnt in pastivt hamorrhaget from kidntgi, bladder, tUf
rut, 4r«.

134. Cinnamon Draught.

9. Tinotora Cinnkmomi Comporitn, Sij. Aqun CiDnamoml, y. Hiue,
flat hanatas, tar die aamendui. In menorrhagia ttpecially, but al$o in
other variitiei of pattive hamorrhage. Set a Paper by the Author, in
Lancet, 15th October, 1853.

136. Matieo and Rhatany.
9. Tinotnrc Hatioo, St] ; Infasi Eramerin, Mj ; Sympi Crooi, Sij.
Ifisee, flat mistara, enjat capiat gemiuneiam tartiisvel quartii borii. Nb-
LIQAS. — Tn the diarrhaa of phthitit, IfC.

13S. Catechu Draught.
i)>. Tinoturo Cateoba Compoaitffi, Ssa ; Confeotionis Aromalici, gr. it ;
Infnri Cateoba Compositi, Ij. Mine, fiat baartna, ter die snmendoi.

137. Catechu and TormentiUa.
4. Tinotane Cateoba Composit«g, Sij ; Deoocti Tormentillte, Svj. Hiaoe
Samat Sj ter quaterre indiea. In chronic diarrhaa and dysentery.

138. Catechu and Opium.
9. Palveria Catecbn, gr. zv ; Pulreria Cretaa Compoaiti cam Opio, Sj.
Hiaoe, flat pnlria, mane et vespere eumendua.

139. Sulphate of Copper and Opium.
Vr. Capri Sniphatia, Palverii Opii, SS gr. ai ; Bztraoti Oentisna, gr Wj.
Hiaoe, flat pilola, ter die anmenda. In obttinate diarrhaa.

140. Nitrate of Silver and Opium.
9. Argenti Nitratia, gr. j ; Extraoti Opii, gr. y. Hiaoe, flat pilala,
noote maneqae aamenda. In very obttinate diarrheea when opium agreet
with the tyttem.

141. Ki}u> and Logwood, i/c.
9. Tinotoras Kino, Srj ; Vini Ipeoacaanhas, Sy ; Oecooti Haematozyli
ad S<j. Miaoe. Capiat 8j ter die. In chronic dysentery, diarrhaa, IfC.,
vhfu opium ditagreee.

640

APPKNnrX OF FORMULA.

142. CmeariHa and SfMilh.
H. TiootnrB Seilln, 3i«a ; Aoidi Salpbarici Diluli, 5j ; Tinetune Opii,
Sh ; Infari CaKBrillie, STJ. Misce. Suaut Sj ter die. In ehrotae trm.
e/iitu with pro/use €J-ptctvrittiou.

143. Alum Mixtun /or iHfanti.
H. AlaminiK, gt. zvj : Syrupi Rbocsdoi, iij ; Aqnie, SiJ. Hiaos. Sa-
mat Sj Mcundii vel («rti& qa&que borft. XfseJ'ui when tht utreiiun frmn
tk* brimehial tttht$ is excestiv:

144. OiuteofZine.
H. Ziooi Oiidi, gr. ir ; Extracli Ilyospyiuni, gr. iij. MUcc, fiat pUuU,
borft somni onmenilit. RrcomnunJai by Db. Tbkopoilcii TnoMPSOR, /or
ths Ttluf of nigfu-ttctati in phthisis. The aiUhor can confirm the rtani'
menJatioH,

145. Biimuth atui Dover's Powder.
■i. Bumatbi MitriitU, gr. z ; PalTcria IpeoMoaDbat Oompoilti, gr. t.
Misce, flat palvi*, omni noct« samendua. As a stdutive attd ostrifigtHt
in the diarrhaa uf phthisis.

146, An Astringent Enema.
K. Olei TerebintbiDiB, Sss ; Tincturie Kino, Sij ; LiquorU Opii Sedatiri,
V\xx ; Decooti Amyli, My Mirao, fiat onema. To check the purging i*
typhtsid/ever. It may be employed twice or thrice daily ^ if Heeessarf.

147. Chloioform, Opium, and Castor OH.
^. Ohlororonnyli, "Itj— nu ; Olei Rioini, SiJ ; TiDotune Opii, niu ;
Hiatune Acaciie ad Siu. Mtwe, fiat banatiu, itatim lamendaa. In eho-
ieriiic diarrhaa.

148. Alum and Sulphuric Acid.
H. Alumioia ExBJcoati, 3j ; Byrapi Rhteados, Sim ; lufaai Rone Com-
potiti ad JxiJ. Miace. Capiat Sj omnibaa aextia boria. /n pauiv Ma-
morrhage. Also in some eases of lead colic.

149. Iron Alum.
n. Ferri Ammonio-Sulpbatia, Sas — 3j ; Aqon Deatillata), Sfj. Fiat
miatora, cnjaa oaplnt uDoinni quater in die. An excellent ailringeut in
MOme forms of htrmatemesis, hirmoptysis, ^.

ISO. Acetate of Lead ami Opium.
R. rinmbi Aeetatia, gr. iij ; Conreetiunis Opii, gr. tj. Miaoe, ut fist
pilula, nmni burl iuinendft cum baaatn aeqaente. Acidi Acetici Diloti,
3j : AquK, SJ. Miace. In severe hwrnoplysis. It is not to it reliod oh.

BATHS.

C41

151. Cinnamon and Logwood.
9. Tinotnne Cinnamomi Comporita, In ; Deoooti HsmatozjH, Sij.
Ifiaee. Capiat ^ poat lingnlai liqoldu sedea.

152. Cold, at a Local Astringent.
The beat and oheapeat freeiing mixture ia made with ioe and common
nit in aqnal parta. Any of the following, howerer, will proTe oaeful :

Hiztttrea. Parta. Therm. Sinka.

gal Ammoniae b\

Nitre, 5^ Prom 50° to 10°

Water, Id)

Nitrate of Ammonia, . . . IJ F„m 500 lo 40
Water 1 )

^°'"'' ■ „ 11 From 32° to 0°

Common Salt, 1 }

Snow or Ice, 12 '\

Common Salt, 5 ^ From 18° to —25°

Nitrate of Ammonia, . 5 )

Tn. BATHS.

Bath.

153. Temperature of Simple Baths.
Watbb. Vapor.

Tepid Bath,
Warm Bath,
Hot Bath, .

85° to 92°
92° to 98°
98° to 10«°

Not breathed.

98° to 108°

108° to 120°

120° to 180°

Breathed.
90° to 100°
100° to 110°
110° to 130°

154. Nitro-miiriatie Acid Baths.
9. Aeidi Nitrioi, liaa j Aoidi Hydroohlorici, 8i[j ; Aqnas calidie, cong.
XT. Miace. To 6* prepared in a tcooden tath. The patient should remain
in it from ten to twentj/ minutes. Useful in eases tohere the Uvtr is in-
aetive.

165. Alkaline Bath.

9. Sodaa Carbonatia, Bij ; Aqnte ferventia, cong. zzx. Hiaee. /« the
Kthie-aeid diathesis, chronic rheumatsm, ifC.

lit. Compound Conium Bath.
9. Eztraetl Conil, SiJ ; Palrerie Amyli, IbJ ; Aqnte ferrentia, cong. zzx.
Miaoe, flat balnenm. Phabiiacop<bia, Hospital pob Scih Dissaibi.
Uuful in certain sHn diseases attended seith great irrittMUtf.

54*

G12

APPKNDIX OF FORMUL*.

167. Crixisoti Bitlh.
H. Crraaoti, Sij ; Glycerinn, Sij ; Aqan) fcrvcntia, cong. zzx. Miao*. —

Phabmacopuiia, Uusimtal run Skih Diseases. Iu cittaiuout ditor-
drrt attended with mtirh irritatioit.

158. lodiiu Bath.
H. I»<linii,Sj; Liqaoris Potaiu), S^ ,- Aquic ealidaei, oong. ixx. Hiaoe.
In trro/uU and chrome rhtumatitiH, ttcoiiJary ti/philu, and etrtain tkin
diseases.

lie. Sulphur Bath.
H. PoUaaii Sniphureti, Sit ; Aqute oalidie, oong. zzx. Hiase. TTstful
in saibieSf lead rtdie, jiaralysis frovflead, ift.

160. Compound Sitiphur Bath.
4. Bulphuria PracipiUli, Sir ; Sods Hjrpoaolphttia, Sj ; Acidi Sul-
phurioi,Sn; AqDK calidm, oong. xxx. Misoe.

161. Tepid Sall-wateir Sponging Bath,
ti. Solia Marini, tti i ; Aquas tgpidas, oong. ir, Miaoe, Sat balneum,
omni mRne ut«odum. Jn general deiitily, chronic rhtnmali>m, IfC. Tht
surface of the body shoiittt be tveil ruibtd with ajttsh-brush.

U2. Sfa.toaltr Bath.

H. Salia Murini (vulgo " Buy Salt"), 1t> i; Magnesias Balphatia, S^ ;
Liquoria Oalcii CtiluHdi, Sj ; Aquv, cong. xxx. Miaee,

1«3. Tht Mereiirial Vapor Bath.
The patient is aent«d on a chntr, and coverud with an oil-oloth lined
with flannel, which ia supported by a proper framework. Under the chair
are placed a copper bath containing water, and a metallic plate on which
ia placed from one to three drachma of the bipulphnret of mercury, or iha
same quantity of the gray oxide, or the biuoxide of thia metal. In ayphi-
litic offectiona of the akin, teatea, and bonea, from Are to thirty grains of
the iodide of mercury may bo employed : or a scruple uf the iodide with
a drnchm and a half of the biaolpburot often prorea elSoaoiotta. Under
the bath and plate, spirit-lamps are lighted. The patient is thus ezpOMd
to the influence of three agents, — heated air, ateam, and the Tapor of
mercury. At the end of five to ten minntea perspiration commence*,
which beoomea excesalve in ten or fifteen minutea longer. The lamp* ar«
now lo be extingniahrd ; and when the patient baa became moderately
cool, he ia to be rubbed dry. He «bnuld then drink a cup of warm de-
coction of guaiacum or aaraaparllla, and repoae for a abort time. —
LAaoSTOX Parkeii. /h eonstitultmuil syphilis trhen merniry is indi-
eal*d. This method uf inlrotlneiiig mereiiry into the SfStem may also A«
adopted u-ith bcnffit in olher diseases, in piaet of administering the metal
by the tnoHlh.

CATHARTICS ANP ANTHELMINTICS. {>43

164. Vtl.
Mb. Hbrrt Lie's mode of proceeding U more simple, and is the one
wbioh I have frequently adopted with great snocess. A oonvenient appa-
ratus is nsed, made by Savigny and Company ; which consists of a kind
of tin case, containing a spirit-lamp. In the centre, over the flame, is a
small tin plate, npon which from fifteen to thirty grains of calomel is
placed ; while around this is a sort of saucer filled with boiling water.
The lamp baring been lighted, the apparatus is placed under a common
cane-bottomed ch^r, upon which the patient sits. He is then enveloped,
chair and all, in one or more double blankets ; and so he remains, well
covered up, for about twenty minutes, when the water and mercury will
be found to have disappeared. About fire minutes afterwards he may
put on his shirt and go to bed ; but it is better not to use a towel, since it
can only be disadvantageous to wipe olf the calomel deposited on the skin.

ie&. Aeid FootbtUh.
9. Acidi Nitrici, Bj; Acidi Hydrochloric!, Siss: Aquss oalidss (96°),
cong. iv. Misce, fiat pedilnvium. Indytpeptia,tnthderangtmtntofth4
liver and cojulipation. It miitl 6e n$ed in a wooden or china veatl.

I6(. MiMtard Foot hath.
I^. Pulreris Sinapis, S\j — iv ; Aquas calidae, cong. iv. Misce, pro pedi-
Invium. In congettiotu of the head and ehett, in tome eatet ofamenor-
rhaa, ifC.

VIII. CATHARTICS AlfD ANTHELMINTICS.

167. The Common Block Draught.
Vr. Magnesias Sulphatis, sy ; Hannse, Sj ; Tincturts Senntc Composttse,
Sij : Infusi Sennas Compositi ad Siss. Misoe Sat hanstas, eras mane
sumendus.

168. Calomel and Jalap, l/e.

If. Hydrargyri Chloridi, gr. v ; Pnlveris Jalapa, gr. zv. Misce, fiat
pnlvis, statim sumendus ; cum haustu sequente post boras tres.

If. Magnesias' Sulphatis, Sij ; Mannse Optimao. 3j ; Tinctnrae Jalapa<,
Sij : Aquas Pimentte ad Siss. Misce. A good active purgative in head
affeclioiu.

169. The White Mixture of Hotpitalt.

9. Magnesias Sulphatis, Sij ; Magnesias Carbonatis, 9j ; Aquis Menthas
Piperitas, Sj. Misce, fiat baustus, omni mane sumendus.

170. Epiom Suite and Sulphuric Aeid.

n. Magnesiss Sulphatis, Sin — iij; Acidi Sulphnrici Dilnti, Siij; Tincturao
Hyoscyami, Sij ; Infusi Quassias, Szij. Misce. Snmat Sj bis vcl ter in die.
Very umful in painter' i tolir.

644

APPENDIX (IF FORMULA.

171. Glauier'g &$/ts and Sttel.
I(. Sods Salpbatii, 3ij ; Ferri Salphntii, gr. ir j Aoldi Sulpbariei Di-
lati, TTixv; Tinetnra HjoKyami, nixx; Infusi Calumbs, Jij. Mime,
flat haustug, primo mane eumendua. /» oiittnate eonstipation with dr-
bility.

172. Eptom Sallt and Sulpknrie Add.
H. MagnesiK Sulphatif, Sir; Infuiii Uosm Compositt. 3lj. Miioc, Bat
haiutos, primo mane sumendas. A good pnrgativa in mUdfehrilf affrc-
tittfu mtk amtlipatioH.

173. Aloft, Semia, ntul Jaiap.
n. TiDctnns Senna) Compo^ittc, Ttncturie Jalapae, ii Sij j Infaii Sennai
Compositi, Sij; Decocti Aloea Comporiti, Stu. Htne. Samat Jj nool*
manequt.

174. Rhuiarb, Ginliaa, and Sfnna.
K TinctursD Khei Comporits, SiJ ; Misturn> Oenllanie ComponUs Sz.
Mi«!e, fiat haustua, omni mane rumendus. A miU piirgativt tii dyi-
pepsia, ifC.

175. Nilrie Arid atul Gfiiliait.
H. Aoidi Nitrioi Diluti, Sin; SpiritOa iGtberis Nitriti, S^; Eztrs«ti
Tarazaoi, Srj ; Mirtune GentianasCumposiUe ad Srj, Fiat mistura, ci^Jiu
capiat para aexta bis torve die. In dytpipsia irilh dthilily and eoiuti-
pation,

170. An Alkaliw Ap^ntnt.
H. Deooeti Aloea Compoaiti, InfnaiQentianaCompoaiti, ijui^; Liqnoria
I'otaaan, 3ij. Misoe. Sumaatarcoobtearia magna duo omni mane. Utftil
in biliofu luadaflu.

177. A Warm Apertent.
^. Eztracti Rbei, gr. x ; godie Pbosphatia, 3J ; I>««ooti Aloea Compodti,
Sm; Aquie Piment«!, Sj. Mieoe, Bat bauataa bort aomni inmendiw. — Dk.
Qaibdher. ViffiU ill iome catri of gout.

17B. Alott, Stiina, and Eptom Sattt.
9. Vini Aloet.Sij; Infuai Sennic Compositi, Sias; Magneaiae Sulphatla,
Sir. Miace. Hujoa capiat nnciam, bor& aeptimt nutattnft; et oireilcr
boram drcimam partem reliqaani aamat, st opoa fuerit.

179. Tanie and Aptrirul.
^. Inrnal Gkniianie Compoaili, Svj ; Acidi Salphnrici Diluti, Xj ; Sodaa
Sulpbatia, S«a. Miace. Capiat cocblearia tria magna poat jentaeulum at
pull prandium qaolidie. UttfiU in MniitHai nnitipulion iritk /InlMUufe,

CATHARTICS AND ANTHELMINTICS. G-15

180. Jalap and Senna.

9. TinstuTS Sannn, Sj ; Tinotum Jalapn, &ij ; Aqos Pimantag, Sij.
HiMC. Capiat dimidiain statim, et semihoHl elapsA, quod reliqunm eat.

181. Saline Purgative.

9. Vini ADtimonii Potassio-tartratis, 3j ; Hagnesiae Sulpbatii, Saa;
Synipi Papaveria, Si^ ; Iiiqaoria Ammonia Oitratia, Siaa ; Hiatnna Cam-
pliorae, Sras. Miaoa. Capiat Sj bia tanre indtea.

182. SnlpkuT and Magnesia.
4. Magneaiaa Carbonatia, 3j ; Salpharia Soblimati, gr. zt ; Sodae Bi-
earbonatia, gr. x; Pulveria Zingibaria, gr. ij. Mia«a, flat palvla, primo
mana ax laota val aqui aumendua. A ute/iil purgative for delicate /e-
malee.

183. Steel and Ahes.
9. Farri Snlphatia, gr. y ; Pilulie Aloaa eum Myrrbas, gr. iij. Hiaee,
flat pilula, tar dia anmanda. In amenorrhaa, ehlorosie, hftteria vrith de-
biliti/, ifC.

184. An Alkaline Purgative.
I^. Sodas Snlpluktia, Siaa ; Sodas Phoaphatia, Sj ; Syrupi Rhamni, Saa ;
Aqnaa MeDthsPiparitae, S\rj. Miaoa. Sumat anoiam atatim, at rapatatur
doais poat horaa duaa, niai alrua priua raaponderit.

185. Glauber's Salt! and Taraxacum.
^. Sodas Snlpbatia, Sij; Daeocti Taraxaoi, Siaa. Hiaca, Sat bauatua,
omni mana aumandaa. In ametipation with deficient secretion of bile.

186. Citrate of Magnesia.

I^. Magnaaias Carbonatia ponderoaas, Sij ; Aoidi Citrioi, Sj. Miaoa, flat
pnlvia. Signatnr — " Ona larga taaapoonful to ba takan aarly in tba morn-
ing in a tnmblerfal of watar." A good simple aperient for gouty or rheu-
matic subjects.

187. Aloes and Galbauum.

B. Pilolas Aloaa onm Hyrrbao, Piluias Qalbani Compoaitas, ail gr. t.
Hiace, fiant piluias y, noota manaqna inmandas. In hysteria with
flatulenee.

188. Elaterium and Ether.

9. Liquoria Ammonias Citratia, Spiritfia .Stbaria Nitrioi, SS Saa ; Ez-
traoti Elatarii, gr. j. Miaca. Signatnr — "Ona amall taaapoonful every
two houra in a wineglaaaful of water, until tba bowala are vary freely
acted upon." In the early stages of acute dropsy with albuminuria.

APPENDIX OF FORMULA.

I8V. Elattriim and Gtntian.
n. Exlrmeti BUtorii, gr. i ; BxtncU 0«Dtiaii«>, gr. iij. Hisee, Imt
pllnla, omni oocte sumeDda. In dropaittU fffutiont, and in ea*es vA«w
«'0 wish to prodicc^ o*piott4 icaierjf §tooU.

190. Gambog4 and QaHantim-
H. Pilalc OftmbogiB Compoiitai, Pilalc Galbani Compotita, U gr. ▼.
MiMe, ftant piluUe dun, omoi nocl« anmenda. A good droMtic hj/dra-
gogiu cathartic, aeting chi*Jly upon the tinall inttttin*!.

191. Caiomei aiui Jaiap.
n. HydrargTri Chloridi, gr. ij — gr. t ; Palverii Jilapn Compoiiti, aj —
Hi. MiMis, flat pulriii, omoi mane Bumendas. A good hi/dragogHt
eatharlie. Tht calomel incftaset l/ie tfftct of the jalap and crtan of
tartar.

192. Ammonia and Rhubarb.

9. SpiritAa Ammoniiti Aromatici, 1U XT : Tioetanc Rbti ComposiUc,
Su: Infuti Rhoi, Sj. Miwa, fiat haiutus, Doota maoeqae •nmaodaa,
Stamachic, tonir, and pnrgaiive. Eapeeiaily uteful in timpU dytptp-
gia, icilh eotutipation .

193. A tVarm Stomaehie Aperintt.

n. Tinctaric Rhri Compoi'ttw, 3j : Tinolunc Otntianc Corapotitae, U» \
6pirilfl« Ammoniw Arnmatici, SpirilQa iEtb«ria Componti, Si S^. Aqua
Pimenliv, ii\. Fiat mifitura, »nju« lumat »ger oochlearia duo, urgant«
rantriculi dolore, flatu, nauiet, vel langoore.

19i. Suiphate of Mangaiuteand Cotehienm.
i(. Iluigaiies!a< Salpbatis, Sir ; Vioi Colcbici, lUxxr; Histum Cam-
pbone, Ij. UiK«, Sat baiutua. A unful purgative in gout, ehrunie
rheuMotiemt ^,

195. AprrinU and Sedtitive.
it, Hiaturte Acacisn, jlij ; Aqua; Cinoamoml, liij ; Olai Bicini, Sin ;
TinotarK Rhel, Srj ; Titictunv Opii, 3aa ; Sympi Aarantii, Svj. MiK<e.
Samat unciam tertiif boris. /» dyeenury.

19S. Salitu Aperient Mixture.
H, Potaaras Tarlratia, Jj ; TinctunD Jalapm, Tinotura Sennn Oom-
poaitc, &a SIv ; Bjrupi Rhainni, Sij ; lafud SannB Componlti, 3t. Samat
partem qaortam, qoartt qu&qae bort donee alraa plena tolata lit.

197. Rkiiharh and Miigiu*io.
H. Magneiin Corbonatia, Sij ; Palveria Rhet, ^|k^ulTarU OianamomI
Oompoaiti, i*\j ; Aqua Mentha Piperita, Srj. MTsce. Capiat Jj omni
muit.

CATHARTICB AND ANTHELMINTICS. 647

148. Cttlom»l and Seammony.
9. HjdTMrgjrri Cbloridi, gr. ij — iy ; PalTerii Soammonii Compositi,
gr. It ; Palrerii Zingiberii, gr. j. Hiao«, lUt paWia. A valuable pur-
gativt in tkt ktad affeeliou ofehildriu, and in intettinal «iorm$.

199. A Ferruginous Purgative.
i. Ifagneain Solpbatia, 3ij ; Ftrri Snlphatia, gr. ir ; Aeidi Snipbnrioi
Dilati, lllzTi Inftui Quania, tin. MitM, fiat haiutas, eras primo
man* aamendai. Db. Riasr . — In eoiutipation mth geiural debility.

200. Coloeynth and Tartar Emetic.
^. PilalaaColocynthiduCompofitae, 3ij ; Pnlreris Antimonii Compositi,
SiJ ; Bxtnoti Hyoscyami, gr. Tj. Mine. Divide in pilulaa zij. Snmat
J oddI DOoto. A ueeful purgative pill in pertont threatened with apo-
plexy.

201. Crotou Oil.
9. Olai Crotonis, Tllj — ^ ; Olei Caryophili, iTlj i Micte pania, qnantum
(nAeiat at flat pilola, atatim aumenda, et horia duaboa npetenda, ai opua
ait.

202. Crolon Oil, Coloeynth, and Galhanum.

9. Olei Crotonia, IHj vel ij ; Pilulae Colocyntbidia Compoaitic, 3aa ; Pi

Inlae Oalbaixi Compoaitae, Sj. Miace, et divide in pilolaa zviij. Sumat

pilnlaa iy omni nocte. Sib Charles Bill and others have cured tomt

obetinate eatet of neuralgia with these pillt.

203. Podophyllum or May-apple,

9. Podopbyllin, gr. ig ; Pnlveria Zingil>eria, gr. vj ; Saoobari albi, Sj.
Mix, and tritarate tborongliiy notil all ia tboroagbly blended. Divide
into aiz powdera ; and order one to be taken every nigbt or every otber
night. Considered a valuable alterative and cathartic by many eminent
American physicians. Useful where mercury is inadmissible. The po-
dophyllin may be gradually increased to one grain in each dose, provided
it does not give rise to griping or nausea.

204, Podophyllum and Gamboge.

H. Podopbyllin, gr. iaa — iy ; Pilaln Cambogiae Compoaitae, Saa. Divide
into aiz pills, and order two to be taken at bedtime. A valuable drastic
purgative in eases of dropsy due to hepatic disease. It may sometimes be
advantageous to add six or ten grains of calomel to the mass before divid-
ing it.

205. Seidlit* Powder.

9. Sodas Carbonatia, »j ; Soda Potaaaio-tartratia, sy. Hiaoe, et fiat
haaatna eifarveaoena earn Aoidi Tartariei, gr. zviy ; Aquae, Siv.

648

APPENDIX OF PURHULA.

206. Ammonia auit Ox-sfott,
n. Amnionic 6e«qnioiirboniitia, gr. xxir ; Fellla Borini Inspimti, Sm;
Maellaginis Acaciic, q. s. MiM< ; Bant piluln; duodecini. Capiiit nnam
l«r in die. In dysyrptia u^ith vofnitin^, coiulipaiion, and dtpotitt of
litkaUM i» the urint.

207. Rhtiharb and Ox-gall.
^. Polverit Rhei, 9« ; Fellia Borini Invpissati, Sm ; Ole) Carui, 'nVx ;
Piluln Onlbani Comporitir, !)j. Hiace, fiat mnaaula, et dirtd* In pilolu
duodeoim. Snmftt pilulie daie omni Doot«. To prevnttan aenimHlaiiam
tfffacu, when rA« large imeitinet are torpid.

208. Culocynth. Atxifatida, and Ox-gall.
n. Pflnla: Caloc;nthidia Composittc, Aaanrojtida; prepmrsta, Fvllis Bo-
tIqI In!ipl.ianti, na 9j. Misce. Divide in pilulaa xij. One or Iwo to be
taken daily jint hrfore dinner, in conttipalion vilhjlotuletu* and imper-
fect digettioH of food.

309. Senna, Jalap, and Ox-gall.

H. MBgneala; Carbnnntia, Sm : Tinctune J*lsp«, Sij ; TiootonD Senna
Compoailip, Sj ; Fellia Bovini Inapiaaati, SJ ; Jliatnnp Cnmphom ad Sir.
Mtace. Capiat dimidiam atatiin, et poat boras trea qnod reliqunm eet, ri
opus lit. A valuuiU purgative vrAen the reetuM i* blocked up hy kard-
tned facet.

210. Calomel and Jalap.

R. nydrargyri Cbloridi, gr. ij \ Pulveria Jalapic, gr. i\j ; Saeebari Pu-
rtficati, gr, ir. Miaoe, fiat pulria. A purgative for ehildrrn in head
affections, or iflierr there are wormt.

211. Calomel and Rhubarb.
Vr Pulveria Rhei, Aj ; Hydrargyri Chloridi, gr. iij ; Byropi AltkaM,
qaantnm sufflciat ut fiat bolua, borft aomni aumendua.

212. Rhubarb and Blue Pill.
R. Pilalo Hydrargjri, Pilalac> Kbei Compoeltte, Extroati HyoHjami,
in gr. iij. Miace, fiant pllul» duiD, altern& qutqae nocte aomend*.

213. Colocyntk and Blue Pill.

9. Pilnlag Hydrargjrl, Pilulaa Colocynthldig Compofita), Bxtracti II7-
otcyaml, SI gr. iij. Miaoe, fiant pilulaa duie, pro re nat& ramandja.

214. Colocynlh and Ateafatida.

n. PilnlB ColooyntbidisCompoaitn, gr. Tij ; AasafoetldB, gr. i\J. Mi«o*,
fiant piluln duv, pro re nat& lumendc. In conttipalion with JtatMltntt.
A ntefnl purgative for hypochondriaet.

CATHARTICS AND ANTHELMINTICS. 649

215. Gamhoge oHii Slue PHI.
9. Pilnln Cambogis Composite, gr. r; Pilnlw Hydrargyri, gr. ig.
Miieo, flant pilnlae dnie, noote maneqae nimeDdB. In atcitts, tff-t vhtrt
a dnutie purgative it rrquirtd.

316. Nux Vomica, Ipetacuanha, and Rhubarb.
9. Eztraoti Nuoig Vomica, gr. iy ; PnlTeris Ipeeaonanha, gr. TJ j Pi-
Inla Khai Compoaitn, 9ij. Oontnnde in mauam, et dirida in pilalaa doo-
daeim. Somat doaa omni noota, vol altarni qalU]ne noota. In liabitual
mmtipation from atonif of the roatt of the bowel, with deficient secretion
rfmnmu.

217. Purgative Mixture for Infante.
^. Pnlraris Rhei, gr. it ; Magnerin Carbonalia, 3j ; Aqno Anetlii, Sjn.
Mine, flat jnlepam, eigiu nnnm ooobleare minimum infantalo lactanti
datnr, aaonndii horia.

218. Sulphate of Zine.

9. Zinei Salphatia, gr. t ; Mian pania quantnm antBoiat, nt flat pilala,
tar die aamenda. Rtcommended by Mr. Balt, «'» habittuU eotutipation,
after tht boieele have been cleared out with a purgative of calomel and
colocyMh. The pill ehould be taken immediately after a meal, for two or
three weeke.

219. Sulphate of Soda.

^. Soda Salpbatia, Sir; Infoai Boats Compoaiti, Bij. Fiat hanitoa,
primo mana aomendaa.

220. Quinine and Rhubarb.
9. Qninaa Diaolpbatia, gr. ij ; IHIalag Bhei Compoaitaa, gr. iij. Miaee.
A good dinner pill, in eomeform* of dytpepeia.

221. Ipecacuanha and Rhubarb.
9. Pulreria Ipeoaeuanbae, gr.- aa — gr. j ; Palreria Rbei, gr. i^ ; Con-
fectionia Roan, q. a. nt fiat pilula. To be taken just before dinner. Vary
netful in removing the uneatirute and tetue ofoppreetion after meal* —
resulting from stow digestion.

222. Elaterium and Calomel.
9. Eztracti Elaterii, gr. iaa; Pulreria Capaioi, gr. TJ; Hydrargyri
Cbloridi, gr. zg ; Eztraoti Oentianaa, Sas ; Saoobari faecia quantum infli-
oiat nt flant pilnlaa duodeoim. Sit doaia pil. j, vet y. The Elaterium
may be increased to twelve grains, if a very active drastie purge is re-
quired. Tht Capsicum prevent* the nausea which Elaterium usually
causes.

660

APPENDIX OF FOKMVL».

223. TfiiF Vomica and Coion/nth.
R. Extrnoli Hyoaeyami, sij ; Pilulic Colocjnlhidia Comporilie, Sj ; Ex-
tract! Nuci> Vomicai, gr. iij. Mivce, nt fiiil izi«Ma, to pilnlsa dnoilMim
diridcndk. Capiat pilulu duu omni noctc. In huhiiual nnstipatioH.
TA«y may be eoniiniud for about tnt dayi.

224. ChdUiiliam. Watert.
R. Ferri Solphatia, gr. x; Sodn Balphalii, MagoestK Snlpbatii, U Ij ;
Sodii Ohloridi, Sij \ AqotD, Oj. Mi<oe. Sumat Sij in aqut ealidt ix primo
xnaoe. In deMUty with constipation.

226. Karltbod Watiri.
K. Sodie Sulpbatis, Sij — Sir ; godm Carbonatit, 3j ; godii Chloridi, gr.
XT ; Grata prrparatn-, gr. x ; Fcrri Carbonatii, gr. it. MiMe, fiat pul-
Tig. Signatnr — " To be taken rarl; in the morning, In half a pint of
water.''

22(1. Turpcnline Anthelmintic.
B. Olei Rieini, Jm j Olei Terebintbinw, .\i. Mima, flat banatai, prima
mane tumondai. /» tapeworm, Ift.

227. Koiisso.
R. Konfro, in pnlrere, St ; MpIIIk, quantum snfilciat ot fiat Eleotnarinm.
Thia is sufficient Tor two doses ; tbe second being required three bonn
after tbe first. In cases of tapeworm, vhen Use expevsive drugs/ait,

228. Spigelia avd Poieder of Tin.
B. Pulreris Spigelic, gr. x ; Pulreris Stanni, Sij \ S;rapl Zingibcris,
Sis ; Mellis, quantum sufficiat at tint bolns, boril ante jentaculnm snmen-
das. Postea adbibeatur mistura pnrgans ad plenam alvi solutionem.
This is said to be a vaitiahle nntkeimiutic in cases of tnmbtici.

220. Fomegranatt Anlhelminlit,
B. Deooeti Oranati Radicis, i^. Omni semibora sumandai usqne do-
■is rj.

230. Vet,

B. Oranati radicis eorticis, 3iij ; Pulreris Sabadillie, gr. rj ; Confee-
tionis Aromalici in pulrere, ^j. Mince, et diride in pulreres sex. Capiat
nnum omni semiborlt ad scxtam vicem. Mors active than the preeadittg.
A saline purgi is to be taken after the last dose.

231. Oil of Male Fern.
B. Olel Fllicis Maris, Sira : Sjrrupi Zingiberis, Sij : Misluraa Aoaeln,
Siss. M lace, fiat bauslus, primo raane snmendas. Ah exrelleHi auiJul-
miiUir, especially for tajieuvrms. Tiro hours after this draught kni btlH
UJun^ a brisi purgative may be advantageoHsly administered.

CATHARTICS AND ANTHELMINTICS. G51

232. Simple Enema.
9. Sodii Chloridi, 3j; D«<!o«ti Hordei, Szij. Miaea, fiat enema. /»
rimple eoiulipatio», to dettray asearides, ifC.

233. Caitor Oil and Rue Enema.
^. Confeotionis Rate, 5j ; Olei Ricini, 3j ; Tinotarte Anafcelidc, 3^ ;
Deeooti AveoK, Svij. Misoe. Exeeediagly netful injlatulent distention
of the inteetinet.

234. Steel Enema.
^. Tinotnne Ferri Seiqaiohloridi, Sss ; Aqun, Svi^ ; Misee. To de-
etrof atearidei, a dose of calomel and jalap being adminietered at the
tame time.

23S. Toiaceo E)iema.
9. Tabaci Communii, gr. xt ; Aqnss BulUentis, Sviy. Haoera per
horam, et eola. To be employed eautiouily in tome eatei of tleue, ttran-
gulated hernia, obuinute constipation, ifC.

23C. Turpentine and Cattor Oil Enema.
9. Olei Rigini, Olei Terebinthinae, iia Bin ; Tinctara Aiiafoetidn, 3ij j
Deeooti Avena, Szij. Hisce, flat enema. In obstinate constipation. It
should he thrown up by meaiu of a long tube. A stomaeh-pttmp tube mil
tuffiee.

237. Croton Oil Enema.
9. Olei Ricini, Olei Terebinthinn, Sa 3j ; Olei Orotonis, nivj ; Deooeti
AvenB, Siv. Misoe, flat enema. In oittitiate constipation. Tobethrotim
into the reetum and retained there.

238. Purgative Electuary.
9. Confeotionie Sennee, Sisa ; Palrerig Jalapae, 3aa ; Snlphnrig Precipi-
tati, !m ; Syrupi Senna, q. i. at fiat eleotnariam. Samat 3j noote
maneque.

239. Cream of Tartar and Taraxaettm.
^. Confeotionis Sennts, Potasras Bitartratii, Extraoti Taraxaoi, Hi Su.
Mifoe. Snmat coohleare parvum pro re naUl. In constipation with in-
aelive liver.

240, Purgative and Tonic Electuary.
9. Confeotionis Sennas, Potasue Bitartratis, Ferri Sesqaioxydi, Syrapi
Zingibaris, Si ilss. Misce. Capiat cochleare parvum omni nocte. In
eformt of eonttipation with wattt of totu.

652

AI*PEN-DIX or ruBMl'LJE.

rx. CAUSTICS, Airo couirrER-iEEiTAirrs.

241. TJu Arid ?Citrat4 of Mrrnry.
ft. HydrargTri. Sj ; Acidi Xitrici («p. ^. 104U.) Sij. Solre. — Pa^a-
MACOPOiA, Hospital roa Cittaxeocs Diiiasis. A cauttic Jluid for
mneiT or Input : utful alto in thugUing uUtrt, ioift, twtaU Havi, ii<.
Hit lo6t ofplitd bji mtont of a glatt rod or iruA.

242. Arid Nilralt of Mrrrury Patlr.
ft. Lii\Dorii Hrdrirgyri Pemitratu, Sij ; Pulreru Tngaoantbie Compn-
siti, quantum fuffioit ut fiat mana

243. LanHolfi't Putti.
ft. Bromii Cbloridi, Zioc! Cbloridi, Auri Cbloridi, Antimonii Chloridi,
paries HMtnalefl. Mix iuto a pa«t« of fuSioient tbtokneM with flour or
powdered liquorice. To dtitroy caneirotit growtkt.

244. C/Uoridt of Zinc.
ft Sanguinariai Caoadenrii, So — 3j ; Zinoi Cbloridi, Ua — Sij ; Aqua,
Jy ; Fariner, quaDlnm tufficiat. Mixe. Tki paste thus formed thould
have the eontittence of treacle. This it the eaiistie employed tty Dr.
FCLL.

24S. Ch/oridi of Zine PaMt.
ft. Zinci Cbloridi, 3u — 3j ; Farion, 3\j ; AqniB Deatillata, q. •. Flat
maaa, qui part morbida exedatur.

240. Siiper-Sulphtttt of Zime.
Take half an ounce of iulphuric aciil, and saturate it with sulphate of
line, prevtoaal; dried and powdered. lir. Kimpson recommend* that thil
caustic should be used bj dipping a pen in it, and then drawing lines
across the tumor, so as to eat tbrougb the skin in a few minutes The
fissures thus made are to be filled with the paste ; renewing the scratohiuf
and oanstic ever; da; or two. In this way, fire or eight days ma; sufflo*
fur the removal of a good eised tumor. By this combination also we can
penetrate deeply without hardening the parts and without fear of pro-
duoing hamorrbage,

247. Depilatory Potcder.
ft. Calolt reeentif, Siv ; Areenici Sulphured Flavi, 9j ,- Pulreris Amylt,
Sty. Mlaoa, flat pulris.

248. Nitric Oridt of Mtrctiry Powder.
ft. Ilydrargyri Mitrioi Oxydi, Aluminii, ail 5j. Misce, flat palrii. Th
t» tprinUed ovtr tjcuitratu and ipOHgy groHHtatiout.

DIAPHORETICS. 653

249. Carhonate of Copper Ointnunl.
9. Coprl Carbonatis, Sj ; Adipis prepantie, Sm. Miaee, flat nngnen-
tnm. Dbtbroib. /» ekronie eczema and impetigo of the tealp tchere
etimnlating opplieatiota are required.

250. Dnpuytren't Povder.
9. Aoidi Aneniosi, gr. xy ; Hydrargyri Chloridi, Sj. HiiMS. /» «/-
etrated iuptis. Mutt it eautioitsly need.

251. Vienna CauHie. ■

9. Potane Hydratif, Calcis, Bingularam nnoiam. Ter« siniDl. This
pattt it diluted with alcohol, ayid applied with a ipatula over a imall tur-
fact. It it identical with the Potaita enm ealee of the hondon Pharma-
eopaia.

2S2. loditu Paint.
9. lodinii 9ij— 3j ; Potasaii lodidi, 3sa ; Spiritfls Vini RMti6oali, Jj.
Mine. To be applied with a eameVi-hair pencil. Very uteful in many
chronic paine.

253. Tartar Emetic Embrocation.
4. Antimooii Potassio-tartratis, sy ; Aqan Rosa, sy. Solve, dein
add* Tinctane Cantharidis, 5j. Hisce, fiat embrocatio. To be employed
if the ungiientiim antimottii potauio-tartratit {Phar. Land.) failt to pro-
duce the required eruption.

254. Croton Oil Limment,
9. Olei CrotODis, 3aa ; OM OltTte, Siira. Hise«, flat linimentam. To
produce rubefaction arid a piutular eruption, where cotinler-irrttation ie
required to relieve diteatet of internal organ*.

X. DIAFHOEETICS.

255. Nitre and Ipecacuanha.

9. Potassn Nitratia, Sj ; Vini Ipeoacnanbse, Siss ,- Deooeti Hordei Com-
positi, Oj. Hisce. Signetnr — "One teaoapful every two boars." /»
tevere catarrh with tore throat.

256. Antimony and Opium.

9. Tini Antimooii Potasaio-tartrslia, 3j — ij ; Tinotnrs Opii, Sss; Li-
qnoris Ammoniss Asetatis, S^ ; Hiaturte Camphorse, Ut. Hisoe. Samat
Sj ter die.

55»

C5l

AVPESDIX OF FORMLL^.

2&7. Solution of CitraU of Ammonia,
9. Liquoris Ammonia! Citrslia, Aqon, && Hr. MiMe, Sat miftora, ei^ua
capiat cooblearia ampla dao t«rti& qa&qafl bor&. In pnetitnoniof and
manif other amttt inJ!ammatioiu.

258. Nilre, JEllur, and Citrate af Ammonia.
R. Potusne Nitratis, 5Mi SpirttQi jflthsria Milrici, Siij ; Liqnori* Am-
nionia> Citratis, Siu ; Minlarni Cam|>boric ad Svj. Misoe, fiat miatDra, da
qua aomatar oyathum vioarium t»r quaterve in die. In the early ilaget
of many febriU and injtnmmatory disorders.

2i9. Stimulant and Diaphoretic Draught.
R. Aminoniin Sesquioarbonatia, gr. iij — r ; Spiritfla iBtb«rii Cblorini,
lUx ; Vioi Colchicl, ^It ; Liqnoria Ammonia} Acetatia, Kiij ; Miatune
Aoacifv ad Siaa. Miaoe, et fiat haiaatua, ((uartA qntkque hoHI sumandua.
ValuahU in some forms of pueiimouia, ift.

260. Dover^s Powder and Antimony.
O. Palvcria Ip««acuanb0 Compoaiti, gr. T ; Antimonii Polaasio-tartra-
'<■• p. i' Uia««, fiat paWia, umnibaa 8«xtia boria aumondua.

281. A Snislil lite for Dover's Powder.
H. Pnlveria Opii, p. j ; PulTcria Ipccacnanhn, gr. J ; PotsBS* Nitratia,
gr. Tiij, Miacc, fiat pnlvia, bora aomni aumrnda.

2A2. Senega and Gnaioeum.

H. Tincturas Guaiaci CompoaiUe, Svj ; Miaturw Acacias, Sj ; t«r« aimul
et adde Daoooti Senegie, Sr. Hisee. Somat Sj ter die. Diaphoretic, diu-
retic, stimuianS, and e.rpectorant . V»eful in the totter stages of brotuhitist
loHsiltitis, IfC.

263. hifanliU Cough Mixturt.
R. Vini Iperacuanba!, Sij ; Syrupi Pa|>arer!j, Siij ; Histnrs Acaoia,
SxlJ ; Miaee. Capiat Sj tcrtil qul^ue boril.

2A4. Tartar Emetic Mixture for ChiUreu.
n Vini Antimonii Potaario-lartratta, riiaa; Vini Ip«ea«nanhB>, Sij;
8jrapi Papareria, Siij ; Liqnoria Ammonia) Citralia, ij ; Hiatura Cam-
phora ad Svj. Mia««. Sumat 3aa nmiii hnrH. A depressing mixture
for rhitdren two or three years of age.

265. Infantile Fever Mixture.
H. Vini Ipacacuanbia, Sias ; S;mpi. laa ; Tioatarn) Oampbona Com-
poailas, Siij ; Liqnoria Ammoniie Citratla, Sn ; Miatarie Camphone ad sy.
Miae*. Snmat Sj — ij racundil vel tertill qu^ue horiV, In infantile fever,
ervere catarrh, pnenmonia, ironchitie, IfC.

DIURETICS. (>■'>'>

ZI. DIXTBETICS.

266. Broom, Sqvilb, and Potash.

9. Potssaa AoeUtis, Sv ; Aceti Seilla, Sas ; Spiritns iBtherto NitVici,
lllzxi Tinctuiw Digitolia, '"It; Deoocti SeopariiCompositi, Sin. Miaoe.
Ter di« rameDdus. Diuretic in ateUet dtptndtnt upon dittatt of htart,
Uver, or peritontum.

267. Acetate of Potath and Digitalis.
9. Spiritaa ^tberia Nitriei, 5m ; Liqaoria Potuas, itx — u ; Syrapi
Croci, Saa ; Infuai Digitalia, iij : Uistorae Camphone, StJ. Miaoe, flat
hanatua, tor die anmendua. Valuable in cardiac and hepatic dropsy.

268. Winter Green and Ether,
tfi. Potaasae Nitratia, Saa ; Spirltfla Janiperi Compoaiti, Siy ; Spiritfla
^theria Nitrioi, 5iT; Decooti Chimaphilaa ad STig. Hiaoe. Oapiat
ooohleare amplom qoartt qnftqae borL A tome and stimulating diure-
tic. Useful in ascites, and also in some cutaneous affections.

269. Buehu aiui Potash.

I(. Potaaaaa Bitortratia, Siy ; InfUai Baohn, StJ. Hiaoe. Sumat Sj ter
die. Diuretic and aperient. It is also useful iti irritable eondiliotts of
the bladder, especially where there is an excessive secretion of uric acid.

270. Broom and Squills.

9. Tinoturaa Soillas, Sij ; Tinctarte Campboraa Compoaitn, Srj ; Liqnoria
Ammoniaa Acetatia, SiJ ; Decoeli Seopnrii Compoaiti, St. Miaoe. ' Sumat
Sj ter die. A diuretic and laxative ; useful in dropsies ututecompanied
by acute inflammation, not dependent upon disease of the kidneys.

271. Digitalis and Nitre.
9. Potaaan Nitratia, gr. t ; Syrupi Aarantii, Saa ; Yini Colohioi, 'nizT;
lofuai Digitalia, Liquoria Ammonia? Acetatia, aS Sir. Miaee, flat hana-
tua, bia die anmendua. Diuretic and sedative.

272. Urea.
9. Ureas, gr. x — xt ; Syrnpi, Sj ; Aqnn, Sj. Miaoe, flathaoataa, omni-
bna aextia boria anmendua. Remmmended by the Author as a diuretic
in eases of cardiac dropsy. See Mtdieal Times and Gazette, May, 1852.

273. Cantharides and Nitre.
9. Tinetarae Cantbaridia, in.XT ; Spiritaa Liberia Nitrioi, Saa— j ; Sy-.
rapi Zingiberia, Sj ; Miatune Csmpborie, Sz. Miaoe, flat hanatua, ter die
anmendua. May be cautiously tried in some eases of suppression of urine.

G56

APPKN'DtX Ur FORMUL.S.

274. TamxacntH and Nitric Aeid,
IV. Acidi Mitrici DiluU, Sj ; Extract! Taraxoci, Sij ; Decocti Tarnxaol,
Ivj. MJMe. Sumat Sj C«r di«. Laxative, i{iitrelir,aiiJalleralive. El-
ptcially utefiil in diuam of the liver, UHaceompanieJ Ay in/tommatioH.

275. Cream of Tartar and Taraxaeitm.
■v. Pota«Me Bitartrati>, 5iu ; Decooti Tarnxaoi, Sim ; Miace. Tcr di*
BOmendas. }n jaundice, independent of hepatitit, or of ob$truelioH of the
duel of the gall-bladder.

270. OilofJuniiier.

IV. Olei Janip«ri, gntls ir; Byrapi Aurontii, 3j; Hintarae Aeaeic, St^.
Miacc, fiat halutu^ ter qiiaterve indiea tumaadua. The oil of juniper
ha* not only a Hitirftic aetiaii, but i$ also a diaphoretic, an emmena-
gogrue, and a carminative. In large dose* it eauees irritation of the
Uiuider.

Coninm, DiE^italis, and Calomel.

IV. Extract! Conii, Sj ; Pulrerit Dig!tal!s, Hydrargyri Cbloridi, uS gr.
V. Tere optima aiinul et divide in pilulaa xr equaloi, quorum aomat
onam t«r die. A* a sedative attd diuretic in dropsy from heart dis-
ease, tfC.

278. Di^lnlis and Blue Pill.
R. Pilulte Hjfdrargyri, Sag ; Putveria Scillw, gr. vj ; Pulrtria Digilalia,
gr. xij. Miace. Fiat maaaa, et divide in pilulaa duodeoim. Signetar —
"One pill lo be taken night and tnurning, with a wineglaaaful of the fol-
lowing mixture." — 5. Becocli Sooparii Compoaiti, Sriy. In
of dropsy dependent ttpon heart disease.

XII. EMETICS AND EXPECTOEAITTS.

279. Tartar Emetic Mixture.
H. Aniimonll Pota8.«io-tnrlratia, gr. vj ,- Syrup! Rh<eadoa, Sj ; Aqua*
Punc, Siv. MiKe. Capiat oocbleare minimum subinde, ad oaoaeam vel
Tomilum promovendam. Usifulineases inhere it it thought necessary ta
lower the vital powers.

280. Warm Emetic.
R. Pulveria Ipecacuanhis, Ammonite Seaquicnrbonntia. (lil 9j ; Spiritfta
-LavundultD Compoaiti, ihxv ; Aqua;, Siaa. Miace, ftat bauatua. Bibat
rger |Ki>t«a infuai anthemidia tepldl octarium. Dtt. Dkditt. In the •>••
rtpieitt stage of fever, erysipelas, ^-e.

EMETICS AND EXPECTORANTS. ii^U

281. Depreuiiig Emelie.
9. Antimonii Potsnio-tartrfttis, gr. j ; Vini IpMUiunbaB, sy ; Aqaa,
Sin. Mine, fl»t luostoa Tomitam ezoitare.

282. va,

Vr. Antimonii Potarato-Urtratis, gr. j j Palverii IpeoaensnluB, sj.
Miace, Sat palris statim ramendiu.

283. Vd,

9. Vini Ip*eaoaanha, SJ. Statim sumendas.

284. Stimulant Enutit.
Q>. Polreria Slnapls, in ; Aqoa, Siy. Miice. Snmat dimidinm itatim
•t qnod reitat post hors qoadrentem, A opna <it.

28S. Vel,
9. Capri Snlphatia, gr. x ; Aqnn, 8iy. Miaoa, flat haaatns emBtioiu,
itatim samendiu.

288. Vel,
9. Zinoi Sniphatis, Sn ; Aqnn, Siij. Miaee.

287. An Enutiefor Childnn.
9. Tini Ipeoaoaanho, Sj. Statim anmendaa.

288. Exftetorant and Stdative.

9. Tinoturas Soills, iUzt; Tinotnro Campboraa Compoaitaa, Sas;
Sjrropi Simplicia, Saa ; Infuai Lini Compoaiti, St^. Miaoe. Ter die an-
mendaa.

289. An Expectorant Mixture.

9. Sympi Tolntani, Sis ; Tinotaraa Caatorei, Sj ; Tinotnm Campbone
Compositn, Siij ; Hiatane Ammoniaoi, AqoaeCinnamomi, i& Siias. Miaoe.
Snmat Sj ter die. In the chronic tronehitie of elderly people.

290. StimulatU and Expectorant.

^. Ammonia Seaquioarbonatia, Saa j Tinotnra Seilla, Sisa ; Tinotara
Camphora Oompoaita, Siiaa ; Syrapt Tolntani, Sir j Deooeti Senega, Ivij.
Miaoe. Capiat Sj qallrta qaftqne borft. In the chronic bronchitit of old
ptoph.

291. Stimulant Expectorant Mixture for Children.

9. Ammonia Sraqnicarbonatis, gr. ij ; Tinotara Seilla, Tltv : Deoooti
Senega, Saa ; Sacobari facia, Saa. Miace, Sat baaatus, aeoand& qutqne
bor& anmendna. An excellent stimulant expectorant for young children
recovering from croup.

668

APPENnix OP FnRMrr..«.

202. Itrprctorant and Touic.

I Sj ; Acidi N'itrioi Diluti, 3<a : Extrxti Hyoaejaini,

ft. Tinetane Bcilli
Sj ; Sjrrnpi Paparcria, Sss ; Infusi CiDchonie, Jir.
teire die. Jn eJtronic catarrh with reitUitiiess.

MiMo. Samat Jj hia

293. Ammonia and Senega,
H. Ammoniio i>ei<quicBrbonalis, 3ij ; Tincturie Scillae, Sin ; Deoootl
6enfga>, SriiJ. Mucc. Sumit Jj omoibua sextia horia. A good slimu-
laiit exjitctoratU in eomi eatee a/ ironchilit.

204. Expectorant and Stimulant.
H. Tinctnrii! Scilla;, Siaa ; Aramonioi Seaquicarbonatia, Saa ; Byropi
Ziogiberia, Siij ; TinctariB Caniphorie Compoaitie, Sij ; Infaal SerpenUria,
Sraa. Miace. Samat Sj ler indiu. In chronic catarrh.

lib. SaJint Draught with Antimony.
9. Vini Antimonii Potaaaio-tatiratia, irtzr — zxr ; Bptritfla iBthsrii
Nitrici, '"Ixx ; Miaturo; Camphora!, Sj. Miacs, fiat banatna, qnarti qnt-
que hor& auinendua. T/u lafge dou of antimonial wine ie to be given
only when it it detiraile to produce ttoHiea.

29S. Iperacuanha and Tola.
ft. Vini Tpecacuanbae, Sij ; Syrupi Tulutani, Sir ; Mtatnne Aeaolos, Sz.
Fiat mietura, pujaa capiat cochleare parvum omni horft vel qu&que •«•
cuo<t& bor&. For childrtn thrattcnfd with an attack of croup or bron^
ehitie.

207. Tfidian Tobacco and Hetnlock.
ft. TiDctnrie Lobelin jEthereao, Sij : S;rapi Uemideami (Phar. Dab.],
Sj I TinctDro Conii, 3iij ; Miilunc Ainjrgilalie ad Stiij. Fiat miatara,
cujua capiat cochleare nmplum lertiia boria. A good mixture in tome
aitee afaethma, and in matt tpatmadie caught.

398. Conium and Squilli.
ft. Pilulv Conit Compoailn, PilnliF SciUm Oompoaitic, ta Saa. Flat
maaaula, et divide in pilulaa dnodeoini, e qnibna aamantur dun aeztia
boria, In ttverc chronic kranrhitit, when opium it object iotutile.

299. Conium, A'ilric Ether, and Iptcaewinha.
H. Extraeti Conii, Extracti Qlyoyrrhiite, a& 9\ ; Boise Bioarbooalia,
fr. xvj , Vini Ipeoacnanbsa, '"Ixl ; SpiritOa ./Gtharia Nitrici, 3j i Miatara
Caniphnrw ad Sir. MiKe. Capiat Sj omnibua lexlia boria. In bronchitie,
when there it little or no fever, and an expectorant and sedative it indi-
eated.

EMHENAGOGUES. 659

300. Syuillt and Opium.

^. Oxymellis Soilln, Stj ; Tinctune Camphors Compositae, Sij. Hiioe,
nt flat linotoa. Capiat Sj tossi argent*. In the chronic l>ronehiti$ of old
people.

Xm. EMMEHAOOOUES.

SOI. Iodide of Iron.
H. Potanii lodidi, gr. xij — xriy" ; Ferri Ammonio-Citratis, 8ij ; Tine-
tnra Nneii Tomion, iTlzxi — Sj ; Aqan Destillatn ad Brj. Fiat miitara,
d« qvA capiat onciam t«r in die. In amenorrkaa with torpid circulation.

303. Sulphate of Iron and Savin.
9. Ferri Sulphatis, Sj ; Olei Sabins, itxriij ; Pilnls Aloat «nm
Hjrrhft, Sj. Hiiee. Fiat mannla, et divide in pilnlai uir, e qnibns
■nmantar ij bis qnotidie.

303. Ergot of Rye and Aloes.
I^. Tinotaro Ergotie .£therese, Siij ; Decooti Aloes Compositi, ad Sij.
Fiat miatura, e^joa capiat oochlearia ampla i} omni mane. In amenorrhaa
dependcM on timple atony of the uterine orgattt.

304. Aloet and Strel.
I^. Deeoeti Aloei Compositi, Hiaturn Ferri CompoaitaB, U Mr. Fiat
miatnra, onjaa capiat aextam partem ter in die. In amenorrhaa with
anamia and eonetipation.

305. Valerianate of Iron and Savin.
9 Ferri Talerianatia, gr. xij ; Olel Sabinaa, niriy ; Hannaa dnraa
qnantum snfficit nt fiant pilnla daodecim, qaarnm capiat nnam ter in die.
Deanrentur pilolas. In amenorrhaa with hysteria.

300. Borax and Ergot.

l)>. Sods Biboratia, Si — Sij ; Tinotoras Ergotas iBtherea, S^ ; Aqnaa
Cinnamomi ad Syj. Miaoe. Capiat Sj ter die.

660

APPENDIX or rORHULiC.

ZIY. OABOLES AND INHALATIONS.

307. Acid GargU.
K. Aoidi Hjdroohlorici Diluti, Siij ,- Mellis, Sj ; Aqnn, Jviaa. Miso*.
In tontillUis, after the acute stage^ ifc.

308. Burax Gargle.

^. Sodas Biborati*, Sm ; Tinotnra Mjirhog, Sj ; AquB, SxM. ilisa«,
XJuiful in aphtha and uicfratiotu about thafattctM.

309. Tanuiu GargU.

R. TtoniDW, 9j ; BpiritOa Vini Oallici, Sj ; Hiatara CamphoroB, It.
Hiac*.

310. Myrrh GargU.

R. TinotnrB! Myrrhas, Sj ; Aluminia, Sj ; Aquas, Brij. Hiaa«. In mtr-
piiriat salivation, ulceration about t/ie mouth and/aucee, ^rc.

311. Opiate Gargle.

H. Tinclarai Opii, Siij ; Tinctaras BelladoDDiF, Sij ; Miatans Campbora,
Ivi. Miace. To he utrd frequently in tontillilit, IfC.

312. Brandy GargU.
Hay b» made by adding one part of brandy to four of water. Dr.
IVatbok recommends it 'in tnercurial salivation.

313. Disinfectant Gargle,
R.. Liquoria Soda Cblorinalaj, Sj ; Aqun, Sxj. Hiaoe, flat gargariama.
In nJcerated sort throat, in profuse salivation, Ifc. It may also lie used
tts a lotion to foul gangrenous ulcere.

314. Iodine Inhalation.

R. Tinctane lodinii, i^lzr — Saa : Aqnaa tepidR, Sir. Miaea, at atatim
inhalelar rapor. Used in phthisis, with much eaution.

316. Turpentine Inhtilation.
R. Olei Terebinthinas, .Ij ; Aquto tepidie, Sir. Miaee. lohaletur rapor-
/h cAronie inmehitia Krith exeessivt sterttion,

316. Crmsote Inhalation.
R. Creaaoti, Saa ; Aquic bnllientia, Oaa. Miaoe. In oteata, and other
eiffeetioHS of the nostrils, p/mrynx, ^.

317. Bichloride of Mercury GargU.
R. Hydrargyri Biehloridi, gr. it ; Aeidi Nitrlol Oilati, sj ; Tinetara
Myrrba, ^ ; Aqna, ad Sxx. Miace, flat gargariama.

r.0TI0N8, LINIMENTS, AND COLLTBIA. 661

318. Crea$ote GargU.
9. Orewoti, lUzz ; MnoilaginU Aoaoiffi, Sn ; Aqnn >d Svi^. Miaoe.

31S. Criuate and Myrrh.
9. Creasoti, gntUe zz ; Tincturo LaTftndaln Compoaita, TinetaraB
Myrrha, Si Sss ; Syrupi Tolntani, Sj ; Aqaa, Bvj. Miaoe, flat gargarisma.
In ehrotiie in/tammation oftht throat, dy$phonia dericorum, i/C.

320. Capneum and Alum.
^. Ainminia Ezsieeati, Sij ; Tinotnrae Capsiei, ij — Iy ; Syrapi Crooi,
Siij ; Aqase Rosae, Sij ; Aquaa ad STiij. Miace, fiat gargariama. In hoaru-
tutt, tort throat, \c., with relaxation of the uvula.

321. Corrotive Suhtimott Gargle.
9. Liqaorii Hydraii^ri Bichloridi, Sriij ; Extraeti Conii, Sj. Miaoe,
flat gargariama. Uieful in typhilitic nffeetiont of the tongue and throat.
The patient mutt ute one tabltspoonful at a time, and ought to be cau-
tioned againit twailowing it.

322. Borax artd Glyeerirte.
9. Sodas Biboratia, Sj ; Olyoerinii, Sij ; Aquia Roaae, Sir. Miaoe. To
he painted over the tongue in tome formt of ulceration, in aphtha, Jltture,

ire.

323. Stdphite of Soda.
I^. SodiB Bnlpbitia, Sj ; Aqnae Deatillatffi, Sj. Miaoe. To be applied by
meant of a cameTt hair pencil to the motuh, in eate* of aphtha.

XT. LOTIONS, LINIHEirTS, AND COLLTBIA.

324. Prutiic Acid Lotion.
9. Acidi Hydroojanioi Dilnti, Sir ; Plnmbi Aoetatia, gr. xt ; Alooliolia,
Siy ; Aquae St^. Miaoe, flat lotio. ReeommenJed by Di. A. I.Taoxton
in impetigo.

326. Creaeote Lotion.
^. Creaaoti, Sj ; Glyoerins, Siij ; Aqnas, Six. Miaoe, flat lotio. Ute-
ful in pityriatit, ifC.

32t. Cod-liver Oil Embrocation.
^. Olei Morrbnae, Siij ; Spiritfls Ammoniat Aromatici, Sj ; Polreria
Opii, gr. T ; Olei Larandnlaa, Saa. Miaoe. Dr. Tbcopbilus TaoHPSoii.
Very useful in phthitit and other eaeet where the uieof eod-livtr oilit in-
dicated, but where the itomaeh will not bear it. Half of the above thould
be well ruibed over the eheit night and morning.

fl6S

APPKNniX OF FORMUti

327. Carron Oil.

(I. OUi Lini, Liquoria Cftlcis, ili Srj. Muoe, fiat lotio. For irritabli
tt/eerg, burnt, ifC.

328. Pruuie Acid and DigilalU.
Vi. Liqnorii Ammoniie Acetatii, sij ; Acidi Hydrocjanici Dilatt, Sin ;
TiDotura) Digilalin, 3tg ; Aquie Roen, >tm. Minoe, Oat lotio, bU terra
die applicetur parti aSectv ope tpongiolie. In prurigo of old ptoplt.

Sn. Pniuie Acid and Bichloride of Mei mry,
IV. Hydrargyri Bichloridl, gr. ij ; Acidi Hjdroojaniot Dilatl, 3j ; Mli-
turv Amygdalir, Stj. Mibcc, fiat lotiu. To check the itching in prurigo
attd other akin dittatet.

330. Sulphuroni$ Acid Lotion.
The solution of inlpharoiu acid reeommeoded in cams of tinea U mad*
by pairing a stream of the gas through water to saturation. Two oaooef
of this saturated solution is then added to six ounces of water to maliethe
lotion. It may be oblaiDcd from most chemists.

331. Cold Lotion.
^. Liqnoris Ammoniso Aeetalis, Siij ; BpiritOs Vini Rectifieati, ly ;
Aqute Rosa), StJj. Mikc, fiat lotio. A vteful evaporating lotion inpkrt-
nilii, iic.

332. An Ahaorhent Lotion.

Vi. Zinci Oxydi, gr. XT ; Aquv Rosib, Sj. Misce, flat lotio. Uiefut in
impttigo, erueta laetea, ^.

333. An Alkaline Lotion.

^. tiiqaoris Potaasc, sy , Acidi Hydrocyanic! Diluti, Sj i Mistnra
Amygdala;, iTiiii. Mian. Ah txeelleni lotion in pilyriatit, ifC

J)34. Camphor Liniment and Opium.
K. Linimenti Camphone Compoaili, Siiss; Tinctuns Opil, Sra. Misc*.
To ie nihbed over the ecnhicUlue eordie to cheek namea and vomiting,
pain, IfT.

335. lodiilt of Pouuiium Liniment.
t^. Folassii Indidi, Sss ; Aqua), SiJ. Hisce, et add* Qlycerins, S«j.
Mb. Bpbiicer Wkllb recammende a linimttU of thi* nature as utefulin
ditperting the rhalk-tlonei of gotit.

33A. Helltidunmi and Aconite Linim4ni.
». Extract! Belladonnie, Sj ; Olycerinv, Jiss ; Tincturio Aconiti (Flem-
iDg's), iTlj; Linimenti Opii, Jiss. Misce. Utefiil in tome neuralgic
pom*, and in many forme of chronic rhtumatttm, lumhago, triaiiea, ^.

LOTIONS, LINIMENTS, AIJD COLLYHIA. f>63

337. Afialiru and Anodyne Lotion.
9. AeidI Hydroejanici Silati, 3j ; Liqaorii Morphia Hydroohlorstis,
Sj ; Liqooris Potasa«, Sij ; Glyoerioie, Sj ; Aqna DeatiUatn *A iiV^.
Miaoe, flat lotio. For the relUf of prurilut vulva.

338. Colehieum and Morphia Lotion.
Qi. Aoidi Aeetioi, Sisa ; Vini Colohioi, Si$j ; Horpbis Aoetatig, gr. x.
Hiwe, flat lotio. To be applied over the inflamed Joint in gout, on a
piece of lint covered with oiled tilt.

339. Chloroform, Belladonna, and Opium.

9. Chloroformyli, Sias; Tinotane BeUadonoB, Tinctnrs Oonii, tt

sy ; Tioctuns Aooniti, Tinctores Opii, Ml Bm; Qlycerinn, Sj. MiMc, fiat

linimentnm — Signetnr — " To be rubbed orer the paiofnl part night and

morning — Poiion." In neuralgic and rheumatic paimof great eeverity.

340. Borax and Glycerine.

9. Sodn Biboratis, 9j — 3j ; Olyoerinse, Sj ; Aquae Bosn ad Sviy. Miiee,
flat lotio. An excellent local palliative in many of the squamous diseases
of the skin.

341. Collodion Paint.

9. Collodion, Sj ; Olei Palms, nizz ; Anchnsa radioii, qnantam nifli-
oit. Hiaee, et oola. A good-artifloial article may also be made with one
part of collodion to two portions of castor oil. Either preparation may
be used as a varnish in various cutaneous affections, excoriations, or su-
perfieial burns.

342. Glycerine and Lime-aater.

^. Pulreris Tragaoanthn Compositi, 3ij ,- Qlycerinn, Sj ; Mellis, S^ ;
Liquoria Caleis, Sij ; Miatnra Amygdala ad Sriy. Hisce, flat embro-
oatio. A good bland embrocation in eases of herpes, superficial burns,
chapped haiuls, exeoriatioiu, 4^.

843. Ammonia and Cantharides.
9. Spiritfls Ammonia Aromatioi, Spiritfia Roamarini, Olyoerina, U
Sj ; Tinetnra Cantharidea, Sij ; Aqua Rosa ad SviiJ. Miaoe. To be
gently brushed into the scalp night and morning, when the hair is falling
off after fever or any severe illness.

344. Soda and Glycerine.

t).. 8od» Bicarbonatia, Sj ; Aqua Sambnoi, Svias : Slyoerina, Siai.
Misce. Fiat lotio. To allay the itching attendatit on many cutaneous
diseases.

345. Arnica and Water.

9. Tinetnra Arnica, Sisa — Sir ; Aqua Deatillata ad Sir. Miioe. This
lotion is useful in sprains and contusions.

AI'Pe!<niX op POBMDLA.

84A. ArMtca and Opium.
tt. Tin«tan> ArniciF, Slj TiooiiiiTP Opii. Jj ; Linimenti Saponla ul
)>j. Muee, flat eitibrucatio, omui uucln {mrlikui dulentu ap|ilicu>d«.

847. Ruirfaaent Linim»Hl.
n. CkOipbone, Sj ; Palrerii C*p«iei, Sn; Olei Mtcia, nizzz: Olei
OUiriD, Siu ; LiquorU AmmoDlic, SrJ. HiJM, Bal liaimanlom. Rttom-
mtmlrd bf Ua. CoI'1.4nd a> a ituimeHt to lAt cSmU, %h compkeatiunt vf
bivncliilit tvuh tfarlatnia ur mttuUt.

848. A Slimuhiting Limment.
n>. I.iniincnti Ssponia, LinitDrnti Camphone Compoiiti, M Ml ; Tina-
lori' Arnii-ir, Sj. Mi<cr. dit linimentum, fftooibuiextarnis tppiioandam.
In toHtiHUity common tort ihroait 6fC.

J49. Biehloridt of Mercnry.
II. lljinrgyrX Blchloridl, gr. j ; Aqow, 3^. MUoa, lUI lotio. VttftU
in litita favoto, in ehiUrtn.

3i0. Bichloride of Mereury.
n. UydttrgjTi Bicbloridi, gr. TJ ; AqUB DutilUtc, Srj. Hiaoe, fikt
llniniiinlum. Signetnr — ''Poiioo." To it uitd tvtry night in com of
ehlwitiiut.

SSI. Compound Merenrial lAnimnt.
<('. (IngucnU Ilydrsrgjrri, Sji Osmpborw, 3m; Liquorti Ammonln!, Sj ;
Olol OllvB, JiJ. MiMe. — PnAitHACOPiEiA, Uospital roR Skix DiSEASta.

3S2. Mtrniry and loJint hitiimenl.
H. lodioii, Sij; Olyccrina, Sj : (JngaeDti H;drarg;ri, ^, Olei 01ir»,
lij. M1k«,

Si.T. Compound T^rnd Ij/ttion,
n. Liquofis riumbi DiacrUtis, Sij ; UljcertDoa, Sij ; Aqon, Iz. HiMo,
fiat loUo. In pitjfriatit, 4«-

354. Suiphute of Atropia.
K. Atrupin Sulpbntla, gr. j ; Aqun DoatilUta, Sir. Miua. Dila-
tattaii of tkr ptipit it rffertcd mitti tjtcedi/y and it hngtst mainiaintd by ]
a ttdutiuH of thtt kitut. A fuU drop mutt bt yinced in t/u eyt by meaiitt
of a eamrft hair ptnril : iht effect will In prodiiettl in from fiftitn tii
iKWnfy minnlet, and will lomelimtt conlinnt for teven or eight dayt.

Sii. A Siringlhening Eyt-tcoth.
9. Zinot Ox;di, Sj ; Aqaie Rodni, Sriy. Mi4oe, fiat ooUyriam, aoij
maneqne uUndnm.

NARCOTICS AND SEDATIVES. 665

358. AHrinqent Collyria.
Vr. Zinoi Salphatis, gr. ij — iv ; Vel, AlamiDis, gr. ij — vj j Vel, Cupri
Salphatis, gr. sa — U ; Vfl, Argent! Kitratis, gr. j — ir ; Vel, IiiqaorU
Plumbi Diaoetatis, Hlx ; Aqnie DestillaUe, Sj. Hisee.

357. Iodide of Pota$h CoUyrium.
9. Potaasii lodidi, gr. Tj — riij; Aqaffi, Sj. Misoe, Sat oollyriom. To
remove etaiite of tiitrate ofeilverfrom the conjunctiva.

ZVI. If ASCOTICS AND SEDATIVES.

368. Anaethetiet.

The chief anieathetios which hare hitherto been used in the practice of
medicine are chloroform, salphoric ether, and amjiene. As the employ-
ment of one or other of these agents is often indicated in neuralgia, deli-
riam, oonrnlsions, and spasmodic diseases generally, a few words on their
mode of administration may not be out of place.

The chief adrantagea of inhalation are these : That by means of the
immense surface offered by the air-cells of the lungs for absorption, a
deeper and more rapid effect is induced than it would be safe or easy to
effect by other means. At the same time the digestive functions are less
interfered with than when narcotics are given in the ordinary way.

In every form of inhalation the aoaesthetio should be freely diluted with
common air ,' while the breathing ought to be allowed to go on quietly
and naturally.

Chloroform — formed by the union of equal volumes of chlorine and
olefiant gas — may be inhaled by individuals of all ages, from infants under
one year to persons as old as ninety ; and in all states of the system, even
if cardiac or cerebral affections are present. It is best administered from
an apparatus such as the late Dr. Snow recommended ; or if inhaled from
a handkerchief, it ought to be diluted with one part by measure of spirits
of wine. Chloroform should also be given slowly and cautiously ; and
it acts best before breakfast, or when the patient's stomach is empty.
According to Dr. Snow, about four cubic inches of vapor, or rather more
than five grains of chloroform to each hundred cubic inches of air, is the
proportion most suitable for causing insensibility to surgical operations ;
while in medical and obstetric oases it should only be used in a more di-
luted form. When an overdose has been given, artificial respiration is the
remedy to resort to ; the success of which will depend upon the extent to
which the heart has been paralysed by the chloroform. Dr. Snow gave
it in 4000 eases, without one person dying from it ; and amongst these
were patients with heart disease, phthisis, and several who had suffered
from apoplexy.

Sulphuric Ether is thought to be a safer anasstbetio than chloroform ;

OGO

APPENDIX or FORMnl^jB.

bat iiUbough it in (o, gtill it mtut be given with tlie same caution. About
one fluid ounce in Ufuiilly inh&led hy an adult in becoming insentible ;
though not more tban half thi? quantity is absorbed, the remainder being
thrown back Trom the lungs, mouth, ito.

AmylriLt is made by distilling amylio alcohol (obtained from crude
fusel oil, or oil of potato spirit) with chloride of nine. In the present
atala of our knowledge, it is not advisable to resort to this agent. Dr.
Snow seems to have administered it in 238 cases, and to bare had two
deaths from it.

359. Morphia for Hypodermic Injection.

The solution of Acetate of Morphia as used for injection under the
skin is generally made by mixing ten grains of thin salt with one drachm
of distilled water. Sufficient acetic acid is then added to dissolve the
morphia ; the 8uid being afterwards neutraliied by the addition of Li-
quor rotnsfm until a cloud apjiear^. Finally one or two drops of aoctio
acid are used to gently acidulate the mixture.

Each six minims of this solution will contain one grain of acetate of
morphia For flntt injections one minim and a half should be used ; ai
this narcotic seems to act more powerfully whan thus employed, tban
when taken into the stomach.

360. Aretale of Morphia Draught.
B. Liquoris Morpbiie Acetntis, "Ixv— ixi ; Sympi Limoni, ^ ;
torn Camphorn, Sj. Hisoe, flat baostus, umni nocte samendtti.

Mit-

361. ChJoroform and Opium.
IV. Ohioroformyli, "Iv j Tinctnra> Opii, Hlxv — zxx ; Syrnpf Rbocado«,
SJ ; Aquso Destillatin, Sj. Misce. fn severe eotie ami other tpaemudie
diuaus.

3C2. Morphia^ Chloroform, and Indian Hemp.

B. Liquoris Morpbiiv Ilydrochloratis, ^Ixv; Chloroformyli, "Ix , Tine-
turn* Cannabis Indicio, "Ixx ; PulverisTragacnnthtD Composili, 3j ; Aoidi
Bydrocyanici Diluti, nUv ; Aquic ad Siss. Misoe, liat hanstus horft tomni
sumondus. Vtefiil in *nany chronic diseases attended wtth pain and
cunslant rtsltessness.

30.1. Sfdalire and Stimulant.
H. Extract! Opii, gr. ss— j ; Miatnrts Bpirttfis Yini Oalliei, SJ. Misce,
flat hanstus, quartft qu&que hor& sumendns.

S6i. Opiate Draught u-ilh Ether.
V>. Tinctune Opii, ItVxx ; SpirilOs iBtberis Compositi, nizxr; AquB
Cinnamomi, Sj. Miice, Sat hauftui, borft lomnl lamendui.

NARCOTICS AND SEDATIVES. COT

365. Chronic Catarrh Mixture.

9. Tinctaro Tolutanoe, 5iv ; Syrnpi Tolntani, .^j ; Tinctara) Camphone
Composite, 3iij — 3j ; Mistureo Acaciae ad Sviij. Misoe. Capiat Sj ter
die. Uteful in oU people, where the mueout terretion it excetnve.

366. Sedative in Irritable Congh.

9. Acid! Ilydrocyanici Dilnti, kIzxt; Liqaoris Morpbia Aoetatis,
Sai ; Bympi Althes, Sj ; Mistarn Acacia, Hiatnrs Camphors, SS Siiira.
Mine. Capiat Sj qaart& qu&que hord.

367. Sedative in Aethma.
Vf. Spiritfla Ammonin Aromatici, Hlxr; Tinotarse Lobelioi, Spiritfli
iBtheris Compositi, uu ^Ujcx; Miaturae Camphone, Sxj. Miacc, fiat haaa-
tua, ter die aumendaa.

368. Stramonium and Henbane.
9. Extraoti Stramonii, gr. ij ; Extract! Hyoaoyami, aj ; Extraoti La-
pali, Sij. Misce. Divide in pilalatduodecim, quarum capiat anamqaartft
qujlque hori dolorem lenire. fn ehronie dieeaee attended with acute pain.

369. Opium, Ipecacuanha, and Nitre.
^. Extraoti Opii, gr. j i Pnlreris Ipeeaenanbee, gr. j ,- Potasaes Nitra-
tia, gr. Tiij ; Maoilaginis Acacia), quantam attfficit nt flat masaala. Di-
vide io pilalaa duos, hor& decubitfis samenda. In eases where a narcotic
and diaphoretic action is to be induced.

370. Henhatie, Camphor, atid Hop.
R. Extraoti Hyoacyami, Campborae, Lapulina;, ail 3j. Miaoe. Divide
into xij pills, and order tvro to be tatcen every night at bedtime. An ex-
cellent sedative/or hyttericalfcmales suffering from sleeplessness.

371. Henbane, Camphor, (fC,
^. Camphom, gr. iij ; Tinctara) Ilyoacyami, Tinctuns Lupnli, Su Sj ;
Miatura Acacia, ad Sj. Misce, Sat banatua, hori aomni aumendaa.

372. Morphia and Assafatida.
R. Aasafoetida, gr. xij ; Morphia Uydrochloratia, gr. ij ; Camphora,
gr. zv. Misce, fiat masaa, et divide in pilolas aex, quarum capiat anam
horil aomni. A good stimulant antispasmodic.

373. Tincture of Aconite.
R. Tinctura Aconiti, ^v ; Mietura Camphora, Sj. Misce, fiat haas-
taa, tertii qu&que hor& aumendus. Valuable iti moderating general fe-
iiile disturbance, also as an anodyne atid sedative in neuralgia, chronic
rheumatism, {ft.

6U8

APPENDIX OP FORMULAE.

874. Acotiitf ami Mercury.
H. Extracti Aoonlti, gr. u — j ; Ptlulis Hjdrnrgyri Cblorldi Compotitm,
gr. iij. MlBoe, fiat pilula, omni oocte flumeada.

375. BeiiatloHna atui Stitptiatt of Zint.
H. Extracti Belladonna}, gr. t ; Zinci Snlphatii, S«i. UiM«, flat
mannla. Divide in pilulai riginli. Capiat pilalam nnam tar die. In
eatet where a ittdative avii tonic action is to be productd EtpeeiaUy ittt-
ful in Monu fornu of irritable blttdtler,

376. Sedalice and Alterativt.

^. Campbonn, gr. \ , Pilului Hydrargyri, gr. iv ; PnlTeris Opii, gr. j.
Hiaee, flant pilulto duic, borH aomni inmendn.

377. A Safe Infantile Opiatt.

9. Pulveris Ijweacuanbffi Canipo»iti, gr. j ; Sacchari aibi, Bj. Miaca
bene, el divide in pnlveros iv. Sumat unum pro re naUl. For infautt
from otu to four teteii old.

378. Coniiim and Dovtr't Pouter.
4. Eztraoti Oonii, 3j ; Pulreria IpeoaonaobBi Compoiilt, Sas. Misoe.
Divide in pilulaK i. Sumat nnam tertiH qatqne bori. To relieve fimiit
arieiug from cancer, \c.

879. A Nareetiefor Infant*,
n. Tincturo! Opii, ^j Mucilagini.1 Acacia-, Syrupl 8implicis, U S^ ;
Hiitunu Oampbora, 3iv. Hirae. Capiat 3j bi^ terve indiea.

380. Sedative in Cardiae Distaee.

l(. Tinolurtp Digitalio, "li — xr ; Acidi Hydrocyanic! Diluli, "Uij ;
Tincturn Opii. <^lv ; Mistaro) OampboriE, ij. MiKe, fiat baaitiu, Ua
larva die (Dmeadus.

381. Dr. Giiy't Cough Mirtnre.
4. Acidl Sulphurioi Dilati, ^ix; TincluriB Digitalia, nvx; TiaeMMll

Opii, ^v ; lofual QuaniiB, Sj. Miace, fiat haastug, t«r die aumeDdaa.

382. Coniiim and Ilyoseyamttt.

^. Extracti Hyoseyami, gr. i^j ; Extraoti Conii, gr. Ij. Miaoa, Bat p[-
lula, omni noete aninenda.

383. Indian Hemp.

■(. Extracti Caonabii ladies, gr. 1 — i^. Taapere ante tomoum an-
loenda.

S84. Cotigh Mixture.

H. VinI Ipecaoaanhip. Sij ; Syrnpi Tnlutani, 3vj ; Tiootarae Opii, Sn
Miatane Acacioi, Sj. Mince. Suraut 5J omni burH.

OINTMENTS. 669

38S. Sedative Enema.
IV. Tinctara Opii, itxz — Sas ; Vini Ipecaoaanha, Sss ; Decooti Amjrii,
Sij. Hisoe, fiat enema, noote maneque utendnm. In tenesmus, ifS.

386. Opiate Suppository.
9. PnlTerii Opii, gr. ij — it ; Saponia, gr. iij. Misee, fiat snppoaito-
rinm. To procure sleep and allay pain, when opium cannot be taken by
the mouth.

387. Lettvee-Opium.

^. Laotnoarii, gr. t — z ; In pilalce daas borft deoubitfls samends. A
doubtfui narcotic. Has been chiefly used as an anodyne in phthisis.

888. Lupulin and Henbane.
I(. Lapnlina), gr. rij ; Extraoti Ilyosayami, gr. i^. Hisoe. Fiant
pilalse du», hori somni samendn. If the hop possesses any narcotic pro-
perty it must be concentrated in this substance. Hence these pills may be
tried in eases of restlessness w/iere opiates ore objectionable.

389. Opiate Pill.
^. Extract! Opii, gr. tj j Pnlrerig GlyoyrrUue, qnantom Boffioit, nt flat
pilula horS, somni aumenda. For relieving severe pain attd procuring
rest.

390. Morphia Pill.

^. HorphisB Aoetatis, gr. } to gr. j ; Extraoti Hyoscyami, gr. iiJ.
Misce, fiat pilula, omni nocte enmenda. In delirium tremens, mania,
and other affections utith great restlessness.

391. Morphia Linetus.
^. Sympi Rhoeados, Aeati Soillffi, aa Bss ; Synipi Mori, 3j ; Uqnoris
Morphias Aoetatis, IUxt. Misce. Snmat Sj tassi argents.

392. Common Linetus.
9. Tinoturas Camphors Compositie, 3ij ; OxymellisSoillte, Svj. Misce.
Sumat cochleare parram interdam.

393. Simple Linetus.
9. Oxymellis Soillas, Byrnpi Tolntani, Syrnpi PapaTeris, Sa Sas.
Misce ; fiat Linctas. Dosis cochleare parrum pro re natt.

394. Compound Linetus.
IV. Spiritfls iBtheris Chlorioi, Siss ; Tini Ipecacnanhas, Sij ; Liqnoris
Morphiie Ilydrochloratis, 3ss ,• Acidi Hydrocyanici Diluti, TUxx ; Syrupi
Altheae ad Siij. Misce ; flat Linetus. Capiat cochleare parrum secundt
Tel tertll qulque borS.

XYII. OHfTMEHTS.

395. Opium and Coniwn.
9. Ungaenti Conti, TJngaenti Opii, aS Sss. MUoe.

670

APPENDIX OP FORMULiS.

306. Hydroryauie Ariti and Spfrmacati ,
H. Aoidi Itjidroeyanici Dilatl, Sij ; Cngaenti Cetacci, ^. &liac«. //>
etUaueous diseases attended with pruritus, or pmn.

397. Arom'titte and Iodine.
H. Aeouit!DB<, gr. ij ; Ungaeoti lodinli Compo(it), Ij. Mifce. /»
tuiiralgio, tic dontourenx, i/t. Must he used eaatiouslj/,

398. ConeeiUraleJ AeoniliHe.

H. AcoiiitiDii<, gr. ij; SpiritOg Vini RectiRcftti, gutlie vj. Miaoo b«n«
cl ftdde Adipia, oj. Dn. TtinxBt'LL. — A small portion to be fxiinted over
the painful nerve. It must uot be used where there is the slighiesi abro'
siuu tif the skiu. For severe, neuralgia.

399. Bellndontus and Opium.

K. Extract! BoUadonnw, Extract! Opii, as 5j : Extract! PapaTcria, S!j ;
Oljrceriiie, Sir. Miscs. Tu be painted over the iiijlamed part in peritonitis,
pleurisy, (ft. A fomentatioujlamiel or hot poultice is also to he applied.

400. Mercury and Opium.

■V. Unguenti Hydrargjri, gr. x ; PulTerii Opii, gr. ij. Mine, Skt an-
gocDlum. lifeommended by Db. Watdok in cntis of severe nocturnal
pain aroniui the orbit. It is to be rubbed into ttie temple just before lA«
^111 may be expected.

401. Croton Oil and Lard.

H. Olei Crotonis, ^x ; Adipla, Su. Misce, fiat ungaentam. Infricelar
Sj ad nucis, bis terve in die, don«c appareat crnptio catanea. A useful
eounler-irritaM ininterimt injtamnwiious after the acute stage.

402. Vtrolria Ointment.
n. Veratritc, gr. iv, in Alcofaoli, 11 vj soluiic; Adipii, Sss. MiMe
oplitne, fiat uiiguenlum. In cJunuic rhenmatitm, neuralgia, gout, ^.,
a piece the size of a small nut may be rubbed in night and morning. lit
strength may be gradually increased to double the above.

403. Diluted Citrini OintmtHt.
R. Unguenti Hydrargyri Nitratis, Sij ; rnguenli Cet»cei, Srj. Miifl*.
Eujus uoguenti, pnuxillum, ope penicilli camelini, oonloaffecloapplioelnr
nocte maneque. To prevent the eyelids adhering in opthhalmia.

404. Cod-liver Oil and Lii/uor Potosite.
n. Olei Morrbun, %m ; Liquoriii Potaj>ne, So ; Adipia, q. •. Hiioe, Bal
noguentum, Msp* utendum. In sti-umous tores aiul obstinate eultiHtont
diseases.

405. Peruvian lialsam and Spermaceti.

K. Balnmi Peraviani, :sj : ITngurnti CeUcai, \j. Miice.

RRFRIQERANTS AND SAtlNKS. 671

406. Belladonna and Conium.
9. Extraeti BelladonoR, Siij ; Camphors, S^ ; Spiritfls Via! Rectifl -
osti, q. a. ; Extraeti Conii, 58a ; Adipia reeentia, Srjj. Hiaoe.

407. CompoHud Todiiie Ointmtnt.
Vr. Ungaenti lodinii Compoaiti, Olei Morrbnaa, SS Sir. Miaee. TTteful
when rubied upon the throat in ironehoeele, a* mil a$ when applied to
eerofvloue glande, umnppuratitig duioee, and the tumid 6elliet of chil-
dren tcith metenlerie dieeaee.

408., Calomel and Lard.
9. Bydrargyri Chloridi, Sj ; Adipia, Sj. Miaee, fiat nngnentnm. Very
utiful inherpee, peoriatit, attd lepra.

409. Iodide of Sulphur. *

9. Salpbaria lodidi, sj ; Adipia, SJ. Miaee flat nngnentam. Useful
in aene, applied twice daily.

410. Creatote Ointment.

Q>. CreaaotOD, Sj ; Adipia, Siij ; Miaoe. Inpityriatie, and $ome other
chrome eutaneoue dieeatet.

411. Iodide of Lead aiul Opium.
Vf. Plnmbi lodidi, Siij ; Extraeti Opii, sy ; Adipia, 8^. Miaoe, flat
ongnentam. Thi$ ointmetU often give* great relief when applied to ma-
lignant and etrumout ulcere.

412. A Stimulating Pomade.
Q>. Balaami Tolntani, S|j ; Olei Roamarini, lllzz ; Tinetarae Cantha-
ridia, Sj — Siaa ; Olei Rioini, laa ; Adipia preparatta, Siaa. Hiaoe. I have
found thie pomade valuable in eatee of baldiuts following herpet, pityri-
atie, or tinea decalvane. It may be odvantageouely rubbed in night and
morning with an old tooth-brueh.

Xmi. BEFBIOEBANTS AND SALIHES.

418. Effervescing Draught,
^■ SodiB Seaqnioarbonatia, 9j ; Syrnpi, Sj ; Tinotaraa Hyoaoyami, Itiv ;
AqoB, Sj. Miaoe, et flat bauatiu efferreaoena oam Bacei liimonia Baa.
Ter qaaterre indiei anmendaa.

414. Salitu Mixture.
^. Spiritfla .Stheria Nitrioi, Sir ; Liqnoria Ammoniaa Citratia, Sig ;
Tinotaraa Opii, Sas; Miatora CamphoriB ad Srig. Miaee. Snmat ^
qoartt qatqae borl.

672

APPENDIX Oi' FOIIMUL.E.

415, Sn/i)ie Draught.
H. Ozymellla Scilla;, 5m ; Spiritflg .l^theria Nilriei, TinetaraCiimphorB
Compofito), uu 3j ; Hiftnriv Ainygdnlie, Sj ; Mite*, 6>t bkaatus, omoibw
iaxtifl boris samondns. In iu/tiieHza, caturrhy {fC.

il6. Saline teitk Exttu of Ammoma.
n. SpirilQi Ammonlic Aromfttlei, Sig; Liqnorin Ammon!n> Cilratif,
SJT ; Syrupi Limooi, sj ; A q ate ad Sri^. Misoe. Citpiat 3m tertia v«l
quarlH qulqae horft. In lis tarlt/ Unget nf lontiUitiM, diphthtria, ^.

<\1. A Simple Saline.
9. Potoane NitratU, gr. x ; Liquoria Ammonioe Citratia, Mj : Miatura
CampboriB, Srj. Mince, fial batutDi, quarts qii&qne har& tamendaa.

* 418. Dr. Slev»iu'» Saiitu Mixture.

H Sodii Obloridi, By, Potaasc Cbloratia, gr. rij ; SodiD Carbonalia,
ilaa ; Aqnaa, liaa. Hiaoe. Omni aenihora aamendna. In Aeialie r/iolera.

419. Ammonia and Virginian Snake-root.
It. Ammoniic Seeqnioarbonatia, Saa ; Liqnoris Ammonite Aeatatia, Staa;
lofufi Serpontoriae ad Sriij. Mlaoe. Slgnetur — "One-aixth part ereir
aix boura."

42fl. BicarhoHatt of Polau Drink.

^. Potasaaa Biearbonatia, Sij — ir ; Aqnie, Oisa — ij. Hiace, pro pota
omni die aameodua. Very uarfiil in the urir-aciit dialkeni. A Jriitk
eaJUd ** eofUtitHtioH'U'aier^' otvee itt effiatcy to the biearhonate ofpoiaek it
eontaint.

421. Rrfrething Drinl:

It. Pntoanv Bitartratia, Sj ; Olei Limonifi, guttns xv ; Sacobari Parifloati,
Bij ; Aqua; Uullientia, Oij. Miace, pro potn commnni. AntxerUtnt drini
ithen Ih* ihirU it intenu.

422. Rrfreihing Arid Drink.
R. Aoidi Hydrocblorici Dilati, r>ij ; Mellia, SJ ; Deooetl Hordei, OJ.
Mieoe. Siunatar qaoUdie quaai potua fomiliaria.
423. Yel.
H. Aoidi Sutpbarici DUati, Saa j Deooeti Hordei, Oj . Hiaee, pro pota.

' 424. Photphoric Acid Drinl.

K. Aoidi Pboapborici Bilati, 3ij ; Decoeti Hordri, Oj. Miace pro potn.
Very effitaeiout i« attnaging iht ihirtt tffJiaielet, Ire.

425. Fever Drini.

H. Potaasae Cbloratia. SJ : Aqnae, Oj. Miaoe, flat potoa. Recgmmmded
iy Da. Watsox, at a daily drinl in rattt of ftvtr.

STIMULANTS.

fi73

43tt. ColeJiienm and Magtusia.
R. Vini Colebioi, Sin, Mtgj>et\m CBrbonstii, 3ij : Mistnr* Camphoriv,
Ivj. Misce. 6umat 3j noct« m*n»qae.

427. ColrMinim ami Chlorate of Potath.

R. Vini Colcbici, i\»t ; Polaera Cblorntin, Sij — Sj : liiqnnri* AmmnniiB
Citrttia, Misluriv Cam|ihorn!, aii Siy. MiKC. Sumat Jj ter die. In gout.

418. Bcrax Mixture.
H. SodtB Bilior>tiii, Sj ; SpiritOK Athens Nitrioi, Sij ; Bjrupi Pip»Terl»,
Byrupi Aurnntii. iiii Siij ; Infnn Lini CompoeiCi ad 3vj. MtMe. Sumat
Sj quart& qu!U|ue hnni.

XIX. STIM¥IANTS.

429. Ammonia and Clothe.
H. AmmDniffi Sesquicarbonatis, gr. t ; Spiritfta Myriaticiv, Sm ; Tine-
tune Cardamorni Composttse, Sj ; Infiui Caryophylli, Sx. Misce, flat
hanstus t«r dia aumenduB. In debility tfilh nausea atui Jtattilew». hi
Mome easee alto of eryti-p^lae, searUt fertr^ ^.

430. Ammonia in Effervesrenee,

B. Ammoniw Sesquicarbonatit, gr. xviij ; Acidi Ilydrocyanici Diliili,
"liij ; TinctariE Cardamorni Composita!, Sm ; Liqnoria Opii Bedativi, fir ■
Aqaaj, Siss. Mieee, et fiat haastnt eB«rve<c«n8 cum Acidi Citrioi, gr. ZT'
Ter die flumendaa. In irritable stomachy with natuea or vomiting, and
drjrreuion.

431. Awiii%onia and Caetoreum.

B. Spiritfla AmmoniaD Aromatici, Sj ; Tinctnm Caatorei, Siij ; Spiritfla
Larandalaa, Sij ; Aquae Pimrntte, Sj. Fiat mialura, oujua drachmn dnm
pro re natt ingerantur, contra langaorem et deliqutum. Dr PERKiiia :
Insome eaies of hysteria.

432. Ammonia and Ethttr.

Hi. Spirilde Animoniae Aromatici, Sj ; iSpiritfla J^tfaeris Compoaiti,
'n.zl ; AquR ad Sij. Miaoe. Capiat Sj rel Sij aeoondk qu&qae horae.
Uerfnl in infantiU diseases attended with great exhaustion.

433. An Arid Stimulant.

R. Acidi Eydrochlarioi Diluti, Tixiv ; Bpiritds .Liberia Compositi,
^viij , Mialumi Cumpburre, Siij. Mince, Rat lianataa, omnibua aeztia
boria aamendaa. Rreonimended by Dr. Steiolitz, of St. Petersburg,
en a stimulant for a ehiltt, aged abotttfive, stiffering from fever,

434. Ammonia and Gentian.

B. Spiritfla Ammonin Aromatici, Sij j Tinoturae Hyoseyami, i\m ; Mif-
tarae Oentianas Compofitaa, Svj. Ulace. Capiat ^ ter die. Inphosphu-
ria with ronsiipation.

674

APPENDIX OF FORMULA.

435. Cajfpiit Oil and Clove.
Vi. Olet Cajepnti, Tllr ; Palvcrig Tragaoanthae Compositi, 5j ; Aqoa
DeatillatiiB, Sij. Tere limul ct adde Tnfasi Carjophylli, \x. Misce, Bat
haustos, pro re nstlk cumendnB. In hyiterieal niiit ijKijmoJir afferlionj.

43t. Chlorie Ethxr and Brandy Mixture.
A. Spiritfii J!theri> Cblorici, SJ ; Mitturff) SpiritOi Yini Oalliol, Sij.
Fiat mistura, de quil capiat partem quartam omnibaH sextis horia. A
lutfui ttimvlani in Iht low ttaget of/ever.

437, Chlorinated Soda and Virginian Snale-root.
K. Liqnoria Soda Chlorinata!, "Ixl — 3ij ,- lafasi Serpentarin, StUs ;
Sjnpi Tolntaoi, Sx. Miaea. Capiat cocblearia ampla duo ter quaterra
in die. Jh low /ever thi* mixture will eltan the tongtw, promote the action
of the ekin niui hidntye, correct the offensive ttate of the evacuatioru, and
rotue the patient.

438. Citrate of Poiaeh and Calumba.
H. Polagno Bicarbnnatii, Sij ; Spirit&s Ammonia) Aromatiol, SUi i
Bpiritfls J'Uherii Cblorici, 3j , Acidi IIjdroojaDici Diluti, TIlxxT; Tino-
turie CalumbH), Svj ; lafoBi eju«dem ad Sxij. Miace. Fiat mittura, de
qui capiat ancias duaji bis io die cum Sucoi Limonii, 3ss. In irritabU
ttomaeh with acid tearetions.

439. Sumiiil.
H. TiDotnne 8ambuUs, Sas — 3j ; Aqan, Siaa. Mine, Bat baaatna, ter
die sumendua. In jome caeet of hyuleria, epilepey, and neuralgia, loAara
a etimnlant and antiepasmodie it needed.

440. Soda and Calumha.
E. Sodo Bicarbonalia, 3j ; TincturaB Calnmbn, 5tj i Aqac Aoelbi »d
8tj. Mitce. Capiat Sj ter quaterve in die. To relieve tuiuiea or vomit-
ing teith heart kurn.

441. Quinine and Rhuhorh,
R>. TlBOtur»QniDa>Compofita», Tinotnrte BbeiCompoaitat, Uit). Hiaea.
Capiat OQohleare minimum ter in die ex cyatho aqos. A good ttimu-
Ltting etom/tchie and aperient.

XX. TONICS.

442. Bark and Ammonia.
R. Ammonia! Seaqnioarbonatis, Sua — 8ij ; Syrnpi Zioglberia, laa ; In-
fttii Cinchona, triin. Hi>o«. Doaia, para MZta tar qnaterva in die.

TONICS. 675

443. Acid Draught, with Barh.
9. Aeidi Snlpharioi Oilati, '"Iz ; Syrnpi Anrantii, Sj ; InfUd Cin-
ebona, Sz ; TinotonB Cinohonn Compoaita, ^. Hisce, fiat haoitoa, tor
die raDwndiu, ante oibam.

444. Quinine and Ammonia.
9. Qaitue Diaalphatia, gr. vj ; Spiritna iSthsria Compoaiti, Spiritna Am-
moniaa Aromatiei, && 5aa ; Tinctaro Opii, triv — z ; Infaai Cinobonaa, Szj.
Hiaoe, fiat haaatna, ter quaterre in die aamendaa. In eatet of grtat «x-
hauMion, toith Uno muttering delirium, reellessness, {fc.

446. Quinine and Iron Draught.
9. Qainaa Dianlpbatia, gr. ij ; Aotdi Hydrooblorioi Diluti, 'Olz ; Tinc-
tnm Ferri Seaqaichloridi, iKxr ; Infaai Calombaa, SJ. Hiaoe, fiat baua-
toa, omnibaa aeztie horia aamendaa. A valuable agent in diphtheria,
general debility, Ife.

44fi. Quinine and Actd.
^. Tinetarae Qainaa Compositae, Sj ; Aoidi Salpbartoi Dilati, Sj ; Infiui
Anrantii Compoaiti, Srij. Hiace. Capiat Ij tor die. Amongst other pur-
pose*, this mixture may be used to cheek the night-stceats in phthisis.

447. Quinine, Steel, and Epsom Salts.
^. Qaina Dianlpbatia, gr. j ; Ferri Solpbatia, gr. ij ; Aoidi Snlpburiet
Dilnti, tn.z ; Tinotnrae Hyoaojami, Tilzz ; Tinctnrte Zingiberia, Saa ;
Hagneaiee Sulphatia, Sj — ij ; Inftiai Qnaaaiie ad S^. Hiaoe, fiat banatoa,
bia die aamendaa. A valuable tonie aperient.

448. Quiuitu and Iodide of Iron.
9. Syrnpi Qninaa et Ferri lodidi. Sea ; Infaai Calnmbaa, Sj. Miace, fiat
banatoa, tor die aamendaa. This triple syrup is especially useful in etru-
mous affections.

449. Quinine and Iron.

9. Qainaa Dianlpbatia, Ferri Sulpbatia, iS gr. iaa i Eztraoti Hyoaoyami,
gr. y. Hiaoe, flat pilala, tor die anmenda.

450. Quinine and Steel.

9. Ferri et Qainaa Citratia, gr. v j Infaai Calombaa, Sj. Hiaoe, flat
hanataa, tor die anmendna. An excellent tonie where there is debility,
with a weak arui irritable stomach.

451. Quinine and Belladonna.
Vr. Eztraoti Belladonnte, gr. r^ ; Campboiae pnlreria, S^ ; Qainaa Di-
aalphatia, Saa. Hiaoe, flant pilnlaa viginti. Capiat nnam bia torre in die.
In some painful diseases {tic douloureux, cancer, dysmenorrhaa, IfC.) ,
where a sedative and tonic are iiuOeated.

UTd

AI'HENblX OF r<IRMl'r.JE.

452. Quirtinf it»U IiuH.

H. QuiDie DisulpbatiB, Ferri gulphntia, U gr. xij ; Alaminia Sulphittit,
S«( — Sj; Aoidi Rutphurici Diluti, 3j ; Tincturn HjoteTBmi, Si;a : Infaiii
Qnossin, SvJ^K.Miaoe. Sumst .1j ler die, post oibum, ex aqut? cjKlbu.

^ 453. Quinine Miztun for ChiUrtH.
R. Quinns Dinulpbatis, gr. j; Aciili Pboupborioi Diluli, ^W'y, Sjrnipi
Aurantii, 3»; Aqac, 3ir. Miaes. Ter ilie aumgndua. Very u$tful tn
Hiiimout ophi/ui/mia, and oiteatet ofdfhilily.

454. A Htibuit lite for Qttiuitu.

n. BebmriD» Rulpbatia, gr. xvj ; Aoidi Sulphuric! Diluti, nix j Sympt

Flurum Aurantii, Saai Aqueo beatillatn, iiijaa. Mime. Capiat coohlearia,

aropla duo 0«xlia horia. lu ruttratgic ajfettioitt amtmiitg a periodic

elw riirtrr. •

455. Tonic Acid Draught.

H. TincturtD Oalninbc, 3j ; Aoidi Sulphurioi Diluti, ^izr ; SyrRpi

Auraotii, Saa ; Infuai CaluubB, 3x. Hiaco, Bat baualua, ter die aameodoa.

456. Iodide of Iron and Cod-liver Oil.
H. Sjrrup! Ferri lodidi, SiiJ ; Mnoilitginia Aoaciie, ^ ; Olei Horrhua,
Sivaa . MiMB. Somal Saa bia Icrve indiea. In lome formt of pkthiti;
icrofvUt, iff.

457. Chiretta nnd Acid.
K. Acidi Ujrdrooblorioi Diluti, tHx; Acidi llydrocjanioi Diluti, TaiiJ ;
InfViai Cbirettn, Sj. Miace, flat baurtua, ter die anmeodua. Al a §10-
Miiehir^ especially in the dytpepsia of gouty stthjeets.

458. Olyceriiu and Slui.
K. Tinetune Ferri Seaquiobloridi, S^ ; TiQctura Calumbie, Siij ;
(iiyceriniK, 3rJ — Sij ; Aquie Dralillatsp ad Srj. Uiace, Bat mialura eajaf
oapiat unciam bia terve in die. In mses when eod-liver oil is indlicated,
inl aiuitot hr toleratetl.

45W. Griffith' I Mixture vith Aloe; IfC.
H. Zioci Sulpbatia, gr. ij ; Miaturn Ferri Compoaitte, Deeoeti Aloe*
Compuaiti, EK Ua. Miace, flat bauatua, ter die aumendna. Kery unfvl
in uitamtii, turrwusttgjt, and eontti pation with general dtbtlity.

4(10. Nitro-mnrialic Acid Drop*.
n. Aoidi Nitrioi, Tat; Aoidi Hjrdrooblorici, 5j; Tioeturai Chiretta*
(Pbar. Dub.), Sxir. Miace, capiat gutloi xxx ter quaterve indiea, ex
ojrathu B<)UK. In uralnria, dytpepiia, {<•

TONICS. 677

461. Nitro-muriatie Acid Mixture.
If. Aeidi Nitrioi Dilati, Sj ; Aoidi Hydroehloriot Dilati, Sin ; Infosi
Oeiitianaa Compoaiti, Stj. Misce. Somat 8j ter dia, • eyktbo vinario
aqan. In dyspepiia, vtith sluggish nation of the liver. The effioac; of
this miztare may often be increased by giving with each dose a pill con-
taining one grain of snlphate of lino and foar of extract of gentian.

4(12. Steel Electuary.
I(. Ferri Sesqnioxydi, Tberiaees, Si >g. Miice. Capiat Sj ter die. 7»
chorea, {fC.

463. Steel and Acid Mixture.
If. Tinotarte Ferri Sesqaicbloridi, Siij ; Aoidi Hydroohlorioi Dilnti,
Sij; Tinctarag Hyoscyami, Siss ; Hiaturss Camphorae, Sxij. Hisce. Samat
Sj ter die.

464. Bart and laquor Potatsit.

If. Liqaoris Potassie, Sss j Tinctnrss Cinchonas Compositae, ii ; Deeooti
Cinehonas, Sz. Misoe, fiat hanstus bis die sumendas. In deUHtf, at-
tended with the lithie-add diathesis.

465. Saliei»and Sarsaparilla.

9. Salicin, Sj ; Syrupi Sarsae, Sj ; Infnsi Oentianas Compoaiti, Svij.
Hiace. Capiat coofalearia ampla dao ter in die. During eonvaletetnce
from acute diseases of the digestive organs.

466. Salicin and Bitters.

If. Salicin, Sij; Tinotnrn Anrantii, Siij. Hisce, flat mistara, oigiu
capiat cochleare parTom mane meridieqne e cyatho vinario aquie. When
the stomach is easily nauseated, and cannot digest quinine.

467. Ammonia and Bark.

9. Ammonite Sesqnicarbonatis, Sias; Spiritfls .fitheria Chlorici, Svj ;
Liqaoria Horphiaa Hydrochloratis, Sj ; Tincturae Cinchonte ad Siij. Misce.
Signetar — "One teaapoonful in a wine-glassful of water three times a
day." In certain cases of phthisis, u>ith eod-tiver oil, good diet, i(C.,
this mixture proves very useful.

468. Ammonia and Rhubarb.
Q>. Spiritfia Ammonias Aromatici, iHxv; Tinotarn Rhei Compositae,
Ssa; Infoat Rhei, Sj. Misce, flat hanstus ter dieeamendoa. In dyspepsia
with constipation.

469. Steel and Ammonia.

9. Ammonias Sesqnicarbonatis, SJ ,- Ferri Ammonio-eitratis, Sj — y ;
Tinetnia Hyoacyami, sy ; Infuai Quassias, Szg. Misce. Sumat Sj ter die.

b1*

878

APPKN'lUX OF FORML'L.E.

470. Phoipkalt of Iron.
H. Ferri Phaapfamu, p. xxx : Pulverig Mjrrrbic, gr. xij ; Sncchari albi,
gr. vj. Mi«oe. Divide in pnlveres sex, qaoram anioatar anui ooote
BUDeque. /» riettta and other trumout dutatti of thildnu.

471. B<tri- and Phosphoric Arid.
4. Infuri Oinohons Spiuali, .%ij; Acidi Pbosphorioi Dilati, sy ; Ai|tte
■d Sriij. MJMe. DosU, pan oeita ter die.

472. MoHganrtf and Iron.
H. Manganesii Pfaosph)iti9, Siss ; Ferri Pbo^pbati^, 5iiJ ; Tinoture Oa-
luinbw, Sij : Olei Hentba> Piperitie. Ssn : Byrupi Tolutani, Siv. Miace,
flitt mtJilura, de qafl capiat cochleare parvum rel -mediain ter in die, e
i-ynlbu vinarirj aquic. In rh/oroM^ tuArreuionM, tci-ofHlOt 4^.

473. TAfl Acrtata of Strychnia^
9. Stryohniie Aoetatia, gr. j ; Aoidi Acatoai, "Ixx ,- Alcoholig, i\j ;
Aquie j^eetillatic, Svj. Miaoe. Samat gutUe x ter die. RrnrmmtHiM
6if Dm. Marhhall Hall at a tonic in eaua of lu^ttttHs txMaiution^ ^,
Ten dropt contain ahmit the fiftieth part of a grain,

474. Stryrhiiin PilU.
9. StryohniiB, gr. j ; Conreclionia Kosie Oallicte, Su. Miace aeeunduia
artem, et divide in pilnlai xij. Samat nnam nocte maneqae. In par-
tial jmralyiiM, nvuiHrosii, ^., when the acute symptom* hjive subsided.

475. Canthariiie* and Steel.
H. TiocturR Cnnlharidiii, "Ixv ; Mistune Ferri Compoaits, Sj. llias*.
Ter die samenduti. }n itebility of the genertttive organs.

47«. Vel,
R. Tinetura Cantharidia, Tincturs Ferri 8e«qaiohlortdi, 11 Sa : Tine-
tune Capeici, Sj ; Syrupi Croci, 5iij : Aquee ad Svj. Miaoa. Sammi IJ
ter die.

477. Phosphorns Pills.
It. HicBi Pallia, 3j ; Aqu>< Dealillata), quantum aalta ait nt flat raaae*
idooeae eraaailudioia; dein adde Pboapbori itranam unnm. Hiaceantor
bene, atdiridi^ in pilalaj< riginti. Somat tinam ter qualerve indies. In
eTtr*mt delilily, after cholera, 4*.

478. Valeria twte of Zine.
H. ZInel ValeriaDatis, gr. J ,- Confeotionia Roaw q. s. at Bat pilola, ter
diesumenda. Deanrentnr pilulw. In rpiUpty, iifiirolgia. hysteria, SfC.
Cfu rnlerianate of ifuinine, of zinc, af ammonia, and of steel, may he ma-
jduyej in the sitmc innnitrr.

TONICS. 679

479. Valerianate of ZtHC and QutHtHt.
IV. Zinoi Valerianatis, gr. zij ; Qnina Dinilphatia, gt. y) ; Pilala Shei
CompoaiUB, gr. x^ ; Eztraeti Antbamidig, Sj. HiM«, dirid* in pilnlH
zy. Samat anam bU dU. Deanrantur pilaln.

480. Iodide of Iron.
9. Farri lodidi, gr. y ; Bztraoti Oentiame, gr. ly. HiMe, fiat pilnU
t«r die anmanda.

481. Sulpkate of Zinc.
9. ZiDoi Salpbatia, gr. y ; Eztraeti Oentiann, gr. iy. Uiaea, fiat pi-
lola, bis tarre die sumenda. /» epilrjuy aud eatee requiring a gentle
tonie.

481. Sulphate of Ziuc and Vomnm.
9. Zinei Sniphatia, gr. J ; Pilaln Conii Oompoaitaa, gr. ir. Miaoe, lUt
pilala, bia terra die aamanda. /» the chronic bronehitie of old people, ae
a tonie and tedative ; opium ieing inadmieeiile.

483. Xfux Vomica and Nitro-muriatie And.
K. TtnetnrB Nneia Vomion (Pbar. Dab.), Sj ; Aeidi Nitrioi Diluti,
Acidi Hjdroohlorioi IMlati, U Sj ; Tinctara Zingil>eria, sy ; Syrupi, Siy ;
Aqaag, Sraa. Hisce. Doaia, para aazta ter die. Da. Dkditt : Inanyform
of functional paralt/tie lifter all known raueee are remedied. In obeli-
note debility, diahetee ineipidue, alkaline urine, ifC.

484. Citrate of Potath and Steel.
H. PotaaasB Bioarbonatia, sy ; Spiritfia Ammonia Aromatiei, Siaa ; Ferri
Ammonio-eitratia, Sj ; Infosi CalnmlMB, Syj, Hiaoe. Somat Sj bia terra
die onm Snoei Limonia, Ut. In debility trith irritability of the etomath.

485. Steel and Aloet, ^.

9. Ferri Carbonatia cum Saoobaro, gr. r ; Aqna Anelbi, y. Miiee,
fiat liaaataa, bia die anmendna.

9. Eztraeti Rhei, gr. zy ; Sodas Phoaphatia, Sj ; Deoooti Atoaa Oom-
poaiti, Saa ; Aqaas Pimentaa, Sj. Miaoe, flat banataa, altarnia nootibna an-
mendna. Db. Oaibdher : In gout with debility.

486. FhotphaUof Iron.
9. Ferri Phoapbatia, 9y ; Aoidi Phoapborioi Dilnti, sy ; Pnlveria Tra-
gaoantbae Compoaitas, Siaa ; Aqa» ad Srj. Miaoe. Doeia, pan lezta tar
die. In eome caeet of tubereuloeie, cancer, low nervout vigor, ifC.

487. Steel and Bpeom Salte.
^. Tinotnraa Ferri Ammonio-ebloridi, Saa ; Spiritfla Ammonia Aroma-
tiei, Titxx; Magnesia Sniphatia, Saa; Infnai Qnaasia, Siaa. Miaee, fiat
hanatua, ter die anmendna. lu anamia.

68U

APPENDIX or FORMULAE.

488. Ammonia and Bark.
SoMjuicnrbonttis, Sw ; Tinotare CincboDn Composilie,

i^. Ammoni
Slij ; Aqun Menthie PiperiUe, ad Sriij
omaiba* iextu boria.

MiMe. Capiat partem sextam

480. Ammonia^ Bark, and Opiitm.
H. AmmoDJa! BeaqoicarboDalin, gr. t ; Liquorig Opii SedatiTi, 'ntr ; In-
fu«i CiDobooie, Sij. Miitce. fiat haastus, qoarifL qu&que horl lumendUB.
/n eatf whtre v* fear that a dtfotilion of Jib i in hat taken plact >» tht
luari or one of the large veeeele.

400. Steel and Arsenic.
ft. Vini Ferri, J!i ; Liqnoris Potassar Arsenltif, T^W. MiMe, Sat baaa-
ttiA, ter die sumendus post cibum. An txeelUnt tonic in eaaes of purpura.
In smaller tlutei it it useful as a tonic and alterative in tome of the skin
diteaeei of children.

491. Phosphate of Zinc.
ft. ZInel Phoapbatis, gr. xrj — 9g ; Aoidi Pho5pborioi IKIuti, Sin ;
AqofB Deatillnlir. ad Sviij, Miaoe. Capiat pari«m sextam ter die. Jh
some affections of the nervous system when a tonic is tieeded.

492. Oxide of Zine.
ft. Zinoi Oxydi. gr. xij ; Confectionis RoEie, Rj. Misce, et divide in
piluiaa sex. Cnpint pilulam UDam bis die. In chronic utcohotitm, cho-
rea, hysteria, \c. Dk. Qoi.DfNO BinD entertained an opinion that xine
has a specific infiueuce an the nen'out system, just as iron has on the
iitood. The dose may be gradually increased until Bj or even 5jf of the
tine it taken in the day. It may sometimes be advotUageoutly combined
vith opium.

493. Bark and Serpentnria.
ft. TiDCtnras CinchoDW Compoaitie, Sj ; Tincturtc Serpentaris, Sir,
Aqnc Mentbn Piperita, ad SviiJ. Misee. Capiat JJ ler die. An cxeet-
lent to/lie iti sopte eases of chronic rheumatism, and rheumatoid orthritie.

494. Quinine and Ipecacuanha.
ft. QuiniF Diaiilphalia, gr. iij ; Pulveria Ipecaouanbro, gr. rj ; Con-
feotioDia Rosae, gr. x. iliaoe. Divide into rix pills, and order one to be
taken erery day at dinner. Thie it an excellent remedy in eaeet of slow
digestion.

495. Quinine and Rhubarb.
ft. Tincturae Qainat Compoailae, Tineturn Rhei Compoeito), ii Srj ;
Aqn« Dealillat«> ad >rj. Misoe. Capiat Sj noete maneqne. In some
forms of nervous headache trith constipation.

TONICS.

6Sl

4tft. Stesl aiul GeiUian.
9. Ferri Salphatia ezsiocati, Eztraoti Qaotiuia, U gr.
Fiant pilalae dan, ter die namendn. In eases of Chlorosis.

r. Mins.

497. Steel and Conium.
9. Pilale Ferri CompoaiUe, Pilolae Conii Composita, Sigr. ▼. Miaoe.
Fiaot pUolB due, bia terra die anmenda. In ineipient phthisis, and in
many ehronie disease* attended toith eeugh and deiilily.

498. Pepeine and Steel.

*. PulTeria Ferri (Fer rMait), gr. tj Pepsins, gr. xt ; Palveria Tr«-
gaoantbft, Compoaiti, gr. xt ; Aqan Cinnamomi, Ij. Hiaoe. Fiat hanatna,
omni die poat prandinm aamendna. In eaees of anamia, with weakntes
of the digestive organs and eonttipatitm.

499. Phosphont* and Cod-liver Oil.
Vr. Pboaphori, gr. j ; Olei Morrhnn, Bi^. Miaoa. Capiat ^ bia terra
die. In tuberculosis, riekets, IfC.

500. Zine, Bart, and Glycerine.
9. Zinoi Snlpbatia, gr. xii ; Tineturn Cinebonae Compoaltae, Sj ; Olyoe-
linii pari, Siaa ; Aqaa HenthaB Piperitas ad Sriy. Hiaoe. Capiat Sj ter
die. During eonva/eseence from acute dieease, espeeially where there it
ewtaeiation and great nervoueneee.

tt82

LIST OF PRINCIPAL MINERAL WATERS.

A CLASSIFIED LIST OF THE PRIKCIPAL MINERAL

WATERS.

I. Salirx Aperient.

1. Carlibad, in Bohemia (IB5° Fnhr.).

2. Kiwengcn, in Buraria (cold).

5. Mnrienbad, in Bohemia (ooldK
4. Franzenibftd, in Bohemia (cold),

i. Chelteobam, in Oloncefterabire (cold).

0. Leamingtoa, in Wnrwicluhirs (cold).

7. Scarborough, in Yorlisbire (cold.).

II. Hot Salikb.

1. Wiesbaden, in the Duoby of Namau (It0°).

2. Baden-Baden, in the arand Duob; of Badao (liS").

III. Hot ScLriu'REOOS.

1. Aix-la-Cbapelle, in Prania (130°).

2. Bariget, in Iba Pyrenees (130'^).

3. Bagneres de Luchon, in the Pjrreoaea (130°).
rV. Hot Alkalirb.

1. Vichy, in Central France (108°).

2. Mont Dora, in Central France.

3. Ein», in Duchy of Ntuwan (83°— 116°).

4. Toepliti, in Bohemia (IU°— 122°).

6. Soblangenbad, in the Duchy of Nossaa (86°).

8. Wildbad, in the King<lom of Wurtemberg (88°— 19°).

SlllPLB DxMIIIKnALIIED, UoT,

1. Pfefferf, in Switierland (100°).

2. Oajtein, in the Tyrol (118°).

3. Buxton, in Derbyghire (82°).

4. Bristol, in OlonoeBterfthiro (74°).
6. Matlock, in Derbyshire (06°).

yi. SivPLi Mi.tenALiiED, Hot.

1. Bath, in Someraetfbire (II2°— 116°)

2. Pyreneei (80°— 122°).

yU. OHALrBKATE.

1. Spa, in Belgium (cold).

2. Bchwalboch, in the Duchy of Naaaau (eold).

3. Pyrmont, in Wcstj/holio (cold).

4. Marienbad, in Bohemia (eold).

5. Bruckenau and Booklet, in Bavaria (cold).

6. Tunbridge, in Kent (cold).

ym. CUALriBATB AMD Sl/'LPRCBBODS.

1. Harrogate, in Yorkshire (cold).

IX. loOL-RKTTEIi AXD BsiuU IXAT ED.

1. Creutnacb, in Khenish Prussia (alio lallot, S5°).

2. Ischl, in the Tyrol (also powerfully (aline).

3. Woodhall, in Liooolnihir* (S&°).

INaREDIENTS IN IMPORTANT PREPAaATIONB. 683

PROPORTIONS OF ACTIVE INGREDIENTS IN SOME
IMPORTANT PREPARATIONS.

MERCDBIAL FBEPABATI0N8.

Hydrargyram cnm Cretl, . . .

Pilnla Hydrargyri

Linimentnm HjdrargTri, . ■ .
Ceratom Ilydrargyri Compositum,
Cngnentam Hydrargyri, . . .

Pilnla Hydrargyri CUoridi Compo-
■ita,

Liqnor Hydnu'gyri BicUoridi, . .

Of Herenry.
contains gr. i\j in gr. rUj.
" gr. J in gr. i(J.
" gr. X in Sj.
" Siy in STij.
" Sj in sy.

Of Calomel.

gr. J in gr. t.

Of Bichloride of Hereory.
gr- * in ^j.

PREPARATIONS OF OPIVV.

Of Opiam.

Confectio Opii, contain! gr. j in gr. zzz^.

Enema Opii, " gr. iuin liv.

Linimentam Opii " gr. zy in S^.

Emplaetmm Opii " Sj in Szin.

Pilnla Saponis Composita,. ... " gr. j in gr. ▼.

Pilnla Styraois Composita " gr. jingr. t.

Pilnla Ipeoaonanhn cnm Soilla, . . " gr. ^ingr. x.

Pnlris Cretn Compoaitoj cam Opii,. " gr. j in 9^.

PalTisIpecaeoanhaCompoaitns,. . " gr. jingr. z.

Pnlrie Kino Compositni " gr. j in 3J.

Tinetnra Camphors Composita, . . " gr. ij in Sj.

Tinotnra Opii, " gr. j in "Ixiz.

Ungnentnm Opii, " Sj in Sj.

Vinnm Opii " gr. j in itziz.

Godfrey's Cordial " gr.jinsy.

Dalby's CarminatiTe " gr. i in sy.

Of Morphia,

Liquor Horphin Aoetatis " gr. j in Sj.

Liquor Morphias Hydroohloratis,. , " gr.jinSj.

Tinetara lodinil (Phar. Dub.), - '
Tiootnra lodinii Componita, . . ,
Liqaor Potaiuit lodidi Compositiu,
Voguenlum lodinii Compoiiiluin,

Syrnpan Ferri lodidi,

PBEPARATI0X8 OrTJllW!^^^^*
or I.Mlin«.
oontaiDi gr. r in 5j.
" gr. iss in 3j.
" gr^j ia JiT.
" gr. r in 3iij,

Of Iodide of Iron.
oonUioi gr. j in iHxy.

FRKPARATIONS OF ARSENIC.

or Argenioaa Aoid.

Liquor Pota«fffi Anenitis contains gr. iv in 9J.

Liquor ArKnioi Cbloridi " gr. ix in SJ.

Ths Liquor H.Tdriodatia Arganici ct Hydrargfri oontains in each 3j,
f'( of Artenions Acid, gr. i of Ozida of Mercury, and gr. ^ of lo
in the form of Hjdriodio Aoid.

FREPARATIONS Or CAXTBARIDK8.

Of Cantbaridea.

Aoetnm Cantharidtii, oontaing Sir in St.

Emplastrum Cantharidis, .... " 3j in 3^.

Ceratam Canlliaridit " ii ia Srij.

Tinolara Cantharidia " :y in Ix.

DIIA'TK AC'llig.

or Strong Aoid.
. . contains Siu in Sx'ij.
t} in iir.

Acidnm Aceticum Dilntum, . . .
Acidum Hjdroohtoricum Dilutum, .
Aoldura Nitrioum Dilutum,
Acidnm Sulpliuricum Dilutum, . .
Acidum Hydrocyanicum Dilutum

Siaa in Is.
qinHJ.

1 nar cant.

INDEX.

Abdominal aorta, anenrUm of, 612
parietea, abaoMM in, 47A
phthisis, 519
typhus, 176
AbMDoe of bile, 44
Abscess, feeal, 475

in abdominal parietes, 476
of the brain, 318
lirer, 483
Abscesses, absorption of, 46
Absorption of pns, 46
Aoephalocysts, 499
Acbolia, 44

from disorganisation of the
liver, 492
Acritochromacy, 578
Acinesia, 374
Acne, 573

AotlTe congestion, 30
dropsies, 94
hnmorrhage, 68
Acute bronchitis, 334
cystitis, 550

desqaamative nephritis, 533
dropsies, 94
encephalitis, 213
fitrey, 67
gastritis, 436
glanders, 66
inflammation, 84
peritonitis, 508
ramollissement, 218
rheumatism, 151
wasting of the lirer, 489
Adherent pericardium, 377

AfViean fever, 187

Ageustia, 275

Agminatad glands, disease of, 1 79

Ague, 182

cake, 184
Albugo, 587

Albuminous infiltration, 127
Albuminuria, 525
Alooholism, chronic, 240
Algide cholera, 452
Alimentation, forced, 261
Aliments, 621
Alopecia, 133

circumscripta, 564
Alteratives and resolvents, 624
Alveolar cancer, 103
Amaurosis, 275, 595
Amblyopia, 596
Amnssat's operation, 470
Amyloid degeneration, 127

degeneration of kidney,
532

degeneration of liver, 495
Anamia, 31

death from, 25
Annsthesia, 276, 298
Anasarca, 513

(scarlatinal), 204
Androphomania, 253
Aneurism of the aorta, 609
heart, 404
Angina pectoris, 402
Anginose scarlatina, 202
Animalcules in the blood, 55
Anosmis, 275

ISP**'

liver, il"
A„VopV.om.vn'». ^^^^

B»V« « """•,„ „f, 133

Bengal f.;-.^«'
Beriberi, »»

Biliary a«"«- ,,,
;»"*""• ;"U..f»„ 180, .ST

/..bid •o^""*''

,»*^"°^;:p.ii...«

Bl.ckc»u"',A«*
nbthlm'- 3^

Bleeding "<"»'" ,„„p. 16
moulb, 15

"■^•''tis

gtomae**' 1»

«joeM "« '

p„,.rtj of. 3^

vomif."!?''^'' ttl-.609

''^'"^■'"'"."iSdi-*""*'''*
B„tbnocepb»»f, ,,..«»

;Bo--°;x..^io»o--*^*

B'-»-''''r«iono'f\^--'»'
eoncow»»° 2

-^""•JrrC'^"-^^"'*
••"'"•Sot of *..»'»
j^olli— »•"*

INDEX.

.687

BriokUyer'i iteh, 687
Bright'! diMue, S30
Bronohial fiatala, 353
BroDohi, haemorrhaga from, 76
Bronohitu, iU

unU, 334

ehronio, 337

gonty, 338

plaitio, 337

rhaamstie, 338

(ubBoata, 337

^philitis, 338
BroDoboeale, 138
Brow-Bgus, 263
Buffy ooat on blood, 83
Balam faver, ISO
Balla, S69

OaohazU of csnoer, 100

Cadararie softaning of ■tomaoh, 436

Oalonli, biliary, 603
urinary, 633

Camp farer, 170

Cancer, 96

of tha liidnay, 639
lirer, 498
lung, 376
(eaophagus, 414
■tomaob, 437

Cancroid, 102

Canoroide, 676;

Canornm oris, 410

Capillary bronohiUi, 334

Capsniar oataraot, 693

Carbonaoaoaa bronobitia, 338

Carcinoma, 96

Cardiac ananrism, 404

Talvalar diMaaa, 386

Cardialgia, 419

Carditia, 385

Carniloation of the long, 343

Oatalapay, 301

Catamenia, exceaaira flow of, 82

Cataract, 692

in diabetaa, 636

Catarrh, 312

Catarrh, of tha atomach, 429

Catarrhal ophthalmia, 580

Catarrho-rhenmatie ophthalmia, 585

Catarrhaa aenilia, 337

CatharticB and anthelmintioi, 043

Cause of death, 26

Cauatics and connter-irritanU, 663

Cellulitis venenata, 47

Cephalalgia, 362

Cerebral haDmorrhage, 72, 227

paralyaia, 278
Cerebriform cancer, 101
Cerebritia, 212

Cerebro-spinal meoingitia, 267
Challc-stones, 143
Change of type in disease, 87
Cbeloidea, 575
Chemosis, 679
Chicken-pox, 198
Child-crowing, 329
Chloaamu, 565
Ohioridea in the urine, 360
Cblorosia, 31
Cholera, malignant, 463

aummer, 450
Choleaterina infiltration, 137
Choleemia, 46
Chores, 301
ChoToiditia, 691
Chromato-paendopala, 678
Chronic alcoholism, 242

atrophy of the liver, 492

bronchitis, 337

desquamative naphriUf , 637

diureaia, 634

dropaiea, 94

encephalitis, 217

fitrcy, 67

gastritis, 427

glanders, 66

gout, 143

inflammation, 84

peritonitis, 611

pneumonia, 361

rheumatic arthritU, 169

^^^^^^^^^K

i^^BI^^^^I

^^^^^^^^^^^^^BH

^^H 688

INDEX.

^^^^^^B Chronic rbeamatUm, liA

Oorneitis, 58S 1

^^^^^^^B CiDcbonism. 173

Coronary arteriea, diseue of, 406 H

^^^^^^B Circumscribed palmooary apoplexy.

Cnrjin, 312 H

^^^H

Coitivenesi, 461 ^M

^^^^H Cirrhoaia of Ifae IWcr, 486

Cotton pbthiaia, 338 ^M

^^^^^^H

Coanter-irritanta, 853 ^^^^t

^^^^^H Clami byatericaa.

Coup de aoleil, 234 ^^H

^^^^^^1 Olgrgymana sore throat, 331

Cow-pox, ^^^H

^^^^^^P Climate, change of, HI I

Craclced tongue, 407 ^^^H

r i Clonic «pa«m, 304

Creeping palay, 383 ^^^^|

1 Clot* ill Ibe heart, 40

Creliniira. ^^^^|

1 CoraitiF, 444

Critical ha'morrbage, 89 ^^^^|

I Ciwsum, inflammatlnn of, 443

Crossed palsy, 270 ^^^H

H^^^^K

^^H

^^^^^^^B Coffee'groandi vuiniling, 70

Criista lactea, ^^^H

^^^H 4«0

Crystalline lens, opacity of. 69S^^^H

^^^^^H CotioB piotonum, 288, 460

Outaneoua affections, 553 ^^^H

^^^^H 44S

Cntia anaerina, 184 ^^^|

^^^^^H Colloid

Oyanoaia, ^^^H

^^^^^H Colon, torpor of the, 4A3

Oynnnche Inryngen, 327 ^^^^|

^^^^^^1 Color blindoest, 678

Cynanobe maligna, 203 ^^^H

^^^^H eAl

parotidea, ^^^^H

^^^^^^1 Coma, death from, 28

^^^^1

^^^^^^B Coinpuaition of the blood, 2A

^^^H

^^^^^^B Concentric cardiac hjipertropbj, 3U5

Cyetio bronobncele, 139 ^^^|

^^^^^^B CoDoretioQn in the heart, 60

Cyatic 103 ^^^H

^^^^^^1 Cooouaaion of the brain, 233

Cyatitis, ^^^H

^^^^H 271

Cytoid oorpoaole*, 38 ^^^|

H^^^^F Condylomata on the tongue, 408

^^^^t

W P Congenital oataraol, 693

DandrilT, 571 ^^^^H

KL Congeation of blood, 30

Deafness, ^^^H

■■ 477

Death, cause ^^^H

^^^K Conical cornea, 5H5

Defloienoy of bloud, 31 ^^^H

^^^H Conjnnctiva. inflnmniatlon of, S79

Degeneration, amyloid, 127 ^B

^^^^^^ ConJuDctiritia, i79

fatty, ^^M

^^^^^H

Degenerations of the liver, 494"^^^^

^^^^^^^K Conatitulioual disturbance, 80

Delirium tremens, 237 ^^^H

^^^^^^B

Delusions, ^^^|

^^^^H

Dementia, ^^^H

^^^^^^B ConsumplioD.

Dengue, ^^^|

^^^^^^1 Conlngiuua ophthalmia, 581

Depoaition of fibrin, 49 ^^^^H

^^^^^^B Continued ferer.

Derbyshire neck, 138 ^^H

^^^^^^1 Convulaiona, arwmio, 42

Desquamatire nephritia, 527 ^^^|

^^^^^H

Diabetes inslpidua, 5.14 ^^^|

^^^^^^^P Curnen, dii«ea^eF of the, 58d

^^H

INDEX.

689

Diabetio eatumot, 635

Disphoretios, 053

Diarrhoea, 450

Diffaaed hapatitU, 489

pulmonary apopleiy. 77

DigHtiTB organs, diaaaiM of (ha, 406

Dilatation of (be haart, 397

■tomaoh, 432

Diphtheria, 318

Diplopia, £04

I)Lpflamanifi^ 340

Ditchnrget from the ear, 699

DieB&fl«^ change of tjpe in, 87

DiMans, ganeral, 2^

of the bladder, 643
blood, 2S
bloodreaaeU, 808
boweli, 440
brain, 212
cornea, 685
organi of digestion,

408
ear, 598
Baatachian tat>e,

604
eye, 576
heart, 374
iri>, 587
Itidneyi, 622
liver, 477
longs, 312
membrana tympani,

801
month, 406
nerrons system, 212
oeeophagns, 413
panoraaa, 605
peritonenm, 608
skin, 552
spinal oord, 265
spleen, 506
stomach, 425
snprs- renal oapanles,

641
tongne, 404

Disinfectants, 834
Dissecting anenrism, 810
Disseetion wonnds, 47
Disseminated lobular pneamonia,

343
Distemper or rot, 56
Distomahepatioam, 58

lanoeolatom, 68
Diuretics, 656
Dropsy, 93

acute inflammatory, 623

after scarlatina, 204

of the brain, 222
ovary, 515
peritonenm, 613
spinal eord, 270
Drop wrist, 288, 481
Dry tetter, 570
Duodenal dyspepsia, 418
Duodenitis, 441

Duodennm, perforation of, 438, 439
Dysentery, 446
Dyspepsia, 417

stmmons, 118
Dysphagia, 414
Dysphonia olerioorum, 331

Ear, diseases of the, 598

Bcoentric cardiac hypertrophy, 396

Ecehymoses, 57

Echinococci, 600

Ecstaoy, 301

Ecthyma. 561

Ecsema, 558

Egyptian ophthalmia, 681

Elephantiasis, 672

Emetics, 666

Emmenagogues, 659

Emphysema, 350

interlobular, 350
vesicular, 360

Emprosthotonos, 305

Empyema, 353

Encephalitis, 212

Bnoephaloid eaneer, 101

5«»

■^

^^^^^■B

^I^^^^^^H^^IB!— ^^^^^^^^1

690

INDEX. ^^^1

SndDMrditiii, 38S

Fatty degeneration of liver. IBI, 4V4

EnglUh cholera. 4H

Fatty growth of the heart. 3*7

Enteric fever, 170

■tools. 505

EnteriliK, 440

Favui, 563

Entoioa, inteirlinni, 471

Febricula, 164

in the blond, bi

Feigned epilepsy. 393

Epidemic caUrrh, 340

Saver, continued, 164

cholera, 452

intermittent, 183

Epilepsia renaliii, 42

relapaing, 180 ^^^H

El'ilepa.T, 2»l

^^^H

Epileptic lunatic?, 24(1

simple, ^^^^H

EpiiitnziB, 7.3

fymptomalie, 163 ^^^^|

Epithelial cancer. 102

^^^^H

Epithelioma, 102

^^^H

Equine fare^. Aft

190 ^^H

glanders, 65

^^^1

Eqninin, 65

^^^1

Erelhiitmua troploua, 2.14

Fibrin, deposition of. 50 ^^^H

Eruptive fever», 191

Fibrinous formations, 50 ^M

Erjripelaii, 207

Fibroid inflltration of atuouuih, 491 ^M

Erythema, 555

Pish-skln diseaM. 571 ■

EuKtachian tube, diteaM* of, 604

Fissured tongue, 407 ^M

Exhnliilion of blood, 68, 75

Fistula between ttomaoh and ooIob, V

* Exanthemata, the, 554

Exophthalmic goitre, ISO

Fistoln between stomaoh and duo- H

Expectorant*, 656

denum. 43U ^t

BxUmal otitiii. 600

Fistula, bronchial, 353 H

^^ Eye, diwama of the, 576

Fits, apoplectic. 228 ^^^^

^^H

^^^B

^^^^ raoe, paralyais of the, 28S

hysteric, ^^^^

^^^^^B Facial nearalgia.

Five-day fever, IHO V

^^^^^1 Ftccal

FoUiool&r disease of the pharynx, H

^^^^^^H

331 ■

^^^^H Falling

stomatitis. 408 H

^^^^^H FalM aneurism, 610

Forced alimentation, 261 ^M

^^^^^^H

Formula), appendii of, 619 ^^^H

^^^^^H False

Framberaia, ^^^H

^^^^H Famine

Fulness of blood, 30 ^^^|

^^^^^^H Farcinoma,

Fungus btematodea, lOi ^^^^|

^^^^^1 Farcy,

^^^U

^^^^^B Fatal jaundice, 480

Qall-bladder. inSammation of, M^^^|

^^^^^B Fatty

Qall-stones, ^^^M

^^^^^H degeneration, 124

Gangrene of the liver, 483 ^^^|

^^^^B of the

lung, ^^^^H

^^^^H 530

Oangrenons itomatitii, 41V ^^^H

INDEX.

691

Oargles, 660
Outralgia, 419
Oastrie csUrrh, 429

dyapepgia, 417

fevars, 430

hamorrhage, 78
Qaatritia, acute, 425

ohronio, 427
flagtro-bitioiw forer, 76
Oiutro-colis fistulED, 439
GaaCro-duudfltial ^talv^ 439
Gnatroiljiiia. 419
Oastrotomy, 470
(lalatiniform oancer, 103
Oaneral disaaaaa, 2S

dropay, 93

paraljaia, 275

paralyais of tha inaana, 245
Glandara, 66

Olanda of maaantery, diaaaaa of, 519
Glauooma, 593
EHubiu bjitericns, 297
Oloaaitia, 406

OlotUa, cedama of tba, 328
Oluoohaamia, 37
Oloooauria, 37, 635
Olyaoganaaii, 37
Ooitra, 138

Oonorrboal ophthalmia, 581
Oooaaakio, 184
Oont, 141

Ooaty bronohitia, 338
deafneas, 606
kidoey, 143, 528
Oraonlar eo^jnnotiTa, 583
Grarado, 312
Oraval, 532
Oray tnberole, 114
Orinder'a rot, 338
Orooar'a itoh, 567
0am cancer, 103
Ootta rosacea, 573

Haamatemeala, 78

Hiematine, 27
HBtniato(^ryita1Hn» 27
IlflBmntoid oiLncer, 104
HffimntoidiDB, 27
Hiematuria, 80
Baemine, 27
Hamoptyaia, 76
Hamorrhage, 68

cerebral, 72
. from the kidney, 80
Innga, 76
moBth, 78
nose, 73
atomaoh, 78
Dtams, 83
Hallncinationa, 250
Hard cancer, 99

cataract, 692
Hay-aathma, 838
Headache, 262
Heart, ananriam of the, 404
atrophy of the, 397
concrationa in, 60
dilatation of tha, 397
hypertrophy of tiie, S94
inflammation of the, 886
rapture of the, 401
valrnlar diseases of the, 886
Heartharn, 41ft
Hmt apopleiy, 234
Hectic fever, 86
Hemeralopia, 596
Hemiehorea, 302
Hemioraoia, 263, 308
Hnmiopia^ 596
Hemiplegia, 274
Hepatic atMoeas, 483
diaeases, 477
phlebitis, 488
Hepatitis, 480
Hernia, 465
Herpes, 558

tonsurans, 562
Honeyoomb ringworm, 563

^M 092 ^^M

^^B Hooping-congh. 343

Infantile laryngismus, 329 ^^^|

^H HoKpil&l fcrer, 170

letnnus, ^^^|

^H Humid tetter, 658

Infants, ophthalmia of, 581 ^^^|

^V Hybrid of meulM and searUtisa,

Inflammation, 83 ^

^B 1»2

ofaonjunoUTa, 579 ^^M

^H n;dsliil8 in the bruin, 219

intestines, 440 ^^M

^H lljrdatid tumors of the lirer, 189

Iris and cornea, 590 ^^H

^H Hydrocele, 93

meatus auditoriua, 1

^H Bydrocephaloid diaaaae, 22i

600 ^J

^1 Hydrocephalus, 93, 222

rtomaoh, 425 ^^H

^^H Hydrsmia, 31

the aorta, 608 ^^B

^H llydropericardium, 93, 379

biliary duota, I

^H Hydrophobia, CO

488 1

^H Hydrora«bis, 270

bladder, 550 1

^K Uydrolburax, 93, 352

brain, 213 ^J

^^m Hyperiemia, >10

^^H

^K Hypemstbetia, 297

eaeam, 443 ^^^|

^H Hyperinosis, 30, 49

eomea, 586 ^^H

^H Hypertrophy of the heart, 394

gall-bladder, ^H

^H Hypinosis, 31

^^M

^^m ItypopyoD, 5R6

587 ^^1

^H Hysteria, 29«

^^M

^H Hyaterioal hemiplegia, 278

mouth, 408

peritoneum, 508

^^K Ichorrhnmia, 45

retina, 593

^^1 Icterus, 602

•elerotio, 584

^^B lobtbyosia, 571

tympanic cavi-

^B Idiocy. 254

ty, 802

^H Idiopathic asthma, 347

reins, 613

^^^ erysipelas. 207

veins of Uver,

^^^^^L fatty degeneralioo, 1S5

^^^^H

Inflammatory fever, 60 ^^^H

^^^^^^m bipmcirrbage, 08

sore-throat, 413 ^^H

^^^^f

Inflaenia, 340 ^^H

^^V Ileam. ulcers in, 179

Ingredient* in important prepara- 1

lions, 683 ^^1

^^m lilac pas,<ion, 405

Inbalationa, 660 ^^M

^H Illusions, 250

Inoeulated small-pox, 195 ^^^t

^^^B Impaired viition, 670

luaoity, ^^^H

^^H Imperfect paralysis, 274

after delivery, 348 ^^1

^H Impetigo, 5A2

with epilepey, 340 ^^H

^^B Incotierence of mind, 253

with paralysis, 346 ^^H

^^H Indigestion, 417

InaotatioD, ^^H

^B IndoratioD of the brain ,218

Inspisntioo of pus, 46 ^^^|

^m tonrils. 3S3, 413

Interlobular emphysema, 360 ^^H

INDEX.

693

Intermittent fever, 182
Internal otitii, 803
InteatinkI obstrnetion, 406

womM, 471
Intestine, perforation of the, 179,

474
Inteitinea, inflammation of, 440
IntDssasoeptLun, 460
Iridweoilii, S8T
Iria, diaeawB of the, Sft7
Iriah famine fever, 180
Iritia, 587
Irregnlar gout, ISO
Irritability of the bladder, 643
Imhuria renalii, 42
Itch, SOS

Jail fever, 170
Jaandioe, 4S, S02
Jangle fever, 187

Keloid, 576

Keratitia, 680

Kidney, fatty degeneration of, 124
hnmorrbage from the, 81
inflammation of the, S22

Kleptomania, 25.'!

Land soarvy, 66
Larilaceou^ iafHtratian, 127

kidney, 632
Laryngeal phthiaia, 329
Larjngiamua strtdnlua, 329
Lnryngilia, 321
Larynx, hvmurrbiigs from, 70
Latent inflamnution, 84

plenriay, 354
Lateral paralyaia, 276
Lead oolio, 460
paUy, 288

without lead, 283
Lenticular oataraot, 593
Lepra, 670
I^neocythemia, .13
Leucorvtotia, 34

Leuooma, 687

Leukemia, 33

Lice, 687

Lichen. 566

Liniment*, 001

Linitia, 431

Lipsmia, 36

Liqniform melanoaia, 121

Liver, aoute atrophy of the, 489

amyloid degeneration of the,

496
apoplexy of the, 479
oanoer of the, 496
chronic atrnphy of the, 492
cirrhDels of ih 485
oongeation of the, 477
difeaaea of the, 477
fatty degeneration of, 125,

494
hydatid tnmora of the, 499
iniiammatipn of the, 480
accretion of angar by, 39
suppreaaion of the fanetiona
of, 489
I Liver-ipot, 565
Lobulfir pneumonia, 336
I Lcuml pivrnlysia. 2T4, 282
I Locked-jaw 304
I Lotig-aif^htedne^s, 577
I Long thread-iTorma, 471
Lonaeoesa of the bowela, 460
! Loaa of weight, 309
' Lotiona, 661
I Low nervoua fever, 170
' Lumbitgo, 157

' Lunaliuii, general paralyaia of, 246
' Lung, ^nnc^r uf the, 376
I Longa, bleeding from the, 70
i diaeaaea of the, 312

I gangrene of the, .'in I

inflammation of the, 36b
, Lupna, 103, 574
: Ly pemania, 25 1

I Malaria, 183

^^^Bi^l

H^HlHi

■

■ INOKX.

tl de Siam, 190

Morbid stetei of the blood, 25

■

jtlignaDtobalsra, 463
iaignant feirer, 170

Morbilli, 199

Morbus Addiaonii, 541

■

narlatina, 203

Brightii, 530

■

{ •mall-poz, 19S

cnrnlena, 400

■

|ni>, 247

regius, 502

■

Ibrginal pneumonia, 343

Mouth, bleeding from the, 75

iUlM, 199

inflaromation of the, 408

lebanieal bronchitia, 338

alougbing of the, 410

1 oonge>lioD.30

Uuco-enteritis, 441

lldttemnean fever, 187

Humps, the. 411

•dullar; oanoer, 101

Mune volitantea, 576

ilgriiDt. 203

Muscular nodea, 133

blBDa. 79
klancholia. 2&I

Myalgia, 157

Mydriaaia, 590

llnooid cancer, 104

Myelilia, 2A8

Manusia, 120

Myocarditis, 385

•liluria. 37, A35

Myopia, 570

pnibrana tympani, diMUei of lbs,

MyriDgitia, 601

Narcotics. 665

•ningeal apoplexy. It

Near sight. 576

ningUif, acute, 212

Nephralgia, 522

■

oerebro-tpinal, 307

Nephritis, 522

chronic, 217

Nanroua deafneas, 607

spinal, 2A6

headache, 263

tuberoular, 219

system, diseaias of the,

313 ^

JKiorrhagia, 82

Nettle-raah, 556

^^H

^nses, azoeasiTe flow of, 83

Neuralgia, 307

^^H

iantagrs, 664

Night-soil fever, 176

^^H

krcurial palay, 288

Nodes, 134

^^H

lueoterio glaoda, diseaae of, 1 78

Noiaea in the ear, 598

^^H

tnberole in, 619

Noli me tangere, 674

^^H

IttaaUtic abaceasee, 47

Noma, 409

^^^H

iiteorism, 177

Noae, bleeding from the, 73

^^H

Uamata, 183

Noitrila, inflammation of, 318

^^H

itld yellow fever, 180

Diana, 657

[tlkineas of the serum, 35

ObatrnctioD of the bowels, 466

(Edema, 93

of the glottis, 328

■

JDeral waters, liat of, K8I

(Eaophagns, diseases of the, 413

itral valre. diaeaae of, 390

Ointments, 674

^^^H

Ixed aneuriam, filO
ledifird small-pox, 198

Olignmia, 31
Onyx. 685

■

iollaacum. 573

Opacity of the coroaa, 586

ienomaoia, 247

Ophthalmia, 579

^^^1

inral insanity, 253

Opisthotonos, 305

■

lAPEX.

696

Orchitis, 412
Orgnnlc aelbmft, 347
Osteoid oanoer, 104
Otalgia, &S8
Olitif, extflrnal, 600
internoj, 003
Otorrboca, S9II
Orarian dropajr, 616
Oiana, 3U

Painter'a oolio, 460

Palsy, 274

Palndal fever, 182

Fanoreat, diraves of the, 605

Papular eraptions, 666

Paraljriiie masculaireatrophique, 283

Paralyiia, 274

•giUiM, 200

of the bladder, 546

of the insane, 245
Paraplegia, 280

Paraailio animals, 66, 471, 665
•rnplions, 563
plftnls, 411, 433, 683, 564,
665
Parotid, inflammation of the, 411
Parotitis, 4U
Partial insanity, 249
Pa«ive congestion, 30
dropsies, 94
bamorrbage, 68
Pedicnii, 667
Pemphigas, 560
Perfect paralysis, 274
Perforating ulcer ofdnodennra, 438
stomach, 434, 439
Perforation of the bowel, 474
intestine, 179
membrana tympani,
602, 603
Pericarditis, 376
Perioardinm, effusion into, 379

inflammation of the,
376

obliteration of lb«,377

Periodic ferer, 182
Periosteal nodes, 134
Peripheral hemiplegia, 278
Peripneumonia nolha, .337
Peritoneum, diseases of the, 608
Peritonitis, 608
Perityphlitis, 444
Pertnml glncomria, 343
Pertnaais, 342
Petechias, 69

Peyer's patches, disease of, 171
Phlebitis, 613
Phlegmasia dulens, 616
Phlegmonous erysipelas, 208
Photophobia, 583
Phrenitis, 214
Phthisis, 364

laryngea, 329
Piarrbsmla, 36
Pigment lirer, 496
Piozfcmia, 35
I Pityriasis, 871

Tersieolor, 666
Plague, 210

Plastic bronchitis, 837

linitis, 431

Plethora, 30

Plethoric headache, 163

Pleurisy, 352

Pleurodynia, 167, 364

Pleuro-pnenmonia, 363

Pleurosthotonos, 306

Plica polonica, 664

Pneumonia, 358

treatment of, 90

Pneumo-plenritis, 362

Pneomotborai, 355

with effusion, 355
Podagra, 141

Poljnimia, 30

Polypi of the heart, 49

larynx, 329

Pompholyi, 660

Porrigo decalrans, 564

farosa, 663

^^^^BH

IH^H

P^^P 096 ^H

Porrigo seatoUtft, 5«3

Red-gum, 558 '^^^^|

PorUI phlebitis, 488

Red softening of the brain, 2IS

Portio dun, paralyiis of th«, 283

Reflex amaurosis, 596

Vorntj of ths blood, 31

paraplegia, 281

PrMbyopia, 577

Refrigerants, 878

Prelobercular sUte, 3flft

Relapsing ferer, 180

PrograsaiTB paraljnis of the inmoe,

Relaxation of the bowels, 450

24i

membrnna tym*

Prorigo, 5(17

pani, 603

Pnudo-apinal dijeuM, 274

Remittent fever, 187

^^^_ Pgore, 585

Renal cancer, 539

^^^^b Puriwria, 571

' diseases, 522

^^^^H Plods pAlpebno. 275

Resolrenta and alterntivei, 824

^^^^^H Ptyalistn, alcera on tongn« Trom, 407

Retinitis, 593

^^^^^B Puerperal 50V

Retrocedent gout, 143

^^^^H

Revaccination, 198

^^^^^" Pnlraonary apoplexy, 78

Rhenmalio bronchitis, 3.t6

1 cancer, 375

deafness, 808

1 collapse, ,')35, 343

fever. 151

1 oonaumplion, 304

ophthalmia, 584

■^^^^^ emphysema, 350

pericarditis, 377

P^^^^P diseaae of.

Rheumatism, 150

^^^ Pnnetiform melaoosis, 121

chronic, 158

Purpura, 58

Rheumatoid arthritis, 159

Purulent afasorplina, 45

Rhiniirrhcca, 314 ^^^^H

ophtbnliuia, 580

RingiTorm, 583 ^^^^|

Pus, inspisMtion uf, 46

RIaus sardonicus, 305 ^^^H

Pustular eruptions, 581

Rodent ^^^1

■^^ Pyelitis, 522

Roseola, ^^^^|

^^^L^ Pylorus, induration of the, 430

Rose rash, ^^^|

^^^^^K

Rothein, 192 ^^H

^^^^H

Rot or distemper, 56 ^^^|

^^^^^H

192 ^^^1

^^^^H 419

Running scall, 658 ^^^H

^^^^H Pythogenic ferer, 170

Rupia, 560 ^^B

^^^^^H

Rupture of the heart, 401 ^^^H

^^^^^H Quartan

^^^^H

Saccharine diabetes, 37 ^^^|

^^^^H Quotidian ague.

fit. Anthony's Are, 307 ^^^H

B^^^^H

8t. Vituss dance, 301 ^^H

r Rabies, HO

Salines, 671 ^^^B

L Ramolllssement of brain, 218

Sanguineous apoplexy, 387 ^^^|

^^^^^

Sarcinae ventriouli, 433 ^^^|

^^^^^H Raving madness.

^^^1

^^^^^1 Reenrrent

300 ^^H

INDEX.

697

Scarlatinal dropay, &23
Soarlatioa morbillosa, 192
Scarlet farer, 200
Seiatioa, .108
SoirrhooR cancer, 90
Sclerotitia idiopathioa, 584
Scorbatns, 56
Sorofnla, 113
Scarry, 56
Sea aoorvy, 56
SednliTe^, 6A6
Serous apoplexy, 227
Serum, mUkinen of the, 35
Pcv»n-d»}- fever 180
^hinglea, baS
Short sight, &7S
Sick licadaohe, 429
Sierra Leone fever, 187
Sight, affections of, 576
Simple apoplexy, 227

atrophy of the heart, 397

cardiac hypertrophy, 394

erysipelas, 207

fsTer, 163

scarlatina, 201
Skin, diseases of the, 552

syphilitic, 132
Slow digestion, 420
^mnll-pox, 1^^
Soft cancer, 101

cataract, SO-t
Poftcning of tlie liver, 489
Spasmodic asthma, .347
.Spansemia, 31
Spasmodic strictnre of oesophagos,

415
Spasm of the bladder, 545
Specific inflammation, 84
Spina bifida, 271
Spinal cord, diseases of the, 206

haemorrhage, 269

irritation, 273

meniDgiti!), 2&a

paralysis, 2T8
Spleen (ague cake), 184

Spleen, diseases of the, 506
Spontaneous), hromorrbngR. 68
Spurious hydriMephalnr', 224

melanosis, I2A
I Squama us eruptionii, 569
I Staphyloma iridis, 586
Stimulants, 678
Stomach, bleeding from, 78
eascerof the, i'.iT
diiaUtion of the, 4.12
t inflnmmAtiou of, 425

perforation of the, 434,

439
softening of the, 426
I ulcer of the, 434

Stomatitis, itiS
Stomatorrhagia, 75
Strangulation of intestine, 465
Stratiform melanoiia, 121
Stiirtureof maophsgai, 415
, Stroke, paralytio, 278
I Strumous dyspepsia, ] 18
ophthalmia, 583
peritonitis, 511
Subacute, bronchitis, 337
I inflammation, 84

! Sndamina, 557
Sugar in urine, tests for, iX'
Suicide, tendency to, 2.'>2
Summer catarrh, 339
cholera, 450
Sun-pain, 309
, Sun-stroke, 234

i Suppression of functions of liver,
{ 489

I Supra-renal capsules, disease of, 541
Swallowing, difficulty in, 414
Sycosis, 564
Symptomatic ferer, 86

bsemorrhage, 08
Syncope, death from, 25
Synocba, 180
Syphilis, 131

Syphilitic bronchitis, 338
lepra, 570

^^H

^^ Syphilitie uloeri on tongoe, 407

Tnuurerae palsy, 376 ^^^^|

^H SyphilUktion, 136

Traaoutio erynipeloa, 207 ^B

bBmorrbage, 68 ^^^H

^^m Tnbu mosrnterica, 619

teUnoj, ^^^H

^^m Tapiiin nolium, 472

Treatment of oonte dinaoes, SB ^^^H

^H Tnjie-worui), 472, 473

Triohosis furfaracea, 663 ^^^^|

^H Tertian ngiie, 182

plion, ^^^H

^H Tnta for albamoo, 525

Trioooephalus di,«pttr, 471 ^^H

^^m naguT in urine, 537

TriouDpid ralve, diseoae of, ■301 ^H

^H T«taniu, 304

Trismai, 304 H

^H Teller, 558

nascentium, 305 ^H

^^B Tbomcic nortn, iinoDriBm or, 610

True aneurism, 609 ^H

^^B Threail-iromu, 4T1

empyema, 353 ^H

^H Tliruitl, blemling from the, 76

melanosis, 120 ^H

^^B inflammation of, 412

Tubercle, nature of, 114 ^M

^^M Tiirobblng of aorta, AUa

Tubercular meningitis, 219 ^H

^H Thramhi, 54

peritonitis, 511 ^M

^K Thra>b, (be, 411

pbthisit. 364 ■

^^H Tio-doaloarcnz, 308

akin diieoaes, 572 H

^^H Tinea (leealraos, 563

Tuberontoais, 113 H

^^B

Tuberiform melanoai), 121 ^H

^^H InpinoMi, 5fi3

Tumid spleen, 506 ^H

^^H >;oo>i5,

Tumon of the brain. 219 ^H

^^1 tonsaraiu, 563

spinal cord, 270 ^M

^^m Tinoitni aurinm, 58tt

syphilitio, 133 H

^H Toolb-ra»h, 566

Tympanio earity, inflammation of, ^M

^H Tophi. 143

602 ■

^^M Torpor of the colon, 462

TympaniUi, 177 H

^^H Torala, 530

Typhlitis, 444 H

^^M Toxvmia,

Typblo-enteritis, 444 H

^^H Tongue, baldnem of the, 408

Typhoid forer, 176 ^M

^^1 eeFurp! nfthe, 407

Typhus ferer, 167 ^M

^^H iDflnminntinn of, 408

Typhus iolerodes, ISO ^M

^^H papillar}' patchea of, 408

^^P ulcers of the, 407

Ulceration of membrnna tympani, ^H

^^^1 warts and condylomatii of

602 H

^^1

Ulceration of the oenopbagiu, 414 H

^^H Tonioe, 630

Cleerolire stomatitis, 409 ^^H

^^m Tonic ppodin, 3114

Ulcer of the stomaeb, 434 ^^^H

^H Tun!iillili>, 412

nieers, intestinal, 178 ^^^|

^^H TootiU, hypertrophy of the, 331,

lypbilitio, 134 ^^^H

^H 413

of the tongue, 40T ^^^^|

^H Traebenlia, 322

Urea in the blood. 43 ^^^H

^^H Traobevtomy in croup, 325

^^H

^^H Traorfunion, 72

tTrvmIs intnxicntion. 4 1 ^^^H

INDEX.

699

Unthra, bleeding from the, 80

TTrinary oalonli, 533

Vrine, defloieno7 of chloridet, 380

Urticaria, 566

Uterua, hnmorrhage from, 82

■yphilitio diiease of, 134

Vaoeinia, 107

Vaginitii (searlatinal), S04

Yalrnlar diuasei of the heart, 38t

VariceUa, 198

Tarietiea of grkTel, S33

Variola, 193

conflaeni, 194
gemieonilaeni, 194
Varioloid, 198
Veiiu, inflammation of the, M3

of liver, inflammation of, 488
Vesionlar emphymma, 360

eruptions, 5S7
Vibioes, 59

Vioariona hnmorrhage, 08
Villoua cancer, 105
Vision, impaired, 576
Vital oapaoity, 368
VolTuIns, 466
Vomiting of blood, 78

Waleheren foTer, 187
Warts on the tongue, 408
Washerwoman's iteh, 567
Wasting of the lirer, 489

palsy, 283
Water-brash, 419
Waters, mineral, list of, 681
Wax, aooumulation of. in ear, 599
Waxy Inflltration, 127

kidney, 632

liver, 496
Weakness of rision, 578
Weight, loss of, 369
White-cell blood, 33
White softening of the brain, 218
Willan's classifloatioD of skin dis-
eases, 564
Winter cough, 337
Worms in the blood, 65
intestinal, 471

Yaws, 674

Yellow atrophy of the lirer, 489

fever, 190

tubercle, 114

Zona, 658

LANE MEDICAL, LIBRARY

To avoid fine, this book should be returned
ou or before the date last stamped below.

■

L46 Tanner, T.H. 16922
T16 Manuel of practice of

NAME

HATE UtJE

.«« — »....J. «...«

/ 1

Internet Archive Audio

Featured

Top

Images

Featured

Top

Software

Featured

Top

Books

Featured

Top

Video

Featured

Top

Mobile Apps

Browser Extensions

Archive-It Subscription

Save Page Now

Full text of "A manual of the practice of medicine"

See other formats