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FinSBO^iU^^/CFL-EDW
^ A322 NORTH CRAIG STREET,
PITTSBURGH, PA.
DICTIONAEY
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PRACTICAL MEDICINE:
COMPRISING
GENERAL PATHOLOGY,
THE NATURE AND TREATMENT OF DISEASES, MORBID STRUCTURES,
AND THE DISORDERS ESPECIALLY INCIDENTAL TO CLIMATES, TO THE SEX,
AND TO THE DIFFERENT EPOCHS OF LIFE;
WITH
NUMEROUS PRESCRIPTIONS FOR THE MEDICINES RECOMMENDED,
A CLASSIFICATION OF DISEASES ACCORDING TO PATHOLOGICAL PRIN-
CIPLES, A COPIOUS BIBLIOGRAPHY, WITH REFERENCES;
AND AN
Stypcuolj: of Styproortr iFormttlac: \
THE WHOLE FORMING A LIBRARY OF PATHOLOGY AND PRACTICAL MEDICINE,
AND A DIGEST OF MEDICAL LITERATURE.
BY JAMES COPLAJVD, M. D.
Consulting Physician to Queen Charlotte's Lying-in Hospital ; Senior Physician to the Royal Infirmary
for Diseases of Children ; Member of the Royal College of Physicians, London ; Member
of the Medical and Chirurgicul Societies of London and Berlin, etc.
VOL. I.
BOSTON:
LILLY, WAIT, COLMAN, AND IIOLDEN.
1 834.
SOLD BT ALL THE PRINCIPAL BOOKSELLERS IN THE UNITED STATES.
V!
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CONTENTS
ABDOMEN— External Examination
of, in Disease 1
ABORTION 5
ABSCESS 12
ABSORPTION— In relation to the
Causation, Continuance, and the
Removal of Disease 23
ABSTINENCE— Its Morbid Effects 26
ACNE 27
ADHESIONS— Reparative and Mor-
bid 32
ADIPOSE TISSUE — Its Morbid
States 36
AFTER-PAINS 37
AGE — Considered with relation to the
Nature and Treatment of Dis-
eases 38
Of the early Periods of Age 39
Of the advanced Periods of Age 44
AMAUROSIS 50
ANGINA PECTORIS 62
ANTIPATHY 70
AORTA— Nervous Pulsation of the 70
Inflammation of the 71
Aneurism of the 72
APOPLEXY 79
Of New-born Infants 107
APPETITE— Insatiable— Bulimia 107
Vitiated — Pica 110
ARTERIES— Diseases of 111
Nervous Affection of 112
Inflammation of 112
Morbid Structures of 116
Aneurisms, &c, 117
ARTS AND EMPLOYMENTS—
In relation to Disease 122
ASPHYXY 12S
Of New-born Infants 134
ASTHMA 135
ATROPHY 154
AUSCULTATION 156
BARBIERS
BERIBERI
BLOOD— Its States in Health
Exuberance of— Plethora
Local Determinations of
-: — Deficiency of— Anssmia
Morbid Effects of its Loss
-Alterations of, in Diseases
Contamination of the, &c,
Nervous Influence on the
Action of Poisons on — Various
Morbid States of — Signs and
Treatment of' &c, &c,
BLUE DISEASE
BRAIN — Alterations of its Mem-
branes
Alterations of its Sinuses and Ves-
sel's
Alterations of its Substance
Abscess of the
Softening — Haemorrhage — Hy-
pertrophy — Atrophy — Indura-
tion, &c,
Tumours in the, &c,
Cerebral Plethora
Congestion of the
Inflammation of its Membranes
Inflammation of its Substance
Inflammation of its Membranes
and Substance
Softening of the
BRONCHI AND AIR PASSAGES
Alterations of their Structure
Congestion of the
Inflammations of the— Acute and
Chronic
BRONCHIAL FLUX — Bronchor-
rhoea
BRONCHOCELE
BULL.E
163
164
166
16S
171
173
175
180
192
193
194
199
201
208
209
210
214
221
2261
227
228
230
232
241
244
248
249
267
269
271
\£fcfc^
CONTENTS.
CACHEXY 272
African 273
CECUM— Diseases of the 274
Functional Disorders of the 275
Inflammation of the 277
of its Appendix, &c, 278
CANCER 282
CATALEPSY 290
CATALEPTIC ECSTASY 291
CATARRH 293
CELLULAR TISSUE— Alterations
of 29S
Diffusive Inflammation of the 299
Induration of the 306
CHEST— External Examination of the 309
Deformities of the 310
CHICKEN-POX 312
CHLOROSIS 315
CHOLERA 318
CHOLERIC FEVER OF IN-
FANTS 325
CHOREA AND RELATED AF-
FECTIONS 327
CLIMACTERIC DECAY 336
CLIMATE— Its Physical Relations 338
Its influence on the Human Con-
stitution 342
In the Cure of Disease 349
COLD— Its Pathological Effects 354
Its Remedial Operations 358
COLIC— Forms depending on Func-
tional Disorder 360
COLIC— Bilious— Hepatic — Madrid,
or West-Indian 362
From the Poison of Lead, &c, 364
From Change of Structure and
Relative Position of the Bowels 366
COLIC AND ILEUS-Comprising
Introsusceptions, &c, 366
Treatment, &c, 371
COLON— Nature and Treatment of
its Morbid States 382
COMA AND LETHARGY 387
CONCRETIONS, BILIARY 392
CONCRETIONS, INTESTINAL 397
CONGESTION OF BLOOD 401
CONSTIPATION 405
CONVULSIONS— Partial and Gen-
eral 412
Infantile 417
Puerperal 418
COUGH 436
CRANIUM AND ENVELOPES—
Their Lesions 439
CRETINISM 441
CRISIS AND CRITICAL CHAN-
GES 443
CRITICAL DAYS • 448
CROUP 449
Its Varieties 452
Its Complications, &c, ' 454
Its Treatment 462
*'*S©
DICTIONARY
OF
PRACTICAL MEDICINE,
ABDOiUEN. Stn. Ventre, Fr. Unterleib,
Bunch, Ger. Ventre, Pancia, lta\. Belly, Eng.
External Examination of the Abdo-
men in Disease.
Classification. — Pathology. Semei-
ology, or Symptomatology; Diagnosis.
1. The abdomen may be considered as the
fundamental part of the frame, inasmuch as it is
never wanting in monstrous fetuses; and as it
contains parts which are the first formed in the
embryo, and are the centres and sources of or-
ganic life. The number and importance of the
viscera contained in its cavity; the number, the
diversity, the extreme frequency and complica-
tion, of the maladies to which these viscera are
liable, are circumstances which pressingly urge
upon the practitioner a careful examination of the
parietes of this cavity, in order to ascertain the
nature and extent of disease. Much, however,
will depend upon the manner in which the ex-
amination is made, in respect both of acquiring
information as to the existing state of disease, and
of drawing inferences as to its origin, and the best
means of removing it.
2. Pathologists have generally divided the ab-
domen into certain Regions, with the view of
describing with more accuracy the seat of morbid
actions. These regions are marked out bv means
of imaginary lines, drawn in horizontal and ver-
tical directions. The horizontal lines, four in
number, divide this cavity into three zones. The
highest of these lines pass over the xiphoid carti-
lage; the second, by the margin of the tenth rib;
the third, by the anterior and superior spine of the
ilia; and the fourth, by the superior margin of the
pubis: thus giving three zones, the epigastric, the
umbilical, and the hypogastric.
3. For the sake of additional precision, each of
these zones is divided into segments by vertical
lines, also four in number, drawn from the acro-
mial extremity of the right and left clavicles to
the insertion of the ligaments of Foupart; and
from the posterior margins of the axillae, over the
most exterior part of the crests of the ilia, to the
large trochanters. The spinous processes of the
vertebrae may likewise be considered as forming a
fifth line of demarcation; as we cannot overlook
the posterior parts of the body in our investigation
of many of the diseases affecting the abdominal
organs. The vertical lines now enumerated, di-
viding the horizontal lines very nearly at right
Bogies, give us nine regions on the anterior and
lateral aspects of the abdomen, and six posterior
regions. The anterior regions are the epigastric,
umbilical, hypogastric, and right and left inguinal;
the lateral regions are the right and left hypo-
chondriac, and right and left iliac; the dorsal
regions are the inferior dorsal — right and left, the
right and left lumbar, and the right and left glu-
teal regions.
4. It does not belong to the scope of this work
to enumerate the anatomical boundaries of the
abdomen; the parts forming its parietes; or the
viscera contained in each region. These are
matters which are, or ought to be, familiar to all
who peruse this work. But it is necessary to
remind the reader, that organs which, in the
healthy state, are always situate in a particular
region, will be so changed in form and bulk by dis-
ease as frequently to extend to adjoining regions,
where they will often be detected upon a careful
examination; or they will be altogether displaced,
either by the specific gravity of their contents, or
by tumours developed in their structure. The
former phenomenon is often remarked in respect
of the liver, spleen, kidneys, ovarium, uterus, &c;
the latter, in the stomach, pylorus, gall-bladder,
colon, &c.
5. This change of the position of the abdominal
viscera Is chierly observed in the more chronic
kinds of organic diseases, and is pointed out in
the articles in which they are described: it is gen-
erally more manifest in one posture of the body
than in others; and is to be ascertained, with the
other maladies to which these viscera are liable,
by the modes of examining the abdomen about to
be explained, assisted by other rational or infer-
ential symptoms. These modes may be made the
source of much information as to all the relations
of abdominal diseases; but attention, repeated
observations, and much natural discernment, are
required to obtain from them all the knowledge
they are capable of conveying. I shall discuss
this subject in the brief manner to which I am
necessarily driven, by noticing, I., Inspection;
11., Manual examination; 1IT., Percussion;
and, IV., Auscultation, of the abdomen.
6. I. Inspection by the sense of sight mere-
ly, although the best mode of acquiring an idea
of the form, size, and motions of the abdomen, is
chiefly valuable as a means of investigating the
diseases of its viscera in conjunction with the other
modes just enumerated; yet simple inspection
furnishes us with the most important information
in many diseases, particularly in those of infancy
and childhood, as well as in many acute and
chronic maladies occurring in adults. The form
of the abdomen, although necessarily in 6ome
ABDOMEN — Investigation or, in Disease.
measure changed by marked variation of its bulk,
may, nevertheless, be much altered without any
decided difference in its size. 'Ihus, it is some-
what changed in severe diseases of the respiratory
passages, when the entrance of air into the lungs
is obstructed; the epigastrium and hypochondria
being then pressed inwards and upwards: whilst
in some morbid states of the liver and gallbladder,
of the spleen, and of the ovaria, an unusual promi-
nence in their respective regions is frequently ob-
served. But the most remarkable changes in the
form of the abdomen is met with when the size of
the cavity is also altered. It is scarcely necessary
to allude to examples; but, in all those diseases
attended with enlargement or diminution of the
bulk of this important part of the body, either in
one of its regions, in several of them, or in all, in-
spection should always be performed ■" it gives
greater precision to manual examination; enables
us to compare the bulk of a region with the corres-
ponding region on the other side, and with others
in its vicinity ; and impresses upon the memory
the changes which the part may experience dur-
ing the progress of disease. It should, therefore,
never be neglected in all the forms of abdominal
dropsy; in peritonitis, chronic or acute; in inflam-
mation of the stomach, liver, spleen, and bowels;
in the different kinds of colic, in fevers, in uterine
and ovarian diseases; in affections of the kidnevs
and urinary organs; in all disorders accompanied
with obstruction to the excretions; and, in short,
in all chronic maladies. It ought never to be
overlooked in the diseases of infancy and child-
hood, of whatever nature thev may be.
7. Besides, however, attending in those diseases
to the form and size of the abdomen merely, the
motions which it presents ought not to be neg'eet-
ed. When rightly interpreted, they often furnish
important diagnostic and therapeutic hints. Put
they require to be viewed in connection with the
motions of the thorax, and state of the heart s ac-
tion. In diaphragmitis, peritonitis, gastritis, enter-
itis, and ce;tain states of hepatitis, the motions of
the abdomen are slight or obscure, whilst the ac-
tions of the thorax are increased. On the other
hand, in several severe diseases of the respiratory
organs, particularly in croup, laryngitis, bronchitis,
several varieties of asthma, pleuritis, pneumonia,
&c., the parietes of the chest are nearly motion-
less; whilst the movements of the abdomen, es-
pecially at the epigastrium, in croup and asthma,
are remarkably increased, or laborious. rJ he
motions of the abdomen, also, are often not limit-
ed to those caused by respiration; but in some
cases, particularly in organic changes of the heart,
pericardium, aorta, &c, and even in certain nerv-
ous disorders implicating these organs, con. prises
those occasioned by the action of the heart, in-
creased by the state of the large abdominal vessels,
and by the emaciation or other morbid condition '•
of the patient.
8. II. Manual, examination of the ab- [
domen is one of the most important means of di-
agnosis we possess but it furnishes information in
proportion to the perfection of manner in which
it is made. In this very requisite mode of inves-
tigation, the temperature of the hand of the prac- |
thinner at the time of making it should be attend-
ed to, in the great majority of diseases; both as a
moderate warmth of the hand is necessary to the
greatest delicacy and accuracy of touch, and as ,
its application to the surface of the abdomen will
not in that state occasion any disturbance or con-
traction of the muscular parietes. In entering
upon the examination, care should be taken not to
excite the alarm of the patient. 1 he hand ought
to be applied at first in the gentlest manner pos-
sible. By observing this, three very important
objects will be best obtained ; namely, a know-
ledge of the form, of the temperature, and of the
sensibility of the surface of the abdomen.
9. As much more information than this is re-
quired from manual examination, the patient
should be directed to place himself in a favour-
able position for a more general and complete
investigation. lie should be placed on his back,
with the head and shoulders slightly and comfort-
ably elevated, and the thighs drawn nearly to a
right angle with the trunk. If the bladder be
full, it should be emptied. When proceeding to
examine, the patient should be told to relax all
the muscles, particularly the abdominal muscles.
Commencing, therefore, with the utmost gentle-
ness, and passing the hand slightly over the ab-
domen, we should slowly increase the pressure,
with the view of ascertaining the following con-
ditions— 1st, Its temperature; 2d, Its form and
size; Sd, Its sensibility-; 4th, Its degree of tension
and firmness; £th, 1 he existenceof enlargements,
tumours, &c. ; Ith, rlhe presence of effused flu-
ids; 7th, 'ihe probable existence of accumulated
secretions and faecal matters; 8th, Hernia] protru-
sions and displacements. On each of these I pro-
ceed to offer a few remarks.
10. 1st, Ihe temperature of the abdomen fur-
nishes most important indications as to the nature
of disease. It is generally always higher than
natural in diseases of increased action; and is also
often higher when the patient is actually com-
plaining of cold, particularly at the commence-
ment of fevers. In many fevers and inflamma-
tions of the abdominal viscera, particularly those
of a dangerous or malignant character, the in-
creased ten perature is accompanied with a pecu-
liar acrid pungency to the sensation of the exam-
iner; a phenomenon which indicates the utmost
risk of rapidly supervening disorganization. Di-
minished temperature of the abdomen is met
with in the period of depression, or cold stage at
the commencement of fevers, but very seldom at
their termination, even in death, unless in the
most malignant or liquescent forms. It is also
met with after injuries of the abdomen, particular-
ly blows on the epigastrium, in anamiia, chlorosis,
and other disordeis of debility.
11. 2d, 1 he form and size of the abdomen
are frequently altered, as already noticed (§6, 7.);
but, in order to ascertain the nature of the altera
tion, various means of investigation are generally
required, particularly those which remain to be
considered. When pioceeding with the manual
examination of the abdomen, it is necessary very
gently to increase the pressure, and, when acute
pain is Hot con plained of, to make it in various
directions, — laterally, downwards, upwards, and
backwards to the spine, — so that if altered sensi-
bility of any of the contained viscera exist, it may
not escape detection, but be accurately ascertain-
ed and estimated; and the examination should
always be made with a careful observation of its
effects upon the expression of the countenance of
the patient. It will also often be requisite to per-
ABDOMEN — Investigation of, in Disease.
form the manual examination; now with the points
of several fingers, now with the whole of one, or
erven of both hands; and occasionally, at the
same time that a full inspiration Is being made.
But it should always be performed with attention
to the sensations of the patient, particularly as
expressed by the countenance, and to the feelings
and ideas it may excite in our own minds. Even
the state of action in which the abdominal muscles
are often thrown by the examination ; the degree
of pressure occasioning such action ; and the cir-
cumstance of tension of those muscles preceding
the examination, or being excited by it; as well as
the continuance of their contractions, and the pe-
riods and occasions of their relaxation, are all im-
portant matters in our estimate of the state of
the viscera underneath, — more particularly in the
various states of inflammation seated in the peri-
toneum, in the alimentary canal, &c.
12. 3d, The sensibility of the parietes of the
abdomen is most intimately associated with that
of the contained organs, both in health and dis-
ease. The sensibility of the epigastric region
varies most widely in different persons. It is fre-
quently, even in tolerable health, very great in
delicate and thin females. It is always so in
inflammation of the viscera, more particularly
when the serous membranes are affected ; and
the more superficial the inflammation, the more
tender is the surface. In order to obtain an
accurate idea of the state of the sensibility of
the abdomen, pressure should be commenced in
the gentlest manner, and with the fingers and palm
of the open hand. When the patient cannot en-
dure the slightest touch, the disease is then com-
monly in the parietes, or in the serous membrane
reflected over them. When the cause exists
more deeply, the tenderness is less acute, and the
muscles are almost instinctively brought into action,
even before pressure is made, in order to protect
the diseased viscera from it.
13. When superficial tenderness is absent, the
examination may be made with increased pres-
sure, in order to ascertain the presence of tender-
ness, pain, or soreness, in any degree or at any
part. But caution in thus increasing the pressure
is always necessary when the parenchyma of an
organ, particularly of the liver or spleen, is enlarged
or otherwise affected ; for many such affections
may be very serious, and yet the sensibility of the
diseased part not much increased. I have known
rupture of an enlarged and softened spleen occa-
sioned by the rudeness of the examination ; and
writers have mentioned similar accidents to have
occurred to the liver.
14. 4th, The tension and firm net1; of the abdo-
men require attention, and due estimation of their
actual amount ; and in connection with the other
diagnostic indications furnished by the examin-
ation. Thus, when the tension is associated with
increased temperature and sensibility, inflamma-
tion of one or more organs underneath, particularly
of the peritoneum, may be predicated. The tu-
mefaction, degree of sensibility, position of the
patient, &c. will further prove the accuracy of
the diagnosis. Tension and firmness are always
present in the different forms of peritonitis and
inflammations of the subjacent viscera, but not
uniformly throughout all their stages. Even in the
worst or most malignant forms of peritonitis, as
those met with in puerperal females, these symp-
toms are often either almost altogether wanting, or
they exist for a short time only. When effusion
of a serous or sera-purulent matter occurs in
peritonitis, or when suppuration has followed in-
flammation of the enveloped viscera, tension as
well as firmness disappear) 'I hey are generally,
however, both present, even when the sensibility
of the parietes is not much greater than natural,
in chronic peritonitis with the formation of ("also
membranes, or the agglutination of the opposing
surfaces of the viscera.
15. 5th, the presence of tumours or other mor-
bid growths, or the fact of their absence, has also
to be ascertained by a manual examination. This
information can be obtained only by this mode of
investigation, carefully conducted. If we detect
anv degree of unusual tumefaction or hardness,
we should endeavour to ascertain its exact site ; its
form, size, connections ; its consistence, degree of
sensibility ; and whether it is fixed or moveable,
soft and yielding, or hard ; pulsatile or not. The
situation of the tumour ; its size, form, and degree
of fixedness, will enable us to form an idea of the
part affected : whilst the absence or presence of
morbid sensibility in it, of fluctuation and puls-
ation, and the manner in which the nearest parts
of the abdominal parietes are affected by it, will
furnish important indications of its nature. When
tumours or unusual circumscribed indurations are
detected in any part of the abdomen, we should
bear in mind that their sources and kinds are
numerous : that they may be formed in the liver,
pancreas, spleen, stomach, pylorus, mesentery,
omentum, caecum, kidneys, uterine organs, &c. ;
that their nature may be extremely various ; and
that they may consist either of accumulations of
some fluid contained in a cyst, or infiltrated in
the substance of an organ, or enclosed in its natu-
ral cavity, the outlet of which has been obstruct-
ed ; or of a deposition of some morbid structure,
the nature of which can only be known by a com-
parison of numerous symptoms, and the history
of the disease. Care should be also taken that
the accumulations of faecal matters occasionally
formed in the caecum, and in various parts of the
colon, or that an unusual anterior protuberance
or curvature of the inferior dorsal or lumbar ver-
tebra:, be not mistaken, as have sometimes hap-
pened, for morbid growths ; and that unusually
large collections of the natural secretions in their
c\sts, as of the bile and urine, owing to temporary
obstruction to their discharge, be not treated as
morbid formations of a very different kind. I have
known cases in which distension of the gall-blad-
der, from great accumulation of the cystic bile,
was mistaken for abscess of the liver ; and an
enormously distended urinary bladder was viewed
as dropsy.
16. tith, The presence of fluids effused into
the peritoneal sac is best ascertained by placing
the patient in the erect posture. If this cannot
be done, and if he cannot even sit up, the
shoulders and limbs should be placed low ; and,
whether in the erect or recumbent posture, the
palm of one hand laid with a gentle pressure
upon one side of the abdomen, whilst we tap
somewhat smartly with the other hand, on the
opposite side. The impulse occasioned by the
stroke will occasion, if fluid be effused, a vibratory
undulation or shock which will be felt by the
other band, and which constitutes the diagnostic
ABDOMEN — Investigation of, in Disease.
symptom in diseases of the abdomen attended
with effusion.
17. 7th, Accum illation of '/cecal matters in the
bowels are not unfrequently mistaken for tumours.
These matters usually collect and harden in the
caecum, or in some part of the colon. They
seldom accumulate in the small intestines, unless
they consist of certain kinds of intestinal concre-
tions (see the art.); which are with difficulty dis-
tinguished from tumours seated in some one of
the abdominal viscera. It is indispensably re-
quisite to examine the abdomen carefully in all
cases of habitual or occasional constipation, par-
ticularly in the region of the caecum and course
of the colon ; as, when conducted with an expe-
rienced tact and discrimination, these collections
will generally be ascertained : and when the his-
tory of the case, and numerous contingent rational
symptoms, are taken into account, little risk
will be run of confounding them with morbid
growths. The accumulation of secretions in the
gall-bladder, and in the urinary bladder, are chief-
ly, particularly the latter, ascertained by manual
examination. The diagnosis of those disorders
is fully pointed out in another place.
18. 8th, Protrusion of some part of the abdo-
minal contents, giving rise to any either of the
more common kinds of Hernia:, or of those which
are unusual, should never be overlooked. Inguinal,
femoral, and umbilical hernia? are so frequent,
and, when either incarcerated or strangulated, oc-
casion so serious effects, that in all cases where
severe symptoms are referred to any of the viscera
contained in the abdominal cavity, or in its vici-
nity, or when the functions of the bowels are
obstructed, this source of mischief should be par-
ticularly enquired into.
19. I may observe generally, in respect of
manual examination of the abdomen, that it fur-
nishes valuable means of diagnosis in very many
diseases, particularly when estimated in due con-
nection with those derived from other sources ; but
I should add, — what I shall often have to prove
hereafter, — that it does not always give us exactly
the same kind of information that is stated in
several, and even in some very recent, works.
Thus it is said to be the most certain means of
ascertaining the presence of enlarged mesenteric
glands, and by actually feeling these glands en-
larged. Now this is not the case, and I state it
from an experience of many hundred cases : for
there are comparatively but few instances in
which these enlarged glands can be satisfactorily
detected, by the most careful manual examination.
But this mode of investigation furnishes certain
indications of their presence of a different kind
from that which writers have laid down. It may
also be remarked, that a manual examination of
the abdomen is generally much more successfully
made in lean subjects, in females than in males,
and in children than in adults ; whilst in mus-
cular men, and in fat persons, it furnishes much
less information, owing to the muscularity and
thickness of the abdominal parietes.
20. III. Percussion has been employed as
a means of diagnosis in diseases of the abdomen
from a very early period of medical knowledge,
but chiefly with a view of recognising tympanitic
affections, or unusual accumulations of air, and
dropsical effusions ; and it was not until very
lately that attention was directed to it as a means
of investigation in a very large proportion of other
diseases of the abdominal viscera. Percussion
of the abdomen as well as of the thorax is either
direct or mediate : the former is that which was
first ably insisted on by Auenbrugger, and
brought into notice by C'orvisart, chiefly in the
investigation of thoracic diseases ; the latter, both
in its application to abdominal and thoracic affec-
tions, is the invention of M. Piorry, who has
paid great attention to its perfection, and has
written ably on it as a means of diagnosis.
2 1 . Direct percussion consists of simply striking
the parts, somewhat smartly, with the points of
two or more ringers united and brought to the
same plane, and attending to the sounds elicited.
Mediate percussion is performing the same with
a thin plate of ivory, box wood, or any other
hard elastic body, placed over the part to be thus
examined, and striking upon it. The advantages
derived from having such a body interposed be-
tween the surface and the fingers are, 1st, The
part is protected in a great measure from the
stroke, which, although slight, yet is frequently
unpleasant to delicate and sensitive persons ; 2d,
It assists in the production of the sound for the
obtaining which percussion is employed. (See
art. Percussion.) The body on which the per-
cussion is thus made usually consists of a small
ivory plate of about 24 or A inches in diameter :
M. Piorry calls it the plcximcter, or measure of
percussion. In all cases in which we wish to ex-
amine the abdomen by percussion, it will be ne-
cessary to use the pleximeter. The information
it conveys varies according to the state of the parte
underneath. If we place it over the liver, per-
cussion gives out a dull sound ; from the circum-
stance of a dense body lying beneath thai |
the abdominal parietes : if it be moved in the course
of the stomach and colon, a sound will be elicited
clear in proportion to the quantity of air contained
in these viscera.
22. During our investigation of the abdominal
contents with the aid of mediate percussion, it
will be necessary to attend to certain facts: — 1st,
That the pleximeter will furnish, in the same
person, a sound varying from dull to t\ mpanitic
as the parts over which it ma\ be placed differ in
density and the quantity of air they may enclose ;
2d, That in situations of the abdomen where,
owing to the quantity of air usually contained in
the bowels, mediate percussion generally gives
a tympanitic sound when the plate is placed
lightly on the surface, it will give a much duller,
or even a dead sound, when pressed inwards so
as to displace the air from underneath it, and to
approach nearer to some solid body, or to bring
the parts nearer to that condition by the pressure ;
3d, That the stomach and whole tract of the iiv-
testinal canal always contain a certain quantity
of air or gaseous fluid, particularly the large
bowels ; and that they approach more nearly to
the abdominal parietes in proportion to their dis-
tension, whether with air, or with fluid or more or
less solid contents ; and -It li . The quantity of air
contained in the digestive tube, especially the s;(v-
mach and large bowels, is great in proportion to
the deficency of its vital energy, and the degree of
inflammatory action affecting it.
23. These facts being attended to in our in-
vestigations of abdominal diseases bv means of
percussion, mediate or direct, the extent of the
ABORTION— Causes of.
liver may be distinctly traced by its means ; and
the degree of inflation of the bowels, or stomach,
may be ascertained with tolerable certainty. When
the stomach is nearly empty (for it always con-
tains some air secreted from its internal surf ice),
it retracts backwards, and recedes from the abdo-
minal parietes towards the centre of the trunk ;
having then the colon, more or less distended with
gas, placed before it. As it becomes filled with
air or the ordinary ingesta it extends to the left
hypochondrium, and approaches the left and an-
terior parietes of the upper zone of the abdomen.
In proportion to the quantity of air it contains,
percussion gives out a clear sound, which is dull
or dead as it is filled with fluid or solid ingesta,
and as the air is displaced. When we know that
the stomach must be empty of food, and yet find
that a dull sound is emitted on percussion, we
should always suspect organic disease. In these
cases air is often secreted with great rapidity from
its internal surface, but is immediately expelled,
owing to the irritable state of its muscular coats,
without being retained, and before any very
material distension of the viscus is occasioned
by it
24. The small intestines generally contain air;
although, I believe, much less than is usually
found in the large bowels. In a state of health,
particularly a few hours after a meal, when the
chymoas matter is passing along them, percussion
over them, — that is, over the umbilical region, and
the immediately adjoining parts of the surround-
ing regions, — generally yields a dull sound; which
becomes clear in proportion to the quantity of
air they contain, excepting in very fat persons.
In a great majority of abdominal diseases, the
quantity of air contained in the small intestines
is increased much beyond what exists in health:
this is particularly the case in several diseases of
debility, as chlorosis, indigestions, colicky affec-
tions, torpid states of the liver, constipation, cer-
tain states of fever, hysteria, &c. ; and still more
go in inflammatory states of portions of the diges-
tive tube, in peritonitis, in puerperal fevers, &c.
2-5. When the mucous surface of the bowels
or of the stomach is irritated or inflamed, the
quantity of air secreted is often very great; but,
excepting in the slighter states of such diseases,
it is seldom retained within the sphere of the in-
flammation so as to occasion that degree of dis-
tension which may be detected by percussion,
although it is often retained in adjoining parts of
the tube, occasioning distension, great pain, tor-
mina, &c. This disposition to expel the morbid
collection of air arises from the irritability of the
muscular fibres of that part of the intestines, the
mucous surface of which is in a state of irritation;
the morbid action of these fibres propelling it
either upwards or downwards, where it may accu-
mulate or be evacuated, but most commonly into
the large bowels, or into the duodenum and
stomach, where it may be detected by percussion.
In diseases which paralyse the contractile actions
of the muscular coats of the bowels, as the malig-
nant puerperal peritonitis, the last stages of ente-
ritis, rabies canina, .and the advanced states of
adynamic fevers, the quantity of air which is
secreted and accumulated in the whole digestive
tube, and the consequent distension, are often
enormous. The sound on percussion, in these
cases, generally becomes quite tympanitic long
before death, indicating the cause, as well as the
lost tone of the muscular coat of the canal.
26\ The phenomena now noticed to occur in
respect of the small intestines affect, in a still
more marked manner, the large bowels; flatulent
distension of these being readily traced by medi-
ate, or even direct percussion, particularly in the
course of the colon, even when the small intes-
tines, are comparatively free from it.
27. It is not merely the presence of accumu-
lated air in the different parts of the digestive tube,
and the important pathological and therapeutic in-
dications to which the knowledge of this fact natu-
rally leads, that render percussion of the abdomen
a valuable means of investigation, but it is also the
information it conveys of the existence of more
solid formations — of fluid collections, and morbid
productions. Unusual distension of the bladder ;
all the forms of abdominal dropsy ; ovarian dis-
eases ; purulent collections in, or enlargements of,
the liver; tumours of every kind, particularly
when they reach a considerable size ; enlarge-
ments of the spleen or kidneys, &c. ; are more
readily and earlier detected by means of mediate
percussion than without this aid : and, in all
these, the sound emitted is dead over the diseased
part, and becomes clear as the boundary of dis-
ease is passed, and when the plate is placed over
the hollow viscera.
28. IV. Auscultation, mediate or direct,
particularly the former, is often necessary in abdo-
minal diseases, particularly in ascertaining whether
or not the large vessels are affected ; and even in
tracing disease of the right side of the heart and
of the pericardium. It may also be useful in
those diseases of the liver which extend to tha
lungs through the diaphragm, particularly abscess,
or hydatidic cysts of the liver breaking into the
lungs. Auscultation of the abdomen has been
resorted to by M. Kergaradec to ascertain the
existence of pregnancy; and by M. LisFRANC,to
determine the presence of stone in the bladder,
when the sound is imperfectly heard to strike
against it.
iiiiiLioGHtFHY. Ba?livi, Prax. Med. lib. iv. c. 9. |
Double, Semeiologie Generate, t. i. p. 333. — CruveUhier,
Dicti >nnaire de Med. etChirur?. Prat. t. i.— Piorry, De
la Percussion Mediate, Paris, 1823; et I'roce'de Opera-
toire dans l'E.tploration des Organes par la Percussion
Mediate, Paris, 1830.
ABORTION. Syn. Abortus, aborsus, affluxio.
Jia<p8ooa, txTQouia, ixTQuirsuoc, Arist.
^4u°?.ouu, iz<jcu§?.o<nic. Hip. Avortement, Fr.
Aborto, Ital. ' Falche Geburt, Fehlgeburt,
Ger. Miscarriage, Eng.
Classif. 5. Class, Diseases of the Sexual
Function ; 3. Order, Affecting Impreg-
nation (Good). I. Class ; V. Order
(Author, see Preface).
1. Defin. TJie expulsion of an embryo or
fcetus which is either already dead, or is at a
too early periol of fatal existence to live.
2. This definition will distinguish abortion from
premature labor, which latter is applicable to
delivery after the sixth month, when the fetus
may live; and from false delivery, which sig-
nifies the expulsion of a mole, or false germ
instead of an embryo. Under this term I also
include expulsion of the ovum before the sixth
week, commonly called miscarriage.
3. Causes. These may be divided into such
as act primarily upon the mother, or depend
ABORTION — Causes of.
upon her ; and into those which are connected
with the product of conception, and are owing
to diseases of the foetus and its appendages.
(Duces.) Or they may be divided into the pre-
disposing, exciting, and efficient causes. It will
be necessary to consider the causes with some
relation to these distinctions.
4. I. Prc/ixposing causes. The disposition
to abortion is, in some females, so strong that the
slightest exciting cause will produce it ; in other
females the most serious injuries, and the most
violent mental and moral impressions, are insuffi-
cient to occasion it. Some of the predisposing
causes are referable to the mother, others to the
foetus and its appendages.
5. A. The predisposing causes referable to the
mother are numerous, and consist of certain states
of the uterus, and particular conditions of the
habit and constitution, inlluencing either the
uterus or the embryo itself.
6. The conditions of the uterus favoring abor-
tion are great rigidity of its fibres, and an un-
yielding state of its parietes, opposing too great
a resistance to the dilatation which the organ
must necessarily experience ; too great sensibility
and contractility of the uterus, in the former of
which suites the other organs of generation often
also participate ; too great a flow of blood to the
uterus and ovaria, either proceeding constitution-
ally, or from causes which excite the nerves of
these organs or parts adjoining ; feebleness and
relaxation of the neck of the uterus, — a condition
of the parts which M. Desormeaux states he
has frequently ascertained to exist in females sub-
let to abortion ; and atony of the uterus itself,
either from original constitution or long-continued
leucorrhaea, or from a severe or protracted labor,
a cause which may be conjoined with the one pre-
ceding it. The foregoing causes are chiefly pro-
ductive of those abortions which occur at the same
period of pregnancy, and which have been called
periodic by some authors.
7. To the above may be added, as strictly re-
ferable, a condition of the organ called by Peu
immoderate heat of the uterus, which is attribut-
able to an excited condition of the nerves of the
organ, and a chronic inflammatory or irritative
state of its vessels ; also scirrhus, fibrous, fleshy,
imatous tumours of the uterus; polypus, drop-
sy, the presence of several children, and the loo
rapid or too great dilatation of the organ thereby
ioned ; tumors of, and fluid effusions into,
the substance of the ovaria ; and inflammation of
the ovaria and parts adjoining.
9: The causes chiefly referable to the consti-
tution and habit of the mother are certain states
of the atmosphere, to which only can be attribut-
ed those frequent abortions sometimes observed,
which have even assumed an epidemic form, ancL,
of which Hippocrates, Fischer, Te«sii;k("'
Desormeaux, and Others have made mejffiCTi :
the sanguine and irritable temperament ; pletneric
habit ; a constitutional disposition to hasmorrnage
independently of, or connected with, the foregoing
states ; habitual menorrhagia ; irregular menstru-
ation ; great debility of bodv ; excessive sensibi-
lity, susceptibility, and mobility of the nervous
and muscular systems ; hysterical states of the
nervous system ; the syphilitic and the mercurial
poisons ; a cachectic condition of the frame ; pain-
ful and clironic dieases ; addiction to masturb-
ation in early life ; curvatures of the spine ; mal-
formations of the spine and pelvis ; hereditary
disposition ; an acquired disposition arising from
previous abortions caused by accidental circum-
stances ; marriage or impregnation late in life ;
deficient or improper nourishment ; too close
cinctures of the body ; worms in the intestinal
canal ; conception at a too early period after
delivery, or after a previous abortion ; the atonic
state of plethora generated by luxurious indul-,
gences, by sleeping in soft and too warm beds, by
indolence, a too full diet, &c; local plethora,
or excitement of the uterine organs, occasioned
and kept up by sensual gratifications ; and the
constitutional and local commotion occasioned
by infectious, exanthematous, pestilential, and
febrile diseases.
10. B. The causes which depend vpon the
fat us are referable either to the foetus itself or to
its appendages. They operate either by favouring
the death of the foetus, which acts then as a
foreign body in the uterus, exciting the organ to
expel it ; or by impeding its growth, so that it does
not consume, or does not arlbrd a ready circula-
tion to, the blood sent to the uterus ; thus occasion-
ing an accumulation of this fluid in the uterine
vessels, and consequently congestion, terminating
in haanorrhage and the expulsion of the embryo.
Owing to these circumstances, abortion is favour-
ed by debility, or imperfect developement of the
fcetus ; by monstrous conformation, and disease
affecting it at some period of its early growth ;
by the imperfect adhesion of the placenta to the
surface of the womb, or its implantation over the
neck of the organ ; by disease of the placenta,
as inflammation, apoplectic haemorrhage into its
substance, calcareous deposits, fatty degenera-
tion, scirrhous or cartilaginous induration ; the
formation of serous cysts, of hydatids, aneurism,
or varices of this organ ; by atrophy, hypertrophy,
or disproportionate size of the placenta ; by a too
short or a too long umbilical cord ; by twisting
of the cord around the neck or one of the limbs
of the foetus ; by diseased structure of the cord
itself, as extreme tensity or softness, the formation
of tumours or hydatids in it, by knots or adhe-
sions preventing or impeding the circulation
through it ; great tenderness of the membranes of
the ovum ; inflammation, thickening, opacity, and
irregularity of the membranes ; the presence of
too much or too little amniotic fluid, and collec-
tions of serum, or of a sanguineous fluid, be-
tween the chorion and amnios ; adhesions formed
between the placenta and parts of the surface of
the foetus ; and, in the more advanced periods
of gestation, constitutional diseases,. particularly-
eruptive and infectious diseases, or continued
fevers, extending from the mother to the embryo.
10. II. The occasional exciting causes are ex-
tremely numerous. It may be even said, that there
is scarcely an occurrence in life which may not
be occasionally concerned in producing abortion.
(Desormeaux.) The chief causes of this class
are acute diseases; such as fevers^ scarlatina,
n;eas'i's, small-pox, and inflammations, particu-
larly of the uterus, ovaria, pelvic peritoneum,
colon, &c. ', the irritation of adjoining viscera ;
diarrhoea, dysentery, tenesmus, colic, constipation.
haemorrhoids ; hysterical and epilectic convul-
sions ; syphilis ; violent pain ; disappointment and
anxiety of mind; anger, fright, excessive joy;
the impression of various odours; threatened as-
phyxia, particularly from the vapour of carbon;
violent exertions and fatigue; dancing; riding on
horseback, or in an uneasy carriage, or on a
roughly paved road ; excessive venereal indul-
gence; severe. coughs; hiccup; immoderate laugh-
ter; vomitings; sea-sickness; injuries on the loins
or abdomen; .any sudden shock, even the extrac-
tion of a tooth; the use of irritating or drastic
purgatives, or of emmenagogues; pediluvia; hot-
batlis; large blood-lettings, particularly from the
feet; convulsive movements of the fetus; rupture
of the umbilical cord or of the membranes; adhe-
sions formed between the serous surface of the
fundus of the uterus and the adjoining viscera,
preventing the, dilatation or the ascent of the
womb, arid occasioning its reaction on its con-
tents.
11. The foregoing causes act variously in pro-
ducing abortion. Some of them may produce
directly a separation of the placenta from the sur-
face of the uterus, particularly when the placental
mass is very considerable; but this is a rare oc-
currence, and can only be inferred to exist when
uterine haemorrhage follows immediately upon the
application of the exciting cause. A violent shock,
injury, fall, compression of the uterine region,
riding, dancing, coition, &c. may have the im-
mediate effect, or they may occasion rupture
of the cord or of the membranes ; but more fre-
quently these, and, in a still more particular
manner, the other exciting causes, produce cer-
tain intermediate effects, as congestion of the
vessels of the womb, which is soon followed by
haemorrhage and by separation of the placenta;
or they occasion contractions of the uterus, owing
to the excitement and irritation of its nerves, or
of the nerves of adjoining or sympathising parts,
the separation of the placenta, and expulsion of
the fetus.
12. Klein and many other authors have re-
marked that the causes of abortion generally have
a more marked effect at the period at which the
menses would have returned in the imimpregnat-
ed state. The molimen, or tendency to congestion
in, and haemorrhage from, the uterus, which then
may be supposed to exist, renders it more suscep-
tible of being injuriously impressed by the occa-
sional causes of the disease; and, where other
predisposing causes are already in existence, has
a direct influence in separating the placenta, and
inducing uterine contraction and abortion: several
of the causes produce spasmodic or convulsive
actions, which are sympathetically transmitted to
the uterus, whilst others seem to act primarily on
the fetus. The direct action of certain of the ex-
citing causes on the foetus may be doubted; but
every experienced and observing practitioner must
have remarked the very frequent and immediate
effect of strong passions of the mind of the mo-
ther upon the motions of the foetus, inducing con-
vulsive actions, painfully and distinctly felt, and
sometimes followed by its death. Amongst the
most common exciting causes of abortion are
those means which, from their occasional action
in this way, have been called abortives, and
which the practitioner should be acquainted with,
so as to enable him the better to counteract their
effects.
13. The production of abortion is a felonious
act, and one which the practitioner never will
ABORTION — Symptoms. of. ^SBURq^ pA ' 7
resort to, except in the case of irreducible retro-
version of the uterus. The means usually resort-
ed to by females themselves, or by persons who
criminally usurp the medical character, and em-
ploy feloniously the little empirical knowledge
they may have acquired, either surreptitiously or
otherwise, are, large bleeding from the feet; pedi-
luvia; violent emetics; drastic purgatives, particu-
larly those which act upon the colon and rectum;
active emmenagogues, as savine, ergot of rye, ju-
niper, hellebore, &c. ; and stimulating injections
into the vagina : also various mechanical means
employed to break the membranes, or to procure
the discharge of the amniotic fluid. Many of the
foregoing, or all of them excepting the last, will
often fail of producing the desired effect. They
frequently also succeed, and sometimes they oc-
casion the death of both mother and fetus. Mau-
riceau, De la Motte, Boer, Desorme-
aux, Duges, Burns, Hamilton, Ryan,
&c. have satisfactorily shown the uncertainty of
those means, and have met with numerous instan-
ces in which they had been carried to the utmost
extent without acting in the way desired; but had
occasioned enteritis, dysentery, peritonitis, metri-
tis, and other dangerous diseases. Many cases are
also on record where attempts had been made to
produce abortion by puncturing the membranes ;
and the uterus itself had been penetrated, and the
death of the mother thereby occasioned. It is a
matter of the utmost difficulty, even to the most
expert surgeon, to puncture the membranes at
that period of pregnancy, when it is usually at-
tempted by ignorant persons; the only persons,
indeed, who would make the attempt.
14. The symptoms of abortion vary re-
markably with the period of pregnancy at which
it takes place: also with the cause producing it.
They do not, therefore, admit of being divided in-
to precursory and essential symptoms: the former
being frequently wanting. In the two first months
of pregnancy the ovum, which is then small, is
sometimes expelled without any remarkable pain
or haemorrhage; but more frequently there are
pains, accompanied with coagula, in which the
ovum is generally enveloped, and where it often
escapes observation. This is particularly the case
when, the membranes being broken, the embryo
escapes without the placenta. At this early peri-
od females often suppose that they have been the
subject merely of an interruption of the menses,
followed by a more abundant and painful return
of them than usual, instead of a true abortion, or
miscarriage.
15. As the period of utero-gestation advances,
and the size of the fetus increases, the pains and
haemorrhage accompanying abortion are augment-
ed: the haemorrhage being generally more consid-
erabltfthau .that attending delivery at the regular
period.
Tho abffttions which proceed from chronic dis-
eases, or 1&m 'causes acting slowly, and particu-
larly those'which are occasioned by morbid states
of the embryo, or of its membranes, are generally
preceded by horripilations or rigors, followed by
febrile movements, by heat, want of appetite,
| nausea, thirst, pain in the loins, lassitude, leipo-
thymia, syncope, coldness of the extremities, pal-
pitations, lowness of the spirits, paleness of coun-
tenance, tumefaction or lividity of the eyelids,
deficient brightness of the eyes, fetor of thu
8
ABORTION — Diagnosis of.
breath; a Feeling of weakness in the abdomen, or
of co.d about the pubis; of weight about the anus
und vagina; flacciditv and diminished size of the
breasts, sometimes with a slight discharge of ser-
um; a flow of a sanious, then of a sanguineous
fluid, and afterwards of blood, either in a fluid or
grumous state, bom the vulva; diminished motion
of the child, soon afterwards followed by perfect
cessation of motion; lessened bulk of tlie abdo-
men or of the hy pogastrium ; uterine pains, which
become more and more frequent and severe; pro-
gressive dilatation of the uterine oritice, and promi-
nence of the membranes; and, lastly, expulsion
of the amniotic fluid and fcetus, followed, at an in-
definite time, by the placenta. Most frequently
the discharge of blood does not cease until the
placenta is expelled. (Desormeaux.)
16. Abortion proceeding from the more ener-
getic exciting causes is sometimes preceded by
pains, and an unusual sense of weight in the loins;
and at the lower part of the vagina by horripila-
tions or rigors, by general uneasiness, and cardi-
algia or nausea. From the first there is often an
appearance of blood, followed by the discharge
of a sanguineous serum, which soon passes into
serious haemorrhage. In other cases the action
of the cause is instantly followed by a large effu-
sion of blood, which continues until after the
expulsion of the fcetus and its appendages. Fre-
quent lancinating pains dart through the abdomen,
chiefly in the direction of the umbilicus and vul-
va: the uterus makes efforts at expulsion, and the
fcetus is expelled. The more advanced the
term of pregnancy, the nearer do the symptoms
approach to those of delivery at the full time;
and the nearer also do its consequences assim-
ilate to those following upon a natural confine-
ment, as the lochial discharge, after pains, milk-
fever, &c.
17. It is sometimes observed, even up to the
middle period of utero-gestation, that the fcetus
is expelled enveloped in its membranes. But it
sometimes also occurs in the first months, that,
after the rupture of the membranes, the fcetus and
placenta are retained, decomposed, and discharg-
ed in the form of a brown foetid sanies. In other
cases the placenta is not expelled until several
weeks after the foetus, either in the state now de-
scribed, or in that of a putrid mass. It occasion-
ally is observed that the placenta continues at-
tached to the uterus, and is nourished, increasing
in size, and assuming the appearance of a fleshy
mass, in which are sometimes1 found simple cysts,
or cysts containing hydatids. This latter occur-
rence takes place either when the fcetus had
been expelled, or had died at an early period of
its formation; and, whilst it was yet small and
nearly gelatinous, being dissolved during the pro-
cess of decay in the amniotic fluid, or preserved
in it.
18. This change in the placenta forms what
has been called by Desormeaux and others the
mole of generation; the chief character of which
is that it possesses a cavity lined with a smooth
membrane, the remains of the amnion. Fre-
quently, at the more advanced periods at.Which
abortion takes place, the foetus is expelled alive;
but the duration of its life subsequently depends
upon its age, and the circumstances attending its
abortion. It sometimes also is dead before it is
expelled, occasionally for a considerable time; al-
though it may have reached the age of several
months. Its death does not necessarily lead,
although it does generally, to its expulsion. In
some cases it is retained even up to the full pe-
riod of utero-gestation, and is then thrown out in
a state of peculiar softening and maceration, but
without putrefaction: this only occurs when the
membranes have remained entire, and air been
excluded from the interior of the uterus. In other
instances it is converted into a substance resem-
bling adipocire, or the fatty substance generated
during the decomposition of animal matter. In
rarer cases the foetus and envelopes become har-
dened, and even converted into a bony or petrous
state, and retained till the natural death of the
mother; or, in the course of some months, or
even years, occasion inflammation of the uterus,
and suppuration. Sometimes, in cases of this
latter description, a portion of the uterus forms
adhesions to the parts opposite; the abscess which
is formed extending in that direction, and opening
on the surface of the abdomen, or in the interior
of the intestinal canal, or into the vagina, and
giving issue to purulent matter, mixed with a foetid
sanies, and portions of bones arising from the de-
composition of the textures of the embryo. But
these latter consequences of abortion are rarely
met with unless in cases of rupture of the womb,
or extra-uterine impregnation. '
19. In some cases of abortion the haemorrhage
from the uterus continues to a serious extent for
several days. This may be the case at various
epochs of pregnancy; and may result from the
detachment, partial or general, of the placenta,
and its retention along with the foetus in the
uterine cavity, owing to imperfect action of the
uterus to eject it. It may also proceed from the
expulsion of the fcetus, and the retention of the
placenta, either altogether or partly separated
from the uterus. In some cases the presence of
the placenta, or of a portion of the membranes in
the womb, or in theos uteri and upper part of the
vagina, by the irritation thereby occasioned, may
have the effect of keeping up a constant and ex-
hausting haemorrhage. In a case of abortion to
which I was recently called, the practitioner in
attendance stated the foetus to have come away
two or three days previously. Upon enquiring as
to the discharge of the appendages, I was led to
recommend an examination per vaginam; when
they were found lodged partly in the vagina and
os uteri. After their removal the patient rapidly
recovered.
20. Diagnosis. The diagnosis of abortion
should be directed to three objects: 1st, its cause;
2dly, to the possibility of preventing its recur-
rence; and 3dly, to ascertaining the stage or de-
velopement of the process. 1 he causes of abor-
tion are generally readily recognised, and admit
of an easy explanation. There are two, however,
to which Professor Desormeaux has particular-
ly directed attention ; namely, rigidity of the fibres
of the fundus and body of the uterus, and laxity
of its neck. The former' of those is generally
connected with a similar state of the whole svs-
tem, and accompanied with scanty or painful
menstruation. In the first impregnations abor-
tion takes place at an early* period; but in sub-
sequent impregnations the period of gestation
approaches more nearly the natural epoch, tha
female at last bearing children to the full time.
ABORTION — Treatment of.
When the abortion is referable chiefly to laxity
of the neck of the uterus, a result contrary to the
foregoing takes place; the period of abortion ap-
proaching nearer, in successive conceptions, to
the time of impregnation. Examination per vagi-
nam discloses this state of the cervix uteri, which
sometimes permits the escape of the ovum with-
out much pain. The presumed existence of either
of the foregoing states, particularly if any of the
symptoms enumerated as characterizing abortion
be present, should lead us to suspect its ap-
proaching occurrence. And it may be considered
as commenced if pains occur at regular intervals,
which become of shorter duration, and are di-
rected from the umbilicus to the os coccygis;
if the os uteri dilates, if the membranes become
prominent during the pains, and if the amniotic
fluid escape. M. Desormeaux, however, hits
detailed instances where, notwithstanding the
above phenomena, the patient was not delivered
for several weeks afterwards; but these are ex-
tremely rare.
21. In cases where more than one child is
contained in the uterus, or where this organ is
double, one of the foetuses may be expelled in
the course of gestation, and the other may still
remain and arrive at the full period of foetal life.
The eminent author whom I have now quoted
mentions the case of a female, pregnant for the
first time at the age of forty years, who expe-
rienced abortion at two months and a half: the
symptoms of pregnancy, however, continued, and
the motions of the firtus were felt at the usual
time. At the seventh month, a severe fright was
immediately followed by symptoms indicating the
death of the child ; however, the motions of the
child were still felt in the uterus: at last, after
two months, and at the usual period of gestation,
this female was delivered of a dead child, and of
another which had arrived at the full period, and
was living and healthy. M. R,ousset has also
related a similar case ( Traiti de VHyst&TOtokie).
When abortion occurs during the first two months,
we can often only distinguish it from excessive
menstruation by the coagulating of the blood.
Cases, however, sometimes are met with where
coagula form during menstruation, but seldom or
never during healthy menstruation. Abortion is
most frequent during the three first months of
pregnancy.
22. Prognosis. Abortion has been considered
of more serious import than delivery at the full
time, by Hippocrates, ^Gtitjs, Mauriceau,
and others. The prognosis will, however, entirely
depend upon the nature of the causes producing
abortion; the period of gestation at which it takes
place; and the symptoms accompanying it. It
may be stated generally, that the danger increases
in proportion as it approaches the full period of
gestation; inasmuch as the hemorrhage ^ great-
er, the expulsion of the fostus and appendages
more difficult, and the milk-fever more violent,
the longer the period of utero-gestation. The
abortion which occurs from accidental, or active
exciting causes, is generally more dangerous than
that which follows the predisposing causes; this is
more particularly the case, the more violent the
cause, the more prompt its effects, and when
it acts upon females not predisposed to abor-
tion. The most dangerous abortions are those
which are procured by substances of an irritating
nature taken internally, and by attempts to ex-
cite the uterus, or to puncture the membranes per
vaginam.
23. On the other hand, when abortion takes
place spontaneously, and without any very mani-
fest or sufficient cause, it is often unattended by
pain or difficulty, leaving behind it scarcely any
unpleasant consequences: but this form of abor-
tion is most liable to recur; and its repeated oc-
currence often gives origin to a number of ail-
ments, some of them of serious moment, such as
irregular menstruation, chronic metritis, organic
lesions of the uterus and ovaria, irritable uterus,
hysteria, and a debilitated and cachetic habit of
body.
24. Abortion is chiefly dangerous from the
hemorrhage attending it; and hence the risk is
proportionate, to the extent of this effusion. Abor-
tion, accompanied by convulsions, diarrhoea, dy-
sentery, or supervening in the course of fevers,
inflammations, or of eruptive diseases, are seldom
devoid of danger, which, under certain circum-
stances, is even great. Inflammation of the womb
of great severity, endangering the life of the pa-
tient, or causing adhesions of the Fallopian tubes
or of the ovaria to the serous surface of the uterus,
and consequent sterility, is not an unfrequent con-
sequence of abortion.
25. On the other hand, it may be productive of
certain advantages, according to Maukiceau,
Desormeaux, and some others, who have, hi
rare cases, observed abortion occurring before the
third month to be followed by a more regular
state of the catamenia, in those who had been
irregular previously, and by an unproved state of
health ; even fecundity taking the place of former
sterility.
26. Treatment. The treatment of abor-
tion is divided into, 1st, the preservative; 2d, the
palliative; and, 3d, the remedial. On each of
these I shall offer a few remarks.
I. The Preservative treatment comprises the
following objects; viz. to remove the predispos-
ing causes as far as this may be accomplished ; to
repress all undue action whenever it may appear;
and to prevent, as well as to counteract, the effects
of the exciting causes. These ends are to be kept
in view, and applied to individual cases, appro-
priately to the causes and circumstances by which
thev are characterized. Where plethora, general
or local, exists, it should be reduced by general
or local depletion, in very moderate quantity, and
repeated at short intervals; but more preferably
by a low and antiphlogistic diet and regimen,
acidulous and cooling beverages, the recumbent
posture, and tranquillity of mind. In cases char-r
acterized by relaxation of the system, and of the
reproductive organs, an opposite or a tonic and
invigorating, regimen is required. In every in-
stance the preservative treatment must be based
upri&Jftur views respecting the pathological state
of'tbeuiterus, and of the whole frame at the time
of prescribing it.
27. When the horizontal posture is considered
necessary, the patieal will be more benefited by
recalling on a mattress, than on a soft, hot bed.
1 1 it apartment should be cheerful, large, and airy;
the bed-clothes light; and all anxiety of mind re-
specting the issue, and depression of spirits, pre-
vented; a confiding and cheerful state of feeling
will materially conduce to a favorable result.
10
ABORTION— Treatment of.
The ditt, under ordinary circumstances, ought to
be light and digestible, and varied according to
the particular circumstances of the case. The
beverage should be mild, and, in cases of local or
general plethora or excitement, rather cooling
than otherwise, and such as may promote, rather
than retard, the natural actions of the bowels.
Lemonade, imperial, barley-water, toast-water,
&c, are amongst the best in this class of cases.
28. Much will depend upon the perseverance
with which this plan may be followed, particu-
larly in cases of habitual or precedent abortions;
where it ought to be rigorously enforced and con-
tinued for months, or, at least, for a long time
after the period of gestation at which the former
abortion occurred. If the threatened abortion be
accompanied with pains, or by any degree of dis-
charge, an opiate should be given at bed-time;
and, in every case where we have conceived it
requisite to abstract blood, either generally or lo-
cally, even as a preventive measure, the operation
should be followed by a dose of opium.
29. Attention to the bowels is indispensable ;
but great discrimination is necessary in the choice
of laxatives when, the bowels are constipated.
These should be of the most cooling and gentle
description. The soluble tartar, and cream of tar-
tar in the form of electuary, or with confection of
senna, particularly in cases of plethora, are very
eligible. Castor oil, with a very few drops of
laudanum, which will not retard its operation; or
small doses of the super-sulphate of potash, are also
suitable laxatives.
SO. When, from our knowledge of the state of
the ovum, in previous abortion, we suspect a re-
petition of it, we may endeavor to prevent it,
by using those means which are most successful
in imparting energy to the constitution, and,
through it, to the generative functions; so that the
process of fatation may proceed to a successful
issue. This is, perhaps, best accomplished by
change of air; the use of the tonic mineral
waters, both internally and in the form of baths;
by the mineral acids given in the infusions of bit-
ter tonics, or with the solutions of the salts of
iron: as the tinct. ferri muriatis; the tinctura ferri
cetherea (see Ajrpendix;) by the sulphate of zinc,
with the compound infusion of roses; by the ex-
hibition of the various balsamic and terebinthinate
medicines, combined with the pulvis cinchona1,
or the pulvis rhei, and the subcarbonate of the
alkalies, or magnesia; and by attention to the
state of the bowels, to diet, and gentle but regu-
lar exercise. The balsams most serviceable in
cases of this description, as well as in all those
characterized by'Veak and imperfect uterine func-
tion, are the balsajns of Peru, of Canada, of
Chio, ami of Copaiba; the terebinthina vulgaris,
and T. Veneta. Siebold recommends the balsa-;
mum vita; I'otfmanni (F. 317.), a medicine which
enjoys great reputation on the Continent in many
diseases of debility. Tire loins may be rubbed
night and morning, for some time, with the lini-
mentum snponis et camphora: comp. (F. 300'.), the
linimentum terebinthina; compositum (F. 311.),
or the liniment, airodynum (F. 298.). The appli-
cation of the emplastrum cumini, the emplastrum
picLs compositum, or the emplastrum roborans
(F. 118.), to the loins will also prove of service.
31. When diarrhoea occurs during the period
of utero-gestation, and more especially if it be
accompanied with tenesmus, in delicate females,
or in those who have experienced previous abor-
tions, it should be immediately checked or lessen-
ed. In these cases disorder is chiefly confined to
the colon and rectum, which should be soothed
by small emollient and anodyne enemata, or by
the use of suppositories of lead plaster, and opium.
Whilst, however, we thus prevent the irritation
from being extended from the large bowels to the
uterus, we should take care to prevent the reten-
tion of hardened frees in the cells of the colon,
by which irritation will be perpetuated; and to
remove them, when we suspect their presence, by
the use of gentle laxatives, and emollient and ape-
rient injections, avoiding the use of saline purga-
tives and cathartics.
32. In cases of threatened abortion in debili-
tated constitutions, the mineral acids, particularly
the sulphuric, either with or without small doses
of laudanum, or combined with small doses of
colchicum, or of digitalis, are extremely useful.
Where the circumstances of the case permit the
horizontal posture to be dispensed with, the pa-
tient may be allowed very gentle exercise, for
short periods, in the open air, avoiding all exer-
tion and local excitement. She should live ab-
stemiously, yet not too low. In many cases of
this description a glass or two of light wine may
be allowed daily, and in several a still more tonic
treatment is required. When this is the case, the
infusion of calumba, or of quassia, with the car-
bonate of soda and tincture of hyoscyamus, has
seemed to me very serviceable; and the patient
has been allowed the occasional use of the swing,
or a gentle ride in a carriage. The tepid and
cold hip-bath, particularly with sea-water, are
often of use in cases of this description, as well as
the treatment recommended in a preceding pa-
ragraph. The necessity of abstaining from sexual
intercourse, in all cases of threateiied abortion, is
most evident.
33. In cases accompanied with incipient dis-
charge, either the cold hip-bath, or sponging the
hips, thighs, and lower parts of the trunk with
cold water and vinegar; or by squeezing a large
sponge filled with cold water, so that its contents
may fall in a scattered stream from some height
upon the hips and pelvis; will sometimes be ser-
viceable. Injections of cold or iced water, or cold
astringent solutions pervaginam, or a lavement of
cold water, will sometimes arrest the accession of
haemorrhage.
34. It will occasionally be observed that weak,
nervous, and delicate females are often irritable^,
and dispirited from a tedious confinement, during
gestation, and even abort owing to this cause; ob-
viously, in many cases, from the effect produced
upon tire uterus, and upon the nutrition and health
of the embryo. This should be anticipated and
prevented by a timely relaxation of the plan, and
by allowing the patient as much exercise, amuse-
ment, &c, and by adopting as much of the treat-
ment recommended above (§32.), as may be con-
sistent with the accomplishment of our end.
When, in these cases', the nervous symptoms
predominate, the use of antispasmodics, with ano-
dynes, and their combination with vegetable bitters,
chalybeates, &c, are often required. 1 he diet
should also be nutritious, but easy of digestion, and
not too heating and stimulating.
35. The foregoing plan will often succeed in
ABORTION — Treatment or.
11
preserving the infant, unless the discharge con-
tinues or becomes more copious ; the uterine
pains, with the other symptoms of commencing
abortion, still persist or increase; and the woman
be advanced in pregnancy; when little advantage
will he obtained, particularly if the orifice of the
womb dilate. When this is the case, attempts at
preservation will entirely fail, and we must adopt
the second intention.
86. I!. The palliative measures now required
consist, in addition to those recommended (§:>:>.),
qf cold applications to the genital fissure and insides
of the thighs, and the tampo /, or plug, as recom-
mended by a number of authors, and sanctioned
by Denman, Hamilton, Burns, Merri-
man, Dewees, Ryan, &c. These are espe-
cially requisite where the haemorrhage is great,
particularly when the abortion takes place between
the third and sixth month. Opium, with the su-
peracetate of lead, given in a very large dose at
the ii.st, and repeated according to circumstances,
should also he exhibited. Opium, as well as
plugging the vagina, are chiefly serviceable where
the ha;iiiorrhage continues after the expulsion of
the embryo. The plug recommended by Dr.
Dew r. es is a sponge squeezed out of vinegar. Dr.
Ryan advises either old linen or a sponge to be
wetted with a saturated solution of alum, and
smeared with some oleaginous matter, to be pass-
ed up the vagina, so as completely to fill it. Dr.
Bh'ndell directs a scruple of alum, dissolved
in a pint of water, to be injected into the uterine
cavity.
37. The practitioner should in every instance
be satisfied as to the expulsion of the embryo and
the whole of its appendages, for he may be de-
ceived in this matter (§ 19.); a small remnant of
the placenta or of the membranes, when still left
in the cavity of the uterus, or even lodged in its
orifice, being often sulficient to keep up an ex-
hausting, or even dangerous discharge. When
the embryo only is expelled, the appendages being
still retained, or when the haemorrhage is great, the
entire ovum still remaining in the uterus, the ergot
of rye will often prove of inestimable service: and
when given in the form of decoction, with as much
borax as it will dissolve, will seldom disappoint
our expectations. When a portion of the append-
ages remain at the orifice of the womb, it may he
drawn down by the finger, or by a curved dress-
ing forteps. In eases of great haemorrhage in the
early months of pregnancy, the ovum being re-
tained, Dr. Burns advises the use of smart clys-
ters, and plugging the vagina. In every case of
hemorrhage from abortion, as well as after deli-
very at the. full period, but particularly when the
haemorrhage proceeds from inefficient contraction
of the uterus and retention of the ovum, or some
portion of the append iges of the embryo, 1 have
prescribed, with complete success, an enema, with
from one to two ounces of the oleum terebmthinai
in a pint of water-gruel.
38. The injection of water into the rectum, or
a solution of acetate of lead and opium, h;is been
advised by Dr. Dewebb and Dr. Conquest.
When the hemorrhage occurs in robust and
plethoric females, and the discharge has not
produced much exhaustion, vena-section may be
tried. In cases of this description, digitalis, in
half drachm doses, has been recommended : but,
owing to the loss of blood, the effect, although not
produced with the necessary celerity, will often
be too violent and unmanageable, and will so en-
danger the patient as not to justify its use unless
under very peculiar circumstances. I once pre-
scribed colchicum in large doses in a case of hae-
moptysis, with violent paroxysms of cough and
threatened abortion, occurring in a plethoric lady
at the fourth month of pregnancy. Full vena>
section was performed, chiefly on account of
tin' severity of the pulmonary disease; the col-
chicum was directed with an anodyne; and the
patient left under the care of the family practi-
tioner. Abortion took place, and was attributed
chiefly to the sickness, retching, and depression
occasioned by the colchicum ; it having been un-
remittingly administered until my next visit, on
the third day from that on which it had been pre-
scribed, notwithstanding the discretionary power
with which the practitioner had been invested.
(See also, on this subject, the Treatment of 'Hjg-
morrhage from the Uterus.)
39. III. The remedial treatment of abortions
is next to be considered. It occasionally happens
that the retention of the ovum, or of a portion of
the appendages of the embryo, produces much
constitutional disturbance, particularly nervous
symptoms, and irritative fever, which sometimes
assume serious features, with disorder of the bow-
els, tvphoid or ataxic signs, and an offensive vagin-
al discharge. The decoction of cinchona and
muriatic acid, or this decoction with the liquor of
the acetate of ammonia, or the following, will
prove extremely serviceable : —
.No. l. R Mi i. Camphors ~j ", Liq. Amnion. Aret. ^ ijss ,
.Aci.li Acetici Pvrolignei IT] xxv. ; Syrup. Zingiberis. Jsa
M. Fiat haustus ter quaterve in die sumendus.
No. 2. R Caniphone nsac, »r. ij. — iij. ; Extr. Cinchon.
Resin. s;r. iij. — v. ; Conserv. R05. q. s. ut liant 1'iluls ij.,
ter die capiendo.
In cases of this description a turpentine enema,
administered every second or third day, is ex-
tremely beneficial : and advantage will be derived
from injections of a solution of the chloruret of
lime, or of Labarraque"s liquor, per vaginam.
No. 3. R I. in. Labarraquii t'hloro-Sod. Jjss. i Mist. Cam-
phura>, ^vij*5. M. Fiat injectio.
40. When troublesome diarrhcca is present, in
cases of this description, the chloruret of lime,
either in the form of pill or solution, is extremely
edicacious. I have prescribed it as follows : —
No. 4. R Chlorureti Calris er. viij. — xvij. ; Pulv. Traea-
canlh. Comp. r,j<-.; Syrup, q. s. M. Fiant Piluhe xxiv.,
quarum capiat binas ter quulerve in die.
Xo. 5. R Chlorureti Cnlcis gr. vj.~ — xij. ; Tinct. Calumba
^i;j. ; Aq. Menth. Virii!., vel Aq. Carni, vel. Aq. Ane-
thi, 5 vj. — gvij s. Fiat Mist., cujus sumat coch. j. vel ij.
larga ter quatei * e oun(idj6.
The chloruret of lime may also be administered
in water gruel, as an enema, in closes of viij. to xij.
grains, once or twice daily.
41 'I he debility occasioned by abortions re-
quire the use of tonics, with mineral acids, nour-
ishing but light diet, a wholesome air, gentle
exercise, and the tepid or cold salt-water bath : —
the mineral waters of Bath, Bareges, or Tun-
bridge; those of Ems, Spa, Pyrmont, and Geik-
naii; or the artificial mineral waters of the last-
named places, are also beneficial. When nervous
or hysterical symptoms supervene, the exhibition
of antispasmodics, with gentle tonics, and the oc-
casional use of cooling aperients, are required.
The treatment of the effects of abortion is, in
every respect, the same as that recommended m
12
ABSCESS — Pathological Doctrine of.
the articles on Hemorrhage from the Uterus, in
the unimpregnated and puerperal states.
Bibliography. F. Albinos, Diss, do Abortu, Franc.
4to. 1699. — Stnkl, Diss, de Aliortu et Foetu Mortuo, Hala>,
1704. —Vide Haller, Disser. Collect., t. iv. No. 139. —
Stoll, De Aliortu, in Diss. Med. edit. Egerel, t. iv. —
Detharding, De Foetus ininiaturi Exclusione, Kost. 1748.
— Jasscrini, De Abortu, Vien. 1777. — Mayer, Aphorismi
de Causis Abortum provocantilius, 4to. Franc. 1730. —
Becker, De Abortu, Got. 1793. — Gregorini, De Hydrope
Uteri et Hydatidibus, Hal. 1795. — Le Roy, Sur les Pertes
de Sang pendant la Grossesse, et sur les fausses Couches,
Paris, 1801. — Stewart, On the Causes which destroy the
Foetus in Utero, in Medical and Chirurgical Transactions,
vol. 7. p. 144 — El. v. Siebold, Von den Fruhgeburten in
dessen llandh. rur Erkeuntniss und Heilung der Frauen-
zimmer krankheiten, ii. b. u. 2., Frank. 1823. — Professor
Dcsormeaux, art. Avortement, Diction, de Medicine,
(. iii. p. 177. ; et art. (En/., ibid. t. xv. — Dr. Blundell,
Lectures on Midwifery, &.c. Lancet, vol. xiii. — Good,
Study of Medicine, vol. v. p. 174. — Els. v. Siebold, art.
Abortus Encvclopadisches Wb'rteibuch der Medicinischen
Wissenschaften, &c. erster Band, Berlin, 1328. —Ryan
Manual of Midwifery, 12mo. Lond. 1831, 3d ed. Duges, in
Revue Medicale, 1824, t. iii. p. 74. ; et Manuel des Ac-
couchemens, Paris, 1830. — Audry, Sur le Maladies du
Foetus et ses Annexes, in Journ. des Progres des Scien.
Med., 2d ser. t. i. p. 126.
ABSCESS. Syn. Jlbscessvs (from abscedere, to
depart, to separate), Aposte.ma, Abscessio, Vo-
mica, Imposthuma, Auct. Lat. Aitoaxr^ia.
Gr. Abets, Fr. Die Eiterbeule, Ger. Ed-
derbyld, Dan. Bulning, Swed. Ettergezwel,
Dut. Ascesso, Ital. Abscesso, Span. Absces-
so, Port. Abscess, Imposthume, Eng.
Classif. — See Inflammation.
1. Defin. A collection of purulent matter
formed or deposited in the structure of an or-
gan or part.
2. An abscess is never an original disease, but
is constantly the effect or termination of inflamma-
tory action, in some form or grade, or of irritation
of the part in vvliich it is seated. This may not
seem to be in accordance with certain phenomena
connected with the formation of purulent collec-
tions, in parts at a distance from those in which
inflammatory action originates, and where pus is
originally formed: but I shall have occasion to show
that it is not opposed to sound views as to this
topic, or, at least, that the exceptions to it are few.
3. Without noticing further than to enumerate
them, the older distinctions of abscesses into the
warm, phlegmonous, or inflammatory, the cold
or congestive, and the acute and the chronic, I
shall have to show that, instead of proceeding
from different sources, they are equally the result
of a certain state of inflammatory action, modified
into a variety of forms according to the degrees
of vital energy and action of the part, and of the
system generally, the organization of the part af-
fected, and the peculiarity of constitution and
diathesis. In the present article, a general view
will be taken of the pathology and medical treat-
ment of abscess, the consideration of the different
kinds of abscess; their various seats, and relations
to other diseases, fall under different heads, where
they are more advantageously discussed.'
4. I. Of the Pathological Charac-
ters of Abscess. 1st, Of abscess proceeding
from acute inflammation , ivith integrity of the
constitutional energy. $Vhen a part' becomes
inflamed, the vitality of which has not been previ-
ously injured, as respects either its individual state
or constitutional relations, its temperature becomes
increased, and its vessels are injected with a great-
er quantity of the circulating fluid than in health,
and generally in proportion to the violence of the
irritation upon which this afflux of fluid depends.
At first the fluid does not extend beyond the vessels
in which it has passed : but, in proportion as it dis-
tends them so as to exhaust their tone and power
of reaction, and as the vital cohesion of their ex-
tremities, and of the tissues which they supply, is
weakened, a portion of the more fluid constituents
of their contents escapes into the texture of the
part affected; infiltrates, and combines with, its
constituent elements; and renders it, at first, more
compact and dense. But, at the same time that
the inflamed part undergoes this change, it looses
its vital elasticity, is more friable or lacerable, so
as to break down more readily from foreign press-
ure, or upon the application of a firm ligature.
5. If the inflammatory action stops not here,
the tissues affected by it undergo further changes.
They pass, more or less rapidly, from a dense but
friable state to that of softening; and this quickly
but insensibly assumes a pulpy condition, owing
to its continued and increasing infiltration with
the more fluid parts of the blood, and even with
more or less of its coloring particles; the mole-
cules composing the tissues of the part being so
combined with, and separated by, the infiltrated
fluid, that all distinct traces of proper organiza-
tion are lost. Prom this pulpv state, to which the
central portion of the inflamed structure is reduc-
ed, the transition to pus proceeds rapidly. But
it is not to be understood that the tissues them-
selves are converted into this' fluid. The fluid
poured out from the extreme capillaries gradually
distends the surrounding parts, and partially dis-
solves the softened and disorganized tissues in
which it is effused. The congulable lymph, which
the tonic or unexhausted vital energv of the ad-
joining vessels form in the surrounding texture,
confines the effused fluid, and prevents it from
extending beyond the barrier it opposes; whilst
the impaction of the cellular tissue, occasioned
by the increasing quantity of purulent effusion,
and the pressure it produces in all directions', with
the thickening, and the continued deposition of
lymph in the parietes of the abscess, tend still
further to fulfil this end, and thus to limit the mis-
chief, and to prevent the contamination and dis-
organization of the adjoining structures; conse-
quences which not ur.frequently supervene, when
the vital energies of the frame and the state of lo-
cal action are insufficient to admit of the formation
of coagulable lymph and to throw up this barrier
against the extension of disease.
6. The first step of the suppurative process is the
dissemination, particularly in the softest, in the
first and most intensely inflamed part, of minute
collections of a sere-albuminous or sero- sanguine-
ous matter. By degrees, this fluid becomes more
abundant. These minute collections enlarge, ap-
proach each other, and, at last, the partitions of
softened tissue between them are altogether dis-
organized and disappear; the whole, at last,
forming only one cavity of variable extent. As
this process advances, the effused fluid changes
from a thin albuminous lymph into pus; which be-
comes more thoroughly elaborated, losing its col-
oring matter which it had derived from the blood;
and dissolving the shreds or Mbris of the disor-
ganized tissues in which it had formed : and when
the suppurative process is matured, the pus forms
an homogeneous fluid, presenting certain charac-
ters distinguishing it from all other animal fluids.
ABSCESS — Acute, its Pathology.
13
7. Pus, taken from a matured abscess of the
description now exhibited, is generally a whitish
or cream-like fluid ; friable, homogeneous, soft,
and smooth to the touch ; somewhat heavier than
water, in which it is only partially soluble ; with-
out any disagreeable smell, and producing of itself
no irritating effects upon the I issues enclosing it
as long as it is excluded from the action of the
atmosphere. Upon a closer examination, it is
found to consist of minute colourless globules,
resembling the colourless globules found in the
blood, floating in a thin albuminous fluid.
8. It is often a matter of importance to distin-
guish pics from the mucus secreted by a mucous
membrane in a state of irritation ; and, accord-
ingly, various attempts have been made to esta-
blish some specific character. The circumstance
of pus s'mking in and partially mixing with water,
whilst mucus remains at its surface, has been
taken as a common test ; and in many cases will
be sufficient, with the history of the disease, and
various concomitant phenomena, to enable us to
decide : but it should be recollected that the mu-
cus, which is frequently secreted in great abund-
ance by the internal surface of the bladder, and
which is very remote from pus in its characters,
always sinks in water. Besides, mucous surfaces,
when in a state of inflammation, secrete a fluid
varying from a thin watery or frothy matter; and
in some cases, from a thick albuminous and vis-
cous mucus to a friable cream-like pus ; but most
commonly, a muco-purulent liquid, which pre-
sents more or less of the characters of both pus
and mucus. The appearance exhibited by pus,
when pressed between two plates of glass, which
are afterwards separated, Is often distinctive: this
fluid attaching itself to their surfaces, without the
viscous adhesion of mucus, and partly consisting
of small globules. The viscous elasticity of mu-
cus, of which character pus is entirely deprived,
distinguishes the one from the other more com-
pletely, and in a more intelligible manner, to the
practised eye, than any other feature they present.
In addition, however, to this, it may be added that,
when water Is added to a solution of pus in dilute
sulphuric acid, a more or less abundant precipi-
tate Is formed ; whilst, with a solution of mucus
in the same acid, whitish filaments form on the
surface upon the addition of water.
9. As the partitions of softened tissue placed
between the incipient purulent collections, in a
part undergoing the early process of suppuration,
lose their vitality, and become broken down in
the effused fluid, the vessels and nerves, as well
as the more solid tissues passing through the part,
continue to resist the disorganising process for a
longer period, so as to form isolated hridles, and
communications between the separated parietes of
the absces3.
10. The interior of the parietes of the cavitv is
generally more or less reddened, tomentous, and
very close in its texture, owing to the impaction
or distending power exercised by the accumulat-
ed fluid and the effusion of lymph; so that the
fluid contained by them is completely isolated
from the surrounding structures. The membrane
thus formed presents all the characters of a mu-
cous surface, particularly when the gravish pellicle
which usually covers it is removed. Its interior
surface is in contact with the purulent collection ;
whilst, externally, it adheres intimately to the
surrounding tissues, and is confounded insensibly
with them. It approaches more nearly to the cir-
cumference of the inflamed part, the more com-
plete the softening of the tissues, and the more
the abscess has advanced to maturity. Its dens-
ity and thickness are generally in proportion to the
slowness of its formation and the length of time it
has existed.
11. In parts abundantly supplied with cellular
tissue, the membrane proper to abscesses acquires
a great degree of resistance and density, forming
thick cysts; whilst in very soft organs, or in those
but scantily provided with cellular tissue, as in
the brain, it remains long in the state of a vas-
cular pellicle, scarcely distinct from the healthy
structure with which it is connected. It is in
general rare that we find a thick or firm cyst in
the acute abscess now under consideration; for it
forms too rapidly to admit of the thickening and
condensation usually occasioned by inflammatory
action of some duration. In some very acute
abscesses, as in those which sometimes form in
the liver of Europeaas residing in India, after in-
tense inflammation of the internal structure of the
organ, no cyst, membrane, or even pellicle can
be detected on the internal parietes of the ab-
scess; the whole surrounding structure being in-
flamed, softened, and sometimes portions of it
hanging or floating in shreds in the midst of the
purulent collection. In these cases the purulent
collection, although existing as a circumscribed
abscess, more nearly approaches the diffused ab-
scess next to be noticed.
12. The functions of the membrane lining ab-
scesses are not confined to the containing and
isolating the purulent matter, so as to prevent the
contamination of the adjoining structures. Owing
to the absorption and exhalation proceeding in its
surface, the contained fluid is continually renewed,
its qualities are modified, and its decomposition
prevented. It Is not altogether removed from the
influence of life, but participates in the vitality of
the surrounding textures, as all fluids accumu-
lated in organized parts do, though in a feeble and
obscure degree. M. Dupuytren remarks, that
it is through the medium of this living envelope
that the matter contained in abscesses is augmented
and diminished in quantity; Is thickened, or ren-
dered more fluid ; or Is occasionally changed by
substances absorbed or injected into the circulation.
It is becaase the cysts of abscesses are connected
by an intimate sympathy with the chief centres
of vitality that the excitation of the more impor-
tant viscera affects them in so marked a manner;
and that remedies, judiciously applied to these
viscera, often tend to promote the absorption of
the matter they contain.
13. 2d. Of Abscesses proceeding from acute
inflammation in a cachectic habit of body, defi-
cient vital resistance, and with a tendency to
spec id ; or Diffuse Abscess. In debilitated and
vitiated habits of body ; in persons of exhausted vital
energy ,jfthose assimilating and secreting organs are
torpid; ano owing to ti^ operation of certain nox-
ious and intense causes;' particularly those which
contaminate the structure to which they are ap-
plied, as various animaf-'poisons, animal and vege-
table matter in a state of decomposition, or what-
ever produces, from its local or constitutional action,
a sceptic effect upon the living textures: from these
circumstances especially, inflammatory action is
14
ABSCESS — Diffuse, its Pathology.
not limited to a particular part, or within distinct
bounds; and the fluid which is poured out from
the inflamed vessels is not circumscribed, or con-
fined to the centre of the inflamed part. The
inflammation which produces this unhealthy and
imperfect form of abscess is always characterized
by that state of asthenic, or ataxic action, local
and general, which is incapable of producing co-
agulable lymph from the blood, that may limit
both the morbid action and the effused fluid.
(See art. Inflammation.)
14. The present kind of abscess not unfre-
quently forms in erysipelas ; or after wounds, in-
juries, and punctures ; and from the inoculation
of an animal poison. The character of the suc-
cession of morbid actions it presents is want of
vital power and resistance, and a speedy solution
of the vital cohesion of the affected tissues. It
would seem that the influence of the ganglial
nerves supplying the capillaries of the part is ra-
pidly, or almost instantly, destroyed by the cause
of the disease ; and that the vessels, thus deprived
of a great proportion or the whole of their vitality,
allow the escape of the more fluid parts of the
blood, and the infiltration of the tissues. The
vessels pass rapidly, and without the previous
grades of healthy inflammation, into that state
which admits of the effusion of a watery or puri-
form sanies. The state of vital energy, and the
deficient crasis, or unhealthy condition of the
blood itself, probably contributes to this result ;
and, with the effect of this effusion on the diseased
part, promotes the rapid exhaustion of the remain-
ing action of the capillaries.
15. Diffusive abscesses generally commence in,
and spread rapidly in the direction of, the cellular
tissue. They affect also, in a very marked man-
ner, the other structures placed in their way.
They seldom commence in the internal viscera,
as the liver, lungs, &c. ; but when they do thus
originate, as is occasionally observed in the latter
stages of malignant or ataxic fevers, in exhaust-
ed states of the frame, &c, they nearly approach
the characters they assume in the cellular struc-
ture. In almost every case of this disease, the
constitutional disturbance is very remarkable ;
and the powers of the nervous system, particu-
larly that presiding over the organic and assimi-
lating functions, uncommonly depressed. Locally,
the effusion of a watery, or sero-albuminous, or a
sero-sanguineous fluid is nearly coeval with the
affection of the cellular tissue and congestion of
its capillaries. The vital cohesion of the inflamed
texture is rapidly dissolved ; and the fluid, abund-
antly poured out in its areolae or cellules, distends
the part, diminishes its vital functions to the
lowest grade, and, at points, lacerates its tissue,
therehy partially cutting off its connection with
the adjoining structures. Thus the fluid is effused
from the congested capillaries of the affected part
in numerous places : in some, forming consider-
able collections ; in others, mere infiltrations.
Parts of the cellular tissue itself, and, in rare in-
stances, as the mischief proceeds, portions of ad-
joining or intermediate textures, are deprived of
all vitality, sphacelate, and mix with the fluid
effused.
16. In many cases the integuments participate
but imperfectly, and often not at all, in the mor-
bid actions, whilst the process, as now described,
is going forward ; and the great effusion into, and
partial destruction of, the cellular tissue, have
enormously distended the limb or part in a dif-
fused manner and to a great extent, and given it
a boggy or imperfectly fluctuating character. At
a later period, parts of the more attenuated or dis-
coloured integuments vesicate, ultimately burst,
and give issue at first to a discoloured puriform
secretion, which afterwards becomes offensive and
otherwise modified. When the skin is affected, it
generally presents a dark or livid hue : its tem-
perature is seldom above (excepting, sometimes,
at the very commencement of the antecedent in-
flammation), and frequently sinks below, the na-
tural standard.
1 7. With respect to the appearance of the se-
cretion in this form of abscess, I may state, that
it not only varies remarkably in different cases,
but also at different stages of the same case. At
first, the fluid effused and infiltrating the cellular
structure consists chiefly of a limpid, reddened
serum, which readily flows from the divided struc-
tures ; in a more advanced stage, the effused mat-
ter is less fluid, often high-coloured, but without
the whiteness and opacity of purulent matter.
Afterwards, the cellular membrane is engorged
with a white semi-fluid matter, which separates the
particles of fat and cellular tissue at an unusual
distance from each other. In subsequent stages
it continues opaque ; but often becomes reddish,
greenish, and more fluid. At a still more advanced
period, the infiltrated cellular and adipose tissue
are entirely broken down, and the sphacelated
portions hanging into, or mixed with, the puriform
matter; which sometimes now presents the appear-
ance of a brownish, purulent sanies, sometimes a
greenish pus, and at other times a sero-purulent
matter of various shades of colour and degrees of
consistence. At no period of the disease is the
matter contained in any circumscribed cavitv, but
is gradually and irregularly lost in the surround-
ing cellular tissue ; without any demarcation, or
appearance of coagulable lymph about the circum-
ference of the diseased part. In general, the
purulent secretion speedily assumes an offensive
odour, and its sensible qualities are otherwise al-
tered, and often variously, upon the admission of
ail- to the diseased surf ice.
18. The muscular structure, and other parts in
contact with the puriform matter, and in the way
of the spreading disease, is generally much discol-
oured, softened, easily torn, and sometimes par-
tially destroyed. In some cases the muscles are
paler ; in others, darker, and more livid than na-
tural. In rarer instances, the adjoining bones
and more resistant structures are also affected.
(See Inflammation, Diffusive.)
19. 3d. Abscesses consequent upon inflamma-
tion of lower grades of intensity. — The more slow
and obscure the progress of inflammation, the less
marked are the signs of irritation preceding and
accompanying abscesses. It is not uncommon to
observe, in lymphatic and phlegmatic tempera-
ments, fluctuating tumours of various sizes, both
superficial and deep-seated ; without any consider-
able pain or increase of animal heat, either ante-
cedent or subsequent to their formation. Purulent
collections, of a chronic and indolent character,
generally proceed from a low but continued state
of irritation, or from reiterated excitation of so low
a grade as scarcely to influence the sensibility of
the part ; and occur in constitutions of weak vital
ABSCESS — Chronic, its Pathology.
15
resistance and defective restorative energy. On
the other hand, the abscesses described in t lie pre-
ceding sections result from inflammation of a more
or less acute character, occasioned by active stim-
ulation or deleterious agents, and generally affect
the system in a more or less active manner.
20. Owing to the low grade of irritation in the
affected part, the vessels are but little, and often
scarcely perceptibly, injected. The abscess, in
place of commencing with a number of distinct
centres or foci, appears at first as a single isolated
collection in one or more of the cellular areolae,
and presenting, from the commencement, a mani-
fest fluctuation. In some cases, this appearance
of the affected part is less that of true phlogosis
than of a deviation from its nutritive actions. The
tissues, instead of attracting, in virtue of their
vital endowment, the nutritive particles ; and the
vessels, instead of imparting them in an appro-
priate condition, and exhaling a fluid suitable to
the healthy state of parts, are so far changed as to
fail in the performance of these actions ; the ves-
sels furnishing a fluid of a certain kind, apparently
composed of the particles or globules which,
under the influence of healthy vital endowment,
would have been separated from the circulating
fluid for the nourishment or growth of the
tissues, and of the watery exhalation destined
to lubricate them, and render them fitted for their
functions.
21. In the chronic varieties of abscess, the pus,
being secreted under the influence of a lower grade
of excitation, differs from that previously described
(§7, 8.). It is frequently yellowish, serous, trans-
parent ; continuing flocculi of an albuminous or
fibrinous nature, and whitish, opaque appearance :
sometimes it is mixed with minute shreds of
cellular-like substances. In other cases it is near-
ly analogous to mucus, from its thickness and vis-
cosity, in some subjects, when very slow in its
formation, it assumes a greater consistence and
opacity, resembling half-eonjrealed lard or liquid
honey ; and the tumours which it forms seem to
constitute a connecting chain between pure ab-
scesses and melicerous or steatomatous cysts.
These latter differ in no respects from abscesses
devoid of active inflammation, but in the greater
consistence of the matter they contain : and in
some cases, as M. Dupuytken remarks, it is
difficult, if not impossible, to distinguish between
them.
22. Owing to the extreme slowness of their
formation, and the absence of acute inflammatory
action, the pariet es of the present kind of abscess
have a more distinct organization than those of
the first species. Vascular injection and redness
are here seldom observed exteriorly to the cyst
enclosing the purulent collection. The skin cover-
ing the tumour, and through which the fluctuation
is readily felt, is generally i'n'f, moveable, and
unaltered. All the morbid action seems concen-
trated in the diseased membrane enclosing the
matter. This membrane or cyst is, internally, of
a reddish gray tint, and more or less intimately
connected with the surrounding structure. It is in
some cases soft, thin, and cellular; in others, thick,
strong, and of a cellulo-fibrous, or even fibrous
structure. The slower the tumour is in enlarg-
ing, the more liable is the cyst to undergo change,
and to modify the state of the matter it contains :
and, hence, abscesses of a very slow or chronic
kind often approach slowly but nearly to the
characters of several other encysted tumours.
23. The purulent collections w Inch form around
foreign bodies, that occasion but little irritation,
generally belong to the present kind of abscesses.
They are always lined with a firm cellular cyst,
analogous to that enclosing the foreign body itself.
The abscesses which proceed from bodies occasion-
ing great irritation are preceded by great pain
and inflammation, and belong to the preceding
kind of abscess.
24. 4th. Of symptomatic absresscs, or collec-
tions of matter at a distance from the places
zohere the pus is first formed. In the foregoing sec-
tions I have considered the formation of abscesses
in, and their limitation to, the primary seat of irri-
tation : but if the parts affected are surrounded by a
loose areolar cellular tissue, readily permeable by
the matter as it is formed ; and especially if the state
of vascular action and vital energy of the frame are
insufficient to the production of coagulable lymph
around the inflamed centre ; the matter gradual-
ly finds its way in the course of the cellular
structure to adjoining parts, particularly to those
which are more dependent, infiltrates them, and
forms, more or less distinct and fluctuating, tu-
mours at a distance from the primary seat of in-
flammation. Instances of this kind of abscess are
furnished us in diseases of the hip-joint, and in
cases of inflammation commencing in some or
one of the vertebrae, or their fibro-cartilages. In
this latter case, if the disease commences in one
of the dorsal vertebra?, the purulent fluid may ac-
cumulate under the pleura, infiltrate the adjoining
cellular tissue, and, following the direction of the
ribs, appear at some part of the side or back, or
even near the sternum, far from its origin. When
the inflammation attacks one of the dorsal or
lumbar vertebra', or intervertebral structures, it
may travel in a similar manner behind the pillars
of the diaphragm, proceed in the course of the
psoae and iliac muscles, following the cellular
tissue behind the peritoneum, and appear ex-
teriorly, most frequently under the crural arch,
but sometimes through the inguinal ring. In
other cases it proceeds to a shorter distance, and
points at the sacro-iliac symphysis, or in the angle
between it and the spine : or it may extend down
the pelvis in various directions, following the
cellular substance surrounding the vessels and
nerves. 'I bus it may pass through the ischiatic
notch, forming an abscess at the internal part of
the gluteal muscles ; or along with the great
sciatic nerve, and point on the superior and pos-
terior part of the thigh ; and, lastly, it may find
an issue in the perineum, at the margin of the
anus, or into the rectum, or even into the vagina.
In some rare instances a double tumour and open-
ing are formed. In the case of a female by whom
I was consulted, the matter had found its way to
the integuments of the .eacro-spinal angle ofthe
loins, where it was punctured by a surgeon, and
yet had also burst its way into the vagina. In
the case of a groom whom I attended, a tumour
formed at the sacro-iliac symphysis, below the
crural arch, producing the most violent and pain-
ful tumefaction ofthe limb, owing to the pressure
of the matter on the nerves and veins ; and the
matter afterwards burst into the lower part ofthe
sigmoid flexure ofthe colon.
25. The matter proceeding from abscesses symp-
16
ABSCESS — Consecutive, its Pathology.
tomatic of inflammation and ulceration of bones
or cartilages is generally grayish, thin, mixed with
albuminous llocculi, minute clots of blood, and
portions of phosphate of lime. It exhales a nau-
seous odour : but this characteristic is present only
after the opening of the tumour, and when the air
has access to the cavity.
26. If we examine the cavities of symptomatic
abscesses, and trace them from their origin to
their outlet, we shall rind, in the former situation,
the cartilages and bones profoundly changed : the
bones are softened, friable, changed to a grayish
black, partially absorbed and carious, and their
periosteum destroyed. From this origin of the
disease is formed a channel or sinus, traversing
the cellular structure frequently in the course of
the large vessels or muscles, and terminating with
the external outlet of the tumour. The whole of
this canal or sinus is usually surrounded by a
softened, friable, or lardaceous state of the tex-
tures; and lined with a smooth, thick, firm, cel-
lular, or fibro-cellular membrane, which in some
cases is of a fibro-cartilaginous structure. At the
lower part, the canal generally dilates into a con-
siderable cavitv, sometimes irregular or sinuous
in its form, and lined with the membrane usually
found in the more chronic kinds of abscesses.
27. 4th. Of consecutive abscesses! or collc^
tions of matter found in situations consecul ively
to its formation in distant parts, between which
there exists no communication. It has been not
infrequently remarked, that inflammation of a part
has taken place, and has gone on to suppuration ;
that the matter thus formed has been absorbed ;
and that it has subsequently formed in some other
viscus, generally in an internal organ. The nature
and procession of the morbid phenomena now
enounced have led to some enquiry, particularly
in recent times. The circumstances in which
consecutive abscesses occur in practice are the
following: —
Inflammation of the internal surface of the
uterus, or of its veins, or of both the substance
of the uterus and veins, occasionally takes place
after child-birth, and terminates the life of the
patient. On dissection, purulent infiltrations or
distinct collections of pus are found, in one case,
in the lungs ; in another, in the liver ; in a third,
in the substance of the brain ; in a fourth, in
the capsules of the joints ; and, in a fifth, in
both the lungs, liver, and perhaps, also, in the
joints. A man, from injury of the head, has in-
flammation of the sinuses of the brain, followed
hv all the symptoms of a vitiated state of the cir-
culating fluid, terminating in death : after which,
abscesses, or purulent infiltrations, are found in the
liver or lungs. A similar procession of pheno-
mena occasionally results from phlebitis conse-
quent on blood-letting, or other causes ; also
during the suppurations following amputations, par-
ticularly when the matter is confined on the face
of the stump, by the adhesion of the integuments
which had been drawn over it. A child is seized
with severe or confluent small-pox ; and during,
or subsequently to, the secondary fever, fluctuat-
ing tumours form in the joints from matter accu-
mulated in their capsules. Upon dissection, the
cartilages are found eroded ; and, in other rare
cases of this kind, purulent collections are found
in the internal viscera. In other instances, ab-
scess disappears from external parts; the patient
sinks with low fever ; and, upon dissection, collec-
tions of pus are found in internal organs. In cases
of this description, the following require notice: —
1st, The state of the vital energies preceding or
during the occurrence ; 2d, The symptoms char-
acterizing the progress of the phenomena ; and,
3d, The nature of the results.
28. 1st, The energies and vital resistance of the
system are generally greatly impaired, either from
pre-existing or concurring causes, in cases where
consecutive abscesses form. (See article on In-
flammation of Veins.) 2d, The depression of
the powers of life increases as the disease advances.
The nervous system is seriously affected ; the cir-
culating fluid betrays change in its appearances
after its emission, or after death ; the soft solids
lose their vital elasticity and cohesion ; the surface
of the body and countenance become dusky and
livid ; and low delirium, rapid and weak circula-
tion, &c. take place. 3d, The purulent matter is
generally either infiltrated into the parenchyma-
tous structure of some organ, or collected into
one or more distinct abscesses, or it is effused into
the cavity of one or more joints. When the mat-
ter is infiltrated into the texture of an organ, the
infiltrated structure is very frequently also soft-
ened. The purulent collections that are found in
other cases generally have no distinct cyst, and
the surrounding substance of the organ seldom
presents any marked redness of injection of its
vessels, or indeed any remarkable change, ex-
cepting in some instances a slight softening. The
matter is usually found in several distinct ab-
scesses or collections, varying from the size of a
small seed to that of an egg, or even larger.
Sometimes the immediately surrounding structure
seems impacted around the abscess, but not other-
wise changed. The purulent matter itself varies
but little from that which is observed in the ab-
scesses described in the first section. (§§ 6, 7, 8.)
It is occasionally of a darker or greenish hue,
particularly when found in the liver.
29, As to the Origin of these purulent collec-
tions, some doubts may be entertained. That they
are very intimately connected with the primary
inflammation and formation of matter in other
parts of the system, cannot be doubted, but in
what way cannot be so readily stated. It seems
to me extremely probable, from the attentive ob-
servation of the progress of a number of such
cases which have come before me in practice,
that, owing to depressed vital energy, and defi-
cient resistance of the frame, purulent matter
passes into and vitiates the blood; that the morbid
condition of the circulating fluid, thus induced,
depresses still lower the already weakened nervous
powers ; and that the irritating matters carried
into the circulating current change the state of
the capillaries of parenchymatous and some other
organs, so that they secrete purulent matter with-
out any evident sign of previous or accompanying
inflammation. Several French pathologists sup-
pose that the purulent matter conveyed into
the blood circulates without combining with it,
and is merely deposited by the capillaries, or
separated by them, from this fluid in parts ; the
vessels and texture of which are most disposed to
permit its elimination, or the best constituted to
admit of its deposition. It is difficult to deter-
mine in which of those ways the consecutive
abscess is formed. Indeed, both may approximate
ABSCESS — its Progress.
17
the truth, the consecutive formation of pus arising,
in one case, from the irritation occasioned by the
presence of morbid mailers in the blood; and, in
another, chiefly from the separation or secretion
of it in the parenchyma of an organ, without any
previous or attendant irritation.
30. II. Of the Progress and Termin-
ations ok Ausckssf.s. — At any period of its
existence, the inflammatory action in an abscess
may cease, ami tin- matter which has been formed
be absorbed. In these cases the purulent matter
is carried into the circulation ; and, whether the in-
flammation is primarily and gradually extinguished
in the abscess, or whether intense pain and inflam-
mation, developed in some other organ, exercises
on the first centre of mischief a true revulsion,
the absorption of the pus is only consequent upon
the subsidence of the local signs of inflammation
and congestion. The part looses its turgescence,
redness, increased heat, and tumefaction, and is
restored to its healthy state without any deformity
or cicatrix. In these cases the absorbed matter
is eliminated from the circulating mass, without
accumulating in it to a hurtful extent, by the ac-
tive or unimpaired functions of the various elimi-
nating organs, particularly by the kidneys, and
niucuous surface of the intestinal canal, — the
Blatter, in some cases, being apparent in the urine,
and in the others exciting a temporary diarrhoea.
31. In other instances, the inflammation pro-
ductive of suppuration being but slight, or being
less completely dissipated, and the solid tissues,
and particularly the firm and thickened cyst, op-
posing the extension of the abscess, it occasionally
rests long stationary. In this case the pus remains
inactive and inoffensive in the part, like a smooth
and inert body lodged in a cyst. Abscesses will
sometimes continue for a very long time unchang-
ed, and without occasioning much disturbance to
the economy, particularly when deeply seated.
In such cases the cyst becomes more and more
firmly constituted, thickened, and changed from
the state of the surrounding parts; so that the pus
is in some measure isolated from the adjoining
structures : in this state it may remain, as in the
brain and liver, for a considerable time, without
any very marked symptoms, until some accident
or exciting cause occurs to affect it and the adjoin-
ing parts, when the usual course of the disease
will be resumed.
32. The foregoing changes are comparatively
rare. In the great majority of cases, pus dis-
tends, compresses, and obscurely excites, the
parts in which it is lodged. Instead of being
diminished, the abscess is increased in size, and
tends to find an external outlet, uniformly in the
direction of either the cutaneous or one of the
mucous surfaces. Purulent matter is thus submit-
ted to the general law of the economy ; the
vital resistance, opposed to all substances calcu-
lated to excite or otherwise injure the textures,
detruding it by a regular procession of pheno-
mena, as long as tin; energies of the svstom are
not entirely overwhelmed, to the nearest or most
unresisting part of the surfice, and at last expel-
ling it altogether from the body.
33. The succession of morbid phenomena oc-
casioning the deliverance, of the svstem from col-
lections of matter, is of great importance to the
practitioner, particularly as respects deep-seated
or internal abscesses. Generally the quantity of
2*
matter is continually increasing, owing either to
the extension of suppuration in the inflamed part,
or to a continued secretion from the internal sur-
face of the abscess, or to the concurrent operation
of both causes. In consequence of this increase
of quantity, the parietes of the .abscess are dis-
tended and applied more closely to the surround-
ing parts, which are pressed outvvarils by the
accumulated matter. This distending power is
equally exercised from the centre to the circum-
ference. But, as all the adjoining parts do not
exercise the same degree of resistance, the abscess
extends in the direction of the external or free sur-
faces; its more deeply seated parietes being sus-
tained by all those parts which are placed beneath
them; whilst the tissues which are exterior to it,
being deprived of aid, are readily elevated and
distended by the increased effusion.
34. As to the nature of this effusion, and the
changes it undergoes, certain questions have been
urged. It has been supposed that the matter
found in abscesses is not secreted in the state in
which it exists at the period of maturation : but
that the fluid effused is in a state which may be
called albuminous serum; which, owing to the
continued exhalation and absorption taking place
in the internal surface of the abscess, is changed
into what is called well-digested pus. Others
suppose that the purulent fluid is secreted in the
state of pus, or nearly approaching to it, by the
membrane forming the cyst, and which, as it pre-
sents many of the characters of mucous membrane,
may, like this membrane, when highly inflamed,
secrete a purulent fluid. It is extremely proba-
ble that both views may be in a great measure
correct : for attention to the maturative process in
recent abscesses shows that the fluid first effused
is not pure pus; and it is undeniably proved that
the matter contained in the different kinds of ab-
scesses is variously modified according to their
duration, their situation, and the circumstances
attendant on their progress. Whilst, on the other
hand, it must be conceded that the internal sur-
face of an abscess, particularly in a high state of
inflammation, or when irritated by the contact of
the air, will secrete a purulent fluid, or a matter
which very rapidly assumes the puriform charac-
ter; the vessels terminating in it giving issue not
only to the watery part of the blood, but also to
many of its smaller globules, so as readily to form
a pure pus, which quickly becomes thick, upon
the evaporation or absorption of a portion of its
more fluid constituents.
35. Another important matter, relative to the
progress and external pointing of abscesses, is the
fact, that inflammation generally seizes upon the
adjoining structures as the internal membrane
is more closely applied to them. The parts
most distended and stretched by the contained
fluid have tin; inflammatory action extended to
them from the parietes or membrane of the abs-
cess. To the inflammatory irritation thus induced
in the surrounding textures succeed their adhe-
sion to the parietes of the abscess; absorption of
their solid elements, with attenuation; and, lastly,
ulceration, — the integuments merely often resist-
ing for a considerable period the discharge of the
fluid.
36. If we take as an example the not unfre-
quent occurrence of abscess in the substance of
the hver, and trace its progress in one of those
13
ABSCESS — its Progress.
directions which it sometimes follows, namely,
through the diaphragm and lungs, until it empties
itself into the bronchi, we shall find the following
to he the course of the morbid phenomena: —
As the inflammatory action and the secretion of
purulent matter proceed, the abscess which has
been formed, generally in cases of this kind in the
convex part of the organ, advances towards the
surface; the inflammatory action extends to this
part; and lymph is thrown out, which, with the
pressure of the swelling and pointing of the ab-
Bcess, irritates the peritoneal surface of the dia-
phragm, inflames it at the part opposite, and oc-
casions its agglutination at this situation to the
parietea of the hepatic abscess. As the tumour
points upwards, the inflammatory action advances
in the same direction; extends to the muscular
structure of the diaphragm, which is softened and
attenuated, assuming at the same time a dark
or bluish tint; and invades the diaphragmatic
pleura, where it throws out coagulable lymph.
This secretion occasions irritation and inflamma-
tion in the opposite part of the pulmonary pleura,
and the cohesion of the lung to the diaphragm at
the part where the collected matter is advancing
prominently upwards. As the parts thus succes-
sively involved undergo the softening process con-
sequent on inflammation, and yield before the
pressure of the accumulated fluid, owing to their
diminished vital cohesion, absorption commences
and proceeds in the central or prominent part of
the tumour; and the matter thus finds its way in
the direction which is most yielding, where the
inflammatory action most readily advances, and
where the resistance to it is thereby still further
diminished. I have had frequent occasion to
trace the above phases of the progress of large and
deep-seated abscesses; and to satisfy myself that
they proceed in a similar manner, whether they
advance to the external surface of the body, or
open upon a mucous surface, or into a shut cavity;
which last is a rare occurrence.
37. It is of importance to observe the proces-
sion of phenomena now stated; inasmuch as the
successiver eddening, inflammation, adhesion, soft-
eniiiir, and absorption of the various structures, as
the tumour advances exteriorly, are the guides to
a very important part of the treatment of these
formations. Thus, when we observe marks of
inflammatory irritation of the skin take place in
the situation of an internal abscess, we may infer
that the ulterior phenomena now enumerated, par-
ticularly adhesion, have taken place in the parts
beneath, and we may safely decide upon earn ing
an incision from the centre of the inflamed integ-
uments to the seat of absciss.
38. It must not be overlooked, that various
aberrations of purulent collections take place, in
their progress to the surface, and that they often
proceed in a direction opposite to that of gravita-
tion, owing to the resistance of bones, fascia', and
aponeuroses ; which last oppose them in a most
remarkable manner, and cause their extension in
various directions, giving rise to the most severe
local and constitutional sufferings.
39. Abscesses, besides, cause the inflammation
of parts placed between them and the centre of
the system, as respects the direction of the cir-
culating vessels, as well as of those parts situated
exteriorly to them, although in a much less degree,
and followed by very different results; for, in-
stead of the thinning, erosion, and ulceration of the
exterior parts, tending to advance them to the sur-
face, the inflammation of the parts behind, or
more deeply seated than they, is frequently ac-
companied with thickening, and increased density
of structure; whereby the system is, in a great
measure, protected from their extension to more
internal and vital parts. Numerous instances oc-
cur, where the periosteum or the peritoneum, the
pleura, the fibrous and synovia] capsules, undergo
a marked thickening, opposing thereby an in-
creased obstacle to their extension in that direc-
tion, when abscesses form in the vicinity of those
membranes. When, however, the energy of the
system and its vital resistance are deficient, ex-
ceptions sometimes occur to this rule, and ab-
scesses find their way, when situated favourably
to this mode of termination, into important cavi-
ties and organs. Thus, an abscess seated deep in
the parietes of the chest or abdomen, may open
into these cavities, as in the case of the son of the
eminent M. Petit; or an abscess in the liver
may find its way into the pericardium. Put any
disposition to its opening internally, is opposed not
only by the thickening of the serous and other
membranes, &c, as here instanced, but also by
the support of the viscera underneath, which resist
the pressure and extension of the tumour in this
direction.
40. The progress and spontaneous opening of
abscesses, advancing in the manner now explain-
ed, terminate with the erosion of the integuments,
which, having been reduced to a pellicle, have
their epidermis elevated in the form of a pblyc-
tena, which soon breaks, and gives issue to a por-
tion of the contents of the abscess; and the dis-
charge is renewed at intervals, by the gradual
retraction of the parietes of the cavity upon there-
accumulated secretion. The successive evacua-
tions occasioned by the reaction of the parietes of
the abscess, are particularly favourable in cases
of large abscess, by preventing any vacuity. In
cases of empyema, for instance, where the ar-
tificial opening is often fatal, a favorable result
not unfrequently follows a spontaneous and suc-
cessive evacuation of the purulous collection: for
it is chiefly by imitating the natural process in
those cases, that we secure the greatest advanta-
ges to the patient, where we find it requisite to
open symptomatic abscesses, as those usually call-
ed lumbar; and not by making large incisions, and
producing a large evacuation, whereby the air has
access to their cavities, but by successive punc-
tures, the margins of which are immediately clos-
ed, upon the evacuation of that part of the contents
which are first expelled by the reaction of their
parietes.
41. The passage of air into the cavities of ab-
scesses is always followed by an increased state
of irritation of their lining membrane. The hurt-
ful effects of this communication have been de-
monstrated by M. DrpuYTREN, and other em-
inent men, although denied by others, but without
either the satisfactory proofs of experience or of
reasoning. In some cases the accession el' in-
flammatory action in the part, upon the access of
air, is very remarkable. In cases of small chron-
ic abscesses this effect is often beneficial; but in
large and acute abscesses the irritation thus in-
duced may be too great for the powers of the
system to withstand.
ABSCESS — Diagnostic Symptoms.
19
12. Under the most Favorable circumstances,
the effects of the admission of air into the cavitj
of an abscess are counteracted by the accompa-
nying treatment; and the discharge soon assumes
a different appearance from thai of the matter
first evacuated : it becomes less white and con-
sistent; and, subsequently, when the parietes
commence forming the adhesions which precede
cicatrisation, it is merely a more or less copious
citron-colored serositv.
After the opening of slow and indolent ab-
Bcesses, the serous, thin, and Bocculent pus with
which they are filled, is replaced by the discharge
of a more digested, homogeneous, and cream-like
fluid, indicating a more intense state of action in
their parietes.
43. I'p.m examining the interior of abscesses
which have been opened, it will be seen that
their parietes gradually discharge themselves; that
they cast oil' the grayish and flocculent pellicle
which covers them; and that they become cov-
ered with cellular and vascular granulations, of a
lively red and solid appearance, formed from co-
agulable lymph thrown on the inflamed surface,
into which new capillary vessels shoot, and re-
sembling the granulations on the surface of
wounds, from which is exhaled the matter which
succeeds to that first discharged from them. The
parietes thus cleansed contract towards their cen-
tres, and in the direction of their most deeply
seated parts. They afterwards unite; so that the
cavity, which has been thus circumscribed, at
last disappears. In the situation of the abscess
nothing is found but its cicatrix; at first consisting
of a cellular lamina, or plate, of various thickness
and density, penetrated by coagulable lymph, and
subsequently converted into a- scarcely apparent
cellular line, which sometimes, at last, entirely
disappears.
44. But the progress of abscesses after they
have been opened, is not always so favorable. It
may be premised, that the irritation proceed-
ing from the contact of air with the internal sur-
face of an abscess is, in general, in proportion to
its volume, and the unyielding state of its parietes.
When the abscess is small, the resulting irritation
"i9 but faintly marked: but if the parietes be of a
large extent, and if the abscess is deeply seated,
particularly if it be in any of the viscera, the in-
flammatory excitement occasioned by the air not
only increases all the local phenomena, but also
gives rise to serious constitutional disturbance,
often terminating the life of the patient. The
yielding state of the parietes, and their apposition,
are sometimes calculated to counterbalance the
bad effects occasioned by their extent. When
the diseased surfaces have 1 a freed by the
complete discharge of matter, and admit of being
closely applied to each other, the admission of air
is in a great measure prevented, and adhesions
frequently proceed rapidly. Where, however,
the parietes cannot be brought closely together,
and the cavity can be obliterated only by means
of granulations formed to an extent that may fill
it, the duration of the suppuration is prolong-
ed, and the effects produced on the constitution
by the extent of the discharge are often serious.
45. But this is not all the mischief resulting
from the access of air to the cavity of an abscess:
the pus which still remains, particularly in deep-
seated abscesses, is more or less changed by it,
and exhales an infected or putrid odour, proceed-
ing from decomposition occasioned by the tem-
perature to which it is subjected, and its contact
with atmospheric air. It is also often observed,
that when large abscesses are opened, and air
gains access to them, the morbid excitement
thereby occasioned in their parietes, re-acts upon
the principal vital centres; the nervous systems,
the digestive organs, and the circulation suffering
from and participating in it, and the suppurative
process is thereby greatly increased ; at the same
time the constitutional powers are much de-
pressed, the matter is rendered much more of-
fensive, and otherwise changed, according to the
seat of the abscess. As the powers of life sink
under the disease, the fluid secreted is more
offensive and disposed to decomposition, until it is
often doubtful whether the change proceeds more
from the access of air, than from the low state of
vital energy. Indeed, in many cases, the latter
cause seems much more influential towards pro-
ducing this state of the discharge than the pre-
sence of air ; for we not infrequently observe,
that as long as the constitutional powers remain
but little depressed, the access of air has but
little effect, the discharge exhaling no offensive
odour; but as soon as, owing either to the increase
of inflammation in the cyst, or to other concurrent
causes, the febrile commotion is increased, and
the nervous system and digestive organs evince
serious disturbance and loss of energy, the dis-
charge becomes rapidly offensive and increased
in quantity; the matter often changing from a
more or less pure pus to a state approaching to
putrid sanies.
4b'. III. Of the Diagnostic Signs of
Abscess. When inflammation has attacked a
cellular structure, or viscus, in which this tissue i9
a prominent constituent part, and particularly if it
be intense in degree, rapid in its progress, aiid ac-
companied with a pulsative pain, we may with
confidence decide upon suppuration being about to
take place. This result is announced by a dimi-
nution of the pain, which changes to a pulsatory sen-
sation isochronous with the pulse; by a feeling of
weight and tension in the part; by a diminution
of the febrile action, succeeded by a large, broad,
open, soft, or undulating pulse; and by irregular
chills or rigors, which extend, after various inter-
vals, along the back, loins, and sometimes the
lower extremities. If the matter is not soon
afterwards evacuated, the symptoms of chronic
irritation succeed; especially small and frequent
pulse, heat or burning of the palms of the hands
and soles of the feet; irregular fits of perspiration,
and night sweats; loss of strength; and all the
characteristics of hectic fever, which makes more
or less rapid progress, and is sooner or later fol-
lowed by colliquative diarrhoea, according to the
seat and extent of the abscess, the constitutional
powers of the patient, and the treatment employ-
ed. The above symptoms .indicate that a per-
il' ut cause of irritation, and of constitutional
contamination, has succeeded to the state of active
inflammation.
•IT. The tumefied state which characterises
sthenic or phlegmonous inflammation, is greatly
modified after suppuration has advanced. It be-
comes less diffused, is much lessened in the cir-
cumference of the periphery of the tumour, and
seems more and more concentrated. Hence it
20
ABSCESS — Prognosis of.
becomes more elevated, prominent, and softened
at the centre of the surface. The redness and
tension undergo a similar change. The circum-
ference of the inflamed surface Is restored in some
degree to the natural state; but the more promi-
nent part acquires a dark red tint, afterwards a
bluish hue, and yields more and more to the pres-
sure of the subjacent pus. for some time previ-
ous to this stage the tumour evinces a more or
less distinct fluctuation when suitably examined,
and this sign becomes more manifest as the ab-
scess advances to the surface.
48. When an abscess forms in deep-seated parts
or viscera, particularly those protected by solid
envelopes, or by thick and unyielding structures,
the diagnosis rests entirely upon the nature of the
constitutional disturbance, and the disorder in the
functions of the affected organ or part, and here
the physician should seize and appreciate the
slightest difference taking place in the pulse, the
animal heat, and the state of all the natural and
organic functions. In these cases he requires the
most exquisite tact for examination, in order to
arrive at an accurate opinion. The symptoms
which should guide him in cases of this descrip-
tion will be stated when I treat of the diagnosis
of the different kinds of visceral abscess. I may,
however, remark at this place, that, even in parts
much less deeply seated, when the cyst of an ab-
scess is greatly distended and very tense, fluc-
tuation of its contents are generally extremely
obscure, or even not to be felt, although its con-
tents may be very fluid. Also, when the purulent
matter is contained in no distinct cyst, but is dis-
seminated through the textures, or infiltrated be-
tween fasciae or muscles, or is confined beneath
aponeuroses, great incertitude may exist as to its
formation. The parts in such cases present more
of a diffused oedema than of a fluctuating tumour ;
and if fluctuation can be at all felt, it is only ob-
scurely.
49. It must be evident that the more feeble
and latent the phenomena of the precursory in-
flammatory irritation, the more difficult is it to de-
termine the period at which the elaboration of pus
commences. We frequently observe in practice,
particularly after phlebitis, injuries of the head,
fractures, and capital surgical operations, abscess-
es form in the liver, mediastinum, lungs, kidneys,
or ovaries, preceded merely by obscure and occa-
sional pain, and furnishing no certain symptoms
of a local kind, by which we can decide as to their
formation, until the time that they appear exter-
nally, or are detected upon post 'mortem examin-
ation. In cases of this description, the constitu-
tional symptoms are our chief guides; but even
these are often so uncertain and so imperfectly
developed as to leave us in doubt. The accession
in this obscure manner of internal abscess is par-
ticularly remarkable as respects those which su-
pervene to inflammatory disease existing in other
parts, particularly to phlebitis, and which I have
denominated consecutive abscesses. (See Veins
— inflammation of.)
50. Symptomatic abscesses generally escape
detection until they advance externally. Previous
to this, pain, uneasiness, tumefaction, &c. are only
felt chiefly in the part originally afieotod. But
the symptoms already noticed (§ 46 — 48.), espe-
cially the unhealthy aspect of the surface, the
state of the febrile action and of the pulse, the
night perspirations, the disorder of the respiratory
and alvine functions, will generally serve, in con-
junction with the changes in the part to which
symptomatic abscesses extend, to indicate the na-
ture of the mischief.
51. It is important, as M. Dupuytren has
very justly remarked, to take into account, when
determining the existence of abscess, the greater
disposition inherent in some constitutions to form
purulent matter. In some persons, the least irri-
tation is followed by the suppurative process.
This is particularly the case in persons of a pale
visage, of a soft flaccid state of the different
structures, and of the lymphatic temperament.
It is also remarkable in those w hose vital ener-
gies have been lowered by previous disease ; by
chronic affections of the digestive mucous sur-
faces; and by those diseases which require the
performance of amputation, or other important
surgical operations. When the suppurative pro-
cess has continued for some time, and has after-
wards been suddenly stopped by an operation, or
any other active treatment, the disposition to form
abscesses is generally remarkable. A similar re-
mark may be extended to the sudden suppression
of any accustomed secretion or discharge. The
most familiar instance of this kind is noticed in
the breast of nurses, which are extremely liable
to suppuration upon interruption to the secretion
of milk. These considerations should have their
due weight with us when estimating the signs of
the existence of internal abscess. Those symp-
toms which are peculiar to collections of matter
formed in each of the internal viscera are pointed
out in their respective articles.
52. IV. Of the Prognosis of Abscess.
The danger from abscess is in proportion, 1st, to
the extent of their internal surface ; 2d, to the
depth at which they are seated; 3d, to the indo-
lence of their action, or the deficiency of vital ac-
tion accompanying them; 4th, to the severity and
danger of the disease by which they have been
occasioned; 5th, to the sinking or deficiency of
the constitutional powers under them; and, 6th,
to the severity of the symptoms accompanying
them, or produced by them. These positions
are so obvious, that no remarks need be offered in
support of them. I may, however, observe, that
abscesses seated in internal viscera are always
attended with danger; but the degree of danger
will depend upon numerous circumstances con-
nected with their seat, the direction which they
take, the state of the vital energies of the frame
during their progress, the chances of their evacua-
tion, and the means of reparation and renovation
the constitution may still possess.
53. The prognosis of chronic, symptomatic,
and consecutive abscesses depends as much upon
the nature of the preceding disease, as upon the
state of the abscess itself. In chronic abscess,
the danger is in proportion to the extent of the
surface of its parietes, and to the grade of consti-
tutional vice. In symptomatic abscess, the danger
depends almost wholly upon the nature and extent
of the original disease, of which it is the conse-
quence, and upon the largeness of surface extend-
ing thence to the ultimate limits of suppuration.
In consecutive, abscess, the danger is extreme;
owing, in many cases, to the iTature of the prima-
ry disease, the depressed state of the constitution--
al powers, and to the vitiation of the circulating
ABSCESS — Treatment of.
21
fluid and soft solids of the body, with which it is
connected.
54 V. Of the Medical, Treatment of
Abscess. — The indications of cure which we
propose in abscess is, 1st, to remove the purulent
collection from the part containing if, and, 2d, to
procure the obliteration of the cavity in which it
was lodged. The first intention is accomplished
either by procuring the absorption of the purulent
matter, and its elimination from the body; or by
opening the parietes of the abscess, and thus
giving a direct outlet to the contained matter.
When the means used to accomplish the absorp-
tion of the purulent matter fail, or when the cha-
racter of the abscess and state of the frame forbid
the employment of these means, opening the ab-
scess must be resorted to when the proper period
for having recourse to the measure arrives.
53. 1st, Means which may be resorted to, in
order to procure the absorption of the purulent
matter, and its elimination from the frame. —
Nu rous instances have occurred of the rupid
absorption of the matter contained in an abscess,
and of its discharge from the circulation, 1st, by
the urinary organs, the urine becoming abundant,
jmd containing either a puriform secretion, or
Deing otherwise altered; 2d, by the mucous sur-
face of the bowels, attended with diarrhoea; and,
3d, by the cutaneous surface, in the form of a co-
pious, thick, or viscid, and offensive perspiration.
These are the most common channels of elimina-
tion of the purulent secretion, when absorbed into
the circulation from the cavity of an abscess. The
purulent collection may, also, disappear in conse-
quence of other critical or accidental evacuations;
but this result is of rare occurrence, and is a much
more remote contingency than those enumerated.
Experience having shown the possibility, and the
great advantages, of removing the matter contain-
ed in an abscess by exciting absorption, the means
most effectual in attaining this end should be first
put in practice.
56. With this view drastic purgatives may be
prescribed, when the state of the patient admits of
them ; and next to them, such diuretics and diapho-
retic-, as may be appropriate to the circumstances
of the case. Contemporaneously with the use of
those internal derivatives, external applications
should be employed, particularly those which pos-
sess discutient, resolvent, and styptic properties.
Frictions with stimulating substances, as nuimoni-
acum, iodine, hydriodate of potash, &c. ; cold,
warm, or tepid affusions on the part, either of
simple or mineral waters, of sulphureous or saline,
natural or artificial, may likewise be tried con-
jointly with the internal means. But this ener-
getic plan of treatment, — this combination of
the revulsive and discutient practice, — this metho-
dus perturbatrix, is not applicable to all cases.
There are many circumstances connected with
the seat and condition of an abscess, and with the
State of the different functions, that either alto-
gether forbid its employment, or require impor-
tant modifications and adaptations of it.
57. Thus, abscesses preceded by acute or ac-
tive inflammation, are rarely susceptible of being
absorbed; the opening of them, therefore, is al-
most inevitable. Chronic abscesses, which are
generally provided with thick cysts, also admit not
of removal by this practice ; it being generally
requisite to excite a new action in their parietes,
which may modify their texture, and render them
susceptible of contracting the adhesions requisite
to their obliteration. The majority of purulent
collections which are removed by absorption. Is
such as form rapidly, without much previous in-
flammation, and in debilitated habits, or in those,
weakened by pre-existing disease. In persons of
this description, the excitement or irritation of the
kidneys, or of the mucous surfaces, will often over-
come the irritation existing in the seat of abscess,
and consequently promote the absorption of the
pus it contains; at the same time that the fluid
abundantly secreted by the parts artificially ex-
cited will assume, in consequence of the state of
the patient, a puriform character. (Dupuytren.)
But, in the majority of instances of this kind, it is
necessary that the artificial irritation or excitement
shall be greater than that previously existing in the
seat of abscess, and that the organs or parts in
which it is induced be in a sound state ; otherwise
the revulsion cannot be either successfully or safe-
lv practised. However we may explain the mode
of action of revulsants on abscesses of this kind,
there can be no doubt that it is almost entirely in
them, and particularly when they are seated in
lymphatic glands, that we can hope successfully
to employ this plan of cure.
58. When the evacuations procured from the
first passages, and from the kidneys and skin,
have no effect upon the tumours, and particularly
if the stomach and bowels seemed to support
their action with difficulty, they must be aban-
doned, and recourse be had chiefly to the more
direct means of cure. The local excitants, as
iodine, the sulphureous douches, frictions with
mercurial, camphorated, and terebinthinated lini-
ments, and the repeated application of blisters
for a short time, are only suited to the chronic
kinds of abscess, where little or no inflammatory
action exist. But these remedies should be watcli-
ed, lest they increase the heat and inflammato-
ry action of the external or superficial part of
the tumour, and thus occasion their external open-
ing.
59. In the majority of abscesses, it is requisite
to keep three facts in recollection: 1st, that the
inflammatory action in their parietes does not
cease on the formation of the purulent collection;
2d, that an abscess is generally a complication of
this inflammation, and of the retention of purulent
matter in the inflamed parts which formed it, the
inflammatory action being still present, although
in a somewhat modified state and grade, and still
continuing to form this matter; and, 3d, that the
existence of pus does not necessarily or materially
change the nature of the action which produced
it. The therapeutical indications to which these
facts necessarily lead are important, particularly as
they show, what, indeed, has been proved by expe-
rience, that antiphlogistic remedies, especially those
of local application, should not be laid aside with
the supervention of suppuration. In the majority
of cases, and particularly when increased heat of
the part still continues, this class of local remedies
should be employed with an energy in proportion
to the activity of the local symptoms. As long as
pain, redness, heat, and tension remain around the
abscess, so long should leeches, or other modes of
capillary depletion, directed to its vicinity, be had
recourse to, particularly if the state of the patient
offers no urgent indications against the practice.
ABSCESS — Treatment of.
Emollient and astringent applications should also
be constantly employed. These will generally
reduce the inflammation of the surrounding tissue,
favour the resolution of the parts not yet suppu-
rated, limit the quantity of the morbid secretion,
and favour the maturation of the abscess, so that
it may be opened with the best hopes of success.
In some cases, the use of these antiphlogistic mea-
sures will give rise to the absorption of the puru-
lent matter, even after this had been attempted to
no purpose by means of revulsives.
60. It should be recollected that the surfaces
of abscesses are the constant seat of two kinds of
action ; one of exhalation or secretion, the other
of absorption; and that whatever excites or irri-
tates them increases the former, and whatever
soothes or diminishes this irritation lessens it, arid
favours the latter action. This consideration should
lead us strenuously to adopt a continued antiphlo-
gistic and soothing treatment of the affected part,
until the thinning of the skin at the most promi-
nent part of the tumour indicates the necessity of
opening it.
61. In symptomatic abscesses, the treatment
should chiefly be directed to the primary seat of
disease; for as long as the mischief continues or
advances there, the purulent collection increases,
and diminishes as it subsides. Thus, the abscesses
that point near the anus or crural arch, in conse-
quence of disease of the vertebra?, will sometimes
disappear after the use of active means directed to
the original malady, and judiciously adapted to
the state of the patient.
62. Consecutive and spreading abscesses re-
quire a very ditferent management from that now
pointed out. These generally occur in persons
of an unhealthy habit of body, or who have been
weakened by acute disease ; or they are the
result of an adynamic or ataxic and spreading
inflammation occasioned by a specific or poison-
ous agent ; and they are not infrequently the
consequence of the inflammation of veins, or of
the presence of morbid secretions or purulent
matter absorbed into the circulation, (§§25 — 28.),
or of the transfer of irritation from a distant part.
But from whatever cause they may proceed, — and
they may, and occasionally do, proceed from
either of those sources, — deficient constitutional
energy, and vital resistance to the influence of
the exciting cause, with a marked disposition of
the structures to be invaded by it, and to partici-
pate in the morbid action it excites, are their con-
stant concomitants; requiring the energetic use
of those means which are the best calculated to
rouse the powers of the frame, to restore the de-
ficient tone of the capillary vessels, and to thus
enable them to form coagulable lymph, by which
the spread of the local mischief may be limited.
Instead, therefore, of having recourse to antiphlo-
gistic remedies, the state of local action, and of
constitutional power, requires a tonic, stimulat-
ing, and restorative treatment; conjoined with the
means best calculated to promote the functions of
all the abdominal viscera, so that morbid matters
may be eliminated from the circulating current,
and healthy nutritious elements conveyed into it;
and with a" pure air to perfect the changes which
it undergoes during respiration, and which arc
requisite to the continuance of the functions of
life. The treatment necessary in such cases is
fully detailed in the articles on Inflammation
of Veins, on Spreading Inflammation
of the Cellular Tissue., and on the treatment
of Animal Poisons.
63. 2d. Of opening abscesses. — When we fail
in procuring the absorption of the puriform mat-
ter, its artificial discharge will, sooner or later, be
required, when this can be accomplished. Certain
abscesses require a more immediate performance
of this operation than others, and more particu-
larly the following : — 1st, Abscesses proceeding
from the escape, into the substance of any organ
or part, of irritating secretions or excrementorial
matters, as the urine, or faecal substances. 2d,
Abscesses preceded by very acute inflammatory
action, and occurring in cellular or adipose struc-
tures, as the margin of the anus, the sides of the
neck, or the groins. 3d, Purulent collections
deeply seated, or confined under fascia? or aponeu-
roses. 4th, Abscesses formed in the parietes of
the splanchnic cavities, in order to prevent the
chance of their breaking internally. 5th, Ab-
scesses formed in parts through which large nerves
and blood vessels pass, and on which the puru-
lent matter occasions a painful and injurious pres-
sure ; as abscesses in the neck, and underneath
the sterno-mastoid muscle, at the top and inside
of the thighs and arms, &c. 6th, Abscesses which
embarrass the respiratory organs, and which press
upon the larynx, pharynx, or trachea, or which
endanger the integrity of those parts.
64. In all these the strict antiphlogistic treat-
ment will be requisite, unless they are of the dif-
fusive or consecutive kinds, with emollient appli-
cations, in order to limit the extent of the inflamed
parts, to diminish their size, and to hasten their
maturation ; and in many cases this mode of
treatment must be continued for a considerable
time after the discharge of the matter, in order to
limit or prevent its re-accumulation, and to pro-
mote the collapse and diminution of the parietes
of the abscess. The cases where it will be fre-
quently necessary to retard the period of discharg-
ing the purulent collection, are chiefly those in
which it is formed in the internal viscera, as the
liver, spleen, kidneys, lungs, &c. ; respecting
which I have treated fully under their appropriate
heads.
65. Chronic abscesses should be opened as
soon as it is shown that their absorption cannot
be accomplished ; or when they augment in bulk
under the discutient and derivative treatment.
Symptomatic abscesses also require to be opened,
when we find that the means which we have di-
rected to the original seat of disease fail of limit-
ing their extension, or lessening their bulk. Con-
secutive abscesses require to have their contents
immediately discharged, when their situation ad-
mits of this being done ; for the morbid state of
the matter thev sometimes contain, and the weak
vita] resistance opposed by the surrounding parts,
and by the constitution, favours the contamination
of the adjoining structures, and, indeed, of the
whole frame. But this intention can seldom be
fulfilled, owing to the seat of the purulent collec-
tion ; and, when it is put in practice, it should be
followed by as complete an exclusion of the at-
mospheric air as possible.
66. It does not come within the scope of this
work to notice, at this place, tUe ditferent modes
of opening abscesses, and the treatment with
which the operation should be accompanied and
ABSORPTION — as productive of Disease.
23
followed. This necessarily differs in every case ;
but that part of it which belongs to my province
is stated at the place where abscesses in the dif-
ferent viscera are discussed, and the means which
may he employed to procure the obliteration of
their cavities, the second intention of cure, are
noticed, with reference to abscess of each of the
important viscera and structures in wluch it is
liable to form.
BlBLIOBBAPHV. — Stahl, De Abscessu et Furunculo,
Hals, 171 I. — Lodwig,De Abscessu Latente, Lips. 1758,
4to. — Meyer, De Abscessu in Febribus, ice, Got. 1759.
— Schroeder, De Puris absque prezressa inflammatione
Origine, Got. 1766. — Bordenave, De Abscessu Abdominis,
tc.', Paris, 1774. — Frey, De Apostematibus, Lips. 1775.
— Darwin, Experiments on Mucilaginous and Purulent
Matter, Lilcbf. 1780. — Salmiith, De Diagnosi Puris, Got.
1783. — J. Hunter, On tbe Blood ami Inflammation, Lond.
— Home, Dissert, on tbe Properties of Pus, Lond. 1788.
— Justamond, Versuch. ub. d. Entzundunz. Air., Leip.
1790. — Ifidchind, Allgem. Theoried. Entzundungen,
Leip. 1791. — Dupuy, Sur les Abces, ou Tumeurs pu-
rulentes, Paris, 1804. — Lassits, Patbologie Cbirurgi-
cale, t. i., Paris, 1809, 8vo. — Pearson, Observat. on Pus,
Philo,oph. Trans., Lond. 1811. — Rust, Uber Absuesse, in
dessen Mazazin, b. i., Berl. 1816. — Thomson, On Inllaiu-
mation, Edin. 1823, ch. 9. — Heurthloup, In Diclionnaiie
des Sciences Medicales, t. i. et t. viii. p. 431. — R'vhtcr,
art. Abscess, Encvclopad. Worterbucn der Mediriniscbcn
Wissenschaften. b. i., Berl. 1828. — Rotor, art. Abcis, in
Dictionnaire de Medecine, t. i p. 4. — Dupuytren, art.
Abce;, in Dictionnaire de Medecine et de Cbirurg. Pra-
tiques, t. i., Paris, 1829.
ABSORPTION. Syn. Absorptio, Lat. Absorp-
tion, FY. Die Einsaugung, Ger. Assorbim-
ento, Ital.
Classif. General Pathology and
Therapeutics.
This is one of the most important functions in
the system, and one of the most frequent channels
through which disease is caused, perpetuated, or
removed. As to each of these relations it requires
a brief notice.
1. Of Absorption in relation to the
Causation, Perpetuation, and the Re-
moval of Disease. — The importance of en-
tertaining accurate ideas as to the channels through
which noxious agents affect the system, must be
manifest. Without them, many of our pathologi-
cal doctrines must be erroneous, and the thera-
peutical indications founded on them worse than
useless: on the other hand, just views as to the
nature and extent of the causes which operate
through this medium, give rise to the most im-
portant inductions, — the chain of morbid causa-
tion is traced without interruption, the nature of
pathological conditions is more accurately ob-
served, and ultimate effects are recognised in
due connection with remote causes. The prac-
tical advantages which accrue are great: pro-
phylactic measures are based on sound princi-
ples; remedial agents are directed with precision;
and the physician prescribes in a spirit of rational
induction, instead of blind empiricism.
2. The agents which affect the system inju-
riously through the medium of absorption consist,
first, of those which are external and foreign to
the body, and act upon it only occasional , or
under certain circumstances; and, secondly, of
those which are generated in the body itself, and,
when carried by means of absorption into the
current of circulation, produce very important
effects. The former rank among the primary
causes of disease; the latter are themselves the
result of disease, but become important seconda ry
causes, perpetuating and generally increasing its
severity. The first class invade the system on the
mucous and cutaneous surfaces, — the skin, the
lungs, the alimentary canal, &c: the second class
form in the parenchyma or texture of organs
and parts, or are generated on secreting surfaces,
whence they are absorbed into the circulation.
On each of these F shall oiler a few remarks.
3. 1st. Of absorption on the skin in relation
to the pro hid ion and removal of disease. — a.
That disease frequently proceeds in this way is
evinced by certain contagious and chronic affec-
tions of the skin itself: that it is possible to produce
various derangements, by applying to it several
active agents, which affect this surface no further
than in being absorbed from it, may be proved
by direct experiment. But it is chiefly when the
skin is deprived of a portion of its cuticle, how-
ever minute, that we perceive affections produced
through the medium of cutaneous absorption.
Several eruptive and contagious diseases are
familiar examples of this; and the majority of
deleterious agents produce a most decided effect
when applied to the skin thus exposed.
4. b. The same channels through which dis-
ease invades the system, are often the most suitable
through which to counteract or remove it. This
is shown by the treatment of syphilis; by the use
of baths, lotions, fumigations, and inunctions in
cutaneous and visceral affections; and by the
employment of various remedies to the skin, which
are partially absorbed from it into the system.
When the skin is deprived of a portion of its
cuticle, it absorbs rapidly many of the most active
agents employed in medicine; and it is thus ren-
dered one of the most eligible situations to which
we can direct our plan of cure. Thus, when the
stomach will not retain the sulphate of quinine,
it may be efficaciously administered to the de-
nuded cuticle; or when we wish to produce an
anodyne effect upon the system, or to assuage
violent pain, the preparations of morphine, as the
acetate, may be applied in this way. And in
various diseases, when the function of deglutition
is lost, or the mouth cannot be opened, certain
active remedies may be thus administered; more
especially those which operate their effects after
having been absorbed into the circulation. Even
purgatives, as the croton oil, and elaterium, some
preparations of iodine, striebnine, prussic acid,
tartar emetic, &e, if judiciously employed in
this way, will be often productive of advantage,
and are not infrequently required to be thus pre-
scribed.
5. 2d. Of absorption from the lungs in rela-
tion to the causation and removal of disease.—
a. There are very few, if indeed any, of the nu-
merous maladies which are usually denominated in-
fectious, that are not caused through the medium
of the lungs. And, though the greater proportion
of them are most probably induced from the
morbid impression which their exciting causes
make upon the nerves supplying this organ, yet
several of them are also, more or less, occasioned
by the absorption of the cause itself into the cir-
culation, and by its influence upon the blood, and
the nervous and vascular systems. Probably,
also, certain other causes of disease, of no mean
importance, particularly marsh miasmata, and
noxious animal exhalations, act directly upon the
organic nerves of the lungs, and on the blood
itself, through the medium of absorption. We
24
ABSORPTION — its Pathological Relations.
have reason, moreover, not only to infer that the
more material causes of disease are absorbed from
the surface of the lungs, when inhaled into them
with the atmosphere, in the moisture of which they
are dissolved, or otherwise combined ; but also
that the foreign gases, which sometimes mix with
the air, act in some measure through the same
channel.
6. The organization of the respiratory surfaces,
the nature of the circulating functions on these
surfaces, and the more immediate relation subsist-
ing between the ah in contact with, and the blood
circulating in, them, will readily explain the rapi-
dity with which foreign matters floating in the
atmosphere are frequently conveyed into the cir-
culation. Besides, we have strong reasons to infer
that several of the gases, and of the soluble sub-
stances which float in the air, are carried directly
into the blood from the surface of the lungs, with-
out passing along absorbent vessels. The experi-
ments of Professor Mayer, and of Drs. Law-
rence and Coates, as well as those of MM.
Segalas, Fodera, &c, fully confirm this in-
ference; whilst those performed by MM. Magen-
die, Seiler, Ficinus, Tiedemann, Gme-
lin, and several others, show, that even in the al-
imentary canal, and especially when capillary ves-
sels are divided in any of our tissues, the function
of absorption is not confined to lacteal or lymphatic
vessels, but is frequently extended to the venous
capillaries, which, in respect of certain substances
particularly, chiefly perform this function. Hence
I may conclude that foreign substances dissolved
in, or combined with, the moisture of the air, or
mixed with this fluid, may, when inspired, be car-
ried from the surface of the lungs into the blood,
independently of the absorbent vessels ; although,
doubtless, these vessels perform their appropriate
functions in this as in other parts of the body.
7. 6. The rapidity of absorption in the lungs, and
the ready access to the blood which foreign mat-
ters find through them, are sufficient to -vindicate
then importance as channels through which to
convey our means of cure, not only in those ma-
ladies to which they are liable, but also in a num-
ber of diseases affecting the whole frame, or par-
ticular parts of it. General suggestions on this
subject are all that can be advanced in this place :
the particular recommendations for its use are
given in their appropriate places. Those gaseous
bodies which possess active medicinal powers; all
those remedies which are more or less volatile, or
are soluble in aqueous vapour; and many medical
substances which may be rendered volatile or
soluble in water, when combined with other bod-
ies that do not destroy altogether their remedial
powers, may be prescribed advantageously through
the medium of the lungs. Chlorine, the nitrous
oxide, dilute oxygen gas; the vapour of iodine, or
the sulphuret of iodine; the vapour of turpentine,
camphor, of the common, the aromatic, or the
pyroligneous vinegars; tar vapour; the chlorides or
chlorurets of lime or of soda; aqueous vapour hold-
ing the active principles of opium, henbane, hem-
lock, belladonna, digitalis, colchicum, &c. in so-
lution ; the volatile principles of various salts,
the aroma of a number of vegetable bodies, — all
exert powerful effects upon the system when ad-
ministered in this way.
8. c. Through this channel a number of fevers,
especially those which are characterized by great
depression of the powers of life, or which rapidly
pass into this state ; various chronic atiections of
the lungs themselves, which are unattended by
acute inflammation, but consist chiefly of a mor-
bid state of the respiratory nerves, and are accom-
panied with spasm, and a morbidly increased
secretion; the different kinds and forms of as-
phyxy; the diseases which threaten life by inter-
rupting the respiratory functions ; and various
maladies in which the blood is vitiated, and where
it becomes important to act in a direct and de-
cided manner on this fluid, and on the circulat-
ing organs generally, may be successfully com-
bated.
9. d. The knowledge that we thus acquire re-
specting the channels, through which the causes
of many diseases invade the system, and the re-
medies for removing them may be efficaciously
administered, furnishes us with important indica-
tions as to the employment of prophylactic mea-
sures, and rational plans of regimen and hygiene.
Miasma) or contagious fevers furnish us with nu-
merous opportunities of proving the justness of
these views. Observation shows us that the
causes of this class of disease act upon the system
chiefly from their presence in the air we breathe:
it further enables us to decide that these causes
invade the system chiefly through one of two, or
perhaps by both, routes; viz. by the nerves sup-
plying the respiratory organs, or by the partial
absorption of the causes themselves, from the
pulmonary mucous surface, into the circulation.
From the same source, or from the collateral evi-
dence of experiment, we know that foreign sub-
stances do not so readily enter the circulation,
when its functions proceed with energy, and the
vital resistance is perfect, as when they act feebly
and imperfectly; and that the depressing causes
of disease have less power over the nervous in-
fluence of the respiratory organs, and of the system
in general, when the vital actions which take
place in the lungs are performed with due acti-
vity. The same sources of observation make us
acquainted with the important facts, that the dilu-
tion of the atmosphere, which contains the causes
of febrile diseases floating in it, by free ventil-
ation; that the destruction, or neutralization, or
counteraction, of these causes, by the evaporation
of certain disinfectant and stimulating agents; and
that a due energy of all the vital and secreting
functions, with an equable state of the mental
powers and manifestations, and with a steady con-
fidence ; are the most successful means of prevent-
ing the attack and diffusion of those maladies.
10. By combining these facts as to the source,
mode of operation, and methods of counteraction,
of the chief causes of a most important class of
maladies, and by directing the measures they sug-
gest as fir as may be according to the peculiari-
ties of individual cases and diseases, we are thereby
enabled to furnish persons, and even whole com-
munities, with instructions and means calculated
either to counteract or to lessen the dangers to
which they are exposed.
11. 3d. Of absorpt ion from the alimentary ca-
nal, in connection with the causation of disease
— a. It may be received as a pathological axiom
that the rapidity and extent with which deleterious
matters are absorbed fromjhe digestive mucous
surface, as well, indeed, as from the respiratory,
and other organs of the body, are nearly in pro-
ABSORPTION — its Relations to Disease.
25
portion to the depression of the nervous ener-
gies and vital resistance! of the system. The
truth of this is evinced in respect not only of
the actions proceeding on the mucous surfaces,
hut also of those taking place in the different
organs and structures. It is necessary to allude
here to the numerous agents which cause, coun-
teract, or remove disease, by their being absorb-
ed from the alimentary canal. Whilst many
agents produce their effects chiefly by modifying
the states of the nerves and mucous tissue of
this canal, others act principally from being ab-
sorbed, either by the lacteals, or by the venous
radicles, and carried into the circulation ; and a
still more numerous class seem to operate through
both channels, impressing immediately the nerves
and tissues to which they are applied, and subse-
quentlv being absorbed into the blood, where they
produce important effects not only upon this fluid,
and on the vascular system, but also upon the
functions of various secreting organs, especially
those by which they are eliminated from the body.
12. A very large proportion, therefore, of the
ingesta, whether alimentary, medicinal, or poison-
ous, thus acting upon the system chiefly through
the medium of absorption, the importance of di-
recting a considerable portion of attention to this
function in our pathological investigations, as well
as in the appropriation of medicinal means, must
be apparent. Besides these more obvious rela-
tions of the subject, there are others which have
been either imperfectly investigated or entirely
overlooked. To these I can merely allude: but.
amongst the most interesting are the absorption of
unwholesome-and imperfectly digested chyle from
the intestinal surface ; the absorption of a portion
of the vitiated secretions which occasionally accu-
mulate in the alimentary tube, particularly in the
crecum and cells of the colon ; the absorption of
some part of the fa?cal matters, when they are
long retained in the above situation, as evinced by
the sensible qualities of the perspiration, foul state
of the skin, &c.,or of the obstructed and accumu-
lated urinary secretion, as proved by similar phe-
nomena ; the passage of bile into the circulation,
when it has been retained in the liver, the biliary
ducts, or gall-bladder, from torpor or obstruction
of these parts, or when it is secreted in large
quantity, and does not readily pass oft* with the
egesta. All these are very fruitful sources of
disease ; and, although generally connected with
some degree of pre-existing disorder, or of torpid
function, they are often the chief aggravating
causes of many of the maladies we are called
upon to treat, from the constitutional and visceral
disturbance they occasion and perpetuate.
13. There are few disorders which implicate
the digestive and ch ylopoietic organs, and very few
febrile diseases, which do not, at some period of
their course, evince signs of the absorption into
the circulation of a portion of the morbid secre-
tions or fecal fluids retained in the alipientary
canal, when due evacuations are not practised.
Therefore, besides the other effects produced by
medicines of this class, the due evacuation of
these secretions and fecal matters from the prima
via is one of the best offices they perform.
14. b. It Is unnecessary to do more than to
allude to the advantages that accrue to the scien-
tific practitioner from some knowledge, — although,
in the present state of medicine, necessarily im-
perfect,— of the remedies which act by beinw ab-
sorbed, either altogether or in part, from the ali-
mentary canal. Most of those substances which
are found by experience the most efficacious in
promoting the actions of the different secreting
viscera, and in producing a marked and perma-
nent change of the general state and functions of
the economy, operate after having been absorbed
into the circulating current, and conveyed through
this channel to vital and secreting organs; and,
although, during the healthy performance of the
secreting functions, or whilst the vital energies
are not far reduced, these substances seldom accu-
mulate in the blood so as to be detected in it by
chemical analysis, owing to the balance which is
preserved between the rapidity of absorption and
the activity of elimination, yet their passage
through it is proved by the fact, frequently ob-
served in regard of all of them, of their being
found in the secretions of the eliminating or de-
puratory organs. This fact was established by ex-
periments performed by myself, — some of them
as far back as 1819, — and published in several
periodicals in 1821 and 1S22.
15. 4th. Of absorption from- diseased organs
and structures. — a. When morbid secretions are
generated, or accumulated in any organ or texture,
or when any part is changed in such a manner as
to secrete a matter different from the healthy con-
stituents and fluids of the body, the matter formed
is generally, after a while, absorbed into the cir-
culation, and contaminates, in a more or less
marked manner, according to its nature, the other
fluids, and the soft solids, and thereby at last de-
stroys life. Illustrations of this procedure are fur-
nished us in the pathological history of internal
and deep-seated abscesses ; in some morbid states
of the uterus; in scirrho-cancer, fungous haemato-
des, and other malignant diseases. The celerity
with which the absorption of the morbid matter
and the contamination of the frame proceed, is
generally according to the principle already recog-
nized (§ 9.), — in proportion to the diminution of
the vital energy and resistance of the constitution-
al powers.
16. b. The commencement of the contamina-
tion can scarcely be determined by an apprecia-
tion of symptoms : but the experienced observer
will readily recognize, in the colour of the surface
of the body; in the state of the heart's action, and
of all the circulating functions, as well as in the
blood itself; in the failure of the energies of life ;
in the morbid condition of the nervous functions
and of the powers of the stomach, and indeed of
the whole digestive canal, sufficient proofs of the
early, as well as of the advanced progress of dis-
ease, arising from the absorption of morbid mat-
ters from the primary seat of morbid action, and
the consequent vitiation of the circulating fluids,
of the soft solids, and of the secretions and excre-
tions of the body. (See Art. Blood.)
17. In many of the more chronic diseases
which either commence with or terminate in the
malignant state, this contamination is frequently
first evinced by the tumefaction and pain of ad-
joining lymphatic glands, owing to the irritation
produced by the morbid fluid conveyed into them:
the inflammation or obstruction thus produced in
them becoming an obstacle to the rapid transit of
the morbid matters from the original seat of dis-
ease into the circulation. But in many cases this
ABSTINENCE— Morbid Effects of.
is an insufficient barrier ; and in others, these mat-
ters seem to pass onwards, either without circu-
lating through lymphatic glands, or without occa-
sioning irritation, obstruction, or inflammation in
them; or are almost directlj conveyed into the
venous circulation. Whatever may be the chan-
nel of conveyance, there can be no doubt of the
fact — the practical importance of which is very
great — that the rapidity of the absorption of mor-
bid matters, and extent of their hurtful effects on
the constitution, are in proportion to the depression
of the vital energies of the frame, — this depression
being frequently the cause of their absorption, par-
ticularly in respect of puriform fluids; or at least
the circumstance which more especially favours
its occurrence, and the rapidity of its progress.
BiuLiouii vphv. — G-asparJ, Sur les Maladies Putrides,
Ur.. in M. .Vij n.'i 'sJourn. de Physiol., t. ii. — Copland,
in Lonlon Medical Repository, vol. xvii. for May, 1822 ;
and in his Notes and Appendix to M. RihcraiuVs Elements
of Physiolojv, Loud. 1824. — M:igendie, art. Absorption,
in Diet, defied, et, Chiiutg. Prat., t. i., Paris, 1829.—
Fodera, Archive, Gener. de Med., t. ii. p. 57. —Piullct,
Revu» Mel.. 182U, t. i. p. 1(55.
ABSTINENCE. Its Morbid Ejects. Syn. Ab-
stinentin, Lat. Astinenza, Ital. Die En-
thal tuns;, Ger. Abstinence, Fr. Starvation
from Hanger.
Classif. I. Class, V. Order {Author,
see Classification in the Preface.)
1. It does not come within the scope of this
work to enter upon the consideration of the thera-
peutical relations of abstinence; but that the prac-
titioner should be acquainted with the states of
disease which it occasions, and with the best means
of treating it, Ls extremely important ; more espe-
cially as, when it is too rigidly enforced during
the treatment of several diseases, it not unfre-
quently gives rise to effects of a serious nature,
which not infrequently have been mistaken for
the spontaneous course of the malady.
2. Of the Morbid Effects of Absti-
nence.— Abstinence has been long employed as
a means of cure, and generally as a part of the
antiphlogistic regimen, in a very great number of
diseases, particularly in fevers and inflammatory
affections. Very great difference, however, exists
both among writers and practitioners as to the ex-
tent to which it should be carried, and the mala-
dies in which it ought to be prescribed. As to its
applicability to the class of diseases now noticed,
there is no doubt : but in disorders of debility, or
of irritation merely, particularly those which occa-
sionally simulate chronic inflammation, and in va-
rious nervous affections, it is extremely injurious;
and I believe that it has been carried to a hurtful
extent in many of these affections, particularly
by Broussais and his followers, as indeed has
been recently well shown by MM. Piorry and
Barras. A case of this description, which had
been long under the care of M. Broussais, very
lately came before me, with many of the morbid
effects of this practice, which had been carried to
a hurtful extent. There can be no doubt, how-
ever, that it is extremely beneficial, when care-
fully watched and regulated, in many of the dis-
eases of the stomach and its associated viscera ;
but the fact is equally incontrovertible, that it will
often produce effects very nearly resembling those
for which it has been prescribed. The importance,
therefore, of keeping these effects in recollection,
when treating several diseases, particularly those
of irritation and debility, must be apparent.
3. In appreciating the usual effects of abstin-
ence it is extremely requisite to be aware of two
things: 1st, That the effects vary with the state of
the patient at the time that abstinence is endured;
2d, that they differ materially according to the sud-
denness with which it is entered upon, the extent
to which it is carried, and the circumstances with
which it is associated. By very corpulent and
plethoric persons, abstinence is generally borne
well for a long period, and by those labouring un-
der febrile or inflammatory excitement; and it is,
in them, one of the most necessary means to dimi-
nish the one and lower the other. In these, par-
ticularly the latter, total abstinence may be en-
dured for many days; whilst, if carried to the
same extent in healthy persons, its effects would
be fatal, or nearly so. Abstinence, also, is longer
endured by persons of the middle or matured
epochs of life, than by those of an early age.
4. That the absolute or sudden deprivation of
food should be productive of more rapidly serious
effects is very obvious; but it is not so well known
that there are circumstances, which modify the
effects of the less absolute states of abstiuence, and
which, when thus combined, give rise to very im-
portant and dangerous diseases. In order to place
the subject more clearly before the reader, I will
first notice the effects of abstinence simply, and
unassociated with other causes of disease; and
next, the morbid conditions, which its association
with certain influential agents usually occasion.
5. 1st. The morbid effects of simple abstin-
ence. — Keeping in recollection the modifications
depending upon the extent to which deprivation
of nourishment is carried, and the age and state of
the person at the time of its adoption, I may brief-
ly describe the morbid effects of abstinence as fol-
low:— Paleness and languor of the countenance;
muscular debility and emaciation; a weak and
small pulse; thirst; at first quickness of intellects,
constipation, and flaccidity of the muscles. To
these succeed increased frequency of pulse, pal-
pitations, alternating with leipothymia, or even
full syncope; headach or delirium; flashes of light
before the eyes; tinnitus aurium; slight amaurosis;
parched state of the throat, and thirst; pains in
the stomach; great wakefulness, followed by de-
lirium, sometime*, mild, but in other cases furious,
or at first mild or muttering, and afterward strong
or furious; sinking of the animal heat, or alter-
nate coldness and burning in parts of the body;
and lastly, morbid sensibility of the organs of
sense and surface of the body, and greatly de-
pressed temperature, followed by insensibility, stu-
por, or coma, terminating in death.
6. It is obvious that the severity and duration
of these symptoms will vary in- different cases,
according to circumstances peculiar to each.
But it is not so well known that they will be
actually produced by pursuing a too rigid absti-
nence in the treatment of various diseases, and
particularly when the nature of the disease is mis-
taken: as when the irritative symptoms frequently
attendant upon diseases of debility, or on nervous
affections, are viewed as resulting from inflam-
mation. Many cases have occurred to me in the
course of practice, where the antiphlogistic regi-
men, which had been too rigidly pursued, was
itself the cause of the very* symptoms which it
was employed to remove. Of these symptoms, the
affection of the head and delirium are the most
ACNE.
27
remarkable, and the most readily mistaken for an
actual disease requiring abstinence for its removal.
A ease of this description lately occurred to me.
A professional man was seized with fever, for
which a too rigid abstinence was enforced, not
onlv during its continuance, hut also during con-
valescence. Delirium had been present at the
height of the fever, and recurred when convales-
cent. A physician of eminence in maniacal cases
was called to him, and recommended him to he
removed to a private asylum. Before this was
carried into effect, I was requested to see him.
A different treatment and regimen, with a grad-
ual increase of nourishment, were adopted, and
hi! was well in a i'cw days, and within a fortnight
returned to his professional avocations.
7. The morbid appea ra nces observed after fatal
cases of deprivation of food possess some interest.
The most remarkable are the emaciation and
absorption of every particle of fatty matter : the
paleness, flabbiness, softening, and emaciation
of the voluntary muscles, and of the substance
of the heart ; an exsanguined and pale state
of the viscera ; slight atrophy of the liver and
spleen ; diminished size of the stomach and
colon ; and particularly the increased vascularity
of the brain, and sometimes of the membranes
also, compared with the other viscera. It would
seem that a very large proportion of the blood
continues, as in many cases of great vascular de-
pletion, to be sent to the brain to the very last.
This is obviously owing to the pressure of the
air on all parts of the body, from which the
encephalon is guarded by its unyielding case.
In addition, also, to the vascularity of this part,
a limpid serous effusion between the membranes,
or in the ventricles, is sometimes met with.
8. 2d. Of 'the morbid effects of abstinence when
it is associated with other hurtful agents. — These
effects are occasionally presented to medical men
under a variety of circumstances, and from a
varied combination of causes ; but in the great
majority of instances they result from deficiency
of food merely, rather than from a rigid abstin-
ence, conjoined with the depressing influence of
cold or insufficient clothing, great or continued
exertion, or with a moist and unwholesome at-
mosphere. Thus we find the association of these
causes, particularly insufficient or unwholesome
food, laborious exertion, mental depression, a
moist, cold, or unwholesome atmosphere or local-
it)', not nnfrequently give rise to purpura hemorr-
hagica, scurvy, scorbutic dysentery or diarrhoea,
low or typhoid fevers, affections of the brain and
nervous system, emaciation, with chronic ulcera-
tions, &c. — effects which have received a partic-
ular notice in their respective articles.
9. The best illustration of the effects of this
association of other agents with a continued defi-
ciency of food is furnished by the diseases which
appeared a few years ago in the Milbank Peniten-
tiary. The prisoners confined in this prison were
suddenly put upon a diet from which animal food
was nearly altogether excluded, excepting in as
far as it entered into the composition of a weak
soup. They were at the same time subjected to
a low grade of temperature, to considerable ex-
ertion, and confined within the walls of a prison
situate in the midst of a marsh which is below
the level of the adjoining river. The conse-
quences were, first, loss of colour, of flesh and
| strength ; subsequently, diarrhoea, dysentery,
scorbutic dysentery, scurvy ; and, lastly, low
[ ataxic or adynamic fevers, or headach, vertigo,
convulsions, delirium or mania, apoplexy, &c.
The smallest loss of blood produced syncope or
leipothymia, and fatal results. Yet, in the great
majority of the fatal cases, independently of the
lesions observed in the mucous surface of the
digestive tube, or in other situations, increased
vascularity of the brain and its meninges, fre-
quently with effusion of fluid in the ventricles or
between the membranes, was found upon exam-
ination after death.
10. The Treatment of the morbid effects
of abstinence is very obvious, yet considerable
care is necessary to its successful issue in very
urgent cases. Nourishment shouid be adminis-
tered cautiously, in a very small quantity at a
time at first, but frequently. It ought to be
bland and farinaceous : animal food may be en-
tered upon subsequently, and the quantity grad-
ually increased. The animal warmth shouid be
promoted, at the same time, by the usual exter-
nal means — by frictions and warm applicatious ;
and the bowels assisted by the occasional use of
bland enemata. Soups may be allowed early in
the treatment, but in a small quantity at a time.
Milk is often prejudicial, unless diluted and made
into gruel with some of the farinaceous articles of
food. Internal stimulants are seldom required,
unless when symptoms of cerebral or nervous
irritation exist, when they may be given ; par-
ticularly the preparations of ammonia, theathers,
camphor, vegetable bitters and tonics, at first in
very moderate doses, in conjunction with small
quantities of an anodyne, as the extract of hop.
the extract of hyosciamus or of opium, the pare-
goric elixir ; and by warmth, frictions, and stim-
ulating applications to the cutaneous surface and
lower extremities. These means will generally
succeed in removing the effects of simple abstin-
ence whilst they admit of removal. The treat-
ment of the effects resulting from the conjunction
of other causes with the one now discussed, is
considered under their respective heads.
Bibliography.— Cm-rie, Medical Reports, 4lo ed.,voI.
i. p. 304. — Willan, Miscellan. Works, by A.Smith, p. 437 !
— BaiTas, Traiie sur les a tatralgies el le» Enteralgies, &.c,
3d ed. Svo, Paris, 1829.— Piorry, Procede Operatoire dan,
I' Exploration des Organes, kc. &c, 8vo, Paris '831, p.
368.— P. M. Latham, On the Diseases in the Milbank
Penitentiary, 8vo, Lond. 1824.— Andral, Precis d' Ana-
tom Patholog., t. ii. p. 769.— Rattan, Diet, de Med. t. i.
p. 154.— Ch. Londt, Diet, de Med. et Chir. Prat., t. i. p.
103. Collitrd de Martigny, hi Magendie's Journ. dc
Physiol., &.C., t. viii. p. 152.
ACNE. '.•-//?! ■»;. Derived, according to Cassius
(JVat. et Med. Quest., &c, Prob. 33.), from
'axiitj. Syn. a7or6og, Gr. Varus, Lat. Psy-
dracia Acne, Sauv. Gvtta Rosea, Darwin.
lonthus, Good. Bouton, Couperose, Fr. Die
Finn e n, Ger. Carbuncle, Stone-pock, Whelk.
Classif. 3. Class, Diseases of the San-
guineous Function ; 2. Order, Inflamma-
tion ( Good) ; 7. Order, Tubercles ( Will-
an and Bateman). IV. Class, IV. Or-
der {Author, see the Classification).
1. Def. Hard, inflamed, tubercular tumours,
suppurating very slowly, occurring chiefly in the
face ; sometime*, also, on the neck and shoulders
2. One or more, sometimes a number, of these
tubercles appear, generally in succession, in the
face, and sometimes on the neck, shoulders, and
28
ACNE — Simplex — Indurata — Rosacea.
breast, but never lower ; remain permanent for
a considerable time ; and suppurate slowly and
imperfectly, leaving a dark or livid mark, which
graduallv disappears. They occur chiefly in per-
sons of the sanguine temperament ; commencing
at the period of puberty, and generally disappear-
ing after thirty or thirty-five. They are common
to both sexes, but are most frequent and numer-
ous in the male sex.
3. This is one of the most constant and unva-
rying in its characters of any of the affections of
the skin ; but writers upon this class of diseases
dilfer widely in respect both of its particular cha-
racter and seat. Willan, Plenck, Bate-
man, and Thomson consider it a tubercular
affection ; whilst Alibert, Biett, and Rayer
view it as pustular. 1 believe, however, that both
opinions are in some respects correct ; and that
in certain forms or states of acne the tubercular
change is predominant, little or no suppuration
taking place, but a state of slow inflammation
giving rise to a continued exfoliation of the cuticle,
or formation of thin scabs on their apices ; and
thus they slowly disappear ; whilst in others the
pustular character is very distinct, but always
preceded by the characteristic tubercular hardness.
This affection may be viewed, therefore, as form-
ing an intermediate link between the tubercular
and pustular eruptions.
4. In respect of the particular tissue in which
this disease is seated, some dill'erence of opinion
also exists. The greater number of writers on the
pathology have considered this disease to be
seated in the proper structure of the cutis vera ;
many of them admitting, at the same time, an
affection of the sebaceous follicles very nearly
resembling it. Mr. Plum be, however, attributes
it entirely to obstruction and chronic inflammation
of these follicles. I believe that this opinion is
too restricted ; and that, whilst one form of acne
evidently depends upon this cause, others are
essentially disease of the cutis vera.
5. Spec. I. Acne Simplex, Simple Acne.
Syn. Gutta Rosea Hereditaria, Darwin.
Dartre Pustuleuse Miliare, Alibert. Ion-
thus varus simplex, Good.
Simple acne affects most frequently young sub-
jects, at the period of puberty, and particularly
females. They generally appear on the forehead,
shoulders, and upper part of the thorax, and are
liable to recur at the menstrual periods, especially
in cases of dysmenorrhoea. Many of these vari
do not proceed to suppuration, but slowly subside.
They are very commonly developed in succes-
sion ; commencing with small, hard, and inflamed
tubercles, of the size of a pin's head. These
continue to enlarge for three or four days, and the
inflammation becomes more apparent. In seven
or eight days they have reached their greatest
size. They are then dark red, smooth, prominent,
shining, hard, and slightly painful to the touch.
After two or three days a small speck of matter
appears on the apices of some of them ; and
when these break, a thin humour exudes from the
tubercular induration, and dries on its surface,
forming a thin scab, which adheres firmly ; but,
after a few days, is loosened at the edges, and
falls off; the tubercular hardness and livid redness
gradually subsiding, and disappearing after three
or four weeks.
6. In some persons this eruption recurs fre-
quently at short intervals, the vari being more or
less numerous ; in others it is more extensive, and
never altogether disappears, although it is more
troublesome at one time than another. When
the vari are numerous, many of them undergo no
suppuration ; but the sebaceous glands are often
excited, giving the skin a greasy appearance. In
many of these cases, several of the vari assume
the characters of the next species.
7. Spec. II. Acne Indurata, Stone-pock.
The tubercles are larger, more indurated and
permanent than the foregoing ; and are apparently
the consequence of a slower and more deep -seated
inflammation. They often appear in considerable
number, of a conical or oblong-conoidal form ;
some of them assuming a roseate hue, and tend-
ing to suppuration at their apices ; others remain-
ing in a hard, elevated state for a very longtime,
without any appearance of the suppurative pro-
cess, or disposition towards it. In some cases,
two or even more of them coalesce, and occas-
ionally suppurate at their respective apices ; but
one only may undergo this change. As they
continue they become more purple or livid, par-
ticularly when they have no tendency to suppu-
rate. When they experience this process, the
same process of scabbing and exfoliation, already
described (§ 5.), is gone through ; but it some-
times happens that when they experience any
irritation they may suppurate a second time. As
they very slowly subside, they leave a purple or
livid discoloration, and, occasionally, a slight de-
pression, which is long in wearing oft", and which
sometimes never altogether disappears.
8. This species of acne generally is most fre-
quent and numerous along the rami of the lower
jaw, on the temples, the nose, and cheeks ; also
on the back and neck. They are frequently ac-
companied by a greasy state of the skin, from
an excited state of the cutaneous follicles ; are
commonly sore and tender to the touch ; and,
when numerous, are in every stage of progress,
giving the surface a spotted and variegated ap-
pearance,— owing to the prominence and redness
of some at their commencement, to the yellow
points in those that are suppurating, to the scaly
crusts covering those which have undergone this
process, to the lividity of those that have exfo-
liated or are subsiding, and to the discoloured
depressions which others have left after them.
9. The general health seldom suffers mate-
rially from either the simple or the indurated
acne, excepting as far as regards some pre-existing
and concomitant disorder of the digestive func-
tions. If fever, or acute disease, attack persons
affected with these eruptions, the vari generally
disappear ; but they frequently also re-appear
upon its subsidence,, becoming in some respects a
critical eruption.
10. Spec. III. Acne Rosacea, Rosy-drop.
Syn. Gutta Rosea, Auct. var. Gutta Rosea
Hepatica, Darwin. Ionthtis Corymbifcr,
Good. Dartre Pustuleuse Coupe rose, Ali-
bert. Goutte Rose, Couperose Rougeurs, Fr.
Kupferbandel, Roth-nase, Ger. Carbuncled
Face, Eng.
The first and second species, described above,
might have been, with propriety, viewed as varie-
ties of the same species ; but this is a very dis-
tinct species from the preceding. It consists of
small, slowly suppurating tubercles, accompanied
\CNE — Punctata — Syphilitica.
Of)
with a shining redness, and an irregular granu-
lated appearance of the skin of the part aileeted.
This species commonly appears first at the end of
the nose, and afterwards spreads from hoth its
sides to the cheeks, which it never altogether
covers. At first it is not uniformly red ; hut is
p&le in the morning, and intensely red whenever
the patient is excited or heated, and particularly
after dinner, or drinking wine or spirits. After
some time the texture of the cuticle; is gradually
thickened, and its surface granulated and varie-
gated by the ramifications of cutaneous veins,
and the suppuration of small, prominent vari,
which successively arise in different parts of the
nose and face.
11. This species of acne seldom appears before
the age of forty , excepting in those addicted to the
immoderate Use of vinous or spirituous liquors, or
who possess great hereditary predisposition to it.
In advanced life, or in the worst of these cases,
it sometimes spreads to the greater part of the
face, even to the forehead and chin. The nose
usually becomes very tumid, and of a fiery red
colour, and sometimes is enlarged to an enormous
size. The nostrils, in these cases, are generally
distended, and their alse often fissured and divided
into lobes. In advanced age, this species of acne
becomes more livid ; and if any of the tubercles
suppurate, they often ulcerate, and are indisposed
to heal. In younger persons, who are attacked
chiefly from hereditary disposition, it is often ac-
companied with irregular red patches on the face,
which are often smooth, devoid of tubercles, and
accompanied with occasional slight exfoliations
of the cuticle. These patches are extended, or
aggravated, by intemperance in food or drink.
12. Spec. IV. Acne Punctata, Maggot
Pimple. Syn. Crimones, Auct. var. Punclee
Mucosa, Darwin. lonthvs Varus puncia-
tus, (>ood. Der Gries, Ger. Tannes, Fr.
Grubs, Eng.
This is, in my opinion, the only species of acne
which is seated in the follicular glands ; and, al-
though often observed as the only form of erup-
tion, it also is frequently found intermingled with
the species already described, particularly the
first and second. It consists of a number of
black points, surrounded by a very slightly ele-
vated border of cuticle, proceeding from con-
creted sebaceous matter accumulated in the glands
and their ducts, whence it may be squeezed out in
a vermicular form, the external extremity being
dark from its exposure. In consequence of the
accumulation and distension, these glands some-
times become inflamed, and give rise to small
tubercles, with minute black points in the centre
of their external surface. These tubercles sup-
purate partially, as the preceding, whilst others
remain stationary for a considerable time, and
several are distended without even being in-
flamed. They are not infrequently mixed with
tubercles without the black pnnctae, which are
evidently owing to a similar obstruction, and to a
more complete closure of the outlet of the ducts.
In this species of acne the accumulated secretion
may be squeezed out.
13. Spec. V. Acne Syphilitica, Venereal
JLcne.Byn.Gwtta Rosea 8yphiliHca,'P\enck.
Syphilids Pustuleuse Miliaire, Alibert.
Amongst the very numerous forms of cutane-
ous afiection in which secondary syphilis may
manifest itself, this may be enumerated as one,
although not a common one. Plenck. has giv-
en a very correct description of it. This spe-
cies nearly resembles, in the size and form of the
pustules, the acne rosea. !l chiefly allects the
forehead, face, neck, and upper part of the trunk.
The vari are round and conical, with an inflamed,
copper-coloured, tubercular base and areola.
They suppurate slowly at their apices, where a
yellowish brown scab is formed ; and leave a
dirty, dark, and slightly depressed mark. They
present a darker colour, and more permanent tu-
bercles, on the nose, the adjoining parts of the
cheeks, and forehead, than elsewhere ; and are
there observed in discoloured patches, in every
stage of their growth. They are frequently found
complicated with other eruptions, chiefly of a scaly
character, on different parts of the body ; are
always a secondary venereal afiection ; and, al-
though sometimes unaccompanied with other sy-
philitic symptoms, are most commonly attended
with ulcerations in the throat, with nodes, inflam-
mation of the periosteum, and nocturnal pains.
14. Diagnosis. — Acne can be confounded
only with ecthyma. The tubercukir pustules of
the former, however, are small, slowly developed,
with an indolent and hardened base ; whilst the
pustules of ecthyma are large, superficial, unac-
companied with chronic induration, and forming
thick scabs, more or less prominent, much less
adherent, and such as never are formed in acne.
The characters of syphilitic acne, the antecedent,
and accompanying symptoms (§ 13.), the colour
and predominance of the eruption about the nose
and commissures of the lips, the tendency of the.
vari to ulcerate, and the associated affection of
the throat, and sometimes of the periosteum, suf-
ficiently mark the nature of this species of the
disease.
15. The Prognosis of acne regards merely
the persistence of the eruption, and the inconve-
nience attendant on it. Acne simplex and punc-
tata, are often of comparatively short duration.
The acne indurata is much more tedious ; and in
some constitutions will resist, even for many years,
every mode of treatment, particularly if the causes
in which it not infrequently originates be over-
looked. Acne rosacea is seldom or ever cured,
excepting by a strict attention to regimen.
16. The Causes of acne are extremely various.
The species simplex, indurata, and punctata
usually occur during youth, in the sanguine and
bilious temperaments, and disappear about middle
age. They are very generally connected with
chronic affections of the stomach, bowels, and
liver; with haemorrhoids; in some, with a tenden-
cy to phthisis ; and in females, with painful and
scanty menstruation. These species, as well as
the acne rosacea, evidently arise, in many cases,
from hereditary predisposition ; and are most
common in cold and moist climates, — probably
owing to the use of ardent spirits. Excesses at
table, cold indigestible articles of food, sedentary
habits, fits of passion, anxieties of mind, and the
depressing passions, cold drinks — particularly if
taken when the body is overheated — the use of
irritating cosmetics, and disorder of the digestive
functions, are very common causes of these
eruptions, I believe, however, that the simple,
indurated, and punctated species of acne ar«
most frequently occasioned by uterine irritation.
30
ACNE — Treatment of.
and excitement, or an imperfect performance of
the uterine functions ; by constipation ; by torpid
conditions of the liver ; and by the injurious ad-
diction to onanism.
17. Treatment. — In the treatment of these
affections, our chief attention ought to be directed
to their pathological relations and causes. These
latter must be removed as far as may be done ;
and the former should both guide our indications,
and direct our means of cure. The apprehensions
entertained by the older writers, of producing in-
ternal disease by the sudden repulsion of the
eruption, were founded on the results of observa-
tion, although explained by partially inaccurate
or unsound pathological views. Affections of
the stomach, bowels, chest, and head, have been
thus induced, and been relieved upon a re-appear-
ance of the eruption : but such consecutive dis-
eases are more common after the repulsion of
other eruptions. We should, however, as being
both the safest and the most permanent method
of cure, direct our remedies to the constitutional
or internal relations, as well as to the external
manifestations of disorder.
In the treatment of this, as well as many other
diseases, the causes, the state of the habit and con-
stitution of the patient, its morbid relations, and its
duration, are severally to be kept in recollection.
18. 1st. Treatment of acne simplex. — Indeli-
cate constitutions, the chief attention should be
directed to the state of the digestive functions.
These should be promoted by gentle aperients,
combined with tonics, and the functions of the
skin promoted, by preserving a free transpiration
on its surface. With this view, sulphur may be
combined with magnesia, or with cream of tartar,
and confection of senna, and taken in a sufficient
dose, at bedtime, to procure a full evacuation in
the morning, or any one of the formulas ( Ap. Nob.
82. 89. 98.) may be had recourse to. These may
be occasionally' changed for a powder with rhu-
barb, sulphur-, and magnesia, or for the extractor
decoction of taraxacum, with subcarbonate of
soda or sulphate of potash. If the functions of
the liver are torpid, the following may be taken
for a few nights : —
No. 6. R Pdul. Hydrarg. Suhmur. Comp. '£).).-, Fellis
Tauri Inspiss. zr. xv. ; SapotiU Castil. gr. x. ; Extr. Ta-
raxaci 3j. M. Fiaut riluia: xviii., quarum capiat binas
vel tres hoia, sonini.
After the bowels have been evacuated, and the
secretions brought to a healtluer state, the dilute
mineral acids, either alone or with bitter infus-
ions, may be taken through the day.
19. When the eruption occurs in young ple-
thoric persons, and when it is in females attended
with scanty and difficult menstruation, small blood-
lettings may be practised ; in the latter, by the
application "of leeches to the superior and internal
parts of the thighs. In more delicate females the
functions of the lower bowels are to be promoted
bv the pilula aloi s cum myrrha, combined either
with pilula ferri composita, or with the extraction
gentiana?. When the eruption is obviously con-
nected with imperfect and painful menstruation,
the use of the warm salt water hip-bath, or of the
hip vapour bath, or warm salt, water pcJiluvia,
after the application of a few leeches to the
insidesof the thighs, will be extremely serviceable.
In such cases, the internal exhibition of the sub-
borate of soda, either in the form of pill or draught,
combined with camphor, the extractum taraxaci,
or the extr. rutae, or, as directed in Form. Nos. 93.
184. 209. 254. will be found of great advantage.
20. In addition to these internal remedies,
which require to be varied according to different
pathological relations of the eruption, external
applications will be necessary ; and when con-
joined with the above treatment, or employed
subsequently to it, no dread may be entertained
of any injurious consequences from them. The
ancients, particularly Celsus, Pliny, Aetius,
Paul, us, Actuarius, &c. recommended lotions
and liniments with vinegar and honey ; and these
sometimes combined with turpentine, emulsion of
bitter almonds, myrrh, alum, soap, Cimolian
earth, the bruised roots of the lily, the cyclamen,
narcissus, and the fruit of the wild vine ; the
most of them calculated to be advantageous in
many states of the common forms of acne.
21. If the tubercles are much inflamed, and
inclined to be pustular, mildly stimulating appli-
cations are most serviceable, as dilute spirit, or
the pyroligneous acetous acid, or liquor ammonia
acetatis, with rose or elder-flower water. In the
more indolent cases, or when the skin can bear
an augmented stimulus, Willan and Bateman
recommend from half a grain to a grain, or more,
of the muriate of mercury, in each ounce of the
vehicle ; or a drachm or more of the liquor potas-
sce, or of the muriatic acid, in six ounces : and
Thomson advises that the emulsion of bitter
almonds, containing ten minims of hydrocyanic
acid to each fluid ounce of the emulsion, should
be the vehicle adopted. The solution of the
suJphuret of potass, in the proportion of a drachm
to twelve or sixteen ounces of water, may also be
employed ; and, in the more obstinate cases, the
baths -directed in Form. No. 14 — 17. may be had
recourse to. The solution of the muriate of am-
monia, either alone or with the chloride of mer-
cury, is often serviceable.
22. The lotion from which I have derived the
greatest advantage in practice, and which I have
found the most generally applicable, is a solution
of the sub-borale of soda in rose or elder-flower
water, or in water which had been poured in the
boiling state over sulphur, and allowed to infuse
for ten or twelve hours. The borax may also be
dissolved in equal quantities of elder-flower water
and honey, and used as a lotion in the more
chronic cases.
23. 2d. Treatment of acneindurata. — In young
and plethoric subjects, or in females, when the
eruption is accompanied with a scant}' and pain-
ful menstruation, the treatment already pointed
out (§ 19.), should be put in practice. When we
suspect that sexual irritation or masturbation is
connected with the causation of. the eruption,
early rising, mental occupation, the use of gentle
cooling aperients, of soda combined with small
doses of camphor, soda water, sulphur with soda
or antimony, are the most serviceable internal
remedies. After these, the mineral acids, the
sulphureous mineral waters, and gentle vegetable
tonics, will be useful. Where the eruption is de-
pendent upon torpid function of the stomach, or
liver, or bowels, mild alteratives, exhibited at bed-
time, as the pills already prescribed (§ IS.), and
gentle tonics through the day, will be required.
In a most obstinate case, which some time ago
came before me in a lady, whom all the prac-
titioners who had acquired a reputation in the
ACNE — Treatment of.
31
treatment of cutaneous affections had attended,
strict attention to the stale of the digestive and
uterine functions removed the eruption. The fol-
low ing electuary has sometimes been used by me
in this and other obstinate cases.
No. 7. R Potassss Supertart. in pair. J j. ; Sub-borath
Sodss 3 ijss. ; Sulphuris Prsecip. Jss. ; confecttonis Sennas
et Syrup. Zingiberis aa 5 jss. M. Fial Elei luarwm, cujus
capiat Coch. uniim loinimum omni node.
At the same time a solution of two grains of the
chloride of mercury in four ounces of the compound
tincture of cinchona was prescribed, and a tea-
spoonful of it directed to be taken twice daily, in
half a glass of infusion of camomile flowers. The
lotion already recommended (§ 22.) was also
employed. In cases similar to this, and, indeed,
in all those accompanied with disorder of the
digestive functions, cold or drastic purgatives
ought to be avoided; and the bowels should be
regulated with the pilula aloe's cum niyrrlia, com-
bined with a little blue pill, or with the pill pre-
scribed above (§ 18.); or the ext. aloe's puiif.
conjoined with the e.xtr. gentianre; or the electuary
now directed. Advantage will also be obtained
from a draught of infusion of cascarilla, or of
calumba, with subcarbonate of soda or potass, or
the liquor potassa?, taken twice a day.
24. As to external applications in this form of
acne, little need be added to what has been
already stated. The lotions with the chloride of
mercury, or with the borax, are most to be de-
pended upon, particularly when dissolved in an
emulsion of bitter almonds, or in camphor mix-
ture, with the addition about twelve minims of
the hydrocyanic acid to each ounce of the vehicle.
In cases where the tubercles have at all suppurated,
it will be advisable to open them with the point
of a lancet before the lotion is used.
25. At the commencement of the eruption, mild
emollient poultices and fomentations are useful ;
and afterwards, particularly in the more obstinate
cases, M. Biett, and after him MM. Cazenave
and Schedel, recommend the following oint-
ments to be used, in order to promote the resolu-
tion of the tubercles : —
No. 8. R Protochlor. ITvdrarc. et Ammonia* (Sub-
ninr. Hydrarg. et Amnion.)}- )j. — ^.j- \ Axungiae 5J. Misce.
Of this ointment I have had no experience;
but the following I have employed with advan-
tage in several chronic eruptions, and in two cases
of this species of acne : —
No. 9. R Sulphuieti Iodinae gr. xii. — xxiv. ; Axuncria'
%)■ M-
Ambrose Pare and Darwin considered
that blistering successively small portions of the
face was the most successful means of ridding it
altogether of this very obstinate eruption. Tbi
been already recommended, or a weak solution of
pure potash, or of ox-gall, or of sulphuret of
potash, also followed by frictions, are particularly
indicated in this species of acne.
27. Internally, the solution of the carbonate of
potash, or the oxymuriatic acid, advised by Un-
derwood and Willan, may likewise be em-
ployed. Sulphur, magnesia, soda, rhubarb, and the
subborate of soda, are also of much benefit. Dr.
Thomson states, that he has seen the skin com-
pletely cleared by the use of the following alka-
line tonic for six weeks; at the same time regu-
lating the bowels: —
No. 10. R Zinci Sulphatis gr. xxiv.; Liquoris Potassa
I. J y''l- Solve. Sumaiitur gullae xxx. ex cyalho aqus bis
quolidie.
It ought always to be observed, as a general
principle, in this as well as in the other forms of
acne, that attention to the secretions of the abdo-
minal viscera, and to the general health, by pro-
moting the digestive functions, will of itself, in-
dependently of external means, go far in promoting
a cure; and that, without such attention, no cure
will be permanent. *•
28. 4th. The treatment of acne rosacea is gener-
ally unpromising. It should always have a strict
reference to the particular nature of the affection
of the liver, or digestive canal, or both, with which
this eruption is associated, and in many respects
symptomatic. A. rosacea often precedes serious
disease of the liver, more frequently co-exists with
it, and most commonly indicates a congested and
obstructed state of the viscus. To this organ,
therefore, ought our remedies to be particularly
directed. A moderate blood-letting; the applica-
tion of leeches on the region of the liver; and, if
the eruption occurs in females, and is attended
with obstructed or scanty menstruation, leeches
also to the upper part of the insides of the thighs,
or bleeding from the feet, and stimulating pe-
diluvia, or the hip-bath; the use of mild mer-
curials, or alterative and deobstruent medicines,
such as the pills previously prescribed (§ 18.);
the blue pill, or the hydrargyrum cum ereta,
with soda and taraxacum; Harrogate, Barege,
and other sulphureous mineral waters; the de-
coction of dulcamara, liquor potassa?, and chlo-
rine or sulphureous fumigating baths; are severally
of advantage in some cases. But from none of
these will any permanent benefit be derived, un-
less the regimen presently to be noticed is rigidly
observed, and the pathological relations of the
eruption appropriately treated.
29. Blood-letting in tliis, as well as the fore-
going species of the eruption, was strongly insisted
on by Ambrose Pare ; and certainly in the cases
pointed out as requiring this practice should never
practice has been employed at the hospital St. ! be omitted; more particularly when accustomed
Louis, by M. Biett, with great benefit. When discharges have disappeared, as the hemorrhoidal
the disease has disappeared, this scientific physi- flux and the menstrual evacuation. In this form
cian has derived great advantage from a douche of the disease, much advantage will sometimes be
of colu sulphureous water in preventing a return [ procuredfrom the nitro-muriatic acid foot-bath;
of the eruption. i and from a lotion with these acids applied to the
26. 3d. In treating the punctated species of affected parts twice or thrice a day (see F. 4. 5.).
acne, it will be frequently necessary to press out This practice has received the sanction of M.>1.
the accumulated and hardened matter from the Biett, Cazenave, and Schedel. The ad-
follicles. The vapour bath, the warm sulphur vantages to be derived from the use of these acids
bath, followed by frictions either with a coarse ' as a lotion will be more certainly secured by app!y-
towel or a flesh-brush; and lotions such as have ing a few leeches to the vicinity ofthe eruption, and
_^____ afterwards a fomentation, which may be followed
* Prepared hj subliming equal quantities of ibe cor- either by a spirit and alum or zinc lotion, or by
rosive sublimate ami mui ia.< ammonia-. i the lotion with the sub-borate of soda (F. 334.)
32
ADHESIONS.
If these fail, the nitro-muriatic acid lotion maybe
employed. Stimulating and irritating applications
ought to be avoided; and whilst the tone of the
digestive organs ami the secretions of the liver
should receive the closest attention, drastic and
cold purgatives are to he avoided.
30. 5th. The treatment of the syphilitic or
specific fonii of acne must be directed as in other
states of secondary venereal disease. At the same
time, however, that the mercurial preparations
are being exhibited, the external means which
have been recommended may be employed, ac-
cording to the particular form the acne may as-
sume. The mercurial preparations should be com-
bined with sarsaparilla or taraxacum, or both, and
with small doses of antimony. The decoction of
Feltz, which chiefly consists of a combination of
these remedies (see F. 5S8.), is much employed
in these eruptions on the Continent, and may be
taken to the extent of a pint and a half daily.
When the tubercles remain long, the ointments
formed with the iodurets of mercury or sulphur
(F. 774, 775.) may be employed twice daily, and
assisted by douches of vapour.
31. The diet and regimen of persons affected
with acne, particularly the A. rosacea, ought to
be carefully restricted. In the A. simplex, in-
durata, and punctata, the diet should be light,
nutritious, and easy of digestion. Cold, raw, and
indigestible vegetables, particularly cucumbers and
nylons, and very cold fluids, should be avoided.
Moderate and regular exercise in the open air,
and early rising, as tending both to promote di-
gestion and invigorate the frame, are always of
service. In the acne rosacea, more will often de-
pend i^pon regimen, than upon the medical treat-
tice, they are generally one of the consequences
of inflammatory action, affecting the adhering
surfaces, or which had affected them previously;
and occur in those parts which are in contact, or
so nearly in contact, that the effusion of a com-
mon product of the inflammatory act becomes
the medium of union.
2. It is requisite to all adhesions, that a
fluid be thrown out from the inflamed surface,
previously to the adhesion being commenced.
This fluid varies somewhat in its characters with
the state of inflammatory action; but it soon
passes into a much more consistent condition, and
thus becomes the medium of adhesion. In some
places it is scarcely perceptible between those
parts of opposite surfaces which are naturally
very nearly or altogether in contact with each
other, the agglutinating medium being there so
remarkably thin ; whilst those parts that are fur-
ther separated in their natural state, have the
interstices filled up by a copious exudation. The
fluid exuded in thus variable quantities, has been
denominated, in its first stages, or inorganised
states, coagulable and coagulated lymph, albu-
minous exudation, coagulated albumen, &c.
When first poured out from the inflamed surface,
particularly of serous membranes, it consists of a
lymph-like fluid, which soon becomes somewhat
opaque, more solid, and assumes the appearance
of a softly coagulated albumen, — its chemical
properties very nearly approaching to those of
pure albumen, containing a small proportion of
the usual saline ingredients of the blood.
3. The longer this matter has been effused,
and the longer adhesions, which it has occa-
sioned, have endured, the more firm and more
inent of the patient. The careful avoidance of closely resembling cellular or cellulo-fibrous tis-
•all its exciting and concurrent causes, and of I sue do they become. This change in the state of
excesses of every description, both in eating and the adhesions, according to their duration, is fully
•drinking; the adoption of a mild farinaceous diet, | stated in the article on the morbid states of sermis
with a small portion only of light and nutritious | membranes. It may, however, be here premised,
animal food, and of toast-water or barley-water that the medium of adhesion, which is first fluid,
for chink; shunning mental excitement and de- i and afterwards albuminous and nearly solid,
pression, as well as heating and fatiguing exertions; ' soon becomes partially organized; blood-vessels
gentle and regular exercise, and attention to the ! shoot into it, and thus opposing surfaces become
promotion of the secretions and functions of the ' more or less firmly united, according to the de-
abdominal viscera; are essentially requisite to the \ gree of motion occurring between them, that
removal of tins very obstinate and often uncon
querable eruption.
BliiMouiiAPUV. — Ambrose Pari, De la Goutte Rose,
liv. xxvi. ch. xlv. — Pltnck, Doctrina de Morhis Cutaneis,
■&.C., 2d edit. Vien. 1783. — Darwin, Zoonomia, class ii
1. 4. 6, et cl. iv. 1, 2. 13. and 14. — ii ataman, Synopsis of
Cutaneous Diseases, by Thompson, and Atlas, p. 387.
— Alibert, art. Coupervse, in Diction; des Sciences Med.,
t. vii. — Hiett, art. Couptrose, in Diction, de Medecine,
t. iv. — Uaytr, Des Maladies de la Peau, he, t. i. p. 446.
Paris, 182b'. — Plumbe, On the Diseases of tlie Skin, 8vo,
2d ed. Lond. 1829. — Cazenave et Schedel, Ahrege Pra-
tique des Maladies de la Peau, 8vo, Paris, 1829, p. 208.
may either prevent their firm adhesion, or disturb
it after it has been already formed, and to the
state of the fluid which becomes the medium of
union. In some cases I his fluid is secreted so
copiously, and is so deficient in the albuminous
constituent, the watery part being so predomi-
nant, that adhesions are formed only in differ-
ent, or in numerous and irregular points, be-
tween which serum in various states is effused,
separating the opposite and partially united sur-
faces, stretching the adhesions, breaking down
ADHESIONS. Syn. Adlv'sions, Adhcrences, j some, and reducing others to cellular bands run-
Fr. DieAnhanglichkeit,Gei. Congiunzioni, , ning between these surfaces through the effused
unioni, aderenzce, Ital. j fluid, which is in such cases usually very tur-
Classif. Morbid Structure. — Thera- ' bid, and abounds in flakes of albuminous matter.
peutics. Chiefly a result of some one of the This appearance is not unusually observed in
Inflammatory States. — See Inflamma- cases of adhesion of the pleura, pericardium, and
occasionally of the peritoneum.
1. Adhesions of opposite surfaces of tissues are
4. The concrescible fluid, as will appear in the
amongst the most common organic lesions present- sequel, which is formed between the surfaces of
ed to our view in post mortem examinations. They divided structures, originates in two distinct modes,
may be congenital, arising either from an original generally iissun.es a firmer and more fibrous cha-
disposition of parts, or from intra-uterine disease, racter in its advanced stages, and undergoes a
As they are commonly brought before us in prac- more marked diminution of volume than is ob-
ADHESIONS — Reparative.
33
served in those adhesions which form on serous
Surfaces. From this it will he apparent 1 1 ■ ; . t ad-
hesions are formed by the medium, Lst, ofa con-
crete inorganic albuminous matter; and 2d, of
lliis matter, at a later period, in a more or less
organized state, and presenting various appear-
ances, according to the length of their duration,
and the nature of the inflammatory disease which
produced them. It will he also apparent, from
the foregoing, that the adhesion of opposite sur-
faces is not in itself a specific disease, hut the
result of disea.se, — generally of inflammation in
some one of its grades.
5. Adhesions, in respect of their ultimate tenden-
cies, are either reparative or morbid. M. Cru-
veilhier, who has divided them in two classes,
according to this view, comprises under the former
the adhesions between divided tissues and sur-
faces brought about by surgical aid; to which I
may add those that take place around puru-
lent formations, and prevent the extension or
effbsion of the collected matter into adjoining
parts. Whilst the reparative class of adhesions
are stated to form generally between divided
structures and diseased surfaces, it should be
kept in recollection that all the tissues do not
admit of adhesion taking place immediately be-
twefn their divided surfaces. Blood-vessels, nerves,
muscular fibres, and tendons do not unite after
division. It is the minute vessels of the cellular
tissue which surrounds them, and their individual
fibres, that chiefly furnish the means of their
adhesion. From these vessels, if protected from
the atmospheric air, a coagulable lymph is thrown
out; which gradually becomes vascular, organ-
ized, and in a few days cellulo-tibrous, and as
firm as the parts which formed it. This newly
produced substance is the medium by which the
muscular fibres, or other structures which had
been divided, are united; and this gradually be-
comes thinner and less apparent, and admits of
the nearer approximation of the separated parts,
until they at last seem continuous, although the
existence of the medium of union may still he
detected. This constitutes primary adhesion, the
union by the ''first i tention" of surgeons.
6. When the division takes place between
bones, this exudation forms the callus, into which
ossific matter is deposited. Some pathologists
believe that the concrescible lymph, thus fur-
nished by the capillary vessels of the divided
surfaces, particularly those of the cellular tissue,
is the matrix, in which the peculiar structure, of
which nerves or muscular fibres consist, is after-
wards formed or deposited. But, if this were the
ease, the firm, and even fibrous, matter into which
the medium of union is ultimately changed would
at last disappear, and these structures be actually
continuous. This, however, never unequivocally
occurs; for, although the uniting medium is re-
duced to a very thin, and scarcely perceptible,
substance, yet it may be made apparent by ma-
ceration and careful dissection.
7. When air is admitted between the divided
structures, or when primary adhesion fails of
taking place, a different process obtains; minute
granula- or earuncula) form upon their surfaces,
whence proceeds at first a fluid pus, subsequently a
more concrescible fluid, which forms a sort of false
membrane, and which, when the opposite surfaces
are kept in a state of near approximation, be-
comes the medium of adhesion, unless the state
of the system is such as not to admit of the form-
ation of this concrescible fluid, and of the other
steps of this restorative process. When di-
vided parts come in contact with the air, the
adhesion is always formed in this manner, — by
the suppurative process, whatever may be the
nature of the structure which is thus circum-
stanced; and the false membrane, which is the
medium of union, becomes more thin, firm, and
fibrous, and, at the same time, less apparent with
the lapse of time. Tins may be called consecu-
tive adhesion. When the divided surfaces are
protected from the air, and primary adhesion
takes place, the process is more rapid; but its
quickness will depend upon the quantity of blood
effused between the divided surfaces, if this be
considerable, one of two things will result, —
either the effused blood will be absorbed, and
a cyst, or cellulo-fibrous medium of union, be
slowly formed, which will be gradually diminished
in thickness; or the coagulum may act as a
foreign substance, keep up irritation of the vessels
in the divided surfaces, cause suppuration, and
consecutive adhesion, with the cicatrix formed by
the medium of union. (See art. Abscess.)
8. There is one important point connected with
adhesions in their various states and seats, — whe-
ther reparative or morbid, whether primarily
reparative or consecutively reparative, and whe-
ther taking place between cellular, serous, or other
structures, — which has not received the at-
tention from modern pathologists that its prac-
tical importance requires for it, and to which
John Hunter first directed notice. I allude to
the important truth, that adhesions of either of
the above descriptions, but particularly the pri-
mary reparative, whether taking place between
divided surfaces or around purulent formations,
either will not form, or, if in the process of form-
ation, will be dissolved, in certain states of the
vital energies of the frame, and of the circulating
fluid. Great depression of the vital influence will
have this effect, whether it be produced by the
exhaustion proceeding from profuse discharges,
by contagious and other noxious miasms, by the
close air of hospitals, and other places loaded
with animal effluvia, by the inoculation of cer-
tain animal poisons, by the absoiption of puriform
or sanious secretions, or other morbid matters,
into the current of the circulation, by the mercu-
rial affection of the frame, or by the gouty dia-
thesis. When the vital energies of the frame are
greatly depressed, and the tonic action of the
capillaries much relaxed, by causes acting either
extrinsically or intrinsically as respects the blood-
vessels, the ability of throwing out a concrescible
or coagulable lymph from the divided or inflamed
vessels is destroyed, and in its place is produced
an ichorous serum, or sanious fluid, which may
either pass out, or, if no ready outlet is afforded,
will infiltrate itself through the tissues adjoin-
ing, or be partially absorbed and vitiate the per-
haps already morbid blood. (See art. Blood.)
9. In order to prevent this very dangerous
state from supervening in all cases where the
reparative process of adhesion Is required, the ut-
most attention ought to be devoted to the state of
the vital energies, particularly as indicated by the
tone and frequency of the pulse, and the states of
the digestive organs. When the former becomes
34
ADHESIONS —Morbid.
very quick, and the powers of the latter fail, that
much dreaded state of the frame, which is insuf-
tirirnt for the formation of coagulable lymph,
may be considered as approaching, if it be not
actually present. In all cases where blood-ves-
sels arc' liable to lie intlamed, this state of the
constitutional powers, owing to the risk of the
blood being vitiated, is particularly to be guarded
against. Having advanced as much as belongs
to my province respecting the reparative states of
adhesion, 1 proceed to state briefly the doctrine
of Morbid adhesions. The particular morbid
adhesions are noticed under the articles on the
pathology of the parts in which they form.
10. Adhesions in some one of the states de-
scribed above (§ 1 — 4.) are liable to occur, as a
consequence of certain grades of inflammation, in
the following situations: — 1st, In the cellular
tissue; 2d, between serous surfaces; 3d, between
mucous surfaces; -1th, between synovial surfaces;
5th, in the internal surface of blood-vessels; and
6th, between the surfaces of morbid or accidental
formations.
11. A. Adhesions of cellular tissue. — The
first step of the process is the exhalation of a
quantity of yellowish serum and of coagulable
lymph into the cellules of this tissue, which ulti-
mately agglutinates them together, upon the
absorption of the former, and the concrescence
of the latter. The consequence of this is, that
the product of inflammation formed in the centre
of the inflamed cellular tissue, consisting chiefly
of the more fluid and least concrescible portion of
the exhalation, is prevented from permeating the
agglutinated cellules, and a barrier is set up
against it. If resolution takes place and the pu-
rulent matter is absorbed, the surfaces of the
cavity become united, and the medium of union
is changed, as in cases of recent wounds, and in
the manner described above (§ 5.). If the parts
go on to the evacuation of the matter, adhesion
is also ellected, as in the cases of consecutive re-
storative adhesion (§ 7.); leaving, however, a
cicatrix, which is gradually diminished, formed of
the cellulo-fibrous medium of union. In all cas-
es of inflammation of cellular tissues, adhesion
of the cellules, from the exudation of a concres-
cible lymph, takes place; and it is this adhesion
which forms the fibrous cysts to abscesses, iso-
lates their contents from the surrounding struc-
tures, and in some respects excludes them from
the economy. Adhesions of the cellules of this
structure also strengthen the cysts of aneurisms,
and form sero-fibrous cysts around foreign bodies
that are accidentally lodged in it.
12. B. Adhesions between serous surfaces
are the next most common ; being formed through
the medium, either of a more or less thick and
firm inorganic albumen, in the form of a false
membrane, or of this substance advanced to a
more or less organized state, and assuming either
the appearance of cellular tissue, with a surface
partaking of the serous character, or one of the
states about to be noticed. The organized nature of
those adhesions has been denied by some; but the
observations of. Stole, Hunter, Dupuytren,
Baillie, Mecke, Home, Lobstein, Cru-
veilhier, Gendrin, Baron, and others, who
have traced blood-vessels in them, have put the
question at rest. Adhesions occur most frequently
between the pleura?, next in the peritoneum, and
next to these in the pericardium. They are
comparatively rare in the tunica vaginalis; and
in the arachnoid they are still more rare.
13. It is not necessary to the formation of ad-
hesions between opposite serous surfaces, that the
pre-existing inflammation shall extend continu-
ously to both. When the coagulable lymph is
thrown out upon one of the two inflamed surfaces,
— as, for instance, of the peritoneal surface of the
small intestines, — it seems to act as an irritant to
the opposite part of the omentum, with which
it is brought in contact, inducing inflammation
of that part only, and leaving the intervening
surface both above and below it unaffected. The
part thus irritated by the contact of the coagu-
lable lymph, poured out by the part primarily
affected opposite to it, becomes also inflamed,
and exudes this concrescible fluid; and the
inflammation thus secondarily induced in a part
of the omentum may advance to the external
surf tee of the omental duplicature, and, by means
of the exudation of this product of inflammation
in that situation, excite a similar state of action
in the directly opposite part of the peritoneum
reflected over the abdominal parietes. Thus the
inflammation and its consecutive adhesions may
proceed, without the disease having affected any
of the continuous surfaces intervening between
them. A similar circumstance is sometimes ob-
served in respect of the convex surface of the
liver and peritoneal surface of the diaphragm.
Inflammation, commencing in a part only of the
former, will excite it in the part of the latter
exactly opposite, and be followed by adhesion;
and the inflammatory action, not infrequently ex-
tending upwards through the diaphragm to the dia-
phragmatic pleura, will be further followed by the
exudation of coagulable lymph on its free surface,
which, irritating that portion only of the pulmonic
pleura opposite to, or in contact with it, will inflame
that part, and form adhesions with it, without
affecting the continuous surface intervening be-
tween, and surrounding the adherent parts. The
unadhering cavity, however, not infrequently
contains a turbid or flaky serum, with patches of
false membrane, arising from a less acute state of
inflammatory action in those parts of the serous
surface immediately adjoining the adhesions. Thus
it is not unusual to find, in cases of acute inflam-
mation affecting either the peritoneum, pleura, or
arachnoid, and limited to a particular part, a
similar state of disease, and the same product,
formed only in the parts opposite, and most nearly
in contact; whilst the continuous surfaces sur-
rounding them are either altogether sound, or
much less affected; — most commonly only so
far as to give rise to a serous exudation, or- slight
albuminous coating in their immediate vicinity.
14. From this it will appear, that the near
approach, and more especially the immediate
contact of opposite surfaces, and the want of
motion between the oue surface and the other,
will favour the formation of adhesions : thus they
are most frequent at the superior parts of the
pleura, between the convex surface of the liver
and the diaphragm, and the serous surfaces of
parts included in Hernia:. The different species of
media, by which adhesions of serous surfaces are
affected, are the following, according to M. Cru-
veilhier : — an iuorganized false membrane;
a filamentous adhesion, and a cellular adhesion,
ADHESIONS. — Morbid.
35
in neither of which blood-vessois are evident ;
a permanent organized membrane ; and a tuher-
culated membrane. All these originate in a con-
crescible lymph, as in adhesions of cellular tis-
sues. (See art on Serous Membranes.)
15. C. Adhesions between mucous surfaces
are not frequent. Bichat denied the possibil-
ii\ of their occurrence, unless destruction of the
mucous membrane had taken place. I le was led
to this conclusion mora by the functions of tlus
membrane in health and disease, than by observ-
ation of facts. There can be no doubt, however,
that the opposite surfaces of canals, covered as
they are by mucous membranes, occasionally
adhere, in consequence of very acute attacks of
inflammation ; but this occuis very rarely, owing
to the access .of atmospheric air, to the pre-
sence of gases, to the various matters constantly
passing through them, and to the nature of the
fluid which usually proceeds from inflammation
of these surfaces. The most common exception
which takes place to the general inference adopted
by Bichat is met with in the vagina. I have
observed several cases, at the Infirmary for Chil-
dren, where adhesions of the opposite surfaces
of this canal had taken place in consequence
of inflammation, — some of them at so early a
stage, that they were removed by merely forci-
bly separating the adherent surfaces, when the
mucous membrane was found perfectly entire,
but highly inflamed, and covered by an exuda-
tion similar to that which is thrown out upon
inflamed serous membranes. Similar facts are
recorded by MM. Dupuytren, Villerme,
Breschet, and Cruveilhier. Adhesion also
of the os uteri, as a consequence of inflamma-
tion, is sometimes observed. Occlusion of the
Fallopian tubes, and even the adhesion of the op-
posite internal surfaces of the uterus, have been
occasionally met with. Walther, Renaul-
din, and .Meckel observed these changes so
often in prostitutes, that they attributed them to
the frequent irritation of the parts, and imputed
the barrenness of these females partly to this
cause. Hut, in the cases of occlusion of the
Fallopian tubes, more is to be imputed to the ac-
cumulation of an inspissated or albuminous mucus,
the product of inflammation, which, from its ten-
acity and consistence, cannot flow along these
tubes, than to actual organized adhesion of their
opposite surfaces. The occasional occurrence of
obliteration of the canals of the common bile-duct,
and of the ureters from the impaction of a calcu-
lus, seems to proceed from the irritation and
abrasion occasioned by calculi, and the conse-
quent exudation of a concrescible fluid, which
agglutinates their surfaces, and ultimately tends
to reduce them to a cellulo-fibrous cord.
16. Adhesions are either never met with in the
air passages, or so rarely, as to render their actual
occurrence doubtful. I believe that, although
albuminous concretions are occasionally formed
in the bronchi, and frequently in the trachea
and larynx, &c, they cannot be so produced as
to give rise to adhesions of the opposite surfaces.
They never, or at least very rarely, become or-
ganized ; and, although they may completely ob-
literate the canals of several of the bronchi, they
cannot have this effect on the trachea without
causing immediate death. The organization and
form of the larger air-tubes completely prevent
their adhesion ; although they are often nearly
filled up with concrete albuminous formations, as
a consequence of certain states of inflammation.
Adhesions of the internal surface of the cesopha-
gus, or of any other part of the digestive tube, are
never met with ; although constriction, with
thickening, &c. to the iihnost entire obliteration
of this canal, is not infrequent. As in the air pas-
sages, nature has made in the functions, during
health and disease, of the membranes which line
them, sufficient provision to prevent this lesion
from occurring. And we uniformly observe, when
inflammation attacks any portion of those tubes,
the preservation of the canal of which is essential
to life, that, although a copious albuminous exu-
dation will sometimes occur, its organization will
generally be prevented, and its detachment from
the surface on which it is formed will be secured,
sooner or later, by the secretion of a more fluid,
or mucous, or muco-purulent matter underneath,
which loosens the concrete albuminous coating
or false membrane from its attachment to the
surface on which it is formed. The circumstances
which chiefly seem to favour the formation of
adhesions between mucous surfaces, are : 1st,
The abrasion of the epidermis which covers them ;
owing to which their secretions are changed, and
they partake more of the characters of cellular
tissue. 2d, Entire destruction of the mucous
membrane in a great part, or the whole, of the
circumference of a canal, favouring its gradual
constriction, suppuration, and ultimate obliter-
ation. The bile-ducts, ureters, urethra, rectum,
and oesophagus occasionally furnish proofs of this
change in some one of its stages. (See art. on
Mucous Membranes.)
17. D. Adhesions of the synovial surfaces of
joints are rarely observed, excepting in cases of
anchyloses, of which they cannot be considered
even as the commencement, although they may
accompany the earlier stages of this change, par-
ticularly in anchyloses consequent upon rheu-
matism. Many, however, of the alterations which
take place in the synovial apparatus of tendons
are consequent upon their adhesion and oblitera-
tion. Inflammation occurring in them primarily,
or extending to them from contiguous parts, is
generally followed by their adhesion, and reduc-
tion to a slate of dense cellular tissue. Hygroma
almost always terminates by adhesion.
18. E. The adhesion of the internal surface
of blood-vessels takes place through the medium
of the coagulated lymph secreted by the inflamed
rasa-vasorum. The vessel becomes impervious
in consequence of this exudation, which is poured
out in the form of a false membrane from its in-
ternal surface. The lymph which is exuded,
particularly when its eoagulable or concrescible
property is well marked, frequently produces
coagulation of the blood in contact with it ; so
that, generally, the obliteration is occasioned both
b) this lymph, and the COagulum of blood which
inns. In a short time the coaguluni thus
formed within the inflamed bipod-vessel becomes
more and more pale and dense, sometimes par-
tially organized ; and, as its density is increased,
so is its bulk diminished : the coats of the vessel,
at the same time, lose their specific characters;
they seem constricted around the substance form-
ed within them, the middle coat becomes less
distinctly fibrous, and at last they are reduced to
36
ADIPOSE TISSUE — Morbid States of.
the state of a cellular, or fibro-cellular, chord.
This may be viewed as the primary form of their
adhesions, and its usual results. When, how-
ever, suppuration takes place in their internal
surface, the adhesion is formed consecutively in
the manner described above (§7.) ; or the pri-
mary may pass into the consecutive form of ad-
hesion, particularly when the false membrane is
insufficient to (ill up the entire canal of the vessel.
19. Adhesions take place more readily in veins
than arteries ; are produced in both, and in lym-
phatics also, in the manner now stated, generally
in consequence of inflammatory action, attended
with sufficient power of the constitution to form
concrescible lymph (see the articles on Arte-
ries and on Veins) ; and sometimes, even
after a very slow and slight grade of this action,
when the opposite surfaces of the vessels are
pressed together by any tumour existing exteriorly
to them. When artificially excited in arteries, as
by the application of ligatures, the inflammatory
state which produces the adhesion is not so prone
to extend along the axis of the vessel, or to occa-
sion dangerous effects, as when it is excited in
the same way in veins. When thus produced in
these latter vessels, fault of constitution, an un-
healthy habit of body, unwholesome state of the
atmosphere, &c, or the other causes above as-
signed (§8.), will generally interfere with the
process, and occasion that state of morbid action,
and of its products, which will vitiate the current
of the circulation, and even destroy life. (See
Veins — Inflammation of.)
20. F. Adhesions of the internal surfaces of
cysts, and other morbid formations, sometimes
take place from a consecutive state of inflamma-
tion extending to them. Large cysts, which in
consequence of their situation cannot be removed,
may be obliterated by their puncture, and the
production of inflammation of their internal sur-
faces, so as to procure their adhesion.
21. G. Adhesions may also form between parts
of the cutaneous surface, when deprived of the
cuticle, and kept in close contact. This is not
infrequent after scalds and bums, and is produced
in a similar manner, as I have explained, in re-
spect of adhesions taking place primarily, and
without suppuration, or subsequently to the occur-
rence of this process in the cellular and mucous
tissues. Adhesions also occur in other situations,
as between the iris and capsule of the crystalline
lens, &c. ; but I have noticed those which more
especially belong to my province.
LlBLK'.GRAPHY. — Bkhat, Anatomie Generale, t. ii.
passim. — Copland, Lond. Med. Kepos., t. xv. p. 372. —
Scautetttn, Archives Gener. de Med., t. iii. p. 4137., t. iv.
p. 336., t. v. p. 537. — Renauldin, art. Adherencts, in Diet,
des Scien. Med., t. i. — Breschct, art. Adherence*, in Diet,
de Med., t. i. p. 340. — Baron, On Tuherculated Accre-
tions of Serous Membranes, ?vo, 1819; and Illustrations
of Tuberculins Diseases, 1822. — CruveilMer, Es«ai sur
l'Anat. Pathol., t. i. p. 144. ; et art. Adhesions in Diet, de
Med. et ( hirurg. I ratiques, t. i. p. 317. — Meckel, Anato-
mie Geiieh et Patkoloe., t. iii. passim. — Gendrin, His-
toire An; torn, des Inflammations, 2 ts. 8vo. Paris, 1827.
— An-lnl, Archives Gen. de Med., t. iii. p. 246. ; et Cli-
nique Medicale, tc, t. iii. et iv. passim; et Anatomie
PatholoL'ii|i:e, passim. — Craig-ie, on General and Pathol.
Anat., passim.
ADIPOSE TISSUE. Tela adiposa, Lat. Tissu
graisseux, Fr. Das Fett, Ger. — Its Morbid
States.
Classif. IV. Class, IV. Order (j3u-
thor, see the Preface.)
1. The adipose substance is frequently either
diminished or increased far beyond the healthy
standard. — A. Excessive diminution of this sub-
stance, atrophy, occurs naturally in very aged
persons ; and there seems to be, even in early
life, a tendency to it hereditarily in certain consti-
tutions, particularly in those of a peevish, anxious,
and irritable temper. It is often met with as a
consequence of, or conjointly with, pulmonary
and other organic diseases, particularly those
which interrupt assimilation and the supply of
nutrition. But it is also a symptom of all dis-
eases which impair the vital energies by morbid-
ly increasing the secretions and evacuations :
as in diabetes, diarrhoea, and dysentery. It
also necessarily proceeds from long abstinence,
&c.
2. Atrophy of this substance may be temporary
or permanent. It is usually the former in early
or middle life, and continues merely as long as
the causes which occasioned it. It is usually
permanent in advanced life, and in those of an
active, peevish, restless disposition. In every
case the removal of the fatty matter is produced
by absorption ; and, according to the experiments
of Magendie, Tiedemann, Gmelin, May-
er, &c, this process may be ascribed, at least in
part, to the minute veins. The circumstance of
fatty and oily matter being constantly found in
the blood, but in variable quantity, as shown by
Trail, Babington, Le Cantj, &c, seems
to support this view ; for, if taken up by the
absorbents, it may have been changed or assimi-
lated in its passage through the absorbent glands
before it could have reached the blood.
3. B. Excessive deposition or hypertrophy of
this" substance (adiposis) is very common, affect-
ing the body generally, but sometimes locally
only. Persons have weighed as much as 500 or
600 lbs. owing entirely to this state of hypertro-
phy. This tissue is naturally abundant in females
and eunuchs. Its hypertrophy is frequently occa-
sioned by excessive venereal indulgences, particu-
larly in early life, and when conjoined with high
living and indolence. It generally is attended
by a weak languid circulation, weak digestion,
with craving appetite, defective secretions and
excretions, and disinclination to active mental or
physical exertion. It also evinces a marked here-
ditarj character. Full living, particularly on food
which abounds with the elements of the fatty sub-
stance, as sugar, spirituous and malt liquors. &c.
tend greatly to promote it. The connection of
this morbid state with deficient assimilation ap-
pears fully proved. It would seem that hi persons
whose vital energies are diminished, whilst the
appetite remains unimpaired, or is excited by sti-
mulating liquors, &c, the sanguifactiou of chyle
does not take place so rapidly nor so perfectly as
in health ; that a large portion of this fluid assumes
an oily or fatty character, and is deposited in the
adipose tissue, which thus becomes one of the
emunctories of the frame, in which a substance
that cannot readily be carried out of the circula-
tion by any other organ is set apart for the
purpose of future absorption, assimilation, and
nutrition, as the wants of the system may require,
and to prevent its hurtful accumulation in the
circulating fluid. Thus, in persons otherwise ap-
parently healthy, the excessive accumulation of
J fat is often one of the earliest and most remark-
AFTER-PAINS — Symptoms and Diagnosis.
37
able si<rns of diminution of the vital energies of
the frame. (!^ee Art. Obesity.)
4. C bi many instances, when the powers of
the constitution are either greatly reduced or other-
wise perverted from the healthy state, the adipose
matter is also changed in colour, composition, and
consistence, becoming remarkably pale, or dark,
reddish, or gelatinous. It may likewise be, par-
ticularly in cachectic persons, uncommonly
watery, soft, smearv, or jelly-like; and, on the
contrary, but more rarely, hard, waxy, or even
horny.
5. D. It roay be a question whether or not this
tissue is liable to inflammation. Considering it
merely as a modification of the cellular structure,
chiefly in as far as it contains the fatty substance
of the body deposited in its areolae, the containing
tissue only must be looked upon as that which is
liable to inflammation or any other disease; the
fat or contained matter being entirely passive, and
modified only by the morbid states of the tissue
which secretes and contains it. There seems little
doubt that the adipose tissue participates in the
various states of diffuse inflammation; whether
that attending upon certain forms of erysipelas, or
following accidents, or the inoculation of morbid
matter. When thus inflamed, it rapidly passes
into a state of sloughy and fetid suppuration;
large portions of it being not unfrequently con-
verted into an ash-coloured, semifluid pulp, mixed
with shreds of cellular tissue and albuminous
matter, or becoming entirely sphacelated.
6. E. Effusion of blood into the adipose tissue
occurs under similar circumstances to those con-
nected with haemorrhage into the cellular sub-
stance, but much less frequently. This change
has been occasionally noticed by Huxham,
Cle ghorn,Cr a igie, and by myself and others,
in scorbutus, purpura haemorrhagica, and in the
liquescent or malignant forms of remittent fever
in warm or unhealthy climates.
7. F. (H'lhe tumours most frequently developed
in this tissue, the most remarkable are, — a. adipose
sarcoma, which is surrounded by a thin capsule of
cellular tissue condensed around it, and consists
of an unusual accumulation of fatty matter in
cells, the component fibres of which are so firm
as to give consistence to the tumour: it closely re-
sembles a local hypertrophy of the adipose tissue,
excepting thai it is surrounded by a capsule; and
it may have either a broad or narrow base: b. stea-
tomalous tumours are chiefly a peculiar modifi-
cation of the fatty secretion, which is accumulated
in masses, surrounded by a spheroidal cyst: they
are not formed of cells, in which the fatty matter
is deposited, but consist of a simple semifluid sub-
stance secreted by the inner surface of the cyst:
they occur more frequently in the cellular, than in
the adipose tissue: c. atheromatous and melicerous
tumours are either modifications of the steatom-
atous, or proceed from the change induced in
small chronic abscess; but they are most com-
monly the former when seated in this tissue.
8. G. Melanoid deposition is sometimes found
m both the internal and external adipose substance.
It may be either disseminated in the form of small
inky spots, or accumulated in spheroidal masses;
or found in a semifluid state and brownish-black
colour, surrounded by a cyst formed by the con-
densation of the contiguous cellular tissue. As to
the state in which this peculiar matter is formed,
great diversity of opinion exists. Laennec sup-
posed that it is first secreted in a solid form, and,
like tubercular deposits, afterwards becomes soft.
I am, however, inclined to adopt the opposite
opinion; viz. that it is secreted in a fluid or semi-
fluid state, and that it afterwards becomes firm by
the absorption of its more fluid parts. The obser-
vations of Drs. Cullen and Carsewell, and
of M. Chomel, seem to confirm this opinion.
BinLloan.\PHV. — Art. Graisse, Corpulence, ami Obe.-,itc,
in Diet, des Sciences Medicales. — Chraefe, in Journ. fiir
Chirurg. un 1 Augenheilk. b. ix. p. iii. p. 367. — Grune, De
Sanl et Morbosl Pinguedinis in Corpore Secretione, 8 vo.
Ber. 1826.— Otto, in Sell. Beohachl, p. ii. p. 166.— Cho-
mel, Nouv. Journ. de. Med., t. iii. p. 41. — Craigic, Gen-
eral and Pathological Anatomy, p. 62.
AFTER-PAINS. Syn. Parodynia Secundaria
Dolorosa, Good.
Classif. 5. Class, 3. Order (Good). II.
Class, III. Order (Author).
1. Defin. Pains, more or less severe, cither
continuing or supervening shortly after the ex-
pulsion of the placenta in child-birth.
2. Symptoms and Diagnosis. Attacks of
pain in the abdomen are usually experienced in
the early part of the puerperal state. They pro-
ceed, when very severe, from the contraction of
the uterus, irregularly excited by the presence of
coagula. They usually soon follow delivery, are
least severe after a first labour, are increased
upon the application of the child to the breast,
and last for a day or two. They are generally
aggravated by flatulence and costiveness.
3. It is extremely requisite for the young prac-
titioner to be on his guard respecting the nature
and seat of pain after delivery, as the commence-
ment of the most fatal diseases to which the sex
are liable may be mistaken, if not carefully ob-
served, for after-pains. These latter are the
result of the natural contractions of the womb,
and of its return to its former state ; and are dis-
tinguished from disease, particularly inflamma-
tions of the uterus, ovaria, or pelvic peritoneum,
by their remissions, and by the absence of ten-
derness or tension of the abdomen, especially on
pressure. The uterine discharge also is not ob-
structed; the milk is secreted; there is no shiver-
ing nor vomiting; and the pulse is seldom in-
creased in frequency.
4. When the patient's bowels have been neg-
lected previously to confinement, and when
much flatulence exists, the after-pains are often
complicated with colic, or they assume a colicky
character. In cases of this kind the abdomen is
often somewhat more tense and distended than
usual: the fits of pain are severe, with complete
remissions; the patient complains of flatulence;
the bowels are constipated: but the pulse is not
much affected ; the skin, particularly of the
trunk, is not hot; the tongue is moist; and the
feel are often cold; in a few cases there is retch-
ing. It is important to attend carefully to the
character of pain consequent upon delivery, and
to consider it in relation to the attendant symp-
toms, particularly the states of the pulse, and of
the abdomen. We ought, therefore, to enquire
into its exact seat, examine the pained part care-
fully with the hand; and, having ascertained in
what manner it is affected by the examination,
we readily arrive at just conclusions as to its
nature. When it is felt in the regions of the
uterus and ovaria, and accompanied by great fre-
38
AGE ITS DIFFERENT PERIODS.
quency of pulse, disorder of the lochia! discharge,
tenderness, and fulness of the hypogastric region,
ice. the existence of the inflammatory diseases of
the uterus, and of its appendages, are to be in-
ferred. If it be complained of about the groin,
it may be the forerunner of phlegmasia dolens;
and if it be felt about the hip, or in the muscles
of the pelvis, abdomen, or thighs, it may be
rheumatic, owing to the application of cold in
some form or other. The pains of rheumatism
are readily recognised from their seat, their ach-
ing or gnawing character, the manner of their
affecting the motions of the part, and the attend-
ant symptoms. The diagnosis, however, of these
diseases is fully pointed out under their respect-
ive heads.
5. Treatment. The exhibition of an ano-
dyne, with attention to the state of the bowels
subsequently, has generally been considered suf-
ficient for the relief of after-pains. In the more
severe cases, an anodyne liniment has been re-
commended to be applied to the abdomen, in
addition to the exhibition of a dose of laudanum
internally; and in protracted cases, Dr. Burns
advises a purgative — certainly the best part of
the treatment usually resorted to. I am, how-
ever, of opinion, from remarking the results of
this practice, that the common or less urgent
cases would have been better left, to nature; and
that friction of the abdomen merely with any of
the liniments in the Appendix (F. 297, 298.), or
friction followed by a purgative, or an enema, is
all that is necessary. We ought to recollect that
these pains are merely the result of the healthy
tonic contractions of the uterus upon the congested
veins, and the coagula remaining in it, occasion-
ing their expulsion, and the discharge of the
blood accumulated in its sinuses; and that the
more effectually these ends are accomplished,
particularly in unhealthy situations, and lying-in
hospitals, the less risk will there be of the occur-
rence of dangerous forms of puerperal disease.
6. Whilst, however, anodynes allay the morbid
sensibility of the uterus, they tend to diminish its
tonic contraction, to induce a congested and re-
laxed state of its parietes and mouth, and to
favour the admission of air into its cavity. Air,
when admitted, particularly under certain circum-
stances, is productive of the most dangerous re-
sults, from its effects upon that portion of the
surface of the womb to which the placenta was
attached. Impressed with the justness of this
view, I have usually recommended frictions with
liniments over the region of the uterus, and a
purgative, or purgative injection, which will tend
essentially to favour the contraction of the uterus,
and the expulsion of the cause of irritation.
7. In cases complicated with flatulency and
colic (§ 4.), the above means are still more re-
quisite; but much will depend upon the choice
of purgatives. My own experience, derived en-
tirely from consultation, Is decidedly in favour
of a draught, consisting of half an ounce of the
oleum terebinthinse, combined with the same
quantity of oleum ricini; or an enema, contain-
ing the same medicines. The combination, also,
of a purgative with assafatida, or any other
antispasmodic, and an injection, consisting of in-
fusion of valerian, or containing assafictida, with
a due proportion of any aperient medicine (see
F. 130.135.13S.),will seldom fail of giving relief,
by removing flatus, and promoting the restoration
of the uterus to its natural state. In the more
urgent cases, anodynes may be conjoined to the
foregoing means; for, when thus associated, they
will not act in preventing the contractions of the
uterus. (For Hysteralgia, and the various
diseases of the uterus in the puerperal and unim-
pregnated states, see Uterus.)
BinLiOGRAPHV. — Denman, Introduction to the Prac-
tice of Midwifery, &c. Lond. 181G, 5th edit.— Gurdien,
Traite complet d'Accouchmens et des Maladies des
Femmes, ice., t. iii. Paris, 1826.— Burns, Principles of
Midwifery, ice. Lond. 1824, p. 526.— Good, Study of Med-
icine, vol. v. — Ryan, Manual of Midwifery, 3d. edit. Lond.
1831.
AGE. Syn. JEtas, Lat. Das Alter, Ger. Age,
Fr. Eta, Ital.
Classif. — Pathology and Therapeutics.
1. In the succinct view I purpose to take of the
pathological and therapeutical indications which
this subject will naturally suggest to the mind of
the practical physician, I purpose, first, to sketch
the successive epochs of life, and thus consider
the word in its generic acceptation. When I ar-
rive at those periods of existence to which the
word age is specifically applicable, the changes
which take place in the human frame, in respect
both of organization and function, with the ad-
vanced progress of years, — with age in its specific
acceptation, will be fully stated, as furnishing
important data for practical indications in the
treatment of diseases of this epoch.
2. Of Age in its generic Acceptation,
— or different Epochs of Life. Before I proceed
to consider the subject in its enlarged point of
view, I may briefly advert to the periods into
which the usual natural duration of human exist-
ence may be divided. Without occupying my
limits with the divisions adopted by ancient and
modern writers, I shall adopt that arrangement
of the different epoclis of life which has been
suggested to my own mind, from observing the
varying manifestations of life and function, and
the modifications of diseased action with advanc-
ing age. The division which 1 have thus adopted
may require more to be said in support and illus-
tration of it, particularly in respect of its physio-
logical relations, than I am willing to advance on
a subject which may be considered as nearly
verging on the speculative, heaving, therefore,
out of sight many of the physiological and psy-
chological views, which would arise out of an
extended investigation of the subject, I shall
merely briefly advert to topics of practical im-
portance ; — those which concern the medical
jurist fall not within the scope of this work. (For
epoch of fatal life, see Fojtus.)
3. Before proceeding to consider the different
periods of age individually, it may be useful to
exhibit a view of the arrangement I intend to
follow : —
I. Period, or that of Infancy.
1st Epoch, to the commencement of the fn>t
dentition.
2d Epoch, from the commencement, to the
completion of the first dentition.
II. Period, or that of Childhood.
Extending from the completion of the first to
the completion of the second dentition.
III. Period, or Boyhood— Girlhood.
From the seventh or eighth \ car to the com-
mencement of puberty.
AGE — Infancy.
39
IY. Period, or Adolescence.
Commencing with the fust appearance of
puberty, and extending to adult age.
V. Period, Adult Age.
1st Epoch; or early adult age, or confirmed
virility.
2d Epoch, or mature age.
VI. Period, Declining and Old Age.
1st Epoch, declining age.
2d Epoch, green old age.
Sd Epoch, advanced old age, ripe old age.
4th Epoch, decrepitude, second infancy.
4. 1. Period, orthat of Infancy, (In/nnli a,
from the privation of speech,) commences with
birth, and extends to about the end of the second
year, when the first dentition is completed. It
may be divided into two epochs; the first begin-
ning at birth, and extending to the sixth or
seventh month, when dentition is fully com-
menced; the second proceeding from this age to
the end of the period, the completion of the first
dentition, when the relations of the young being
with the external world are full)' established by
the developement of the sensorial and locomotive
organs.
5. A. During the /?rs/ epoch, or that preceding
the commencement of dentition, all the structures
are merely in the course of developement; par-
ticularly the osseous system, the cerebro-spinal
nervous system, and the organs of locomotion.
The functions are only acquiring activity, and
several of them have not yet appeared. The
vital phenomena gain strength, whilst certain of
those functions, by which the young being is to
hold converse with the objects around him, either
begin to dawn, or have not yet merged into
existence. The manifestations of life are chiefly
vegetative, and the movements automatic. The
attitudes are generally without variety, and the
changes of the countenance express merely plea-
sure and pain to the spectator; but, to the medi-
cal observer, they convey important information,
and often all that he can obtain respecting the
maladies incidental to this period of life. At this
epoch, the position of the limbs, the character
of their motions, the cry, and its numerous va-
rieties; and especially the changes of the coun-
tenance; the state of the eyes and eye-lids; the
openness, contraction, &c, of the eye-brows;
the appearance of the lips and nostrils; of the
mouth, gums, and tongue; — all furnish means
of ascertaining the nature and progress of dis-
ease.
6. a. At this age the organs of digestion are un-
suited to any other food than that derived from
the breast of the mother; and so Little capable
are they to assimilate any other, even of the
blandest and most digestible kind, or the milk of
other animals, that very few, not more than one
in six or seven, ever arrive at the more advanced
periods of life who are deprived of the kind of
nourishment nature intended for this epoch. At
this age the system is extremely susceptible of
external impressions acting upon the lungs, sur-
face of the body, and digestive organs; and par-
ticularly to the influence of cold. Recently re-
moved from a constant and unvaried warmth,
mid having heretofore existed with all the mucous
surfaces shut from the action of foreign agents,
the young infant imperatively requires to be pre-
served, particularly during the first montlw of
this epoch, from the influence of a low ran<»e of
temperature, and from its sudden changes. The
disposition to increased action in all the mucous
membranes, and the great susceptibility of the,
respiratory nerves, require the surface of the
body, and particularly the organs of respiration,
to be guarded from atmospheric vicissitudes; the
chief source of the diseases which are so preva-
lent and f; ital at this age. A similar suscepti-
bility of the digestive mucous surface also exists,
and is but too frequently evinced by the slightest
change in the milk of the. mother, or addition of
articles of food unsuited to the state of the
digestive organs. Much of the mischief, however,
which improper ingesta are calculated to produce
is guarded against by the copious secretion of
mucus, with which the internal surface of the
stomach and bowels is covered, particularly in
very early life.
7. The susceptibility of the mucous tissues to
stimuli and irritants, and their proneness to in-
flammatory action at this age, extend also to the
cutaneous surface, as shown by the frequency of
acute exanthematous diseases, and of chronic
eruptions. The intimate sympathy existing be-
tween both these structures is very strikingly
evinced, by the frequent association of inflam-
matory excitement of the mucous surfaces, par-
ticularly of the digestive canul, with a similar
affection of the skin. The co-existence and close
connection of inflammatory irritation of the di-
gestive mucous surface, and an analogous state
of disease of the brain and its membranes, or the
supervention of the latter on the former, are also
often observed. During the first months of ex-
istence, vascular action in the brain is promi-
nently developed, and engaged in perfecting the
organization of this organ : and partly owing to
this circumstance, as well as to the quantity of
blood sent to it, compared with the rest of the
body, and to the various causes tending at this
age to derange its circulation, is readily kindled
into an inflammatory state of its substance or
membranes, giving rise to active congestions,
effusions of fluid in the cavities and between
the membranes, and to various other organic,
changes particularized in their appropriate ar-
ticles.
8. b. With the susceptibility to be impressed by
the causes of disease, evinced chiefly in the ner-
vous centres and mucous surfaces, and producing
their effects, not only on them but also on the
serous cavities, there is intimately connected a
marked disposition to be affected by medicines,
which exert their influence in an especial manner
upon the nervous system. Of these the most re-
markable are narcotics and irritating stimulants.
The susceptibility to the influence of the former,
particularly the preparations of opium, and their
etfects, primarily in increasing vascular action
in the brain, and secondarily in favouring con-
gestion in the same organ, according to the dose,
have appeared to me so important, that, during
an extensive public practice amongst this class
of subjects, I have scarcely ever ventured, during
this epoch, on the exhibition of these medicines,
excepting under peculiar circumstances, which
will receive a more particular notice in other
places. A similar caution Is also necessary in
the use of stimulating and irritating substances.
The aperient medicines which are so often re-
40
AGE — Infancy.
quired at this age should be chiefly of a mild and
uiiirritating quality; and, whilst cold and moist-
ure must be avoided, too warm clothing, particu-
larly of the head, ought to be equally shunned.
Exposure to a mild, healthy air, frequent ablu-
tions of the surface, with cold water during the
latter part of this epoch, — commencing first
with warm water, and passing on to the use of
tepid, and afterwards of cold water, as the infant
increases in strength, — followed by frictions,
and careful attention to the state of its evacu-
ations, are means which should not be omitted in
the management of this period of life. Although
cold bathing is generally beneficial after the first
months of infancy have elapsed, care should be
taken not to subject the infant to the influence of
cold bevond a minute or two, or longer than may
be requisite to the perfect ablution of the surface;
for, at this epoch especially, the impression of
cold continued for any considerable time de-
presses the vital energies, and prevents the devel-
opement of that state of healthy secretion on the
surface, which usually follows the momentary or
brief action of cold, particularly when followed by
dry frictions.
9. B. The second epoch of this period, extend-
ing from the commencement of the first dentition
to its completion, embraces also the important
period of weaning. The natural changes pro-
ceeding in the different structures and functions
during the first epoch also continue through this.
As this period advances, the functions of external
relation, particularly speech and voluntary loco-
motion, commence, the phenomena of perception
are more perfect, and the manifestations of mind
begin to appear. The instinctive desires and emo-
tions become more and more evident and active,
and furnish, with the other functions, important
indications of disease, and of the means of re-
moving it. The susceptibility of the nervous
system, and of the mucous surfaces, to be im-
pressed by the usual exciting causes of disease,
— particularly by cold, moisture, atmospherical
constitutions, and vicissitudes, contagious or infec-
tious miasms, and errors of diet and regimen, —
is unimpaired.
10. a. Teething, which terminates the preced-
ing epoch, and ushers in this, is commonly con-
nected with more or less disorder of the system.
In infants of a healthy constitution, and in whom
the powers of life are energetic, disorder is
scarcely perceptible unless from the operation of
very efficient causes; but in those who are de-
bilitated, whose conformation has been originally
feeble, or imbued with any hereditary taint or
morbid diathesis, or who have been weakened by
unwholesome food and impure air, this process
is often attended with great disturbance in the
frame, and, owing to the morbid sensibility and
irritability it excites, frequently kindles up most
dangerous disease. During the process of teeth-
ing, particularly at its early stages, the itching
and irritation of the gums are a constant source
of excitement, or focus, whence irritation extends
to the salivary apparatus, as proved by the in-
creased flow of viscid saliva. The continued de-
sire evinced by the little patient to allay the
itching of the gums, by pressing between them
whatever it can lay hold of, and the evident dis-
tress expressed by it if this sensation, which is
known to be more insupportable than pain, can-
not be allayed, are indications which ought not
to be overlooked. If this distressing sensation be
not allayed by judicious means, the nervous sys-
tem becomes inordinately excited, febrile com-
motion is induced, the functions of digestion are
disordered; and we are, consequently, not infre-
quently called upon to remove inflammation of
the membranes or substance of the brain, various
convulsive affections, and inflammatory disorder
of the digestive mucous surface, owing to the
extension of irritation along the alimentary canal,
as well as to the acidities formed in the stomach
and bowels, from the imperfect digestion of the
food. During dentition also, a marked disposi-
tion seems to exist in the pancreas to become ex-
cited, owing to its close sympathy with the salivary
apparatus; and I am persuaded that several states
of diarrhoea observed at this epoch originate in, or
are perpetuated by, an increased secretion of
pancreatic fluid.
11. Owing, moreover, to the excitement and
irritation existing in the gums, affections of the
respiratory and digestive mucous surfaces are
more frequently associated with one another, and
with increased vascular action in the nervous
centres and their envelopes. It would seem that
the irritation existing in the mouth disposes, from
its influence on the nervous system, the mucous
membranes not only to be invaded by the exciting
causes of disease, but also to undergo the morbid
action throughout. How frequently has the ex-
perienced practitioner observed inflammatory irri-
tation of the digestive and of the respiratory
mucous surfaces associated in the same case; and
how often has he had cause to suspect the rapid
supervention of irritation of the membranes of the
brain, or of the brain itself, either with or with-
out effusion, upon inflammation of the digestive
mucous surface!
12. b. Weaning. — During this epoch wean-
ing must take place. This should not be earlier
than the eighth or ninth month, or later than the
fifteenth; and the infant ought to have, at least,
four teeth quite through the gums before it be
commenced. The milk of the mother is the in-
fant's only food during the greater part of the
preceding epoch, or, at least, until the fourth or
fifth month, unless the mother and child be in a
weakly state. From this age upwards it requires
food in addition to the nourishment afforded by
the mother; but this must be given at first in small
quantities, and not oftener than twice daily.
As the period of weaning approaches, food in
larger proportion, and increased frequency, is
necessary ; and as soon as it shall have got teeth
to masticate animal food, this may be given it in
small quantity, and at first only twice in the
week. Animal diet is seldom required before the
completion of the first year, or previous to wean-
ing; afterwards it may be given in gradually in-
creased frequency, as the termination of the epoch
approaches.
13. Whilst the infant is liable to most of the
maladies which affect it during the first months,
it is now also exposed to the invasion of many
more; owing to the excitement occasioned by
teething, the state of the milk, particularly during
the last months of lactation, and the errors in
respect of both the quantity and quality of the
food. At the same time, however, its vital ener-
gies are more developed, and its functions more
AGE — Boyhood.
41
perfect ; and thus increased resistance is opposed
to the extension of disease, and to its disorganiz-
ing effects. All infectious and exanthematous
disorders are very prevalent at this age ; and, in
addition to the maladies of the mucous surfaces
already alluded to, the lymphatic glands, particu-
larly those of the abdomen and thorax, are fre-
quently the seat of disease ; and worms often
begin to form, particularly after the period of
lactation, At this age also, owing to the changes
in the infant's food, as well as to the irritation
occasioned by dentition, the disorders which
originate in depraved or imperfect digestion and
assimilation are especially prevalent, particularly
aphtha', rickets, tuhercules, marasmus, and tabes
inesenterica, remittent fever, scrofula, and nu-
merous cutaneous eruptions.
14. c. The' therapeutical indications at this
epoch chiefly relate to the care which is required
to preserve the head cool, and ward off the vascu-
lar excitement to which it is liable. Anodynes are
less injurious at tliis period than in that preceding
it, and are often required, particularly in sooth-
ing the irritability of the nervous system arising
either from difficult dentition, from the exhaustion
occasioned by previous treatment, or by disease,
and particularly in the advanced stages of whoop-
ing-cough and croup. The state of the gums
requires particular attention ; and where there is
evidence of itching, this sensation requires to be
allayed, first, in the way that nature points out,
by pressing hard and smooth substances between
the gums, as a coral, ivory ring, and what is best,
a gold ring, when this may be directed. If the
least appearance of local affection, as tumefac-
tion, redness, &c, or even merely constitutional
disturbance, manifest themselves, the gums
should be freely and deeply scarified. Aperients,
of a mild and cooling nature, are often required
during tliis epoch ; and in it, as well as in the
preceding, blisters, even for a few hours only,
particularly when the respiratory mucous surface
i< obstructed and its functions interrupted, or
when the energies are exhausted and the vital
resistance consequently reduced, must be em-
ployed with extreme caution, and give place to
the use of those liniments which 1 shall have
occasion to recommend as substitutes for them
under such circumstances.
15. II. Period, orthat of Childhood (Puc-
ritia), extends from about the second to the
seventh or eighth year, when the second dentition
is completed. During this period the develope-
ment of the different textures and organs pro-
ceeds rapidly, and their functions are more and
more perfect. The mental manifestations, par-
ticularly those which are intellectual, are de-
veloped, and the various moral emotions gain
strength. The distinctions which exist between
sexes throughout the whole physical and mental
constitution at more advanced ages have not
yet appeared. All the soft solids of the body
evince increasing firmness, vital cohesion, and
elasticity, and are protected by a firm covering of
adipose matter below the integuments, and in the
interstices between the muscles.
16. a. If the constitution be not vitiated by
hereditary or acquired taint, defective nourish-
ment, or previous ailment, or if the causes Ik; not
of a depressing nature, disease at this period
assumes the sthenic character. Febrile diseases
4*
are generally acute ; and, unless proceeding from
sources of infection, usually the result of local
inflammatory action, which evinces a marked
disposition to terminate in the formative process,
or elfusion of coagulable lymph, particularly
when the serous surfaces are implicated. The
susceptibility to infectious diseases, particu-
larly those with exanthematous symptoms, is
very great ; as well as to inflammations of the
different textures and organs — to pneumonia,
bronchitis, cerebritis, meningitis, gastritis, ente-
ritis, &c. : besides these, glandular obstructions,
chorea, verminous diseases, epilepsy, and the
various forms of angina, are very prevalent at
this age, particularly in those whose digestive
organs have been neglected, and when morbid
matters have been allowed to accumulate in the
prima via.
17. b. The therapeutical indications applicable
to this age present few peculiarities, besides the
necessity of resorting to active depletions, with a
cooling regimen and alvine evacuations in the
majority of its diseases ; and the keeping in recol-
lection the tendency of mucous sordes and se-
cretions to form and accumulate on the digestive
mucous surface. Such accumulations furnish a
nidus for the generation of worms, and sources of
irritation to this surface itself, and to the nerves
proceeding from it ; and originate many of the
affections which appear at this, and a subsequent
period of existence. The necessity of enjoying,
and the injurious consequences of the privation,
of wholesome nourishment and active exercise
in a pure atmosphere, and the advantages of
sleeping alone in a large well-ventilated apart-
ment, should not be overlooked, in their relation
both to the production and to the removal of
disorder. The employment of the faculties of
the mind during this early stage of their de-
velopement should be left, until the last year or
two of this period, more as a matter of amuse-
ment than of exertion ; and, even then, greater
attention should be paid to the developement
of the physical powers, — the organization upon
which sound mental manifestations very ultimately
depend, — than to the precocious and even hurt-
ful excitement of faculties which are merely bud-
ding into existence. The emotions of mind,
however, particularly those which are connected
with temper and disposition, ought first to receive
attention ; strict control cannot be prematurely
applied in this direction. In this and the preced-
ing epochs of life, it is indispensably requisite not
to allow the child to sleep with persons in bad
health, or who are far advanced in life.
18. III. Period, or Boyhood — Girlhood.
From the seventh or eighth year to the epoch of
commencing puberty, is chiefly characterized by
the continued growth of all the structures, and
the developement of the manifestations of mind.
Towards the middle and end of this period the
physical and mental distinctions of sex become
more and more apparent, a. The frame, when
free from disease or hereditary taint, evinces a
sthenic diathesis, a predominance of the sanguine,
or sanguineo-nervous temperament, and a liability
to nearly the same diseases, particularly those
proceeding from infection and inflammation, that
prevail during childhood. There is a greater
liability to be affected with idiopathic continued
fever, with scrofulous enlargements and infiam-
42
AGE — Adolescence.
illations, particularly of the lymphatic glands ;
with various nervous affections, as epilepsy, con-
vulsions, chorea, &c. ; with cutaneous eruptions ;
with inflammations of the throat and air-passa-
ges ; with tubercles, especially in the lungs and
alimentary canal ; with flexures of the spinal
column, and with verminous diseases. The
nervous system possesses great susceptibility of
impressions, moral and physical ; and inflamma-
tory action has a marked disposition to give rise
to new formations, unless when appearing in the
advanced stages, or as a sequela, of eruptive or
infectious fevers, when it generally occasions
serous or sero-albuiniiious effusions.
19. b. The diseases of this period generally
require antiphlogistic remedies and evacuations,
especially purgatives, either alone or in suitable
combination, unless proceeding from depressing
causes, particularly those of a specific kind ; and
even there the necessity of resorting to alvine
evacuations, by means of laxatives, or purgatives
combined with tonics, is imperative. The vital
resistance is usually well marked, excepting in
those who have been deprived of wholesome
nourishment and pure air, or whose constitutions
are radically hi fault ; and in these, whilst tonics
and other means of restoration are required, the
due evacuation of morbid secretions and accu-
mulations is equally necessary. Care also
should be taken during this, as well as in the
preceding period, not to allow the young to
sleep in the same bed with the old, nor even with
those advanced hi age or debilitated, nor with
too many — not more than three — hi the same
sleeping apartment, which ought to be large and
well aired. Want of attention to this, is one of
the chief causes of disease in early life in Lon-
don, and other large towns. Academies and
boarding schools for both sexes are continually
furnishing numerous proofs of this too generally
overlooked cause of disease, not only at this, but
also at a later stage of life. Attention is also
necessary to the exercises of both the mind and
the body. Active amusements hi the open air
are now particularly required. As this period
advances, the mental powers acquire such a de-
gree of developement as to admit of their further
improvement and active exertion, — not only with-
out risk to the organization with which they are
related, but with the certain prospect of advanc-
ing them nearer to the perfection to which our
natures may attain.
20. During this and the earlier terms of life
frequent changes of locality and of air, particu-
larly from one healthy and open situation to
another, and especially to one which is more
salubrious, where this can be attained, are ex-
tremely beneficial, both in promoting the de-
velopement of the frame and in removing diseas-
es, particularly those of a chronic kind, or which
affect the digestive and assimilating organs. In
many of these diseases I have often derived more
advantage from change of air than from the use
of medicine. But, during advanced convales-
cence from these and febrile diseases, the benefit
derived from change of locality is most remark-
able.
21. IV. Period, or Adolescence, commen-
ces with the first appearance of puberty, and ex-
tends to the twentieth year of females, and the
twenty-fourth of males. Puberty appears at va-
rious ages, according to the climate, the'cireum-
stances connected with education, and the consti-
tution of the individual. The usual period in this
country, is from the twelfth to the fourteenth
year for females ; and from the fourteenth to the
sixteenth for males. In the northern parts of
the island, it is often a year or two later hi both
sexes. It is often observed earlier hi boarding-
schools, both in respect of males and females.
In the latter (in London or its vicinity), I have
not infrequently met with instances of menstru-
ation at ten and eleven years ; especially in
sanguine and plethoric constitutions ; and where
the apartments, particularly those for sleeping,
have been crowded and close.
22. a. This is one of the most important epochs
of human existence : for during it the natural
developement of the sexual organs imparts a
healthy and tonic excitement throughout the
economy ; bringing to their state of full perfection
all the organs of the body and all the mani-
festations of mind, excepting those that are de-
rived from experience. The organs of respiration
and voice have acquired their full growth and
tone, the muscles their due proportion, and the
cerebro-spinal nervous system its beautiful or-
ganization ; placing man, by the exercise of its
admirable functions, at the head of all animated
creation, — the dread of all other animals, the
wonder of himself. It is chiefly during this
period of life that the mind becomes stored with
ideas, derived both from the learning of the
ancients, the science of the moderns, and the
arts and accomplishments of highly civilized life ;
and is more particularly and more ardentlv en-
gaged hi decomposing the information thus ac-
quired, and recombining it in new and useful
and attractive forms.
23. As the functions and destinies of this
period are important, so they require the super-
vision of the experienced and the good. For,
with this developement and activity of both the
physical and mental powers, the instinctive feel-
ings and emotions of our nature have also reached
the utmost limits of their activity ; and many of
them, particularly those which are related to the
perfect condition of the reproductive organs, ac-
quire an ascendency, that both the dictates of
reason and moral restraint are required to con-
trol. Hence the propriety, both at tliis and the
preceding period of life, of improving the moral
affections of the mind ; of inculcating sound prin-
ciples of action and conduct, founded on moral
and religious obligations ; and of placing them in
such relations to the feelings, the intellectual
manifestations, and, moreover, to the accomplish-
ments, the elegances, and the .endearments of
life, as to render them attractive to a state of
mind and constitution which is more easily
allured bv example than taught by precept.
24. Ibe practices which both sexes are liable
to acquire at this period of life, and to which they
are more commonly addicted when they associate
in numbers at seminaries and academies, demand
the strictest supervision. They have been too
generally overlooked, both morally and medically,
from the circumstance of their consequences
having been imperfectly appreciated. There is
no practitioner of observation and experience, —
certainly none of even limited knowledge. — who
has travelled into foreign countries, and is yet
AGE — Mature Age.
43
unacquainted with the physical exhaustion, the
mental torpor, and all but annihilation of ex-
istence, which is the ultimate result of indulging
them. Prom this source frequently spring, impo-
tencj hereafter; the extinction of families and
hereditary honours — honours which such per-
sons are incapable of achieving ; the infliction,
during after-life, of many of the diseases which
proceed from debility, and the exhaustion of the
nourishment and vital energy of the various
structures and organs ; of numerous nervous and
convulsive malaqles, as hysteria, epilepsy, neu-
ralgia, chorea, melancholia, mania, idiotcy, &.<-. ;
the dangerous or fatal visitation of fevers ; dis-
eases of the heart, disorders of the digestive
organs, premature baldness and old age, the
formation of tubercles, and the production of pul-
monary consumption ; and, lastly, the transmis-
sion of weak and decrepit bodies and minds to
the offspring; of scrofula, rickets, verminous
complaints, marasmus, hydrocephalus, convul-
sions, tubercles, chorea, &c. : the curse is visited
on the children to the third and fourth genera-
tion, until the perpetuated punishment extin-
guishes the very name of the aggressor.
25. />. The pathological conditions of this
age are especially characterized by exalted
action. At the approach and commencement of
puberty, the glandular system is extremely prone
to congestive inflammations, particularly the
lymphatic glands of the neck and arm-pits.
Tubercles arc rapidly developed in the lungs ;
and this organ is much disposed to acute and
chrome inflammations of both their substance and
mucous surfaces. Pulmonary haemorrhages usurp
the place of the epistaxis of earlier epochs ; and.
in females, dysmenorrhea, protracted or retained
menstruation, chlorosis, hysteria, and occasion-
ally monorrhagia or leucorrhcea, occur. The
sanguine diathesis and plethoric habit, in those
of a sound constitution, and the sanguine, irri-
table, and nervous temperaments, or the one
associated with the other, most commonly pre-
vail at this period of life.
26. The progress of disease is generally rapid,
and its character acute. Inflammations are more
prone to give rise to the formative processes ; and
febrile affections, when they terminate by cris -.
evince a preference to hremorrhages and sweats.
Idiopathic fevers, inflammations of the respira-
tory organs, and of the brain or its membranes,
are the most common diseases of this age.
27. c. The therapeutical indications require
but little remark ; for the system has now nearly,
or altogether, reached its full growth ; and the
general inferences which guide the practitioner
in the employment of remedial means have now
reference, especially, to states of habit, consti-
tutional powers, temperament, and diathesis, —
physical manifestations, which are now, in a
great measure, developed, but which acquire
their most predominant characters in adull age.
As the maladies of this period are generally in-
flammatory, and evince a strong tendency to the
formative process, and as the powers of life are
now most energetic, vascular depletions, with the
antiphlogistic regimen, are generally required,
and are uell borne; excepting in those whose
constitutions have been originally in fault, or
who have greatly injured it by the injurious
practice of masturbation, from which so many
suffer, both at this and subsequent epochs of
life.
28. V. Period. Adult Age may be divided
into the epochs, 1st, of early adult age; and 2d,
of mature age, or confirmed virility. Of each
of these I shall take a brief notice.
A. Early adult age may be dated from twenty
to thirty in the female, and from twenty-four to
thirty-five in the male. During this epoch, if
the constitutional powers have not been injured
previously, the whole frame and its individual
organs continue to acquire strength ; and, al-
though the body has ceased to grow in height,
it increases in bulk, particularly the muscles of
voluntary motion and the parietes of the large
cavities. It is also more capable of enduring
continued exertion and privations ; its vital en-
durance and resistance being greater than during
the period of adolescence. The features and ex-
pression of the face ; the character, disposition,
temperament, and diathesis, are more unfolded,
and towards the termination of this period fully
display their manifestations.
29. B. Mature age, or confirmed virility, may
be considered as being from thirty to forty, or
forty-two, in the female, and from thirty-four
to forty-eight in the male. During this time of
life, the features of the countenance fully assume
those modifications of character arising from the
influence of the passions and emotions of the
mind ; and the appetites, habits, and occupations
of life imprint upon the frame generally certain
appearances, arising from their continued influence
on the constitution. The muscular organs, par-
ticularly the muscles of the extremities, are prom-
inently marked ; the chest fully developed ; the
body spare and active ; the adipose structure ex-
tremely scanty, and the abdomen small, in those
habitually devoted to laborious employments, not
of a sedentary nature, and to active exercise, either
on foot or horseback. The sedentary, those ad-
dicted to the indulgence of the appetites, and
particularly those given to the gratifications of
the table, have large abdomens, small extremities,
and large depositions of adipose matter beneath
the integuments, between the muscles in the
omentum and surrounding the viscera, with a
weak and defective developement of the muscular
parts. The studious present the chief marks of
their occupations on the features of the counte-
nance and character of the head ; the appearance
of the rest of the frame varying with the habits
and indulgences with which study or the pro-
secution of science may be conjoined. At this
period of life also the feelings, the anxieties, the
disappointments, the losses, and the various mo-
ral emotions of life, begin to manifest those effects
upon the frame, which become still more fully
marked during the following epoch.
30. This and the preceding period of adult
. upon the whole, the most exempt of all
othi rs from disease ; but about 'the age of forty,
and still more so as the age of fifty is approached,
the sanguineous circulation becomes more and
more languid, particularly in the veins : hence
the frequency of venous congestions and visceral
i ons, with the various diseases depending
thereupon, particularly haemorrhoids ; bilious de-
rangements ; bilious and gastric fevers ; inflamma-
tions ; ati'ections of the heart ; apoplexy and para-
lysis ; derangements of the stomach and liver ;
44
AGE — in its specific Acceptation.
ha?matemesis ; affections of the joints, as gout and
rheumatism ; diseases of the urinary organs ; hys-
teria and uterine disorders ; hypochondriasis, and
affections of the mind. At this period therapeu-
tical means require to be strictly regulated ac-
cording to the sex, constitution, temperament,
habits, and occupations of the affected.
31. VI. Pkriod. Age, in its specific ac-
ceptation, may be divided into four epochs:
viz. 1st, Declining age ; 2d, Green old age ; 3d,
Advanced oh! age ; 4th, Decrepitude, or second
infancy. Before I proceed to consider these in-
dividually, I will take a view of the changes
which supervene with age in the structures and
functions of the body.
Age, in the sjxeific acceptation of the word,
may be considered as commencing when the
vital energies of the different organs begin to de-
cline,— when the maturity of life glides into de-
cay. The period at which this change supervenes
varies very much in different persons, according
to their constitutions, employments, and habits
during the earlier epochs of existence. In many
it is so gradual as to be imperceptible ; in others
it is more obvious ; and in some it is induced
rapidly and remarkably, by mental anxieties and
bodily disease. The usual period of its advent,
in both sexes, and the different epochs in which
age may be divided, will be stated in the sequel.
32. As age steals on, all the functions are per-
formed more languidly than in earlier life. The
energies of the ganglial system decline, as
evinced by the digestive, circulating, and secret-
ing functions, which it actuates. 1 he sensibility
of the cerebro-spinal system, and of its dependent
organs ; the acuteness of our intellectual powers,
our moral emotions and affections, and the ac-
tivity and strength of the locomotive organs, — all
experience diminution, great in proportion to the
advances of age.
In noticing the pathological and therapeutical
relations of age, those changes of structure and of
function which supervene with it will first re-
ceive attention ; next, the different terms into
which it may be divided, with those modifications
which diseased actions generally assume in each
term respectively, and those indications which
should guide our practice in the diseases to which
each is most obnoxious, will be briefly considered.
33. A. The modifications of structure produc-
ed by age are occasionally slight ; but most com-
monly they are very remarkable, particularly in
certain organs. In some parts they are scarcely
perceptible, in others more oWious, consisting
chiefly of increase of density ; and in many they
amount to actual change of texture.
The integuments, particularly those of the
face, and the hair, are amongst the earliest parts
to exhibit the advance of age ; and they most ob-
viously indicate the different stages of its pro-
gress. The integuments of the face seem more
developed than in early or mature age. They
are denser and thicker, especially the cutis vera
and rete mucosum ; which latter assumes also a
somewhat darker tint. The skin appears more
loosely attached to the parts underneath it, chiefly
owing to the diminution of the subjacent fat, and
shrinking of the other soft solids. Hence it ap-
pears, particularly in the face, neck, and hands,
flaccid and wrinkled.
34. The hairs of the head are, perhaps, the first
to evince the commencement of age ; and the.y
present the most common indications of the pro-
gress of decay, either by a more or less complete
change of colour, or a partial and general loss of
them. The change of colour at first consists of
a few white or gray hairs, scattered amongst
those of a natural hue; but these gradually be-
come more numerous, particularly on the tem-
ples, until the whole hair is altogether gray, and
ultimately white and transparent. As this change
proceeds, the hair also falls out, especially on the
crown and forehead. There are, however, many
circumstances which accelerate these phenomena,
independently of age. Thus fevers, severe cour-
ses of mercury, masturbation, &c. will occasion
the loss of the hair. But when it falls out from
disease, the bulbous roots not being obliterated,
•its reproduction generally follows; whereas,
when it is lost from old age or from masturba-
tion, it is never reproduced. There are also
various causes which occasion a change of its
colour, particularly the depressing passions, in-
tense application to study, anxieties of mind,
venereal indulgences, &c, and which at the
same time accelerate the loss of it. The change
of colour, and subsequent loss of hair, seem to
arise from deficient nutrition, and consequent
atrophy, or destruction of the bulb, together with
some change in the skin itself. In some cases it
seems to arise from chronic disease of the rete
mucosum and cuticle, as stated in the pathology
of certain cutaneous affections.
35. The adipose and cellular tissues experi-
ence considerable change. The fatty deposit
diminishes with the progress of age, and it some-
times becomes more fluid and watery, as well as
of a -deeper tint. The cellular tissue is somewhat
denser, more fragile, and less elastic than in early
life. In some situations it assumes a fibrous
character, particularly that portion of it which
invests the muscular fibres. The serous mem-
branes are also more dense, more subject to ossific
deposits, and their free suiface drier than in early
life. The mucous surfaces exhibit but little
change, excepting as respects their greater pale-
ness, and tendency to certain states of disease.
The fibrous structures become more rigid, and in
various parts the seat of ossific deposits. They
also assume a deeper colour, and firmer and
tougher consistence, whilst their physical cohe-
sion is much increased as age advances.
36. The muscles of voluntary motion expe-
rience a very marked change, particularly at
the advanced epochs of age. They are much
diminished in bulk. Their fibres are more rigid,
less readily influenced by stimuli, and less con-
tractile than in early life. They are also less
under the control of volition, much less energetic
in their actions, more flaccid, and endowed with
less vital tenacity. Their structure is also some-
what modified. They are paler, sometimes of a
light yellow colour, and their fibres less distinct
than in youth. The tendons and aponeurotic
expansions of muscles, as well as the cellular
tissue intervening, are often partially ossified.
Portions of muscles, near their tendons, are some-
times converted into a tendinous structure ; and
the secretions poured into the sheaths of the ten-
dons are remarkably diminished. From all these
changes result the vacillating, embarrassed, and
weak movements of the aged.
AGE.
45
37. The bones acquire a dense structure, and
even a somewhat increased size, particularly the
hones of the head, the sutures of which become
lirmlv united, first in the internal, and afterwards
in the external surface. '! he cartilages are ossi-
fied, particularly those of the ribs. The inter-
vertebral cartilages become hard, inelastic, and
shrunk: hence tlie impaired flexibility of the spinal
column, the bending forwards of the trunk, and
diminished stature of aged persons.
38. The bloo i-vessels undergo very remarkable
changes. The arteries are gradually diminished,
in proportion to the hulk of the body, as age
proceeds; and the predominance of the venous
over the arterial system is more and more appa-
rent. Whilst the arterial vessels become, on the
one hand, more. dense and rigid in their coats,
their calibre diminished, their smaller ramifica-
tions altogether obliterated, and their vasa va-
sorum indistinct, the veins seem, on the other
hand, somewhat thinner in their coats, more
dilatable, and their calibre increased; they are
also more tortuous, and hence their capacity is
augmented : so that, although the quantity of
blood contained in the body is diminished, par-
ticularly at the most advanced stages of life,
about two thirds of it are contained in the veins.
Besides those changes of capacity, the coats of
the vessels present changes of structure. The
arteries are liable to ossitic and other deposits,
rupture of their coats, &c; the veins to varix,
inflammation, &c.
39. The brain and nerves are also somewhat
modified by age. The membranes of the former
are generally slightly thickened and opaque.
The hulk of the brain is diminished, and its sub-
firmer and tougher than natural, and less
readily acted upon by chemical re-agents. The
nerves seem to possess a diminished quantity of
medullary substance, and their blood-vessels are
indistinct. The ganglia become firmer, of a
deeper colour, and smaller than in early life.
40. The organs of sense undergo important al-
as. The eyes are changed chiefly by the
diminished secretion of aqueous fluid into the
ior chamber, occasioning less prominence of
the cornea, and a change of its refractive power.
The crystalline lens acquires a yellowish tint, and
is less transparent. The nerves of the eve, par-
ticularly the optic nerves and ophthalmic branch
of the fifth pair, and the iris, are less sensible
than before ; and hence the dilatation of the
pupil, the distant sight, and the confused appear-
ance of near objects to aged persons. The ear
experiences a change similar to that which takes
place iii the eye. The fluid occupying its inter-
nal cavities is diminished or altogether absorbed;
and the auditory nerve rendered insensible to im-
pressions, from this and other changes in the con-
ditions necessary to its functions. The other or-
gans of sense, particularly taste and smell, have
also their sensibility similarly blunted.
41. Bnt changes are not limited to the more
ttary structures of the body; and organs of
the risrrra of digestion, secretion, assimila-
tion, sanguifaction, and generation undergo analo-
gous alterations. The teeth loosen or decay; the
gums are partially absorbed; and the jaws, de-
prived of teeth and of their alveolae, approximate
more closely. Hence the projection of the chin,
its approach to the nose, and diminished capacity
of the mouth. To these causes are partly to be
imputed the change which takes place hi the
speech of the aged. The stomach and bowels are
generally flaccid, owing to deficient contractility
of their muscular coats; but the liver, pancreas,
and spleen present but little change, excepting
they are, or have been, the seat of disease, unless
slight atrophy, or enlargement and increased dens-
ity. The urinary organs are more frequently
altered: calculi are not infrequently met with in
the tuhuli uriniferi and pelvis of the kidneys; and
the urinary bladder is generally thicker and firm-
er in its coats than in early life; the prostate gland
is commonly somewhat enlarged.
42. The lungs are not necessarily changed by
age, further than that they become less elastic,
their air-cells enlarged, some of the bronchial
ramifications more dilated, and portions of them
emphysematous. They frequently, however, pre-
sent the remains of antecedent disease. The
heart partakes, although in a less remarkable
manner, of the changes experienced by muscular
parts. The tone and energy of its fibres are low-
ered; its structure is softer, more flaccid, and oc-
casionally also paler. It is sometimes diminished
in size; or some of its cavities are dilated, and
their parietes thinned; and cartilaginous or ossific
formations, or both, occur in parts of its internal
surface, particularly in the valves.
43. The organs of generation experience a
marked alteration. The ovaria shrink, become
dense, and their vesicular structure changed.
The uterus is diminished in hulk, unless it is the
seat of organic disease, to which it is very liable,
particularly at its mouth and neck. The mamma
also waste, are soft, pendulous, and lastly are en-
tirely absorbed. The areola? become dark, and
the nipples shrink. At the commencement of
age they are subject to congestions, indurations,
and scirrhous disease. The testes shrink, or be-
come soft and small, or even nearly disappear.
The penis is shrunk, seldom experiences the vital
turgescence, and lastly not at all; the faculty of
generation having previously disappeared.
44. In this rapid sketch of the chief changes
which the structures and organs of the body un-
dergo from age, there are several phenomena
which must strike the reader. The chief of these
are, the gradually increased density of the different
textures, and the consequent diminution of their
watery or fluid constituents, as well as of the
blood itself In childhood and early life the tex-
tures tire succulent, and the circulating fluid
abundant. But as age advances, they acquire
an increase of their physical cohesion, whilst their
vital attraction is diminished. This increase of
densitj and diminution of the fluid elements of the
structures, with the progress of age, are constantly
observed in the vegetable kingdom of nature: and,
as we advance upwards, through the various
grades and classes of animals, we find this prin-
ciple strictly adhered to. In addition to this,
another phenomenon is remarkable; namely, the
redundance of osseous matter, as evinced not only
by the increased quantity of earthy matter in the
bones and cartilages, but also by the deposition
of this substance in the coats of the arteries and
in other textures. Somewhat analogous to these
formations, and sometimes even vicarious of them,
Ls the abundance of sabulous deposits from the
urine, frequently observed to occur either during
46
AGE.
the secretion and retention of this fluid, or after
its discharge.
4-5. Not only are the mechanical conditions of
the different parts of the body modified by age, as
now stated, but their chemical properties are also
similarly affected. The gelatin disappears, or be-
comes changed to albumen; the fibrin is increas-
ed, and assumes a deeper hue, and is less easily
affected by maceration or exposure to the air.
The phosphate of lime is augmented, and often
accumulates to a very hurtful extent, together
with the other earthy salts and urea.
46. B. Of the conditions of function charac-
terizing the advance of age. a. Although the
changes, which have been now described as
supervening in the different structures with age,
may have originated in those imperceptible and
slow modifications which the various organic
functions experience from peculiarities of consti-
tution, of food and employment, or from ac-
quired habits and indulgences ; yet there can be
no doubt that, when once induced, they modify
still further these functions, and thus draw on
other lesions, and ultimately still greater alter-
ations of both function and structure, or even
speedily fatal disease. But we are not altogether
justified in considering these contingencies as the
primary causes of the changes now described.
We are rather to view them as more or less re-
mote effects of the failure of the vital endowment
of the frame, manifesting itself first in a less per-
fect performance of the different functions, and
subsequently in modifications of structure, and
ultimately in very obvious lesions of both func-
tion and structure.
47. b. It is supposed by some, that the embryo
at its earliest formation is endowed with a certain
sum or allotment of vitality, which, in the earlier
epochs of life, is engaged in the formation of, and
in bringing to perfection, the different structures
and organs of the frame; that it is gradually ex-
hausting itself ever after, until it at last expires;
and that the greater the excitement of its different
manifestations and functions during the subsequent
stages of existence, the more rapidly will its
termination be reached; that the oil with which
the lamp of human, and indeed all animal, exist-
ence burns is filled at its commencement, and
is never afterwards supplied; and that the more
brilliant the flame, the shorter will be its du-
ration. This captivating hypothesis, however,
appears, on an intimate view, irreconcilable with
many of the phenomena of health and disease.
It cannot readily be conceded tha't the allotment
of vitality bestowed upon the germ or germs can
exceed that possessed by the parents, — for the
hypothesis is, that the sum of vitality is greater
the younger the animal; and that it diminishes
with the advance of days and years, from the
period of its endowing the embryo. But it is ob-
vious, that the greater vital endowment cannot
issue from the smaller; that the parents cannot
possibly impart to the embryo more than they
possess, they still retaining a portion afterwards :
more particularly when we consider that the
greater endowment is imparted not to one embryo
onlv, but to several, as is the case in the lower
animals, and often in the human species also.
48. The phenomena, moreover, of disease fur-
nish us with proofs that this sum of vital endowment
is neither thus early and at once bestowed, nor thus
uniformly diminished, according to the waste it
experiences, without occasional reinforcement.
We frequently perceive all the manifestations of
life reduced, at different epochs of existence,
nearly to total extinction, particularly in several
kinds of fever, when, having received the requi-
site aid from external stimuli, they have been
gradually restored to their former activity. In-
deed, the various circumstances in which thebodv
is placed, and the different states it presents at
different periods of life, and from numerous causes
which affect it, seem rather to favour the idea that
the sum of vitality, and its manifestations in the
different organs, fluctuate more or less during the
allotted period of existence; that a certain eman-
ation of vitality proceeds from the parents, great
in proportion to their constitutional powers; but
that this endowment is constantly experiencing an
accession, first from the mother, and subsequently
from the common sources of air and aliment;
that this reinforcement is thus constantly supply-
ing the waste arising from the exercise of the
various functions, and adding to the bulk of the
structures, until manhood is reached; and that at
this period the sum of vitality has reached its
greatest amount, from which it gradually declines,
owing rather to the waste, particularly that occa-
sioned by the exercise of the generative functions,
exceeding the supply, than from the continued
expenditure of what is at first bestowed and never
afterwards reinforced.
49. Having been induced by the foregoing, and
other considerations, to relinquish the former for
the latter hypothesis, I infer that the gradual di
munition of the vital energies that accompanies
the progress of age is more or less manifested
throughout all the functions; that the functions
first evince this decline, and that the organs them
selves are at last modified in organization, from
the slightest and almost inappreciable shades to
the most marked alterations. 1 he changes of
structure, once induced, tend most essentially to
heighten and to perpetuate the previously slight
disorders of function, until both the one and the
other undergo, by reciprocity of influence, most
in portant alterations, terminating at last in death,
and the dissolution of the frame. I now pro-
ceed briefly to notice those changes of function,
which, frequently related to the alterations of
structure described above, mark the existence of
Age.
50. c. I have, in another place, stated that, of
all the different tissues of the frame, the ganglial
system is the most intimately related, in every-
way, to the vital influence which endows the body.
And it is precisely those organs which are most
immediately connected with this system that first
furnish proofs of incipient decline in the languor
or imperfections of their functions. Amongst those
functions are comprised those of digestion, secre-
tion, circulation, assimilation, the preservation of
the animal temperature, and generation. The
functions of animal relation are not so soon af-
fected; and at first the change in them is rather
secondary, and owing to the pre-existing change
of the functions of organic life, — of those func-
tions which are excited or actuated through the
medium of the ganglial system.
51. As very intimately dependent upon the state
of the ganglial system, the secretio7is manifest,
with the advance of age, the most remarkable
AGE.
47
lesion. These are generally modified in qua ntity,
in fluidity, and in quality. 1st, 'I he quantity of
the secretions, both recrement itial and excremen-
titial. is sensibly lessened. '1 he salivary, gastric,
biliary, cutaneous, and spermatic secretions evince
this change. 2d, 'I heir fluidity is diminished, as
shown by the salivary, the lachrymal, cutaneous,
and watery exhalations and secretions. And, 3d,
their properties are modified, as proved by their
marked tendency to assume, immediately as they
are secreted, irritating and acrimonious qualities,
as shown by their efforts upon the tissues, with
which they remain for any time in contact, and
to pass rapidlv into decomposition. rl he urine,
and occasionally the lachrymal, the mucous, the
biliary, cutaneous, and sebaceous secretions
evince this change. It very generally happens
that the secreted fluids experience more than one
of the above alterations ; they being diminished
both in quantity and in fluidity, and at the same
time deteriorated in quality. 'I his is remarkably
the case in respect of the cutaneous, mucous, and
urinary secretions ; the chief exception being fur-
nished by the mucous fluid, which is sometimes
increased, although it is of diminished fluidity and
altered quality : but this is rather an effect of dis-
ease, than merely of advanced age.
52. JN'ext to the function of secretion, and
owing to the same cause, — the diminution of vital
influence, — that of circulation is most sensibly
affected. The action of the heart is slower than
in early life, much less energetic, and occasionally
irregular. 1 he capillary circulation is more lan-
guid, and a much smaller quantity of blood pene-
trates the extreme ramifications and nutritious
vessels, in consequence, most probably, of the
diminished calibre of those vessels, and the in-
creased density of the tissues in which they ter-
minate. The venous circulation is more congest-
ed, and more prone to experience the conse-
quences of engorgements, particularly varicose
dilatations, giving rise to effusions of blood and
other serious diseases. The blood itself is not
only diminished in quantity, but is also ofa darker
colour, and is probably also slightly changed in
quality, particularly in respect of certain of its
saline constituents. The absorbent system is less
frequently disturbed in its functions by age than
almost any other part of the frame, although it
occasionally evinces diminished power, but chiefly
in connection with disease. To the predominance
of the absorbent function over that of arterial
circulation has been partly ascribed, and with
apparent justice, the wasting and condensation of
the structures characterising the most advanced
epochs of life.
53. As intimately connected with the weaken-
ed energy of the ganglionic and vascular systems,
the functions of digestion and assimilation are
languidly performed. The gastrin, pancreatic,
and biliary juices are less abundantly secreted in
the aged than in those of early or mature years ;
and the tonic contractility of the coats of the sto-
mach and bowels is diminished. Hence result
various dyspeptic ailments, flatulence, and a slug-
gish state of the bowels. The receptacles which
nature has provided for the temporary retention
of the secretioas and excretions, particularly the
biliary and urinary bladders, react imperfectly on
their contents, owing to the lowered power of the
nerves which actuate them : hence arise distension
from the inordinate accumulation of the secre-
tions poured into them, and changes of the pro-
perties of these secretions during their retention,
either occasioning their expulsion, or producing
actual disease.
54. As closely related, also, to the lowered
energy of the nerves of organic life, and conse-
quent languor of the circulation, the generation of
animal heat in the aged is evidently diminished,
although the causes which usually moderate it in
the young, — namely, abundant exhalation and
evaporation from the surfaces of the lungs and
skin, — exist in a much less degree in the former.
The functions of generation are, however, those
most remarkably affected. In the female the
faculty of conception is altogether abolished, and
important changes occur in the state of her ap-
propriate organs ; yet the sexual desire still lingers
for awhile : and in the male, although the ability
of procreation may remain, under favourable cir-
cumstances, for some time, it is at last entirely
abolished.
55. rI hus we perceive, that as the different vis-
cera of organic life increase in density, and expe-
rience a diminution of vital expansibility and con-
tractility, so their functions become more languid
or imperfect, until some of them cease to be per-
formed, and others are remarkably altered. But
the change is not limited to this class of structures.
Those organs which are devoted to the extension
of our intercourse with surrounding nature, and
are subservient to the manifestations of mind, as
well as those manifestations themselves, in both
their intellectual and moral relations, undergo,
although at a more advanced period, in respect of
some of them, very marked modifications.
56. The changes that take place in the mus-
cular and their associated structures evidently
would render them incapable of performing those
actions, to which volition may impel them, with
energy, rapidity, and steadiness, even although
the nervous system of voluntary motion were
altogether unaffected. But tliis system, owing
probably to those slight, and nearly inappre-
ciable, alterations noticed above (§ 36.), pos-
sesses much less energy and susceptibility of action
than in the prime of life, and therefore actuates
the muscles in a less vigorous manner.
57. The same condition of the brain and cere-
bro-spinal nerves, which contributes to render the
actions of volition less precise and energetic, seems
also to be connected with the less vigorous exer-
cise of the intellectual powers, and the imperfect
conditions of the functions of sense. These func-
tions generally indicate incipient decay before
the powers of mind are affected ; and some of
them are nearly abolished, particularly hearing
and seeing, before the latter evince any marked
change. But more commonly the decay of the
senses is soon followed, occasionally as a neces-
sary result, by a slight failure of some of the men-
tal faculties. The memory, and- the power of
assoi iation as intimately related to memory,
are the first to evince this declension, generali)
by a want of recollection of the names of persons,
subsequently of the names of things and of recent
events, or recently detailed information; the
judgment continuing either altogether or but slight-
ly impaired. 'With this declining state of the
faculties, the emotions of the mind are often re-
markably blunted ; the desires and affections are
48
AGE — Old Age.
impaired, excepting in as far as respect early-
formed associations and affections, which are
often recalled with acute and even overwhelming
emotion.
58. As age advances sleep is much lessened ;
and not only is the duration of repose abridged,
but also its soundness ; the rest of the aged being
imperfect, and disturbed by dreams. It is diffi-
cult to explain this — indeed no satisfactory
explanation of it has yet been offered ; but it is
generally observed, particularly in very advanced
age.
59. Such are the changes induced by age in
the various structures and functions of the body,
as evidently caused by the gradual decline of the
vital energy, from the period of full manhood to
its ultimate extinction. I have described them
as much divested as possible of the effects of dis-
ease. As now noticed, those changes gradually
lapse into death, — the lamp of life having burnt
out, its oil having been exhausted, after a gradual
diminution of the supply, without any single organ
evincing that state of disease to winch the ces-
sation of life can be ascribed. This is, however,
not a common occurrence ; for, during the grad-
ual decay that marks the progress of age, some
organ or other, owing to the deleterious influence
of surrounding agents, or of mental emotions,
and the weak resistance of the vital influence,
experiences a more or less marked derangement,
which increases to actual disease, and either
abridges the remaining short period of existence,
or renders it less supportable.
I now proceed to notice the different epochs of
advanced age, with reference chiefly to the dis-
eases incidental to each, and to the therapeutical
considerations which should influence the treat-
ment of them. (See Climacteric Disease.)
60. 1st Epoch, or declining age extends from
forty or forty-two to fifty-two in the female, and
from forty-eight to sixty in the male. a. During
this period the appetites, occupations, and habits
express themselves still more strongly upon the
outward appearance of the frame than in that
immediately preceding it ; and the feelings, emo-
tions, disappointments, and anxieties of life mani-
fest more fully their effects upon the internal or-
gans, as well as upon the external aspect. Venous
congestions, visceral obstructions and engorge-
ments, with all the specific forms of disease al-
ready enumerated, (§30.) are more frequent than
during earlier epochs, particularly apoplexy and
paralysis, haemorrhoids, hepatic disorder, dropsies,
structural change in the kidneys and bladder, hy-
pochondriasis, haematemesis, gout, and chronic
affections of the respiratory organs.
61. b. In this period, the second great change
to which the constitution of the female is liable
generally occurs, terminating that epoch in which
her sexual constitution is especially marked ; and
with this change frequently commence, or are
matured, several diseases of the female organs.
Morbid changes of the uterus and its appendages,
as well as of the breast, are now very frequent ;
and sometimes they assume a malignant character.
Various maladies, to which the female was less
exposed than the male, are now oftener met with ;
and her constitution, with its disposition to disease,
approaches more nearly to that of the male than
during the time of marked uterine activity.
62. 2d Epoch, or green old age, may be reck-
oned to commence about 53, and to extend to
60 or 65 for the female ; and to begin about 60,
and extend to 65 or 70, in the male. During
this epoch the nervous, circulating, and muscular
energies begin to languish, with the vital actions
of the different internal organs. The functions
of the sexual organs gradually disappear. The
female no longer conceives ; and sexual plethora
ceases to supervene and to relieve itself by a
periodical discharge. The ovaria begin now to
be gradually diminished in bulk, and to assume
a firmer structure ; the appetite for procreation
slowly disappearing (§ 43. 54.). The male organs
also either become less disposed to their proper
functions, or nearly altogether lose the faculty
of performing them, particularly when the ener-
gies of the constitution have been exhausted by
previous indulgences carried to an excessive
length, or by mental exertions. The teeth decay,
and the digestive functions suffer from the imper-
fect mastication of the food (§ 41.).
63. 3d Epoch, or ripe old age, dates from the
preceding, and extends to 70 or 75 in the female,
and to 75 or 80 in the male. During this term
the sensiferous and sanguiferous systems languish
more and more, and all the vital organs expe-
rience a rapid decline of activity. The teeth fall
out, the gums are partially absorbed, and the di-
gestive functions are greatly impaired. The sex-
ual organs are nearly or altogether deprived of
their functions ; the digestive and assimilating
viscera experience a marked diminution of pow-
er ; and senile marasmus, or the leanness of old
age, advances (§ 53.).
64. a. The diseases of this and the preceding
epochs are chiefly weak or imperfect digestion
and assimilation ; chronic inflammations ; general
asthenia and cachexia ; apoplexies ; paralysis ;
loss of the senses of sight and hearing ; senile
gangrene ; comatose affections ; dyspnoea ; dis-
eases of the heart and liver ; dropsies ; organic
changes in the urinary and sexual organs of both
sexes ; passive haemorrhages, from the stomach,
bowels, and urinary organs ; mental disorder ;
and gradual extinction of the vital functions and
energies. Febrile and inflammatory diseases have
a much more marked disposition to terminate in
organic change, owing to the diminution of vital re-
sistance, than during the preceding epochs of life.
65. b. The therapeutical indications of this
period are in some respects important, but chief-
ly with reference to the necessity of supporting
the powers of life during the diseases to winch
it is liable. When inflammatory or febrile disor-
der is present, and depletions or evacuations are
necessary, we should, particularly if we employ
them actively, watch their etfects, and resort to
the use of means calculated to support the frame
as soon as indications of exhaustion are mani-
fested. Purgatives at this period should, if fre-
quently repeated, always be combined with warm,
tonic, or supporting medicines, or with a restor-
ative regimen ; and a strict reference ought to be
made to the habits, constitutional powers, and
feelings of the patient, in all the remedies we
prescribe. Old habits must not be suddenly
relinquished or opposed, and the powers of life
should be carefully watched ; for, if unheedingly
reduced, they will, particularly in large cities,
often sink most rapidly, without the power of
rallying' When we consider that, in persons
AGE — Decrepitude.
49
advanced to this age, a considerable portion of
i lie arterial system is often in a state of slow or-
canic disease; that the venous system is prone
t,i congestion, is sometimes relaxed and almost
varicose, always deficient in vital contractility,
and scarcely able to perform its functions; and
that both the one and the other cannot thereby
so readily accommodate themselves to sudden
or copious losses of blood as in early life and when
they are perfectly free from disease, we cannot be
surprised at the sudden depression occasioned by
vascular depletion, or other means which produce
8 rapid discharge by the emunctories of the watery
parts of the blood, or a sudden depression of the
nervous energy, even although symptoms seemed
unequivocally to demand their employment.
bb'. The last epoch, or that of Decrepitude,
or second infan'cy, commences at 70 or 75 iuthe
female, and at 75 or 80 in the male, and termi-
nates the life of those whose span of existence
is thus far prolonged. During this period, all the
physical and mental powers rapidly decline. The
body emaciates, the muscles wasie, and the adi-
pose structure is absorbed; the integuments be-
coming lax, wrinkled, dry, and disposed to retain
accumulations of sordes. The knees totter and
bend under the weight of the body; the trunk
stoops, and is incapable of any considerable mo-
tion, excepting forwards; and the features are
wan, devoid of colour, wrinkled, and emaciated,
and apparently consisting chiefly of integumental
covering (§ 33.).
67. a. Congestions, enlargements, obstructions,
and even atrophy of the internal viscera; effu-
sions of fluid into the shut cavities; irregularity
of the heart's action from loss of its vital activity,
ur structural change of its valves, its arteries, or
muscular texture, or from disproportion between
the capacities of its compartments; lesions of the
vascular system generally, in which either those
of the arteries or of the veins predominate. Pas-
sive hemorrhages from the mucous surfaces,
particularly those of the alimentary canal and
urinary apparatus; general asthenia, or cachexia ;
and slow extinction of the vital and natural functions
of the frame, — the ganglial, the cerebro-spinal,
and the circulating systems; and the digestive, the
respiratory, the secreting, and excreting organs,
evincing individually, or either of them conjointly
with others, more or less disease, — are the princi-
pal causes of death: and thus man, whose mental
and physical constitution and organization were
objects of profound study and admiration to him-
self, passes away ; the vital essence, that actuated
the wisely devised frame with which it was so
surprisingly associated, returning to the Divine
source whence it emanated; and the gross mate-
rials, which it combined and preserved in won-
derful states of association, assuming novel modes
of existence, and serving to form new beings
much lower in the scale of organized creation.
68. b. The rapidity with which acute disease
generally runs its course at this period, and the
celerity with which organic change will frequently
supervene and extinguish the dimly burning taper
of life, require great decision and circumspection
on the part of the physician. The resistance
which the energies of life usually oppose, both to
the extension of disease to other -viscera from that
first attacked, and to its disorganizing elfects in
its primary seat, is now so excessivehj weakened,
that remedies, directed with a due regard to the
previous habits of the patient, in support of those
energies are particularly necessary. Un the choice
of cordial remedies, and on their appropriate ap-
plication to the circumstances of individual cases,
will depend their success, and the reputation of
the physician. At this period, depletions and
all evacuations, excepting such as are requisite to
carry off" accumulations of morbid matters from
the prima via, and which impart, along with
their evacuating operation, a restorative and cor-
dial influence, must be abstained from; and care
should be taken that fainting, or even nervous de-
pression, may not supervene from their action.
Warmth, at this and the preceding terms of
advanced age, is indispensably required, both in
the clothing and apartments; but it should be
equable, and not too high. The lungs of very
aged persons should be guarded from the ingress
of very cold air, as the impression of cold in this
organ paralyses its functions, arrests those changes
which the blood undergoes during respiration, and
induces apoplectic or comatose seizures, aud
idiopathic syncope or inaction of the heart. For
these reasons, also, atmospherical vicissitudes
should be assiduously avoided, as far as the means
of doing so are placed within our reach. There
is scarcely any measure more influential in sup-
porting the sinking vital energies of age as the
communication of animal warmth, particularly
from the young of our own species. This was
well known to the ancients, and is one of the
oldest restorative means of treatment practised,
having been adopted by David. The aged ought
also to avoid the use of very cold fluids, as being
apt to depress the energy of the stomach below
the power of healthy re-action. Medicines, also,
particularly purgatives of a cold nature, as the
neutral salts, if exhibited at all, require to be
combined with warm aromatics orstimulants, in or-
der to counteract their depressing influence upon the
alimentary canal, and on the nerves of organic life.
Bibliography. G. E. Staid, De Morborum ^talura
Fundamentis Pathologico Therapeuticis. Hala-, 1698, 4lo.
— F. Hoffmann De jEtatis Mutatione Morbuium Causa
ft Reruedio. Hall. 1720, 4to. — Linnaus, Disser. Meta-
morphosis Humana in Aniajn. Acad., vol. vii. p. 143.
IVelsttd, Do /Elate Vergcnte, 8vo. Lond. 1724. — Plaz, He
Brevioris et Infirinioris Vita? Causis. Lips. 1782. — C.A.
Phiiites, De Decremento Homin., TEtatis Periodo, et Ma-
rasmo Senili in Specie. Hala?, 1808. — J.H. F. AuUmieth,
De Ortu quonmd. Moihor. Provectior. JEtatis, kc. Tub.
1805. — J. Schneider, Handb. Uber die Krankh.,des Mann-
baren Alters. 2 abth., 1808-12. — Pinel, in Archives Gen.
Mt-decine, t. xi. p. 7. — Fowart, in ibid., t. v. p. 398.;
t. vi. p. 87. — P. J. B. Esparron, Essai sur les Ages de
l'Homme. Paris, Ann. vi. 8vo. — F. E. Jolly, Apereu
Physiol, (t Medical sur les Premiers Ages de la Vie Ilu-
maine. 4lo. Paris, 1316. — J. A. Gessner, De Mutationibus
quas Bubit Inl'ans statim post Partum. Erlang. 1795. —
//. X. lioer, Versuch einer Darstcllung des Kindlichen Or-
ganismus in Pbvsiogolisch-patbolog. und Therapcut. Iliu-
sicht. YV'ien. 1813. — II. G. Seller, Progr. de Morbis Se-
nium Viteb. 1807. — A. Cm-lisle, Essay on the Disorders ..f
Old Age. Lond. 1817. — L. H. Fricdlaender, Funda-
in. nia Doctrines Pathologies?, he. Lips. 1828. 8vo. —
liuUkr, art. ,/Jg-ii, Dictionnaire de Mldecine, en 18 vol.,
t. prim. Paris, 1821 L. J. Begin, art. Age, Dictionnaire
de Medecine et de Chirurgie Pratiques, t. i. Paris, 1829.
— B. C. Faust, Die Perioden des Lehens. Berlin, 1794.
Svo. — C. IV. Hufdund, und R. A. Rudolphi, Encyclopa-
dischea Worterbuch der Mediciuischtu Wissenscha/teu.
Zwieter Band. Berlin, 1828.
AGEUSTTA. See Taste, Defect or Loss of.
AGRYPNIA. See Sleeplessness.
AGUE. See Fever- — Intermittent Fe-
vers.
50
AMAUROSIS — Pathology of.
AIR. See Disease, its Causation, Removal,
&c.
ALOPECIA. See Hair, the Loss of.
ALUSIA. See Illusion.
AMAUROSIS, from auavgo g obscure. Syn. Gut-
ta Serena, Suffusio JVigra, Celsus, Lucretius,
Pliny. Obscuritas, Hebetudo, Paulus /Egin.
Paropsis Amaurosis, Good.. Cataracta JVi-
gra, Auct. Germ, quibusd. U Amaurose,
Fr. Die Schwarze Staar, Germ. Gotta Sere-
na,\Vd\. Stckelindheit,llo). Suffusion, Drop
Serene, Milton. Dimness of Sight, Blindness.
Classif. 4. Class, Local Diseases; 1. Order,
Impaired Sensations (Cullen). 4. Class,
Diseases of the Nervous Function ; 2.
Order, Affecting the Sensations (Good).
Functional Amaurosis, I. Class, IV.
Order. Organic Amaurosis, IV. Class,
III. Order (Author, see the Preface).
1. Defin. Partial or total blindness, from
affection of the retina, or of the nerves, or of
that part of the brain related to the organ of
right, whether arising primarily from, func-
tional disorder, congestion, inflammation, or
any other change of these parts; or occurring
from sympathy with other organs. Or, in other
words, Partial or total loss of sight , from other
causes than those xvhich obstruct the passage of
the rays of light to the bottom of the eye.
2. Amaurosis is met with at all ages; but most
frequently in the more advanced terms of life. It
is sometimes congenital; and in these cases it is
often difficult to ascertain the nature and seat of
the affection. When it occurs at advanced periods
of life, an attentive enquiry into the history of the
disease, of the previous habits and ailments of the
patient, and of the various resulting and related
morbid phenomena, will generally throw light
upon its pathology.
3. I. Seat of Amaurosis. — 1st, In the. re-
tinae. Viewing the delicate structure of the retina ;
its relation to the optic nerve, of which it is an
expansion of great tenuity ; its connection with the
choroid and hyaloid membrane, and its nervous
and vascular communications; and considering
the various morbid states it is liable to undergo,
in consequence of its relations with these and
other p:-irts; a partial, and even total, abolition of
its functions is to be looked for on some occasions.
It Is, like all other parts of the frame, liable to
congestion and inflammation, with their usual re-
sults; and, like other nervous parts, its functions
are subject to a partial or complete extinction
without itself evincing any change of structure,
its sensibility alone being impaired or abolished ;
owin« either to some unappreciable change, or to
some one or more of those alterations in its adjoin-
ing or related parts about to be noticed.
4. 2d, In the optic nerves. These nerves may
be more or less changed in some part of their course,
from the anterior pair of the corpora quadrigemina,
along the thalami, the tubera cinerea, and their
partial decussation, until they terminate in the
formation of the retina?. In appreciating, however,
lesions in the course of the optic nerves, the results
of experiments on them should be taken into con-
sideration:— if an optic nerve be divided previous
to this decussation, sight is altogether lost on the
opposite side ; but if the division be made between
the decussation and the eye, vision is lost on the
same side.
5. 3d, In the gangUal nerves. There is every
reason to suppose that the retina is in intimate com-
munication with other nerves, and that it mutually
influences and is influenced by them. Branches
of the great sympathetic may be traced upwards,
from the first cervical ganglion, to the ganglion
lodged in the cavernous sinus ; whence branches
proceed and communicate with the third, the first
division of the fifth, and sixth pairs of nerves.
Branches also pass from the cavernous ganglion
directly to the lenticular ganglion. As the internal
carotid artery passes into the cranium, it is sur-
rounded by the sympathetic nerves, which accom-
pany all its ramifications. The ophthalmic artery
is invested with these nerves; its branches to the
choroid, iris, and retina being similarly provided.
Branches of nerves, moreover, proceed from the
lenticular ganglion, asM. RiBES*and others have
demonstrated, to the iris, giving more minute
branches in their course to the retina. This con-
nection being established, morbid states of these
nerves and ganglia, or changes of structure in
their vicinity affecting their functions, must neces-
sarily impair the sense of sight.
6. 4th, Other nerves, as the fifth and third pair,
are, in some cases, also the seat of amaurosis. It
has been shown by Magendie and Desmou-
lins that the integrity of the fifth pair is neces-
ary to the perfect function of the retina; and Mr.
Mayo has furnished evidence that the third pair is
requisite to the motions of the pupil. If the great
sympathetic be divided in the upper part of the
neck, the pupil becomes contracted and immove-
able, and the eye wastes.
7. 5th, Parts of the encephalon connected with
the optic nerves in their course are occasionally
the- seat of amaurosis, as pathological research and
experiment have shown. MM. Magendie and
Serr.es have proved that, when these parts are
wounded, the sight of the opposite eye becomes
either weak or extinct.
8. 6th, The pineal and pituitary glands are
frequently the only parts in which any alteration
can be detected in the examination of amaurotic
subjects. The connection of these glands with
the ganglial system is stated at another place. Be-
sides these, other parts of the brain, when the seat
of organic disease, are not infrequently the princi-
pal source of amaurosis, as shown hereafter.
9. II. Causes. — 1st, The predisposing causes
of amaurosis are very diversified. Amongst these,
the influence of hereditary disposition is well esta-
blished. Beer traced it in several families; in one
of them through three successive generations, and
particularly in the females of that family who had
not borne children, it having appeared in them at the
cessation of the menses. Beer also states, that
dark eyes are much more liable to it than the light ;
the proportion being upwards of twenty to one.
10. Whatever tends to favour sanguineous con-
gestion of, or serous effusion in, the encephalon,
particularly insolation ; forced exertions of the
mind or body ; excesses of passion ; the pregnant
and puerperal states ; occupations requiring fre-
quent stooping; errors of diet, and neglected ail-
ments affecting the stomach and liver ; the abuse
of wine or spirituous liquors ; suppressed dis-
charges, particularly those from the nose and
ears ; interruption, or entire cessation, of the
*M6m. de la Soc. MtJ. d'Emulation, t. iii. p. 89.
AMAUROSIS — Pathology of.
51
menses ; the gouty, rheumatic, and strumous I
diathesis ; the retrocession or suppression of |
eruptive diseases ; and habitual constipation ; —
whatever exhausts the vital energy of the brain,
and nerves supplying the organ, as chronic diar-
rhoea, typhoid levers, the excessive use of snuff,
long continued grief, prolonged suckling, neg-
lected tluor albus, excessive venery, and manus-
trupation ; — and lastly, whatever exhausts slow-
ly the sensibility of the organs of sight them-
selves; as the incautious use of the eyes in a
glaring light or on minute objects, and the exist-
ence of strumous ophthalmia in childhood, gen-
erally predispose to amaurosis.
11. 2d, The exciting causes are very numer-
ous ; indeed, any of the causes enumerated as
merely predisposing to the affection may excite it,
when acting long or intensely, although the suc-
cessive or combined action of various causes are
generally required. Amongst the most common
exciting causes, are over-exertion of the sight ;
exposure to very bright light ; its occupation on
iiiinute objects, or employment in candle or lamp
light, and during the hours usually devoted to
sleep. The sensibility of the retina may be de-
stroyed, even by a single exposure to these causes.
Lightning is another cause, which seems to act
by extinguishing the sensibility of this very deli-
cate part. In general, however, it is the long-
continued over-excitement of the organs of sight
that occasions the gradual abolition of their func-
tions. Injuries on the eye, and in its vicinity,
are also frequent causes of the disease.
12. Poisonous substances occasionally pro-
duce an attack of amaurosis ; sometimes sudden-
ly, at other times slowly. Belladonna, stramo-
nium, solatium dulcamara, &c, fish-poison, vari-
ous fungi, and animal poisons, occasionally have
the former effect ; but it is most frequently only
of temporary duration ; whilst other narcotics
taken habitually, as opium and tobacco, produce
the latter effect, and in a more permanent man-
ner. The poison of lead, blows on the head,
child-labour, and puerperal convulsion,, frequent
attacks of epileptic or other convulsions, cerebral
apoplexies and paralysis, injuries of the branches
of the fifth pair of nerves (three cases of which
have come before me), and even irritation of
these nerves, will produce this affection ; it has
also been observed to supervene to gastric and
intestinal irritation, particularly when occasioned
by worms ; to hypochondriasis, and accumu-
lations of bile in the liver, &c. ; to frights, and to
the irritation proceeding from carious teeth. The
sudden suppression of epistaxis, of haemorrhoids
of the lochia, of the milk in nurses, of the menses,
or of the perspiration ; the repulsion of eruptions
on the head and behind the ears, and the drying
up of old ulcers, have, severally, occasioned the
disease. Put most frequently it is the result of
two or more of these causes, acting under cir-
cumstances of predisposition. Females with dark
eyes are extremely liable to the disease, upon the
cessation of the menses ; and, like deafness, it is
apt to appear after severe attacks of typhoid and
scarlet fevers. Amongst the more rare exciting
causes of this affection, are the gouty and rheu-
matic diathesis, or misplaced and retrocedent gout
and rheumatism ; the constitutional effects of
syphilis, and hurtful influence of mercurial cour-
ses ; — all which have been assigned as causes of
the disease by some authors, and denied by oth-
ers ; but, undoubtedly, producing it on some
occasions, although not so frequently as the for-
mer believe.
13. 3d, The proximate or efficient causes of this
affection are various. It has been disputed whe-
ther or not it can arise from altered function only,
and without change of structure. Mr. Tkavers
believes that it does, but Mr. Mackenzie denies
it can depend upon morbid function merely ; and
other writers take opposite sides of the question.
There can, however, be no doubt, if we atten-
tively consider the disease in relation to the ex-
citing causes and the effects which are observed
to result from them, that, although most com-
monly the consequence of some appreciable
change in some one or more of those parts in-
stanced as its seat (§ 3 — 6.), it is occasionally
unattended with such change, — at least to such
an extent as our observation of the effects proceed-
ing from similar alterations would lead us to
expect. It should not be overlooked that the
operation of many of the causes which have been
adduced above is entirely vital — upon the func-
tions of life, a* manifested hi the organ, or in
remote parts of the frame ; — that their effects are
sometimes almost instant, and before organic
change could have been produced ; and that the
disappearance of their effects has been sometimes
as sudden, and often before the restoration of
morbid structure, providing that it existed, could
have been brought about. I believe, after a care-
ful perusal of the works which have been fur-
nished by surgeons on this disease, that a too
marked disposition has been evinced to consider it
as a result of organic change in the organ and
the nerves, and vessels connected with it, and
without relation to constitutional and vital causes.
14. When describing the seat of amaurosis,
the influence of organic changes has been briefly
noticed ; and a fuller reference to them will be
made in the sequel. Amongst t'.ie numerous
lesions of structure that, occur in the brain and
its membranes, there are many that affect the
nerves of sight, more particularly the optic nerves,
or which implicate them organically in some part
of their course in a very remarkable manner.
Alterations in the bones of the cranium, as well
in the membranes, obstructing the functions either
of these nerves or of the other nerves subservient
to the perfect exercise of this important sense,
are also not uncommon.
15. The efficient causes of this affection,
therefore, are, 1st, vital or functional, depending
upon imperfect or abolished sensibility of the
retina, or the optic and other nerves subservient
to vision, owing either to causes which, from their
direct and local action, depress or exhaust this
property, or to those which, form their primary
influence upon the frame, have an indirect de-
pressing etlect, which is not limited to this organ,
although manifested in it in a more marked de-
gree, owing to various concurrent circumstances.
This constitutes the functional form of amaurosis
admitted by Beer, Wardrop, Travers,
Sanson, and others, and which Beer divides
into two subordinate kinds : first, that which pro-
ceeds from direct depression of the vital sensi-
bility of the eye ; and, second, that which is
owing to inordinate excitement, and consequent
exhaustion of this property.
52
AMAUROSIS — Symptoms.
16. 2d, A congestive or inflammatory state of
the vessels of the retina, or parts immediately
adjoining, or the usual effects of these states.
Portal, Ploucquet, Prochaska, Rous-
seau, Sanson, Magendie, and other path-
ologists, have observed varicose states of these
vessels ; unusual injection of the minute arteries
of the adjoining coats, and of the retina itself ; a
complete retinitis; exudations of lymph under
the choroid, near the ciliary circle ; inflammation
of the external surface of the sclerotic ; vascular
injection, and firm adhesion of the retina to the
choroid ; partial detachment of the retina from
this coat ; and thickening, morbid density, and
change of colour of the retina. Ossification ;
fibrous degeneration, with partial thickening ;
wasting, and malignant disease of the retina, and
even the developement of transparent vesicles in
it, have all been noticed by Hauler, Morga-
gni, Heister, Sanson, and other authors.
17. 3d, Lesions affecting the optic nerves.
These consist chiefly of tumours of various kinds
— osseous, fibrous, encysted, steatomatous, puri-
form, aneurismal, &c. — formed'in their vicinity, ;
either in the brain, the membranes, or in the ;
bones of the cranium, and involving, or com- |
pressing them, in any part of their course. They
are likewise, occasionally, the seat of some one,
or even more, of those organic changes of their
proper structure and sheaths, to which nervous
parts are liable. Their vessels may be varicose ;
their fibres may be infiltrated with serum ; they
maybe injured by external violence, and they may !
be wasted ; which last is very frequently obser-
ved. Adventitious deposits, as osseous and earthy
matter, malignant formations, cysts and hydatids,
may even form in their sheaths, although more
rarely than the foregoing lesions. The writings
of pathologists abound with instances of these '
changes. When only one eye has been amau-
rotic, the optic nerve of that side has been found
wasted anterior to its partial decussation ; and ,
on the opposite side, posterior to this union. But '
this is by no means an uniform circumstance, and, I
when observed, the atrophy is not distinctly con- .
tinuous. Indeed, the wasting has been detected ,
on the same side, after the union of these nerves, ,
as well as before. But if the opinion of Trevi- j
ranus and Wollaston be correct, — that J
decussation of these nerves at their union is only ;
partial, and that it takes place chiefly between !
the parts which are nearest each other, — wasting J
of one of them may be in one case more remark-
able on the same side, and in another case more
observable on the opposite side. When the am-
aurosis is accompanied with wasting of the optic
nerve, from causes not primarily consisting of
inflammation or its consequences in the retina or
adjoining coats, this nervous expansion is also
generally wasted, transparent, or changed in
colour. When the cause exists in the pineal or
pituitary glands, the wasting is often chiefly ob-
servable at the union of the optic nerves. In
these cases, both eyes are affected. Facts illus-
trative of this have been recorded by Vieussens,
De Haen, Rullier, Rayer, Ward, and
Sanson.
18. 4th, Lesions seated in the encephalon. The
scope of this article will not admit of further
reference to the numerous changes which occa-
sionally produce amaurosis, from their affecting
the optic nerves in their different connections with
various parts of the encephalon. All the alter-
ations which are described in the articles on mor-
bid structures of the brain and its mem-
branes, will produce the disease, when they
impede the functions of the optic nerves, although
the structure of these nerves may be uninjured. The
most frequent and remarkable of these are, organic
lesions of the pineal and pituitary glands (§8.),
sanguineous and serous efliisions, various kinds of
tumours, abscesses, softening of the brain, &c.
19. 5th, Lesions of nerves subsidiary to the
integrity of the organ and of its functions. In-
juries, compression, and even irritation of th^ fifth
pair of nerves, particularly its ophthalmic branch,
of the third and sixth pairs, and of the ganglia or
their ramifications, by organic change in the brain,
its membranes, bones of the cranium, or parts in
the course of their branches, have been shown, in
numerous instances, to have been the cliief effi-
cient causes of amaurosis.
20. III. Symptoms. — The symptoms of am-
aurosis are, 1st, those which the patient himself
experiences ; and 2d, those which the physician
detects in the eyes, or in the various organic and
animal functions. Each of these classes of symp-
toms are to be enquired into separately, commen-
cing with either of them. Each eye should be
carefully and separately examined ; and it will be
better that the other is excluded from the light,
whilst the examination is being made.
21. 1st, The patient complains of impaired
vision, which may be of gradual accession, or re-
markably sudden, and amounting to almost total
deprivation of sight. Hence the disease has been
distinguished by the epithets slow and sudden, in-
complete and complete, or imperfect and perfect.
22. At the commencement, the failure of vision
is sometimes only occasional, for a short time, and
after longer or shorter intervals (amaurosis vaga).
In some cases, it assumes the form of day-blind-
ness, in others of night-blindness : and it not in-
frequently recurs for a time after great exertion
of the eyes, either with minute or bright objects.
Transient and sudden attacks of the disease are
often the consequence of disorder of the digestive
organs, or rather the result of a state of the vital
manifestations which occasions equally loss of sight
as well as loss of the digestive functions. The
failure of sight is often at first only partial — ex-
tending only to a part of the field of vision. In
some cases intervening portions of the field are ob-
scured (yisus inter ruptus). In other cases, one
half of it is hid from view (hemiopia). Occa-
sionally objects are only seen in a particular direc-
tion (visits obliquus) ; and some patients discern
objects in a distorted form — cro'oked, mutilated,
shortened, lengthened, or inverted (visits deflz-
uratus). Beer states that the flame of a candle
will often appear elongated, and as if separated
into several portions, to such patients, — a symp-
tom indicating disease within the head.
23. In some instances the failure of sight as-
sumes a myopic or a presbyopic form : but this is
not so frequent as the occurrence of false impres-
sions, in the form either of flashes of light, sinning
stars, globes of light, and various other lucid spec-
tra (photopsia), or of muscse volitantes. False
impressions of colour (chrupsia) are also frequent
attendants on the early stages of amaurosis. I umi-
nous spectra are commonly met with in plethoric
AMAUROSIS — Symptoms.
53
persons, and when the amaurosis depends upon
increased vascularity, or inflammation of the re-
tina; motes, black specks, muses volitantes, and
thick mists or clouds, when the affection is de-
pendent upon exhaustion of the sensibility and
vital energy of the organ, and when it occurs in
dvspeptic subjects from exhausting causes. Double
vision is also a common symptom, particularly
when the cause exists within the head.
24. As the disease advances, the field of vision
appears as if obscured by a cloud, or net-work;
the latter appearing gray or black in a good light,
but occasionally becoming white, silvery, yellow-
ish red, and luminous in the dark. In addition to
these, the patient sometimes complains, particu-
larly early in the disease, of some intolerance of
light, or of pain in the eyes on being exposed to
it. But, in other cases, from the very beginning,
diminished sensibility of the retina, and a constant
desire for a stronger light — a thirst of light — are
present.
25. Pain in the eyes, and commonly also in the
head, is one of the most important symptoms of
amaurosis. It should, therefore, be carefully in-
vestigated. We ought to ascertain its precise seat
and extent; its character — whether it be acute,
gravative, throbbing, occasional, or permanent.
The circumstances which relieve or exasperate it
should also be noted; as the horizontal posture,
temperature, exercise, diet, the use of stimuli, &c.
We should also notice whether it be accompanied
with vertigo, tiiuiitus aurium, watchfulness, or
stupor, coma, forgetfulness, inability of exertion,
or failure of other mental manifestations; as, from
the nature and grouping of these symptoms, we
infer the nature of the efficient cause of the
disease, particularly as they suggest its existence
within the cranium.
26. Unusual dryness of the eyes and nostrils
sometimes is observed in amaurosis; and in these
cases benefit is often derived from a restoration of
the secretions of the lachrymal gland, conjunctiva,
and Schneiderian membrane. (Mackenzie.)
27. The general health, and previous ailments
of the patient, require a particular investigation.
The constitution and diathesis — whether he be
strumous or gouty; whether he has had syphilis,
or undergone long courses of mercury; whether
he has had typhoid fevers, or inflammations of
the brain, or apoplexy, paralysis, epilepsy, or
injuries on the head; whether he has been sub-
ject to complaints of the digestive organs, or has
been, or is, affected with worms : if a female,
whether she has been frequently attacked with
paroxysms of hysteria, or any of its anomalous
forms, or with convulsions in the puerperal state,
and particularly whether or no there exist any
sign of disorder in the uterine organs — are all
particulars most requisite to be known.
28. 2d, The form, colour, vascularity, and mobi-
lity of the different parts of the eye, and habit and
appearance of the patient, next require investiga-
tion. The amaurotic patient walks with a gait
of uncertainty, and a staring and unmeaning look.
In some cases this want of convergency of the eyes
towards an object may amount to slight squmt-
ing, occasionally with oscillation, and sometimes
with unusual fixity of the eyes. In some instances,
the motions of the eyelids, and of the eyes them-
selves, are more or less impeded, or even palsied,
■ — the evator palpebral superioris, and the orbicu-
5*
laris palpebrarum being often affected. These
phenomena are chiefly remarked in »kases where
the motor oculi, or the faciid nerve, is injured.
29. One or both eyes are often unusually pro-'
minent. The colour of the sclerotica is frequently
somewhat changed — being either yellowish, blu-
ish, or ash-coloured. This coat is often covered
with small varicose veins. The consistence, also,
of amaurotic eyes is occasionally altered; in some
cases the eyeball is firmer to the touch, in others
softer, than natural. In rarer instances, it is
flattened on one or more of its sides.
30. The pupil is generally sluggish and limited in
its motions, or altogether deprived of motion, and
dilated. More rarely it is contracted. In many ca-
ses it is neither dilated nor contracted. A widely di-
lated pupil, although generally attendant on pres-
sure on the brain, also occasionally depends on other
causes. Early or incomplete amaurosis Ls rarely
attended with dilated pupil; but after all vision is
extinct, the pupil is generally more or less expand-
ed and motionless. It should not be overlooked,
that where only one eye is amaurotic, the motions
of the pupil of the affected organ will often follow
those of the sound one, when protected from, or
exposed to light ; and even, as observed by Jan in,
both eyes may be completely amaurotic, and yet
both pupils will vary in diameter with the inten-
sity of light to which they are exposed. This
phenomenon can only be explained by referring
to the nerves supplying the different parts of the
organ. The iris, being chiefly supplied with
ganglial nerves, will often retain its faculty of mo-
tion, when the efficient cause of the disease affects
the optic nerves at any place between their origin
and their communication with the third pair;
or when the affection of the optic nerves within
the cranium does not leave the retina altogether
deprived of sensibility, although the impression
cannot be conveyed to the brain, the subsidiary
nerves, particularly the third and fifth pairs, and
the branches from the cavernous and lenticular
ganglions, still bestowing sufficient sensibility and
mobility on the iris to admit of motion on being
stimulated.
31. Besides the size of the pupil, it is necessary
to attend to the characters of the motions of the
iris. This part may contract on one side, or in
one part, drawing the pupil to one side, or giving
it an irregular appearance. It may also seem as
protruded towards the cornea, or it may appear
sunk inwards, and have a funnel-like sliape.
(Mackenzie.)
32. The appearance of the humours of the eye
is also important. In hydrocephalus, or when
occurring in young subjects, the pupil has the
natural black hue. But in elderly subjects some
degree of glaucoma accompanies amaurosis. Tins
appearance is in general unfavourable.
33. The presence of the marks of injuries about
the face and head is important, as- marking pro-
bable injury of parts within the cranium, or of
some nerves subservient to the perfect condition
of the organ. The character of the counten;ince,
the sliape of the head, the state of the vessels of
the bead and eyes, and the general habit of body,
require to be noticed. The inference which ought
to be drawn as to the exact nature of the disease
will be very different when it Ls met with in the
plethoric, the highly fed, and the indolent, from
that which will be deduced from its occurrence in
54
AMAUROSIS — Species of.
the emaciated, or exhausted subjects. The pro-
bable predisposing and exciting causes should also
be investigated, as they have an obvious relation
to their eilects. Attention should be directed to
the previous habits, indulgences, ailments, occu-
pations, and modes of life of the patient, &c, with
the view of throwing light upon the causes and
pathological relations of the malady.
34. The duration of the disease is extremely
various. It may, in slighter cases, be only of a
few hours' or days' continuance; may altogether
disappear, either spontaneously or from treatment,
and never afterwards recur; or it may return after
an indefinite period, from errors in diet, disorders
of the digestive organs, or from the operation of
the causes usually producing the disease. It very
frequently continues all the life of the patient.
35. IV. Stages, Grades, and Forms. —
The stages of amaurosis are incipient and confirm-
ed. In the former the sight is generally not altogether
lost, although more or less impaired. Treatment
will often retard or check the progress of the disease,
and sometimes even bring about a perfect cure. But
the blindness may be complete from the first: in this
case, medicines are generally without effect In the
confirmed stage, the disease is usually stationary;
but the sight is not always altogether lost : the
patient often retaining a perception of light and
shadow, or even of objects, when illuminated or
strongly contrasted. When this power of distin-
guishing any object or colour is still retained, even
in the slightest degree, the amaurosis is said to be
incomplete. When the patient is insensible even
to the presence of light, the disease is complete.
It may be limited to one eye, in the incipient or
incomplete states; or it may affect both equally,
either in an incomplete or complete form. It may
also be incipient in one eye, and confirmed in the
other; and it may be more or less complete in
either. It may likewise, in one or other of these
states or forms, assume a recurrent or remittent
type ; but such cases are comparatively rare.
36. But, besides these stages and grades of the
disease, other forms occasionally present them-
selves, which will be more fully noticed in the
9equel. It may be Idiopathic, depending upon
changes, e'&hex functional or organic, taking place
primarily in the nervous apparatus of the eye, and
existing simply, and without any other associated
lesion : or it may be complicated with lesions of
adjoining parts, or with other diseases of the eye,
particularly of its humours, more especially with
glaucoma and cataract. It may also be consecu-
tive of other diseases; most frequently of organic
changes witliin the head, or in the vicinity of the
orbit, as in apoplexy, paralysis, &c. And, lastly,
it may be symptomatic of, or supervening to, pre-
exlstent disease of distant parts, particularly of the
abdominal viscera; or it may be occasioned by
pregnancy, and more rarely by "diseases of the
puerperal state. It is not infrequently thus symp-
tomatic of colic from lead, accumulations of fiecal
matters in the large bowels, hypochondriasis, &c.
37. According to these states of the disease, its
different species will next be considered, and the
treatment winch is appropriate to each of them
will subsequently be pointed out : for it is obvious,
that the success of remedies will, in this very diffi-
cult and variously complicated disease, mainly
depend upon the strict appropriation of remedies
to its different varieties and states.
38. Spec. 1st, Functional Amaurosis. This
form of the disease generally arises, — 1st, from
suspension or exhaustion of nervous and sensorial
power; from various local and constitutional causes
(§ 13. ) ; from inordinate excitement or exertion of
the visual organs ; from mental exertion, watchful-
ness, and sedentary habits; from the deleterious
action of mineral, vegetable, and animal poisons, as
lead, mercury, narcotics, &c. : 2d, from venereal
indulgences ; excessive secretions and evacuations ;
depression of the vital energies from diseases of
debility and exhaustion : and 3d, from temporary
diminution of the local circulation; from simple
congestion, or occasional determination of blood
in the veins or arteries; and from the irritation or
disturbance of the digestive organs, or of some
other of the abdominal viscera.
39. The symptoms of this species are, chiefly,
more or less obscuration of vision, occurring slowly
or suddenly, the visus nebulosus, and muscse vo-
litantes; a somewhat contracted pupil, and clear
state of the humours; equal imperfection of sight
in both eyes; pale, languid countenance, and de-
pression of the eyes in the orbits; a languid, small,
or weak pulse; increased dimness, or sudden abo-
lition of sight upon quickly assuming the erect,
from the horizontal posture. An improved state
of the sight after a light meal, or grateful stimulus;
nervous headaclis; weak digestion, sluggish state
of the bowels, flatulency, foul or loaded tongue,
and indisposition for, as well as incapability of,
physical or mental exertion or occupation; weak-
ness in the joints; occasionally nocturnal emissions,
&c. in the male, and leucorrhcea in the female.
40. This species of amaurosis may be, 1st,
primary and uncomplicated. In this case it
usually proceeds from causes which depress or
exhaust the sensibility of the retina and its re-
lated nerves. 2d, It may likewise be consecutive ;
particularly of excessive secretions and discharges
from the uterus, mamma?, kidneys, testes, and
prostate; or from exhausting and debilitating
diseases, as adynamic diseases, hemorrhages, kc.
3d, Symptomatic of, or complicated with, hy-
steria, hypochondriasis, colica pictorium, diminish-
ed vital energy of the digestive organs, and all the
various forms of indigestion; the presence of
worms in the bowels; pregnancy; obstruction and
accumulation of bile in the, bile-ducts or bladder,
&c: and 4th, Metastatic, or supervening upon
impeded or checked secretions and discharges; in
which cases it is generally accompanied with con-
gestion, or determination of blood to the head, in
which the eyes may partake, but not to an extent
constituting inflammatory action or organic change;
and it assumes a state nearly approaching to that
characterizing the next species.
41. Spec. 2d, Amaurosis from active conges-
tion. The existence of this species of the disease
is more a matter of inference, than almost any-
other of those in which I have divided the disease.
Yet it seems undoubtedly to exist; especially
when amaurosis is consequent upon obstructed
secretions and discharges, or the drying up of
eruptions; upon frequent stooping, or wearing a
tight neckcloth; upon fits of passion, when it
occurs in plethoric persons; and after narcotic
poisons. »
42. The symptoms indicating it, are throbbing
in the eyes, tinnitus aurium, turgescence of the
vessels of the sclerotica and conjunctiva, a some-
AMAUROSIS — Species of.
55
\vh;it contracted pupil, and clear state of the
humour.-!; turgescence of the features, or lividity
or bloatedness of the face; fulness of the jugular
■% fins, prominence of the eyes, and impeded circu-
lation through the lungs or cavities of the heart.
43. This form ^f the disease is seldom primary
and uncomplicated. It is commonly consecutive,
or symptomatic, generally of obstructed discharges,
&c. (§ 12.), of disease within the head, particu-
larly of sanguineous congestions, or effusions, and
diseases of the lungs and heart. It not infre-
quently occurs transitorily from pregnancy, epi-
lepsy, and hysteria; and more rarely from gout
and rheumatism.
44. Spec. 3d, Amaurosis from inflammation of
the retina, a ml internal parts ofthe eye. In stating
amaurosis to be often a symptom merely of reti-
nitis, I am supported by the opinions of many of
the best British and Continental writers on the
disease. But I believe it very seldom occurs,
that the inflammation is limited to this membrane,
but that the choroid and iris generally participate
with it in the morbid action; and that, when
thev, on the other hand, are thus affected, the
retina is also inflamed. Amaurosis is therefore a
consequence of inflammation ofthe internal struc-
tures ofthe eye : but does inflammation of these
parts uniformly produce amaurosis ? It is not
always consecutive of iritis; and I believe that
the retina may be inflamed, and yet but very
slight amaurotic symptoms may be occasioned
thereby, particularly during the early stages of
the retinitis. It is chiefly when the inflammatory
action has produced some degree of organic
lesion of the affected parts, that amaurosis is
manifested.
45. This form of amaurosis generally proceeds
from nearly the same causes as the foregoing
( § 1 1) — 1 2.). It may be produced by syphilis, mer-
cury, eruptive and continued fevers, cold in any
form acting upon the eyes or face; suppressed
discharges, or eruptions on the head or behind the
cars; injuries of the eye and adjoining parts;
concussions, and the usual causes of inflamma-
tion in other parts.
41). The symptoms vary with the extent and
intensity of the inflammation. In its slighter
the progress ofthe disease, and ofthe
symptoms, is insidious and slow. In these cases,
little or no pain is complained of, either in the eye
or in the head. The pupil is more commonly
contracted than dilated, and the spectra are
usually luminous, but sometimes not very sensi-
bly so. With this slight and often chronic state
of inflammatory action, the amaurosis may be
increasing fist, and the observation of vision very
great, and yet the symptoms may not be dis-
tinctive!; if we except the appearances furnished
b\ the sclerotic, which, in retinitis, as well as in
iriti<. abounds in red vessels, converging in distinct
lines, and forming, by their delicate reticulations,
a red zone round the cornea, and which thus
furnishes the only symptom, that can be de-
pended upon, of slight or incipient retinitis.
47. In the more intense states of inflammation
ofthe internal parts of the eve, the amaurosis is
attended with painful vision; "intolerance of light; I
sparks of tire, or drops of a red colour falling from |
the eyes; flashes of light; pain darting through
the head, either from, or to the bottom of the eye- I
balls; the pupils are dilated, and the humours]
thick or muddy; and there are more or less
acceleration of pulse and constitutional dis-
turbance.
48. This species of amaurosis is often primary
or, idiopathic, it may also be simple or compli-
catei. When it occurs in a complicated form, it
is, most frequently, associated with iritis, with
meningitis, with eruptive or continued fevers,
and with rheumatism, gout, or syphilis. It may
also occur consecutively and from metastatic,
particularly after the disappearance of exanthe-
matous eruptions, as in the measles, small-pox,
erysipelas; of chronic eruptions; and after the
suppression of habitual or periodical discharges,
secretions, and evacuations (§ 12.).
49. Spec. 4th, Amaurosis from advanced dis-
organization ofthe retina and adjoining parts.
Disorganization of these parts is usually a result
of inflammation. But it is ditticult to determine
at what stage ofthe inflammation organic change
commences. I am to consider it here as far
advanced; yet, the inflammation that occasioned
it may be still present. The causes of this species
are the same as those of the foregoing; but the
symptoms are somewhat different The vision is
more obscured. A film seems interposed between
the eye and field of vision. The pupil is sluggish,
and it is often scarcely dilated; it is frequently
irregular. The margin of the iris sometimes
partly adheres to the capsule of the lens. The
sclerotic is often very vascular, and even livid,
from the enlarged and loaded state of its veins,
which are very numerous and tortuous. The
shape of the eye is sometimes changed, particu-
larly in the most advanced cases; it is prominent
in some parts, and depressed in others. The
eyeball is occasionally, also, softer or firmer than
natural.
50. This form of amaurosis is always consecu-
tive of the second and third species, more particu-
larly of the latter; and hence, participates in
many of their characters (§ 41 — 4S.), and occurs
under many of the same circumstances as they.
It is occasionally complicated with cataract, with
opacities of the cornea, or with disorganization of
parts within the head.
51. Spec. 5th, Amaurosis from external inju-
ries if the eyes. A blow on the eye-ball will not
infrequently occasion blindness, without produc-
ing any apparent injury of its visible parts. It is
difficult, or altogether impossible, to ascertain the
nature of the mischief that has been inflicted.
The concussion of the organ, and the lesion of
the sensibility ofthe retina and optic nerve, may,
in some of the cases, particularly when the con-
sequent amaurosis is merely temporary, constitute
the principal or only change. In more perma-
nent and severe instances, it is very probable that
the delicate connections of the retina with the
adjoining parts" are injured. Eccbymosis may
also be occasioned, or inflammation may super-
vene. In these cases the pupil is either dilated,
or of an irregular form; and according to the ex-
tent of injury will the phenomena partake of the
characters which have been assigned to the third
sad fourth species ofthe disease.
52. Spec. 6th, Amaurosis from disease within
the head affecting the functions ofthe optic nerve,
or other nerves subservient to the sense of sight. It
is obvious that disease within the cranium, either
of the substance of the brain, or of its membranes,
56
AMAUROSIS — Species of.
producing pressure of, or interrupted circulation
in, the pints with which the optic nerve is con-
nected at its origin, or during its course, or acting
in a similar manner on the nerve itself, will pro-
duce amaurosis. In these cases it is a consecutive
affection — a symptom merely of disease, often
existing for a long time previously. I have al-
ready alluded to the nature of these lesions, and
to their extreme diversity (§ 17, IS.). Perhaps the
most common and the most interesting of them
are organic changes of the pituitary and pineal
glands, haemorrhage, sanguineous congestion,
aneurismal and other tumours, &c. In these
cases it is very common to find cerebral symptoms
complained of long before the sight is affected;
and to observe the gradual accession of the dis-
ease either in one or both eyes; or first in one and
afterwards in another, with complete loss of vision,
followed at last by changes of the structure of the
eye.
53. When organic lesion of the pituitary
and pineal glands has occasioned the disease,
judging from the cases recorded by De Haen,
Wknzel, Vieussens, Leveque, Ward,
Rullier, and Rayer, both eyes are generally
gradually and equally affected, after the existence
of cerebral symptoms, chiefly consisting of pain and
weight referred to the more anterior parts of the
head; of a repugnance to exertion, apathy, loss of
memory, and weakness of the mental energies. In
cases of sanguineous congestion, or haemorrhages in
the situations referred to, the attack is sudden, and
the blindness is often not the most remarkable
symptom.
54. In some cases resulting from organic dis-
ease within the head, cerebral symptoms, particu-
larly those of an acute kind, are not complained
of until the amaurosis is far advanced. In its
progress, objects frequently seem to the patient
disfigured or perverted. In many cases of amau-
rosis from organic change of the skull, mem-
branes, or brain, the affection commences with
intolerance of light, strabismus, giddiness, lumin-
ous spectra, convulsive motions of the eyes and
eyelids, contracted pupil, and turgescence of the
blood-vessels of the eyes, loss of hearing, smell or
taste, or both, violent headach, rapidly followed
by complete amaurosis, protrusion of the eyeball,
and abolition of the external senses and of the
powers of mind.
55. This species of amaurosis is often compli-
cated with, or preceded by, epilepsy, paralysis,
apoplexy, ottorrhava, or disease of the ears, hyste-
ria, and various nervous affections. It is chiefly by
attending to these antecedent disorders, or other
slighter cerebral symptoms, that we can form any
idea of the nature of the amaurosis. The appear-
ance of the eye, and particularly of the pupil, is
not to be depended upon; for, although the pupil
is usually dilated and immoveable, the exceptions
are too numerous to admit of considering it as an
uniform occurrence.
56. Spec. 7th, Jlmaurosisfrom disease of the
optic nerves, or of their sheaths. This species of
amaurosis always advances slowly, generally
commencing in one eye, with a black cloud, which
grows more and more dense, great disfigurement
and perversion of objects, without pain of the head
or eye. There is, however, a sensation of pres-
sure at the bottom of the eye, as if forcing the
eyeball from its socket. The pupil is generally,
from the commencement, much dilated, and an-
gular from irregular action of the iris. By de-
grees, according to Beer, glaucomatous change
of the vitreous humour supervenes, and after-
wards of the lens itself, but without any varicose
affection of the vessels of the eye. At last the
eyeball becomes somewhat smaller than natural,
but complete atrophy does not ensue.
57. Spec. 8th, Amaurosis from lesions of
branches of the fifth nerve, &c. The experiments
of Bell and Magendie first threw light upon
this cause or form of amaurosis. I believe that it
is by no means infrequent. Four cases of it have
come before me in private practice; in three of
which the principal trunk or branches of the
ophthalmic nerve were implicated. In one of
these the amaurosis was very slight; in the other
two it was very considerable, although not com-
plete, and was a consecutive phenomenon of
very extensive disease. I saw two of them, in
consultation with respectable practitioners in my
vicinity. The fourth case very recently occurred
in a member of my own family. In it the frontal
branch on the right side was pressed upon by a
common boil; the sight of the eye wras nearly
altogether lost, but was soon restored when the
boil broke.
58. Numerous cases are on record, in which
partial amaurosis is said to have occurred after
injuries and wounds of the eyebrows, cheeks, and
forehead; or from the irritation and extraction of
diseased teeth. The appearance of the disease
from these causes was noticed by Morgagni,
Pinel, Beer, Wardrop, Travers, Pena-
da, Ribes, &c, before the functions of this nerve
weje so well known as they are now. Its occur-
rence from wounds of the eyebrows is mentioned
even in the writings of Hippocrates.
59. Amaurosis from these causes is, in some
rare instances, complicated with facial neuralgia,
toothach, rheumatism of the face, and tumours
or abscesses developed in the vicinity of the eye,
and within the cranium in the course of the fifth
nerve. I met with it in a case of ottorrhoea, ter-
minating in caries of the bones, and extensive
disease of the internal parts in the vicinity. It is
also, in some cases, accompanied with paralysis
of the upper lid, and in others with paralysis of
different muscles of the eye. In these cases, the
third or sixth nerves have, most probably, been
chiefly affected. When the ophthalmic nerve is
affected within the cranium, it is difficult, if not
impossible, to determine the particular seat of
lesion from the amaurotic symptoms. Facts
have not been observed in sufficient number, and
with requisite precision, to admit of any state-
ment being made respecting the pupil and motions
of the iris in this species of the disease. I believe,
however, that serious organic, as well as func-
tional, lesions of the organ may supervene to it
CO. There are other varieties of amaurosis par-
| ticularized by Beer, Weller, Sanson, and
other German and French writers, some of them
of rare or doubtful existence, or at least referrible
i to the species into which I have here divided the
disease. From amongst these I may enume-
rate the following: — Gouty amaurosis; rheu-
matic amaurosis; amaurosis from the sudden re-
pulsion, or cure of cutaneous eruptions, or old
ulcers; amaurosis from suppressed secretions and
evacuations; puerperal amaurosis, &c. It is
AMAUROSIS — Diagnosis — Prognosis.
57
e\ ident that these are only occasional, and by no
means frequent, causes of the disease, which
ought to be kept in recollection by the practi-
tioner, l>ut which can act only by inducing some
one or other of tlie forms into which it has been
divided ; more particularly the second, third,
*'ourth. and sixth. In as far as they may require
a modified plan of treatment, they will receive
attention in the sequel.
61. In addition to these, I may notice the caVs-
eye amaurosis of Befr, which is only met with in
the old, debilitated, thin, and emaciated ; parti-
cularly those who are gray, or white-headed. At
the commencement of this amaurosis, the aris
retains its mobility ; but it afterwards is slow and
the pupil dilated. Depp in the bottom of the eye,
a concave pale gray, or yellowish green, or reddish,
variegated opacity is observed. The further the
disease advances, the paler the bottom of the eye
becomes, the paleness extending to the iris, until
at last a slender vascular plexus — the ordinary
ramification of the central artery and vein — may
be discerned. With this state of the eye, decline
or total abolition of vision is the consequence.
This rare form of amaurosis seems to consist of a
deficiency of the pigmentum nigrum, and of the
tapetum of the uvea. It appears closely allied to
far advanced glaucoma. This form of the disease
is, seldom or ever benefited by medical treatment.
62. V. Diagnosis. — Amaurosis is liable to
be mistaken for incipient cataract, and for glau-
coma. When cataract is fully developed, the
two diseases can scarcely be confounded. That
a clear diagnosis should be made between incipi-
ent cataract and amaurosis is of the greatest im-
portance in practice. (A) As to the impaired
vision in both diseases at their commencement, it
may be remarked that in cataract, the difficulty
of sight increases very slowly, and is compared to
a diflused mist, thia cloud, or gauze intervening
between the eye and the object : whereas in
amaurosis, the dimness or loss of sight is either
sudden or partial, resembling a fly, spots, or motes
covering parts of an object. However, a mist, or
thin cloud, often is complained of in incipient
amaurosis, and, increasing in density, at last de-
prives the patient of sight ; but a complete depri-
vation of sight never occurs in cataract. As inci-
pient cataract depends upon commencing opacity,
generally at the centre of the lens, the appearance
of a mist, &c, is generally most perceived when
the patient looks straight forward ; vision being
more distinct when he looks sideways. This com-
monly does not obtain in amaurosis, although it
sometimes does.
63. (B) The degree of light which the pa-
tient desires is also important. When amaurosis
depends upon insensibility of the retina, there is
a great desire of strong light, and he sees the best
at noonday, or when objects are brilliantly illu-
minated. The opposite of this obtains in cataract ;
for a strong light, causing the pupil to contract,
the rays of light reflected from the object must
pass chiefly through the central and more opaque
part of the lens. In addition to this we should
attend to the antecedent and attendant symptoms
of amaurosis ; especially vertigo, headach, dis-
order of the digestive organs, without which cata-
ract usually commences.
64. (C) Upon examining the pupil, incipient
amaurosis presents either the jet-black colour of
health, — •excepting in the cat 's-eye amaurosis of
Beer, which is of rare occurrence, and presented
to us under circumstances not to be mistaken, or
a paleness or greenness, visible only when the eye
is examined in particular directions, constituting
amaurosis with glaucoma. This appearance evi-
dently arises from deficiency of the pigmentum
nigrum, and incipient dissolution of the hyaloid
membrane ; and when it amounts to a high de-
gree, constitutes the cat's-eye amaurosis of Beer.
65. Mr. Mackenzie remarks on this subject,
that attention to the following circumstances will
generally enable the observer to distinguish glau-
comatous amaurosis and cataract: — 1st, The
opacity in glaucoma is always greenish, whereas
in incipient cataract it is always grayish. 2d, The
opacity in glaucoma appears seated at a consider-
able distance behind the pupil, or deep in the
vitreous humour ; whereas in lenticular cataract,
the opacity is close behind the pupil. In posterior
capsular cataract, the opacity is deep in the eye,
but is always streaked ; whereas the glaucomatous
reflection is always uniform, never spotted, nor
radiated. 3d, Upon close examination of the
surface of lenticular opacity by means of a double
convex lens, it is seen slightly rough, somewhat
dull, never smooth or polished — forming, in these
respects, a striking contrast to the appearances
presented by glaucomatous opacity. 4th, The
eyeball, in glaucomatous amaurosis, always feels
firmer than natural ; while in cataract it presents
the usual degree of firmness. 5th, Glaucoma
proceeds very slowly in its course, scarcely in-
creasing for years ; whereas the vision, in cataract,
much more rapidly declines, and keeps pace with
the growing opacity.
66. (-D) The mobility of the iris is a principal
source of diagnosis. For, in incipient cataract,
the contractions of the pupil are as extensive and
as vivid as in health ; but, in incipient amaurosis,
tho pupil is either dilated and fUcd, or its motions
limited and slow. Also, in the latter disease, the
movements of the eyeballs and eyelids are often
imperfect, or difficult ; whereas no impediment of
this description exists in cataract. In many cases
of amaurosis, we observe a want of direction in the
eyes, or a slight degree of strabismus, not infre-
quently with a want of power over the motions
of the upper lid, — symptoms that never occur in
cataract.
67. VI. Prognosis. — This is unfavourable.
When the cause of the disease is evident, and it
is merely functional, or simply congestive or in-
flammatory, and the patient young, or in the prime
of life, but under middle age, a complete cure is
not infrequent. This may be obtained although
much more rarely, even when the loss of sight is
total. But in every case the predisposing and
exciting causes, and the effects of remedies, must
be taken into account in forming our prognosis.
Much more commonly only partial amendment is
produced. Amaurosis is generally less unfavour-
able when suddenly, than when slowly induced.
When the pupil is only slightly dilated, still
moveable, of its natural form, the eyeball neither
firmer nor softer than in health, and no glaucoma
present, the prognosis is obviously more favourable
than when the pupil is fixed in the states either of
expansion or contraction, or when the eyeball is
either boggy or preternaturally hard, or when the
bottom of the eye presents a greenish opacity.
58
AMAUROSIS — Treatment.
68. If the attack has been sudden, and nearly
complete, or if objects are seen in a perverted or
distorted form or double ; if the amaurosis be at-
tended with want of power in the muscles of the
eyeball or eyelids, we should suspect that the
cause consists of general or partial pressure, or
other organic disease, within the cranium, which,
although indicating both danger and the permanent
loss of sight, will sometimes be removed by ener-
getic treatment. If one amaurotic and paralytic
symptom slowly supervene on another, we should
dread the gradual developement of tumours,
cysts, exostosis, &c. within the head, the situation
and nature of which can be suspected only, and
chiefly from the nature of the attendant or pre-
ceding symptoms. But in all these the prognosis
is necessarily very unfavourable.
69. VII. Treatment. — In order to employ
remedies in this affection with any degree of
benefit, it will be necessary to direct them with a
very particular reference to the pathological con-
ditions of the eyes, the brain, and system general-
ly, as now pointed out. Having separated the
disease into the foregoing species or varieties, in
order that the treatment may be pointed out
with greater precision, I proceed to detail the
measures which I consider appropriate to each,
conformably to the most experienced authors,
and to my own observation.
70. A. Of the first species. The treatment
of this, the most strictly functional form of the
dise;ise, should have strict reference to the causes
which induced it, — whether those acting directly
on the organ, or those which act indirectly, and
in consequence of inducing disorder of other parts.
When amaurosis proceeds from direct causes,
either of a depressing or an exhausting nature,
the appearance of the eye, as well as the charac-
ter of the symptoms, require an attentive examin-
ation, chiefly with a \\ow to ascertain the existence
of iiiflanimatoi^ notion, or even active congestion
of the internal parts. A complete removal of
the causes must be insisted on ; and, if no symp-
toms indicative of inflammation (§ 4(i.) exist, but,
on the contrary, debility, a languid circulation,
muscce volitantes, or dark spectra, &c. (§ 39.),
tonics and stimulants, both internally and exter-
nally, are required. A light, nutritious, and
invigorating diet, with change of air, repose of
the organs, moderate exercise, vegetable, and af-
terwards mineral tonics, and the usual means of
improving the digestive organs, and promoting
the functions of the bowels and secreting viscera,
are in these cases chiefly to be depended on.
Small doses of strychnine, or of the extract of nux
vomica, may also be given (Form. 541.565.).
When, however, we find evidence of congestion
or increased vascular action of the internal parts
of the eye to have been induced, the means to be
employed in the next species must be resorted tn.
71. When this species of amaurosis proceeds
from interruption or disorder of the digestive func-
tions, as indicated by the symptoms of such dis-
order, by a foul tongue, acidity and flatulence of
stomach, and torpid bowels (§ 39.), emetics, as re-
commended by Right er, Otto, Schmucker,
Flemming, Scarpa, and Mackenzie, may
be exhibited ; but, unless the symptoms of inter-
rupted digestion, or of indigestible and injurious
substances remaining upon the stomach, or of
biliary obstruction, be unequivocally present, little
advantage will be derived from them : in plethoric
persons, or where these causes of disorder do not
exist, they may be even injurious. Amaurosis
from disorder of the digestive organ is generally
imperfect, and sometimes slight ; and its progress
slow. In this form, Scarpa recommends full
vomiting to be produced by the patient taking
a spoonful, every half hour, of a solution of three
grains of tartar emetic in four ounces of wrater ;
and, on the following day, opening powders to
be commenced with, consisting of an ounce of
supertartrate of potash and one grain of tartarized
antimony, divided into six equal parts. The pa-
tient is to take one of these parts in the morning,
another four hours afterwards, and a third in the
evening, for eight or ten successive days. The
effects of these are, nausea, and increased evac-
uations from the bowels ; and, in the course of a
few days, vomiting. If, during their use, the pa-
tient should complain of a bitter taste in the mouth,
vain efforts at vomiting, and no improvement of
sight, the emetic, as at first directed, is to be
again taken ; and this is to be repeated a third or
fourth time, if the bitter taste, acid eructations,
nausea, &c. continue. The repetition will often at
last succeed in procuring the discharge of a yel-
lowish or greenish matter from the stomach, to
the relief of the head and eyes.
72. The stomach, and through it the liver,
having been thus acted upon, the following re-
solvent pills of Schmucker are to be taken,
to the extent of fifteen grains, night and morning.
No. 11, R Gum. Sagapen., Gum. Galbani, Sapon. Venet.
aa 3j- ; Kliei 3 j-*-. ; Antimonii Tartarizati gr. xv. ; Succ.
Liquor. 3 j. L/ivi If in Pilul. gr. iij.
These pills are to be continued for four or six
weeks. Instead of these, the pills recommended
by Richter may be prescribed.
No. 12. R Gum. Animoniaci, Gum. Assafretid., Sap.
Venn, Rad. Valerian., Summit. Arnicse, aa 3 'j- > Auli-
moii'i Tartar. g . xvij. ; Svrup. q. s. M. et divide in
Fil la gr. iij.
From twenty to thirty grains are to be taken
three times a day for some weeks.
73. If these succeed in improving the state of
the stomach and sight, Scarpa directs means cal-
culated to strengthen the digestive organs, and
nervous system : such as the daily exhibition of
bark and valerian, more particularly in periodic
amaurosis ; a light, digestible animal diet, with a
moderate quantity of wine, and wholesome air
and exercise. He further prescribes, as advised
by Thilenius and Moricgia, the vapour of
liquor a m monies directed to the eye, with the view
of exciting the nerves of the organ ; and em-
ployed, three or four times a day, so as to occa-
sion each time a copious secretion of tears. In con-
junction with the use of this vapour, other external
stimulants, as blisters to the nape of the neck,
behind the ears, or to the temples ; irritation of the
nerves of the nostrils by sternutative powders; and,
lastly, sparks of electricity may be resorted to.
Various volatile substances, spirituous, saline, and
oleaginous, have been recommended to be appli-
ed to the eyes, either in a state of vapour, or of
solution and dropped into them, by Warner,
Sagar, Manardus, Dunckler, Chomel,
St. Yves, and Schmucker ; but these require
to be cautiously resorted to. Substances of a like
description have also beerrprescribed in the form
ofcolhjria, in this species of amaurosis. Plenck
recommends for this purpose a draclun of the
AMAUROSIS — Treatm e nt.
59
crocus mrtiillorum dissolved in rose water; or a
portion of the following: —
N,.. 13. R. Spirit. Lillior. Conval., Spir. Lavand.,Spir.
Run-mar., Miirialis Amuion., ;u Jj.; Spu. Bsls.Vil* Iloll-
ju.ui. 5 Wi M.
to be poured in the palm of the hand, and held
before the eyes. The application of cold and
slightly stimulating washes and baths to the eye,
and bathing the whole head, or eyes, in cold wa-
ter, have been approved by Richter and Beer.
Mr. Travers, however, states, that he has nev-
er obtained any decided advantage, in amaurosis,
from applications made directly to the eyes. Both
electricity and galvanism have received the recom-
mendation of Ware, Lentin (Beytrage, iv. b.
p. 102.), andOssiANDER (Abhu mil. Med. Soc.
zu Erlang., i. b. No. S.). Moxas applied in the
course of the facial nerves have been used by
I.arrey; and the actual cautery behind the ears
by Khlodovitch. 'Archives Genvr. dc Mid.,
t.'xvi. p. 452.)
74. In this species of amaurosis, both in cases
of the above description as well in those which
proceed from the over exertion of the sight, the
external application of strychnine promises to
be of considerable advantage. Mr. Liston, Dr.
Short (Lond. Mel. Gaz., vol. v. p. 541.), and
Dr. ITeathcote (Medico-Chirurgical Rev.,
July 1830.), have thus employed it with decided
benefit. After blistering the temples, and remo-
ving the cuticle, from one eighth to one fourth of
a grain of pure strychnine was applied to the de-
nuded surface on each side daily, and the appli-
cation renewed each day, and gradually increased
to a grain. In one case the quantity was in-
creased to three grains, but it is seldom requisite,
and it may .sometimes not be safe, to exceed half
this quantity. In some cases it will be necessary
to re-blister, oftener than once, the surface, after
repeated applications of the strychnine. Cata-
plasms of capsicum have also been employed with
advantage to the temples. Gahn mentions them
with approbation; and I have seen them used in
amaurosis with decided benefit by the native doc-
tors in warm climates. Hoffmann and Trew
employed the cajeput oil in this manner, and
Warner the animal oil of Dippel.
75. Mr. Travers and Mr. Lawrence are
not advocates for the use of emetics. The former
prefers to remove the gastric disorder by a course
of blue pill, with gentle saline aperients and vege-
table tonics. He recommends the combination
of blue pill with colocynth, rhubarb, and aloes ;
and of soda with columba, gentian, or rhubarb ;
with the view of promoting or regulating the ab-
dominal functions. After these he advises the
use of general tonics, as the mineral acids, bark,
steel, and arsenic. Mr. Lawrence chiefly ap-
proves of attention to the general health, by resi-
dence in a pure air; out-of-door exercise; mild,
plain, but nutritious food ; gentle aperients, and
occasionally an active purgative; repose of the
affected organ; counter-irritation by a succes-
sion of blisters, an open blister, or setons. Beer
is also against the use of emetics. He prefers the
employment of brisk cathartics; followed by the
use of anthelmintics, when we suspect the pre-
sence of worms in the bowels. Rubefacients,
stimulants, and blisters to the temples and eye-
brows, are favourably mentioned by him.
76. There can be no doubt of the propriety of
the measures recommended by the above writers:
but are we to remain content with them alone, in
cases where amendment from them is either slow
or not apparent ? I think not ; and therefore are
we required to devise additional means. Those
already recommended by the eminent Continen-
tal authorities, as stated above (§ 71, 72.), and
the external medication already described (§73.
74.), have both authority and reason in their fa-
vour, if duly followed. But it may be useful to
suggest others. For, in cases of this disease, the
practitioner will have reason oftener to regret the
want, than to be perplexed by a diversity, of ra-
tional resources.
77. After having had recourse to evacuations,
to emetics with great caution, and under the cir-
cumstances stated above (§ 71.), always to ape-
rients, alteratives, and occasionally to brisk pur-
gatives, promoted by enemata, suited to the pecu-
liarities of the case, and repeated as long as the
secretions are impeded, and the evacuations of-
fensive, or of an unhealthy colour, other internal
means must besought for, if necessary. Amongst
these, in this species of the disease, camphor,
combined with arnica, and inconsiderable doses,
has been recommended by Flemming (Hufe-
land's Journ., Sec, Jan. 1810, and May 1S12.);
the rhus toxicodendron, or the rkus radicans, in
the form of tincture, by Basse and Hufeland
(Journ. der Pract. Heilk.fyc, Jan. 1811.); and
phosphorus, by Loebel (Horn's Archie, Nov.
1812, p. 397.) Musk, castor, assafoetida, valerian,
and zinc, have also been favourably noticed by
Beer.
78. It is chiefly in this form of the disease that
advantage, if any, will be derived from the use of
aconitum, which, however, has received the ap-
probation of Boehmer, Collin, Stoeller,
Reinhold, Gesner, and other respectable au-
thorities, particularly when the affection is connec-
ted with chronic rheumatism, or atonic gout, or oc-
curs in the gouty and rheumatic diathesis. Guaia-
cum has been recommended byWiNTRiNGHAM;
and, under the circumstances of disease now allud-
ed to, particularly when combined with camphor
and ammonia, and given after due alvine evacua-
tions have been procured, is calculated to prove
beneficial. The arnica montana, which has been
prescribed by Baldinger, Collin, Franck,
Thilenius, and Angeli, is applicable to this
form of amaurosis only. It is most probably from
having employed it in very different stales of the
disease, — in the inflammatory, or those depending
upon organic change within the head, — that it has
been disapproved of by Richter and Sch-
mucker.
79. The chief complications of functional amau-
rosis require no very different treatment to that
which has been described. The not infrequent
association of the disease with worms demands the
use of anthelmintics, followed by purgatives, and
the administration of vermifuge enemata, &c. (see
Art. Worms.), and afterwards by vegetable
or mineral tonics. But, in the majority of cases
of even functional amaurosis, the use of the pre-
parations of iron, requires caution. When the
<li<e;ise is occasioned by lead, or accompanied with
the lead colic, or attended by paralysis of any
other parts of the body, the exhibition of calomel,
with camphor and small doses of opium, followed
by purgatives, and antispasmodic and aperient
60
AMAUROSIS — Treatment.
enemata, is extremely serviceable. After the se-
cretions and functions of the abdominal viscera
are restored by these means, strychnine, or the
extract of nux vomica, may be prescribed both
internally and topically. (Form. 542. 565.)
The connexion of the disease with hysteria, hypo-
chondriasis, obstructions of any of the abdominal
secretions, chiefly requires the combination of
antispasmodics with aperients; chlorine, iodine,
or sulphureous baths: the occasional exhibition
of a brisk purgative; and, afterwards, the warm
salt water bath, tonics with stimulants, and strict
attention to the secretions and functions of the
digestive organs, and to diet, air, and exercise.
After all obstruction is removed, cold bathing, or
chalybeate or salt water baths, followed by fric-
tions of the cutaneous surface, may be used.
80. B. Of the second species. When amau-
rosis is attended with those symptoms which I
have described as marking active congestion of
the internal parts of the eye, or of the head or
thoracic viscera (§ 41.), a very different treat-
ment to that enjoined above is requisite. In the
first species of amaurosis, blood-letting is gener-
ally prejudicial — it has even caused the disease:
but in the congestive species, blood-letting, either
general or local, or both, according to the cir-
cumstances of the case, is indispensable. In every
form of the disease the means of cure must be regu-
lated by the apparent vascularity of the eye, the
plethoric state of the countenance and body, and by
the state of the arterial pulse, examined not only
at the wrists, but also in the carotids and temples.
After depletion, to an extent which the well in-
formed practitioner will be led to adopt according
to the particular characters of the case, the pro-
motion of the alvine discharges, and of the cutan-
eous and alvine secretions, will next require his at-
tention, as salutary modes of derivation and eva-
cuation ; and afterwards the application of blisters,
setons, issues, and other counter-irritants, behind
the ears, or to the nape of the neck, will generally
be necessary to complete, or to render permanent,
the cure. The tartarized antimonial ointment,
moxas, the mezereon issue, the actual cautery to
the nape of the neck, or to the occiput, and err-
hines, have severally been recommended by emin-
ent Continental writers in* this state of ihe disease.
81. The shower bath, sponging the head with
cold water night and morning, the cold douche, or
the effusion of a stream of cold water on the head,
are means which ought not to be neglected in
those cases in which the congestion is of an active
character, or approaches to the inflammatory
state. When this form of the disease is consec-
utive of interrupted or suppressed discharges or
evacuations, the restoration of these must be at-
tempted. If the menses be suppressed, leeches
to the pudenda, or the insides of the tops of the
thighs; or bleeding from the feet; the prepar-
ations of iodine, aloetic purgatives, and other em-
menagogues; stimulating pediluvia, and the hip
bath, with the other means usually resorted to in
cases of arnenorrhcea, are to be employed. If it
proceed from suppressed haemorrhoids, leeches
may be applied to the vicinity of the anus, and
purgatives, with calomel, colocynth, and aloes,
prescribed. If it supervene on the disappearance
of gout or rheumatism, sinapisms and irritating
cataplasms may be directed to the extremities,
and free alvine evacuations procured; after which
colchicum, combined with alkalies or magnesia,
and, in some cases, with ammonia or camphor,
may be exhibited, or aconitum combined with
antimonials, and purified sulphur; and rubefa-
cients applied behind the ears, or to the templas.
When it appears after the suppression of eruptions,
and healing of old ulcers, the use of the tartar emet-
ic ointment, setons, and perpetual blisters behind
the ears, are particularly indicated. If it follows
a suppressed cold, VVeller recommends weak
sternutatories, with calomel or hellebore.
82. Mr. Travers has very justly remarked,
that a loss of balance of the circulation, produc-
ing undue determination of blood to the head, of-
ten exists independently of general plethora, and
is aggravated by sanguineous depletion. It is some-
times even met with in corpulent persons; and is
not infrequent after over-excitement and chronic
inflammation. Instead of requiring loss of blood
for its removal, this state of the disease demands
an equalization of the circulation, by promoting
the various secretions, and the derivation of the
excessive supply to other parts by the means now
stated, assisted by an abstemious and regular diet,
gentle exercise in the open air, the promotion of
the functions of the liver and bowels, and the
means usually employed to benefit the general
health. Even in some of these cases, the local
means noticed above, as the vapours of ammonia,
&c. (§ 73.), may be serviceable in restoring the
tone of the vessels of the eyes.
83. C. Of the third species. Inflammation
of the internal parts of the eye, particularly of
the retina, requires decision, in the more intense
cases, and a vigorous but judicious application
of the usual antiphlogistic remedies. In the
slighter cases, the exact nature of the disease may
be mistaken for either of the foregoing species.
Slight or slow inflammatory action may exist
without any material affection of the pulse, or
pain of the organ; but the appearance of the
blood-vessels of the sclerotic, and the state of the
iris, will often indicate its presence when other
signs are wanting. When the attack is acute,
both general and local depletions are required.
In these cases Plenck has advised the perform-
ance of arteriotomy; Spigelius and Hoff-
mann, of blood-letting from the frontal vein;
and Sauvages, from the jugulars. But vascular
depletion is not to be relied upon alone. Active
evacuations from the bowels, determination to
the skin by small and repeated doses of antimo-
nials, and the use of the tartar emetic blister or
plaster, behind the ears, or to the nape of the
neck, are to be also adopted.
84. If these means fail of producing a very
decided improvement in a very short time, we
must endeavour to affect the mouth slightly with
mercury, without producing salivation, hi order
that this may be done with rapidity, and with as
little mercury as possible, the preparations of this
mineral to be employed will be advantageously
combined with James's powder, or antimonial
powder, and small doses of camphor. The treat-
ment is, in such cases, similar to that usually
resorted to in iritis. Much of the advantages to
be procured from the use of mercury in this form
of amaurosis, as well as in iritis, depends upon tlie
promptitude with which it is employed. In this,
Travers, Lawrence, Mackenzie, and oth-
ers agree. Indeed, the use of calomel, and other
AMAUROSIS — Treatment.
Gl
preparations of mercury, either alone, or com-
bined with other substances, lias been adopted in
the inflammatory states of amaurosis, from the time
ofJ I bibtsb and IIoerhaave. Banc, Hude-
MANN, SCHMUCKER, ZuiCKEN, and BREIT-
rNG, agree in recommending them. Boettcher
advises the combination of calomel with belladon-
na; and He v, calomel with camphor: both being
judicious modes of combining this medicine.
Me AI>. S I A HI., I l()FFMANN,andIsENFI.AMM,
advise the production of salivation; hut I agree
with Tr avers in considering the affection of the
mouth as sufficient The use of mercury is much
praised by Bees in such cases, as well as in (hose
of a syphilitic origin, or which are complicated
with engorgement of any of the abdominal vis-
cera, t'are should he had not to employ it in
debilitated or scorbutic persons, and when the eye
B soft or boggy. Many of the Continental wri-
ters, and Mr. Ware, prefer the sublimate to other
preparations. It is best exhibited, as recommend-
ed by Van Swieten, dissolved in brandy, and
taken in a basin of sago or gruel. It may be
continued for sLx weeks, or even longer.
85. The success which has resulted from the
exhibition of the oleum terebinthince in iritis in-
duced me to prescribe it, after depletions, in two
cases of this form of amaurosis ; and w ith satisfactory
results in both. In persons far advanced in life, in
scrofulous subjects, and in debilitated persons, this
oil is certainly a less hazardous medicine than the
mercury exhibited so as to affect the system.
86. In the slighter or more chronic inflamma-
tory forms of amaurosis, particularly when met
with in the description of subjects just now al-
luded to, much circumspection is necessary in the
use of depletions : general bloodletting is here
inadmissible, particularly when this class of pa-
tients are ill i'ed, and live in close and ill venti-
lated streets and apartments in large towns, and
local depletions only are indicated. In cases of
this description, and under these circumstances,
the oleum terebinthinae will prove a valuable me-
dicine; and even, although we may deplete thus
locally, the internal exhibition of tonics, with a
nutritious diet, attention to the alvine secretions
and evacuations, and a wholesome air, will prove
the most beneficial remedies.
87. This form of amaurosis, as well as the
preceding, will occasionally supervene from sup-
pressed evacuations and eruptions, and more
rarely from misplaced gout and rheumatism.
(§ 48.) In such cases, the treatment already'
recommended, as appropriate to each of these
(§ 81.), will he equally applicable here.
87. Besides the above means, it has been re-
commended by Bromfield, to insert an issue in
the scalp; by Hoffmann, to apply leeches to the
insides of the nostrils; by numerous authors, to
employ errhines and sternutatives, with the view
of provoking a copious secretion from theSchnei-
derian membrane; and by as many others, to use
the actual or potential cautery, setons, moxas,
&c. to the nape of the neck, or to the occiput.
Leeches and counter-irritants are sale, and some-
times useful, remedies in this and the preceding
ppecies; but errhines and sternutatives may he
hurtful, unless the affection has arisen from sup-
pressed discharges from the nostrils. They are
most serviceable in the functional state of the dis-
ease. The safest that can be employed in thisspe-
6
cies of amaurosis is the one recommended by the
[ate Mr. Ware. It consists often grains of the
hydra rgyrus sulphuratus, well mixed wit b a drachm
of common sugar: a small pinch of it generally pro-
duces a copious discharge of mucous from the nose.
89. D. Of the fourth, and remaining species.
When we have reason to suspect that the amau-
rosis depends upon advanced organic lesion of
the internal parts of the organ consequent upon
inflammation, we should still bear in mind that,
with the supervention of such lesion, whatever it
may be, the inflammatory action seldom alto-
gether subsides, hut continues, more or less, in a
chronic, atonic, or disorganizing form. There-
fore the propriety of still having recourse to local
depletions, particularly if these have been neg-
lected early in the disease, to purgatives, deriva-
tives, or revulsants; the cold douche to the head;
and, afterwards, to the use of stimulating vapours,
when we have reason to suspect that the change
continues rather in consequence of lost tone of
the vessels, and inaction of the absorbents, than
from increased action. Under such circumstan-
ces, the vapour of camphor and acetic acid, or of
the liquor ammonise, may be tried.
90. a. If the amaurosis have arisen from exter-
nal injury of the ball of the eye, or concussion of
the organ (§ 51.), the chief indication is to pre-
vent, or to repress, increased vascular action, by
the means already recommended; to attend to
diet and regimen, and to keep the organ in a
quiet inactive state for sometime; after which, if
the affection still continue, the treatment must be
directed according to the particular lesion, func-
tional or organic, that may have been primarily
or consecutively produced.
91. b. When the history of the case leads us
to suspect the dependence of this affection upon
disease within the head (§ 52.), or tumours press-
ing upon the optic nerve, &c. (§ 56.), the
treatment must necessarily be directed, accord-
ing as the symptoms referrible chiefly to the
head may lead us to infer the nature of the pri-
mary lesion. If such symptoms, particularly the
temperature of the head, and the action of the
carotids, indicate the existence of congestion,
interrupted circulation, or increased action, the
treatment must be accordingly. But under almost
every circumstance, counter-irritation, and exter-
nal as well as internal revulsants, will prove safe,
and sometimes serviceable, means of cure.
92. If we have reason to suspect the formation
oC tumours; thickening, or other change, of the
membranes or of the bones, particularly as a
consequence of syphilis; and extravasations of
blood, or of serum, within the cranium, or in the
course of the optic nerves, &c. (§ 52.), the
internal use of the preparations of iodine, and
particularly of the hydriodate of mercury or of
potash (see Form. 323,324.), should not be over-
looked. I have employed these preparations
wiili much benefit in three easels of amaurosis
connected with paralysis; two of them consequent
upon apoplectic seizures. In the interval between
the courses of iodine, deobstruents, and alterative
doses of blue pill, with the extracts of sarsaparilla
and taraxacum, or with the decoction or other
preparations of sarsaparilla, should be prescribed.
93. c. When the affection seems connected with
h inn of the other nerves subservient to vision
(5 57.), the treatment must necessarily depend
62
ANGINA PECTORIS— Symptoms.
upon the seat and nature of this lesion, and, in some
rarer cases, upon the state of the associated de-
rangement. If it be connected with neuralgia of the
nerves of the face, disorder or irritation of these
nerves may exist at their origin, or in their
course through the membranes and bones of tbe
cranium. The cause may also be external — in a
diseased tooth or stump, or a partially separated
external branch of the opthalmic trunk of the
fifth nerve. In all such cases, as well as in the
other forms, states, and associations, of the fifth,
sixth, seventh, and eighth species, which have
been enumerated, the treatment must vary in
each, and be directed according to the very nu-
merous pathological conditions, which the well-
informed pathologist will detect, either as their
efficient causes, or as their related effects.
94. Throughout the treatment of this disease,
the practitioner should keep the following facts in
recollection : — 1st, An appropriate, and hence
successful, method of cure should have an inti-
mate relation to both the remote and proximate
causes of the disease, and the natural or morbid
diathesis of the patient: 2d, It must be directed
after a minute inspection of the eyes, and exam-
ination into symptoms connected with the head
and the digestive viscera: 3d, It must be modified
according to the nature of its related, associated,
and symptomatic disorders: and, 4th, That much
of the success will often depend upon the strict
regulation of the patient's digestive and organic
functions; upon diet and regimen; and upon a
regulated exercise both of the organ of sight and
of the bod)7, with a pure and temperate air.
Keeping these indications in recollection, the
practitioner will modify and adapt the treatment
to the presumed nature, seat, complication, and
relations of the disease.
Bibliography. — Cradolc, Generalia circa Suffusionem,
Guttam Screnam, et Infiam., &c. Leid. 1693.— Htister,
Apologia et Uher. Illuslratio Systematis sui de Catar.,
(ilaucom., et Amaurosi. Alt. 1717, l2mo. — (Ehme, De
Amaurosi. Leip. 1748, 4to. — Warner, Descript. of the
Unman Eve and its Diseases. Lond. 1754. — Sproegel. in
Miscel, Berol. t. vi. p. 64. — Sauvages, Nosol. Meth. t.i.p.
746. — Trinket, Hisloria Amauroseos, Vindob. 1781.— Plouc-
quet, De Amaurosi. Tubing. 1799.— Schmucker, Chirurgische
Wahrnehmungen. Ber. 1774. — et Vermische Chirurg.
Schrif. 1786. — Richter, Anfansgninde der Wunderzneik.
Goet. 1790. — Scarpa, Osservasioni sulle Malattie decli
Occhi. Venet. 1802 ; 2d ed. 1816.— Flujani, Collezione
d'Osservazioni. Rom. 1803. — Wenzel, Manuel de l'Ocu-
lisle, &c. Paris, 1806. — Kiesser, Ueher die Natur, Ursa-
chen, Kennzeichen, und Iieilung des Schwaxze Staars.
Goet. 1811. — Beer, Lehre, von den Augenkrankheiten, kc.
Wien. 1817. — Wardrop, On the Morbid Anatomy of the
Human Eye, 2 vols. 8vo. Lond. 1818. — Travers, Synopsis
of the Diseases of the Eye, &o Lond. 1820, 8vo".— Ste-
venson, On the Nature, &tc. of the different Species of
Amaurosis. Lond. 1821. — Demours, Precis Theorique et
Pratique sur les Maladies des Yeux. Paris, 1821. — Welter,
Manual of the Diseases of the Human Eye ; by Mon-
teath. Glasg. 1821, 2 vols. 8vo. — Rayer, Archives Gendr.
de Mfcdecine, t. vi. Paris, 1823 Marjolin, art. Amuu-
rose, Diet, de M£d., t. ii. Paris, 1822. — Sanson, art.
Amaurose, in Diet, de M£d. et Chirurg. Pratiques, t. ii.
Paris, 1829. — Lawrence, Lectures on Diseases of the Eye.
Lancet, vol. x., 1829. — Benedict, art. Amaurosis, in En-
cyrlop'adisches Worterb. der Medirinischen Wissenchaften,
b. ii. Btrl. 1828. — Mackenzie, Practical Treatise on the
Diseases of the Eye. Lond. 1830, 8 vo.
AMENORRHCEA. See Menstruation.
AMNIOS. See Dropsy of the Amnion.
AN/EMIA. See Blood, Deficiency of.
ANAESTHESIA. See Sensations, Morbid
States of.
ANASARCA. See Dropsy of the Cellu-
lar Membrane.
ANEURISM. See Aorta, Aneurism of; and
Arteries, Morbid Structures of.
ANGLNA. See Croup. Fauces, Inflammations
of. Larynx, Inflammations of '. Pharynx,
Inflammations of . Throat, Inflammations
of
ANGINA PECTORIS. Syn. Cardiogmus Cor-
dis Sinistri, Sauvages. Angina Pectoris,
Heberden. Asthma Arthriticum, Schmidt.
Diaphragmatic Gout, Burton. Asthma Dolo-
rificu m , Darwin . Sy n cope Angi nosa , Parry.
Angor Pectoris,}. Frank. Asthma Convulsi-
vum, Eisner. Pnigcphobia, Swediaur. Ster-
nodynia Syncopalis,Shi\s. Asthenia Pecto-
ralis, Young. Stenocardia, Brera. Asthma
Spastico- Arthriticum , Stoeller. Sternalgia,
Baumes and Good. UAnginc de Poitrine,
Fr. Brustbrtiune, Herzldemme, Brustklem-
me, Ger. Angina di Petto, Ital. Suffocative
Brenstpang, Eng.
Classif. 2. Class, Diseases of the Respi-
ratory Function; 2. Order, Affecting the
Lungs, their Membranes, or motive Power
(Good). II. Class, I. Order (Author,
see Preface).
1. Defin. Acute constrictorypainat the low-
er part of the sternum, inclining to the left side,
and extending to the arm, accompanied with
great anxiety, difficulty of breathing, tendency
to syncope, Sf feeling of approaching dissolution.
2. This affection was not recognised as a distinct
disease by medical authors, until Dr. Heberden
described it as such in the Medical Transactions of
the London College of Physicians( vols.ii. and iii.) ;
but the works of Morgagni and Hoffmann
show that they were not unacquainted with it in
practice. It was also noticed byPoTER (Opera,
No. 22. p. 302.) , under the head " Respirandi diffi-
cultas, qua; per intervalla deambulantibus incidit;"
and he remarks respecting it, that the attacks were
sometimes so severe that persons had been sudden-
ly carried off by them. Obscure notices of affec-
tions, which probably were of this nature in some
instances, may also be detected in authors from
Hippocrates downwards. From amongst these,
the reader may refer to Aretjeus ( Opera, p. 7.
Oxon. 1723.), Coslius Aurelianus (lib.ii.c.i.
p. 34S.), Barteletti (Methodus in Dyspna-
am, Bon. 1632.), and others, adduced by Zechi-
nelli (Sulla Angina di Petio, Pad. 1813.),
who supposesthat the case of Seneca ( Opera, t.
ii. p. 136.), which he has himself described by the
term suspirium , was actually this malady. Dr.
Cullen has passed Angina Pectoris over in his
work; but it has been well described by Drs,
Fothergill, Wall, Duncan, Butter,
Percival, Darwin, Ma.cbride, Hamil-
ton, Macqueen, Johnstone, Haygarth,
Parry, Nicholl, and Good, in this country;
and by Jurine, Brera, Lentin, Despor-
tes, Kreysig, Ritter, Zechixelli, and
Stoeller, on the Continent ; and by Dr.
Chapman in America.
3. Pathology. — I. Symptoms. An attack
of this disease is often preceded by considerable
derangement of the digestive organs, especially by
flatulence, acid or acrid eructations, or other
symptoms of indigestion, with torpid bowels,
pains in the limbs, and occasional spasms about
the chest: but it frequently also attacks a patient,
particularly when walking or ascending an emi-
ANGINA PECTORIS — Causes.
63
nence, without any, or with but alight, premoni-
tion.
4. A. In it*s acute form, the patient is seized
with a sense of painful constriction of the chest,
particularly at the cardiac region, about the lower
part of the sternum, inclining to the left, and ex-
tending to the left, occasionally also to the right,
arm — at fust, no further than the insertion of the
deltoid muscle ; but the pain often successively
reaches to the elbows, wrists, and sometimes even
to the lingers. This is the mildest form of the
disease, and soon subsides with the disappearance
of its exciting cause.
5. In the more violent form of the attack, the
pain and sense of constriction in the chest, and
pain in the left arm, which also frequently ex-
tends to the right, amount to excruciating agony ;
being likened, by Laexnec, to the piercing of
nails or the laceration by the claws of animals.
This feeling is accompanied by a sense of syncope
or suffocation, sometimes with suffocative orthop-
nea, convulsive dyspnoea, and palpitations; al-
ways with extreme anxiety, and a sense of ap-
proaching dissolution. The suffocative sensation
is characterized by concomitant tightness and
fulness of the chest, and flatulent distension of
the stomach, and irritative feeling in this organ,
which is relieved by eructations. During this
period the pulse is variously affected, sometimes
little changed, at other times extremely weak,
irregular, or intermittent ; and occasionally it is
full, active and bounding. If the attack has been
induced by walking or exercise, the patient sud-
denly stands still, from a feeling that perseverance
in either would produce a total suspension of living
power. In the slighter attacks, or early in the
disease, rest merely will often immediately remove
it ; but this is seldom the case in the protracted
and severe forms in which it frequently occurs.
6. The paroxysm continues from a few minutes
to one or more hours, according to the severity
and the duration of the disease. When the mal-
ady has assumed a chronic form, and its attacks
occur during the night, or when the patient is at
rest, the paroxysm is less violent, but generally of
much longer duration ; whereas, when it is in-
duced by exertion, &c. it is of extreme violence,
but of short continuance : the average duration
of the fit may be about half an hour. Upon its
cessation the patient merely retains a slight feeling
of the various symptoms, with numbness of the
arms, particularly the left. When the disease is
of short standing, the paroxysms occur at long
intervals, which an' gradually shortened, until
there is but little exemption from them, and the
affection assumes a less acute character.
7. B. The chronic form of the disease is char-
acterized by the circumstance of its being frequent-
ly a consequence of the acute ; by the occurrence
of the fit from the slightest causes, and after short
or imperfect intervals of exemption ; by its recur-
rence when the patient Ls at rest, or asleep ; and
by its much longer duration, but less extreme
violence. Even if this form be induced by exer-
cise, rest has little influence in shortening its
duration, as in the preceding ; and the paroxysm
has been protracted not only for some hours, but
even for several days. Palpitation of the heart,
irregular and intermitting pulse, are more fre-
quently concomitants of this state of the disease,
than of the other. In the case of a very eminent
and learned member of the profession, whom I
long attended in this form of the disease, the
attack has often continued as now described, with
little remission for several weeks. Sometimes the
irregularity of the pulse is observed only during
the paroxysm ; but in some cases it is continued,
as Dr. Fothergill. has correctly remarked,
during the intervals, particularly when they are
marked by imperfect relief.
8. This firm of the disease may also occur
primarily. It has twice presented itself to me in
this manner. During the severity of the attack,
leipothvmia, a feeling of dissolution from the in-
tense agony, and these followed by palpitations,
and an irregular state of the pulse, generally oc-
cur. In some cases the agonizing pain extends
not only to the arm or arms, but ascends also up
the throat and lower jaw, accompanied with a se-
vere sensation of spastic constriction. In the ma-
jority of cases the above sensations are only pre-
sent, when excited by motion, by assuming sud-
denly the erect posture, or even by attempting to
read ; a neuralgic kind of pain generally, however,
being felt under the sternum, and extending to the
arms : but in some cases, and in two which oc-
curred to me, the exacerbations were often refer-
able to no very evident cause, they sometimes
occurring during the night, although the above
causes generally induced them.
9. Notwithstanding the remarkable distress
characterizing the paroxysm, this disease, par-
ticularly in its acute state, sometimes does not
early affect the constitution, or entail any per-
manent lesion ; the patient often enjoying toler-
able health in the intermissions, and" perform-
ing all his functions naturally, and without em-
barrassment, until shortly before an attack. After
its protracted continuance, however, the vital
energies of the frame, particularly as they are
manifested in the digestive and circulating organs,
give way. Marked disorder of the chylopoietic
viscera, attended with various dyspeptic symp-
toms, occasionally with great irritability of the
stomach and bowels, impeded respiration, anxious
and pale countenance ; flabby state of the integu-
ments and muscles ; marked derangement of the
circulation, oedema, dropsy, &c. ; at last super-
vene. But it more generally happens that the
] »at icnt is carried suddenly off by a paroxysm
before tliis state of the system is occasioned ; or
he sinks under the complicated derangement
proceeding from an attack, and from someone of
the organic changes which the continuance and
repeated (its of the disease had induced.
10. II. Causes. — 1. Predisposing. This dis-
ease usually -Attacks the middle aged, and those
beyond it ; a.n. Tien much more frequently than
women. Of nearly one hundred cases, about sev-
enty were upwards of fifty years of age; and seven-
ty-nine out of the number were males; nearly one
half terminated fatally, and almost the whole of
them suddenly. It has been said also to occur more
commonly in robust and corpulent persons with
short necks. But Jurine and Chapman dis-
pute this. My own experience agrees with theirs
in respect of its being equally common in persons
of a spare as of a full habit. It is most prevalent
in those of gouty and rheumatic diathesis, and
who lead an indolent, or studious and sedentary
life, or who have been subjected to much anil
continued anxiety and distress of mind, or in-
64
ANGINA PECTORIS — Diagnosis — Prognosis.
dulged in much food, and spirituous or other
liquors. Jurine and Parr state that they have
scarcely met with it under fifty years of age. The
most violent and distinctly marked case of it
\\ bich ever came before me, occurred in a gentle-
man at the age of thirty-four. During 1821, I
attended an unmarried lady, aged twenty-six, who
laboured under it in a slighter form ; and re-
cently, in 1S30, another single female, at the age
of twenty-five, came under my care, with the dis-
ease in its most violent grade. In both these
females, it seemed perfectly unconnected with
uterine disturbance, menstruation being regular,
and no tendency to hysteria having at any time
evinced itself, or could be detected, my attention
ha\ tag been directed to this point. They both
ultimately recovered after a long treatment, and
the employment of very decided measures. Nearly
all the cases which have come under my obser-
vation were more or less referrible to mental
causes, particularly to disappointment, anxiety,
and other depressing passions. Dr. Hamilton
conceives that there is an hereditary disposition to
the affection. If we consider it to be of gouty-
origin, as contended for by Butter, Mac-
queen, Ritter, Stoeller, Thilenius,
Elsner, and Chapman, an hereditary disposi-
tion may be also conceded. But, although very
satisfactory proofs have been adduced by these au-
thors, and particularly by Dr. Chapman, in an
able paper he has recently published on this disease
(American Journ. of Med. Sciences, No. xiii. p.
67.), yet it does not seem always to depend upon
gout. Of the four cases which occurred to Dr.
Black, of Newry, one only was subject to gout
(Med. Chir. Trans, vol. vii.).
11. 2d, The disease is usually excited by walk-
ing, especially walking against the wind, or up
hill ; by ascending a flight of stairs, or any ac-
clivity, particularly when the stomach is full or
distended by flatus. It is also readily induced by
either the exciting or the depressing passions, and
by whatever perturbates the mind, or occasions
emotion. It may also be induced by the most
trifling causes, in some susceptible and irritable
habits, as by gentle walking, coughing, speaking,
or reading aloud ; by suddenly assuming the
erect posture ; by straining at stool ; or even by
a meal, however moderate, &c. It may also oc-
cur in a state of absolute repose, particularly
when the disease has become chronic ; and the
patient may be roused from sleep by an attack.
12.1 have seen it occasioned by rapid changes of
temperature, particularly by aTapid change to great
cold ; but different persons seem differently affect-
ed by extreme states of atmospheric temperature.
In some slight cases the fit has been shortened, by
the patient struggling to overcome it, by frequently
attempting to make a full inspiration ; but this
has also failed. The patient is incapable of mak-
ing this attempt in the more severe paroxysms.
13. III. Diagnosis. — Angina pectoris is more
liable to be confounded with asthma, than with
any other disease. But a close attention to the
phenomena attending upon both affections, will
readily disclose a very great difference between
them. The paroxysms of asthma always come
on during the night, or at the close of the day :
they are characterized by a heavy dyspnoea,
wheezing, and cough ; are relieved by expector-
ation and exposure to fresh air, and subside gra-
dually towards morning. They are not excited
in the same way, nor by similar causes, nor
marked by the acute and peculiar pain in the
sternum and left arm, which is distinctive of
angina pectoris. The stethoscope and percussion
furnish us with no signs peculiar to the disease
under consideration, unless it be complicated, as
is sometimes the case, with organic lesion of the
heart and lungs, or with effusion of fluid within
the cavity of the pleura or pericardium, when they
materially assist us in ascertaining the nature of
the complication ; and they also serve, by ena-
bling us to ascertain other affections of the heart,
to distinguish between it and them.
14. IV. Prognosis. — In recent cases, of no
very violent character, recovery will frequently
take place under judicious management. Eut when
the disease has become inveterate from neglect,
or from being associated with, or from having
given rise to, organic lesion, and when it has ap-
peared in a decayed constitution, or has been
preceded by other diseases of the heart or lungs,
an unfavourable result should be apprehended
sooner or later to take place : but the period of
its occurrence is uncertain ; and the event is gen-
erally sudden — sometimes like an electric shock;
the movements of the heart being instantly arres-
ted. This issue is often occasioned by a full meal,
or by exercise or mental emotions; but it also
occurs in old or chronic cases, when the patient
is at rest, and apparently uninfluenced by any
circumstance or occurrence. When it is follow-
ed by symptoms of effusion of fluid within the
thorax, or oedema of the extremities, a fatal ter-
mination is seldom far distant.
15. V. Proximate Cause, &c. Notwith-
standing the number of examinations which have
been made after death from this disease, but little
light has been thrown upon it. This is not so
much owing to the absence of morbid appearances,
as to the extreme diversity of those which have
been observed. Like epilepsy, or dyspnoea, it has
presented almost every lesion, to which the organs
which it affects are liable. Many of these may
be viewed as accidental concomitants, or as con-
current causes ; and not infrequently as results
of the repeated functional disturbance occurring
during repeated attacks. In several instances, not
the slightest morbid appearance could be detected :
but more frequently the heart and the large
vessels in its vicinity have presented marks of
disease, generally varied in its nature, and oppo-
site as to its characters. The most common of
these are ossification of the coronary arteries ;
ossification of the valves of the heart, or of the
arterial trunks; enlargement of some of the cavities
of the heart, either with diminished or increased
thickness of their parietes ; but most frequently
with softening, paleness, and tenuity of the muscular
structure of the organ; varicose dilatation of the
coronary veins (Brera); depositions of adipose
matter, to the extent of impeding its functions;
effusions of serum, blood, &c. into the pericardium
or cavity of the pleura, &c. (Fothergill,
Black, &c.) It has justly been remarked, by my
friend Dr. Uwins, " that there is scarcely any mal-
formation of the heart, or its blood-vessels, that
has not been occasionally found after death, from
what would he considered angina pectoris : while,
on the other hand, individuals have fallen victims
to the affection, fully marked, and the most accu-
ANGINA PECTORIS — Pathological Condition.
65
rate post mortem examination has not been able
to detect the slightest indication of structural de-
rangement." ( Compend. of Theoret. and Pract.
Med.) In some cases, the only morbid appear-
ances observed have been in other, and distant
organs, from that which seems to be, if not the
clue!" scat of the disease, at least the organ chiefly
affected ill its functions by it — the heart and
huge vessels having been altogether exempt from
lesion. These appearances were adhesions of the
serous surface of the lungs to adjoining parts; se-
rous effusions into the pleura ; thickening of the
respiratory mucous surface ; dilatation of the
bronchi ; oedema of the intervesicular cellular
tissue of the lungs ; abscess and tumours in
the mediastinum ; ossification of the cartilages of
the ribs (Wichmann, Jahn); tubercles, en-
largement, scirrhosity, &c. of the liver (Perci-
Val, Latham, Brera, and Walker) ;
scirrhus of the pylorus, &c.
16. These lesions serve less to throw light on
the precise nature of the disease than an attentive
examination of the morbid phenomena during the
life of the patient, and a calm appreciation of
their relations, particularly with respect to the
agents tending to diminish, remove, or to ex-
asperate them. This affection has been considered
by many authors as spasmodic, " although the
part immediately concerned seems not to have
been designated or understood." Dr. Chapman
remarks, that this hypothesis is rendered probable,
by the general complexion of the disease — its
causes, symptoms, and cure — and by its analogy
to other disorders confessedly of this character.
17. Dr. Fothergill supposed it to be occa-
sioned by obesity, and particularly by a collection
of fat about the heart; he also considered that it
was sometimes symptomatic of water in the peri-
cardium or cavity of the thorax. Parry, Jen-
ner, Burns, Kreysig, Bostock, and some
others, have viewed this affection as a species of
syncope occasioned by the accumulation of blood
in the heart, from an ossification of the coronary-
arteries. Drs. Hosack and Forbes conceive
that it most frequently arises from a plethoric state
of the blood vessels, more especially from a dis-
proportionate accumulation of blood in the heart
and large vessels. To the first and second of
these opinions it may be objected, that there is no
obvious connection between the eflect and the
cause ; for, as the cause is permanent, the effect
should be continued, or at least present but
little abatement, whereas the intermissions be-
tween Uie paroxysms are often characterised by a
return of the healthy functions. It may be further
stated, in opposition to this hypothesis, that many
fatal cases have occurred in which this par-
ticular lesion was not found on dissection. La-
ennec states that he has examined several sub-
jects who had laboured under this disease, and in
none of them did he find the coronary arteries
Ossified. Besides, cases are recorded by Mor-
gagni,Senac, Watson, Corvisart, And-
ral, and others, in which ossification of these
\ .--els were not productive, during life, of the suf-
ferings characterising this disease. Indeed the
coronary arteries are often found ossified in old
persons, who had not complained during life of
any affection of the heart, and who certainly never
were attacked by this malady. As to the last
of the above opinions, viz. that adopted by Dr.
6*
Hosack, Dr. Chapman has very justry obser-
ved, " that even allowing the fulness and irregu-
larity of the circulation contended for, which I am
by no means disposed to do, as uniform concomi-
tants, these I should take to be rather the effects
of previous irritation or excitement, than the cause
of the disease. Do we not also know, that such a
condition of the vessels can exist without inducing
angina pectoris ? Were fulness and irregularity
in the circulation only required for the production
of the disease, instead of a rare, would we not
have it as a daily occurrence ? The fact, more-
over, is, that angina pectoris, though oftener, per-
haps, attacking the plethoric, is to be met with,
as 1 have before said, in the feeble and attenuated."
I may add to this, that the severest case of the
disease which has ever occurred to me was that of
a gentleman who had suffered severely from re-
peated and profuse haemoptysis, and other symp-
toms of disease of the lungs. All these disappear-
ed, but were followed, after some time, by angina
pectoris. He was feeble and attenuated ; but it
was considered advisable to try the effect of blood-
letting to a moderate extent : this gave no relief ;
it was repeated, but the symptoms were evidently
aggravated by the measure.
18. Dr. Jurine considers the disease as a ner-
vous affection ; and he supports this opinion by
referring to the sudden and unexpected manner
of its attack — to its sudden termination in death,
or restoration to health — the nature of the ex-
citing causes of the paroxysm — the equality and
regularity of the pulse, in the majority of cases,
during the paroxysm — to the state of the respir-
ation — to the painful sensation extending to the
upper extremities — and lastly, to the circumstance
of antispasmodics being beneficial in its treatment.
The proximate causes, he adds, consists of an
affection of the pulmonary nerves, disturbing the
functions of the lungs, impairing the decarboni-
sation of the biood, and producing the pain in the
sternum. This affection of the pulmonary nerves
is communicated to the cardiac plexus, and de-
ranges, secondarily, the heart and large vessels.
The imperfect decarbonisation of the blood di-
minishes its stimulating influence on the heart and
lungs, giving rise to repeated attacks, until it
occasions the death of those organs, and then of
the brain.
19. MM. Desportes and Laennec have
adopted a nearly similar view of the disease, with
this difference, that they consider its particular
seat may vary according to circumstances. Thus,
M. La i: n n EC states, that when there exists, simul-
taneously, pain in the heart and lungs, we may
presume that the affection is seated chiefly in the
pneumo-gastric nerves ; but where there is sim-
ply stricture of the heart, without pulmonary pain
or difficulty of breathing, its site is in the nerves
which the heart receives from the great sympa-
thetic. But he supposes that other nerves may
also be implicated at the same .time, either by
direct anastomosis or by sympathy ; and that the
branches of the bronchial plexus, particularly the
cubital, are nearly always so atfected. "The
anterior thoracic originating in the superficial
cervical plexus are, moreover, frequently impli-
cated ; and this is sometimes further the case with
the branches derived from the lumbar and sacral
plexuses, when the thigh and leg participate in
the attack, which occasionally happens."
66
ANGINA PECTORIS — Treatment.
20. Brera, Zechinelli, AvERARDi,and
some others, consider the disease to be occasion-
ed by pressure of enlarged abdominal viscera on
the heart, particularly oT enlarged liver. Joseph
Frank conceives it to proceed from congestion
of the cavities of the heart, occasioned by defec-
tive nourishment of its muscular structure ; this
defective nutrition itself resulting from previous
inflammation, or from metastasis of gout or rheu-
matism, or from disease of the coronary arteries.
(Prax. Med. Univ. Precep., t. ii. p. 2t>0.) Re-
specting these, it may only be added, that the
symptoms of angina pectoris are very seldom asso-
ciated with enlargement of the abdominal viscera ;
and that, although they are much more fre-
quentlv connected with the lesions alluded to by
Frank, this connection is by no means uniform,
and is obviously not one of cause and effect ;
these lesions being rather coincident and partial
results of the morbid state of the nerves, the altered
sensibility of which constitutes one of the chief
characteristics of the disease. It may be further
stated, that Dr. Darwin views it as a particular
species of asthma, producing cramp of a peculiar
kind in the diaphragm, or the other muscles of
inspiration ; and Dr. Butter, while he conceives
it to be of gouty origin, also refers it to the re-
spiratory organs, particularly to the diaphragm.
On these opinions it is unnecessary to comment.
21. Dr. Chapman, to whose valuable paper 1
have already referred, states, ' That the disease is
a species of neuralgia, I am entirely persuaded,
commencing for the most part in the pneumo-gas-
tric nerve, and spreading in different directions,
as other nerves may become involved. The de-
rangement of the heart and other structures, with
which it is sometimes associated, I hold to be
coincidences or effects, and not the cause ; since,
among many reasons which might be adduced in
corroboration of it, the disease has undoubtedly
prevailed independently of such organic lesions,
and, conversely, these have existed without occa-
sioning it. But what is the immediate cause of
the irritation of the nerves, inducing this neuralgic
condition, giving rise to the subsequent phenomena
of the disease ? This is a question, which hith-
erto has not been clearly answered. My convic-
tion is, that it is derived from irregular gout,
which misplaced, thus operates as an irritant of
the nerves, and probably first of those of the
stomach.'
22. It will be remarked from the foregoing,
that Jurine, Desportes, Laennec, and
Chapman agree so far as to impute the disease to
a species of neuralgia of the pulmonary and cardiac
nerves, affecting the functions of the heart and
raspiratory organs, and extending by nervous con-
nection to other parts ; the organic lesions found
in fatal cases being either coincidences, or effects
of the disease ; and after an attentive examination
of the phenomena attendant on several cases of
the affection which have come before me, I see
no reason for differing materially from this opinion.
With regard to the origin of this affection of the
nerves in misplaced gout, I cannot so implicitly
agree with Dr. Chapman. The connection had
been previously remarked by several physicians, as
I have already stated, particularly by those whose
names have been adduced, as well as by Schmidt
and Burton, — a circumstance favourable to the
idea that it is founded in truth ; and evidence of
it may even be found in Dr. Musgrave's very
J excellent, but now scarcely ever noticed work, on
Anomalous Gout. Wichmann, however, has
disputed this connection, and apparently with
much reason. The notice which had been taken
of this morbid relation is very candidly referred to
by Dr. Chapman, who has adduced the partic-
ulars of six cases in which this affection was evi-
dently connected with gout, and in which recovery
j took place, after means had been successfully
employed to invite this disease to the extremities.
In the majority of those cases the patients had
never previously suffered a gouty attack, and yet
the means employed were successful in causing
it to appear in the lower extremities.
23. But whether this disease is merely a form
of misplaced gout, or an affection sui generis,
which, when occurring in persons of a gouty dia-
thesis, the induction of the regular gouty parox-
ysm in the extremities generally removes, rny
experience does not enable me to decide. In two
persons whom I was lately called to treat, and
with whom I have been long acquainted, I have
no reason to suspect a gouty tendency ; but the
connection so satisfactorily established by Dr.
Chapman is evidently by no means infrequent,
and is one which ought never to be overlooked
during the treatment of this most distressing and
dangerous disease. I believe that, in addition to
the nervous character of the* malady, the sub-
stance of the heart is often weak, thin, pale, and
attenuated, or even softened, as if its substance
were imperfectly and unhealthily nourished ; and
that its cavities, consequently, become occasion-
ally dilated and congested. This view is accord-
ant with the treatment generally found most
successful in removin<j it. In a great proportion
of the cases before referred to (§ 10.), of which
I had made notes, chiefly collected from authors,
dissection had been made in about fifty of those
which were fatal ; and out of this number nearly
forty presented some degree of disease of the
heart or large vessels ; — most frequent! v ossifica-
tion of the valves, coronary arteries, and aorta ;
and softening and emaciation of the heart. But
whether these lesions were rather the consequence
than the cause of the disease may be disputed.
24. VI. The Treatment of this disease
necessarily respects, 1st, the measures which may
be adopted during the paroxysm ; and, 2d, those
which should be resorted to in the intervals, with
the view of effecting a perfect cure.
25. 1st, //( respect of the means zvhich mayle
employe'/ during the fit, with the vieu-of dimin-
ishing its duration and violence, no very precise
or dogmatic direction ought to be given. Much
will depend upon the peculiar characters of the case.
The patient should always be placed in a state of
tranquillity ; and, particularly, if the countenance
be pale, and the carotids pulsating feebly, in the
supine or reclining position. The propriety of
bleeding in the tit has been discussed by several
physicians, and depends entirely upon the partic-
ular features of the attack. Where the symp-
toms are urgent, the patient plethoric or vigorous,
or the pulse full and possessed of tone, there can
be no doubt as to the propriety of the measure.
Dr. Read (Bub. Me I. Trans', vol. i. p. 105.) has
recorded a case which well illustrates the good
effects of this treatment during the paroxysm. In
more questionable cases, where the pulse is weak,
A\'< JINA PECTORIS — Treatment.
67
and the countenance is collapsed, bleeding from
tin' arm ought not to be had recourse to. It is
doubtful whether or not cupping even should he
employed; but where this latter state is not ex-
treme, and especially in cases of intermediate
grades of se\ erii \ , cupping between the shoulders,
to B small or moderate extent, as the ease may
seem to require, will generally afford relief, par-
ticularly if used simultaneously with derivatives
to tile extremities.
26. Hut in nearly all cases, and still more par-
ticularly in those characterized by syncope, and
an imperfect action of the heart, frictions with
stimulating and irritating substances ought to he
previously" emploj ed over the anterior parts of the
thorax, and stimulants and antispasmodics, ex-
hibited internally. As to the extent and repetition
of the blood-letting, whether general or local, the
practitioner ought to be able to decide, being
guided in this, as in other remedial means, by the
apparent energies of the constitution, and the state
of the vascular system; if these admit, and espe-
cially if signs of plethora, or of congestion of the
cavities of the heart and large vessels of the
chest, exist, the depletion may be carried to a
considerable extent, or repeated, according to the
relief obtained. The object here is to reduce the
body to he moved to a nearer relation to the state
of the moving power, at the same time that we
endeavor to increase the energy of the latter.
27. 1 should add, that the propriety of bleed-
ing, in the paroxysm particularly, has been much
disputed; and especially by Continental authors.
Where the pulse is feeble and soft, and the action
of the heart weak, it is generally inadmissible;
but, wherever we entertain doubts respecting it.
the external and internal use of stimulants and
antispasmodics, with frictions, should be cautiously
premised, and only local depletions adopted; or
depletion of every kind should be entirely omit-
ted until after the paroxysm, when either general
or local blood-letting, according to the particular
circumstances of the case, may be practised with
necessary precautions. I have employed moder-
ate blood-letting in three cases, in which the pro-
priety of the measure seemed questionable, the
patients being of spare habits of body, and weak-
ened states of system; but eyery precaution was
taken to prevent immediate ill effects from the
operation. In one of the three relief was afford-
ed; in another, the advantage was very doubtful;
and, in the third, the disease was evidently exas-
perated by it, although slight benefit seemed to
result from it at the time. In one of those cases
the serum of the blood had a milky appearance,
from the presence of an oily matter, resulting
from imperfect assimilation. From this evidence,
therefore, I infer, that, where there are no signs
of vascular plethora or cardiac congestion, or
where the vital energies of the patient are depress-
ed, and we presume the. substance of the heart is
attenuated and imperfectly nourished, we should
be extremely circumspect in having recourse to
vascular depletions of any description, and should
particularly avoid bleeding from a vein; but, at
tie- same time, we should be equally careful not
to administer too active stimulants.
28. Next to the employment of depletion, un-
der the above restrictions, in suitable cases, and
with the concomitant means recommended, the
bowels maybe opened by a purgative medicine,
combined with some warm antispasmodic and
carminative, as ether, spiritus ammonia? romati-
cus, camphor, musk, castor, spiritus anisi, &c;
and these may be given, at intervals, subsequently.
In the slighter attacks, and where the state of the
vascular s\stem and constitutional energies render
it prudent to withhold depletion, friction, with
stimulating liniments over the thorax and epigas-"
trium, (as the following: —
No. 14. ft Linimenti Camphors Comp., Linim. Ara-
moni f fort., aa gj.; Tract. Capfici gij..M<)
the internal administration of antispasmodics, and
the exhibition of a purgative medicine, will be
sufficient to give some immediate relief. The
following will generally fultil the intention : —
No. IS. R Infus. Valerians 5xj'i Spirit. Ammonia;
Foetid. 3ss,i Tract. Castorei Jss. M. Fiat Haustua bis
terve in die capien lu,.
No. 16. ft Infus. Senna; Comp. §j«s.; Tinct. Senna;
3ij.; Spirit. Amnion. Arom. 35s-i Tinct. Cardamom
Co;np. 3j. M. Fiat Haustus slaliin sumendns, et repel.
>i sit occasio*
Or the following: —
No. 17. ft Mist. Uamphorae 5j.; Liq. Amnion. Acet.
3 ij.; Spirit. .Ether. Sulph. Comp. 3j-j tinct. Uampho m
Comp. 5j-i Syrup, l'apaveris 5j- M-
29. Emetics have been spoken favourably of
by Dr. Good {Study of Mel., t. i. p. 667.). 'in a
case of great severity, in which vomiting occasion-
ally occurred when the paroxysm was excited by
taking food into the stomach, I was induced by this
symptom to try the effect of an emetic during
an attack, but no benefit was derived from it.
30. The employment of derivatives to the
extremities, particularly the lower, is generally
beneficial; and ought not to be omitted in the
paroxysm, whether we adopt the opinion as to the
gouty origin of the disease or not. Stimulating
pediluvia, and sinapisms or blisters, with all the
other measures employed under similar circum-
stances in irregular or misplaced gout, had the
effect, in the six cases of the disease published by
Dr. Chapman, of inducing the regular gouty
paroxysm, and of affording speedy relief. The
affusion of cold water has been recommended bv
some authors, but it is a dangerous remedy in this
disease. Cold epithems to the head have been
mentioned by J. Frank ( Prax. Med. Univers.,
part ii. p. 273.), as having been used with advan-
tage; they seem less objectionable. A similar
remark may be applied to the tepid affusion on
the head.
31. 2d, The means which may be employed
during the intervals or remissions between the
paroxysms are either general or topical. With
respect to the first of these, a most studious atten-
tion to avoid the exciting causes of the disease
must be inculcated. Next to this, all existing dis-
order of the digestive organs should be attended
to and removed; and the diet and regimen of the
patient strictly laid down and enforced. As the
powers of the digestive organs are generally di-
minished, and the bowels either costive or irregu-
lar, v( getable /jitter*, with an occasional alterative
aperient, either given alone, or in combination with
an antispasmodic or anodyne, will often prove
beneficial. With the view of thus strengthening
the digestive organs and removing spasm, Schjef-
fer ( Volkskrankheiten, Jun. 1807, recom-
mended vegetable bitters with opium, musk, cam-
phor, or assafcetida, and Elsnf.r proscribed the
muriate of ammonia with Hoffmann's anodyne.
G3
ANGINA PECTORIS — Treatment.
Sulphate of zinc, recommended by Perkins
{Mem. of Med. Soc. of Lond., v. iii.), in doses
of a grain, with a quarter of a grain of opium,
given twice a day, has a similar action: but it
generally is necessary to give it more frequently,
and to iiicrease the doses. With the same view
I have given the prussic acid, either simply, or
combined with the oxide of zinc, forming a prus-
siate of zinc, and in one case particularly, with
greater advantage than from any other means.
1 have reason to believe that the prussiate of
iron will prove equally beneficial; but my expe-
rience of its effects is too imperfect as yet to
allow me to speak decidedly as to its merits in
this disease.
32. In a case which occurred to me a year
since, I employed the preparations of iron, par-
ticularly the carbonate, being led to adopt, them
by the neuralgic characters of the case, and cer-
tainly with apparent advantage; but I should add,
that local means were also in operation at the same
time. Wherever we have reason to suppose that
the heart is debilitated, imperfectly nourished, or
attenuated, the employment of tonics, particularly
bark, and the preparations of iron, either alone or
with antispasmodics, Is particularly indicated, with
strict attention to diet and regimen. Auscultation
will be found of service, by intimating to us the
particular state of the heart, which must in a
great measure regulate our practice.
33. In a case of the disease which came under
my care in 1824,1 prescribed the nitrate of silver
triturated with a vegetable extract, as recommend-
ed by Sementini. This substance was continued
in increased doses, until it occasioned an eruption,
resembling nettle-rash, on the skin, — an effect no-
ticed by this physician. The relief afforded by it,
after this eruption began to appear, was decided.
The patient is, at the present time, in the enjoy-
ment of tolerable health. At the period of my
prescribing this substance, I conceived that its ex-
hibition in this disease had originated with myself;
but I subsequently found that it had been given
in two cases of angina pectoris, with advantage,
so long ago as thirty years, by Dr. Cappe {Bun-
can's Annals of Mel., vol. iii.).
34. Arsenic', in the form of Fowler's solution,
had been recommended in this disease by Dr. Al-
exander {Mei. Comment., vol. xv. p. 373.),
at a period antecedent to the introduction of the
nitrate of silver into practice, as an internal me-
dicine; and subsequently by Sir G. Blane, who
gave it with advantage, combined with digitalis
and mercury {Med. C'hir. Trans., vol.iv.p.136.).
35. Besides these, preparations of bar k, and
other vegetable tonics, have been recommended,
either alone, or in combination with antispasmo-
dics and anodynes. The hydrosulphuret of am-
monia, in gradually increased doses (from eight
drops to thirty) twice or thrice daily. The differ-
ent preparations of valerian, the cuprum ammo-
ntatttm, and sulphate of quinine, have likewise
been employed, and occasionally with decided
advantage: from the last of these, combined with
an anodyne, particularly with opium and cam-
phor, I have observed much benefit to be derived.
The following formula; may be employed.
No. 18. Hindis. Rosar. Co. 2; ].; Quininoe Snlph.
cr. j. — j.; A<-idi Sul|>h. Arum. TT] x.; Spirit. /Ether.
Sulph. Corap. ~i.; Tmct. Opii, Yl\ xij. M. Fiat II: usius
bis iii (lie capiendus. Or,
No. 19. [\ Extract. Anthcmid. ►) iji.jQuiniaa Sulph.
gr. xij.; Massac Pilul. Oalban. Comp. •) j.; Camphors
Suhactse, gr. xv.; Syrup. Papaveris, q. s. Misce bene et
divide in Pilulas xxiv., quaruin capiat u< am a. bina, vel
tres bis terve quotid.e.
Having derived much advantage from the inter-
nal use of the sub-borute of soda in dyspeptic irri-
tability of the alimentary canal, I was induced to
employ it in a case of this disease which occurred
to me a few years since, in doses of from twenty
to thirty grains, given in the decoctum althaea?.
It produced some relief; but the case was of the
greatest severity, and little benefit, at least of a
permanent description, was derived from any
means which were adopted, excepting from the
prussic acid.
36. Mercurials have received the sanction of
Brera. I have employed them in two cases: at
first as an alterative; five grains of blue pill hav-
ing been directed occasionally at bed-time, and
subsequently so as to affect the mouth. In one
of these the alterative dose had a beneficial effect
upon the state of the stomach and bowe's; but
this was of short duration. When, however,
pushed further, so as to affect the gums, great
irritability of the system, fever, restlessness, and
increased pain, anxiety, and sinking, were occa-
sioned by it. In the other case, evidently con-
nected with hepatic disorder, the blue pill was
also at first given as an alterative, on alternate
nights. It affected the gums after a few doses,
and afforded relief. It was now pushed with the
intention of inducing salivation ; and a somewhat
violent effect was produced on the mouth, \\ hich
was relieved upon exciting the salivary glands.
Decided advantage was now procured; the bowels
were kept open by means of a stomachic ape-
rient, an issue inserted in one of the thighs, and
change of air recommended. This patient per-
fectly recovered.
37. Where plethora exists, blood-letting in the
intervals will be serviceable, with a light abste-
mious diet. When the paroxysms are apt to oc-
cur during the night, I have found an opiate
given at bed-time, as recommended by Dr. Hk-
berden, of great service. In one case of this
description I gave the acetate of morphine, in the
dose of an eighth of a grain, hut it occasioned
such distressing feelings of sinking, and general
depression of the powers of life, that stimulants
were required; yet the same patient had expe-
rienced relief from opium combined with camphor.
On one occasion I tried the effects of iodine iii
the form of the tincture; but although its use was
adopted with great caution, seven drops only hav-
ing been given three times a day, it occasioned an
increase of all the symptoms, apparently owing to
its irritating effects on the digestive mucous sur-
face, and the idiosyncrasy of the patient. I may
here notice the practice recommended by Schle-
singer {Hufeland's Journ., vol. i. p. 57.), con-
sisting in the exhibition, every two hours, of the
extract of the lactuca rirosa, in doses of two
grains, with half a grain of digitalis. What effect
may we expect from the use of colchicum?
Where the disease seems to originate in gout, the
colchicum might be tried; but its use would re-
quire great circumspection. In my opinion, it
should only be given in combination with stimu-
lants, or antispasmodics and tonics, the spiritus
colchici ammoniati being* the most promising
preparation of it in such a case.
38. Although the patient labouring under this
ANGINA PECTORIS— Treatment.
69
disease in generally incapable of any, excepting
the most gentle, exercise; yet this should be
taken under favourable eiirumstanees; and change
ofair, particularly to healthy, dry. and elevated
situations, should not be overlooked. It will
generallj be observed, that persons labouring un-
der the worst form of the disease, incapable even
Of walking or sitting upright for any time, will
bear well, and even i>e benefited by, rapid travel-
ling in a carriage. This was first evinced to me
by the case of a gentleman of great scientific and
literary attainments, residing for a time at Paris,
v\ here I was called to him in the summer of 1829.
He was anxious to return to England, from a
dread of dying abroad. He undertook the jour-
061 with me, and was better during it than either
previously or subsequently. He has since taken
long journeys, with similar advantage, but no
means which have hitherto been employed have
afforded him more than temporary relief.
3.1). Secondly, Much benefit will be often re-
ceived from topical means. Under this head
issues and setons deserve particular notice. They
have been employed on the iusides of the thighs by
Macbride and Darwin. Kreigelstein
and Wolff also have observed advantage to be
derived from them, when inserted either in this or
in other situations. I have resorted to a peculiar
form ol' issue in several cases of this disease, and,
upon the whole, with much benefit. In one case,
however, it failed of having the least good effect.
40. The form of issue to which I allude, and
for the knowledge of which I am indebted to my
learned friend Dr. Hutchinson, is the bark of
me/.ereou root, deprived of its external cuticle,
and, after having been soaked for some time in a
little water, placed upon the surface of the part
from which we wish to procure a discharge. This
bark should be confined to its place by means of
adhesive plaster, spread on paper of larger dimen-
sions than the part covered by the mezereon bark.
The bark may be renewed every night, until it
procures a copious discharge. In some cases the
effect is produced in a single night, or in twenty-
four hours. When the discharge becomes copious
the bark may be renewed less frequently. The
adhesive plaster serves both to keep the mezereon
in its situation, and to retain the discharge, so as to
preserve it from soiling the clothes. When it is
abundant the plaster may be renewed, and the
secretion removed, as its occasional acrimony often
tends to heighten and to extend the irritation. In
a severe and chronic case of this disease, which
occurred to me lately (in 1830), I employed this
form of issue, and kept a surface of about four
inches square over the left small ribs discharging
as long as the patient would endure this treatment
The disease disappeared, and up to this time it
has not returned. The advantages of this issue
are, that the patient can manage it from the be-
ginning \\ ith great ease; and it may be readily
increased to any extent, and the discharge aug-
mented, according to the exigencies of the case.
41. Artificial eruptions, from the tartar emet-
ic ointment or plaster, have now usurped the place
of setons and issues; but, from a very extensive
experience of the former, both previous and sub-
sequent to the publication of an article on them in
the London .Medical Repository for April 1822,1
consider them of inferior elficacy in some diseases,
and particularly in this, to the pea-isue, or the issue
now described. It is singular that the advantages
to be derived from the production of artificial pus-
tulation, in the treatment of various disorders,
were so little known or appreciated until the
appearanceof Dr. Jf.nner's pamphlet on the sub-
ject, since the practice had been recommended
long previously in the Lectures of the second and
third Monros on Morbid Anatomy, as being fre-
quently preferable to the use of blisters ; and had
been found serviceable by Goodwin, Auten-
rieth, and Kreigelstein, in this affection,
in which it had been employed by them at the
end of the last century.
42. Blisters, either frequently repeated, or kept
discharging for a longer or shorter period, have
received the sanction of Percival and many
others. But little benefit will be derived from
them, unless they be used in the way now named1.
Thilenius recommends (Mel. vnd Chir. Be-
merkungen, i. p. 1S3.) repeated blisters applied
between the shoulders. I agree with him in the
selection of this place in preference to others for
their application, as well as in the propriety of
repeating them frequently. M. Laennec states
that he has derived great advantage from magnet-
ism, used in the following manner, both in alle-
viating the paroxysm and in preventing its acces-
sion:— He applies " two strongly magnetized steel
plates, of a line in thickness, of an oval shape,
and bent so as to fit the part, — one to the left
precordial region, and the other exactly opposite,
on the back, in such a manner that the magnetic
current shall traverse the affected part." (Dis-
eases of the Chest, p. 705.)
43. When the affection is complicate! with
other diseases, particularly with organic lesions of
the heart, or enlargement of the liver, the treat-
ment should be modified accordingly. In order
to ascertain the nature of such complications, aus-
cultation may be resorted to ; for, although it
gives us no information respecting the simple dis-
ease, it often enables us to detect the lesions with
which it is sometimes associated, and to direct
our means of cure more appropriately, and with
happier results, than we could otherwise do.
When the substance of the heart is weakened or
attenuated (§ 23.) tonics, particularly sulphate of
quinine, sulphate of zinc, and the various prepara-
tions of iron, given in decided doses, are particu-
larly indicated. In other cases, as well as when
the liver is affected, issues are generally servicea-
ble. When the disease is connected with enlarge-
ment, &c. of the liver, mercury is almost indispen-
sable. In all cases, whether simple or complicated,
attention to diet and regimen, a pure air, amuse-
ment without excitement, and an equable and con-
tented state of mind, are not only requisite to recov-
ery, but are also necessary to render it permanent.
LSiRLIOGBAPHY. Sauvages, Nosologia Methodica, tom.iv.
p. 120. edit. 8vo. — Heherden, Medical Transactions of the
ol Physicians, vol. ii. p. 59. 1768.— KUntr, A I »-
hanlung iiher die Braustbraune. Kcenisb. 1778. — Schtrffir,
t. de Angina Pectoris. Gotling. 1787. — Butter,
Treatise on the Disease commonly called Angina Pectoris.
Lond. 1791.— Schmidt, Dissert.de Angina Pectoris. Gott.
1793. — Parry, An Inquiry into the Symptoms and Causes
of the Svncope Anginosa. Lond. 1799. — Hesse, I)e Angina
Pectoris'. Halle, 1800.— Darwin, Zoonomia, vol. iv. p. 42.
1800.— Stoe?fer,Journ.der Pract.Heilkunde von Huffiland,
17 h. 1803.-./nAn,Ueber dieSvncope Anginosa,(Hufeland's
\. Jouro. 1806. — Beaumes, Traite Elementaire de Noso-
logie. 1806. — Detsportei, Traite de 1'Angine de Poitrine.
p:il. — HI a knl, Observations on tin- Nature and Cure of
Dropsies, fee. Lond. 1813. — Kreong, Die Krankheiten des
Ucrzens. 8vo. Berl. — Zcchinelli, Sulla Angina di l'elto
70
AORTA — Nervous Pulsation of.
Pail. 1813. — Jurinc, Memoire sur l'Angine de Poitrine,
eouronne par la Soriete de Medicine de Paris. 1815. —
Laennee, Traill de l'Anscultation Mediate. Paris, 1826.—
Chapman, American Journal of Medical Sciences, vol. vii.
Phil. 1831. — Jolly, in Diclionnaire de Medicine et Chirurg.
Pratiques, fee., torn. ii. Paris, 1829.
ANIMATION, SUSPENDED. See Asphyxy.
ANTIPATHY. Syn. 'A>Ti7raO;,c,Gr. Antipa-
thia, Lat. Der Widcrunlle, die Antipathie,
Ger. Antipathic, Fr. Antipatia, Arversione,
Ital. Antipathia Sensilis, et A. Inse?isilis,
Good.
Classif. — 4. Class; 4. Order (Good).
I. Class; IV. Order (Author).
1. Defin. Internal horror and distress on
the perception of particular objects, with great
restlessness, or with fainting.
2. This singular affection has merely been men-
tioned by Cullen: it has, however, received
more attention from Sauvages, Linn.s:us,Vo-
gel, Ploucquet, Passament, and Goon.
The last named writer has needlessly divided it
into two species — sensile and insensile antipathy;
the former arising from objects or subjects which
strike some one of the senses; the latter from the
presence of an object, as soon as it comes within
the sphere of some unknown influence, although
unperceived by any of the senses.
3. There are numerous instances of singular
antipathy on record ; and most persons of observ-
ation have met with others in the course of their
experience. The vulgar explain them generally
by considering that the mother had experienced a
fright from the objects of antipathy during the
early months of pregnancy — and there are, no
doubt, some facts which countenance the sup-
position. Thus, James the First could not endure
the sight of a drawn sword : Rizio was killed at
the feet of Queen Mary when pregnant with him ;
and many other instances are mentioned by wri-
ters : but more frequently the persons themselves,
who are thus affected, have experienced frights
during the early months of infancy, or have had
their minds early and indelibly impressed by cer-
tain subjects. Peter the Great had a fall from a
bridge into the water, when an infant, and he
could not afterwards endure to hear the rattling
of a carriage passing over a bridge. Persons often
retain the antipathy to the sight of crabs, lobsters,
&c. which had been occasioned by fright from
them in infancy or childhood. A man-servant in
the author's family, advanced in life, had so great
an antipathy to the sight of a mouse, that he would
fly as fast as he was able from the place where
one was seen ; and become quite frantic at the sight.
He stated that his mother, who likewise had an
antipathy to mice, had been distressed by one
thrown upon her when pregnant of him. Some
persons cannot endure certain odours, from the
faintness, or1 sickness, or sense of anxiety and dis-
tress they occasion. This appears to proceed
from peculiar idiosyncrasy. I have likewise seen
persons who could not touch certain smooth ob-
jects without feeling a peculiar shudder or horror,
followed by faintness in some. This appears to
arise from associations excited in susceptible or
sensitive minds.
4. The most singular instances of antipathy
are those which occur at the presence of objects
unperceived by any of the senses; forming the
insensile antipathy of Dr. Good. Thus, a cat
concealed in a room has been known to produce
a most indescribable distress or horror in a person
who has not perceived it by any one sense, and
has been, in nootherway, informed of its presence.
Some singular idiosyncrasy , doubtless , ex ists in such
cases. Sau v ag es conceives that an effluvium pro-
ceeds from the animal, which, combining with
that emanating from the person thus affected, occa-
sions the unpleasant sensations upon his peculiar
organization or idiosyncrasy. This is, perhaps, the
only opinion that can be formed on the subject.
5. The Treatment to be adopted for the re-
moval of antipathies consists chiefly of resolute
endeavours to overcome the morbid impression,
by gradually accustoming the mind to its influ-
ence. Indeed, this is the only remedy that can
be resorted to. Its adoption, successfully or
otherwise, will entirely depend upon the mental
energy of the patient. But there cannot be a
doubt, that all impressions, however unpleasant
or distressing, may be ultimately overcome by
repetition, and a firm resolution either to endure,
or not to be affected by them. The following
works will furnish some curious information on
this subject, with much trifling, silly hypothesis,
and irrelevant matter: —
BinLiOGRVPHY. — Lipsius, Diss. Antipathiae Sinsulares,
&c. Jen. 1678. — S. Rattray, Aditns Novna ad Occulta
Sympathise et Antipathiae Causas. Glass. 1658. — K. Digby,
Theatr. Sympalhet, p. 138.— Rudolph, De Antipathia
Humana. 'Basil, 1700.— Schurig, Chylologia, p. 96. et
163. et seq. — Mentz, Disser. Antipathiae Phys. Phaenom.
ad suas Causas Revocata. Lips. 1708.— Du Voisin. De
Antipathia Humana. Basil, 1701, — ZvHnger, De Antipa-
thia Humana, Fascic. Dissert. Select., n. 1. — Schvrimmer,
De Antipathia. Jenae, 1669. — Hermstaedt, Wunderhare
Kriifte der Xatur durch die Symp. und Antipathie. Rotenb.
1776,8 vo. — Pass ame7it,Essai sur les Antipathies. Paris,1811.
ANUS. See Rectum.
AORTA. Syn. Arteria Magna. Aorte, Fr.
Aorta, die grosse Schlagader, Hauptstamm
- alter Korperpulsardern, Ger. Its Diseases.
1. This most important vessel is liable to all the
lesions which have been noticed under the article
Arteries. Some of them, however, when sented
in this artery, are so important, particularly as re-
spects their effects upon adjoining viscera, and their
extremely dangerous consequences generally, that
I propose to give a succinct account of them in
this place. In doing this, I shall so far depart from
the alphabetical arrangement, in respect of the
subordinate heads of the subject, as may be requi-
site to the consideration of it in strict pathological
order. Functional disorder, therefore, of this ves-
sel will be first considered; next, inflammation;
and, lastly, those lesions which usually result
from inflammation, &c, as aneurism, constriction,
obliteration of the vessel, &c.
2. I. Nervous Pulsation of the Abdom-
inal Aorta. II. Class; I. Order. This is not
an infrequent affection in weak, emaciated, and de-
licate persons, and particularly hysterical females.
It is often associated with collections of air in the
colon; and with accumulations of fa?cal matters
or morbid secretions in the ca?cum. It is also not
infrequently consequent upon neglected dyspepsia.
3. A. The Symptoms are generally very charac-
teristic of the nature of the complaint, and suffi-
cientlv serve to distinguish it from organic lesion
of the vessel. 1 he morbid pulsation is generally
associated with nervous or hysterical symptoms,
and is of a variable character. It is increased and
diminished, sometimes without any evident cause,
but more frequently by nwntal or moral affections
and emotions, or by constitutional causes. Dis-
orders of the stomach, and irregularity of the
AORTA — Inflammation of.
7t
uterine functions, also sometimes occasion or re-
produce it; and I have observed it to follow upon
the paroxysms of sinking or leipothymia to which
\oi\ delicate females are occasional!) liable.
i. I pon pressing the stethoscope firmly over
the aorta, the pulsation will he generally felt
limited ill extent, in its transverse or lateral direc-
tion, hut it will be very perceptible in the course
of the vessel from the bifurcation to the epigastrium,
[tistead of the gradual, steady, and strong motion
or impulse attending aneurism, there is felt a
vigorous and smart jerk; and the sound is either
merely a slight whizzing, or is scarcely to he heard.
5. The Treatment of nervous pulsation of the
aorta will entirely depend upon the peculiar cir-
cumstances of the case in which it occurs. If
the paroxysm is severe, the preparations of aether,
assaiietida, valerian, and ammonia, should he
exhibited. I have seen much benefit afforded
b\ strong coffee and green tea in these cases. The
dependence of the affection on mental emotious
indicates the propriety of advising a tranquil state
of mind, and a mild diet, with attention to the regu-
lar functions of the bowels. In cases evincing much
irritability, mental or corporeal, hyoscyamus, co-
nium, or the acetate or sulphate of morphine, in
very small doses, particularly hyoscyamus com-
bined with camphor, will be found useful. The
preparations of morphine, however, should be
cautiously administered in this affection. In a
ease which occurred to me some time ago, the
sixteenth part of a grain only of the acetate of
morphine was followed by unpleasant depres-
sion. Upon the whole, more advantage will
accrue from the antispasmodics than from the
sedatives just named; but in cases characterized
l>v attendant irritability, the combination of sub-
en belonging to both these classes of reme-
dies will he of great service.
6. In all cases of this affection occurring in
females, — and the great majority of them do occur
in this sex, — the state of the menstrual discharge
should receive the utmost attention. When the
more distressing state of the affection subsides, a
more tonic regimen and plan of cure may be
adopted. The bitter infusions and decoctions,
particularly those of calumba, cinchona, casca-
rilla, and camomile, with the alkaline prepar-
ations. &c, and subsequently the preparations of
iron, the shower bath, cold salt water bathing,
ehalybeates, regular exercise in the open air, and
light nutritious diet, are the means chiefly to be
depended on. When associate i with other ail-
ments, it is generally symptomatic of them, and
therefore in such cases the treatment must he
directed to the primary complaint.
7. II. [ill LAM.1IATIOM OFTHE AoRTA. Aor-
titis. Aortite, Fr. Die Jlortenentzltndung, Ger.
II. Class; II. Order. Inflammation of the
aorta occasionally takes place, but more frequently
in a chronic than an acute form, and commonly
consecutively of inflammation of the internal sur-
face of the heart, and during the course of certain
of fever. The internal membrane of the
vessel is sometimes alone inflamed, particularly
when the disease takes place during fevers, or
extends to it from the internal surface of the heart's
cavities; but, in several cases, the subjacent cel-
lular tissue, or both it and the internal membrane,
are chiefly affected. Aortitis seldom originates
in the exterior coats of the vessel.
8. The Causes of aortitis are, — 1st, External
injuries, as blows, contusions, falls, &c; 2d,
Violent, or too long-continued exertion; 3d, The
use of hot, stimulating, and acrid ingesta, spiritu-
ous liquors, and the introduction, by absorption
or otherwise, of irritating poisons and morbid se-
cretions, &c. into the circulation; 4th, The exten-
sion of inflammation from the heart, lungs, pleura,
and pericardium, and the suppression of the erup-
tion in eruptive fevers; — M. PoRTALstates (Anat.
Med,, t. iii. p. 127.) that he has met with it in
cases of this description; — and, 5th, The causes
which are productive of diseases of the heart.
9. The Symptoms can scarcely be stated with
any hopes of enabling the practitioner to distin-
guish this disease, which is generally met with in
conjunction with other maladies ; particularly
fe\ ers, and inflammations of the heart, lungs, peri-
cardium, and pleura, and disclosed to us only by
post mortem examination, a. When inflammation
more or less acute extends along the descending
aorta, the patient generally complains of a smarting
and painful sensation in the direction of the spine,
with a violent feeling of pulsation of the aorta;
extending to the iliacs, without any appearance
of enlargement or tumour; and unaccompanied
by smallness of pulse in the remoter arteries, par-
ticularly those of the superior parts and extremi-
ties of the body. In the more acute cases, a
sensation of heat is felt in the region of the vessel,
sometimes with oppressive anxiety, leipothymia,
or tendency to fainting, and always increased
force and vivacity of the pulsations of the vessel.
10. b. The chronic states of this disease admit
not of recognition until they have produced some
one of those organic lesions, which occasion mark-
ed obstruction of the circulation, or aneurismal di-
latations. Dyspnoea upon slight exertion, ema-
ciation, a pale yellowish tint of countenance,
palpitations, hypertrophy and dilatation of the
heart's cavities, cedema of the extremities, &c.
are then the usual symptoms; and, although they
furnish no certain evidence of the existence of
this disease, yet when they are present, without
the signs cf narrowing of, or obstruction in, the
orifices of the heart's cavities, and of the origin
of the aorta, chronic disease of the aorta may be
presumed to exist.
11. The Prognosis of this disease, when its
existence is presumed, is always unfavourable;
on account both of our ignorance of much that is
important respecting its symptoms, complications,
and consequences, and of the fatal nature, sooner
or later, of a great part of the effects to which it
gives rise.
12. Aortitis, particularly in its chronic states,
is occasionally complicated with hypertrophy of
the left ventricle; the hypertrophy either causing
the inflammation of the aorta, or the latter occa-
sioning the former, particularly when the canal
of the vessel is narrowed or obstructed by the
effects of the inflammation. The other compli-
cation.; have been already noticed' (§ 7 — 9.). It is
chiefly owing to the more frequent occurrence of
tin; disease in a complicated, than in a simple
form, that it is so commonly overlooked, and so
difficult to be ascertained, even when its existence
is suspected.
13. The Lesions produced by inflammation
of the aorta are nearly the same as those I have
enumerated in the article on the lesions of arteries.
72
AORTA — Aneurism of
But as these, changes, when affecting this important
vessel, are often the first step to the formation of
aneurism in it, I shall here briefly allude to them
as they actually appear upon examination. Aor-
titis, whether occurring simply, or with disease
of the heart or o,:.er related viscera, presents the
results of various grades of activity. In the more
acute cases, the internal surface of the vessel is
of a deep or dark red, sometimes approaching to
purple; and both the internal membrane and the
middle coat are easily torn. The connecting
cellular structure and the fibrous coat are much
more injected with blood than natural; and coagu-
la, more or less firm, and of a fibrous character,
sometimes adhere to the internal surface of the
inflamed part : but this is not often observed in
the aorta, as the current of the circulation through
it seems to wash away the fluid as soon as it is
etlused, and before it coagulates on the surface
which produced it. Obliteration of the aorta
(see § 53.) may, however, arise either from ex-
ternal pressure, or from false membranes formed
in its internal surface, so as to obstruct the cur-
rent of the circulation in it; or from depositions of
lymph between its coats, sufficient to produce the
same effect, the obliteration being thus a remote
consequence of the obstruction.
14. The results of chronic aortitis, are more fre-
quently met with than those of the acute. These
are yellow spots, or yellow curdy matter deposited
under the inner membrane, which may burst
from the distension and the friability occasioned
by the inflammatory state; the curdy matter pro-
jecting like a tubercle into the canal of the vessel;
bony deposits, which are also just formed under
the internal membrane, and in like manner be-
come exposed and washed by the current of the
blood in the vessel; thickening and induration of
the coats of the aorta; friability and softening of
one or more of them; ulceration commencing in
the lining membrane, and extending more or less
through the. exterior tunics, till at last dilatation of
the external coats in the form of a pouch, or fatal
haemorrhage, ensues; and cracking, and laceration
or dilatation, which, with the former lesions,
generally originate the different forms of aneurism
to which this vessel is liable. (See § IS.)
15. Dilatation of the coats of the aorta may
first occur, and' then the inner or middle coats
give way when it has reached a certain pitch : or
the laceration of the inner coats, with or without
previous ulceration, may take place previous to
the dilatation. But either state of disease — dilata-
tion or laceration — especially the latter, seems to
proceed from a nearly similar pre-existing change
of the internal tunics, one evidently connected
with slow inflammatory action. Even dilatation,
which has been attributed to debility of structure,
is more frequently a result of inflammation, which
in fact occasions here, as it does every where else,
debility of structure; defective \ ifuf .cohesion of
the texture being a general result df-niflainniation.
16. Treatment. Aortitis ijequire^ the same
treatment as other acute inflf&miatfb'ris. Ge-
neral and local blood-letting,, perfect repose,
both mor;d and physical, and the rest of the an-
tiphlogistic regimen, are indispensable. The
E reparations of digitalis in order to quiet the
eart's action, cooling aperients to remove fascal
accumulations, and counter-irritants to elicit a
determination of the fluids to external parts, are
amongst the most efficacious means. In resorting
to counter-irritation, care should be had not to em-
ploy substances calculated to excite general irri-
tation by their use in this way. The tartarized
antimonial ointments or liniments (see F. 305. 749.)
are the only means of this description ; excepting
issues, which should be used in this disease.
17. When those symptoms appear which have
been stated to result from chronic aortitis, or its
effects, local depletions, — particularly when signs
of congestion of either the heart, lungs, or head,
appear — a restricted diet and regimen, perfect re-
pose of body and mind, attention to the abdominal
functions, and the use of the tartarized antimonial
ointment, or setons or issues, are the chief means
that can be called to our aid. Other remedies
may, however, be employed, with the view of
alleviating or removing the contingent symptoms
and ailments that may supervene.
IS. III. Aneurism of the Aorta, — Aor-
teurysma. die Aortenueitung, Ger. IV. Class;
II. Order, — is a not infrequent consequence of
inflammation, particularly of its more chronic
forms. The changes in the parietes of the
aorta, constituting aneurism of it, are the fol-
lowing : — 1st, Si?nple dilatation of the whole
circumference of the vessel; 2d, Dilatation of
one side only, in a sacculated form, without rup-
ture of its coats, or true aneurism; 3d, Dilata-
tion of the external or cellular coat of the vessel,
occasioned by rupture or ulceration of the internal
and middle coats, or consecutive or false aneu-
rism; and, 4th, Ulceration or rupture of the inter-
nal coats taking place after their dilatation, and
occasioning the still further dilatation of the cellu-
lar coat, constituting mixed or com} ound aneurism.
19. A. Simple dilatation of the whole circum-
ference of the aorta may occur to a greater or less
extent along the vessel ; it may be limited to a small
portion only; or it may occur in several parts, giv-
ing the vessel an irregular shape, and forming seve- '
ral oval expansions of it. The second of these is
the most common. The dilatation is various in ex-
tent : it is frequently as great as twice or thrice
the natural calibre of the vessel, or even greater.
It is usually more evident in one side than in an-
other, and is attended with some one or more of
the organic changes described as consequent upon
chronic inflammation of the aorta (see § 13 — 15.,
and Arteries, Pathology of), particularly thin-
ning and thickening of the coats, thereby resem-
bling passive and active aneurisms of the cavities
of the heart. The situations in which this change
of diameter of the vessel occurs most frequently,
are the ascending portion and arch; but it is not
infrequent in the descending aorta. Dilatation of
the pulmonary artery is very rare. This simplest
form of aneurism, although' frequently accom-
panied with various morbid depositions in lite
coats of the vessel, never contains laminated co-
agula, unless the lateral dilatations very nearly
approach the state of sacs or pouches, constituting
the next variety. In some cases of this form of
aortic aneurism, similar changes are also met
with in some of the large arterial trunks, as the
subclavian, cccTiac, and iliac arteries.
20. E. True aneurism, or extensive dilatation
of a portion of the circumference of the aorta, fre-
quently has a neck of less diameter than the body
of the sac. It seems to arise from a loss of elas-
ticity and vital resistance of the portion of the
AORTA — Aneurism of.
73
vend thus affected, in consequence of chronic
inflammation and its effects. < taring to this cause
the dilated portion of the vessel often presents
many of the lesions described as consecutive of
the inflammatory Btate, particularly reddened
spots, minute fissures, atheromatous, cartilagin-
ous, or ossific deposits, &c. This variety most
common!} affects the ascending portion and arch
of the aorta, and shoots out from its anterior or
lateral parts. It often attains a considerable size,
being sometimes as large or larger than the foetal
heart, and general]] inclines towards the right side
of the chest. The dilated coats of the vessel
are generally thicker, and hut very rarely thinner
than natural, unless in parts of the aneurismal
poach. When it arises from the root of the aorta,
and the inner and middle coats hurst, fatal extra-
vasation takes place within the pericardium: no
false aneurism taking place in this situation, owing
to this part of the vessel being destitute of the
cellular coat. Coagula do not frequently form in
true aneurism as long as the current of blood in
the sac continues to he not much obstructed; but
when, owing to the narrowness of its mouth, or
to retardation of the current of circulation in it,
a partial stagnation takes place, coagula then
form, frequently in an irregular or confused state,
but sometimes in regular layers.
21. C. Jlneurism with ulceration of the in-
fernal coats, or false aneurism. This variety
arises, 1st, from rupture or fissures of the inter-
nal coats, owing to a loss of their vital cohesion,
and to friability consequent upon chronic inflam-
mation, associated with fungous, calcareous, and
steatomatous deposits; and is often occasioned
by accidents, or violent or sudden extension of
the vessel : 2d, from ulceration following scro-
fulous and chronic inflammations, and the de-
ta< hment of various depositions formed in the
internal membrane. Cases have been recorded
by LaehREC and GUTHRIE, wherein fissures
of the interna] coats of the vessel, instead of pro-
ducing aneurismal dilatation of the external coat,
had dissected it from the fibrous tunic along the
greater part of the length of the vessel; hut such
occurrences are very rare. This variety of aneu-
rism cannot he formed at the commencement of
the aorta: it is most frequently met with in the
descending aorta, and the part opposite to the
tumour or sac is generally not in the least dilated.
Numerous instances of this variety of aneurism
are recorded by modern authors.
22. 1). .Mixed or compound aneurism. After
all the coats of the vessel have been dilated to
a certain extent, forming either simple expansion
or true aneurism, but, owing to the less extensi-
ble properties of the internal coats, conjoined with
the effects of previous or existing inflammatory
action, rupture or ulceration of them takes place,
the impulse of the current of the circulation di-
lates still further the yielding cellular coat of the
vessel, and a sac or cyst is thus not infrequently
formed of this coat surmounting the primary
aneurism. In this case the perforated internal
eoata form the neck of the eyst, which is always
narrower than the cyst itself. When the ruptured
part of the internal coats is considerable, so that
the impulse from the current of blood prevents its
coagulation in this cyst; or, when in this, as in
the other varieties of aneurism, coagulable lymph
is not formed, so as to give rise to layers of fibrin-
ous coagula within the sac calculated to support
it, rupture of the sac will sometimes occur, and a
diffused form of aneurism be the result
23. E. Of certain changes connected vnth
aneurism of the aorta. In some rare instances
an aneurism of this vessel has been observed by
Haller, Dubois, DtTP0?TREN, and La en-
nec, consisting of hernia of the inner coat through
the ruptured fibrous coat. But it is obvious that
aneurism, or tumours of this description, can sel-
dom reach any considerable size without being
either ruptured, owing to the more friable nature
of the internal membrane, or confined by granu-
lations and adhesions on its external surface, as
shown by the experiments of Howtee, Scarpa,
and Come. .Solid small tumours, of the size of
nuts, and closely attached to the aorta, have been
described by Corvisart and Hodgson ; the
latter of whom supposes, with Laennec and Ber-
tin, that they are the remains of spontaneously
cured aneurisms, their sacs having been filled with
coagula, and their size afterwards diminished by
absorption. The deficiency of the coats of the
vessel, at their points of union with it, seems to
confirm this opinion.
24. a. One of the most important changes
connected with this disease is the deposition of
fibrine and the formation of coagula on the inter-
nal surface of the sac. This process generally
appears to proceed by progressive steps; aud the
deposition thus presents successive layers. The
most central of these generally consist of blood
only, more or less firmly coagulated; and each
layer becomes firmer, drier, and paler, and more
and more fibrinous, until the parietes of the sac is
reached. In many cases, the most external lay-
ers chiefly consist of a whitish or grayish yellow
fibrine, more or less opaque and friabla. Some-
times they nearly resemble dried paste. The
more recently formed coagula are soft, loose, and
often only partially adherent to the layer next it.
In some cases, blood seems infiltrated between
the layers. Those next the vessel are generally
united to it by a fine cellular-like tissue, furnish-
ing appearances of a partial organization. These
depositions evidently proceed from the effusion
of coagulable lymph from the internal surface of
the aneurismal sac, and the partial stagnation or
retardation of the blood, favoured by the narrow-
ness of the neck of the sac, and the inflamed,
uneven, or rugged state of its internal surface.
When neither of these states exists, as is often the
case in respect of the first two varieties of the dis-
ease, and particularly when the neck of the pouch
is wide, neither coagula nor layers of fibrinous
deposits are formed. When, however, inflam-
mation of the internal surface of the dilated ves-
sel or of the sac exists, and when a morbid secre-
tion takes place from it, -this will originate coagu-
lation pf a p«/t(on of the. blood which comes in
contact wjuiTt^and form, at the same time, a
bond of nlfion between the coagulum and the in-
ternal -suiQce ofluhe dilated coats of the vessel.
The thickness ana compactness of the coagula in
aortic aneurisms are often remarkably great, and
are chiefly to be imputed to this mode of origin.
(See art. Blood.)
25. 6. As the aneurismal tumour enlarges, it
generally occasions important changes both in
itself and in adjoining parts. Those which re-
spect the sac itself are chiefly thickening of the
74
AORTA — Aneurism of.
dilated coats, or thinning of them; and, in some
instances, of both these changes in the same case.
When the extension of the sac is considerable, or
when moderate, if opposed by a firm substance, as
cartilage or bone, ulceration or absorption of the
parietes of the sac. inflammation of its more ex-
terior parts and adhesion to adjoining structures;
and, ultimately, as the tumour increases, perfo-
ration or rupture of the more prominent part, fol-
lowed by fatal haemorrhage, take place. The
mode in which the aneurism bursts is different,
according to its situation and the structure which
it compresses and destroys: thus it not infre-
quently breaks by ulceration arid perforation of a
limited part of the sac. In some cases, particu-
larly when it opens into a serous cavity, distinct
laceration of the more exterior covering occurs;
when it reaches a mucous surface or the skin, a
slough is formed on its most prominent part, which
is soon detached, and fatal haemorrhage is the
result. In the majority of such cases, the proper
coats of the vessel may have been long previously
destroyed at one part or other of the sac. But,
if the aneurism form at the root of the aorta, rup-
ture or ulceration of the proper coats of the vessel
is followed by instant effusion of blood into the
pericardium. Rupture of the aneurisnial tumour,
as respects the coats of the vessel, whether burst-
ing into a hollow cavity or upon a surface, or
forming a diffused aneurism, is generally trans-
verse; but it is, in some cases, longitudinal, when
it irnpli"ates all the coats of the vessel; orthe rup-
ture of the internal coats is transverse, and that of the
external coat longitudinal; the former being almost
universally transverse. The effects of aneurism
upon adjoining parts require particular notice.
26. F. Of the effects of aortal aneurisms on
adjoining parts, and the situations in which they
break. The effects of aneurisms on adjoining
parts necessarily depend upon their volume, firm-
ness, and position. The heart, lungs, trachea,
large bronchi, oesophagus, pulmonary artery, large
veins, thoracic duct, and various organs contain-
ed in the abdominal cavity, may be displaced,
atrophied, or partially destroyed, by the compres-
sion occasioned by them.
27. a. The vena cava is not infrequently more or
less obstructed by the pressure of aortal aneurisms.
M. Reynaub (Journ. Hebdom. t. ii. p. 109.) met
with a case in which this vessel was very nearly
obliterated by an aortal aneurism, andM. Boujl-
laud mentions a case in which the superior vena
cava was so much compressed by an aneurism at
the arch of the aorta, that apoplexy was caused by
it (Diet, de Mtd.,et Chir. Prat.,t. iii. p. 403.) ; and
Corvisart (Journ. de Mid. par MM.Corvvsart,
&c, t. iii. p. 85.) and Bertin, relate similar in-
stances. The thoracic duct has also been de-
stroyed by it, as was observed by M. Laennec
Mr. Hodgson and Sir A. Cooper met with cases
in which the common carotid, and subclavian
arteries were completely obliterated by the press-
ure of aortal aneurism.
28. b. When the pressure of an aortal aneur-
ism destroys an adjoining viscus or structure, the
ulcerative inflammation is often extended from the
parietes of the sac to them, followed by the ad-
hesion and absorption or ulceration of the parts
most compressed, until the tumour bursts, in one
of the modes now stated ( § 25. ) , into one or other
of the following situations: — Aneurism of the
ascending or pericardial aorta generally opens
into the pericardium: in three cases it bursts into
the pulmonary artery, recorded by Dr. Wells
( Trans, of Societij for Improvement of Med. and
Chirurg, Knowledge, vol. iii. p. 85.), M. Sue
(Journ. de Mid. Contin., t. 24. p. 124.), and MM.
Pa yen and Zeink (Bui. de Fac. de 31 Id., No. 3.
1819.). Aneurism of the arch of the aorta may
break into the trachea, oesophagus, pleural cavity,
or into the pericardium. That of the descending
aorta generally bursts into the pleura, oesopha-
gus, posterior mediastinum, or into the lungs.
Aneurisms of the pectoral aorta most frequently
burst into the left pleura; they have, however,
been known, but in two instances only, — record-
ed by M. Laennec and Mr. Chandler, — to
open into the spinal canal, having destroved the
bodies of the vertebrae, which are generally more
or less injured in cases of aortal aneurism of con-
siderable size. When seated in the ascending
aorta, they often destroy the sternum; in both
cases causing interstitial absorption of the bone,
and often of the parietes of the sac and fibrinous
layers of coagula in contact with it, so that the
blood washes the bone itself. The cartilages
usually resist the pressure of aneurisms, either
altogether, or much longer than the bones; and
when the periosteum is inflamed by the pressure
of the aneurism, an ossific deposit is not infre-
quently formed around the tumour.
29. c. Aneurism of the aorta may, however,
destroy life, even without breaking in any of the
above directions; either by impeding the action
of the heart and displacing it, or by compressing
the organs of respiration, or by occasioning con-
gestion, infiltration, and hepatization of the lungs;
or by compressing the oesophagus, or injuring
some of the thoracic ganglia; or it may destroy
or compress the thoracic duct and large veins, as
stated above (§ 27.), to a fatal extent.
30. d. The bursting of an aneurism of the aorta
is not necessarily followed by instant death, as has
been shown by MM. Laennec and Masjoi.in,
and very recently by Mr. S. Cooper. In a case
read by this very able surgeon, at the Medico-
Chirurgical Society, where the aortal aneurism
had pointed under the left shoulder-blade, but
subsequently broke into the oesophagus, several
pounds of blood were discharged by vomiting
and stool, yet the patient lived for many months
afterwards, and pursued a laborioas occupation;
a second haemorrhage at last proving fatal. When
the sac of an aortal aneurism bursts, and the blood
flows into a cavity or viscus, from which it is
readily discharged, death usually is soon produ-
ced. But when the opening in the sac is so sit-
uated that the blood is effused into the cellular
structure, and what was before a true or encys-
ted abscess becomes a diffused one. life may be
prolonged for some days or weeks, or even long-
er. This, however, will depend upon the situa-
tion in which the rupture takes place, and the
nature of the parts into or upon which the blood
is effused. When the sac of an aneurism is rup-
tured, the laceration is generally in the same axis.
or nearly so, with the opening into the sac. ow-
ing to the impulse beuig greatest in this direction,
unless a divergence is occasioned by the un\ ield-
ing nature of the parts »in this situation, and by
the slight resistance opposed by part* immediate-
ly adjoining.
AORTA — Aneurism of.
75
31. G. Of the causes of aneurism qftheaorta.
Diseases of arteries, and consequently aneurism,
are much more frequent in men than in women.
Mr. Hodgson states, that of sixty-three cases of
aneurism, externa] as well as internal, seen by
him, only seven were in females. But the pro-
portion of eases of aortal aneurism met with in
females is certainly much larger than this. I have
seen three eases of aortal aneurism in females;
Imt I have certainly not seen nearly twenty-four
eases in males, which is the proportion here
indicated. Syphilis and the use of mercury have
been considered predisposing causes of aortal
aneurism, but upon no just grounds. I am in-
clined to believe, with Sir. (Iuthrie, that the
habitual use of ardent spirits has a more marked
predisposing effect than any other cause with
which we are acquainted. A more immediate
state of disposition is created in the vessel itself
by inflammatory irritation of its parietes, and the
consequent diminution of its elasticity and vital
cohesion, or power of resistance opposed to the
casually augmented impulses of the heart, espe-
cially during mental excitement and corporeal
exertion. Hypertrophy of the left ventricle, par-
ticularly if consequent upon chronic inflamma-
tion of the vessel, and influenced by moral and
physical causes, will tend to produce dilatation
or rupture of the coats of the aorta. The most
frequent exc iting causes:, undoubtedly, are exces-
sive mental emotions, and violent exertion, par-
ticularly of the trunk of the bodv, and when
suddenly made ; hut it seems evident that a
morbid state of the vessel has existed previously,
at least in the majority of such cases.
32. H. Of the symptoms and diagnosis of aortal
aneurism. These naturally divide themselves
into, — 1st, the rational or general signs; and,
2d, those which are detected by auscultation.
a. The rational symptoms of aneurism of the
aorta, whilst the tumour still remains con-
cealed in the large cavities, are very equivocal.
The effects produced by it also proceed from
various other diseases. Those symptoms, even
when considered collectively, are extremely fal-
lacious; but when viewed in connection with
those which are detected by auscultation, they
are very important aids to diagnosis. 1st, Aneu-
rism of the pectoral aorta occasions a sense of
oppression or infliction in the chest; but this
is felt in various diseases of the thoracic viscera.
Dissimilarity of the pulse in both wrists is some-
times present; but this is also met with from
diseases of the subclavian artery, from tumours
pressing upon it, or from an irregularity in the
distribution of the brachial or radial arteries.
A purring tremor, as pointed out by Corvisart,
is sometimes perceptible when the hand is placed
upon the middle and upper part of the sternum :
when distinctly felt, it indicates aneurism of the
ascending aorta : it is also felt above the clavicles
in aneurism of the arch, and is one of the surest
symptoms of the first and second varieties of the
disease; hut it is often indistinct when the aneu-
rism is sacculated and contains layers of coagula.
This tremor, however, sometimes proceeds from
other causes than aneurism, more particularly
from the mucous rattle seated in the large,
bronchi; but, in this case, the purring tremor is
not so constant or continued as in aneurism.
33. Pressure from tliis disease on the trachea
and large bronchi occasions a wheezing or sihil-
lous respiration, which is generally permanent,
referable to the lowest part of the throat, and
sometimes with a whispering or croaking voice;
the breathing is also anxious and laborious.
Pressure of the tumour on the oesophagus renders
deglutition of solids difficult and acutely painful
Or lancinating, and sometimes even impracticable.
But these effects upon the function of respiration
will be produced by various diseases of the la-
rynx, and by frequent accumulations of viscid
muces in the upper part of the trachea. The
attentive observer will, however, readily ascertain
the existence of these affections. Other tumours
may also exist and occasion similar symptoms
both of respiration and of deglutition; but, in
such cases, the diagnosis is often impossible.
34. When the aneurism has eroded any of the
bodies of the vertebra, a gnawing or boring pain
is felt in the spine; and, when the tumour affects
the brachial plexus of nerves, an aching of the
left shoulder, extending to the neck and scapula,
with impaired power, formication, and numbness
of the arm, is complained of. Rheumatism of
the shoulder-joint, or parts adjoining, and severe
spinal disease, are often attended with similar
sensations; and the symptoms referred to the
shoulder and arm are frequently present in peri-
carditis, organic diseases of the heart, and angina
pectoris, from the ramification of branches of
nerves from the cardiac ganglia to the brachial
plexus.
35. Pulsation felt beneath the sternum, oi
ribs, at the upper part of the thorax, is amongst
the most certain signs of this disease; but we
should recollect that it will also be occasioned by
any tumour interposed between the thoracic parie-
tes and the aorta, and in contact with the latter;
by adhesions of the pericardium to the heart and
effusions of fluid into the former, and by consi-
derable enlargement or dilatation of the heart
itself. Pulsation above the clavicles, although
a frequent symptom of aneurism of the ascending
aorta or of its arch, may likewise proceed from
other causes, as enlarged glands, or various kinds
of tumours, receiving the impulse of the sub-
clavian arteries; from subclavian aneurism, and
aneurisms of the innominata and common ca-
rotid, between which and aortal aneurism the
diagnosis is most difficult, as Burns, Cooper,
Monro, and Hodgson- have pointed out. Violent
pulsations of the carotids have been adduced as
a sign of aortal aneurism; hut thev may arise
from uervous affection of the heart, hypertrophy
of the left ventricle, or from obstruction of the
How of blood in the descending aorta, or in tlie
subclavian arteries.
86. When aneurism of the ascending aorta
attains a certuin size, a tumour is usually formed
about the fifth and sixth ribs of the right side :
when seated in the anterior part of the arch, it
appears at the third and fourth libs of the same
side, at their sternal extremities :' when in the upper
part of the arch, the tumour rises above the ster-
num and sternal ends of the clavicles. When
aneurism is seated in the descending thoracic aorta,
and in the lower part contained in the thorax, it
often points, alier destroying the ribs and bodies
of the vertebra', under the left shoulder-blade,
and pushes out this part. The strong pulsations
always present in the tumour indicate its nature.
76
AORTA — Aneurism of.
Notwithstanding, it may subside, or altogether
disappear for a time under au appropriate treat-
ment. Previous to the appearance of the tumour,
the symptoms are, as already shown, extremely
fallacious.
37. In the advanced stages of aneurism of the
thoracic aorta there are generally coughs with
mucous or bloody expectoration, dyspnoea, and
even orthopncea, dysphagia, attacks of spasmodic
suffocation, pain in the left shoulder, axilla, inner
side of the arm, and ascending up the left side of
the neck, with pricking pains in the tumour, and
sometimes with a sense of whizzing or rushing at
the top of, or under the sternum, and occasionally
sensible to the hand. A dragging downwards of
the larynx is sometimes complained of. All
febrile symptoms are generally absent. Although
these are the rational symptoms which are most
to be depended upon, they must be viewed with
those reservations which I have particularized in
the preceding paragraphs.
38. 2d, When the aneurism is seated in the
abdominal aorta, acute pain is complained of in
the lumbar region, occasionally shooting into
either hypochondria, and downwards into the
thighs and scrotum. It is generally constant,
but is also sometimes intermittent. It is often
exacerbated into violent paroxysms, being dull
and fixed in the intervals. It is aggravated by
constipation, change of position, or pressure on
the loins, and is unattended by any sense of heat
in the part. In some cases there is also numb-
ness of the lower limbs, as in that recorded bv
Mr. Mayo (Med. Gaz., April, 1829), where
the aneurism was situated between the crura
of the diaphragm and the dorsal pains were ex-
cruciating. The patient often complains of severe
fits of colic, accompanied with spasm of the
abdominal muscles, and occasionally there are
nausea and irritation of the stomach, but with
little loss of appetite. Constipation is always
present. Decubitus on the left side or back often
produces great distress, and occasions palpitation,
which generally subsides upon turning on the
face or right side. Coldness, formication, prick-
ing, and numbness of the lower extremities, are
not infrequent; and in some cases paraplegia has
occurred, with involuntary evacuations of the
urine and fa?ces.
39. The tumour may not become perceptible
externally; but as it increases it will press in-
juriously upon, and sometimes displace, one or
other of the abdominal viscera, particularly the
stomach, liver, and even the heart. When the
tumour can be detected externally, it has ge-
nerally been in the left side, nearly on a level
with the last dorsal vertebra. When large, it
often impedes the action of the diaphragm, and
thus deranges the respiration. In some cases it
has pressed upon the pericardium, and thus had
the double pulsation of the heart communicated
to it. (See Cases by Drs. Graves and Stokes,
Dub. Hosp. Reports, vol. v. p. 24.)
40. b. Signs furnishci by auscultation. — Dul-
ness of sound upon percussion of the upper sternal
portion of the chest and cartilages of the right
ribs, although present in aneurism of the pectoral
uorta, also occurs in other lesions of the thoracic
viscera. Dr. Elliotson states, that a thrilling
sensation given to the hand only, or chiefly,
when applied above, or to the right of the cardiac
region, and a bellows-sound heard in the same
situation, may justly give a strong suspicion of
the disease. But that neither the bellows-sound
nor the thrill, always occurs. In four cases out
of seven he found both wanting. Laen.nec never
observed the thrill before the tumour became
visible externally. He considers that the chief
diagnostic of aortal aneurism is a strong and
single pulsation, discernible by the ear in the
situation of the aneurism, synchronous with the
pulse at the wrist, stronger and louder than the
action of the ventricles, and unaccompanied by
the sound of the auricles. When, however, the
aneurism comes in contact with the pericardium,
a double instead of a single pulsation of the
heart is communicated to the tumour. This
was remarked in the cases recorded bv M. Cru-
veilheir, and by Drs. Graves and Stokes.
41. Dr. Hope, in his work, which appeared
after this article was prepared for press, observes,
that it is unimportant whether the pulsations be
single or double; for, though the latter, they may
be distinguished from the beating of the heart by
unequivocal criteria, viz.: — '' 1st. The first
aneurismal sound coinciding with the pulse, is
invariably louder than the healthy ventricular
sound, and, generally, than the most considerable
bellows-murmurs of the ventricles. — 2d. On
exploring the aneurismal sound from its source
towards the region of the heart, it is found to
decrease progressively, until it either becomes
totally inaudible, or is lost in the predominance
of the ventricular sound. Now, if the sound
emanated from the heart alone, instead of de-
creasing it would increase on approximating
towards the precordial region. — 3d. The second
sound actually does sustain this progressive aug-
mentation on advancing towards the heart; and
as its nature and rhythm are found to be pre-
cisely similar to those of the ventricular diastole
heard in the precordial region, it is distinctly
identified as the diastolic sound.* The second
sound, therefore, corroborates rather than invali-
dates the evidence of aneurism afforded by the
first; for, if both sounds proceeded from the
heart, both would, on approximating towards it,
or receding from, sustain the same progressive
changes of intensity." (Diseases of the Heart and
Great Vessels, p. 423.) Besides these views, with
which I concur, the sound of the aneurismal
pulsation is deep, hoarse, and of short duration,
commencing and terminating abruptly, louder
than the loudest bellows-murmurs of the heart,
and of a rasping or grating character.
42. The sound of aortal aneurisms is generally
audible in the back; and, "when the descending
aorta is the seat, it is louder in. this situation than
on the breast. If it presents the abrupt, rasping
character, when heard on the back, the evidence
of aneurism is complete; for, as Dr. Hope ob-
serves, the loudest sounds of the heart, when
heard in this situation, are so softened and sub-
dued by the distance as totally to lose their
harshness. This is in accordance with the opinion
of M. Bertin,w1io very correctly observes, that
when the stethoscope is applied upon the sternum
in aneurism of the substernal aorta, and on the
back, near the pectoral spine in aneurism o( the
descending aorta, the disease may be recognised,
* See ail. AUSCULTATION, as to the sounds of this organ.
AORTA — Aneurism of. — Treatment.
77
before any external tumour is seen, by a strong
single sound, oi* greater intensity than thai of the
heart Hie pulsations of aneurismal tumours of
large arteries are indeed so intense, hoarse, sharp,
and peculiar, as to be readily recognised by a
pejson who lias once examined them with the
stethoscope, although the sounds they furnish
cannot be readily described.
43. The purring tremor, already noticed as
felt by the hand, may also be ascertained by the
aid of the stethoscope. It is chiefly found above
the clavicles, in cases of simple dilatation of the
ascending aorta and arch and sacculated aneurism
in the same situations. In old and large aneur-
isms, containing layers of coagula, it is generally
absent, and is more intense the more unequal
and rugged the interior of the diseased portion of
vessel, particularly when it is studded with osse-
ous or cretaceous deposits. Dr. Elliotson
states, tliat when the aneurism is large, a single,
nnd more frequently a double, bellows-sound is
often heard in the seat of aneurism, distinct from
the beating of the heart : when the sound is
double, the first is beard along with the pulse,
the latter, often the louder of the two, afterwards.
The bellows-sound in these cases may be ascribed
to the passage of the blood from the dilated aneu-
rism into the narrower commencement of the
healthy vessel; and, when the sound is double,
the second may proceed from the reaction of the
dilated part of the vessel impelling a portion of
the blood into the narrow and healthy vessel after
the action of the left ventricle.
44. 2d. Aneurism of the abdominal aorta is
more easily detected by auscultation than aneur-
ism seated within the chest. A constant and
powerful pulsation is felt by the hand, and still
more remarkably by the ear resting on the
stethoscope, accompanied with a brief, loud, and
abrupt bellows-sound; but not so hoarse as that
of aneurisms in the chest. The pulsation is single,
unless the tumour comes in contact with the dia-
phragm and pericardium; and it is either inaudible
or verv indistinctly heard in the back. By press-
ing the instrument in various directions, so as to
bring it as close as possible to the tumour, its seat
and dimensions will be ascertained.
45. Treatment. — The method of cure first
recommended by Valsalv \ has beensince very
generally adopted, not only in aneurisms of the
aorta, but also in similar diseases of arterial
trunks. I believe, however, that it has been
often carried to a very hurtful length. I have
seen cases in which aneurismal tumours had
existed for a long time without any increase, as
long as the patient avoided any marked vascular
excitement, and continued his wonted diet; but
when repeated depletions and vegetable or low
diet were adopted, great augmentation of the
tumour and fatal results soon followed. In three
eases winch occurred in my own practice, and in
which the method I am about to recommend was
employed, a marked amendment was the conse-
quence.
4li. In order to devise a rational method of
treating this formidable lesion we should con-
sider, in the first place, the process adopted by
nature to remedy it: and having correctly inter-
preted this process, we should endeavour to assist
nature in accomplishing it. We have seen that
aneurismal dilatation, &c. of arteries, particularly
of the aorta, (§§ 14, 15.,) commences in slow in-
flammatory action, and that as the coats dilate or
rupture, lymph is thrown out, which coagulates
the blood, entangling its fibrine and red globules,
and thus a fibrinous coagulum, attached to the
inner surface of the vessel, is formed, and by its
aid the inflamed and otherwise diseased coats of
the vessel arc strengthened, particularly as the
fibrinous layer of coagulum becomes more and
more consolidated or organized. Now, what are
the circumstances proper to the circulation and
state of the constitution calculated to promote this
change on the one hand, or to counteract it on
the other; for whatever advances it, or assists
nature in its completion, will tend to remedy the
disease; whilst whatever counteracts it, will lead
to fatal results ? I shall first consider the mea-
sures calculated to counteract the process which
nature adopts to remedy the disease.
47. a. 1 believe that there is no position in
pathology more firmly established, since it was
insisted upon by John Hunter, than that what-
ever greatly lowers the vital energies will impede
the formation of coagulable lymph and fibrinous
coagula, especially in diseased vessels; and that
increased rapidity of the circulation, throbbing of
the arteries, abstraction of the fibrine and red
globules of the blood, by repeated or large de-
pletions, and the absorption of serous, watery,
or bnassimilated materials into the current of
the circulation, in order to supply the place of
the portion of blood abstracted, will, with other
effects, inevitably tend to prevent those changes
from taking place which we wish to bring about.
That large depletions produce increased quick-
ness of the pulse, reaction of the heart, throbbing
of the arteries, and all the effects now instanced,
must be evident to every thinking and experi-
enced observer; and that these effects are actually
those which counteract the changes which nature
produces, in order to remedy disease of the cir-
culating system, must be equally manifest. That
these results will be still further promoted by
undue, or too great abstinence, is no less obvious;
and yet, how frequently do we find both inor-
dinate depletion and unreasonable abstinence
recommended, in the very teeth of their fatal
consequences on numerous occasions, for the cure
of aneurisms.
4S. b. But what are the means which are cal-
culated to advance the process which nature
uniformly adopts in order to restore as nearly as
possible the vessel to a healthy state? These
may be stated, in a few words, to be whatever
restrains or retards the action of the heart, with-
out reducing the vital energies of the frame, and
the preservative influence they exert, both on the
coats of the vessel, and on the surrounding
structures. Conformably with this view, strict
quietude of body and mind, a light digestible diet,
the careful avoidance of spirituous and malt liquors,
and the adoption of moderate general or local
depletions, only if the state of' the circulation
unequivocally requires them, are chiefly to he
relied upon; and, as iiir as my own observation,
and the careful study of the cases recorded by
various writers have enabled me to judge, they
are the only means which deserve any share of
confidence. Whilst change of air is generally
beneficial, exercise on loot, or on horseback,
especially the latter, must be avoided, and the
78
AORTA — Constriction and Obliteration of.
Utmost attention should he always directed to the
digestive, secreting, and excreting functions.
4;>. When, in consequence of the energetic
action of the heart, or the plethoric state of the
circulation, or excessive action of the tumour, we
determine on depletion, it ought to he performed
in the recumbent posture; and the quantity as
well as the manner of abstracting it should be
such as to prevent any risk from too great depres-
sion, and its consequent reaction, whether of the
heart or of the arteries. When the disease is
attended with paroxysms of palpitation, depletion
will be seldom of any use, and should therefore
be cautiously employed in such cases. Local de-
pletions may be resorted to when local pains are
complained of; but, if the tumour has nearly
reached any of the surfaces, they are seldom pro-
ductive of benefit.
50. Digitalis has been generally recommended ;
it may be of some service when exhibited cau-
tiously, and in moderate doses, but its full effects
must be guarded against. The same remarks
apply to colchicum. The supcracetate of lead,
combined with the acetic acid, and small doses
of opium, is preferable to digitalis ; and any
hurtful effect that would arise from it will be
prevented by an occasional dose of castor oil. In
cases attended with palpitation of the heart, or
inordinate pulsation of the tumour, I have pre-
scribed the sulphate of zinc, and the sulphate of
alumina, generally combined with small doses of
camphor and hyoscyamus, with considerable bene-
fit as palliatives. The acetate of lead may also
be exhibited in a similar state of combination.
51. The application of ice to the tumour has
been advised by Continental physicians; but it
is often productive of much distress. A lotion,
or repeated sponging, and occasionally the con-
tinued application of epithems may be employed;
and either of those recommended in F. 157. 332.
336. may be adopted. Perfect repose, however,
morally and physically, with careful prevention
of plethora and sur-action of the heart, is indis-
pensable; other means will be useful, chiefly in
as far as they conduce to these states. By en-
deavouring in this manner to bring about the
spontaneous cure of aortal aneurism, it may be
supposed that we risk inducing the obliteration of
the vessel: but I believe that this is not so likely
to occur in the aorta as in smaller arteries; and
even were it to occur, the result does not appear
so hazardous as the continued increase of the
aneurismal tumours; as sufficient evidence is on
record of the possibility of a collateral circulation
being established.
52. IV. Rupture of all the coats of the
Aorta, without aneurismal dilatation of the ves-
sel, is a very rare occurrence, and has been met
with only after violent external injuries, such as
fills, or leaping from a great height, and from
mental excitement, when the vessel has been
previously diseased. In the Ephemerides Phy-
sico-Medicce NatureaR Curiosorum (Dec. iii. Ann.
ii. 06s. 70.), a case is recorded, in which it
was ruptured by a blow on the hypochondrium.
Mr. James has recorded an instance of rupture
and instant death in an active seaman, previously
in good health, from jumping out of his ham-
mock (Lond. Med. and Phys. Journ., vol. x\ iii.) ;
and Mr. Aknott has given a similar case, pro-
duced by a violent concussion of the body, from
falling from a scaffold (Ibid., vol. Iviii. p. 19.)
The most instructive case, however, of rupture of
the aorta without aneurism has been minutely
detailed by Mr. Rose (Lond. Med. and Phys.
Journ. , vol. Iviii. 4to. p. 15.). In this case, as in
the others, the coats of the aorta were all rup-
tured. They were more readily lacerated than
usual, and the inner coat had a thickened
stertomatous appearance. A case is given by
Dr. Hume (Glasgow Med. Journ., vol. iv. p.
14S.), in which rupture of the aorta took place
in a strong man upon getting into bed, followed
by death in a few hours. An aperture, the size
of a quill, was found in the vessel about two
inches above its bifurcation. No account is given
of the state of its coats.
53. V. Constriction and Obliteration of
the Aorta have been observed by several pa-
thologists. Stoerck (Annates Med. ii. p. 262.),
Meckel (Mimoires de Berlin, 1756), Sandi-
fort (Observat. Anatom. Path. iv. No. 10.), and
Dr. Graham ( Trans. Med. Chir. Soc, vol. v. p.
2S7.), with other recent authors, have recorded
cases of extreme constriction of the aorta ; whilst
M. Desault (Journ. de Chirurg. 1792), M.
Brasdor (Recueil Ptriodique de la Soc. de Med.
a Paris, t. iii. No. 18.), Dr. A. Monro) On
Aneurisms of the Abd. Aorta, p. 5.), Dr. Good-
ison (Dub. Hosp. Rep., vol. ii. p. 193.), M.
Velpeau, (Revue Med., t. iii. 1S25., p. 326.),
and M. Re ynaud (Journ. H'ebdom. de Med.,t. i.
p. 161.), have adduced cases wherein this vessel
was entirely obliterated, the circulation having
been preserved by the anastomosis and enlarge-
ment of the arteries sent off above and below the
seat of obliteration.
54. With respect to the origin of this lesion, it
may be referred primarily to inflammation of the
vessel. But various intermediate changes will
necessarily have taken place, from the more im-
mediate effects of inflammation to the complete
obliteration of the vessel. It is probable that, in
some rare instances, as in large arterial trunks,
the transverse rupture of the internal membrane
of the vessel, with the consequent effusion of
lymph, and formation of fibrinous coagula, mav
so obstruct its canal as to give rise to its partial
or total obliteration, without any aneurismal
tumour having formed; and it is not improbable
that obliteration or constriction of the canal mav
have proceeded in other cases, from the advanced
stages of the spontaneous cure of aneurism ; the
deposition of fibrinous coagula, and the subse-
quent changes which had taken place in them,
and the diseased coats of the vessel, having ended
in obliteration, and the establishment of a collat-
eral circulation.
Bibliography. — Morgagni, De'Sed. et Caiis. Morb.
epist. xvii. et xviii. — Nichols, Philos. Trans, vol. xxxv.
p. 443. et vol. Iii. p. 269. — Halter, De Aort* Venieque
Cava» Gravior. quibusdem Morbis. Goet. 1749. — Burns,
On Diseases of the Heart, !tc. p. 206. — Cnmeilhier, Sur
l'Anatom. Patholog. Paris, 1816, I. ii. p. 60.; — Hodgson,
On Diseases of Arteries, &c. p. 127. — Corvisart, Sur les
Maladies du Cceur, ttr. p. 313. — Scarpa, Kidessionised
Osservazioni sull' Aneurisma. Pavia, 1S04. — Krrt/sig, Die
Krankheiten des Herzens. Berl. 1814-16 — Testa, Delle
Malattie del Cuore, &.C. Nap. 1826.— Proxidfmt. Edin.
Med. and Surg. Journ. vol. xxii. — Laennec, lie I'Ausculta-
tion Mediate, ice. 2d edit. Paris, 1826.— iVroerre, Sur les
Aneurysmes de l'Aorte, Paris, 1820. — Andrei, C'linique
Medicale, &c. t. iii. Paris, 1825. — Bouil/aud. Sur Ii
nostique de- Aneurysmes de l'Adrte. Paris. 1 823. — Moliison,
in Trans, of the Medico-Chirurg. Sqp. of Edin. vol. iii. —
CMhrie, On the Diseases and Injuries of Arteries. Lond.
APOPLEXY — Approach or premonitory Signs of.
79
1830. — /?^i-li>» et Bouil/aud, Traits de Malad. <I" CoeUl el
... Vaisseaux. Paris, 1824. — Qravet, Stakes, and
Hrnih', in Dub. Hospit. Rep. vol. v.— -JEWibtton, On (lie
Diagnosis, of Dnanej ol the Heart, Sec. fbl. Lond. 1831. —
//.;/■<■. i»n |ii-< asea of the Hurt and Great Vessels, &c. 8 \".
Lond. 183I| •""! Medical Gazette volumes, vol. iv. paisim,
i number of detached instances of disease of iIh-
idduced by Ploucquet, in his Medicina Digesta, from
various authors, to whom I have not thought il nei essar} I"
refer.
API 1< >NIA. See Voice, Morbid States of.
APIFTI1.K. See Thrush.
APOPLEXY — Doc think of. Deriv. and Sy-
non. Apoplexia, from anonl-i'/now, percutio.
Aphonia, Hip. Nervorum Resolutio, Cels.
Morbus Attonitus, Lommius. Siderotic, Per-
cussio, Molinar. Schlagfiuss, Ger. Apoplexie,
Fr. Accidente, Colpo, Gocciola, Ital. Apoplex-
ya, Pol.
Classif. 2. Class, Nervous Diseases; 1. CV-
d«r, Comatose Affections (Cullcn). 4.
C/ass, Nervous Maladies; 4. Order, Af-
fecting the sensorial Powers (Good). IV.
Ct v^s,lI1.0Ki>ER(vii(//(or,see Preface).
1. Nosolog. Df.fin. A toss of consciousness,
feeling, and voluntary motion; or, in other words,
a suspension of the functions of the brain, respir-
ation and circulation being more or loss disturbed.
Path. Defin. Consists of defective vital enei*-
gy, with hemorrhage, or derangement of the vas-
cular system of the brain, and their consequences.
2. Distinctions. There are few diseases
which present a greater variety of modes of at-
tack, or which depend upon a greater number of
lesions of the organ affected, than that now under
consideration. Its sources, modes of manifesta-
tion, and morbid relations are numerous, and many
of them difficult of investigation. These circum-
stances have given rise to various attempts at
arranging the phenomena of the disease in such
a way as to indicate the relations which subsist
between the changes within the head, on which it
depends, and the mode and progress of attack.
Apoplexy has long been described as consisting
of certain forms, which have been distinguished
l.v -onie authors as the sanguine and serous, with
reference to the nature of the effusion; by others,
as the nervous and bilious, according to their idea
of the more immediate causes. By several writers
it has been, with more justice, divided into active
or sthenic. m\(] passive or asthenic; or entonic and
atonic, according to the state of the constitutional
or vital powers and respiration, and the degree
of vascular action accompanying it. All these
arrangements arc, however, only partially founded
in truth: in many respects they are entirely erro-
neous. Wherein they are either the one or the
other will appear in the sequel. M. Cruvilhier,
one of the most recent and best writers on the
disease, confines the term Apoplexy to the occur-
rence of spontaneous hemorrhage in the brain,
and divides it into two species: — 1st, That con-
sisting of a collection of blood in a torn part of
the brain, or on its surf ice, from a ruptured ves-
sel; and, 2d, That with sanguineous infiltration
into the softened structure — or capillary exud-
ation into, .and combined with, its substance.
The defects of this arrangement, as well as of
this pathology, particularly in regard to practical
purposes, must be apparent; for it will often be
impossible to ascertain, during life, whether ex-
travasation of blond has actually taken place, or
merely great congestion of the vessels, with or
without serous effusion; and many cases of true
apoplexy occur occasioning death, as well as
where complete recovery takes place, without
either of the lesions to which he imputes the dis-
ease, having existed.
3. In the account which I will endeavour to
give of the disease, its common form of approach
and attack will be described; next, the different
modes in which the attack is made, distinguish-
ing the principal forms it assumes; and after-
wards will be noticed several important states of
the malady, arising from peculiar causes and
antecedent affections. When detailing the dif-
ferent varieties and states of the disease, it will
be made manifest that the distinctions heretofore
offered, although occasionally obtaining, have no
uniform or even general relation to the lesions
existing within the head; that apoplexy, with the
symptoms described as characteristic of serous
effusion, has been frequently found to proceed
from sanguineous extravasation ; and that the
sanguineous has sometimes only presented slight
serous effusion: a similar objection being also
applicable to all the other distinctions above enu-
merated.
4. Of the Approach, or premonitory
Signs, of Apoplexy. The importance of recog-
nising the approach of this disease must be evi-
dent to the practical reader ; for judicious measures,
employed at this period, will often succeed in pre-
venting an attack, or will render it less severe,
even when they fail of averting it altogether.
The most common precursory symptoms are, a
tendency to sleep at unaccustomed periods; a
heavier sleep than usual, particularly if accom-
panied with profound, laborious, or stertorous
breathing; stridor of the teeth; nightmare; suc-
cussions of the frame, or cramps ; a lethargic
feeling and drowsiness even during the waking
hours; more rarely, unusual wakefulness; pains
in different parts of the head, or general head-
ache or megrim; a sense of weight or fulness iu
the head, or of pulsation of the arteries; inco-
herent talking, resembling intoxication; a turgid
appearance of the veins of the head, particularly
of the forehead; lividity or redness of the counte-
nance; slight or imperfect attacks of epistaxis;
loss of recollection ; irritability of temper, or
unusual sere&ity or apathy of mind; a disposition
to shed tears; suffusion of the conjunctiva; col-
lapsed appearance of the alee nasi; moats floating
before the eyes, or dimness of vision (amaurosis);
scintillations, or bright or shining coruscations
before the eyes during darkness ; inability to
follow the line in reading; double vision, or a
sharper sight than usual; diificulty in shutting or
opening tin' i-\<^^ noises in the ears; dulness of
hearing; a sensation of an unusual feetor; dry-
ness of the nostrils; continued sneezing; frequent
yawning ; singultus ; stammering, or indistinct
articulation; the substitution of one word for
another, or forgetfulness of words and names;
difficulty of -swallowing, or tits of coughing upon
deglutition; leipothymia, vertigo, or a sensation
approaching to faintness; difficulty of writing, or
inability to spell the words, or to follow a straight
line; torpor, or numbness, or pricking of the ex-
tremities; itching, or formication of the surface;
pains of the joints or limbs; a feeling of fatigue
upon slight exercise: partial or slight paralytic
affections, chiefly of the muscles of the face, or
80
APOPLEXY — Simple and Primary.
confined to a limb or prut of a limb, occasioning
drooping of the eyelids, imperfect utterance, slight
distortion of the mouth; an unsteady or tremulous
gait; tripping upon ascending or descending a
stair, or in walking ; difficulty in voiding the
urine, &c.
5. The characteristic Symptoms, or
those constituting the Attack. After one
or more of the foregoing signs, or after the suc-
cession of two or more of them, and their contin-
uance for a short or long period, the phenomena
which constitute the disease supervene. Some-
times the premonitory signs are so slight, and of
so short duration, as to escape notice, the attack
being severe and sudden: at other times they are
very remarkable, and several of them are grouped
together, the attack advancing either gradually
and severely, or suddenly, and disappearing rap-
idly; yet recurring after an indefinite time. The
mode of approach and attack sometimes has a
close relation to the state of internal lesion; but,
occasionally, no such relation can be traced, as
will be shown and explained hereafter. The pre-
monitory signs, as well as the early part of the
attack, generally present more or less either of
augmented or diminished vascular action, partic-
ularly about the head, according to the state of
the vital powers. The character of the symp-
toms, therefore, in respect of degree of vascular
action and constitutional power, should receive
the utmost attention, as being our best guide to a
successful treatment.
6. A. In the most severe and sudden forms of
attack, — the apoplexia fulminans of the older
authors, and some of the Continental writers of
the present day; the fortissimo of Dr. Cooke and
others; the apoplexie foudroyante of the French,
— the patient is struck down instantly, sometimes
froths at the mouth, has a livid countenance,
complete relaxation and immobility of the volun-
tary muscles and limbs, and inconscious evacn-
tion of the urine and fasces ; and dies very shortly
afterwards, either with or without stertor, or
rattle of the respiration, with cold, livid extremi-
ties; cold perspiration, and sometimes a cadaver-
ous cast of countenance.
7. B. In the more active, or sthenic forms of
attack, — the Apoplexia fortis; the entonic apo-
plexy of Dr. Good; A. exquisita of various au-
thors,— the patient is more or less suddenly seized
with profound sopor, the eyes being either open
or closed; the breathing deep, slow, sonorous, or
stertorous; and the pulse slow, full, hard, or
strong: sometimes irregular or unequal. In this
state of the disease, the above are often the chief
symptoms, no signs of paralysis being observed.
But frequently the mouth is drawn to one side,
the eyes are distorted, and one eyelid immove-
able, with relaxation, loss of sensation and of
motion of a limb, or of one side of the body; the
arm of the non-paralysed side being often closely
applied either to the chest or to the genital or-
gans. In this latter state of the disease, there is
sometimes also some degree of paralysis of the
urinary bladder, or of its sphincter, giving rise to
ischuria, or eneuresis, or a combination of both.
The patient generally lies on the paralysed side,
which is relaxed, incapable of motion, and insen-
sible to the application of irritants; whilst the
limbs of the opposite side are sometimes subject
to spastic contractions.
8. C. In the more gradual seizures, or those
of a less complete character, — the atonic apo-
plexy of Dr. Good; the Apoplexia imperfecta,
the parapoplexia of various writers, — the patient,
after experiencing some of the premonitory symp-
toms, is seized with alarming vertigo, leipothymia,
or feeling of faintness; sickness at stomach and
vomiting; disturbance of the senses, particularly
of the sense of sight; loss of memory; partial loss
of sense, consciousness, speech, and- voluntary
motion ; weak, irregular, and sometimes quick
pulse, with more or less of sopor.
9. Besides the foregoing forms of apoplexy, —
which differ merely in respect of the state of the
constitutional powers, the severity of attack, and
the grouping of the symptoms, and not as to the
organic lesions which occasion them, — other dis-
tinctions offer themselves, which are still more
deserving of attention, as generally having a more
intimate relation to the changes which are going
on within the head, than the degrees of severity
of seizure merely. Viewing, therefore the pre-
monitory symptoms as common to all its varie-
ties, I shall divide the disease according to the
form, manner, and complication of the attack,
and consider, briefly, — 1st, The sudden form of
apoplectic seizure, in its simple state, and unas-
sociated with paralysis ; 2d, The gradually in-
creasing, or ingravescent attack; 3d, These states
of seizure complicated with paralysis; and, 4th,
that form which commences with paralysis, and
| after an indefinite period passes into complete
apoplexy.
10. I. Simple and Primary Apoplexy.
A. Description. In this variety of the disease
the patient falls down deprived of sense, con-
i sciousness and voluntary motion, is like a person
] in a very deep sleep, with his face much flushed,
tumid, and occasionally livid; his breathing slow,
deep, and stertorous; his pulse full, natural in
1 frequency, or slower than usual. Sometimes
slight convulsions of the limbs, or contractions of
the muscles occur, or contractions of the mus-
cles of one side, and relaxation of those of
I the other. The attack, in rarer instances, is
! either ushered in or accompanied with general
convulsions, passing into complete apoplew. or
profound coma. The patient may continue in
! this state of profound stupor for several days; or
he may recover after some hours, or even min-
utes, when judicious assistance has been instantly
procured.
11. B. This form of the disease terminates,
1st, in perfect recovery", — often in the course of
a few hours, — but rarely when the attack has
continued longer than one or two days. I have,
however, seen cases of perfect recovery in com-
paratively young or robust subjects, after the
apoplectic state had been of several days' dura-
tion. 2d, In death, which may take place in the
course of a very few hours, or after some days,
but most commonly from the first to -the fourth
day.
12. C. The appearances which this class of cases
present on dissection may be arranged into — 1st,
Those which are insufficient to account for the
symptoms, or their termination in death; 2d, Those
which proceed from intense injection and conges
tion of the membranes o£ the brain, and of the
cerebral structures; 3d, Those which are accom
panied with an effusion of serum, or engorgement
APOPLEXY — Simple and Primary Form.
31
of the vessels of the head, or both; and, 4th,
Those which arc attended by extensive extrava-
sation ol' blood.
18. 1st. Cases of apoplexy in which no morbid
appearand- could lie detected al'ler death, have
been recorded by Willis, Stark, Powel and
rcrombie; and similar eases have occurred
to MoRGAGNI, TlSSOT, (JUARIN, OzANANAM,
Fodere, and Hildenbrakd. !t is to this va-
riety of apoplexy that the term nervous has been
applied by several eminent authors, particularly
by KoRTUM, ZlLIANI, and HlLDENBRAND.
Nicolai referred it to spasm of the meninges;
Lecat and Weikard to spasm of the nerves
and vessels of the brain. Borsieri termed it
convulsive apoplexy; and Tisso r and some other
authors hysteric apoplexy. Hildenbrand con-
ceives that it is the cause of death in contagious
typhus; patients dying after profound coma in this
disease, without any effusion or appearance of
-lion or compression, but apparently from a
sudden collapse of the nervous energy of the brain.
Apoplectic seizures, rapidly terminating in death,
have been occasionally observed to occur in epi-
leptics and maniacs, as recorded by Fodere,
Nacq,uart, Bklloc, and Gexdrim, without
any manifest lesion of the encephalon. This
particular state oC the brain seems also, in some
instances, to obtain in the course of a few other
■ s, and to be occasioned by certain external
causes, particularly injuries producing concussion
of the brain, lightning, extreme cold, and poison-
ous substances.
1 !. \ case occurred to me of this description
in a man aged about forty, who had complained
of vertigo, leipothymia, and loss of recollection,
suddenly followed by profound sopor. He had
been blooded largely when I saw him. His
breathing was not stertorous; his pulse was weak,
small, and quick, and his countenance sunk. The
brain, on a careful examination, presented no
change in colour or consistence, and was even
less vascular than usual. The pineal gland was,
in my opinion, smaller and softer than natural,
and contained scarcely any of the small gritty
bodies which are generally found in it. The pitu-
itary gland was not examined, the case having
occurred to me a number of years ago, and before
my attention had been directed to the nature and
functions of this part.
1"). 2d. In a large proportion, however, of this
class of apoplectic cases, excessive injection of the
vessels of the pia mater, and engorgement of the
whole vascular system of the encephalon, are the
chief lesions. The pressure to which the brain
has been subjected from this cause, as well as the
interrupted state of the circulation, whence the at-
tack most probably proceeded, being sufficient to
. life in a few minutes, or a very few hours
at the furthest. This forms the simplest state of
sanguineous apoplexy, and is of comparatively
rare occurrence. It constitutes the coup de sang
of the French, and is observed iii these cases nf
coup dr solfil, or sunstroke, which proves rapidly
fatal. I have met with it in two cases of this de-
scription.
lfi. 3d. Serous effusion Ls one of the most
frequent appearances found in this form of apo-
plexy, hut it seldom occurs alone, being generally
accompanied with engorgement of the veins and
sinuses of the brain. It is often also observed in
the symptomatic and complicated states of apo-
plexy which will come under consideration in the
sequel. The very judicious observations which
have been made by Dr. Ab£RCROmbie and M.
Cruviii.h Kin, particularly the firmer, as to the
relation which this lesion presents to the apoplec-
tic state, is well deserving of the attention of the
pathologist. I perfectly agree with them in
considering the distinction proposed between san-
guineous and serous apoplexy as not supported by
observation; for many of tin- cases which termin-
ate by serous effusion, exhibit in their early stages
all the symptoms usually assigned to sanguineous
apoplexy, such as flushed countenance, strong
pulse, vigour of constitution, &c; whilst, on the
other hand, many of those accompanied by pale-
ness of the countenance and feebleness of the pulse
will be found to be purely sanguineous; even the
pre-exLstence of dropsical effusion, or the leuco-
phlegmatic diathesis, or great age, &c. furnish no
certain data, although a strong presumption, of
the attack being that depending upon the effusion
of serum.
17. The serous effusion in those cases in which
it constitutes even the chief lesion, cannot be
viewed in any other light than in that of a result
of pre-existing disturbance of the circulation, de-
pending, as wiH be more fully alluded to in the
sequel, either upon imperfect vital tonicity or ac-
tion of the vessels, or upon obstructed circulation,
especially in the veins and sinuses of the organ,
or even upon both. Another circumstance, well
deserving of notice, and evincing that the serous
effusion is of itself to be viewed as merely a part,
and indeed no very important part, of the existing
lesions, although the most demonstrable, is the
fact also insisted on by Dr. A be rcrombie, that
the quantity of fluid effused bears no proportion to
the degree of the apoplectic symptoms: for we find
it in large quantity when the symptoms have been
slight; in small quantity when they have been
both strongly marked and long continued; and,
finally, we find most extensive effusion in the
head, where there have been no apoplectic symp-
toms at all. The inference, therefore, clearly
deducible from the most faithfully observed facts,
is, that the effusion is not the cause of the apo-
plectic seizure, but the consequence of that state
of circulation on which the disease more imme-
diately depends. Indeed, I am even of opinion
that a considerable portion of the effusion takes
place either immediately before death, or soon
after life is extinct; and that several cases referred
to serous effusion have not arisen from this cause,
the quantity of serum having evidently not been
greater than we have reason to believe naturally
exists in the head, as necessary to the regularity
of its functions, under the varying states of circu-
lation, and of atmospheric pressure on the surface
of the body, from which the unyielding bones of
the cranium protect it.
18. 4th. Extensive extravasation of blood is a
rare occurrence in this form of apoplexy, being
most commonly observed in other varieties of the
disease. When, however, extravasation is met
with, it is either found diffused about the base of
the brain, and pressing upon the medulla oblon-
gata, in the fourth ventricle, or in both the lateral
ventricles, from rupture of some diseased vessel,
or from extravasation of blood near to, with lace-
ration of the cerebral structure at, the surface of
82
APOPLEXY — Ingravescent Form.
the brain. When extravasation of blood is found,
the attack has generally been characterised by
symptoms closely approaching those of the next
variety, viz. an invading and slight attack, rapidly
followed by a short interval of sensibility, which
is as quickly followed by profound coma and
death.
19. IT. The gradually increasing or
ingravescent Apoplexy. — A. Description.
In this form of the disease the patient is not at
first seized with loss of sense and voluntary mo-
tion; or if he be so seized, the attack is momenta-
ry, and passes off without the use of any remedy.
It more usually commences with a violent and
sudden attack of headach, very frequently accom-
panied with paleness, sickness, and vomiting.
Sometimes the patient sinks down from its sever-
ity, pale, faint and exhausted; and experiences a
slight convulsion, but recovers from this state in
a short time. This invading and slighter attack
generally soon abates, or some of the symptoms
subside, and others continue in various degrees or
differently modified. The pain is generally refer-
red to one side of the head, and the vomiting
sometimes returns. Coldness, paleness, and faint-
ness are complained of, with all the other symp-
toms indicating a serious shock received by a vital
organ. The pulse is weak and frequent, the
countenance cadaverous and sunk, and the patient
feels depressed, but sensible. After this state has
endured from an hour, to two, three, or even
more, the surface acquires some heat, and the
pulse improves in strength. The face now becomes
flushed, and the features expanded. The oppres-
sion increases rapidly; he answers questions slow-
ly and heavily, and at last sinks into a state of
profound stupor or coma. The period which
elapses from the invading attack, to the continu-
ed and perfect coma, varies from less than an
hour to three days. But Dr. Abercrombie,
who has illustrated this form of apoplexy in an
able manner, has observed an interval of not
more than twenty minutes, and has seen it pro-
longed to a fortnight.
20. E. This is the most fatal form of apoplexy,
very few recovering from it. On inspection after
death, extensive extravasation of blood is always
met with. From the whole history of this class
of cases, Dr. Abercrombie thinks that they
depend upon the rupture of a considerable vessel
without any previous derangement of the circula-
tion, the rupture probably arising from disease of
the artery at the part which gives way. He con-
ceives, that, at the moment when the rupture
occurs, a temporary derangement of the functions
of the brain takes place, but that this is soon
recovered from; and the circulation then goes
on without interruption, until a quantity of blood
has been extravasated sufficient to produce coma.
This may possibly be the case, particularly in
those instances where the coma soon follows the
first attack. I am more inclined to think that a
depressed or deranged state of 'the vital energy
and circulation of the brain, similar to that which
occurs in the foregoing variety of the disease,
takes place at the commencement of the seizure,
and that the extravasation frequently accompanies
the reaction, supervening on the oppression which
precedes the perfect attack; or, if extravasation
have taken place in the first instance, that it is
only to a small amount, the state of energy of the
circulation of the organ at the time preventing it
from proceeding to any considerable extent, and
that it is afterwards renewed in the same situation,
or even in a different part, upon the reaction
which takes place soon after the shock which the
first seizure occasions. Dr. Abercrombie is of
opinion, that in some cases the extravasation com-
mences with the early part of the attack, and that
it goes on until such a quantity has been accu-
mulated as is sufficient to produce fatal coma;
and that in others, after the rupture has taken
place, the haemorrhage is stopped by the forma-
tion of a coagulum, and, after a considerable in-
terval, bursts out afresh and is fatal. It is by no
means improbable that some cases present the
phenomena which this accomplished physician
contends for, whilst others may proceed in the
manner which I have suggested. A chief reason
for my believing that this form of apoplexy fre-
quently originates in the way I have stated, is,
that I have met with cases in which the disease
was gradual, or consisted of several attacks of
either incomplete Or complete loss of recollection
and voluntary motion, from which the patients
had recovered, but had at last been carried off by
a more severe seizure; and yet, upon dissection,
appearances of recent extravasation merely, or
of congestion and engorgement, with or without
serous effusion, but without the least extrava-
sation of blood, were the only lesions which
existed.
21. The rapidity with which the disease advan-
ces, will, of course, depend upon the nature of
the lesion, and upon the size of the vessel or ves-
sels from which the haemorrhage proceeds, and the
extent of the extravasation. The situation, also,
will have some influence; inasmuch as a small
extravasation, if it press upon the medulla oblon-
gata or the annular protuberance, will be more
certainly and rapidly fatal than a much larger
effusion into the ventricles, or into the substance
of the hemispheres.
22. C. The Appearances on Dissection, chief-
ly consist of extensive extravasation of blood,
most commonly in some part of the brain in the
vicinity of the ventricles, as the corpora striata,
and thalami optici, or some other situation adjoin-
ing those cavities, and which frequently lacerates
the cerebral structure, and passes into and fills the
ventricles. In some instances the haemorrhage
takes place in a part of the brain nearer to its
periphery than its internal surfaces; in such cases
the blood ruptures the cerebral substance, and is
effused on its surface. In the more suddenly fatal
cases, this is observed to have occurred generally
towards the base of the brain.
23. In cases of profound coma supervening
after a considerable time from the first seizure,
the parietes of the cavity formed in the substance
of the brain by the effused blood, are softened,
discolored, and broken down, evidently indicating
that in these cases softening and disorganization
had either preceded the seizure, or speedily fol-
lowed the first extravasation, and that a recurrence
of the haemorrhage had produced a lacerated
opening, communicating either with the ventricles
or the exterior surface of the organ. In a con-
siderable proportion of cases of this form of apo-
plexy, the arteries are ejther ossified or otherwise
diseased. The veins and sinuses also sometimes
present morbid appearances (§ 29).
APOPLEXY — Ingravescent Form.
83
24. In rarer instances the extravasation of
blood takes place in the cerebellum. When the
effusion i8 either in this situation or below it, the
symptoms are more severe and rapid in their
progress than when it is in the substance of the,
bram. This remark is also applicable when the
blood flows from or into the substance of the
annular protuberance, or accumulates around the
medulla oblongata and foramen magnum. In
sonic of those latter rases, which are much rarer
than the foregoing, the fatal result is rapidly pro-
duced. In nearly all the cases of extravasation
taking place, either within or near the surface of
any part of the cerebral structures, it is extremely
difficult, if not entirely impossible, to trace its
exact source, or the vessel or vessels whence it
lias proceeded. It is very probable that the la-
ceration produced by hemorrhage separates seve-
ral vessels, and thus a greater number are laid
open than are concerned primarily in producing
the extravasation. Besides, the softening of the
surrounding cerebral structure may destroy addi-
tional vessels, and give rise to secondary extra-
vasations of blood, either into the original cavity,
thus forming a more recent portion or layer of
eoagnlum, or into the surrounding structure in the
state of capillary infiltration.
25. Besides the foregoing sources and seats of
extravasation, others have been observed. M.
Serres describes a casein which the hemor-
rhage had occurred in the substance of the pons
varolii, whence the blood had burst into the occi-
pital fossa. It may also take place from the
superficial vessels, forming the meningeal apo-
plexy of this writer. In cases of this description,
the blood generally seems accumulated between
the dura mater and arachnoid; but cases have
been recorded, in which the blood appeared to
have been discharged from the r etiform plexus of
vessels at the base of the brain, and confined
beneath the pia mater. The haemorrhage may
also proceed from ulceration and rupture of a con-
siderable arterial vessel. Dr. Mills met with a
case in which it was traced to ulceration and rup-
ture of the basilar artery; and Morgagni and
Serres have found it proceed from a similar
lesion of the internal carotid. Morgagni, De
Haen, and iiiKKi.AND have traced the extrava-
sation to the vessels of the choroid plexus. This
is probably the source of the haemorrhage when
it is confined to the -ventricles, without lacer-
ation of the surrounding substance of the brain.
Rupture of one of the lateral sinuses has also been
observed: a case of this description occurred to
Dr. Douglas. (Edin. Med. Essays and Observ.,
vol. vi.)
26. Small aneurisms in various parts of the
cerebral vessels may have formed, and by their
rupture occasion apoplexy. Serres relates
eases in which aneurism occurred in the ba-
silar artery, and, in a small artery in the circle
of Willis. (Archives G6n.de M/id.,t x. p. 419.)
Similar cases are also recorded by Blane and
Hodgson. Numerous other instances of extra-
vasation from disease of the cerebral vessels have
beennoticed by Morgagni, Lieutaud, De 11a-
BW, Baixlie, Portal, Lai.lemam>; and espe-
cially by liouiLLAUD, (M6m. de la Soc. Med.
d'Emul.t ix.),and Dr. Bright (Medical Reports,
vol. ii. p. 266, et seq.), who have adduced several
proofs of this kind of lesion. In a case of ap-
oplexy recorded by Bang, the extravasation had
taken place between the occipital bone and dura
mater. Dr. Watts, of New York, met with a
case in which the haemorrhage had proceeded
from the erosion of a vessel in connection with
caries of the inner surface of the parietal bone.
27. Infiltration of the blood into, with soften-
ing of, the cerebral structure, also seems to form
one of the lesions which are sometimes met with
in this form of apoplexy, although not nearly so
frequently as in the seizures which supervene on,
and are accompanied with, paralysis, where this
state of softening forms the principal lesion ; where-
as, when it occurs in this variety, it is one of seve-
ral other changes, or at least a subordinate one.
28. Perhaps the most common causes of h;c-
morrhage in this form of apoplexy, particularly
when occurring in the substance of the brain, are
ossification, earthly deposits in various places, and
a peculiar friability, of the vessels of the organ.
This state of the vessels, as disposing to aneurism
and haemorrhage, has been well illustrated by
Scarpa, and is justly insisted upon as being con-
nected with apoplexy by Abercrombie andCRU-
veilhier, and frequently met with in the brains
of elderly persons. "There is much reason to be-
lieve," Dr. Abercrombie remarks, "that this
diseased condition of the arteries of the brain may
give rise to a variety of complaints in the head;
and that, after going on for a considerable time
in this manner, it may at length be fatal by rup-
ture." The remarkable frequency of osseous or
cretaceous deposits, &c. in the arteries of the brain
in cases of apoplexy, had been noticed by Cor-
tesius and Morgagni. There can be no doubt
that changes of this description, in connection
with alterations of calibre and of vital cohe-
sion taking place in vessels, the coats of which
are remarkably thin and fragile even in the
healthy state, will readily dispose them to rup-
ture; particularly when influenced by the varying
actions of the heart, and the different emotions of
the mind, or when congested by derangement of
the vital energy bestowed on themby theganglial
system, or by disorder of the veins or sinuses, and
interruption to the return of blood through those
channels. Indeed, there is every reason to believe
that the hemorrhage may even proceed from the
smaller veins, in many of the cases where con-
gestion has been concerned in originating it, and
especially when the return of blood from the
head has been interrupted so as to produce the
disease. It may therefore be inferred, that the
laceration of the cerebral structure is occasioned
by rupture of either an arterial or venous capil-
lary vessel or vessels, and extravasation of blood;
and that, in cases of this description at least, the
morbid change commences in the vessels, and not
in the cerebral tissue itself, the cerebral structure
being only consecutively diseased.
29. Cases have also occurred, in which this
species of apoplexy has arisen from disease of the
sinuses, chiefly thickening, induration, and ob-
struction or obliteration of their canals. When
this is the case, the veins running into the sinuses
are generally enlarged, tortuous, engorged, and
as if varicose. I have met with cases in which
all the symptoms of this disease proceeded from
the developement of tumours in the central parts
of the brain, and similar instances have been re-
corded by several writers.
84
APOPLEXY — Complicated with Paralysis.
30. Besides disease of the vessels of the brain,
lesions of the membranes, as ossific deposits, ossifi-
cation of the falx (MoRGAGNl), but particularly
derangements of the circulation m them, espe-
cially in the pia mater, — as evinced by copious ex-
travasation on the surface of the hemispheres, or
at the base of the encephalon, — and inordinate in-
jection and congestion, deserve to be enumerated
among the sources of this variety of apoplexy;
although they are, perhaps, more frequently pro-
ductive of congestion and serous effusion, and
consequently of the most common forms of the
preceding species. But there can be no doubt that
this form, as well as the foregoing, will also some-
times proceed, although much more rarely, from
injection and engorgement of the vessels of the
membranes and of the brain itself, without extrav-
asation; and that in other instances the degree of
congestion, and the accompanying serous effu-
sion, when occurring without extravasation, are
not of themselves sufficient to account for the fatal
issue, without imputing something to the vital con-
dition of the encephalon itself.
31. III. Apoplexy complicated with, or
terminating in, Paral ysis. — A. Description.
This form of the disease may take place either
suddenly or in the manner of the immediately
preceding variety; but more frequently the lat-
ter, with the additional phenomenon of paralysis,
which may be either coeval with the attack, or
supervene as the apoplectic state passes off In
the majority of cases, the patient complains of
symptoms referrible to the head, particularly of
acute pain in one part of it; and is suddenly or
gradually seized with stupor or profound coma,
loss of speech and voluntary motion — with per-
fect apoplexy. The mouth is often distorted, and
the patient moves the limbs of one side ; whilst
one or both limbs of the opposite side are found
to be deprived of all motion upon their being
pinched or tickled. The patient generally lies
on the paralysed side, and one or both the oppo-
site limbs are sometimes contracted or slightly
convulsed.
32. In other cases, the seizure is less perfectly
apoplectic in its character, varying in the degree
of coma and disturbance of the respiration; and,
as the seizure declines, the paralytic symptoms
become the prominent disease. In some instances
of this description, the comatose state is slight or
of short duration; but the eyelid, or orbicularis
of the eye, or one side is paralysed; or the eyes
are distorted, the mouth twisted, and the tongue
drawn aside upon its being held out. In the major-
ity of these cases, the speech is either altogether
lost or greatly impaired; but the patient appears
sensible of his situation, and even attempts to
express himself by words or signs: but he is fre-
quently incoherent, unintelligible, and without
recollection, even when the power of speech is
partially retained. In many of this class of cases,
complete hemiplegia exists, or gradually mani-
fests itself as the seizure declines. Sometimes
one limb only is affected, which is commonly the
arm; although the leg is sometimes the only pa-
ralysed part. In rare cases the power of swallow-
ing is lost, owing to paralysis of the muscles of the
pharynx and the upper part of the oesophagus.
33. This form of apoplexy presents various
modifications in its further progress, which may-
be arranged under the following heads : —
a. The apoplectic attack may, under judicious
treatment, pass off entirely and quickly, and
leave no trace of its existence after a short time;
the paralytic symptoms, particularly when slight,
either disappearing with it, or soon afterwards.
b. The recovery from the apoplectic seizure
may be more gradual, taking place only in the
course of some days; whilst the paralytic symp-
toms require several or many mouths for their
removal.
c. The apoplectic seizure may be either quickly
or slowly removed; but the paralysis may be per-
manent,— may continue for years, either until
the patient is carried off by a subsequent seizure,
or by some other disease.
d. In other cases, the patient experiences a
very partial recovery merely, or is subject to
several exacerbations; is confined to bed or his
roo. ., speechless or paralytic, or the latter only,
with his mental faculties either more or less im-
paired, or but little affected; and at last sinks
gradually exhausted, after many weeks, or even
months; sometimes having become comatose for
a short time before death.
e. The apoplectic seizure may pass off in a
shorter or longer time, leaving either hemiplegia,
or paralysis of a single limb, or impaired speech
and mental faculties; and may recur after a
period of indefinite duration, and either carry off
the patient, or leave his symptoms greatly aggra-
vated. In this latter case, either another seizure
again takes place after a time, or he sinks into
the state characterising the immediately preceding
modification.
34. B. The morbid appearances which this
variety of apoplexy, in its different states, pre-
sents, are very diversified: — 1st, In some cases,
no lesion is detected sufficient to account either
for the symptoms or the termination; 2d, In
other cases, serous effusion merely to a slight
extent, or little beyond what we ha\e reason to
suppose usually exists within the cranium, is
found, sometimes conjoined with more or less
congestion of the vessels; 3d, In some instances,
congestion is the most remarkable and only mor-
bid appearance; and, occasionally, this state is
connected with disease of the arteries, generally
of the kind already described (§ 2S.).
35. 4th. Extravasation of blocd into a defined
cavity is amongst the most frequent lesions met
with in this form of apoplexy. We have already
seen, that, when the haemorrhage is very con-
siderable, or bursts its way into the ventricles, or
to the surface of the brain, the apoplectic seizure
is complete; and, owing to the quantity of blood
effused, and the pressure thereby occasioned on
the whole encephalic mass, the patient is either
suddenly carried off before any paralytic symp-
toms become evident, or rendered comatose, and
incapable of sensation and voluntary motion in
every limb. In the majority of cases in which
evtravasation takes place in this form of apoplexy,
there is every reason to believe, from its small
extent, that it is merely a consequence of the
simple apoplectic state occasioned by congestion
or interruption to the circulation, — these states of
the circulation being follou ed by the extravasation,
on which the paralytic symptoms chiefly depend.
36. 5th. The extra vasated blood presents various
appearances, according to the period which has
elapsed from its eflusion; and the surrounding
APOPLEXY COMPLICATED WITH PARALYSIS.
85
portion of the brain, and parietes of the ca-
vity formed by the coagulum, likewise undergo
changes — in some cases extremely slight, in oth-
ers ven extensive — which generally have an in-
timate relation to the various states the patient
has presented in the progress of the disease.
When the cerebral substance surrounding the
extravasated blood continues but little changed,
i of considerable size are gradually and
often completely absorbed. About fifteen or
twenty days after the attack, tbc more fluid part
of the effused blood disappears, and the coagulum
is firm and of a dark brownish colour. At a re-
moter period it assumes more of a firm and fibrous
texture, and the dark re 1 or brown tint is Inst.
At last the coagulum is nearly or altogether ab-
sorbed; and a small quantity of fibrinous matter,
of a slightly reddish colour, which after a time
passes into a loose cellular-looking substance,
only remains. These changes generally take
place at the end of four or five months; but
exceptions not infrequently occur. Riobe found
blood in the apoplectic cavity after twenty months;
Moulin met with a small coagulum at the end
of a year; and Serres has observed firm coag-
ula at the termination of two and three years.
37. The parietes of the cavity also experience
an important change. They frequently consist of
a firm yellowish membrane; and, when the co-
agulum is altogether absorbed, this membrane
("inns a more ur less complete cyst and well-
defined cavity, which is either empty or contains
a little very louse cellular substance connecting
its opposite sides in all directions; sometimes with
yellowish bands of a denser consistence running
through it. Dr. Ajbercrombie has never found
the cavity entirely obliterated; while Dr. Bright,
M. ( Kcvr.iLHiEK,and some other French patho-
logists, have gem it in some instances, after a
remote period, reduced to a dense nucleus; and,
in others, to a linear induration resembling a ci-
catrix (§53.). In some cases the cyst has been
found distinctly organized, and with blood-vessels
ramified in it.
38. The firm membrane constituting the apo-
plectic cyst, or covering the sides of the cavity,
seems to form soon after the extravasation has
taken place, and apparently arises from the lymph
thrown out upon the torn surface of brain. It
may generally be detected as early as a fortnight
or three weeks after the attack, or even earlier.
At a remoter period, when the coagulum is re-
moved, it is either empty, or it contains a serous
fluid, usually tinged with blood or the remains of
the coagulum. Riobe and other French writers
suppose that the serous fluid is exhaled from the
membrane covering the cavity, and absorbed af-
ter dissolving a portion of the coagulum. When
blood i- extravasated into the ventricles in cases
of this description, although extravasation in this
situation much more rarely occurs in tliis than in
the preceding form of the disease, there seems no
doubt of the possibility of its absorption. In this
case, the membrane lining the ventricle contain-
ing the effused blood becomes thickened, and of a
yellowish colour. M. EtlOBE records a case of
apoplexy, with palsy of the left side, which was
completely removed. The patient died ofdi
lungs after eighteen months; and the rig-fa lateral
ventricle contained a small quantity of coagulated
blood, and its membrane was changed as now de-
8
scribed. Absorption of the coagulum, with the
formation of a cyst similar to those formed in the
cerebral structure, also takes place when the
blood is etl'used on the surface of the brain, or in
the cellular structure of the arachnoid and pia-
niater.
30. As the coagulum disappears, the paralytic
Symptoms in some cases subside: but more "fre-
quently the improvement is only partial, and the
patient continues paralytic, although the congu-
lum is either altogether or in a great measure
absorbed, and all unusual pressure or interruption
to the circulation is removed from the adjoining
parts of the brain. It would seem that the fibres
of cerebral structure being once ruptured, and
not being susceptible of a direct reunion, remain
ever afterwards incapable of conveying volition
to the paralysed limbs, which are always on the
side opposite to the seat of lesion in the ence-
phalon.
40. In some cases of apoplexy complicated
with paralysis, the apoplectic symptoms pass
away speedily; and the paralysis also disappears,
either with the apoplectic attack or very soon
afterwards. In these, sufficient time for the
absorption of extravasated blood has not elapsed:
are we therefore to infer that it has been effused,
and recovery taken place notwithstanding? I am
more inclined to think that no effusion has occur-
red in these cases; but that either congestion
of vessels in a part of the brain, sufficient to in-
terrupt the functions depending on it, or retard-
ation of the circulation through it, owing to
deficient vital energy of the part, occasioning a
temporary abolition of its functions, particularly
the power of voluntary motion, or both these
states, have merely existed. In many cases, one
or more coagula, in distinct parts of the brain, or
cavities or cysts in older attacks, arc found, and
generally their number has a relation to the num-
ber of seizures. But it occasionally happens that
extravasation takes place in two parts of the en-
cephalon, either at the same time or during the
same attack; and thus the number of lesions will
be greater than of the seizures: and in other
cases, particularly in the next form of the disease,
the second or even third extravasation takes
place in the same situation as the first; forming
either an external layer with appearances distinct
from the centre coagulum, or a separate portion
with the characters of more recently effused
blood.
41. 6th. The substance of the brain surrounding
the extravasated blood often presents important
lesions; chiefly consisting of change of consist-
ence and colour. This portion of brain is some-
times very much softened, and is either colour-
less, or of a yellowish or greenish yellow tint;
or presents the usual appearances proceeding
from capillary injection or sanguineous infiltra-
tion. This change of structure seems to com-
mence from five to ten days after the sanguin-
extravasation, and to arise from inflam-
matory action having taken place in the part
surrounding the effused blood. We have already
seen that the formation of a membrane around
the coagulum, upon the lacerated surface of
brain, is necessary to the reparation of the apo-
plectic effusion; and that the membrane seems
formed from Ivmph thrown out upon this surface.
If the local action necessary to the production of
86
APOPLEXY PRECEDED BY PARALYSIS.
tins membrane and to the process of reparation or the attack supervenes on repeated aggravations,
pass the healthy standard, inflammation is the or after a gradual increase and extension, of these
result; occasioning either a considerable effusion symptoms. In some cases, the patient sinks gra-
of serum or a second haemorrhage, as already dually into a comatose state; from which he
stated, or softening of the surrounding cerebral ! may at first be partially roused, and give rational
structure. This consecutive inflammatory action : answers, the state of complete loss of sensation
may also give rise to exhalation of serum into the and voluntary motion having gradually advanced,
ventricles or into the sub-arachnoid cellular tissue, j From this state the patient seldom or ever re-
according to the situation of the primary extra- I covers. In certain cases the apoplectic seizure is
vasation; or even, though much more rarely, to [ more sudden, but is not so profound, or it passes
a secretion of puriform matter. It sometimes j away more quickly than in others. The apnplec-
happens, when the consecutive inflammatory tic attackhaving occurred, the patient is either
action has been slight and of long duration, indu
ration of the surrounding cerebral texture takes
place, the intellectual faculties having been gen-
erally much impaired in these cases; which,
however, are much less frequently met with than
those of consecutive softening.
42. There is no part of the brain exempt from
the lesions described under this form of apoplexy,
although they are most frequently observed in the
corpora striata, the thalami,and the substance of
the hemispheres. They likewise occur, though
less frequently, in the cerebellum, annular pro-
tuberance, &c. In all these situations the pa-
ralytic symptoms affect the side opposite to
that in which the lesions of the encephalon are
seated. Some exceptions, however, to this have
been recorded; but either the various circum-
stances connected with the cases, in which they
have been said to have occurred, have been in-
sufficiently investigated, or they admit of explan-
ation without invalidating the accuracy of the
general inference. Of forty-one cases in which
extravasation of blood was found in the brain on
dissection, by M. Rochoux, eighteen were in the
left side, seventeen in the right, and six in both
sides. Of these forty-one, there were twenty-four
in the corpora striata; two in the thalami; one
in both these situations; and one under the cor-
pus striatum: making altogether twenty-eight
cases in the corpora striata and vicinity. Of the
remaining cases, five were in the middle of the
hemispheres; two in the posterior part of the
ventricles; two in the anterior and interior part
of the hemisphere; three in the posterior and in-
terior part; and one in the middle lobe. (See art.
B R a i n , A Iterations in Substance — Heemorrh age. )
43. IV. Apoplexy, commencing with Para-
lysis, WHICH, AFTER AN INDEFINITE PERIOD,
TERMINATES IN A COMPLETE APOPLECTIC AT-
TACK.— d. Description. The commencement
of this form of disease is various. The patient
often complains of pain, vertigo, and other symp-
toms referable to the head; with want of recol-
lection, loss of memory of words, cramps, pains,
or with numbness, pricking, tingling, or weakness
of a limb or limbs on one side, generally beginning
in the hand. The speech is sometimes at first af-
fected, or the mouth and eyes distorted ; the limbs
being subsequently paralysed. In many instances,
the local symptoms continue in a state short of
paralysis for a considerable time previously to this
state being fully developed. In this case, inflam-
matory action seated in a part of the brain has of-
ten existed., although the symptoms have been so
obscure as not to have been detected. After a
period of indefinite duration, the paralytic symp-
toms are followed by a complete apoplectic seiz-
ure, occasionally preceded or accompanied with
spasms or convulsions of the unparalysed limbs;
carried off by it, or he recovers after a time the
state in which he was previous to it, or he is left
by it in a still worse condition: either gradually
sinking, and at last dying in a state of exhaustion
or coma; or experiencing a recurrence of the
apoplexy, which terminates his existence. This
forms a variety of M. Cruveilhier's second
species of apoplexy. It is often a result of pre-
vious acute disease, proceeding from a feeble ca-
pillary exudation.
44. As soon as the patient suffers the first com-
plete apoplectic seizure, the progress and termi-
nation of the disease very closely agrees with the
description given of the immediately preceding
form; but the appearances observed on dissection
are frequently somewhat different, and are alto-
gether much more diversified.
45. B. Appearances on Dissection. — Many of
the changes observed after this form of the dis-
ease are entirely similar to those described under
the foregoing head (§41.); whilst others fall
under a different article, where they are fully de-
scribed (see article Paralysis). There are
some lesions, however, which seem more strictly
related to the present variety of complicated
ap'oplexy, than either to the other varieties of the
disease on the one hand, or to simple paralysis on
the other. The most frequent morbid appear-
ance which I have met with in this form of
apoplexy, or seen described in the works of
Bayle, Recamier, Cayol, Rostan, Riobe,
Serres, Ckuveilheir, Lallemand, Bouil-
laud, Abercrombie, and Gendrin, who have
paid great attention to its pathology, consists of
softening, with a reddish tint, of a portion of the
brain. In cases which I have examined, the
softening was accompanied with infiltration of
blood into the cerebral structure. In some cases
the softening and infiltration increased from the
circumference to the centre, whilst in others the
change from the healthy state to this took place
abruptly; the diseased part presenting the ap-
pearance of a cavity containing a softened and
reddish pultaceous mass, which could be removed
without evincing any connection with the sur-
rounding brain. In some instances the softened
part is of a jellowish green tint, and the sur-
rounding portion of brain more vascular than
natural. The parts most commonly affected
with this lesion are nearly those which are most
frequently the seat of haemorrhage; the chief
difference being, that the gray substance of the
hemispheres is oftener the seat of the former than
of the latter.
46. As to the origin of this particular form of
softening of the cerebral structure, I must refer
the reader to what I have^adduced respecting it
in the article on the Alterations in the substance
of the Brain. As, however, the origui of this
APOPLEXY — its Symptoms, &c.
37
species of softenins has a very intimate relation
to the treatment of this class of cases, it becomes
a matter of importance to trace its origin. The
French pathologists, with very few exceptions,
ascribe it to inflammation of the cerebral struc-
ture. There can be no doubt that it someti s
proceeds from this source. But as soon as the
inflammatory action has given rise to this change,
the vessels no longer enjoy their requisite tone,
— their vitality has evidently become exhausted,
and tbev allow the red particles of blood to
escape from them, and to be infiltrated into the
cerebral structure ; as we observe sanguineous
infiltrations into the parenchymatous structures to
occar ia scurvy or in purpura hemorrhagica.
When the softening arises from this cause, the
paralytic and apoplectic seizure more frequently
is met with in patients not far beyond the middle
age, and whose constitutions are not much injured;
and the attack is more commonly preceded by
acute or febrile symptoms, than when it proceeds
from the cause about to be adduced.
47. Dr. Abercrombie considers that it also
depends upon disease of the arteries, chiefly ossi-
fication, thickening, contraction, or separation of
their inner coat, occasioning a failure of the cir-
culation, and gangrene of the part of the brain
which is supplied by the diseased vessels as is
observed to take place in the toes of aged persons.
This may possibly occur; but still we have no
satisfactory proof that it does so. This far 1 may
concede, — that the disease proceeds from a change
of a stale of the capillaries of the part, and of the
cerebral structure in which they ramify, other-
wise, we should not observe infiltration of blood,
and great softening of structure; but which of
the two is the primary lesion is very difficult to
determine. .Most probably, both are dependent
upon the state of that part of the ganglia) system
which supplies the encephalon, particularly its
blood \essels.
48. The other appearances with which this
lesion is associated in this form of the disease,
consist of the morbid states of the arteries of the
brain already noticed; of aneurisms (Blane re-
cords a case which arose from rupture of aneu-
rism of the internal carotid); congestion of the
vessels, veins, and sinuses; more rarely extrava-
sations of blood in some one of the situations and
states ahead v noticed, or the remains or marks
of antecedent 1 hemorrhage; empty cysts from
which coagula have been absorbed; portions of
the brain in various degrees of induration; puru-
lent collections in different forms; encysted and
other tumours of various descriptions; a large pro-
portion of the lesions described in the articles on
the Alterations in the substance of the Brain;
thickening, injection, or ossifications of the mem-
branes; and, occasionally, accumulations of serum
in the sub-arachnoid cellular tissue, and in the ven-
tricles. The further exposition of this form of the
disease, especially in relation to the paralytic
symptoms, falls more appropriately under the head
of Paralysis, where they are fully discussed.*
* I may subjoin the following classification of apoplexies,
according to a different principle to that adopted above.
It is based upon the chief pathologiaal stales from which
the attack proceeds, and approaches nearer the arranee-
incnts adopted by the German patholoeists, particularly
HARLRSfl j l)rr Specietlen Nosologic, be, p. 131. Cobl.
1824.), than that usually followed hv our own writers,
la some respects it may be preferable to that which has
49. Of the Phenomena of the Disease
which have no particular dependence
! upon its separate Forms. — A. There are
: certain symptoms occasionally met with in till the
states of apoplexy, to which I shall briefly refer.
The pulse is frequently full, strong, and slow, or
of natural frequency, particularly in the first, third,
and occasionally in the fourth varieties into which
I I have divided the disease. In other cases, es-
1 pecially in those which are extreme, and particu-
larly in the second and fourth varieties, it is often
small, feeble, and unequal or irregular. The
respiration, both as to strength and frequency,
' generally presents similar characters with the
pulse: when the latter is slow and strong, the
former is deep, slow, and stertorous; and when
the pulse is weak and frequent, respiration is
quick, less laboured, and much less sonorous.
Deep sighs are occasionally observed in all the
forms of the disease. The state of the pupils is
very various: sometimes they contract and dilate
independently of the influence of light ; hut
in the first and third varieties they are gen-
erally dilated; and they are often contracted, or
! one is contracted and the other dilated, in the
second, third, and fourth varieties. Contraction
of the pupils has been remarked as a not infre-
quent attendant on the worst forms of apoplexy,
and particularly on those characterized by a ten-
dency to spastic action, by Arf.TjEUS, and re-
cently by Cheyne, Cooke, and various other
pathologists;. The features are usually large,
bloated, relaxed, and flushed; but they are some-
times pale, and even collapsed, particularly in the
ingravescent and consecutive forms of the malady.
The fcecal and urinary evacuations sometimes
take place involuntarily, in all the varieties of the
| disease.
50. The muscles most frequently paralysed,
I either antecedently, consecutively, or at the
I same time, with apoplexy, are those of the su-
perior and inferior extremities, particularly those
! of the superior; next those of the tongue and face;
and lastly, the muscles of respiration. In gener-
al, the power of feeling is more or less deficient,
as well as of voluntary motion of the affected
been now fully described, particularly as I have here plac-
ed those forms of the disease which depend upon the ner-
vous or vital enertrv of the encephalon in a more promi-
nent point of view, than they can hold in a classification
framed according to the symptoms and mode of seizure, in
connection with the internal lesions.
I. SANGUINEOUS Apoplexy, — with extravasation of
blood in some part within the cranium.
II. CONGESTIVE AND Serous Apoplexy, — from ob-
structed return of blood from the head, and frequently
from the metastasis of gout, rheumatism, or eruptive dis-
eases.
III. Asthenic Apoplexy, — Nervous Apoplexy of Au-
thors,— from depression, exhaustion, or abolition, of the vital
influence bestowed on the encephalic organs, and occasion-
ally giving rise to extravasation of blood, or of serum, and to
congestion of the cerebral vessels.
A. From intoxication. B. From narcotic poisons, and
gases. C. From a stroke of lightning. D. From
the influence of great or continued, cold. E. From ex-
haustion of the mental and bodilv powers, and from convul-
sive affections. K. From violent mental emotions.
IV. Apoplexy prom Pre-existing Chronic Lesi-
ons within the CRANIUM, — from tumours, inflammations,
abscesses, Ike. &.c.
V. Traumatic Apoplexy, — From external injuries.
Concussion, or shock of the vital powers of the organ ; —
pressure from depression of bone or extravasation of blood.
VI. Complicated Apoplexy, — supervening at the in-
bt advanced stages of febrile diseases of an adyna-
I mic or asthenic Upe.
88
APOPLEXY — Relations of Symptoms, &c.
limb or side; but sometimes voluntary motion is
lost, whilst sensation remains. There are also
very rare cases recorded, where the feeling only
was lost, and sensation has been observed pa-
ralysed on one side, and motion on the other.
These phenomena will be more particularly con-
sidered and explained in the article on Paraly-
sis. As the patient convalesces, sensation returns
in the paralysed limb before the power of volun-
tary motion; and generally the lower extremity
recovers its functions before the upper, unless
disease of the spinal chord, producing more or
less of paraplegia, coexist with, or is consequent
upon, the apoplectic disease, — an occurrence
which is sometimes met with.
51. B. The duration of the apoplectic state is
extremely various. The attack may terminate
fatally in a few minutes, particularly the first
variety; or it may pass away in as short a time,
and the patient recover, especially in this and the
third form of the disease. Dr. Cooke thinks
that death seldom or ever occurs in less time
than one or two hours, in genuine apoplexy; and,
I believe, as respects those apoplexies which con-
sist of cerebral haemorrhage, this is generally the
case; but when large haemorrhage takes place
into the ventricles, and about the base of the
brain, death is very quickly produced. An attack
often, however, continues for a much longer time,
generally from several hours to as many days.
If no remission of the symptoms be observed
after twenty-four hours, the disease generally
terminates unfavourably. The progressive or
ingravescent variety sometimes continues for sev-
eral days; the apoplectic state becoming more
and more profound; and at last usually ending
fatally.
52. C. The termination of apoplexy has al-
ready been noticed, when describing the different
forms of the disease. I may, however, remark
generally that the attack may end as now stated,
or it may go off" completely, leaving no further ill
effects than a tendency to recur upon the action
of the remote causes. This favourable termina-
tion, however, is entirely owing to the nature of
the causes; a larger proportion of cases either
terminates in, or is accompanied with, paralysis.
When the speech and mental faculties are affect-
ed in a marked manner from a first attack, they
return but slowly; the memory, the strength of
mind, and force of character, are more or less
impaired; the patient becomes weak, puerile,
easily excited, and timid; and a disposition to a
subsequent attack is produced, which either car-
ries him off, or weakens still further his mental
and motive powers, until perfect imbecility of
mind and body is occasioned. Sometimes, after
repeated attacks, with marked injury of the men-
tal faculties, a considerable diminution of the vol-
ume of the cerebral convolutions is observed upon
dissection, — they no longer fill the cranial vault;
but the space is occupied by a greater or less
quantity of serum infiltrated in the subarachnoid
cellular tissue, and not only on the exterior sur-
face of the convolutions, but also between their
anfractuosities. In some cases this change is more
remarkably developed in certain convolutions than
in others, or in those of one lobe or hemisphere
than in the rest.
53. D. The changes which the seat of haemor-
rhage undergoes have already been described at
length (§§ 37 — 40.). The most remote changes
which have heen observed in the ruptured part
of the brain, from which the coagulum has been
absorbed, are, in some cases, a complete cyst,
either empty or enclosing a little reddish serum,
or a loose cellular substance; in a few instances,
a firm nucleus, seemingly consisting of the fibrin-
ous remains of the coagulum, and in others, ac-
cording to Creveiehier, merely a linear indu-
ration from the cicatrisation of the lacerated cere-
bral structure. In whatever form the remains of
the coagulum and laceration may present them-
selves, at periods remote from the seizure which
these lesions occasioned, no direct union of the
divided fibres of the brain is observed to have
taken place. Even when an apparent union of
the divided cerebral structure is noticed, it will be
found to have been brought about indirectly, and
through the medium of the cellular or fibrinous
substance left after the absorption of the coagu-
lum; the cavity having gradually closed, owing
to the atrophy of the ruptured fibres, and the
hypertrophy of those surrounding them from hav-
ing had to perform additional offices.
54. E. Of the supposed relations subsisting
between the seat of hemorrhage, or lesion of the
brain, and the symptoms accompanying and fol-
lowing tin1 attack. — M. Cruveilhier stati -
that those parts of the brain most subject to
haemorrhage, or laceration -from the external
injuries occasioning counter-stroke of the crani-
um, most commonly present extravasation of
blood in apoplexy. This seems to some extent
correct, as far as relates to corresponding fre-
quency; but there are parts of the encephalon,
occasionally the seat of apoplectic haemorrhage,
which are seldom or never so affected from this
spi cies of external injury.
55. a. It has been supposed by MM. Serres,
Fovillf., and Pixee-Graxdchamp, that lesions
of the corpora striata are followed by paralysis
of the lower extremities, and those or ilw thulami
by palsy of the upper. This inference is. how-
ever, neither supported by anatomy, nor borne
out by facts: a mere coincidence of internal lesion
with external signs cannot always warrant the in-
ference that the disordered function has its origin
in the part diseased, especially when we are ig-
norant of the offices of such part. The upper and
lower extremities are most frequently paralysed
from apoplexy ; and the corpora striata and
thalami are the parts in which the apoplectic
haemorrhage most frequently occurs. Hence the
coincidence of these lesions of structure and func-
tions must be frequent. But these parts of the
brain are sometimes diseased without the corres-
pondent affection of the limbs contended for;
whilst, on the other hand, the extremities are
often paralysed without any lesion of those parts.
5!>. b. The disciples of Gale consider the an-
terior lobes of the brain as presiding over the
organ of speech, and as the seat of the memorv
of words, &c, and that therefore lesions of this
part affect this organ, as well as this particular state
of recollection. M. BouiLLAumhas supported this
opinion by the history of several cases; and M.
Cru veii.hier has controverted it, by adducing
the details of others (Nouv. Biblioth. Aftd.1826.).
Several other French pathologists have also
espoused opposite sides, and adduced cases sup-
porting their views. The inference deducible,
APOPLEXY — Diagnosis.
;i;>
from tlio facts already accumulated is, that a co-
incidence of lesion of these functions, and of these
parts of the brain, is sometimes observed; but
the relation between them is neither so uniform
nor so precise as to warrant the opinion that there
exists anv necessan dependence of these particu-
lar functions upon the parts of the brain to which
they have been ascribed. Without reference,
however, to the part of the brain on which the
memory of words depends, it has been remark-
ed by M. Itard, that aged persons struck by
apoplexy frequently lose the recollection of them
in the following order: — First, want of recollec-
tion of proper names, next of substances, after-
wards of verbs and adjectives; which last arc
often the only words which can be recollected.
57. e. It was contended by MM. Delaye,
Fovillk, and Pinel-Grandchamp (Nouv.
Journ. de M6d. 1821.), that disturbance of in-
telligence: depends upon lesion of the gray sub-
stance of the brain, whilst disorder of locomotion
proceeds from change of the white or medullary
structure. But this doctrine seems no better
founded than the preceding, being open to the
same objections which have been urged against
them. Lesion of the cineritious substance is,
perhaps, more frequently accompanied with
spas'ns and convulsions at the commencement
of the attack, than when it is seated in the
medullary structure.
58. d. The cerebellum. Morgagni has re-
corded that Valsalva once stated to him, that
a case of apoplexy to which he was called was
seated in the cerebellum. Dissection verified the
diagnosis; but he does not mention the symp-
tom-; on which Valsalva founded his judgment.
M. Serres, adopting the doctrine of Gall,
says, that erections, or seminal emissions, in men,
and discharges, sometimes of a sanguineous ap-
pearance, from the female organs, are the distin-
guishing signs of apoplexy of the cerebellum.
M. (ruveilheir states, that he has seen apo-
plexy of this part, but that these symptoms were
not present. Some cases have certainly occurred
to countenance the opinion of Serres, and oth-
ers to overthrow it. It seems more probable that
the effusion in the cerebellum affects the medulla
oblongata, and occasions a partial asphyxia and
of the blood, from the influence of this part
upon the respiratory class of nerves, and thus in-
duces a state favourable to erection. Cruveil-
Hikr states that he failed to produce this symp-
tom by irritating the cerebellum of dogs. I may,
moreover, add, that the symptoms contended for
by Sekiiks, and the followers of Gall, as dis-
tinctive of cerebellic apoplexy, have occurred in
cases wherein the cerebellum has been found
sound on dissection.
59. Apoplexy of the cerebellum occasions,
ctcteris paribus, a more serious lesion of the
functions of circulation and respiration, and is
Biore dangerous than apoplexy of the cerebrum.
The symptoms are evinced on the side opposite
to the se il of lesion, in this as in other apoplexies.
The opinions that the cerebellum is the regulator
of all the voluntary movements, and the source
of all sensibility, according to certain Continental
physiologists, particularly MM. Flourews, Fo-
iiera, Foville, and Pinel-Grandchamp,
have not been confirmed by the history of apo-
plexy seated in it. The hypothesis of Rolando,
8*
| professor at Turin, that the cerebellum performs
I a function analogous to the Voltaic pile, in «en-
I erating a fluid or principle requisite to the func-
tions of voluntary muscular action; and that it
transmits this fluid, under the influence of the
J brain, and through the channel of the spinal
chord and nerves, to the muscles; seems much
more accordant with comparative physiology,
and the pathology of the nervous system.
60. e. The annular jrrotuberance — the point
j of junction of the spinal chord, brain, and cere-
bellum— the centre of the cerebro-spinal system,
is sometimes the seat of apoplexy, notwithstand-
ing its density. When the extravasation of blood
in this part is to any considerable extent, imme-
j diate and complete paralysis of the trunk, and of
j both the superior and inferior extremities, is pro-
duced, with the most profound lesion of respira-
tion, quickly followed by death. When the effu-
sion is to a small extent, and in one side of the
protuberance, the paralysis which results seems
, on the opposite side of the body, as may, indeed,
be inferred from anatomy. The extravasation
[ must be to a small extent, to admit of recovery.
| Sometimes the effused blood is observed to have
j been disposed in layers between the lamina of
1 white matter entering into the structure of the
protuberance. The reparation of the apoplectic
lesion of this part takes place in a similar manner
to that which I have already described (§§ 37 — ■
40.). It would seem that the smallest division
of the fibres of this part is followed by permanent
affection of feeling and motion.
61. Connected with this subject, M. Flourens
concludes, from his experiments and observations,
that the cerebral lobes, the cerebellum, and the
tubercula quadrigemina, may lose a considerable
but limited portion of their substance, without
losing the exercise of their functions; and they
may re-acquire them after being totally deprived
of them: that the spinal marrow and the medulla
oblongata are the only parts which directly affect
the same side of the body with that in which they
themselves are affected; whilst the tubercula
quadrigemina, the cerebral lobes, and the cere-
bellum, alone produce these effects upon the op-
posite sides to that in which they are diseased, —
the former acting in a direct course, the latter in
a cross direction. These inferences, however,
want confirmation in several particulars.
62. Diagnosis. — Apoplexy is, in general,
readily recognised: but it may occur in such a
way and under circumstances which will render
its diagnosis a matter of difficulty. Thus we may
be called to a patient, of whom nothing is known,
with the following symptoms : — Coma, laborious
or stertorous breathing, relaxation or rigidity of
the limbs, complete loss of consciousness; he may
oi- may not have had convulsions, or a blow upon
the head; there may be hemiplegia or not. In
this case, is the patient in a state of dead drunk-
enness, asphyxied, poisoned by narcotics, or af-
fected with the profound coma consequent upon
epileptic or hysteric convulsions ? Is it concus-
sion of the brain; the advanced effects of organic
disease within the head — as of cysts, abscess,
or of inflammation terminating in effusion; or
fever, either at its commencement or close, with
apoplectic symptoms ? It is true that these states
differ but little from apoplexy; the difference
consisting chiefly in grade, unless lucmorrhage
90
APOPLEXY — Prognosis.
baa taken place, when paralysis generally mani-
fests itself. But it should be at the same time
recollected, that there is sometimes haemorrhage
without local palsy, and even palsy without
sanguineous extravasation. The diagnosis o\' such
cases is very important; but without information
of the circumstances counected with the history
of the case, its difficulty is extremely great. I
once treated a case of adynamic fever, originating
in infection, and commencing with sudden loss
of sense and voluntary motion, as a case of apo-
plexy, and gave an opinion accordingly. _ The
history of the case, and its subsequent course,
showed the error. When paralysis is present, !
the nature of the case is then manifest, although
the particular cause of the palsy may be a matter
of doubt. We should, therefore, enquire after j
this symptom, by observing the attitude and mo-
tions of the patient, by pinching the extremities,
tickling the soles of the feet, &.c. The existence I
also of stertorous, laborious, or snoring respira- ,
tion, will confirm the diagnosis.
63. It should be kept in mind that, whilst the j
comatose state consequent on epilepsy or hysteria \
may closely resemble apoplexy, the convulsive
stages of these diseases may give rise to the true ]
apoplectic state. But, in the usual consecutive
coma of epilepsy there is no stertorous breath-
ing, and the limbs are not so relaxed as in apo-
plexy. The coma, which supervenes to inflam-
mation of the membranes of the brain, is chiefly
to be distinguished from apoplexy by the antece-
dent symptoms, and by the loss of sense and cer-
ebral function being greater than the loss of mo-
tion; independently of the association of para-
lysis so frequently characterising the apoplectic
seizure.
64. The symptoms consequent upon injuries
of the head, whether simple concussion, or com-
pression from depressed bone, or extravasation of
blood, are in all respects identical with certain of
the varieties of apoplexy described above, and are
not to he distinguished from them, but in respect
of the exciting cause. A similar remark is ap-
plicable to cysts, tubercles, and other tumours
slowly developed in the encephalon, which some-
times produce no very marked external sign of
disease, until apoplexy and stiil more frequently
hemiplegia suddenly take place. In such cases
there Is no actual difference in the proximate
cause of the abolition of function, but only in the
compressing body whereby abolition of function
is occasioned.
65. In cases of loss of sense and voluntary
motion from the action of narcotic poisons, or
breathing deleterious gases, there is also little
actual difference from several of the apoplectic
states described above (§ 10.), excepting that the
functions of the lungs have, in the case of breath-
ing deleterious gases, been primarily affected; for
the chief lesioil Is to he referred to the state of
nervous energy and vascular action in the brain,
its circulation being retarded, and its vessels con-
gested with dark blood. Indeed, in many such
cases, the true apoplectic condition, either with
or without hemiplegia, is produced; although, in
the majority, the state of profound but simple
coma is the result.
66. In asphyxia the lesion of function com-
mences in the lungs, the pulse being either dimin-
ished in strength or entirely abolished; whilst
in apoplexy the lesion is in the head, and the
pulse is generally fuller and stronger than natural;
but the exceptions to this state of pulse are nu-
merous. In syncope, the marked diminution, or
almost entire absence, of the pulse, paleness of
the countenance, and the very gentle or scarcely
apparent respiration, are sufficient to distinguish
it from apoplexy, even in its weakest forms; ex-
cepting at the commencement of, or early in, the
apoplectic attack, when the states of vital energy
of the brain, in both affections, are not materially
different.
67. Complete intoxication may readily be
mistaken for apoplexy; and, hi some cases, may
terminate in this disease. This state of intoxi-
cation is evidently attended with congestion of
the vessels of the encephalon. The smell of the
breath, and the appearance and smell of the mat-
ters thrown up by the retching that frequently
accompanies intoxication, will readily distinguish
this state. The greater frequency, also, of the
pulse, and absence generally of stertorous breath-
ing, in drunkenness, will also assist the diagnosis.
But these symptoms are occasionally observed in
apoplexy; and, on the other hand, the pulse may
be slow or natural, and the breathing stertorous
in the former : but tliis is very rare, particularly
slowness of the pulse.
68. In concussion of the brain, the state of its
circulation, and the influence of that portion of
the ganglia 1 system which supplies it, are as re-
markably depressed as in the weakest form of
apoplexy, — in concussion from the shock receiv-
ed, in apoplexy from internal causes; in many
cases no difference existing. In some instances,
however, even of this form of apoplexy, the res-
piration is much more laborious, the countenance
somewhat more tumid or distorted, ar.d the pulse
fuller and more developed than in concussion.
In the stronger states of apoplexy there can be no
risk of mistake, the characteristic symptoms of
each being very different.
69. Prognosis. — An attack of apoplexy is
always dangerous : — 1st, It may be fatal imme-
diately; 2d, It may also be fatal within two or
three days, and previous to reaction having com-
menced; and, 3d, It may occasion death during
reaction, — a. by a recurrence of the attack; 6. by
inflammatory softening and infiltration of the cer-
ebral tissue surrounding the extravasated blood;
c. by the exhalation of serum; d. by inflammato-
ry action of the membranes of the brain and sub-
jacent cellular tissue, and of the membrane lining
the ventricles. Even in more favourable circum-
stances, it leaves behind it debility of feeling,
motion, and of the mental faculties: and a first
attack is generally followed by a second or even
a third.
70. A. The unfavourable symptoms are fre-
quency or intermittence of the pulse; continu-
ance of the symptoms for twenty-four hours, or
for little more than half of this time in the strong
apoplexy, after a judicious treatment; verv pro-
found coma, and obtuseness of the senses: invol-
untary discharges of the urine and faces; con-
traction of the pupils, or contraction of one or
both pupils accompanied with spastic actions of
muscles : very laborious stertorous breathing, par-
ticularly if attended with fogn about the month,
and a weak pulse; cold and profuse sweats; the
occurrence of convulsions; the association of
APOPLEXY — Causes.
91
heniiplegic symptoms with the apoplectic and
complete loss of vision. Frequent yawning or
continued somnolency indicate effusion, or in-
og effusion. Q,< irin observes very justly,
that when the patient frequently applies the hand
to a determinate pari of the head, or when deli-
rium supervenes, or if partial perspirations occur
early in the attack without benefit, the result is
generally fatal. Complete hemiplegia, without
coma, but with integrity of the mental faculties,
and perfect motion and sensation of the non-
afiected side, is less dangerous than a more par-
tial paralysis, with stupor or coma. When one
pupil is contracted and the other dilated, the
existence of unequal pressure may bo inferred.
It has generally been stated that complete loss
of feeling and motion, accompanied with coma or
stupor, is extremely dangerous. Cruveilhier
remarks that he has seen recovery in such a case.
1 have met with it in two cases, one of which was
by Dr. Hooper.
71. Delirium is an unfavourable complication;
and indicates either the escape of blood from the
seat of extravasation upon the membranes which
it irritates, or the occurrence of inflammation of
the cerebral structure or meninges. Accelera-
tion of the respiration, and vomiting supervening
spontaneously, unless from matters occasioning
the attack, are very dangerous symptoms. A
similar remark is applicable, to loquacity, or com-
plete loss of speech, particularly when attended
with a frequent pulse.
72. When the disease occurs in the course of
insanity, or in epileptics, an unfavourable result
may be generally anticipated ; a nearly similar
conclusion may be drawn if it seize iiged persons,
and broken constitutions, upon the disappearance
of gout from the extremities. In the majority of
cases of apoplexy proceeding from efficient causes
originating in the brain, a perfect recovery is not
to be expected. On this, M. Portal has insisted
strongly; and although it is just as a general rule,
many exceptions will present themselves. If the
pulse sink, or intermit, or become remarkably
quick; and coldness of the extremities, or cold
elammy sweats come on; or the power of respir-
ation be greatly diminished ; inevitable or fast
approaching dissolution may be predicted.
73. B. The favourable signs of the disease
moderate attack; a decline of the symptoms
after treatment, and particularly if a warm, gene-
ral, and gentle perspiration take place; the occur-
rence of discharges of blood from the nose, hae-
morrhoidal vessels, or uterus; and a free state of
the bowels, with consciousness of all the evacua-
tions. The accession of the menses, of the piles,
or of ptyalism, have been justly viewed as the
most favourable signs by I Iii>i'ocrates,Schadt,
DoL.-f.rs, aiid main' subsequent writers. Go-
avarts considers haemorrhage from any part par-
ticularly epistaxis, ptyalism, a copious and general
perspiration, with free alvine and urinary dis-
charges, the most favourable signs. The acces-
sion of fever has been considered favourable by
Hippocrates and Portal ; but many experi-
enced authors do not agree with them. I believe
that, although some may recover from this state,
it indicates the accession of inflammatory action
of the portion of brain or membranes adjoining
the seat of hemorrhage; which will be dangerous
in respect of the extent to which it may proceed,
and the effects it may produce on the part, par-
ticularly in causing a renewal of the haemorrhage.
In all cases, the practitioner, even under favour-
able appearances, should give a cautious prognosis
until the tenth day ; the eighth being that on
which an unfavourable change is apt to occur, and
the extravasation to be renewed.
74. Causes. — The causes of apoplexy, both
predisposing and exciting, have generally a direct
or indirect influence upon the state of the vital
energy and circulation of the brain. The man-
ner, however, in which causes may individually
influence either the vital condition or circulation
varies extremely ; and the action of several of
them is even peculiar. Those causes, which in
some cases are merely predisposing, may in
others be exciting; and changes previously induc-
ed in the organization of the brain, or in the state
of its vessels, even from causes which lead to
other maladies, may, either directly or indirectly,
occasion apoplexy.
75. A. The predisposing causes of apoplexy. —
This disease occurs most frequently in persons of
the male sex, owing to their habits, and greater
exposure to the exciting causes; and in the far
advanced stages of life. The majority of authors
state the period intervening between forty and
seventy as that in which it is most common ; but
it is not infrequent at both earlier and later
epochs, particularly the latter. M. Rochoux
found, in C3 cases attended with extravasation of
blood, that 2 were between 20 and 30 years of
age, 8 from 30 to 40, 7 from 40 to 50, 10 from
50 to 60, 23 from 60 to 70, 12 from 70 to 80,
and 1 from 80 to 90 years. I have met with the
true haunorrhagic apoplexy at the early age of
eighteen. The hereditary tendency of the disease,
as shown in several instances by Forestus,
Wepfer, Portal, Blane, Frank, and others,
cannot be doubted.
76. The form and habit of body may also pre-
dispose to the attack ; but, I believe, much less
frequently than is usually supposed. A large
head, short neck, full chest, sanguine and ple-
thoric constitution, and corpulency, are generally
considered signs of disposition to it ; but the state
of the heart's action, and of the circulation through
its cavities, with a plethoric state of the vascular
system, has a more marked influence, as will
appear in the sequel. In the 63 cases which
have been minutely analysed by M. Rochoux,
only 10 were fat and plethoric persons, 23 were
thin, and 30 were of the ordinary habit of body.
He therefore maintains that there is no external
appearance of habit and temperament whereby
the disposition to apoplexy is indicated.
77. Long and intense thought ; disappoint-
ments ; depressed and anxious states of mind ;
the habitual indulgence of the temper, passions,
and appetites ; the irritable and sanguine tem-
peraments ; sedentary and luxurious living ; too
great sexual indulgence, particularly when ac-
companied with full living; habits of intoxication,
or the too free or constant use of wine and malt
liquors ; laborious employments, especially when
they require the stooping posture; the suppression
of accustomed haemorrhages, discharges, or ha-
bitual diseases, particularly those which are ac-
companied with evacuations ; and the neglect of
vascular depletion after their suppression ; the
influence of other diseases, particularly those of
92
APOPLEXY — Causes.
the heart, liver, lungs, kidneys, and digestive
organs ; a gouty diathesis ; extremes of tempera-
ture, particularly when conjoined with moisture ;
sudden vicissitudes of temperature ; frequent in-
dulgence in sleep after a full meal ; the use of
neckcloths worn too closely around the neck ;
sleeping with too low a pillow, particularly after
a meal ; and lying too long in bed ; are among
the most common predisposing causes of apo-
plexy.
78. Alberti and Seiz have insisted on the
greater frequency of this disease amongst the
studious than in other classes. Frank says that
the greater proportion of his apoplectic patients
had been previously subject to haemorrhoids. The
use of tobacco, particularly in the form of snuff,
has also been considered to favour the occurrence
of apoplexy. As to the influence of 'weather and
seasons, it may be stated, that Morgagni and
Lancisi observed this disease most frequently in
hot weather suddenly following cold and rainy
seasons. Kaiser says that he met with the
greatest number of cases in the months of Octo-
ber and November; and Hippocrates, Galen,
Forestus, Keelie, and others, have noticed the
influence of cold in producing it. I believe that
very cold weather, or cold conjoined with moist-
ure, favours its occurrence in very old subjects;
and that very hot and moist seasons occasion it in
robust and plethoric persons. The influence of
hot weather in its production has been insisted on
by Morgagni and Cheyne. The Franks
found apoplexy most prevalent at Petersburgh
and Wilna during the height of summer (J.
Frank, Prax. Med. Univ. Pracep. t. ii. p. 308.).
79. Apoplexy seems to be as frequent in the
poorest as in the richest classes; but in the former
it is more commonly attended with paralysis, and
oftener assumes an asthenic or iveak character,
the attack chiefly proceeding from frequent ex-
posures to the vicissitudes of season and tempera-
ture, to severe and long-protracted exertion, and
a less nutritious diet. In the latter it more gen-
erally assumes the sti'ong or active form, arising
most frequently from ease, luxury, and various
indulgences.
80. It will be observed that nearly all these
causes act by habitually favouring determination
of blood to the head, or by impeding its return,
and by diminishing the vital energy of the brain
at the same time that they favour a plethoric
state of its capillary vessels. These derange-
ments of vital manifestation and of circulation.
when frequently produced, will occasion further
changes, and sometimes will, upon the occurrence
even of the slightest exciting causes, terminate in
those lesions which constitute the disease itself.
81. B. The exciting causes frequently act in a
similar manner to the foregoing ; but generally
in a more sudden manner and intense degree.
These are, immoderate perturbations of mind, as
consternation, terror, fear, despondency, anger,
disappointments, anxiety, distress of mind from
losses, sorrow, violent chagrin, great joy, im-
moderate fits of laughter, and all painful, depres-
sing, or exciting mental emotions and exertions.
Numerous illustrations of the immediate influence
of the above passions in producing the disease are
to be found in the writings of Arktsus, Fores-
tus, Zuliani, Portal, Boucher, Cheyne,
Cooke, Abercrombie, &c.
82. Intemperance in eating and drinking is
amongst the most common exciting causes of the
disease ; and numerous instances of its immediate
ill effects are adduced by the above writers, and
by Bonet, Morgagni, Mead, Fothergill,
and others. Oppletionand distention of the stom-
ach prevent the descent of the diaphragm, impede
the dilatation of the cavites of the heart, obstruct
the circulation through the lungs and the return
of blood from the head, whilst the vital energy is
abstracted from the brain, and determined to the
digestive organs, in order to dispose of the load
by which they are oppressed. Owing to this
procession of phenomena the vessels of the ence-
phalon are engorged at a time when their vital
energies are diminished; while the rapid influx of
fluid matters into the circulation as the process
of digestion advances, tends to heighten the vascu-
lar fulness and disposition to effusion. Besides,
habitual intemperance of this description gener-
ates a plethoric state of the system, with con-
gestions of internal viscera. Spirituous liquors
are seldom productive of apoplexy until after a
continued addiction to them, unless they are
taken in excessive quantities ; and perhaps the
habit of drinking much malt liquors or wine is
still more frequently a cause of the disease, than
indulging in spirits, which, when thev occasion
apoplexy, act more upon the vital endowments
of the brain, than hi causing extravasation of
blood ; the chief changes produced by them,
being serous effusion with injection of the ves-
sels. Sir A. Carlisle has adduced a case of
apoplexy, arising from drinking an immense quan-
tity of gin. Upon dissection, the odour of the
spirits was detected in the serum effused in the
ventricles of the brain.
83. Connected with the use of spirituous or
fermented liquors, I may here allude to the in-
fluence of the class of narcotics, particularly
opium, stramonium, hvoscvamus, tobacco, &c,
the excessive use of which sometimes occasions
all the symptoms of congestive apoplexv, and
even extravasation. Of all the narcotics, the
different species of monkshood most readily occa-
sion apoplexy, when taken by mistake. I was
lately consulted in the case of a young man who
had incautiously chewed some seeds of this plant;
he was shortly afterwards seized with a sense if
numbness of the face, soon followed by complete
apoplexy, as described under the third variety of
the disease, from which he recovered with great
difficulty, and with palsy of one side, with which
he is still affected, now upwards of a twelvemonth
from the time of attack.
84. Nearly allied to the operation of narcotics
is that of the fumes of charcoal, and various
mephitic gases, which, whilst they diminish, or
altogether arrest the changes affected by respir-
ation on the blood, thus occasioning asphyxia,
and carus without stertorous breathing, some-
times produce all the symptoms of complete ap-
oplexv, owing to their effects upon the vital en-
dowment of, and circulation in. the brain. In
respect of the modus operandi of narcotics and
deleterious gases on the system, somewhat differ-
ent opinions have been entertained by Cullen,
Gc-ODWYN, CURRIE, ORF1LA, BRODIE, and
others who have investigated the subject There
can, however, be no doubt that they act chiefly
upon the ganglial system, particularly on that part
APOPLEXY— Causes.
93
which actuates the brain, when they produce apo-
plexj . destroying the influence of tins system on
the vessels of the encephalon, and thereby retard-
ing tlie circulation in, and favouring congestion
of. its capillaries, and interrupting tlie functions
of the organ.
65. Violent straining in lifting heavyweights,
or muscular exertions; straining at stool ; the
venereal act, particularly under unfavourable
circumstances, or too frequently repeated ; the
metastasis of oilier diseases, especially o{" gout
and rheumatism; whatever impedes the return
of blood from the head, as a dependent posture
of the head, or holding it long in an averted
position, or looking backwards without turning
the body, particularly when the neck is short;
sleeping upon too full a meal, especially with a
>ih or other- ligatures around the neck;
violent tits of coughing or sneezing; pregnancy
and child-birth; exertion of body, with an anx-
ious mind; stumbling; the use of the warm bath;
and the sudden exposure to heat or cold ; are
among the most frequent exciting causes of apo-
86. The effect of the sun's rays in producing
wht is commonly called coup ele soleil, Ls well
known. Many of the seizures thus occasioned
amount to complete apoplexy, in some one of its
forms, particularly tlie fust and third. Put other
conditions of heat will also sometimes occasion
an attack', as heat combined with moisture, and
t\e exhalations from a number of persons crowd-
ed together in ill-ventilated apartments. The
nee of crowded rooms and assemblies in
causing apoplexy is well known, and in occasion-
al:: headache, and sense of fulness in the vessels
of the encephalon, even in persons not predispos-
ed to an apoplectic attack.
87. Cold also, particularly when applied sud-
denly to the surface of the body and lungs, excites
the disease in aged persons, whose vital energies
are already greatly impaired. The vessels of the
brain in this class of subjects are weak, fragile,
and liable to rupture, or to permit a portion of
their serous contents to escape. Eesides, cold
ill lower the vital powers of the frame,
and tends to retard the circulation, whilst it drives
the blood from the surfaces into the large viscera,
and particularly into the encephalon, which,
from its unyielding case and exemption from at-
mospheric pressure externally, is more obnoxious
to congestion, retarded or interrupted circulation,
and compression from vascular fulness, than any-
other organ; occasioning lethargy in the robust
or young, and apoplexy in the old or predisposed.
• illustrative of apoplexy produced b\ long
exposure to great cold, particularly when the dis-
position to sleep which it induces is yielded to;
by the incautious use of the cold bath, and of
ice applied to the head; and by the practice in
Russia and Poland, of using a snow bath after
the warm bath; have been recorded by Wepfer,
Walther, Penada, .Macard, Brandis,
Ki i .mi:. Portal, and Frank. Of about fifty
sea of the disease, the causes were
analysed by Dr. Chkvnk, and ranked as fol-
low-:— 1st, Drunkenness and habitual indulgence
in exciting liquors; 2d, The form of the bod) ;
3d, Temperament, Banguine, Banguineo-choleric,
choleric : 4th, Gluttony ; 5th, Indolence; 6th,
Mental anxiety; 7th, Fits of passion; 8th, Exter-
nal heat; 9th, The use of tobacco. (On Apo-
plexy and Lethargy, p. 149.)
88. <'. Modus operandi of the above causes. — •
If we endeavour to trace the relation subsisting
between these causes, and what we know of their
uniform effects, either upon the brain or on other
parts of the body, we shall find that they tend
li'st to excite, and afterwards to exhaust, the
vital energy, and to distend the capillaries of the
part. Now, as the brain is enclosed in an un-
yielding case, it. must follow that, when the
capillaries are excessively distended, the veins,
which are the most yielding, will be propor-
tionately compressed, whilst the force of the cir-
culation in the arteries will tend to perpetuate
this distension, and consequently the compression
of the veins. Thus the circulation will be re-
tarded; the portion of the ganglial system sup-
plying the brain be likewise, to a certain extent,
benumbed by the increased pressure to which it
is subjected, and the functions of the organ
abolished, even without extravasation having
occurred. Upon dissection after death, the
blood, which had distended excessively the capil-
laries, will be found to have passed into the
veins, giving the appearances of venous con-
gestion merely, as is uniformly observed in other
parts of the frame, which have been the seat of
congestion, without inflammation, — venous con-
gestion, at least to any considerable extent, be-
ing incompatible with the physical condition of
the encephalon during the life of the patient, un-
less it be occasioned by impeded return of blood
through the sinuses and large veins, although con-
gestion of its capillaries undoubtedly frequently
exists.
89. When hemorrhage takes place, the effused
fluid will occasion more or less pressure, accord-
ing to its extent; but, from the condition of the
encephalon, the pressure will almost equally
aflect all parts of it; the blood being thereby
prevented, to a certain extent, from returning by
the veins, whilst the capillaries and arteries will
be unnaturally distended. This state, however,
will pass off after death; and venous congestion
only, with extravasation, present itself. When,
however, the extravasation is large, the pressure
will prevent both the veins and the capillaries
from receiving their due proportion of blood;
whilst the ganglial system of the encephalon will
be analogously, or injuriously, affected. But this
topic will be pursued hereafter.
90. D. Consecutive and complicated Apoplexy.
— An attack of apoplexy may be caused by other
diseases, in various stages and states of their pro-
gress. It may occur after the pre-existing disease
has disappeared, and in consequence of its disap-
pearance, as in the case of suppressed haemor-
rhages, particularly epistaxis and haemorrhoids;
or suppressed evacuations and eruptions, as those
from the uterus, bowels, &c. ; or it may supervene
in such a way as will lead us to infer that its
occurrence has been the cause of the disappear-
ance of the pre-existing malady, as in cases of
misplaced or metastatic gout, rheumatism, &c;
or it may likewise appear in the course of other
diseases which it cannot thus displace, and as-
sume the character of a most serious or fatal
complication. The importance of these morbid
relations of apoplexy requires for them a more par-
ticular notice than they have generally obtained.
94
APOPLEXY —Complications.
91. a. Consecutive. — The supervention of apo-
plexy after suppressed haemorrhages, evacuations,
and eruptions, has been satisfactorily noticed by
many writers; and seems to proceed from unusual
fulness of the vascular system, owing to the sup-
pression, and the accidental co-operation of causes
which determine the blood to the head, and favour
its extravasation. Besides the suppressed evacu-
ations, noticed above (§ 90.) as being influential
in causing an attack, 1 may mention the sudden
healing up of chronic ulcers; the arrest of habitu-
al perspiration from the feet; unusual continence;
and suppression of the lochia or of leucorrhcea.
It is not infrequently observed after suppressed
Ottorrhea; and from inflammation of the ear hav-
ing extended to the membranes and substance of
the brain, and produced abscess. I have met
with several cases of this description in which the
apoplectic state was complete, and attended with
hemiplegia. Numerous instances are also record-
ed by Lallemand, Gendrin, Itard, and other
writers. (See Brain, Abscess in.)
92. b. Metastatic. — The occurrence of the dis-
ease, from misplaced or metastatic gout, has been
noticedbyMoRGAGNi, Weickard,Musgrave,
Juncken, Tode, Hagendorn, Conradi, and
Cheyne. The last named author thinks that the
symptoms differ, when occurring from this cause,
from those which constitute true apoplexy. I
believe, however, that they differ in no respect,
in general, from those which characterise conges-
tive apoplexy; and that, as haemorrhage within
the head does not commonly constitute the attack
of apoplexy from this cause, hemiplegia or para-
lytic symptoms seldom accompany it.*
93. Nearly similar seizures to the foregoing
will occur from attacks, or metastases, of rheu-
matism to the membranes of the brain. The apo-
plectic symptoms are, however, seldom so fully
developed as in other cases, a comatose state
being the more usual result. On dissections of
fatal cases of this description, Morgagni, Hoff-
mann, Plenciz, Ranoe, Weickard, and
Stoll, found the membranes injected, thickened,
and with serum interposed. Very nearly similar
symptoms and appearances within the head result
from erysipelas extending to the membranes of
the encephalon. Here, as well as in the rheumatic
disease of the same structures, the apoplectic
state is not so strongly marked as in its more
idiopathic forms; and paralysis rarely occurs, ex-
cepting in the advanced progress of the cerebral
disease.
94. c. Complications. — Apoplexv occasionallv
supervenes in the course of many diseases, even
at the commencement of some of them, and be-
comes associated with them. It is sometimes an
* Some years since I was called to a medical friend in
Westminster, who, after complaining of symptoms of indi-
gestion, was suddenly seized with complete apoplexy, with
stertorous breathing, hut with no signs of paralysis, for
which the usual means were promptly and decidedly employ-
ed. On the following day a complete attack of gout in both
feet took place, with disappearance of the cerebral dis-
ease. Warmth to the feet, and aperients, were prescribed ;
but from his eagerness to rid himself of the pain, and to
visit his patients, he took, contrary to the advice given him,
a large dose of colchicum. A few minutes afterwards
the gout left his feet, and seized his stomach ; whence it
was with difficulty recalled to the extremities. This was
the first time he fiad ever been seized with gout, and the
first part it attacked was the brain, in as complete a form of
apoplexy as can be conceived. Metastasis of gout to the
head may also occasion inflammation of the brain, with
coma, or lethargy.
attendant upon the cold stage, or the period of
invasion, in fevers, particularly those which pro-
ceed from concentrated marsh effluvia, and from
the infection of animal miasms. The epidemic
prevalence of apoplexy, noticed by Baglivi,
Lancisi, Morgagni, Formey, and Stoll, may
be explained by a reference to this connection;
although the observations of the Franks and
Cheyne, which are conclusive of the great fre-
quency of the disease in hot and moist seasons,
seem to countenance the opinion of these authors.
When apoplectic seizures usher in fevers, whether
paludal or infectious, the attack is seldom accom-
panied or followed by paralysis. In a case, how-
ever, of perfectly formed apoplexy ushering in a
case of endemic fever of a warm climate, which
occurred in my practice, paralysis supervened
upon the seizure. An attack of true apoplexy
may also occur in the stages of depression and
collapse of adynamic and typhoid fevers, par-
ticular!}' in the former stage: in the latter, coma
is generally present, but it very rarely amounts to
the true apoplectic state ; and when it does,
hemiplegia generally attends it.
95. The occurrence of apoplexy after epileptic
convulsions, the convulsions and eclampsia of the
puerperal state, and, more rarely, during the
hysteric fit, is well known. It may even take
place during the pains of labour, without pre-
vious convulsion, and in the latter months of
pregnancy. In these cases' the attack offers no-
thing to distinguish it from the first, second, or
third varieties described above. It is a not in-
frequent termination of inflammation of the brain,
or of its membranes. Indeed, there seems every
reason to suppose that acute inflammation of that
part of the cerebral structure in which haemor-
rhage takes place, not infrequently precedes the
extravasation. It also occasionally supervenes
upon mania, and the various states of insanity,
particularly in its fourth or last noticed form
(§. 43.). It also occasionallv arises from inter-
rupted circulation through the lungs, — a fact
well demonstrated by Bonet, Bang, Huxham,
J. Frank, and Cheyne. Its occurrence during
the advanced stages of both acute and chronic
diseases of the air-passages and lungs, particularly
those characterised by violent attacks of cough,
has also been observed by myself, most frequently
in hooping-cough, bronchitis, asthma, and emphy-
sema of the lungs.
96. The connection which sometimes subsists
between apoplexy and organic disease oftheheart,
especially hypertrophy of the left ventricle, has
been remarked by Valsalva, Morgagni, Liec-
taud, Testa, Portal, Cheyne, Richerand,
Bertin, and Hope; and has been viewed by
them in the light of cause and effect, the apo-
plectic seizure arising from the cardiac disease.
Corvisart and Rochoux, physicians of large
experience, have thrown doubts upon the nature
of this connection; have likewise denied the fre-
quency of its occurrence ; and have viewed these
diseases as sometimes consecutive in their origin,
although co-existent in their advanced state, but
without the relation of cause and effect : thus
considering the occurrence of apoplexy or para-
lysis in the advanced stages of disease of the
heart as entirely an accidental coincidence.
But when such a complication of morbid states
is frequent, prominent, and observes the same
APOPLEXY — Complications.
95
succession, B more intimate connection than
mere sequence or coincidence ought not to be
entirely rejected, particularly when admitting of
a rational explanation. The frequency of apo-
plexy or paralysis, and the general presence of
the latter when the former occurs in the advanced
progress of cardiac disease, especially hypertrophy
of the left side of the heart, have led me to be-
lieve that more than mere coincidence actually
exists. It is, however, by no means improbable
that the disposition to organic change throughout
the whole vascular system, sometimes associated
with disease of the heart, may so far exist in the
delicate vessels of the brain, as to favour the
occurrence of hsmorrhage from them when the
action or impulse of the heart is increased by
disease or the influence of passion or emotion; or
when the return of blood from the head is impeded
h\ congestion, or interrupted circulation through
the lungs or right side of the heart.
97. The association of apoplexy and hepatic
disorder has been noticed by Stole, Baldinger,
Moll, Chetne, and others. The circumstance
of icteric patients frequently being cut oti" by apo-
plexy marks the connection. I have met with
several cases in which both apoplexy and paralys-
is have supervened to, and become complicated
with, hepatitis, both acute and chronic, particu-
larly the latter. The liver is seldom diseased
without disordering the functions of the brain;
and I believe that accumulations of vitiated bile
in the gall-bladder and hepatic ducts, independ-
ently of any actual disease of the liver, will
predispose to the apoplectic seizure. I am the
more confirmed in these opinions by having ob-
served disease of the biliary apparatus in a very
large proportion of those who had died of apo-
plexj or paralysis; and, in many of those who
have recovered, the active use of purgatives had
produced morbid evacuations, containing a large
quantity of blackish green, greenish, or yellowish
brown bile, before much amendment had taken
place. It may, however, be conceded that serious
disturbance of the brain equally induces disorder
of the liver; and that the latter may have been
occasioned by the former. But this merely proves
the frequency and intimacy of the association.
It should also he kept in recollection that the
apoplectic seizure generally masks the hepatic
in ; the practitioner should, therefore, ex-
amine the region of the liver, where, as well as
at the epigastrium, fulness, and, in some cases,
the existence of tenderness, may be detected:
and, as the consciousness of the patient returns,
the hepatic disorder will occasionally become
more manifest. This complication is so important
and frequent, that it ought always to be looked
for in practice ; for many of the causes which
occasion hepatic disorder also give rise to cere-
bral disease : and the production of either the one
or the other singly, often favours the appearance
of the other subsequently. I have no doubt,
however, that an inflamed or actively congested
state of the substance of the liver has a very
marked effect in exciting that state of the capilla-
ry circulation of the brain on which the apoplectic
seizure has been shown to depend (§88.).
98. The influence of gastric disorder in pro-
ducing apoplexy, not merely as evinced by in-
toxication, a surfeit, fee, hut" also by some one
or more of the several ailments which charac-
terise impeded or otherwise disordered function of
the stomach and intestines, has been noticed by
8cnEMCK,ScHROEin:R, Weickard,Me/.i.i K
FOTHERGILL, ScHJEFFER, ThILENIIJS, Hijfk-
land, Louyer Villermay, and Chomel ;
and more strongly insisted on by Broussais and
his followers. Although the general dependence of
the latter on the former has been too absolutely
contended for by Broussais, the occasional con-
nection cannot be doubted. Indeed, in several of
those cases wherein the association with hepatic
disorder is observed, gastric and intestinal disturb-
ance is also evinced. But however complicated,
whether with either gastric or hepatic disorders
only, or with both conjoined, apoplexy is, perhaps,
as often the concurrent result of the same causes
that produced these disorders, as a disease spring-
ing from and dependent upon them. The fact
ought not to be overlooked, that the vital manifes-
tations of the stomach, liver, and brain, although
different, are yet actuated by the same system of
nerves — the ganglial; and that, notwithstanding
the individual parts of this system seem to per-
form modified offices, yet the healthy condition
of the one is necessary to the perfect functions of
the rest ; and, consequently, a morbid state of
one considerable portion of the series will neces-
sarily, sooner or later, be followed by derange-
ment throughout, — causes which operate upon
one part of the circle, thus having their effects ex-
tended to other parts remote from the seat of pri-
mary impression. It should not, however, be
overlooked, that a large number pf instances of
gastric affection, retching, &c. accompanying the
apoplectic seizure, proceeds from the sympathetic
effect produced upon the stomach by the severe
injury or shock sustained by the brain.
99. The occurrence of apoplexy either after,
or during attacks of colica pictonum, has been
noticed by Hagendorn and Cheyne. Although
palsy is the common consequence and state of
complication, yet apoplexy, with or without par-
alysis, particularly the former, is sometimes met
with. An instance occurred to me some time
since of a patient having died of apoplexy during
an attack of this disease. The constipated state
of the bowels to which persons affected with cer-
ebral disease are liable, when neglected, or not
readily yielding to medicine, will sometimes favour
the occurrence of the apoplectic attack.
100. The association of apoplexy with disease
of the kidneys has been noticed by several writers,
particularly Bonet, Littre, Morgagni, and
Bright. The occurrence of apoplexy, particu-
larly serous apoplexy, after suppression of urine,
is not uncommon. By some writers, however,
the suppression has been imputed to pre-existing
disease el' the brain. But this is a supposition
merely : for, in the great majority of cases, the
kidneys and ureters offer evidence of having been
the parts primarily affected. The experience of
Bonet and Morgagni, and of numerous later
writers, fully support this conclusion. Besides,
the cerebral nervous system can only indirectly
influence the urinary secretion. That apoplexy,
coma, or lethargy, should occur when the urinary
secretion is suppressed, and the vascular system
overloaded, may be readily imagined. The occur-
rence of the disease, as a consequence of organic
change in the secreting structure of the kidneys,
whereby their functions are more or less ob-
06
ArUl'LLAl 1'ATIIOLOGICAL STATES.
Btructed, has been illustrated by the cases record-
ed l«\ Dr. Bright.
101. The sudden or more gradual supervention
of apoplexy after the slow de\ elopement of many
of the organic changes which are described in
the article on the Pathology of the Brain, — in
some cases even when little cerebral disorder had
previously been complained of ; in others when
more violent and even paralytic symptoms had
occurred, has ahead) been noticed (§ 45 — tS.),
and lias also received due attention in the article
on Palsy.
102. The Pathological States consti-
tuting Apoplexy have been in part comprised
in the observations offered on the principal kinds
of apoplectic seizure, and on the modus operandi
ot' the remote causes (§ S8.). There can be no
doubt that much misapprehension has existed on
this subject, and consequently that the treatment
adopted has been frequently either nugatory or
injurious. The opinion, that the disease depends
upon compression solely, has been too generally
adopted, without considering the relation in which
such compression, granting its existence, stands in
to the causes which occasioned it, and the symp-
toms it produces. The idea that compression is
indispensable to the existence of the disease has
thus been empirically assumed, and acted upon in
practice. A careful consideration, however, of
the morbid appearances on dissection, in relation
to the symptoms, and to analogous changes and
their phenomena, have led me to infer that com-
pression of the brain never can take place ; that
pressure exists in the great majority of case-, but
even that it is not indispensable to the apoplectic
state; and that, although retarded circulation,
whether caused by pressure or by any other state,
seems very frequently to obtain, it does not con-
stitute the only morbid condition of the brain in
apoplexy, — or, in other words, that apoplexy is
Dot merely a disease of the vessels of the brain,
although these vessels are either consecutively or
coetaneously affected. It should not, however,
be overlooked, that even those who argue for
compression being the cause, do not thereby im-
ply, as their opponents would make it appear,
that the tissue of the brain is actually compressi-
ble, but contend for the effects which pressure
undoubtedly produces upon living and sensible
parts. Therefore, although the brain is not com-
pressible, it does not follow that it may not be ;
atTected by pressure, even independently of the
obvious effects which pressure must produce on
its vessels and the circulation through them.
103. Before entering further on this subject, it
will be necessary to premise, that the circulation
of the brain, like that of other important organs,
is chiefly under the dominion of that portion of
the ganglia] system of nerves which is ramified
on its blood-vessels, and is distributed otherwise
to the organ itself ; and that an exhausted or
morbidly depressed state of the influence those
nerves exert on the circulation and manifesta-
tions of the brain, with the consequent effect this
State has upon the capillaries, particularly in dila-
ting or congesting them, and disposing to their
rupture, is the principal cause ot\ and often con-
stitutes, the apoplectic seizure, — whether this in-
fluence emanate from their chief centres, or from
the local sources provided for the peculiar offices
of the organ, as the pineal and pituitary glands.
104. From this it may be inferred, that the
proximate cause of a large proportion of tin
of apoplexy, not omitting even those which are
attended with retarded circulation and haemor-
rhage, is here imputed primarily to the condition
of that part of the ganglia! system which supplies
the blood-vessels of the brain and the brain itself.
That this actually is the case, is shown by the
nature and mode of operation of the remote causes
of the disease ; by the frequent affection of the
functions of the brain previous to an attack ; by
the nature of the principal part of the phenomena
accompanying the attack ; by the disorders ob-
served subsequently, when partial recovery takes
place; by the tendency to relapse ; and by the
morbid appearances which present themselves on
the dissection of fatal cases.
105. It is obvious, that the appearances in these
cases are merely ultimate lesions, as in all fatal
cases of organic disease, ;md some of them even
post mortem changes; and yet, although the most
advanced in the procession of morbid phenomena,
they are often of themselves obviously insufficient
to occasion death. Leaving out of question those
cases which are unattended with extravasation,
the venous congestions, even admitting their ex-
istence, or the serous effusion, formed in the other
cases, are seldom such as to account of them-
selves for the event : inasmuch as they are fre-
quently observed to an equal, .or even greater,
extent in cases « here neitjier apoplectic nor co-
matose symptoms had preceded death ; and are,
as I have already shown (§88.), the result of
the accumulation in the veins, after death, of the
blood w Inch had distended the arterial capillaries
during life, and thus had been instrumental in
abolishing the cerebral functions.
106. The circumstance of the morbid changes
being insufficient to account for the result, had
induced various writers, particularly Kortum,
ZuLIANI, ScHELXER, ScHJEFFER, and Ik'I E-
land, to consider apoplexy frequently to proceed
from the state of the nervous power, which they
considered defective ; and led Wuckard to
contend that it seldom depends upon compression.
Dr. Abercrombie, evidently influenced by the
above considerations, refers the disease to inter-
rupted circulation in the vessels of the brain, ow-
ing to pressure from the effused blood, or to other
causes. It is extremely probable that a retarded,
if not an interrupted, state of the circulation very
generally obtains; and that, partly in consequence,
the sensitic and motific powers are not generated.
This, however, is only a matter of inference: for
we have no evidence that complete interrup-
tion ol' the circulation of an organ or part can
exist for any time, and its functions be so rapidly
restored, as is sometimes observed in apoplectic
seizures, or without gangrenous disorganization
being sometimes the result : and even it* we admit
this state of the circulation, we must still refer it
to some antecedent and more general morbid
condition.
107. That a congested state of the vessels and
retarded circulation of the brain should, however,
exist, owing to the diminished, or exhausted, or
suppressed state of that influence which undoubt-
edly actuates the vessels, may readily be conceded ;
but that, even in the brain, the effusion ot a small
portion of blood should occasion pressure sufficient
to interrupt the circulation through it, requires
APOPLEXY — Pathology of.
97
further proof. It seema more probable, andcon-
witli facts observed in other parts of the
body, that, in cases where the extenl of effusion
or external injury warrant the admission of pres-
Ihis state gives rise to the apopli
as n, ects it produces upon the
gnnglial apparatus of the encephalon as from in-
terrupted circulation through its ires els.
lo>. The Pathological condition or the
bb \in. tli srefore, in apoplexies, may be stated to
be as follows: — ■«. That the tissue of the brain is
compressible i but, being lodged in
an hi \ i tiding case, it may be injuriou . it cted
by pri a "/•. . chiefly bj di placing the contents of
its lild. nl vessels, altering the he ive pro-
n of their cont tries of
. and impeding the circulation through a
part or the whole of the organ : ;m<l thai pressure
exerted in one part, whether from distended ves-
sels, extravasated blood, or the developement of
tumours, when reaching a certain pitch, will al-
most equally affect the whole of the organ, partic-
ularly when the pressure is great : the yielding
nature of the cerebral structure, as well as the un-
yielding ease in which it is placed, must necessari-
rise to this result.
109. 6. The various states of vascular impulse
ins and
- of the brain, and distension of its capil-
laries, whethi r arising from the influence of the
organic nerves on the bloi or from mor-
ed action, or from obstruction in the
veins, the lungs, or the right side of the
heart, will, either individually or in partial con-
junction, occasion th ! iwing chiefly
to the unyielding walls of the encephalon.
IK), c. Owingalso to this physical condition of
. which
culation of all other pats
I modify, in a direct or sensible
r, that of the brain : and hence the cranial
contain nearlj the same quan-
tity of blood daring life, the differences which oc-
cur beiug chi sflj those of rapidity of circulation,
f relative proportion in each part of the
; sed quantity in the
a proportionate diminution
to this condition,
the forcible injection and distension of one set of
Kirily diminish the capacity of,
istruct the circulation through, the other;
and that part ies which is nearest to the
propelling power — the first to receive the impulse
of the heart, and the nearest capable of being
much distended by it — will, from relative situa-
tion, overcome the distension^ and dimini
capacity of that beyond it. Thus the arterial
capillaries of the brain will be the first distended
from increased action of the heart and large arte-
ad, by their distension, will soon overcome
that of the veins, if it have previously existed;
and hence, by compressing them, impede the cir-
culation through them.
11!. The frequent inflammatory character of
apoplexy, or the common occurrence of reaction,
will be readily accounted for from what has now
been stated ; for, whether the attack commences
with dilatation or increased action of the arterial
capillaries, or with exhaustion or deficiency of
their \ital power, or with retardation of the' cir-
culation through the veins and venous capillaries,
9
the result will generally lie augmented action of
tin arteries going to the brain, extending itself in
some in. an to the heart, and this state v, ill
continue until the abolition of the cerebral (unc-
tions shall have impaired, or altogether destroyed,
the heart's action.
112. d. I 'pon tracing the relation subsisting
between the various causes of the disease, the
Bymptoms, and the appearances on dissection —
upon ret as far as my own observation
Ins gone, the frequency of change in the pineal
and pituitary glands of apoplectic patients, I am
induced to infer that functional lesion, or organic
change, often commences in that portion of the
gangual system which supplies the encephalon
and its blood vessels ; and that, owing to exhaus-
tion of its influence, the capillaries lose their vital
tone, have their circulating functions impaired,
become more or less dilated, and are disposed to
rupture.
113. e. When apoplexy proceeds from causes
of an obviously exciting nature, or from sur-action
of the heart and arteries, it seldom occurs until
a certain degree of exhaustion of the vital tone
of the capillaries has taken place, whereby they
become dilated and congested, so as either to
press the encephalon against its unyielding case,
and, owing to the pressure, impede the return of
blood by the veins (§ 109, 110.), or to give rise
to extravasation, which, when considerable, has a
similar effect; injection of the arteries of the brain
and its membranes resulting equally frotn both,
owing to the obstructed circulation through the
veins.
114./. Where pressure unequivocally exists, it
may also benumb or suppress the vital influence
of that part of the ganglia! system which supplies
the encephalon, thereby heightening the effect
produced both on the organ itself and on its circu-
lation.
1 1 5. g. There are cases of apoplexy generally
presenting the phenomena, which have given rise
to the appellation of weak apoplexy, which, oc-
curring from depressing causes, operating upon
exhausted states of the encephalon and frame gen-
erally, directly suppress or abolish the vital influ-
ence of the organic or ganglia! nerves of the
brain, and consequently the cerebral functions,
without producing further change of its vascular
system, than retarded circulation to so slight a
. as not to amount to great distension and
compression, and without occasioning extravasa-
tion of blood, although extravasation often does
supervene to this state, giving rise to pressure and
tsequences, so as to heighten or prolong the
. lesion, and to occasion paralysis.
116. h. [n cases proceeding from depressing
causes, acting on a plethoric habit of body, the
effect is also more or less directly produced on the
organic nerves of the brain, whereby the capilla-
ries lose their tone, are congested and dilated, oi-
ly ruptured, and the return of blood by
as retarded, whilst the smaller arteries and
capillaries are more and more engorged by the
impetus of the blood in the large arteries, the
pressure thereby occasioned suppressing the cere-
oral functions as in the other cases.
117. i. When the disease proceeds primarily
from impeded returnoi the blood from the head,
the congestion only commences in the veins ;
but, as the action of the heart and arteries con-
98
APOPLEXY — Treatment of.
tinues. the capillaries are soon afterwards injected
;md dilated; and, in proportion as they enlarge
from the distending power to which they are more
immediately subject, the veins are compressed,
owing to the physical condition of the brain,
in or less emptied, and admit of the greater
dilatation of the capillaries, some one or more of
which may be even ruptured from the increased
action and distension.
IIS. k. In cases accompanied with hemor-
rhage, and consequent laceration of the cerebral
structure, the deprivation of function may be as
much an effect of suppression of the vital inilu-
ence of the organ, owing to the shock produced
by the injury, as of pressure upon the veins, and
consequent injection of the arterial capillaries. In
eases of this description, the state described above
(§112. d.) may exist, and be followed by hae-
morrhage and laceration of the part in which it
occurs, producing the abolition of the cerebral
function, great vital depression, sickness, and
other signs of dangerous injury sustained by a
vital organ. The pressure occasioned by the
haemorrhage will be followed by obstructed cir-
culation, and, under favourable circumstances, by
increased action of the arteries and heart to over-
come it.
119. /. In apoplexy presenting on dissection
congestion and serous effusion, these states may
be often considered rather in the light of post
mortem changes than the pathological states which
had existed previously to death : it may even be
presumed that the distension and congestion of the
capillaries, chiefly the arterial capillaries of the
organ, had overpowered its functions ; and that,
as in other parts, when the injection of the blood
into them no longer is continued, and the distend-
ing cause has ceased to exist, they have gradually
discharged their contents into the veins, which
now had space given them for dilatation, owing
to the emptying of the capillaries ; and thus the
blood has passed into the veins soon after death.
120. m. Haemorrhage in the brain may result
from the following states : — a. Exhausted vital en-
ergy of the ganglial organic nerves supplying the
vessels and organ favouring their distension and
rupture: (S. Diseased state of the coats of the ves-
sels themselves : y. Organic change of the cere-
bral structure, extending to, or influencing the
state of, the vessels ramified in it: 8. Incr< ised
impetus of blood from augmented action of the
heart and larger arteries, combined with either of
the other states : f. Impeded return of the blood
from the head, similarly associated.
121. n. The. vital energy of the organ, result-
ing chiefly from the mutual influence of the gang-
lial and vascular systems, may be so far affected
as to occasion the attack with all the organic
changes observed in fatal cases ; and sometimes
in such a manner as to constitute the disease,
even without these changes having taken place ;
although they are most frequently produced,
thereby heightening the primary lesion.
122. o. As corollaries from the foregoing, I infer
that apoplexy often originates in exhausted or
suppressed influence of the ganglial apparatus of
the encephalopv with a congested state of its arte-
rial capillaries, or impaired condition of their cir-
culating functions, and still more frequently in
extravasation of blood, either or all of which
changes must necessarily exist to the extent of
suppressing tire functions of the organ ; and that,
as apoplexy does not uniformly depend upon the
same pathological state of the nervous influence
and circulation of the brain, particularly in respect
of the kind or degree of vital depression and vas-
cular reaction, a due regard ought therefore to be
had to the nature of the change in each case, as
fir as it may be ascertained, and a treatment
strictly appropriated to it adopted.
123. 'JLreatjiest. — The treatment of apo-
plexy has long furnished subjects for discussion,
not only as respects the more subordinate means
of cure, but also as regards the most energetic
measures, and the intentions with which they
should be employed. This is evidently owing to
the difference which has been long acknowledged
to exist in the pathological states constituting the
disease, but which has recently been questioned.
Without recurring to the changes so fully de-
scribed above, I may remark, that a person is
seized with apoplexy, and, instead of being blood-
ed, is treated with stimulants and restoratives,
and yet he recovers without paralysis having- su-
pervened. Another person is blooded largely,
and he recovers. A third is treated in a similar
manner, and he becomes hemiplegia in the course
of the attack ; and a fourth is also blooded, and
he dies. Now these are very common occur-
rences, and point to very important considerations,
which I will pursue a little farther. A thin, spare,
and debilitated man staggers as he wall s, and
fills down in the street, with pale countenance,
feeble pulse, and laborious or slightly stertorous
breathing. He is blooded by the nearest medical
man almost immediately, and recovers. A large
man, of a full habit and lax fibre, suddenly be-
comes apoplectic, and is instantly treated with
stimulants, and volatile substances held to the
nostrils, and his consciousness and voluntary mo-
tion are restored in a few minutes. One practi-
tioner of large experience states, that he never
draws blood from a patient in apoplexy, except-
ing under peculiar circumstances, and avers that
he is more successful in his treatment than those
who do. Another considers that when one full
blood-letting fails of a:\inu- relief, no benefit will
be derived from pushing it further, but much risk
of giving rise to paralysis. A third physician,
equally eminent and expi I, c Dfides in
blood-letting almost solely, and carries it often to
a great amount ; and a fourth, whilst he cli-
dep'.etion, trusts to stimulants chiefly.
124. But if we examine into their success, we
shall find, perhaps, that si to de-
gree may exist ; and that, whilst many pj
seem benefited, others experience no relief, if
they be not even actually injured, by the kind of
practice thus exclusively adopted. Ihere is, how-
ever, one part of the treatment which is u
less adopted by all : this is the use of purgi
v\ hieii. when judiciously administered, are 1 1
generally applicable and beneficial of i
usually advised. Were it possible to ascertain
during life the exact pathological condition ob-
taining in the various cases of apoplexy, and
to convey a correct description of the signs by
which each may be known, then the basis for a
rational method of cure could be firmly laid :
but the skilful practitioner is guided in the treat-
ment he adopts by considerations, circumstances,
and appearances, which scarcely admit of de-
APOPLEXY — Treatment of.
99
scription; and all attempts to impart his know-
ledge comes tar short of his wishes.
125. The method of cure in apoplexy neces-
sarily divides itself into : — 1st, That which is re-
quired when an attar!; is threatened, in order to
prevent it, — or the prophylactic treatment; 2d,
The moans which are to \n' adopted when the
disease is developed ; and, 3d, The plan which
should be subsequently pursued, with the view
of perfecting recovery, and preventing a return
of the disease, — or the consecutive treatment.
[■ WHICH MAY BE
EMPLOYED TO PREVENT AN ATTACK WHEN IT
i- i i .;. \ i ened. — [t is difficult to state the means
whi.-h may be resorted to with this view, as they
to be direct id with strict reference to the
circumstances of the case; which are almost
always different, and, not infrequently, even op-
A strict regard mast necessarily be had
to the habits, age, and constitution of the patient;
the predisposing and exciting causes ; and the
evidences of previous ailment or existing disorder
in remote but related organs. The character of
mntenance; the puis •, particularly in the
carotids; the temperature of the head; the state
of the abdominal functions, secretions, and dis-
charges, must he our chief guides. It should not
be overlooked in this stage, any more than when
the disease is fully formed, that it may result
from nearly opposite st ites of the vascular action
of the brain, and of the circulating system gene-
rally ; that, although the majority of cases are
attended with that appearance of countenance,
and action ol' the arteries, which warrant the in-
ference of existing congestion, retarded circulation,
or even increased vascular action in the brain, —
there are others, in which the external characters
of the head, the face, and action of the carotids,
would lead us to infer, either that the vital energy
of the organ is so far depressed as to give rise of
itself to abolition of the cerebral functions, or that
the extravasation of blood and laceration of the
ae of the organ has occasioned such a
shock to its vitality as to be followed by the same
on it- (unctions; vascular reaction sometimes
in either case, and thus imparting to
the attack similar characters to those possessed by
seizures which originate in, or are, from their
commencement, attended with, vascular turges-
cence or incr
127. [n the premonitory state of the disea
scarcely can be admitted that extravasation or its
juences has occurred, unless in those cases
I id by paralysis; hut the signs of in
congestion, or incn ased action, are frequently
' ; whilst also, in many other cases, the
ims nt' exhausted or depressed vital power
are manifest; this latter state being more fre-
. antecedent to congestion of the capit-
is generally supposed, although the
fully formed disease may evince inordinate ac-
tion, with all its usual consequences. Even in
the earlj stage of an attack, this state of the vital
i w ill often constitute so import-
ant a pari of the disease, and will yet beal
only by simple congestion and retardation of the
circulation, that the us,, of stimulants may then
be beneficially resorted to ; whilst soon after-
wards, when reaction has supervened, they would
no longer be admissible, large depletions, kc.
being then required.
128. We should, therefore, endeavour to in-
terpret correctly the origin of the premonitory
symptoms, and prescribe accordingly, [f the
countenance is full or flushed, tin- eyes promi-
nent or suffused, the pulse of the carotids full or
strong; or even if, with this state of the counte-
nance, they are natural; blood-letting, general or
local, hut preferably cupping on the nape of the
neck, should be prescribed. If these symptoms
li ive Come on after the disappearance of ha a.c ,-
rhages and discharges, this treatment is still more
imperatively required, and should be directed to
the restoration of the pre-existing disorder, assisted
h\ other means, such as irritating purgatives, re-
vulsants, and external derivatives.
129. When, on the other hand, the action of
the carotids is weaker than natural, the counte-
nance sunk, and the head cool, &c, opposite
measures are called for : restoratives, antispas-
modics, and stimulants are here of service, but
their use requires caution ; for if the pulse in the
carotids is full, or strong, or at all above the natu-
ral standard, although the countenance be sunk or
pale, and if the attack threatens to commence
with paralysis, stimulants given internally, or
even the outward use of them, as volatile sub-
stances held to the nostrils, would be hurtful. In
such cases, blood-letting must be resorted to; and
a purgative of quick operation, assisted by ene-
mata, exhibited.
130. There are few cases, presenting even the
premonitory signs of an attack, that will not be
benefited by a judicious use of purgatives, par-
ticularly such as are suited to existing disorder of
the digestive and biliary organs. In those cases
which evince a disposition to vascular excitement
of the brain, — where the premonitory signs are
accompanied with plethora, heat of the head,
injection of the conjunctiva, and Hushed coun-
tenance,— after depletions and purgatives have
been resorted to, the tartrate of antimony, or
James's powder, given in moderate doses, and
combined with saline medicines, so as to act
gently upon the skin or the bowels, and continued
for some time, has always appeared tome pro-
ductive of advantage : but it is only in such
cases that antimony is useful as a prophylactic ;
where, also, digitalis may be given with the
view of lowering the action; but its use ia these
case-; i _ I caution.
131. When the incipient symptoms present
much of the character of vital exhaustion of the
brain, the combination of purgatives with gentle
stimuli and vegetable tonics and stomachics has
proved the most successful in my practice. If
the symptoms appear after the suppression of
haemorrhoids, aloetic cathartics, or the extract
of colonjnlh, combined with calomel, are amongst
tin' best that can hi; employed ; as they tend to
induce, by their action on the rectum, a return of
the hemorrhoidal affection.
132. In threatened apoplexy from congestion
and impeded circulation through the hums, heart,
or liver, local blood-lettings and purgatives are
necessary, in cases characterised by a combina-
tion of either of these states with exhaustion or
debility, the abstraction of a small quantity of
blood by cupping, and afterwards dry-cupping,
issues, or blisters, are sometimes \ery service-
able.
133. The insertion of setons or issues in the
100
APOPLEXY — Treatment of.
nape of the neck, or the use of the tartar emetic
ointment; and, in very urgent cases, large issues
in the scalp of the occiput, particularly when the
precursory symptoms evince a paralytic charac-
ter ; cold-sponging the head night and morning,
or the shower-bath, with a free state of the alvine
secretions and excretions, especially where there
is a disposition to congestion, or increased action
in the brain, and after blood-letting has been
employed; stimulating or irritating pediluvia, or
a blister applied to the nape of the neck, and
kept open lor some time, in similar cases and
preceded by the same measures, constitute im-
portant items of the preservative treatment.
134. The patient ought carefully to avoid all
the predisposing and exciting causes of the disease
(§ 77 — 87.), particularly crowded apartments,
the application of cold to the feet, and violent
mental emotions. He ought to sleep with his
head and shoulders somewhat elevated; and rise
early in the morning. The diet should receive
particular attention: it ought to be spare in a!!
cases accompanied with plethora; but not too
low, when this state of the vascular system does
not exist, and when the vital energies of the brain
are already depressed or exhausted. It should,
in these latter, be of moderate quantity, and di-
gestible. In all cases, tranquillity of mind and
body ought to be carefully preserved; and sti-
mulating beverages avoided, with very few ex-
ceptions, which are to be made in favour of those
only who present great cerebral and constitution-
al exhaustion. The beverages for these should
be gently strengthening, but not heating, and
used in moderation.
135. B. The Treatment of the Apo-
plectic Attack. — The patient should be car-
ried into a well-ventilated and spacious apartment,
and placed with his head and shoulders very con-
siderably raised, or in a sitting or semi-recumbent
posture, with every thing removed from his neck.
Directions should also be given to have hot water
in readiness. His countenance, state of the eyes
and pupils, the degree of fulness, flushing, or
pallor of his face, the temperature of his head,
state of the pulse in the carotids, and condition
of his limbs in respect of sensibility, capability
of motion upon their being pinched, &c. ought
to be carefully examined; and, according to the
evidence thus obtained as to the ;tute of infc !
lesion, the propriety of depletion, and tiie extent
to which it is to be carried, should be promptly
decided on.
136. a. Treatment of apoplexy unattended by
depression of vascular action, or by marked ex-
haustion of vital power. — if the pulse be strong,
or full, and especially if the countenance be
flushed, livid, and tumid, general blood-letting
to a large extent, or according to its effect, is to
be instantly employed. Much discussion has taken
place as to the propriety of opening a vein of the
paralysed or non-paralysed side, when paralysis
accompanies the attack. Aketjeus, V ixs \ i.-. i,
Morgagni, andCuLLEN advise it to be perform-
ed in the sound side, wlulst Baglivi prefi is the
other : this is, however, a matter of little im-
portance.
137. The next points are the extent to which
blood-letting may be carried, and 'now far certain
states of the frame and pulse warrant the prac-
tice. In robust, plethoric, and full-living persons,
particularly when the attack lias proceeded from
exciting causes, and paralysis is not present, thirty
or forty ounces may be abstracted at once; and
the operation may be performed a second or even
third time to a somewhat less extent. When,
however, the habit of body is spare, the person
far advanced in life, the pulse not full or strong,
or little fuller than natural, the heat of the head
not increased, and the countenance neither full
nor flushed, we must be cautious not to carry it
too far. In cases of this kind, local depletion!;,
particularly cupping between the shoulders, or on
the occiput, and leeches to the neck and behind
the ears, seem preferable. Age is no reason
against venesection, if the symptoms indicate its
propriety; but very old age, even when the oper-
ation is otherwise indicate;!, is a strong reason for
great caution in its performance. In aged per-
sons, local depletions are more serviceable; but
even these, employed either indiscriminately or
too largely, may occasion a very dangerous, or
even fatal, collapse.
138. An intermitting or irregular pulse has
very justly led practitioners to hesitate as to the
employment of blood-letting. But a single
torn is not to guide us in the use of this, or any
other remedy. If, conjoined to either of these
states, there be slowness or fulness of pulse, ster-
torous or strong breathing, constitutional vigour
and fulness of habit, tumid, flushed, or livid coun-
tenance, blood-letting, even to a very considerable
extent — either general or local, or both — may be
practised ; but when, with irregularity and inter-
mission, the pulse is also small, weak, or quick,
the countenance pale, the temperature of the
head either not increased, or somewhat depress-
ed, aud the respiration weak rather than strong,
blood-letting would be highly injurious : a very
opposite treatment is then called for.
139. In cases where it is a matter of doubt •
whether or not general blood-letting should be
carried further, or be adopted at all, local blood-
letting, to an extent which circumstances will
point out, may generally be still employed, and
often with great advantage. Vascular depletion
being indicated in one form or other, the situation
in which it should lie performed next remains to
be considered. The temporal artery has been
recommended to be opened by some: others
advise the jugular vein. "When the di-ease arises
from congestion, and when the face is livid, the
attack strong, and the operator expert, the jugular
vein may be opened, as sanctioned by Valsal-
va, Morgagni, Hiester, Friend, Lancisi,
Stole, Burseri, and Portal. But undue
pressure of the vein, either before or after the op-
eration, must be avoided. Bleeding from -the feet,
they being plunged in warm water, has been very
generally prescribed by Continental physicians :
and, in those cases which have occurred after the
disappearance or retention of haemorrhages and
periodical discharges, or from metastasis, the
practice is very judicious.
140. Local depletions in this disease are usual-
ly directed on the temples, nape of the neck, or
between the shoulders. I prefer the latter situ-
ation, as well as cupping, to the use of leeches, —
the former being much quicker and more decided
in its operation. Hippocrates, Aket.eus, and
Morgagni advised cupping to be performed on
the occiput : and I unequivocally agree in the
APOPLEXY — Treatment of.
101
practice. If leeches are applied, the neck, occi-
jnit, and behind the cars, are the besl situations.
Lancisi and Cruveixhiee advise them to the
inside of the nostrils, after general blood-letting,
particularly in apoplexy preceded by opistaxis;
ami Waltheb (Dp Apop., p. 88.), to tli«' veins
near the canthns of the eye. In cases of sup-
pressed haemorrhoids or menses, the application
of leeches to the anus, the anterior part of the
insides of the thighs, particularly alter blood-let-
ting from the feet, certainly is frequently produc-
tive of advantage, even although it very often
Tails of restoring the suppressed evacuation.
1-11. Some physicians rely almost entirely on
blood-letting, wlulsl others too frequently discard
it. Others more rationally view it as a most im-
portant, aiid a frequently, but not an universally
required remedy. -It is by not attending to the
pathological states, which 1 have endeavoured to
point out (§ 108 — 122.)., and to the changes of
vascular action which take place during the attack,
that such difference of opinion exists, and the in-
discriminating practitioner is led to the injurious
adoption of one mode of practice only. Among
those who prescribe blood-letting almost unre-
servedly, and to a great extent, I may adduce
the respected authorities of Cullen, Cheyne,
Pitcairn, Cooke, and Abercrombie; whilst
the injurious effects of the practice in many cases,
and its applicability to certain states of the dis-
ease only, have been ably argued for by Kirk-
LAND, FOTHERGILL, HEBERDEN, BaRBETTE,
and Darwin. There can, however, be no doubt
of the propriety of having recourse to vascular
depletion in tiie states of apoplexy now under
deration, — the general character of the
symptoms, circumstances of the case, and the
effects produced by the first bleedings, being our
chief guides as to the extent to which it should
be practised. But in the forms of apoplexy cha-
racterised by marked deficiency of vital power
and action, or sometimes at the commencement
of the seizure, when the symptoms, owing to the
shock sustained by the brain, very closely
resemble those of concussion, and before the pow-
ers of life recover themselves, and react (§ 111.),
hi l-lettiog would generally be attended either
with fatal sinking, or with effusion, giving rise to
hemiplegia where effusion had, us yet, not taken
place, and with a fatal increase of it, in some
where it had already existed.
142. Next to blood-letting, active purgatives
are most deserving of notice, as being very gene-
rally applicable and beneficial. In many of the
most severe and sudden attacks it is often difficult,
and sometimes impossible, to administer purgatives
in the usual form by the mouth. But we may
always succeed by mixing from 10 to 15 grains of
calomel in sweet butter, and placing it upon the
root of the tongue. In some eases, two or three
grains of powdered camboge may be added to if.
14.5. Whilst we are waiting the operation of
the purgative, it will frequently be advisable,
olarly when then: is much heat of head,
and action of the carotids, to plunge the feet and
legs in warm water, and apply cold to the head,
either in the form of affusion of cold water, or of
epithem. Great care is necessary not to continue
affusion too long, nor to depress "the temperature
too low. as the risk of inducing hemiplegia will
be increased by the practice, particularly when
9*
vascular action is not. considerable. After the
affusion has depressed the temperature to about
the natural standard, cold lotions or epithems, el-
even frequent cold-sponging, will be sufficient ;
but increased heat generally returns, and then the
allusion should be again resorted to. In general,
as soon as the temperature of the head becomes
natural, and continues so lor some time, and the
fulness of the features entirely subsides, cold ap-
plications may be omitted. As thus used, they
have received the sanction of Thilenius,Crell,
Weickard,. Carrette, Weber, and Aber-
crombie; butQ,UARiN very judiciously cautions
againsl the indiscriminate and too long continued
use of them. Crdveilhier, and other French
physicians, advise the application of ice for an
hour or two, twice or thrice a day, to the head;
but, excepting in the more inflammatory states
of the disease, it is not required, and may even
be attended with risk.
144. If the purgative already exhibited doe3
not operate in about four hours, one or two drops
of croton oil should be placed upon the tongue,
mixed with a few drops of castor oil, or in a little
sweet butter, as advised above; and, about an
hour afterwards, the action on the bowels ought
to be promoted by the following enema: —
No. 20. R Olei Ricini, 01. Terebinth., aa 5J.— Bjss. ;
Decoct. Avenae, §xij. M. Fiat Enema.
This will generally succeed; but if it come away
without feculent or copious evacuations, it should
be repeated in from one to six hours, according
to the extent of its effect. In obstinate cases,
one part of croton oil added to about eight or
ten of castor oil may be assiduously rubbed over
the abdomen. This, however, will seldom be re-
quisite, as a repetition of the enema will rarely
fail, and will act more beneficially on the disease
than the introduction of so irritating a substance
as croton oil into the circulation. In some cases
it may be advisable to render the enemata more
irritating by the addition of compound extract of
colocynth. Irritating injections are enjoined by
Aret/eus, Forestds, and many modern au-
thors, particularly Thilenius. In cases follow-
ing haemorrhoids, they are more especially indica-
ted, after leeches have been applied to the vicinity
of the anus.
145. After the bowels have been fully evacua-
ted, we must still endeavor to excite the alvihe
secretions, particularly those of the liver. The
region of the liver and epigastrium should be ex-
amined: and, if there be fulness there, cupping
may be performed in this situation. The calomel
may be repeated in smaller doses, oftener than
once, and combined with some preparation of
antimony, or James's powder. In all cases where
the apoplectic seizure is attended with increased
vascular action, antimony may be given; but
sickness or retching should be guarded against,
it will be frequently observed that a repetition
of the calomel, particularly after full depletions,
will be soon followed by a flabby state of the
tongue, indicating its incipient action on the
mouth, and the propriety of omitting it, and of
continuing the purgatives. It is frequently not
till now, particularly where the apoplectic seizure
has been preceded by much torpor of the liver,
and accumulations of viscid bile in the gall-blad-
der and hepatic ducts, that the purgatives succeed
in bringing away, dark, greenish black, offensive
102
APOPLEXY — Treatment of.
motions, the discharge of which is generally fol-
lowed, in robust subjects, by rapid amendment.
146. When the disease is attended with hemi-
plegia, or when the paralysis appears in the
course of the attack, we may generally presume
that extravasation has taken place. In these
cases very large or repeated depletions will not
much accelerate the removal of the effusion; this
is a work of time. The object rather is to arrest
the haemorrhage by the operation; but even this
will not be so readily accomplished, owing to the
physical condition of the organ. Indeed, if the
depletion be carried beyond a certain extent, in
relation to the peculiarities of the case, the risk
of renewing the haemorrhage will even be in-
creased; for, as we cannot, as already stated,
materially diminish the quantity of blood in the
brain, we only accelerate its circulation by large
depletions, and thereby risk an increase of the
liiiscliief. On this account, therefore, the inten-
tions with which blood-letting is to be employed,
are, 1st, to arrest the haemorrhage, and 2d, to
diminish or keep down the action of the heart and
arteries: but, although essentially requisite in the
majority of cases, full blood-letting will be of it-
self insufficient to accomplish these purposes; and
we have therefore to bring to its aid the applica-
tion of cold to the head, active purgatives, deri-
vatives, and a judicious combination of antimoni-
als and cooling saline medicines, which ought
always to be exhibited at short intervals, and con-
tinued for some time during convalescence; two
or three grains of blue pill being also taken at
bed-time, and an aperient draught the following
morning. Any of the following saline medicines
may be employed when we wish to lower the
action of the heart or arteries of the brain: —
No. 21. R Vini Antimonii Tart. TTj xvj. — Jss. ; Liq.
Amnion. Acet. 5'j3s-') Potass* >.itratis ct. v. — x. ; Aquae
Purse 5x-'> Syrup. Croci 5 s3- M. Fiat Haustus, tertia vel
quarta qu'ique bora sumendus.
No. 22. R Potassa: Sub-carbon. £j/ i ^ucci Limon.
recent. *jss. vol q. s.; Aq. Funiculi 5 iij. ; Vini Antimonii
Tart. gij.~ 5iij. ; Syrup. Tolutan. gij. M. Fiat Mist,
cuius sumantur cochlearia duo larga secundi vel tertia.
quaque ho; a.
No. 23. R Potass* Nitratis gr. x. ; Aq. Cinnamomi
Si.; Liq. Ammon. Acet. gijss.; Spirit. VEtlier. Nit. ", -. :
Syrup. Limonis 5ss. M. Fiat Haustus, tertiis horis capi-
endo.
147. When the measures stated above leave
considerable exhaustion, and particularly if accom-
panied with sopor, weak action of the carotids, a
cool state of the head, and unperspirable surface,
it will generally be necessary to venture upon the
use of very gently restorative and diaphoretic
medicines. These ought, however, to be cau-
tiously commenced with; and, when we have
reason to infer that the attack has proceeded from
extravasation, which is mo.-t frequently the case,
we should carefully watch their effect, or delay
them until after the twelfth or fourteenth day
from the seizure. Inflammatory action in the
surrounding portion of brain, consequent upon
the extravasation, usually supervenes from the
fifth to the fourteenth day. During this time,
therefore, perfect quietude of body, stillness, and
silence, and disengagement of the senses and men-
tal faculties, should be enjoined, and febrifuge
medicines prescribed, in order to suppress local
action, and the consequent fever which often
manifests itself at this period. The patient should
be cither kept in bed, or on a couch, with his
head and shoulders well elevated ; and visiters
ought not to be admitted to him. The eighth
day is generally the most dangerous, as respects
either a renewal of the haemorrhage, in the im-
mediate vicinity or surface of the parietea of the
haemorrhagic cavity, or in a different part of the
brain, or the occurrence of serous effusion between
the membranes or in the ventricles. During the
first days, therefore, of the attack, we should only
venture on the more gentle febrifuge diaphoretics;
and after the seconder third week, somewhat
more restorative means may be employed, if the
state of the vital energies requires them. The
follow dug may be resorted to in the order in which
they are placed:- — ■
No. 2-1. R Potassas Nitratis gr. v. — vij. ; Mist. Cam-
phora>, Aq. Funiculi, fta ^ ivss. ; Liq. Amnion. Acet.
3'j. — 3'ij-i Spirit. JEtber. Nit. 5ss-j Syrup. Limonis 3 ss.
M. Fiat Haustus, quarts quaque bora, suiutndus.
No. 2.3. It Vini Antimonii TT] xii. — xx. ; Mist. Cam-
phors "iij.; Aq. Cinnamomi 5^-s. ; Liq. Ammon. Acet.
oiij. ; Syrup. Aurantii "j. M. Fiat Haustus, quarta. vel
quintl quique bora, capiendus.
No. 26., R Mist. Camphors §j- ; Liq. Ammon. Acet.
tUss. ; Spirit. Ammon. Atom. TTJ xx. — 5=s. ; Syrup.
Tolutan. 5j- M. Fiat Haustus.
No. 27. R Infus. Calumbae (vel. Infus. Valeriana-),
Mist. Camphorae, aa ^v. ; Sodas Sub-carbon, gr. x. ; Spirit.
iEther. Sulphur. Comp. Jj. M. Fiat Haustus, bis lerve in
die sumendus.
Before I proceed further, in noticing the other
remedies which may be resorted to, or have been
recommended, I will state the means which are
most appropriate to the weaker states of the dis-
ease, and when the system- is greatly depressed
by the shock of the local lesion, or before in-
creased action has taken place.
148. b. Treatment of the depressed states of
apoplectic seizures. — It will be apparent from the
particular details I have given of the symptoms,
causes, and pathological states of the disease —
1-st, That much depression or exhaustion of the
vital powers of the brain exists in some
throughout the attack, even rapidly terminating
in death without any effort at vascular reaction,
particularly when this state is mistaken, and
treated by depressing remedies; and, 2d, That
this depression is often analogous to concussion
of the brain, owing to the extent of the local
lesion; and, like this result of external injury, is
frequently followed by reaction of the heart and
arteries (§ 111 — US.), when the lesion constitu-
ting the seizure is not so great as to overwhelm
the powers of life.
149. it is owing, in my opinion, either to the
employment of too large blood-lettings in such
cases, to the having recourse to them at ai! in
others, or to practising them without sufficient
regard to this period of the seizure, and before
the occurrence of reaction, — the time when they
are imperatively called tor, — has supervened,
that the practice has disappointed many who
have adopted it, and led others to emplov an
opposite mode of treatment in an equally exclu-
sive, and hence dangerous, manner. The judi-
cious use of gentle stimuli during this state of de-
pression will have the effeel in s :;e case? ofbring-
ing about a moderate reaction, when death would
be the result of other means; and, by diminish-
ing and shortening the stage of depression in
others, and thereby lessening the congestion of
the capillaries vl' the brain, that inordinate degree
of arterial action consequent; upon the obstruction,
and indirectly produced by*it, will be prevented.
In some more doubtful cases, as when the pallor
of the countenance is connected with a natural, or
APOPLEXY— Treatment of.
103
not very depressed state of the pulse, and temper-
ature 01 the head, and when there are vomiting
and other Bymptoms, indicating thai haemorrhage
and laceration of a portion of the cerebral struc-
ture have occurred, blood-letting may lie advan-
tageously conjoined with cordial remedies, calcu-
lated to restore the tonic contractility of the ves-
sels of the brain.
150. It \\ ill appear from what lias been stated,
that those who deny the efficacy of blood-letting
are in some respects justified by the frequent de-
ficient vital enemy of the brain, and by the in-
jurious effects of the remed\ in some cases,
whil>t they err in a too general recommendation
of opposite means. Both parties, however, place
great dependence upon active purgatives, and I
believe that much of the success obtained by the
abettors of both modes of practice is to be ascrib-
ed to them.
151. In apoplectic cases, therefore, with signs
of deficient vital energy of the brain and consti-
tution,— and, when we refer to our experience,
or consider the nature of many of the exciting
causes, as well as the very far advanced ages of
the great majority of apoplectic patients, the num-
ber of such cases will appear by no means small,
— and at the commencement of some seizures, be-
fore reaction has supervened, when the counte-
nance is pallid or sunk, the pulse of the carotids
weak or small, the temperature of the head not
increased, and profound sopor, rather than very
stertorous or strong breathing, is present, gentle
restoratives, administered either internally or ex-
ternals, are the most serviceable.* The pro-
priety, then, of attending to the fact, that apo-
plexy often is originally dependent upon the state
of the sensorinm — upon the depressed vital energy
of the encephalon, as well as upon extravasation,
or primary or consecutive vascular turgescence,
and increased action — is manifest. And hence
will appear the reason that restorative measures
are required in some cases and not in others, or
at one stage of an attack and not at another ;
physicians being led, by the success obtained
from one method of cure on some occasions, to
* Travelling in the summer, in one of the short stages,
1 s;i( opposite an aged and corpulent man, who, very soon
after our leaving town, suddenly lost his consciousness
and power of motion. His countenance became iii~t
pale, then bloated and inexpressive, his breathing slow
mid slie •■ all Bis muscles completely re-
I ixed, <• i • 1 1 he fell, in a few seconds, upon those ^inim;
around him. We were only a fen doors from a chemist's
■hop; the coach wr;s stopped, and he was carried thither.
iti- v. is now profoundly apoplectic; a copious perspiration
01 which
distended, and all his senses were completely aho-
lished. There was no sign of hemiplegia, — but there was
general and complete loss of motion and sensation. His
neckcloth having been removed, the pulsation of the
carotids was found to be slow, and >>( natural strength an I
fulness. Whilst he was held in a sitting posture in a
chair, i - poured gently over his head from a
frequently iponged h ith ii ; volatile
lort time, and at intervals, to
h\- nostrils. The power of this lime
abolished, «n that ii was impossible I" admini
draught, chiefly consisting of a small quantity of spirituous
ammonia- aromaticus and camphor mixture, which was pre-
I. In a very few minutes his consciousness return-
took the draugl '. and, in a short time afterwards,
he walked to a each, in which 1 accompanied him
He now complained onlv of very slight confusion of ideas,
wiih scarcely any head
lv. One full blood-letting, and an
now din . and has
continued so. What would have been the result if he had
been largely blooded previously to the reaction ?
employ it too generally, and hence in many in-
Btances in which it is inappropriate.
152. The restorative means that maybe resort-
ed to, scarcely admit of particular notice. The
practitioner musl be guided in bis choice of them
by the circumstances of the case. Where there
is sopor, or coma, or lethargy, without much
stertor of breathing, and when hemiplegia or pa-
ralysis is not present, camphor in moderate doses,
either alone, or combined with ammonia or the
spir. eetli. sulph. comp., the spir. lavand. comp.,
and various others, may be adopted. It is only in
such cases, and when the action of the carotids is
weak, the head cool, and the countenance sunk,
that the infusions of arnica or of serpentaria,
which have been recommended by Quarin,
Aaskow, Werner, and Thomann, are ad-
missible. In more doubtful cases, the prepara-
tions of ammonia, the spiritus tetheris nitrici, the
infusion of valerian, may be cautiously exhibited.
In some, particularly at the commencement of the
seizure, volatile substances, such as the prepara-
tions of ammonia, and aromatic vinegar, held to
the nostrils occasionally, will be of much service.
Where the attack is either preceded or accom-
panied by hemiplegia or paralysis, (§ 31 — 43.),
stimulants, whether exhibited internally, or held
to the nostrils, may be more hurtful than bene-
ficial. In these, even the use of cold applications
to the head, excepting there be marked increase
of temperature, is seldom productive of much ad-
vantage. Purgatives are, however, required, but
the choice and repetition of them should entirely
depend upon the state of the secretions, the tor-
por of the bowels, and the character of the stools.
153. c. Remedies which have been recommend-
ed, and are admissible in certain states of either
the sthenic or asthenic forms of attack. — Emetics
are amongst the remedies, the admissibility of
which has been most questioned. The young
practitioner will, ii" he have recourse to written
authority, be quite bewildered by the diversity of
opinions respecting them in this disease. He will
find Sydenham, Pitcairn, Kirkland,Selle,
FoTHERGILL, CoLO.UBIER, CoNKADI and Fa-
ber, iii favour of them; and Hagenborn, Bor-
seri, Quarin, Walther, Culi.en, Tdes-
sink, Richter, Portal, andCHEYNE, oppos-
ed to them. But, when the attack has been
brought on by an overloaded state of stomach, by
intoxication, narcotic poisons, or other hurtful in—
gesta, and more especially when hemiplegia is not
present, or if the attack be of the active kind, and
full depletion lias been performed, emetics may
be both safely and advantageously administered.
This opinion seems agreeable to the recommend-
ati us of Hippocrates, Morgagni, Stoll,
Blane, and the late Professor Gregory.
lg I. The propriety of having recourse to blis-
ters has likewise been questioned. The great
majority, however, of authorities tire favourable
to the practice in some state or other of the dis-
ease, the situation, the period, and form of at-
tack, being the chief points of dispute. Bak-
tholinus, Candler, Cullen, and many oth-
:oinmend them to be applied to the head.
Whilst Tode, Baglivi, Stoll, Portal, and
Pk Q.DE consider them injurious in this situation.
in the active states of the disease, in those forms
which are complicated with hemiplegia, or are
preceded by it, blisters on the head scum hazard-
104
APOPLEXY — Treatment of.
ons remedies, and are, moreover, in the way of
rnore appropriate means ; but in the weakest
forms of the disease, when, from the depressed
state of vital energy of the brain and lowered ac-
tion of the carotids, the sensorinm requires to be
excited, they may he of service. Where, how-
ever, there is any doubt respecting the propriety
of applying them in this situation, it will he better
to omit them, or to direct them to another part.
When stupor or coma exists, and the symptoms
are not of the strong character, they may he ap-
plied to the nape of the neck, between the shoul-
ders, or insides of the thighs or legs, after general
or local blood-letting has been practised.
155. Sinapisms, or stimulating frictions, and
liniments, applied to the lower extremities, are
very generally applicable, particularly after re-
sorting to pediluvia, care being afterwards taken
to preserve a continuance of the increased flux of
blood to these parts, when thus procured, either
by warm applications, or by a frequent renewal
of the above means. Sternutatories have been
considered injurious by Baillou, Morgagni,
Buchner, and others, and I conceive with great
justice. A nearly similar opinion may he given
respecting electricity and galvanism, which have
been recommended to be tried by some authors.
156. The exhibition of mercury, chiefly in the
form of calomel or blue pill, in large doses, so as
to act upon the biliary secretion and bowels, and
subsequently to excite salivation, has been recom-
mended by Doljfus, Schurig, Ghisi, and
Horn. My experience of the practice has led
me to think favourably of it in most of the apo-
plectic states, when the powers of the constitution
are not far reduced, and the patient is not very
old. Antimonial preparations have already been
prescribed, and are of much service in the more
active or strong forms of the disease, whether ac-
companied with hemiplegia, or without it. They
are not so admissible, however, in the very de-
pressed states of vascular action, and in the forms
of attack which commence slowly, or are pre-
ceded by, or attended with, paralysis, indicating
softening andinfiltration of the cerebral substance.
James's powder, and the tartarized antimony,
are the best preparations : the former of which
may be advantageously combined with calomel ;
the latter with saline medicines. (See R. 21, 22,
and F. 854.)
157. Setons, issues, and moxas have also been
advised, particularly when stupor continues after
the more urgent symptoms have been mitigated.
I concur with Lancisi and La Motte in con-
sidering them very deserving of adoption in such
cases. Jloxeis applied on the occiput produce a
more rapid effect, and are therefore preferable
during the period of attack; setons are more suit-
able in the prophylactic and consecutive treatment.
The actual cautery and moxas have been strong-
ly recommended by Albucasis, who directed
them in the course of the coronal suture ; by
Marcellcs Donatus, who prescribed them to
the occiput ; by Schf.lhammer, to the vertex ;
by Schrkiber, to both the vertex and soles of
the feet ; by Mistichelli, to the feet ; and by
Thilenius and Sevf.rinus. These means are
very generally applicable, and may be resorted
to in the worst cases of apoplexy, particularly
those complicated with hemiplegia, and when
brought in aid of appropriate means.
158. In cases characterised by a full, tumid,
Hushed, and livid countenance, full or strong
pulse in the carotids, heat of head, with or with-
out hemiplegia, I prefer, after copious general
depletion, scarifications of the scalp, more or
less deep and extensive, to be made over the oc-
ciput, so as to allow of a free sanguineous dis-
charge. The practice has been recommended by
Hippocrates and Morgagni. Cupping glass-
es may be also applied over the scarifications,
when we desire to procure a more copious dis-
charge. In the low or weak states of the disease,
dry-cupping on the nape of the neck may be
tried, as advised by Aketjeus.
159. After the attack h;is been so far mitigated
that the patient has recovered the faculty of de-
glutition, I have often seen decided advantage
derived from a draught consisting of equal quan-
tities of the oleum terebinthinez and oleum ricini,
particularly when the bowels required to be fully
acted upon. If the attack possess the sthenic
character, and signs of fulness of blood about
the head still continue, about half an ounce of
each may be exhibited on the surface of mint
water ; and, if necessary, repeated a second or
third time, from twelve to twenty-four hours in-
tervening between each dose. This will promote
a more complete revulsion from the head than
any other means that can be employed, particu-
larly when preceded by calomel, or other cathar-
tics, or followed by the enema prescribed above.
(§ 144.). In the weaker states of attack", when
we wish the medicine to act partially, by being
absorbed into the circulation; and in cases where,
from the mode of seizure and progression of the
disease, we suspect haemorrhage or infiltration of
blood in the brain, the following draught may be
exhibited ; I have found it serviceable b SUch
cases, even in some attended with the most un-
favourable symptoms ; as very frequent, small,
and intermitting pulse, and unconscious dis-
charges, &c. : —
No. 28. ]\ Olei Ricini, 01. Terebinth., aa ~ s*. — ~ij. ;
Tinct. i lapsici Anrmi TT) *• — xtj. ; Olei Cajeputi TT) i
Aq. Menth. Virid. ~, j-5. Fiat Haustu«, onine bihorio su-
mendus ad secundum, tertium, vel quarium vicem.
In some instances, where the lethargy has been
profound, and the constitutional powers far de-
pressed, I have deriyed much advantage from
camphor, ammonia, and ather, given in suitable
doses in the intervals, and continued after the
above medicine had been carried as far as was
considered either necessary or prudent.
160. It is generally requisite to have the hair
of the patient cut very close, or shaved off, as
soon after the seizure as possible ; and to attend
to the injunction of 3Iorgag.ni. never to omit
enquiring after the state of the "urinary discharge,
and examining the hypogastrium, lest accumula-
tions of urine take place, which should he im-
mediately removed by the catheter, to prevent
their injurious effects on the disease, and on the
bladder.
161. d. Of the treatment of the consecutive
and complicated states of apoplectic seizures. — A
great majority of such cases requires but very
slight modifications of the measures already stated.
The importance of directing our means so as to
restore suppressed discharges, &c when the at-
tack arises from this cause, has already been point-
ed out. When it proceeds from the extension of
APOPLEXY— The atm km of.
105
inflammatory action to the brain, and its termina-
tion in abscess, effusion, &c, the principles stated
above are still applicable. It' the disease possess
either a govty or a rheumatic character (§92, .93.),
bleeding from the feet, local depletions, sina-
pisms, or oilier rubefacient applications, &.e. to
the lower extremities, or to the joints or parts
antecedently affected by goul or rheumatism,
active purgatives, and the preparations of colchi-
cum combined with sod i, and moderate doses of
camphor, arc the mosl advisable remedies, la
most cases of this description great accumulations
of morbid sordes have formed on the digestive
mucous surfaces, viu\ thick or viscid dark bile in
the gall-bladder and hepatic ducts ; therefore,
after cupping on the nape of the neck, active cal-
omel purges, promoted by enemata, are to be
previously to basing recourse to colchicum,
i ought to be combined with alkalies, — with
ammonia or other restorative medicines, it' the nt-
presents the asthenic character, and with
aperients ; active revulsants being simultaneously
eooplo
ib'2. When the apoplectic slate arises from
erysipelas of the head and face, incisions made
into the scalp of the occiput, so as to allow a free
:upping on the nape of the neck; ac-
tive p ODsisting first of calomel com-
bined with the tartrite of antimony or with James's
. and compound extract of colocynth, fol-
lowed by the draught of turpentine and castor
oil advisi d above (§ 159.); and saline medicines,
with the vinum antimonii ; are the means most
led upon. In cases of this descrip-
tion the most active purgatives are required, and
must be frequently repeated. The croton oil may
i hibijfed, as already advised (§ 141.),
and enemata should be administered from time
to time. These already prescribed (§ 144.),
or F. 141. 131. tire most to be depended upon
in this state of disease. Revulsants, and rnbe-
p'diluvia, are also serviceable aids.
. When the apoplectic attack occurs on the
in, or in the advanced stages of fevers
(§ 94.), the general principles of treatment al-
ready laid down cannot be departed from. When
at the commencement of fever, gen-
r local depletions are required, with cold
d, purgath es', a dine mi dicines,
and counter-irritation. But even here, the pro-
of the circulation within the bead
should be enquired into previously to the adoption
of the means of cure; for, if the head be cool,
iction of the carotids natural or below the
healthy standard, and the attack be unattended
by paralysis, restorative measures are called for,
although the subsequent occurrence of reaction
will afterwards require active antiphlogistic meas-
ures. When the attack- occurs in the last stages
of continued or eruptive fevers, it most frequently
presents the asthenic character, and is often an
ited state, or a modification merely, of
unless hemiplegia accompany it. In these
local depletions from the occiput, the
and behind the ems ; active purgatives :
revulsants and counter-irritants, as blisters or
sinapisms to the lower extremities, nape of the
neck, or epigastrium ; camphor, combined with
ammonia, aether, and liquor ammonia- acetatis,
particularly when the head is cool, and the puls-
ation or the carotids is neither full nor strong ;
and, in the most asthenic cases, camphor in larger
doses, the infusions of arnica, or of scrpeutaria
(F. 222. 262.), are chiefly to be depended upon.
After local depletions and revulsants have been
prescribed, and one or more doses of calomel and
rhubarb premised, the draughts directed above
(R 23. 2i>, 27,2s.), or F. 270. 863., followed by
enemata (F. 138. It>.),ma_\ be exhibited.
L64. The association of apoplectic seizures w it 1 1
disorders of the digestive organs, particularly those
of the liver (§ 97, 98.), requires local depletions
from the right hypochondrium and epigastrium,
followed by blisters in this situation, and a strenu-
ous use of purgatives and mercurial preparations,
until the secretions assume a healthy appearance.
When the attack proceeds from impeded circula-
tion through the lungs and right side of the heart
(§ 93, 9b'.), local depletions, counter-irritation,
and diaphoretics, are chiefly to be depended upon.
But in these cases care must be taken not to de-
plete too much, as the circulation may be still
more impeded by the loss of power thereby pro-
duced. In some instances of this kind, it will
even be necessary to support the vital energies
by suitable means, and to deplete the vascular
system at the same time. When the attack is
occasioned by hypertrophy of the left ventricle,
general and local depletions are better borne
than in the foregoing cases, and may be carried
to a considerable extent. In both descriptions of
cases, revulsants and counter-irritants, particular-
ly by issues, and the tartar emetic ointment, are
beneficial.
165. When the attack is occasioned by nar-
cotics or spirits taken in immoderate quantities,
the stomach should be emptied by the stomach-
pump, or by an emetic, a moderate blood-letting
having been premised ; and afterwards, the cold
affusion to the bead ; internal stimuli, as cam-
phor, ammonia, and ether; warm, >trong coffee;
and purgative enemata, should be prescribed. The
occurrence of the seizure, also, during child-la-
bour, or after epileptic or hysteric convulsions,
requires large blood-lettings, preferably from the
feet, the cold affusion to the head, cathartic in-
jections, icc.';:
166. Attacks consequent upon colica-piclonum
(§ 99.), two instances of which have occurred to
me, generally require local depletion, full doses
of calomel, followed by active purgatives and
enemata (§ 142.). The draught of castor oil and
turpentine (§ 144.), or the croton oil, followed
by injections, are here chiefly to be confided in.
If purgatives given by the mouth are thrown off
the stomach,- — a circumstance which not infre-
quently occurs in these cases, — a large dose of
calomel will generally be retained ; and will al-
* r w.i- lately called to a case of puerperal convulsions which
had terminated in die apoplectic state. When I saw the
patient, the lalioiu had not proceeded so far as to admit of
delivery by means of instruments. Tin- pulse was -low and
lull ; the breathing slow, laborious, and stertorous: tin- lips
ith tl countenance turned and livid ; all the
limit- flaccid, insensible, and incapable of motion. .Sin- had
been blooded largely before I was called. The feel am!
directed to be placed in a pan "i bol water, and
hens veins in Ik- opened. Whilst il><' blood Sowed,
the cold aflusia i the head was employed. These means
were evident!) beneficial, though insufficient. A.
i . 149.) was ilir iwn up immediately, and with great
diffic Itv : consciousness slowly returned; when the decoc-
tion of the secalc cornutum, with as much boras soda; as it
could dissolve, was administered. Uterine action afterwards
came on, and the patient recovered.
106
APOPLEXY — Treatment of.
lay the irritability of the stomach : other medi-
cines may he afterwards exhibited, or a mixture
of croton and castor oils rubbed over the abdo-
men, and cathartic injections thrown up. The
other states and complications of the disease must
be treated according to the views and principles
already explained, and with due reference to the
nature of the pre-existing disorder, when it ap-
pears to be a consecutive affection, or a principal
part of a complicated state of disease.
167. C. Treatment subsequently to the
ATTACK, OR THE CONSECUTIVE TREATMENT.
The svmptoins consecutive of apoplexy have a
strict relation to the changes which take place in
the seat of lesion. The absorption of the blood,
and the process of cicatrization, require several
niontlis for their completion, i hiring this time
great care should be observed to prevent inflam-
matory action from taking place around the extra-
vasated blood, and a return of the haemorrhage.
This object is best obtained by adopting very
nearly the same measures as have been recom-
mended to prevent the accession of the attack
(§ 126. et see].). A too sedentary or studious
mode of life, watchfulness, much indulgence of
sleep, frequent stooping, and all the remote causes
of the disease, must be carefully shunned. The
strictest temperance and moderation, in respect
both of eating and drinking ; moderate exercise
in the open air ; tranquillity of mind, sedulously
avoiding the least approach to bodily or mental
fatigue, and excitement of the feelings or passions;
the preservation of a free state of the alvine se-
cretions and excretions, by means of mild and
deobstruent purgatives and cathartic enemata;
general or topical blood-letting, particularly every
spring and autumn, with low living or a vege-
table diet, when there is a tendency to vascular
plethora; caustic issues, or setons in the nape
of the neck, or in the course of the cervical
spine; the use of the tartar emetic ointment, so as
to keep out for a considerable time a pustular erup-
tion on the part to which it is applied ; sleeping
on a hair mattress, with the head and shoulders
slightly elevated, and early rising ; are amongst
the most efficacious means that can be adopted.
168. For persons who are prone to plethora,
in addition to periodical depletions and low diet,
the following pills and electuary may be taken on
alternate nights : —
No. 29. R Pilul. Hydrarg. Submur. Comp. gr. iij. ;
Pulv. Jacobi Veri gr. ij."; Saponis Castil. gr. iv. M. Fianl
Pilula: ij. h. s. s.
Ko. 30. R Potassae Supertart. "j. ; Soils; SuB-boratis
gr. n. (ill Magnesia ; <j ) ; Cohfectionis Senna;, Syrup.
Zingiberis, aa3j. M. Fiat Electuariiim, pro dose, hora
sonmi, alternis noi tibus sumendum.
] (if). When the disease is connected with the
gouty diathesis, vegetable diet, the sub-carbonates
of the fixed alkalies, with the extract of taraxa-
cum or the preparations of aloes, the occasional
use of an active cathartic, and the other prophy-
lactic measures recommended in the article on
Goi r, are requisite. In all cases, as much ben-
efit will now accrue from a strict attention to reg-
imen and diet, as from medicine. The food should
be light and digestible, of very moderate quan-
tity, chiefly farinaceous, and taken at regular
hours. Suppers should be avoided, or be ex-
tremely light, and taken a considerable time be-
fore the usual hour of repose. Fish, and ripe
fruits, may be partaken of in moderation; and the
wraters of Cheltenham occasionally tried, or the
following used as a substitute: —
No. 31. R Magnes. Sulph. ";ss. ; Potassae Sulph. oij.;
Infus. Rosar. Co. et Mist. Camphors aagiijss. BL Capiat
C'uili. iij. ampla priruo mane quotidie.
170. After attacks of the more asthenic states
of apoplexy, a more tonic regimen than that di-
rected above may be adopted ; but it should be
conjoined with the same attention to the digestive,
secreting, and excreting functions. Attacks of
this description most commonly proceed from de-
pressing or exhausting causes, which ought either
to be avoided or counteracted ; and when they
are not characterised by plethora, or disposition
to increased action, gentle tonics, combined with
aperients, a light strengthening diet, the occa-
sional use of the preparations of strychnine, or
iodine, as recommended in the article on Palsy,
and the mineral waters of Bath, Leamington, or
Buxton. The following may also be occasionally
taken: —
Ko. 32. R Potass* Sulphatis ^ij. — 5''j-i Infus. Rosar.
Co. gvijss; Acidi Sulphur. Arom. "j .; Tinct. Aurantii
i o. is. M. Capiat Coch. iij. ampla primo mane.
171. In all cases of the consecutive treatment,
the progress of the paralytic or hemiplegic affec-
tion towards removal should receive attention.
In the more favourable cases, as the period of
attack recedes, first sensation, and afterwards
motion, return in the paralysed limbs ; and gen-
erally the lower extremity experiences the amend-
ment before the upper. As recovery proceeds,
the patient should alwaj s wear his hair cut short,
and sponge his head with spiing water night and
morning. In summer he may use the shower
bath daily, if he be not far advanced in life, or
much debilitated. As much of the treatment de-
scribed in the article Palsy, as may suit the cir-
cumstances of the case may also be adopted, for
the removal of this common sequela of the attack.
(See also Asphyxy, and Poisons.)
BlBLIOCRAPHV. — Hippocrates, TfOl 18(7(01 . ]iti. iii. p.
488. et Aphor., sect. vi. 57. — Arettzus, De Sign, et Caus.
Diut. Morb., I. i. c. 7. ; Curat. Acnt., I. i. c 4 — Cr<
Locis Affect I. iii. c. 10. 14. — J£tius: Telrab. ii. Serm. ii.
c. 27. — Calius Aurelianus, Aeut. Morb., 1. iii. c. 5 — Ori-
Synop.,1. viii. c. 6. — Forestu*. Opera, I. x. obs. 69.
et scq. — Avicenna, Canon I. iii. Ir. 5. — Schenck, De Apo-
plexia. Jen. 1582. — Wcpfer, Anat. de Apoplexia. p. 437.
— Boner, Sepulchretum Anat., 1. i. sect. ii. olis. 37. 57
Sydenham, Opera p. 577. — Bag/hi, Prax. Med., it. 9 —
Roljinck, De Apoplexia. Jen. 1630.. — Lancisi, De Subit.
Moit., ]). 120 —Seiz, Apop. Fern, et Mort. Erudit. Morh.
Alt. 1714. — ]\Iorgagni, De Sed. et Caus. Morb., episl. ii.
iii. v. xi. xxvi. )x. Ixii, lxiii, et lxvii — Hoffmann, De
Apoplexia. Hals. 17 j: : et Opera, sop. ii. p. 2 — Juncker.,
De Apoplexia ex Podagra Retrograda, &c. Ciit-- 1733.
— Musgrave, De Arth: itide Anomala, c. 15. — Borsert,
De Apoplexia, p. 82 — Sauvages, Nosologia Method., t. i.
p. 848. — Mistkhetli, Trattato dell' Koma;.
nS0.-Ba.i-. in Act Reg. Soc. Med. llavn.,vol i. p. 118.
251. — Wekkard, Vermischte Schriften, v. i. et ii p. 21.
etteq. — Fothergill, in Med. Obsenr. and Inquiries, vol. vi.
ami U oiks., m.I. iii. p. 211. —Selle, Med. Clin . p 40 —
. Spermatologia, p. 261. et seq. — Watiher, De
lione Occipitis, plur. Cap. Morbor. Auxilio.
Lips. 1741.—^ Pitcai n, Elem. Med., I. ii c 2 —
Outlines, fee., vol. iii. p. 182.— J. Hunter, On the Blood.
.'.;■ 4tp. nl. i'. -13 — Boerhaave, De Morb. Nervorum,
p. 640. — Dtemerbrbek, Di Morb. Capitis, N. 12. — £>«_
limn. De Apoplexia. Leid. 1745. : et Rat. Med. p. iv. c. 5."
, Ratio Medendi, p. iii 133. : el Prelect., p. 367.
— Mangold, Apoplexia phi
Sc . -.i.M, kc. Eil'. 1765 — Marquet. Traits de 1' A;
Paris, 1770. — Niemann, Do Apoplexia1 Path, et Therap.
Hala>, L772.— 1 i ..'Ann. Med., 1 iii Ob. l".
263, fee — Thilenius, Med. und Chir. Bemerkungen, p.
76. — Quarin, Aniinadwi-i. r*. cap 1. — .'
vazioni v. weigel's Ital. Bibl/ iv. b. i p. U9.—
Von den Artrn und ursachen der Schlagfliissc. Landsh.
1787. — IngelihouSz, De Apop. ejusque Spec. Var. Leid.
AlTLTiTE, MORBID.
107
-Kirk-land, On Apoplectic and Paralytic Affections.
l.,„„l. i Ba», On the Apoplexy. Phil. 1793.—
■ I ,„ -a in Apop. Iffectis. ll J. 1795. , el Memorab.
Olin., ik. iv. ii. 1. — Ploxtcquet, De Vi Vitali in Apoplexia.
Tub. 1796. — Portal, Anatomie Me'dicale, t. iv.p. 99.; e(
■,., plexie. Bvo. Paris, 181X.— fleeter, Brownii
Benlen. 5e Apop. Examen. Erf. 1800. — Crowfoot, Observ.
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Lond. 1801. — Boucht -,.1.111111. de MSdecine, t. xlviii. p. 76.
; il. N. p. 102. — JTodleVd; De Apoplexia.
Aven. 1808. — Montain, Traite de 1'Apoplexie. Paris,
j and Lethargy! Lond. 1 "12.
— Riub ■-, Sur I'Ajtoplexic, el Epanchemenl de Sang dans
le i lei i Kris, 1814. — ( 'heyne, in Dublin I [osp.
Rep., vol. up. 315." — Powel, On the Pathology of the Brain,
Med. Ti ins. i i I ond. Col. of Phys., vol. v. p.' 198. 1815. —
. Trait<5 le 1'Apoplexie, &c. Paris, 1819. — Cooke,
On Nervous Diseases, vol. i. Lond. 1820. — Duncan, in
Edin. Med. and Surg. Journ., vol. \\ii. 1821. — ('
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(. xviii. p. 20. — Stores, Nouvelle Division des Apoplexies,
Annuaire Med. Chirurg. des H6p. Paris, 1819.; el An.ii.
pomp, du Cerveau, t. ii. Paris, 1826. — Bricheteau, Sur
ii. Complement. du Diet, des Sciences Med.
I. i. p. 129. I., i ■. iv. p. 17. Paris, 1310. —J. Fran!.;
Inlrrp. Clin., vol. i. p. 139.; et Praxos Med. Universae
ii. vol. i. sect. i. p. 330. et seq. — Krilof,
Journ. d< Proi I'-. .Vr., t. \ii. p. 243. — Johnson's Med-
ico-Chirurg. Review, vol. i. p. 1. ; Edin. Med. Chirurg.
Journ., vol. xxvii. p. 83. — Good, Stud} of Med., edit, by
. vol. iv. p. tC5. — Prichard, On Diseases of llie
System. Lond. 18221, — Lallemand, Recherches
Anal. Path, sur I'Enceph. et ses Depend. Paris, 1820 —
.. art. dpoplexie, Diet, de Med., (. ii. —
in Med. Chirurg. Trans, of Edin., vol. i. — Mills,
rb. Appear, in Disord, of the Brain. Dub. 1826. —
m.delaSoc. Med. de l'Emulat., t. ix p. 147.
Pari-, 1826. — .Hooper, On the Morbid Anatomy of the
!, i 1. i 126. — ibercromhie, Researches on Dis-
Ihc Brain, &c. Edin. 1828. p. 201. — Crwveilhier,
an. Apopltxie, Diet, de Med. el Chirurg. Pratiq., t. iii.
Paris,! t, Medical Reports, vol. ii. p. 266. et
. Encyclopidisches Wb'rterb.
derMcd. Wissen., b. iii. p. 94.
I.AFOPLEXYof New-born Infants — Ge-
nerally proceeds from a protracted or difficult par-
turition, particularly when llie infant is large and
plethoric, or when the cord has passed around
the ne ning both interrupted circulation
in the cord, ami obstructed return of blood from
the brain. The apoplectic state in new-born
infants is accompanied with tumefaction of the
nd neck, which, with the whole sur-
fiice of the body, is generally of a bluish or violet
colour. The muscles are flaccid, the limbs flexi-
•1 the body warm. The pulsations of the
and of the cord are generally obscure, or
not to be felt; respiration is suppressed; and death
soon takes place, in exb , if judicious
ton be not resorted to.
2. Upon examination offal lI cases, the vesse'.s
of the eneephalon are engorged with blood; and
tonally blood sated in the sub-
of the brain, or between the membranes.
The lungs are also generally congested. It is
evident that the pressure of the turgescent ves-
sels and extravasated blood upon the brain, and
origin of the respiratory nerves prevents the res-
. actions from taking place, and that all
attempts to excite respiration will be inel
until the pressure is removed. The umbilical
cord >liould therefore be immediately divided,
gild allowed to bleed to the extent of two or
ful, according to the size and strength
When the apoplectic state is oc-
casioned by congestion of the vessels merely,
ce as soon as the vessels
are unloaded, if no mechanical obstacles to the
entrance of air into the lungs exist. Mucosities
should be carefully removed from the throat,
mouth, and nostrils; and, if the respiration does
not spontaneously take place, insufflation of the
lungs, as recommended in the article on V.SPH1 X.Y
of New-born Infanta should be performed.
3. When the circulation is so torpid thai the
blood will not flow from the portion of umbilical
cord attached to the infant, the little patient
should be placed in a warm bath, rendered more
stimulating by some salt, or by a little mustard;
the portion of cord attached to the abdomen, or
the abdomen itself, may be pressed momentarily,
at several times, and in the direction of the divi-
sion. If these means fail of procuring blood, one
leech may be placed behind each ear. In some
cases the apoplectic symptoms return after respi-
ration has been established. This is generally
owing to some interruption to the circulation
through the lungs. In these cases of secondary
attack, the application of one, or generally two
leeches, placing the body or the lower part of it
i.i a warm bath, and, if requisite, inflation of the
lungs, and the other measures advised in the ar-
ticle on Asphyxy, must, be resorted to; and they
will be successful if the case admit of recovery.
Bibliography. — Qardien, Traits d'Acc'ouchemens et
Maladies des Femmes et des Enfans, I. iii. p. 130. — Desor-
meaux, Diet, de M decine, t. xv. p. 153.
APPETITE, MORBID.
Classic. 5. Class, Local Diseases; 2. Order,
Depraved Appetites (('alien). 1. Class,
Diseases of the Digestive Functions; 1.
Order, Affecting the Alimentary Canal
(Good). II. Class, I. Order (Author).
1. Defin. — Excessive craving for food, or
desire for improper substances.
2. In this genus may be included two species,
viz. 1st, Excessive or insatiable craving for food;
and, 2d, A desire for improper substances, or what
is not food. These states of function occur in
practice variously associated and. although ap-
parently different in themseWes, yet they are often
individually connected with similar states of the
constitutional energies, and .dependent upon near-
ly the same state of lesion, whether functional or
organic. It would seem that manifestations of
function often differ most essentially, in different
persons, or under different circumstgaees, owing
to causes which are so slightly dissimilar as not
to admit of distinction, or even, in some cases, to
appear very nearly the same. In all, or the great
be! mging to these forms of
morbid function, the general pathological states of
the system are near!] the die difference,
is most marked, b< ing ehioily refer-
rible to variations in grade, and to states of the
stomach, in respect of its sensibility, its secretions,
tonic co , and states of its villous mem-
ivhich can only be matters of inference,
i ! en of demonstration. As regards their
1 ese affections are much more frequently
symptomatic of lesion of function or structure in
some other organ, than idiopathic, or constituting
primary disease of the stomach itself.
ic. I. Insatiable Appetite. — Stn.
Bulimia (from poii, the augmentative par-
ticle, and Aiko-, hunger), Fames Canina,
Limosis avens, Good. Bulimus, Polyphagia,
Lycorexia, Cynorexia, Aid. Lat. Faim Ca-
nine, Pr. Der,l£eissliunger,GeT. Dyspepsia
Bulimia, Young. Glttttqny, Canine Appetite.
4. Dkkin. A craving for food beyond the
natural wants of the system, S07netimes most ex-
cessive in degree.
103
APPETITE, MORBID — Causes of.
5. I. Varieties. An inordinate appetite is
sometimes observed in the course of fevers and
other acute diseases, particularly in convalescence
from them; and in the progress of a number of
chronic diseases. It is not infrequent in cases of
extreme e thaustion, from whatever cause; and it
may depend upon an acquired habit. But in or-
der to consider it with some degree of precision,
I will offer, some remarks, !st, upon habitual in-
dulgence in an excessive quantity of food, or glut-
tony; 2d, an insatiable appetite from exhaustion;
3d, on the excessive appetite, which, from the
extreme voracity of the patient, has been called
canine; and, 4th, on the voracity which is fol-
lowed by vomiting. These constitute varieties
of nearly the same disease.
6. A. Habitually excessive appetite, the Buli-
mia Hetticonum of Cullen. — In some cases, the
excessive indulgence of food has been of so long
duration, and seemingly attended with so good a
state of the genend health, as not to appear in
the light of a disease; but the results ultimately
are, the production of so great vascular plethora,
and disorder of the secreting functions, that, as
soon as the vital energies begin to languish, apo-
plectic, paralytic, or other maladies supervene.
This variety of morbid function may be heredita-
ry, but it is oftener acquired. It is not infrequent-
irved in persons, originally of a strong con-
stitution, who have indulged in large and frequent
meals from having little else to engage their
minds, and thus the vital energy has become con-
centrated towards the stomach and the rest of the
digestive organs, exalting all their functions. Per-
sons of this description usually become large,
bulky, or corpulent; and if they take much ex-
ercise, the great indulgence of then- appetite may
not materially shorten their lives: but when se-
dentary habits and indolence are conjoined with
it, apoplexy and organic disease of the liver,
stomach, bowels, &c. are the common results.
7. B. Inordinate appetite from exhaustion. —
This is often a symptom of other diseases, and is
chiefly dependent upon altered sensibility of the
nerves of the stomach, proceeding from weaken-
ed vital power. In many cases, however, it ap-
pears as the chief ailment, as after great fatigue
of body and mind; after excessive venereal indul-
gences; in cases of great emaciation, sometimes
:' aie; ".id, -ill cause; and during convales-
cence from fevers and other acute diseases. It is
very often obsei ved as an attendant upon organic
diseases of the stomach, pylorus, mesenteric
glands, liver, uterus, &c. It has also been re-
marked in cases where due nourishment could
not be conveyed into the system, owing to dis-
ease of the absorbent system; and it is frequent
in the last stages of chronic maladies, when about
to terminate fatally. In many of such cases the
era's ing for food is attended with a distressing feel-
ing of inanition, sinking, and faintness. Some of
the cases of excessive appetite that occur in preg-
nancy, or from the presence of worms, may also
be referred to the debility and altered sensibility
of the nerves of the stomach. And those which
accompany inanition from a defective supply of
chyle to the blood, may be attributed partly to
the same cause, and partly to the instinctive wants
of the system.
S. C. Voracious or canine appetite, the Buli-
mia Syncojwlis of Cullen. — Tins extreme form
of the disease is generally dependent upon some
organic change of the stomach: but this is more
a matter of inference than of observation. The
chief seat of disease may even be some other
organ. The quantities of food, particularly ani-
mal food, cooked or raw, taken by some persons
afflicted by this disease, are truly surprising.*
One of the most remarkable cases in record is
that published by M. Percy (Diet, ties Sciences
Med., art. Cas Rares). Both Cullen and
Good are incorrect in stating that this form of
Bulimia is attended with faintness. This is ordv
an occasional symptom, which was absent in both
the cases that occurred to me, as well as in that
recorded by Dr. Crane. (Lond. Med. Repos.,
vol. xvii. p. 293.)
9. D. Voracious appetite follotced by vomiting- ,
the Bulimia Emetica of Cullen. — This variety
of bulimia frequently proceeds from inflammatory
irritation about the pylorus, but more commonly
of the mucous surface of the stomach itself. The
quantity of food devoured in this description of
c;ises is often as large as in the last variety; but,
shortly after having been taken, it is either alto-
gether, or in part, thrown up, very little altered,
and thus the patient continues alternately to crave
for and to reject his food. This form of the dis-
ease has generally been imputed to a scirrhous
state of tile pylorus; but the case of Dr. Crane,
already alluded to, was evidently independent of
such a cause.
10. II. Causes. — a. The remote causes of
bulimia are chiefly hereditary predisposition: the
habit of eating largely, voraciously, and without
due mastication; chronic debility arising from
obstruction of the mesenteric glands,
the suppression or disappearance of chronic erup-
tions, the healing of old ulcers, or the suddenly
arresting habitual discharges, and the pathological
conditions noticed in the foregoing remarks.
11. b. The immediate cause, or state of the or-'
•ran on which it depends, seems to be somewhat
different in the different \ i
state of the constitutional or vital power t,
considered to be, in the great majority of cases,
verv nearly the same. I believe that in many
instances the voracious appetite is owing to an
irregular distribution ol' the vital energy, and its
concentration in the stomach, the nerves of this
* I have met with two very remarkable instances of this
affection In children, — the one of seven \,
other of nine. In both these, hut in the younger especially,
ili,, quantity of i t was astonishing.
could be laid hold of, even in its raw stale, was
seized n[ most greedily. Besides oilier articles, an un-
cooked rabbit, half a pound of candles, ami some butter,
:> al "lie time. The mother stated, that this little
girl, who was apparently in good health otfierwi- .
! if she could possibly obtain it, than the i
her family, consisting of six besides herself. In both this
ind i i othei ise, the digestion seemed to be good. Three
or four large feculent motions were passed daily, and a
n r eous smell emanated from their bodies. These children,
who were both verv intelligent, complained of no other un-
easiness than a constant gnawing or craving at the pit of the
stomach, which was never altogether allayed, but which,
tier a me,. 1, impelled them irresistibly
everything that'eame in their way, in the shape of food,
howevei disgu ting. Nearlytwenty years ago I saw, for a
short time, a case of (hi- description, which occurred in a
chil I of about the - ime age, and occasioned alarm, owing to
the circumstance of a large quantity ofraw'nsh having been
devoured by it. Tin- result jn this case did not come to my
; , , I, dee, but the former casqg which occurred at the In-
firmary for Children, recovered In means of the treatment
which will presently he noticed.
APPETITE, MORBID— Trutmkkt of.
109
viscus being morbidly sensible, the muscular coats
more irritable, particularly in the fourth variety
of the disease; and the mucous coat in a state
of erythism, or vascular excitement, and yielding
a much larger quantity of its proper fluids than
in health. The excited state of the nerves of
the organ, will necessarily be followed by in-
crease of iis secretions, greater vascularity of its
inner coat, and a disposition of the muscular tunics
to react upon the enormous quantity of food v\ hich
distends them; and thus there will result the
craving of extreme hunger, a rapid solution of
the food, and a qijick transfer of it into the duo-
denum; or, if the reaction tikes place suddenly,
either vomiting or simple regurgitation of it, as in
cases of rumination, which is sometimes compli-
cated with bulimia. The more remote effects of
this state of the organ are, torpor, debility, and a
sense of faintness arising from the concentration
of th ■ vital energy, and determination of the
circulation and secreting function towards the
stomach and associ ited viscera, and the propor-
tionate abstraction of vital influence from the brain
and heart; imperfect assimilation; irritation of the
digestive mucous surface, from unwholesome and
unchanged food; an impure state of the blood,
disorder of the secreting organs and morbid secre-
tions,— all tending to disorganization, and to the
destruction of life.
12. c. The morbid appearances found on dissec-
tion consists chiefly of inordinate distension of the
stomach and duodenum; a vascular and corru-
gated state of their mucous surface, constituting
complete hypertrophy of these viscera; a flabby,
softened, and sometimes thickened appearance of
all these tunics (Hagstroem); displacement of
the right extremity or the greater part of the
stomach low in the abdomen (French); indur-
ation and thickening of its coats (Goudret);
the insertion of the common bile-duct into its
pyloric extremity ( Vks alius and Bonet); dilat-
ation of the oesophagus (Schurig); taenia in the
bowels; lumbrici in the stomach and duodenum;
enlargement and other organic lesions of the
liver; scirrhus, thickening, and even dilatation
(Roysch), »f the pylorus; thickening of all the
coats of the duodenum, forming hypertrophy of
this part; and various organic changes in the
'tv, its glands, the pancreas, spleen, and
lly in the mucous surface of the small
and large intestines. M. Beclard observed, in a
case of bulimia, the valvulae conniventes as large
as in carnivorous animals. And M. Landbjs-
Beauvais found, in a case complicated with pul-
monary consumption, an unusually large size of
the small intestines, and the gall-bladder wanting.
13. d. Symptomatic bulimia. — Inordinate appe-
tite has sometimes been observed in cases of
chronic disease of the brain, particularly in slow
inflammation of its substance, threatening, or ter-
minating in, insanity. A very marked case of
this description, and two or three slighter in-
-. have come before me in the course of
practice. I have also met with it at the com-
mencement of hydrocephalus, and in epilepsy.
When thus dependent upon disease of the brain,
the inordinate indulgence of the appetite is often
followed by vomiting. In the case of epilepsy,
however, in which I met with it, vomiting never
took place, although the quantity of food some-
times taken was most excessive. The first, or
10
slighter variety of the malady, is not uncommon
in epilepsy, particularly in the hereditary epi-
lepsy of adults; the second variety sometimes
occurs in hysteria, chlorosis, and pulmonary con-
sumption; and the fourth, occasionally, in chronic
encephalitis.
14. Bulimia is more frequently met with, par-
ticularly in its slighter forms, in pregnancy and in
verminous affections, and is then very generally
attended with an urgent feeling t)f inanition and
faintness. When it occurs in pregnancy, there is
usually a fanciful longing for particular articles
of food, of which an enormous quantity is de-
voured. A remarkable excitement of the nerves
of the stomach may be inferred to exist in these
cases, greatly augmenting the secretion of. gastric
juice. When the affection proceeds from worms,
it may be imputed to the irritation of the nerves
and mucous surface of the stomach and duode-
num, whereby the circulation of, and secretions
poured into, these viscera, are much increased,
whilst the vital actions of the rest of the frame
languish more or less.
15. HI. Treatment. — The means of cure
should have strict reference to the immediate cause
to which we attribute the disorder. A. In the first
variety of tile disorder, it is generally in vain to
state any means of cure. They entirely rest with
the patient, by whom medical advice will seldom
be followed. I have great doubt of a single
glutton having been deterred from the habit he
has acquired, by the injunctions of his medical
adviser, until an attack of illness occasioned him
alarm. The cure is sutriciently simple, and may
be comprised in the single recommendation of
employing his mind aaid body more, that he may
abuse his stomach less.
16. B. In the second variety, great attention is re-
quired to adapt the treatment to the circumstances
in which it presents itself. The nature of the
malady of which it is most commonly a symptom,
must necessarily be our guide; and as the means
should be strictly appropriated to the peculiarities
of the case, no general rules can be stated with
propriety, further than that the effects of whatever
is employed should be carefully watched, and that
more mischief will result from indulging the crav-
ing complained of, than from opposing it, and
allowing no more nourishment than the nature of
the case, or the system, may seem to require. In
the bulimia that occurs in convalescence from
acute diseases, the wantsof the economyare gene-
rally greater than in other cases, and here more
may be allowed: if fever or disorder follow the
indulgence, a purgative will generally remove it.
17. C. The preceding observations apply likewise
to the third and fourth varieties of this disease.
The cases which occurred in my practice were
cured by an active course of nauseating purga-
tives, consisting chiefly of the oil of turpentine
with castor oil. In one of the cases, where the
voracity was almost incredible, the first dose of
the turpentine was followed by the sudden ap-
pearance, over the whole trunk of the body, of a
most copious and thick eruption, more nearly re-
sembling porrigo favosa than any other, and by
the equally sudden relief of the symptoms. This
treatment was left off; when, after a few days,
the eruption disappeared, and the voracious ap-
petite returned. It was ultimately removed per-
manently by the hydrarg. cum creta, combined
110
APPETITE, VITIATED — Causes of.
with soda, taken at bed-time, and a turpentine
draught in the morning of each third or fourth
day. Leeches were applied over the epigastric
region; and either the tartar emetic ointment, or
liniment, was rubbed upon the same situation till
a copious eruption of pimples was produced. The
strictest regulation of the diet was enjoined.
18. D. In the variety attended with partial or
general regurgitation, or vomiting of the food
taken in excessive quantity, the best effects will
result from obliging the patient to abstain almost
altogether from food, or to take a small portion
of nourishment in the least possible bulk. Great
distress from hunger will be felt for a few days,
but this will gradually subside. In the instructive
ease published by Dr. Crane, this plan was per-
sisted in; and portable soup, made into pills, was
given, as the only nourishment, for several weeks:
the patient recovered perfectly. A nearly similar
treatment had been previously employed by Mr.
Wastell with success. (Mem. of Med. Soc. of
Lond., vol. iii. No. 2.) Where, however, the
stomach is not so irritable as to throw off* any
portion of the ingesta, and has become distended
and enlarged from habitual ingurgitation, a gradu-
al diminution of the food will be better borne,
and perhaps be more efficacious, than its sudden
reduction. The propriety of employing deob-
struents, small doses of the blue pill, combined
with ipecacuanha, active cathartics, either by the
mouth or in the form of enema, and external irri-
tants and revulsants, in cases of this description,
cannot be questioned. Exercise, where it can be
taken; and employment for both body and mind,
as fur as circumstances will permit; are also most
useful adjuncts.
Bibliography. — N. Jossius, De Voluptate, Dolore,
Fame, kc. Rom. 1520 Van tier Meer, Diss, de Fame
Caaina. Lugd. Bat. 1660. — Vesa/ius, Anatom., J. v. c. 3.
8. — Bouet, Sepulchretum Anat., 1. iii. sec. it. obs. 1. et S.
— Schuri?, Chylolozia, p. 2— 17. — De Reus, De Bulimo
et Appetila Canino." Leid. 1673. — Mortimer, in Philos.
Trans., No. 176. — Rivinus, De Fame Canino, et Bulimo.
Lips. 1716.— Surnames, Nosol. Melh. t. ii. p. 215.— French,
Memoirs of Med. Society of Lond., vol. i. — Hagstroem,
Kuhn Uepertorium, b. iv. p. 630. — Cullen, Synopsis, ci. —
A. F. Wulther, De Obesis et Voracious, ice. in Delect.
Opuscul. Med. Col. a J.P.Frank, p. 236. Lips. 1791.— J. M.
Good, Study of Medicine, vol. i. p. 112. — Landrc-Beauvais,
art. Boulimie, Diet, des Sciences Med., torn. iii.
Spec. II. Vitiated or Depraved Appe-
tite.— Syn. Pica, Citta, Malacia, Pseado-
rexia, Limoxis Pica, Good. Dyspepsia Pica,
Young. Der Sonderbare Appetit, Ger.
1. Df.fin. An appetite for substances which
are not food.
2. Causes. — This state of the appetite some-
times occurs in children, from an early acquired
habit; and it is frequently observed in idiots,
from want of ability to discriminate what is or is
not food, or from perversion of taste. Various
substances also, which are abhorred in one cli-
mate, constitute the chief articles of diet in another.
Thus, the Californians live on snakes, rats, lizards,
&c, and numerous tribes of Africans on monkeys,
dogs, snakes, &c. It is very frequently observed
in pregnant, hysterical, and chlorotic females,
and it is sometimes connected with certain kinds
of mental emotion. I have met with several
instances of it in females at the age of commenc-
ing puberty, when neither hysteria, in any of its
forms, nor chlorosis, existed. In these, and per-
haps in the great majority of cases, it is altogether
a symptomatic affection, arising from altered sen-
sibility of the nerves, and modified state of the se-
cretions of the stomach, occasioned by imperfect
function, or changed condition, of a related organ,
particularly of the uterus, ovaries, large bowels,
and brain.
3. When it is observed as the primary disorder,
it has generally been owing to a habit, commenced
at first with the view of improving the shape and
complexion. Females early in life sometimes
have recourse to acids, particularly vinegar, and
chalk, for this purpose. The form of thedisease,
which has been described by Dr. John Hunter
as dirt-eating, by the negroes in the West Indies,
and which has even assumed an epidemic charac-
ter, is, perhaps, more than other forms of it, de-
serving of being considered as idiopathic. The
earth they devour chiefly consists of a loam or
clay, and may possibly be taken by them from
the circumstance of their having found it assuage
the painful sensations produced in the stomach by-
acidity. This affection is much more frequently
met with in the female than in the male sex; but
instances of its occurrence in the latter are not
rare. I have seen several instances of it in males;
and in females it is often practised in so concealed
a way, as not to come to the knowledge of the
medical attendant.
4. The substances which occasionally become
the objects of desire are sufficiently numerous.
Medical records abound with them. Cinders,
spiders, lice, flies, insects, Wads, serpents, wood,
hair, paper, earth, clay, chalk, vinegar and other
acids, and even ordure, have all been devoured
in cases of this disease. Various other substances
have been swallowed, more as singular exploits
than from actual longing for them. Thus we have
accounts of persons taking into their stomachs
clasp-knives, musket bullets, billiard balls, gold
watches, and Louis-d'ors; and, what is still more
singular, generally discharging them bv stool a
few days afterwards. Knife-eating seems to have
been no uncommon feat, as we have instances
recorded of London, Prussian, Bohemian, Xorth
American, and Brazilian knife-eaters. Our friends
of the United States seem to have surpassed all
others in the rapacity which their knife-eater
exhibited; for in June, 1822 (New York Jled.
Repos., Oct. 1822), after having been dulv ini-
tiated in the art, by swallowing a gold watch, chain
and seals, billiard balls, and various other arti-
cles, at different times, which had passed through
his callous digestive tube, he swallowed fourteen
knives in the course of the day. This was his
great, but his last exploit, for he died two months
afterwards; having passed two of the knives by
stool, the remaining dozen being found in the
body,- — eleven in the stomach, and one in the
oesophagus.
5. The articles most commonly fancied by young
females are paper, cotton, thread, chalk, vinegar
and other acids. I once saw a sicklv-complexioned
lad, who was in the habit of eating sand; and a
robust seaman, who occasionally would devour :i
whole wine or ale glass, having previously crushed
it in small pieces with his teeth, and yet no bad
effects resulted, at least for many months after-
wards. (Lond. Med. Repos. vol. xviii.) The only
other instance on record, where this most danger-
ous feat has been performed, is given by Ca.me-
rarius (Memorab. cent. v.).
6. When pica is complicated with bulimia, as
ARTERIES — their Diseases
111
is sometimes observed, most singular and even
astonishing feats in the way of devouring sub-
stances of the most unsuitable kind are on record,
— man] of them also so large, that the possibility
of their being conveyed into the stomach, if they
had not actually been found there, might have
been doubted. Some really astonishing and au-
thentic instances of this kind have been related
by M. Fournier (ail. Cas. Rares, Diet, des
Sciences Mid. t. iv. p. 135.).
7. Treatment. — The means of cure must,
of course, have strict reference to the morbid
condition of the system, 'of which it is so frequent-
ly a symptom. If it accompany pregnancy, I be-
lieve that the axiom which M. Francier adopts
as the title of a treatise on the subject should be
adopted, viz. A pregnant woman affected with
pica should be wejl purged. If it be attendant
upon chlorosis, aloetic purgatives, with emmena-
gogues, and these followed by or given alternate-
ly with tonics, are the most suitable means, and
are equally beneficial in the pica which occurs
about the period of puberty. In hysteria, similar
measures, combined with valerian, asafeetida,
camphor, and other antispasmodics, are indicated.
Li these three symptomatic forms of the disease,
auv of the Formula? for those medicines in the
Appendix may be adopted.
8. When the affection presents an idiopathic,
which is comparatively rare, it is most common-
ly owing to a weakened state of the digestive or-
gans, with, perhaps, an altered sensibility of the
nerves, and acid state of the secretions of the
stomach. In these cases, the combination of
vegetable tonics with alkalies, and attention to the
alviue secretions and excretions, are chiefly to be
attended to. The treatment of cases of the affec-
tion induced early in life from habit, will be un-
satisfactory, or without avail, until the cause is
removed ; but it dillers in no essential particular
from that now stated. In many cases the per-
nicious habit has commenced with early puberty,
and, as well as in the cases associated with chloro-
sis, hysteria, pregnancy, and irregularity of the
menstrual discharge, is evidently dependent upon
the state of the uterine functions. (See Chloro-
sis, Menstruation, &c.
Bibliooraphy. Francier, Ergo Gravid* Pica Laho-
rnutes Purganda-. Paris 1615. — Heck, Dissert, de Pica
Praegnantum, -lto. Lusd. Bat. 1653. — Schuster, De Pica
aeu Malaria. Arg. 1658. 4lo.— A. Castro, De Morhis
Mulieniin I. iii. p 389. — Forestus, Opera, I. xviii. bbs. 7.
el 1. xxviii. obs. 65. — Scheider, De Appetitu Gravidar.
Wit. 1670. 8vo. — fforstius. Opera, vol. ii. p. 160 Sau-
vages, Op., t. ii. p. 212.— Meyer, Diss, de Pica et Malaria.
Krt". 1702. — Schurisr, Chylologia, pp. 33. 45. 49^ &c,
Sckeulenutntcl, Ilevtriige zur Arzneykunde, No. 5. et
Wo. 34.— Gruner, 'Dissert, de Pica 'et Malacia. Jen*,
1791. — Hunter, On Diseases of the Army in Jamaica
8vo. — Cu/lcn, Synopsis, c. iii. — Good, Studv of Medicine'
vol. i. — Gardien, Traite Complet d' Arcoucheme is, et des
Maladies des Filles, des Females, et des Enl'ans. Paris, 1826.
ARTERIES, their Diseases.— Syn. 'Aot»,<>,«,
(ir. Arteria, Lat. Artere, Fr. Eine Schlagader,
Puhader, Ger. Arteria, Ital. Artery, Eng.
1. The morbid conditions of arterial vessels
cannot be appreciated, either in respect of their
causes, symptoms, or consequences, unless their
organization and connections with other systems
of the frame be clearly understood. It does not
fall within my limits to notice all the connections
which these vessels present with other parts of
the body ; but there are a few to which I will
briefly allude, as most material in the causation
of their diseases, and of certain sympathetic affec-
tions with which these diseases are related.
2. I. Organization. — The arterial tubes are
essentially constituted, 1st, Of an external and
adventitious tunic, consisting of a very delicate
and condensed cellulo-filamentous tissue. This
tissue is never infiltrated by serum, nor loaded by
fat; and possesses the greatest degree of resist-
ance of all the other coats of the vessel. 2d. Of
a proper coat, consisting of fine circular fibres
placed closely together, and forming a strong
tissue of a dun yellowish colour. The nature of
this tissue has been a matter of much dispute
with pathologists. It certainly does not possess
the physical and chemical properties of the fibres
of voluntary muscles, from which it chiefly differs
in being much more close in its structure, and
more elastic and fragile than they. It more near-
ly approximates to the fibres of involuntary and
hollow muscles, as those of the intestinal canal.
3d, Of a very delicate cellular tissue, like a fine
pellicle, the second cellular tunic of Haller,
interposed between the fibrous or proper coat and
that next to be described. It is in this fine mem-
brane that the minute vessels supplying the arte-
ries, and which proceed from the adjoining parts,
terminate; and here also the ultimate distributions
of the arterial nerves may be supposed to ramify,
although they cannot be clearly traced further
through the coats of the vessel than the proper
fibrous tunic where I have distinctly followed
them. This is the most vascular of the tunics
strictly constituting arterial vessels ; and one in
which many of those changes which will fall
under consideration commence. 4th, Of an in-
ternal membrane, presenting no linear or fibrous
structure, semi-transparent, more readily detach-
ed from the one next to it in the longitudinal
than in the transverse direction, and fragile.
This delicate membrane is not possessed of ves-
sels carrying red blood in the healthy state, but
it is penetrated by minute red vessels when in-
flamed. It lines, with scarcely any perceptible
modification, the canals of all the vessels convey-
ing red blood, and the cavities of the heart.
3. The arterial vessels thus formed are sur-
rounded by a sheath of loose cellular tissue, more
or less abundant in some parts than in others,
permitting the vessels to accommodate themselves
to their varying state of dilatation, constriction,
&c., and transmitting the vessels which are em-
ployed in their nutrition. The elastic properties,
also, of the proper coat of the vessels, serves also
to accommodate their capacity to the state of the
circulating fluid ; and as it is generally supposed
that they are in a certain degree of distension
during life, owing to the quantity of blood con-
stantly being impelled through them by the heart's
contractions, so it is believed that the contractions
which they display on the removal of this fluid is
at least partly owing to the abstraction of the dis-
tending cause.
4. No trace of longitudinal fibres can be de-
tected in arteries. The elastic properties which
they present in the direction of their axis, when
extended beyond their natural limits, and their
retraction upon their division, are chiefly owing to
the dense cellular coat immediately surrounding
the proper fibrous structure of the vessel. The
different degrees of tenacity presented by the va-
rious structures composing the parietes of these
112
ARTERIES — Inflammation of.
vessels, acting conjointly with the elasticity of the
proper coat, have been considered by many as
sufficient to account for the absence of haemor-
rhage after laceration of these vessels. Doubt-
less these circumstances contribute, but 1 con-
ceive that they are insufficient of themselves to
account for this and other phenomena, which will
be noticed in the sequel.
5. The arteries are surrounded by the ganglia!
nerves, which form a reticulum around them ;
and from this reticulum very minute fibrillae are
given off, and dip into their fibrous tunic. Tins
disposition of the ganglial nerves on the arteries
ought to be kept in recollection when we enquire
into the functions and diseases of the latter. How
far it is necessary, not only to the discharge of
the most manifest actions which the arterial sys-
tem performs, but also to those changes which
the blood undergoes in disease, and to the as-
similation of the chyle, and other absorbed Quids,
I have ventured to state in the article on the Pa-
thology of the Blood. It is evidently to the very
intimate connection of this class of nerves with
the arteries, and the effects resulting therefrom,
that we must impute those changes, whether
functional or organic, which take place in the
latter, and which influence the state of the blood,
and the circulation through them. (See the Au-
thor's Appendix to Richerakd's Physiolo-
gy, p. 556. 613.)
6. II. Nervous Affections of Arteries.
— II. Class, I. Order (Author).
7. There is sometimes disorder referrible to a
particular artery, or arteries, evidently depending
on an affection of the nerves supplying them. Of
this description are, 1st, Neuralgia of the arteries;
2d, The violent pulsations sometimes felt in a
large arterial trunk. 1st, Laennec admitted the
existence of neuralgia of arteries, and considered
it to be characterised by acute pain in their course,
with increase of their pulsations and the bellows
sound ; and to be independent of inflammation, as
shown by the sudden accession and remission
of the symptoms, and their periodic recurrence.
That this atieetion is sometimes connected with
irritation, or with an inflammatory state of its nu-
tritious vessels, may or may not be the case ; but
it is certainly not always so connected.
8. 2d, Violent pulsation of arteries is more
commonly observed unaccompanied with exces-
sive pain. In these cases a loud bellows sound is
often heard in all the principal arteries, particular-
ly those in which the increased pulsation is felt.
This affection generally supervenes and disap-
pears suddenly in nervous and'debiiitated persons,
particularly after large losses of blood. Morbid
anatomy has not as yet thrown any light on its na-
ture ; and therefore we can only refer it to some
peculiar influence exerted by the nerves supply-
ing the vessels thus affected, and probably de-
pending originally upon the state of the vital ener-
gies of the frame. It is sometimes associated with
hypertrophy of the heart. In this case, it is in a
great measure to be imputed to that disease.
9. Treatment of these affections. — When neu-
ralgic pain is felt in the course of arteries, and is
quite unaccompanied by inflammation, the same
treatment which is recommended in the article on
the painful affections of Nerves may be adopt-
ed. After morbid secretions and intestinal col-
luvies have been curried oil' by purgatives, tonics
combined with antispasmodics may be employed,
The preparations of iron, the sulphate of quinine,
ammonia, camphor, alone or combined with
opium, colchicum, belladonna, or prussic acid ;
the external application of the acetate or muriate
of morphine, or the cyanuret of potassium, &c.
may be tried. In the cases of inordinate pulsa-
tions, unassociated with pain of the arteries, atten-
tion to the alvine secretions and excretions, and
the use of tonics and antispasmodics, will general-
ly be productive of advantage. As these func-
tional disorders are generally consequent upon
disturbance of some internal organ or part, some-
times a distant or remote etiect of pre-existing
disorder, the seat and nature of such disturbance
should be investigated, and the treatment directed
accordingly. In all such cases, residence in a dry
and salubrious air, occasional change of air, gentle
and regular exercise, and a light and nutritious
diet, will be of much service, (see Art. Aorta,
§ 2—6.)
10. III. Inflammation of Arteries. — Syn.
Arteritis, or Arteriitis ; Artereitis, Uilden-
brand. L'JIrterite, I r. Pulsader — , Ar-
teri — , Schlagud erentzimdung , t.er.
Classif. III. Class, I. Order (Author,
see Preface).
11. Defin. Great and tumultuous vascular
excitement, palpitations, anxiety, sense of heat
and throbbing in the course of the principal ar-
teries, folloiced by collapse of tlie vital energies,
and occasionally by gangrene of a limb.
12. This disease was not entirely unknown to
the ancients, as Aretj:us makes mention of in-
flammation of the aorta. But notwithstanding the
incidental notice which was taken of inrlamrnution
of arteries by Morgagni, and Boerhaave, and
afterwards by Grant, the attention of the medi-
cal practitioner was never directed to the subject,
until J. P. Frank noticed it in a particular man-
ner. It is, therefore, to the last-named author
that we are chiefly indebted for the numerous re-
searches of pathologists, respecting it in modem
times. Since the appearance of Frank's work,
arteritis has received due notice from Testa,
Kreysig, Reil, Baillie,Bl rns, Coryisart,
Sch.muck, Portal, Scarpa, Hodgson, Tra-
vers, Rides, Laennec, Breschet, Dal-
bant, Vaidy, Bertin, Bouillaud, Guthrie,
Trousseau, and several others, and it is now
generally recognised as a specific and most im-
portant disease, sometimes occurring primarily,
occasionally cor.secuth elv and conjoined with
other diseases, by no means of rare occurrence,
and, in whatever form it presents itself, always
threatening the most serious consequences.
13. Pathology of Arteritis. — Arteries,
being composed of distinct tissues, may be sup-
posed to be liable to all those kinds of inflamma-
tory action, to which each of their constituent
parts are most disposed. However frequently in-
flammatory action may originate in one rather
than in more of the coats of an artery, it seems
seldom to continue thus limited, but soon affects
the rest to a greater or less extent. It may even
seize simultaneously upon all the coats ; but this
is, I think, of comparatively rare occurrence.
The individual tissues of an artery most frequent-
ly inflamed, in a primary manner, are the inter-
nal membrane of the vessel, and its connecting
cellular tissue.
ARTERIES — Inflammation of, its Pathology.
113
14. Arteritis may be partial or general, as re-
spects its extension through this class of vessels ;
anil it ma\ present every grade of activity, from
the most acute to the most chronic form. It gen-
erally attacks one or more of the arterial trunks
and larger branches. When it affects the arterial
capillaries, it constitutes, in the opinion of some
pathologists, inflammation itself; but whether it
can he demonstrated as existing in this latter class
o\' vessels, or in what respects it may either differ
or agree with inflammation when it does thus
exist, are points which have not been yet settled
by the few pathologists who have agitated the
question.
15. Inflammation may possibly, however, seize
upon a number of arterial ramifications in an
organ, especially in an unhealthy habit of body,
or in a part injured by external violence or exces-
sive cold ; but, when it is thus seated, all circu-
lation through the part is quickly interrupted,
owing to the effusion which takes place and de-
stroys the permeability of the vessels. The con-
sequences in such cases are, 1st, sphacelus and
gangrene of an extremity or part, as we observe
in cases of frost-bite ; and, 2d, when the inflam-
mation is limited to the capillaries of a circum-
scribed portion of an organ, particularly when this
portion is surrounded by healthy structure, a
breaking down of the texture, and its conversion
into a foetid purulent-like matter, as in gangrene
of the lungs, and some kinds of abscess formed
in the parenchyma of several organs.
16. In constitutions possessing the power to
limit the inflammation, which has thus seized
upon a congeries of arterial vessels, by throwing
out coagulable lymph, the extension of the in-
flammatory process to the larger branches and
trunks is prevented ; and, if the part already af-
fected be an extremity, a distinct line of separation
is thus drawn, or if it be situated in the centre of
an organ, a cyst is thus formed by the lymph ef-
fused, tending both to the limitation of the inflam-
mation, and to exclude, as it were, the parts
which the loss of circulation has deprived of vital-
ity, from the surrounding living textures, and
from the contamination which the defect of this
natural partition would allow to take place.
17. When the constitutional powers and vital
energy of the vessels of the part are insufficient
for the formation of the means of limitation here
pointed out, the inflammatory action of the small-
er arterial vessels extends itself to the larger
trunks; and the affection of these, in addition to
the preexisting inflammation of the small branches,
increases the mischief ; the gangrene extending
itself without any line of separation being formed.
In this case the constitutional powers fail rapidly,
owing to the contamination of the surrounding
structures and circulating fluid, from the absorp-
tion of the products of inflammation through the
venous capillaries of the part, which seldom escape
participating in the disease.
18. Such seem to be the results of inflamma-
tion affecting a congeries of arterial vessels, or the
arterial branches and their ramifications through-
out an extremity; and I conceive that those in-
flammations which are rapidly followed by spha-
celation and gangrene, as well as some lesions con-
sidered under different heads, and which have been
generally referred to the common seat and conse- j
queuces of inflammation, are of the nature now
10*
described. It seems extremely probable that sev-
eral lesions of a disorganized and disorganizing
description, following rapidly upon the first devel-
Opement of deranged circulation, arise from the
source now contended for ; or, in other words,
that some of the consequences usually referred to
common inflammation, in conjunction with pecu-
liarity of habit and of the part aflectcd, actually
spring from inflammation and obstruction of the
arterial vessels, and cannot be otherwise satisfac-
torily explained.
19. Inflammation of arteries, like inflamma-
tions of all other parts, may, however, give rise to
effects which will vary according to the degree of
intensity of the morbid action, the coat or coats
of the vessel in which it originates, or to which it
extends, and the habit, diathesis, and constitu-
tional energy of the patient. The duration of this
disease, as well as its constitutional elfects, will
also depend upon the above circumstances ; and
in inflammation of this part of the system, more
perhaps than in the inflammation of any other
part of the body, excepting merely the rest of the
circulating organs, the primary effects and pro-
ducts of the inflammatory act will be rapidly
productive of ulterior effects, serious in their na-
ture and results, even after the morbid action
which originated them had altogether disappeared,
and could be recognised only in those remoter
but palpable consequences, some of which have
been alluded to in the preceding paragraphs, and
which will be more fully referred to in the sequel,
particularly in the section on the morbid structure
of arteries (§ 38.).
20. Causes. — 1st, The predisposing causes of
arteritis are generally those of inflammation in
general ; but those which seem especially to fa-
vour the production of this disease, are the gouty
and rheumatic diathesis ; the middle and advanc-
ed epoclis of life ; certain constitutions of the at-
mosphere, or epidemic influence ; peculiarity of
climate, and whatever occasions a diminution of
the crasis of the blood, or imparts to it an ex-
citing influence on the vessels ; indulgence in the
use of much animal food, and vinous and spirit-
uous liquors; a plethoric habit of body, partic-
ularly when conjoined to the sanguine and irrita-
ble temperaments ; prolonged high temperature ;
intemperate and luxurious habits ; the constitu-
tional effects of syphilis or mercury ; the suppres-
sion of accustomed discharges, particularly the
sanguineous ; reiterated or prolonged attacks of
nervous, convulsive, or spasmodic diseases ; and
deficient secreting powers of the various emunc-
tories, as the kidneys, liver, &c.
21. 2d. The exciting causes of this disease, be-
sides those which are more commonly productive
of inflammation, are congelation of parts from
great cold, and the sudden exposure to a higher
temperature; insolation ; punctured, incised, lac-
erated, or contused wounds ; surgical operations;
ligatures of arteries after the operation for aneurism
(Cline, Abernethy, &c), or amputation, and
from tying the umbilical chord (Of.h.iie); exces-
sive suffering from long-continued operations; con-
tinued and fatiguing exertions ; sudden and violent
muscular action ; the sudden extension of a part
occasioning the elongation of the vessel and rupture
of its internal coat; pressure in the course of arte-
rial vessels ; violent fits of passion ; great mental
emotions; exhaustion of the vital powers; puru-
114
ARTERIES — Inflammation of, its Pathology.
lent and morbid secretions ; animal matters and
poisons absorbed into t he circulation ; chemical
agents of any description introduced into the
vascular system ; and the sudden repulsion or
suppression of exanthematous fevers and eruptive
diseases. Portal records an instance of the
disease which was occasioned by the repulsion of
the eruption of measles. I met with an instance
of inflammation of the internal membrane of the
heart and arteries, in a fatal case of malignant
scarlatina, with an imperfect and evanescent erup-
tion on the skin. ftl. Breschet details seve-
ral cases in which the disease was consequent
upon erysipelas and chronic abscesses. I have
found the internal surface both of the arteries and
of the veins dark red, and softened, in two fatal
cases of puerperal fever, characterised by evident
signs of absorption of sanious matter from the
uterus. A case also lately came before me of
ervsipelas followed by gangrenous escars on
the sacrum, where the internal surface of the
sanguiferous system, and particularly of the aorta
and large arteries, as far as they were examined,
presented a similar appearance. In all these cases
the inspection had been made within eighteen
hours after death.
22. The causes of arteritis consist, therefore,
1st. of those which act externally as respects the
vessels; and, 2d, of those which irritate in a di-
rect manner the internal surface of the arteries
themselves, byMjeing conveyed into the circulat-
ing fluid, the properties of winch they may have
previously changed. But, in whichever of those
ways they may act, their first effect seems to be
to change or influence the vital energies of the
organic nerves ramified to the coats of this sys-
tem of vessels.
23. 3d. Anatomical characters. — As to the par-
ticular tissue of the arteries, in which the inflam-
mation originates, I am of opinion that a careful
examination of the phenomena of the disease in
connection with its causes and complications will
warrant the inference, that, when it arises from
those causes which act exteriorly to the vessels
(§ 21.), and which are chiefly local in their
operation, the inflammation is generally limited
as to its extent, being confined to a part only of
the arterial system, or to two or more considera-
ble branches ; that it often affects more than one
of the coats of the vessel in this case ; and that it
generally assumes the sthenic characters, giving
rise to those changes which usually result from
this form of inflammatory action, such as the
effusion of coagulable lymph, forming fibrinous
concretions and false membranes in the interior
of the vessel, obstructing or obliterating its cavi-
tv; red vascular injection, thickening and soften-
ing of its tunics; and suppuration, with or without
ulceration of its interna) membrane.
24. On the other hand, when the disease ori-
ginates from causes existing within the vessels,
and acting through the medium of the blood
itself, and more especially when it is complicated
with malignant and eruptive fevers, with erysipe-
las, &c, or is caused by the absorption of morbid
secretions, &c. into the current of the circulation,
the vascular excitement is rapidly followed by
symptoms of an ataxic or asthenic character ; the
inflammation is chiefly confined to the internal
surface of the vessels, but it extends more or less
throughout the whole arterial system, and, in
many cases, also to the inner lining of the cavi-
ties of the heart, and even of the veins. In
cases of this description, the lesions of the arte-
ries which it occasions consists chiefly of a dark
red or violet-coloured injection of the inner mem-
brane and connecting cellular tissue ; great soft-
ening and friability of those tissues, with slight
sanious infiltration of the walls of the vessel in
different parts.
25. It should not, however, be overlooked,
that the inflammation of an artery may frequently
commence from local causes, and originate hi,
and be for a time confined to, a particular trunk
or its branches, presenting all the signs of the
sthenic form of inflammatory action, and yet, ow-
ing to causes lowering the vital energies of the
frame, or to the absorption of the matters secreted
from the inflamed vessel into the current of the
circulation, or to both, may pass into the gene-
rally diffused and ataxic state of the disease.
26. Symptoms of Acute Arteritis. —
These will necessarily vary according to the stage of
the disease, the severity and activity of the attack,
and the organic changes which the inflammatory
action has occasioned in the affected vessels. I
shall therefore adduce, first, those symptoms which
characterise the disease previous to the superven-
tion of those changes which affect this svstem so
as materially to impede its functions, or to change
the condition of the circulating fluid ; and next,
those signs which indicate important changes in
the state of the vessel, and of the blood itself.
27. The first stage is one frequently of much
obscurity; and when the inflammation is limited
to the vessels of a single limb or organ, it is very
difficult to distinguish it from the common inflam-
mation of the part. While the internal tunics of
the vessels are yet the chief parts affected, and
the effusion of lymph into their interior has either
not supervened, or not obstructed their canals,
the patient generally feels, either after a rigor, or
at first alternating with rigors, an increase of the
pulsations of the vessels of the part, with a sens-
ation of heat, uneasiness, or pain. When arte-
ritis is more general, and particularly if it be
connected with inflammation of the heart's inter-
nal surface, as occasionally occurs, the svmptoms
are those of fever of an extremely inflammatory
type, as has been remarked by J. P. Frank (lie
Cur. Horn. JMorb. t. ii. p. 175.) and M. BouiL-
i.aud ( Traite Clin, et Exp. de Fievres, p. ] 75. ) :
commencing in rigors, at first alternating with,
and followed by great anxiety, irritability, rest-
lessness, uneasiness, a sensation of burning heat,
and remarkable pulsation, with increased stn>i-
bility in the course of the large arteries. The
patient complains of general and urn-emitting
throbbing throughout the system, sometimes felt
more intensely in one part than in another. 1 he
surface of the body is hot, tumid, and injected ;
the tongue red, the papilla' erect, and its bas
furred and loaded ; the bowels are costive ; thirst
is urgent and unquenchable; the urine scanty^
voided with a sense of scalding, and high-colour*
ed; the patient is distressed with palpitations.
The pulse at this stage of the disease is strong, tu-
multuous, throbbing, full, and frequent: and the
contractions of the heart hurried and tumultuous.
To these are sometimes added cough, occurring
in paroxysms, with fits of dyspnoea. When the
inflammation extends to the aorta and internal
ARTERIES — Inflammation of, its Pathology.
115
lining of the heart's cavities, the characteristic
symptom§ llt inflammation 6f those parts (see
Aortitis, &c.) are superadded to the above.
28 The second stage is chiefly characterised
by llie greater severity of* the symptoms, indi-
cating thai serious changes are advancing in the
internal coats of the vessels, and influencing not
onlv the state of the vital energies of the sangui-
ferous system, but also the state of the blood. At
this period of the disease, the pulse generally be-
comes extremely frequent, and often wiry, weak,
and irregular; whilst the palpitations, anxiety,
and paroxysms of dyspnoea increase. The tongue
is either dry, the papillae erect, and its centre
furred with a dark mucus or sordes ; or it is
smooth, glossy, and of a dark tint. The patient
is liable to startings and spasms in different parts
of the body. The desire for drink increases; the
strength sinks; the' countenance at first shrinks,
is pallid or haggard, but, towards an unfavourable
close el' this stage, it often becomes somewhat
bloated, (edematous, or cadaverous, occasionally
injected, and the lips purplish. The extremities
are frequently oxlematous; and they, as well as
other parts of the body, are sometimes affected
with wheals, ecchymosis, phlyctenoe, or large
vesications. In some cases, effusions of sero-
albuminous fluids take place in some of the shut
cavities; the surface of the body is covered by a
cold perspiration; the extremities become cold,
nnd sometimes of a purplish red colour; and a
low muttering delirium appears during the night,
from which, at last, the patient is never entirely
exempt. To these often supervene a tendency to
syncope upon raising the head; irregular palpi-
tations; weak, irregular, hurried, and quick pulse;
ami a quick, short, and difficult respiration; some-
times orthopnoea and distressing cough. Hiccup
and convulsions at last appear, and the patient
expires.
29. If the inflammation be seated in large
trunks, the serum effused from the internal sur-
face of the inflamed vessel necessarily comes in
contact with the circulating fluid; but I believe
it does not readily mix with it in persons of a
soiiod constitution, or whose vital energies have
not been materially affected, but forms a coagu-
luin, which either sheaths the internal surface of
the vessel, partially obstructing it, or altogether
filling up its channel. In this case, the symptoms
indicate interruption of the circulation through
a considerable branch of an artery: the limb be-
comes oedematous, cold, leucophlegmatic, or
purplish coloured, with irregular phlyctenoe and
large vesications on its surface, which sometimes
go on to gangrene; especially when the disease
bus extended to the collateral arteries, which, if
they had remained unaffected, would have per-
formed the functions of the inflamed and ob-
structed trunk.
SO. When arteritis occurs in a weak or cachectic
habit of body, the fluid secreted from the inflamed
internal surface of the vessels, owing to the state
of the constitutional powers, will not coagulate,
but. being of a dissolved and sanious quality,
readily mixes with the blood, and no interruption
to the circulation through the inflamed vessels oc-
curs: but the energies of life become depressed
from the morbid state of the vital current thus
Occasioned, and many of the symptoms of ataxic
or malignant fever manifest themselves; — such
as great prostration of the powers of the frame;
low delirium; an impeded and morbid state of the
secretions and excretions; weak, quick, and ir-
regular pulse; a cadaverous and lurid countenance;
accumulations of dark mucous sordes about the
tongue and mouth; ilaccidity of the soft solids,
with the rest of the phenomena described as con-
sequent upon inflammation of veins.
31. Chronic Arteritis.— The more acute
and active states of arteritis, although frequently
admitting only of a doubtful recognition during the
life of the patient, are more readily ascertained than
the chronic forms of the disease. These latter, how-
ever, seem more frequently limited to particular
arteries than the acute, and hence oftener produce
local effects; but these are generally so slight,
and of so equivocal a character, that they com-
monly escape detection, and are unattended to by
the patient until the lesion on which they depend
arrives at that degree of advancement which
seriously disturbs the functions, and even the
vitality, of the part. A very large proportion
of the lesions which will be described hereafter
(§ 38.) seem to originate in chronic states of in-
flammation; and, if not actually commencing in
these states, they are frequently complicated with
them. It will be unnecessary further to notice
those symptoms which seem to indicate the pre-
sence of chronic arteritis, than to state that they
consist of many of the signs already adduced as
attendant on the acute forms of the disease, but
in a much slighter degree; and frequently no
functioned lesion can be remarked. When, how-
ever, the circulation through the vessel becomes
impeded or obstructed, we may infer chronic dis-
ease of the arteries, from the inequality or entire
absence of the pulsation in these arteries supph ing
the part whose functions are most affected; from
oedema, coldness, discolouration, vesications, or
from signs of the gangrsena senilis in a limb; or
from a feeling of weakness, and a state approach-
ing to paralysis of an extremity or part.
32. Complications. — The states of morbid
association of which arteritis forms an especial
part have been more frequently disclosed to us
after death than recognised during life; nor is it
to be expected that, in some of the associations in
which it has presented itself, it can be ascertained
by the most diligent investigation of the case pre-
vious to dissolution. We are still so much in
want of faithfully observed cases of the disease,
even in its simple and unmasked forms, and of
correct information on various topics respecting
its history and pathology, as to render our diag-
nosis imperfect and doubtful; and how much
more difficult must be our attempts to recognise
it in its complicated forms, when it is masked by
other diseases, the phenomena of which obscure
it from the observation of the practitioner, and even
ali-tract the attention of the patient himself from
the feelings it may awaken. In noticing, there-
fore, the complications of which this disease often
forms a part, it is with the sole view of turning
attention to their importance, and in order that
the circumstance may receive due consideration,
when we give our prognosis respecting those ma-
ladies with which it has been found associated,
and when we devise means for either their relief
oi their removal.
33. Inflammation of the arteries has been ob-
served in fatal cases of inflammatory and malignant
116
ARTERIES — Morbid Structure of.
fevers, and in those which have been character-
ised by great vascular excitement at their com-
mencement, with symptoms of ataxy during their
progress. In the great majority of such cases, it
is a consecutive affection occasioned either by a
greater concentration of the morbid action in a
particular system, as explained when treating of
fevers; or by an alteration of the properties of
the blood, owing to hurtful materials having ac-
cumulated in it from deficient action of the eli-
minating organs, or to a morbid state of the ner-
vous influence imparted to the blood from the
vessels in which it circulates. (See the article
Blood.)
34. Owing to similar causes, arteritis is some-
times consecutive of eruptive fevers, particularly
when the eruption, and the morbid evacuation of
which it consists, are imperfectly developed or
prematurely suppressed; or it may supervene to
small-pox, occasioning the most dangerous part of
the symptoms forming the secondary fever of this
disease. In cases of this description, the arteritis
is almost always general, chiefly limited to the
serous membrane of the arteries, but extending
also to the same membrane of the veins ; and
evidently induced by the altered state of the
blood, and the presence in it of hurtful materials.
To this cause chiefly is to be imputed its occa-
sional occurrence during erysipelas, phlebitis, and
as one of the chief lesions observed in fatal cases
of those diseases to which the term puerperal
fevers has been applied. The complication of
arteritis with phlebitis is one of the most frequent
which occurs. That this should be the case, we
might infer from the circumstance of the same
causes generally acting upon both divisions of
the vascular system, particularly those which act
through the medium of the circulating fluid. M.
Breschf.t found inflammation of the internal
surface of the veins in a very large proportion of
the cases (S in 13) of arteritis which he has de-
tailed at length in his interesting memoir.
35. Arteritis has likewise been found associated
with inflammation of the heart, with that of the
lungs, and with tetanus, particularly traumatic te-
tanus. A case of this last complication is alluded
to by the writer of an able article in the second
volume of the Medico-Chirurgical Review. It
has also been observed, although rarely, con-
joined with serous effusion into the shut cavi-
ties, particularly the pericardium, pleura, and
peritoneum.
36. Diagnosis and Procnosis. — It has been
very justly remarked by the writer to whom I
have already referred, that, until numerous and
diversified observations in clinical practice, illus-
trated by the examination of fatal cases, shall
have further enlarged our knowledge of this
malady, any attempt to delineate the symptoms
which are diagnostic of its presence must neces-
sarily be somewhat imperfect. But it may gene-
rally be inferred, — when the principal symptoms
which have been enumerated appear — when the
heat and pain attendant on this, as on other inflam-
mations, are not concentrated in one part or
organ, but are more or less generally diffused,
particularly in the course of the arterial vessels —
when these sensations are accompanied with an
audible or perceptible impetuosity of action, pro-
pagated from the large trunks to the smaller and
more superficial ramifications — and when, more-
over, anasarcous injection of the surface or of the
limbs, followed by wheals, vesications, or ecchy-
mosed patches, supervene, — that the disease is
inflammation of the arterial system, either in its
partial or general form.
37. The Prognosis of arteritis may be said
to be, upon the whole, unfavourable, even as
respects its more immediate effects, in the acute
states of the disease; but chiefly as regards its
remote consequences in its chronic forms. The
prognosis is more unfavourable when it is com-
plicated with, or supervenes on other diseases
(§ 33 — 35.). The morbid changes which it
usually occasions are fully described in the next
section of this article.
Before proceeding to offer any observations on
the treatment of arteritis, I will describe the
various changes of structures which arteries pre-
sent, as the greatest proportion of these changes
are produced by inflammatory action in some one
of its various grades or states.
38. IV. Morbid Structure of Arteries.
1st, Lesions of the individual coats of arteries. —
A. Redness of the inner membrane of arteries
is often observed in post mortem examinations.
a. It seems to proceed from three causes: 1st, from
the imbibition of the colouring particles of the
blood remaining in the vessels, being entirely
the consequence of death, and the result of in-
cipient decomposition; 2d, from a change in the
state of the blood occurring hi the course of the
disease which occasioned death, and existing some
time before this event; and, 3d, From a morbid
or injected state of the capillaries ramified in the
coats of the vessel, or terminating in this mem-
brane. In an epidemic amongst horses, which
occurred at Paris in 1825, characterised by
symptoms of disease of the thoracic viscera, no
morbid appearances were found in the lungs, but
the internal membrane of the large vessels was
uniformly red, and the muscular structure of the
heart remarkably softened. From the experi-
ments of Gendrin (Hist. Anat. des Inflam. t.
ii. p. 9.), it is evident that the same varieties of
colour, which we occasionally observe in arteries
after death, may be produced by artificial irrita-
tion. There is, however, this important differ-
ence,— that when their redness is produced arti-
ficially, it is accompanied by other alterations of
tissue, such as softening, serous or purulent in-
filtration, &c; whereas, in almost all the cases
where the arteries have been found of a red co-
lour throughout, the change was unattended by
any other morbid appearance in them. I be-
lieve that this coloration of the internal mem-
brane of the arteries, as well as of the cavities of
the heart, is more frequently owing to a morbid
condition of the blood itself, -than to any in-
flammatory change in them. This opinion is
confirmed by the circumstances and states of
disease in which it commonly occurs; these
chiefly consisting of depressed vital energies,
deficient secreting power, and a consequent mor-
bid condition of the blood itself.
39. 6. The intern;d membrane of arteries some-
times loses its tenuity and natural transparency,
either in a few isolated points merely, or through
a great extent of its surface. This state may
amount to considerable thickening and opacity;
but in many cases these appearances do not de-
pend upon any remarkable change in this mem-
ARTERIES — Morbid Structure of.
117
brant • but "P ,M :l" albuminous exudation in its
connecting cellular tissue.
40. C. Softening also takes place in this mem-
brane, which is sometimes so friable as to he re-
duced to a pulpy mass by the slightest scraping
with the scalpel. Possibly, owing to this stale
o\' the inner membrane, its laceration may take
place upon stretching the vessel by the more vio-
lent motions of the body, or of a limb;
41. d. Rupture or laceration of the internal
coat of an artery is some! imes met with ; it neces-
saril\ occasions an elliision oflymph from the lace-
rated part, and the projection of the flaps of the
divided coat into the canal of the vessel, either
partially or entirely obstructing it. To this oc-
currence is chiefly to he imputed the cases of
spontaneous obstruction of arteries, which are
Bometimes met with.. This subject has been well
illustrated by Mr. TURNER, ill the third volume
of the Transactions of the Medico-Chirurgical
Society of Edinburgh.
-12. c. Ulceration of the internal membrane of
arteries is not infrequent. The ulcers are gene-
rally round : occasionally one only is to be found.
Sometimes the large arterial trunks, and particu-
larly the aorta, are studded with them. But this
\ observed, unless other alterations exist in
the subjacent tissues, such as ossification, soften-
intr, ^.c. M. Bouillaijd is of opinion that the
ulceration of the inner coat occasionally admits
of cicatrisation.
4:s. B. The middle coat is more frequently
diseased than the internal. It is often soft and
friable, and deprived of its natural elasticity ;
giving rise to serious modifications of the functions
of the circulating system. M. Axdkal has found
this coat remarkably hypertrophied ; the yellow
fibrous tissue of which it is composed being as
evident in the human subject as it is in the horse.
Tin* change may be confined to particular parts,
Oiling irregularities in the diameters of the
arterial canals, or it may extend throughout a
whole artery. The fibrous coat may also become
atrophied. In this state it approaches to the ap-
pearance of cellular tissue, and is much thinner,
bling the tunic of veins ; and the artery
loses its elasticity and collapses when divided.
This coat may also acquire much rigidity, and
be transformed into cartilaginous or even osseous
ring's, embracing the whole circumference of the
vessel. This change is rarely met with in the
aorta, but it not infrequently occurs in large ar-
terial trunks, as the femoral artery, &c. Ulcera-
tion may extend to and penetrate this coat, most
frequently advancing from tin; internal mem-
brane.
44. C. The external or cellular coat
of arteries is liable to fewer alterations than the
other coats ; it often remains sound when they
are extensively diseased, when it has alone to
sustain the column of blood injected through it.
But it also frequently participates in the changes
of the other coats, becoming ruptured from the
pressure of the stream of blood thrown into it,
and more rarely ulcerated. — The foregoing chan-
ges of the individual coats of an artery combine
to affect its functions and condition, and ghre rise
to important alterations of its structure and of its
calibre, which may be increased, diminished, or
entirely obliterated. Each of these requires a
separate hut brief consideration.
45. 2d, Changes of the structure and calibre
of arteries. — A. ANEURISM, a. True aneurism,
or dilatation of arteries occurs ; 1st, in a part
only of its circumference, and, 2d, in its entire
circumference : the latter is the more frequent oc-
currence of the two : it may embrace but a small
extent of the vessel, or it may extend to a con-
siderable portion ; as, for instance, to nearly the
whole of the aorta. Dilatation of a part only of
the circumference of an artery is rare, but cer-
tainly not so rare as to warrant some authors in
disputing its existence. M. Andral states, that
on more occasions than one he has traced distinct-
ly the three arterial coats passing over the walls
of a sac which seemed as if appended to the ar-
tery, with the cavity of which it communicated.
Dilatation either of a part, or the whole, of the
circumference of an artery, constitutes the true
aneurism of authors ; and according to its extent
it may constitute simple dilatation, or true aneur-
ism in its first stage, and sacculated aneurism, or
the advanced state of this disease.
4(5. The coats of a dilated portion of artery,
although not ruptured, may be otherwise altered.
They are frequently thinner than natural, and the
middle coat is generally deprived of its elasticity.
In this state the vessel yields like a vein to the
distending impetus of the blood. In other cases,
the coats of the dilated portion of artery are
hypertrophied. M. Andral likens this state to
the dilatations of the stomach and heart, which
are often accompanied with an increased thick-
ness of their parietes.
47. b. False Aneurism. — Mixed aneurism. — ■
Dilatation with rupture of one or more of the
coats, constituting the false aneurism of authors,
is another frequent alteration. The internal and
middle coats are those most frequently ruptured,
the blood coming in contact with the external or
cellular coat or sheath, dilating it in the form of
a pouch, and thus forming the aneurismal sac.
The parietes of this sac are generally much thick-
er than the cellular sheath of the vessel was
originally, owing to the gradual condensation of
the surrounding cellular tissue from the pressure
of the tumour, and the additional envelope it thus
acquires. The interior of the sac is filled more or
less with fibrinous coagula, arranged in concentric
layers, the more exterior of which frequently be-
come so dense as to he distinguished with dif-
ticultv from the parietes of the sac. Around the
exterior of the sac a degree of irritation is induced,
giving rise to adhesions, which unite it more or
less firmly to the surrounding parts. But these
parts sutler other changes, particularly as the
aneurismal tumour increases: they are mechani-
cally compressed or displaced ; or they are worn
away bv absorption promoted by its pulsations,
or bv inflammatory irritation terminating in ulcera-
tion and destruction of parts. This effect upon
the adjoining structures has been shown under
tin' article ANEURISM of the Aorta, and it is
therefore unnecessary to illustrate.it further. Ac-
cording to some authors, false aneurism consists
of the ulceration or perforation of tho internal
mats, and of the dilatation of the external tunic
only ; the changes above described constituting
mixed aneurism.
48. c. Diffused aneurism, fyc. — In general the
irritation created around the sac attacks, after a
time, the sac itself, occasioning its ulceration and
118
ARTERIES — Morbid Structure of.
perforation. Haemorrhage is then the result,
which may be so great as at ouce to occasion
death. It is frequently arrested by the anato-
mical relations of the part : as when blood flows
into the pericardium ; or when the blood passes
into the parenchyma, or loose cellular tissue con-
necting different organs or structures ; in which
case it passes into the state of diffused aneurism.
In some cases the haemorrhage is arrested by
adhesions formed around the sac, constituting
a second envelope to it, which confines the
blood, and prevents it for a time from being
further effused. Perforation of the sac, how-
ever, may take place without haemorrhage, or
even the production of diffused aneurism. This
happens when a part in contact with the sac sup-
plies the place of that portion of its parietes
which has been destroyed, and affords sufficient
resistance to the escape of the blood. Thus we
have seen that the blood, in aneurism of the
Aorta, may actually wash the partially destroy-
ed vertebrae, no effusion taking place till still
further destruction is occasioned ; and the tu-
mour, in other cases, coming in contact with the
periosteum, produces thickening of this structure,
or the secretion of an osseous matter from it
which partially surrounds the sac, forming an
envelope to it, and preventing the escape of its
contents until this also is destroyed.
49. In false and mixed aneurisms, the inner
and middle coats are first perforated or ruptured,
and the third coat either remains entire, or gives
way at some remote period, and thus a secondary
diffused aneurism is formed (§ 48.). But there
is another form of diffused aneurism, in which all
the coats of the vessel are raptured or perforated
at once, and the blood, passing entirely out of the
vessel, forms no sac, but is diffused in the ad-
joining parts ; or it impacts the cellular and pa-
renchymatous structure in its vicinity into a spe-
cies of sac or envelope ; or it is poured out into a
shut cavity, or into some organ, whence it may
be discharged externally, thus constituting pri-
mary diffused aneurism. In the majority of
eases, however, the aperture in the artery is the
result of ulceration of one or more of the coats
of the vessel, the remaining tunic giving way be-
fore the impetus of the circulation ; the blood
being either confined by the surrounding parts,
or escaping into a cavity, according to the situation
of the artery, and of the aperture in it. This per-
foration and rupture of all the coats occur chiefly
in the arteries of internal viscera, as in the splenic,
hepatic, emulgent, iliac, and other arteries.
50. Aneurisms may terminate favourably, a
spontaneous cure being sometimes effected by
some one of the following processes : — 1st, by a
gradual contraction of the sac, and absorption of
the coagula ; 2d, by the compression exerted by
the sac upon the part of the artery immediately
above it ; 3d, by gangrene of the sac and ob-
literation of the artery ; 4th, by inflammation or
abscesses in the vicinity, and the coagulable
lymph thrown out, obliterating the artery, as in
the preceding case; and, 5th, by inflammation of
the sac extending to the artery, and giving rise to
adhesive inflammation of its ulterior, and ultimate-
ly to its obliteration.
51. B. Narrowing of arteries is either con-
genital or the effect of disease ; when the latter,
it is very frequently associated with, or occasion-
ed by, ossific deposits, — a change which will be
considered in the sequel. It is chiefly in the
aorta and large vessels departing from it that we
meet with either congenital or morbid narrowing.
Congenital contraction of the aorta is generally
connected with extreme thinness of its parietes,
and in some cases this defective developement
has been so remarkable that the abdominal aorta
has not equalled the usual size of the external
iliac artery.
52. The contraction of the aorta, or of an ar-
terial branch, may exist throughout its extent, or
may be confined to a particular part. The ab-
dominal portion of the aorta is more frequently
contracted (see Aorta.) than the thoracic ; and
when the former is narrowed, the latter is often
dilated. Sometimes, however, the artery retains
' its natural calibre both above and below the con-
: stricted part : instances of this have been record-
ed by M. Paris, in the second volume of De-
j sault's Journal, and by M. Reynaud (Journ.
Hehd. de Med. t. i. p. 161.). In many cases of
J constriction such as I have now noticed, it is dif-
ficult to determine whether this change has been
congenital or the result of disease, inasmuch as
the coats of the vessel have appeared unaltered
from the healthy state. But there can be no dif-
( ficulty in determining in favour of the latter al-
ternative, when the coats of the contrated portion
are thickened, or contain ossific deposits, or are
otherwise changed. When the contraction is the
result of disease, it is sometimes very remarkable,
the canal of the vessel being nearly obliterated.
The narrowing found in the principal trunks or
branches of arteries is almost always the result of
inflammatory disease ; most commonly of ossific
deposit?, or of chronic inflammation.
53. C. Obliteration of arteries is frequent-
ly observed. This lesion may occur in any part
of the system, even in the aorta itself, but it is
most commonly met with in the second or third
order of arteries. The smaller branches may also
be obliterated ; but they less frequently become
the objects of examination than the larger trunks.
The canal of an artery may be obliterated, 1st,
by fibrinous coagula adhering firmly to the pa-
rietes of the vessel, or incorporated with them;
2d, by the conversion of the vessel to a ligament-
ous chord ; 3d, by osseous concretions, or other
morbid growths, filling entirely its cavity ; and,
4th, by the advanced progress of aneurism to a
spontaneous cure.
54. a. The first species of obliteration has
been found in the aorta by Professor Monro
(Edin. Journ. of Med. Science, vol. ii. p. 351.);
the part affected being somewhat contracted and
filled up by a plug of fibrine, which adhered to
the surface of the vessel by' coagulable lymph.
This form of disease is common in the arteries of
the extremities, particularly the lower, and is
sometimes owing to the rupture of the internal
coat of the vessel. It occurs also in cases of gan-
graena senilis, and, with the third species (§ 56.),
is a frequent cause of the gangrene. It seems
most probable that it is a more immediate con-
sequence of inflammation than the second species.
55. b. The second form of obliteration is not
uncommon in large branches of arteries, and has
been found, in two cases, jn the aorta : it is evi-
dently a more remote cause of inflammation than
the foregoing. The circulation being entirely ob-
ARTERIES — Morbid Structure of.
119
stnicted. by the coagulable or fibrinous lymph
poured out* by the inflamed or ruptured internal
membrane, and by the coagula thus formed, and
being kept up by the enlargement of collateral
branches, the obstructed part is deprived of its
functions, and subsequently undergoes those
chances which all vascular or other canals expe-
rience when they no longer are pervious to the
fluids which usually circulate through them, —
they have the fibrinous coagula, which have been
formed in their cavities, and the lymph effused
between their coats, absorbed, and their coats be-
come condensed into ligamentous chords.
56. c. The third species has been met with in
the aorta by Dr. GooDisas (Bub. Hosp. Rep.
vol. ii. p. 193.), and M. Vf.lpf.au (Rev. Med.
1825, t. iii. p. 321).) In Dr. Goodison's case,
an osseous deposit surrounded the canal of the
vessel, which was completely filled at this part
with a dense fleshy and fibrinous mass, resembling
the structure of the heart. A similar obliteration
also existed in the iliac arteries. In M. Vel-
tf.au's case, the obliteration was owing to the
formation of a scirrhous or carcinomatous tumour
in the vessel, resembling similar tumours deve-
loped in different parts of the body. Obliteration
by polypous or other growths, bv fibrinous
coagula and ceagulable lymph, by ossific depo-
sit-. Sec. are also found in large arterial branches,
especially in those supplying the lower extremi-
ties. The obliteration of the arteries by ossifica-
tion is one of the principal causes of the gangrene
of aged persons. When a considerable artery, or
even the aorta, becomes either much obstructed,
or entirely obliterated, in any of the above ways,
the circulation is generally carried on by enlarged
collateral vessels.
57. d. The fourth species has been observed
in several large arterial trunks. Dr. Monro's case
of obliteration of the aorta may be partly ascribed
to this cause; the coats of the vessel, although
entire, being dilated below the constricted part.
58. D. Albuminous and purulent matter.
— M. Gendriv (Hist. Anat. des Infiam. t. ii.
p. 9.) has clearly proved, by his experiments,
that, when an artery is artificially irritated, its
parietes soon become injected, swollen, softened,
and infiltrated by a serous fluid; its internal sur-
face is coated by an albuminous exudation, and
collections of pus form, either in the interior of the
vessel, or between its coats. He has, moreover,
demonstrated that, if the artery continues full of
blood during the experiment, this fluid is coagu-
lated, and altered in a variety of ways bv the mor-
bid Becretion poured into it from the internal surface
of the inflamed vessel. Similar appearances have
been observed from disease, particularly in the
aorta and large arterial trunks, where they are
most obvious. Mr. Hodgson and M. Bouu.la.ud
found the internal surface of the aorta lined with
a perfect false membrane; and when this was re-
moved, the surface of the vessel was of a bright
red colour. M. Andral has observed the inter-
nal membrane of the artery raised by small ab-
scesses, sometimes as large as the size of a nut,
■ I between the internal and middle coats.
It is probably to the bursting of those into the
vessel that ulceration of the internal tunics is
owing. Pus is also sometimes found in the in-
terior of arteries, either unmixed with the hlood,
or mixed with it and altering its appearance.
59. E. Atheromatous matter is frequently
found between the inner and middle coats of ar-
teries. It was first noticed in this situation by
Monro and Hai.lkr. It is generally of the
consistence of suet, of a cheesy opaque appear-
ance, is greasy to the touch, with minute gritty
particles thinly scattered through it. In some
cases it resembles more nearly a semi-concrete
pus, and seems to result from the changes which
pus may have undergone subsequently to its
secretion. In other cases the atheromatous mat-
ter abounds in gritty particles, which occasionally
even exceed trie suety part; and the deposition
thus passes into the form of a calcareous concre-
tion. It is extremely probable that these varieties
of morbid formation are connected with chronic
inflammatory action of the coats of the vessel.
60. A variety of the atheromatous matter has been
described by Morgagm, Scarpa, Stf.ntzel,
and Craigie, under the denomination of steato-
matous deposition. The name, however, as Dr.
Craigie has remarked, is not well chosen, inas-
much as this formation is not adipose, but a firm
cheesy or waxy matter, of a yellowish or fawn
colour. It seems merely a more concrete variety
of the foregoing, and differing from it chiefly in
the absence of gritty particles. It is more fre-
quently found at the bifurcations of arteries, but
it is not limited to those situations; and is gene-
rally deposited between the inner and middle
coats. When the quantity of this matter is con-
siderable, it encroaches on the calibre of the ves-
sel. This substance is met with either alone, or
with patches of calcareous deposit. It probably
derives its origin from a similar source to the
atheromatous matter; and, according to Scarpa,
always terminates in ulceration: but this is not
invariably the case, as it has been observed, par-
ticularly when unattended with calcareous form-
ations, distending the coats of the vessel to a great
extent without any ulceration. This change,
however, takes place very generally, either when
the deposition of this matter is considerable, or
when associated with calcareous formations.
When ulceration takes place, the coats of the
vessel are soon destroyed to a greater or less ex-
tent, and rupture follows; taking place, as shown
by Mr. Hodgson, in a transverse direction to the
axis of the vessel, and giving rise to extensive or
fatal hasnorrhage, or to circumscribed or diffused
aneurism, according to the situation of the aper-
ture in the vessel.
61. F. Calcareous or osseous concretions are
the most frequent morbid appearances presented by
arteries. These concretions, however, differ from
healthy bone chiefly in wanting the fibrous struc-
ture, in not being necessarily deposited in a car-
tilaginous matrix, in consisting of a larger pro-
portion of phosphate of lime, and less animal
matter, and in presenting an irregular, homo-
geneous, and unorganized appearance. Bichat
and Baillie considered that the larger proportion
of persons above sixty years of age have some
part of the arterial system affected by these form-
ations. This change is very seldom observed in
early life. Yoi NG found it, however, in an infant;
Wilson in a young child; and Andral in the
aorta of a child of eight years of age. M. Andral
has met with Ossific lamina' in the aorta, in five
or six persons of from eighteen to twenty-four
years of age: and an extensive ossification of the
120
ARTERIES — Ossification of.
superior mesenteric artery of a person not quite
thirty. This species of formation always is seated
between the muscular coat and the internal mem-
brane, which it often detaches from its connec-
tions ; and it originates either in the atheromatous
matter described (§ 59.), the place of which it
sometimes takes: or in those whitish patches, al-
ready uoticed, which apparently consist of an
albuminous exudation formed between the inner
and middle coats, and which pass from the albu-
minous, first to the cartilaginous state, and sub-
sequently to that of bone.
62. a. But this is not the only change which
the vessel undergoes; for, whilst the calcareous
deposits are going forward, the middle coat be-
comes either hypertrophied, thus contributing to
the thickened appearance which the vessel some-
times presents, or atrophied, being apparently re-
placed by the calcareous concretion, and leading
to the mistaken opinion that this coat itself has
been transformed into bone. The osseous con-
cretions exist in various forms: sometimes they
consist of minute grains; at other times of irregu-
lar plates of different sizes; occasionally they in-
crust the artery and convert it into an inflexible
tube; and, more rarely, they give the sensation
of a number of small bodies moving on each
other, and as if jointed together.
63. The ossitic concretions may be very con-
siderable, without in any way changing the calibre
of the vessel, or even its form; or they may pro-
ject into it so considerably as to obstruct, or
even to obliterate its canal. They thus occa-
sion gangrana senilis. It has even been supposed,
— and the opinion is very probable, — that they
may project through, or penetrate, the internal
membrane, and fall into the cavity of the vessel ;-
and, being conveyed onwards with the current of
blood until they arrive at arteries of smaller ca-
libre, may thus completely obstruct them. The
calcareous concretions found in some rare instanc-
es plugging up the canal of the vessel, evidently
are produced in this way.
64. 6. As to the comparative frequency of this
lesion in various arteries, I may add a few re-
marks, derived from the interesting materials
supplied by M. Andral {Anat. Path. t. ii. p.
395.). The aorta is the most liable of any to
ossification in some part or another; but every
one of the branches proceeding from it may like-
wise be the seat of this change. The coronary
arteries are frequently ossified, both in their
trunks and in their subdivisions. The large ves-
sels which arise from the arch of the aorta often
present at their origin a bony ridge projecting into
their interior. The cerebral arteries of old per-
sons are frequently found studded with cartilagi-
nous and osseous laminae; and J\I. Bouillaud
has shown that this change disposes remarkably
to apoplexy with sanguineous extravasation. Os-
sification is very common in the splenic artery,
but exceedingly rare in the hepatic, and coronary
artery of the stomach. A bony ridge is often
found at the origin of the common iliacs. The
arteries of the lower extremities are not infre-
quently the seat of these concretions; and they
sometimes occur in the radial artery of aged per-
sons. M. AndraL has never met with this al-
teration in the hypogastric artery. IIai.t.er met
with it once in this vessel (Opusc. Path. Obs. 59.);
and this is the only case of the kind on record.
— All the morbid depositions described above
have been found in the pulmonary artery, but
much more rarely than in the aorta and vessels
proceeding from it.
65. c. Origin of osseous formations in the
arteries. — The ossification of arteries has been
ascribed by many authors to slight chronic in-
flammatory action. The experiments ofM. Rayee
and M. Cruvkilhif.r seem to confirm this infer-
ence, as an occasional occurrence at least, parti-
cularly in the fibrous and cartilaginous structures:
increased vascular action of those structures,
artificially excited, being generally followed by
ossiform depositions; but, m a number of cases
particularly m those where the deposit takes
place in the cellular tissues, no inflammatory ac-
tion can be detected previously to this change:
besides, increased vascular action frequently ex-
ists, without being attended with ossiform depo-
sitions. This lesion, therefore, cannot be alto-
gether ascribed to this cause, although frequently
resulting from it, in a certain order of tissues.
It would be more correct to consider it merely as
a consequence of disorder of the natural process
of nutrition and secretion, frequently induced, in
particular tissues, by a chronic state of inflam-
matory action. But to what cause is this disorder
of the nutritive function to be imputed, particu-
larly when it occurs in parts which have not
evinced any si;_rn of inflammatory action, as in
the cellular tissue connecting the internal coats
of arteries ? The importance of this enquiry may
appear from the very great proportion of persons,
in advanced years, who are affected, in some
organ or tissue, with this lesion, and from the
remarkable part it perforins in the production of
a number of diseases of the most dangerous de-
scription.
66. In answer to this, ."VI. Andral very plau-
sibly observes, that physicians have frequently
noticed the existence or succession of three dif-
ferent forms of calcareous productions in per-
sons of a gouty diathesis: 1st, gravel and urinary
calculi; 2d, hard concretions in the small joints;
and, 3d, ossiform productions in the arterial sys-
tem, and other parts, is it not, therefore, probable
that morbid ossification proceeds from a similar
cause to those other calcareous formations? We
have seen that gout generally originates in an
excessive use of animal food, conjoined witii
deficient assimilative and secreting powers of
the frame. The highly azotised blood of a per-
son thus circumstanced becomes surcharged
with urea and phosphate oi' lime, as evinced by
the state of the urinary secretion, which always,
in such cases, abounds with uric acid and tlie
earthy salts. The experiments of M. Magxndib
have proved, that by changing the diet of a per-
son who has been living chiefly upon animal food,
and by substituting substances containing no
azote, the uric acid and phosphates disappear
from the urine. May we not. therefore, infer that
in consequence of the excessive use of animal
food, conjoined witli imperfect assimilative and
secreting powers, these substances will accumu-
late in the blood to a hurtful extent: the urinary
organs being unable to eliminate them entirely
from the circulating fluid? The necessary result
of this state of the blooifwi'.l be, that these sub-
stances will occasionally be deposited in other
parts, giving origin to the uric acid concretions
ARTERIES — Treatment of their Diseases.
121
found in the small joints, nnd to the phosphate of
liine deposits found in the arterial system and
801110 other parts. From this it will be apparent
that the ossilic formations met with in the arteries
are derived from a similar origin to that which
has been more fully explained under the articles,
(Jout, and Urinary Calcuei. The increased
vascularity, ohserved frequently to co-exist with
the morbid secretion of calcareous matter, may
proceed from the irritation produced in the capil-
laries by the morbid matters circulating in them;
or it may be a necessary attendant upon the se-
cretory process, especially when this process is
of a morbid description; or the accidental occur-
rence of irritation and increased vascular action
in the interior coats of the vessel may prove the
determining cause of the ossiform deposit, to the
formation of which a disposition bad previously
existed, owing to the excessive abundance of the
phosphates hi the blood. If this explanation of
the origin of ossification in the arteries be correct,
a rational method of preventing and combating
this lesion is presented to us for adoption.
67. Treatment. — A. The more acute states
of arteritis require the same general principles
and details of treatment as inflammations of other
parts. General and local depletions, calomel,
and oleaginous purgatives, cathartic enemata, dia-
phoretics consisting chiefly of camphor, antimony,
and opium, &c. (F. 39. 184. 358. 460.); cool-
ing diluents, and the rest of the antiphlogistic
regimen, are indispensably requisite. After a
copious depletion, practised so as not to occasion
full syncope, the following will be found of ser-
vice in preventing the re-accession of increased
vascular action.
No. 33. p. ('amphora rasa; gr. iij.— v. ; Pulv. Jacolii
Vei i gr. v. (vel Aiitimonii Tartar, gr. ss.) ; Calomel, gr. xii. ;
Opii I'm i gr. ij. — iij.; C'onserv. Rosar. q. s. ut fiat Bolus,
slatim post venaesectioncin capieudus.
68. In the more acute states of arteritis, digi-
talis, and emollient diluents, with nitrate of potash,
or the vegetable acids, may be exhibited. After
depletions have been carried as far as may be
considered prudent, and when there exists no
constitutional vice contra-indicating the practice,
the mercurial preparations may be given to the
extent of affecting the gums. The repetition of
the bolus now prescribed will generally be suf-
ficient for this purpose, the bowels having been
well evacuated previously. In this form of ar-
teritis, Hildenbrand recommends (Instit. Med.
t. iii. p. 26.) cold epithems over the seat of the
inflamed vessels, the internal use of lemon ices,
and the cautious exhibition of the superacetate of
lead and opium (F. 206.), after depletions have
been practised. Colchicum may also be given, or
substituted for digitalis; but these medicines re-
quire great caution in their exhibition, particu-
larly after large depletions, and when antimonials
precede or accompany them. The diet ought to
be very low, cooling, and chiefly farinaceous:
and, during recovery, the more heating kinds of
animal food should be abstained from. During
the disease, as well as during convalescence, per-
fect tranquillity of body and mind should be in-
sisted on.
69. In some states of acute arteritis, it may
not be advisable to lower the powers of life too
much; as we may thereby risk the occurrence of
arterial throbbings, the extension of disease along
11
the internal membrane of the vessel, and the
vitiation of the circulating mass by the secretion
poured into it from the inflamed surface. The
tendency also to limit the inflammation by the
formation of coagulable lymph, when the period
of resolution is past, may also be overcome by too
great depression of the vital energies, which ought
therefore to be supported in extreme cases, and
not depressed too low in others.
70. B. Ihe more chronic states of arteritis
require cooling purgatives, occasional depletions,
and a low refrigerant diet and regimen. A vege-
table, particularly a farinaceous diet, is extremely
serviceable in these states of the disease, chiefly
by preventing the consequences to which they
usually lead. The richer and more stimulating
kinds of animal food, and particularly pork, should
be constantly avoided, and all tendency to ple-
thora suppressed or subdued. In the chronic as
well as the acute diseases of arteries, physical
and moral tranquillity is particularly required.
The abdominal secretions and excretions ought to
be duly examined and regulated, undue sinking of
the vital energies prevented or counteracted, pure
air prescribed, and due attention paid to the first
indications of disorder of the digestive functions.
71. C. The consequences of inflammation of ar-
teries, whether those more palpable changes which
constitute the different kinds of aneurism, or those
which are merely matters of more doubtful in-
ference, can be treated only upon the above
principles : above all, vascular plethora must be
avoided, and tranquillity observed. There is,
however, one fact, which, I consider, should not
be lost sight of by the practitioner, and which is
the result of attentive observation; namely, that,
even in aneurism, more mischief than advantage
will be derived from depressing the vital energies
of the frame too low, than from observing a more
moderate, or rather a less vigorous, mode of treat-
ment. When carried too far, relatively to the
circumstances of the case, those guards which the
restorative powers of the frame set up against the
extension of the disease are thrown down; the
destruction of adjoining parts extends; the fibrous
coagula which fortify the weakened parietes of
the vessel, and tend even to a spontaneous cure
of the disease (§ 50.), assume, as Mr. Guthrie
has very justly remarked, a loose and spongy
state, and allow the blocd to pass through it, or
between it and the coat or coats of the vessel;
and the disease, consequently, makes rapid pro-
gress. There can be no doubt, as hinted at by
this eminent surgeon, that the extension, and
ultimately the bursting, of aneurisms, are not
altogether owing to the impetus of the blood in
the vessel ; and that, therefore, the treatment
which is solely directed to this point must be de-
ficient. The suggestions now oftered (§§ 69,70.),
as well as those stated hi the article on Aneurism
of the Aorta, will be sufficient to guide the prac-
titioner in this respect.
72. D. The complications of inflammations of
arteries, and their consequences (§ 32. ct seq.),
require attention to the fact, that, when arteritis
supervenes in the course of other diseases, it is
generally during those stages which are charac-
teiised by depression of the constitutional powers,
when the circulating fluid becomes materially
changed from its healthy condition, and most
probably loaded with an unusual quantity of
122
ARTS AND EMPLOYMENTS — as Causes of Disease.
unnssimilated, morbid, or irritating materials.
Indeed, these are the circumstances which favour
the occurrence of all inflammations affecting the
different circulating systems — the lymphatic as
well as the venous; and they account at the same
time for the very frequent association of* arteritis
with phlebitis, particularly in the last stages of
febrile and eruptive diseases. These considerations
naturally suggest the propriety of having recourse
to such measures as may be best suited to indi-
vidual cases for the prevention of inordinate de-
pression of the energies of life, during the advanced
stages of diseases, when we fear the supervention
or the existence of arteritis; or as may support
those energies, whilst we excite the organs whose
functions are chiefly to eliminate irritating and
hurtful matters from the circulation. By thus
opposing too great depression, further deterioration
of" the blood is more likely to he prevented than
by any other indication of cure; whilst the re-
moval of the cause, — the source of irritation of
the internal surface of the vessels, — presents a
probable chance of the disappearance of its effects.
(See Aorta — Diseases of.)
BIBLIOGRAPHY. — A. Inflammation and its Consequen-
ces.— Licngsvert, De Art, ft Venar. Adfectibus. Prag.
1764. — Morgagni, De Sed. e( Caus. Morb. Epis. xxvi. art.
So. 3G. — Oehme, De Morbis Recent. Natorum. Lips.
1773. — J. P. Fiank; De Curandis Hominum Morbis, t. ii.
Maul). 17JI2. — S hmuck, Observat. Med. de Vnsor. Sanguif.
Inflammations Heidelb. 1794. — Spangenberg, in Hani's
Arcliiv fur Med. &e., b. v. 2. Heft., n. 1. — Saase, Dissert,
de Vasor. Sanguif. Inflammatione. Jlal. 1797. — Portal,
Anatomie VI d>i lie, I. Iii. p. 127. Paris, 1803> — Schvrilgue,
in Biblioth 1 1 1! e Medicate, t. xvi. — Treviranus, Biologic,
b. v. p. 414. — J. Hodgson, Diseases of the Arteries and
Veins. Loud. 1815. — Rimer, Dissert, de Plethora Sanguin.
Jlelmst. 1797. — Kreysig, Herzkrankheiten, iii. theil. Ber.
1817. s. 2d9.— Dalbant, Observat, poiir servir a I'Hist. de
I'Arttrite. Paris, 1819.— Bryant, in Londs Med. Repos. t.
xviii. p. 6. — f^aidy, in Journ. Complement. Aolt, 1819.
— Bach, in Revue Medicate, Mai, 1820. — Kennedy, in
Johnson's Med. Chirm g. Review, vol. ii. p. GO. — Breschet,
De l'Artciitc, Journ. de Progres de Scien. Med. t. \\ii. p.
l 9. Par. 1829. — Bouillaud, Art. Artirite, in Diction.de
Med. et Cbirurg. Pratique, t. iii. Par. 1829. — Langanbeck,
Nosol. uiid Therapie d. Chir. Krankh. bd. i. p. 539.
Gotting. 1822 — tfaiimann, Arteritis, Medirin. Chirurg. En-
cyclopedic, band. iii. Berlin, 1829. — V. N. Hildenbrand,
Institutiones Practico-Medicae, t. iii. p. 21. Wien, 1822.
;;. Morbid Structures, (cc. — Cowjper, Philosoph. Trans.
No. 285. p. 1391. —Nuis/,, Ibid. No. 369. p. 226. — Morg-
agni, De Sed. et Cans. Morb. Epist. xxiii. ar. iv. '3., xlvi.
ar. 20. — Fdse.'ii' , Dissert, sbtens Morbos Arteriarum, &c.
Jena, 1757. — Gemma, in Haller's Biblioth.. Med. Pract. ii.
p. (98. _ Walter, Observ. Anat. p. 41. — Stenstel, Haller's
Disp. ad Morb. Historian!, &c. t. ii. p. 527. — Bichat, Anat-
,•111 Gcnirale, t. ii. p. 293. — Baillie, Trans. oi'Society for
Imp. of Med. and Chir. Knowledge, vol. ii. p. 133. —
WenzeX, in HufelancVs Journ. der Pract. Arzeneykunde, b.
viii. st. 4. p. 160. — Scarpa, Sull' Aneurismo, cap. v. § 22.
— ! 'hausi ti '. in Journ. I i ru'r. de Mid. Mars, 1811. p. 313.
— Maunoir, in Ibid. Mars, 1811, p. 323 — Hagstrom, in
Hufeland u. Hirhly, Journ. der Pract. Ileilk-, Jul. 1811, p.
121.— Travers, in Wed, ami Chirurg. Trans, vol. iv p, 38.
— Telloly, thid. vol. xii. p. 565. — Mondini, Archives Gen.
de Mtd. t. v. p 137. — Turner, Trausao. of .Med. and Chir-
urg. Soc. of Edin. vol. iii. p. 105. — Craigie, Elements of
Gen. and Pathol. Anatomy, p. 87. — A- Monro, in Edin.
Journ. of Med. Sciences, vol. ii. p. 351. — Andral, On Pa-
thological Anatomy, by I'cnuusena, vol. ii. p. 367. — Gttthrie,
The Diseases and" Injuries of Arteries, 4tc. Lond. 1830.
<A work that should lie in the hands of every practitioner.)
ARTHRITIS. (See Gout.)
ARTS and EMPLOYMENTS. — 1. Pa-
thology'.— Etiology. — An infinity into diseases
caused by the prosecution of the various arts of
civilised life is of the utmost importance to the
scientific professor of medicine in all countries,
but. particularly in this; for in no other country
are the useful arts so extensively prosecuted as in
Great Britain. The great importance of the sub-
ject has been acknowledged by the success of the
able works of Ramazzim, Merat, Patissier,
and Thackrah, on the diseases of artisans.
2. As it would be foreign to my plan to take
into consideration at this piace the diseases occa-
sioned by the numerous arts which furnish em-
ployment and subsistence for a very large part of
the population of this and many other countries;
particularly as these diseases will be considered
in their more important relations in other places,
and many of them under distinct articles; I will
here confine myself to a succinct account of the
effects which the prosecution of the various useful
arts directly or indirectly produce in the frame;
interspersed with a few remarks as to their influ-
ence in modifying the characters of various dis-
eases, and as to the means by which their injurious
effects may be partially prevented or counteracted.
3. In offering these observations, I will only,
in some respects, observe the arrangement adopted
by Ramazzini, and closely followed by Fm. r-
croy and Patissier. This arrangement is
founded on the nature of the causes producing the
diseases to which artisans are liable. The First
Class of causes consists — 1st, Of co}ifinemetit, and
insufficient ventilation ; 2d, Of undue exertion ;
and, 3d, Of sedentary habits. The Second
Class comprehends— 1st, Undue exertion of
particular parts, and insufficient exercise of other
parts ; 2d, Unnatural or constrained positioia
in different employments ; and, 3d, Temperature
and moisture. The Third Class embraces
those causes which consist of materia] molecules,
and which, coming directly or mediately in contact
with the body, in the state either of vapour or of
minute disintegration, penetrate the organs, and
disorder their functions. These are — 1st, Mineral
molecules ; 2d, Vegetable molecules ; 3d, Animal
molecules; and, 4th, Mineral and vegetable mole-
cules acting mechanically. On the operation and
effects of each of these, as being intimately con-
nected with the nature, complication, and removal
of diseases, I proceed to otler a few remarks.
4. I. Class first. l?t. The hurtful influence
of confinement, and of insufficient ventilation, is
great in proportion to the youth or early years of
those who are thus circumstanced. In the ma-
jority of factories, artisans are congregated in great
numbers, necessarily confined during the greater
part of the day in the same apartment, which,
being usually warmed by artificial heat, — by pipes
conducting heated air or steam,— have not the air
renewed with that rapidity which necessarily ob-
tains in apartments provided with the fire-places
in common use. The consequences are, that
those confined in them breathe an impurer air
than under ordinary circumstances ; and expe-
rience the debilitating influence occasioned by an
atmosphere loaded with an increased quantity of
carbonic acid gas and animal effluvia.
5. Persons who have already attained to their
full growth, and those particularly who have
nearly reached the meridian of life, seldom ex-
perience the deleterious effects of confinement
under such circumstances, to nearly the same
extent as those in early life. When the subject
was brought before parliament by Sir Robert
Peel, Mr. Owen of New Lanark stated, respect-
ing the children employed in his manufactory, that,
although they were extremely well fed, clothed,
ARTS AND EMPLOYMENTS — as Causes of Disease.
123
and lodged, looked fresh, and, to ;i superficial
observer, wore healthy in their countenances, yel
their limbs were generally deformed, their growth
stunted, and they were incapable of making much
progress in the first rudiments of education. This
statement, which appears to have been made as a
result of large experience, agrees with the observ-
ations of other able men. The evidence of Sir
A-ri.F.v Cooper is even slill more decided, and
is perfectly in accordance with the experience of
ever] competent judge. The result of confine-
ment, this eminent surgeon states, is not only to
stunt the growth, hut to produce deformity. KVery
travelleriii countries, the population of which con-
sists chiefly of those whose avocations bring them
much in the open air, or in agricultural districts,
must have remarked not only the much more fully
developed frames, and larger lower extremities, of
the inhabitants of those parts, hut also the more
phlogistic or inflammatory characters of their dis-
orders, ami their greater vital resistance and pow-
ers of restoration when exposed to the causes, or
suffering fom attacks, of disease, than are mani-
fested by the inhabitants of crowded manufacturing
towns.
6. Not only is confinement in itself detrimental
to the frame, particularly during the epochs of
developement of the various structures of the
body, when air and exercise are nearly as requi-
site as food to their perfection, but the construc-
tion of the apartments, the want of ventilation,
the accumulation of animal effluvia, and the moral
depravation consequent upon continued assem-
blages of persons, little under physical or moral
control, essentially increase its injurious effects,
and co-operate with it in impressing an asthenic
character on the frame; in disposing to the for-
mation of tubercles, and to the strumous diathe-
sis; in depressing the vital energies and mental
manifestations; and, consequently, in disposing
the body the more to the usual exciting causes of
disease, and the mind to vicious habits and in-
dulgences.
7. 2d, Oser-erertion is a very frequent cause
of disease among many artisans; and, like con-
finement, it is the more injurious, the earlier in
life it comes into operation. In the lower ani-
mals, particularly in the horse, the consequences
of over-exertion are fully manifested. This ani-
mal sol,), mi reaches one half of its natural life as
employed in this and many other countries. As
to effects of over-exertion on man, much will de-
pend upon his habits and modes of living. When
well fed, and of regular habits, its injurious conse-
quences are neither so great, nor so soon appear,
as when he is poorly fed or addicted to the use of
spirituous liquors.
8. Over-exertion shortens life, 1st, by injuring
the continuity, cohesion, or relative situation of
various parts; 2d, by inducing tint degree of ex-
haustion which runs on to irremediable or fatal
■: and, 3d, b\ that gradual and insensible
expenditure of vital influence, beyond the power
of reinforcing it, whereby the moan duration of
human life is shortened. The trades which chiefl]
illustrate the above positions are coal-heavers, na-
vigators or ballast-dreggers, smiths, miners, &c.
9. It should not be overlooked, that in many
trades the artisan is not only subjected to confine-
ment in close and imperfectly ventilated apart-
ments, but is at the same time obliged to over-
exert his physical powers. In such cases the ill
effects are necessarily greatly augmented; more
especially in children or very young persons, who
are naturally impatient both of confinement and
over-exertion; and in them particularly are the
injurious effects, moral as well as physical, chiefly
in. aiif.sted. Many of those who become the most
drunken, immoral, or feloniously depraved, have
been initiated in vice from the associations formed
in factories.
10. 3d, Sedentary habits are also adverse to
health, but only in a negative manner, as respects
persons living in well ventilated and wholesome
situations. 'I he simple neglect of clue exercise,
however, is after a time generally productive of
disease, owing both to its effects upon the nervous
anil muscular energies — the manifestation of all
our functions being improved by a moderate ex-
ertion of them — and to its influence on the se-
cretions and excretions, which require a certain
degree of muscular exercise for their promotion.
Literary men suffer in a particular manner from
want of bodily exercise, chiefly owing to the
over-exertion of the mental powers, the bent
position of the trunk, and the stagnant air of close
apartments. Clerks, and various artisans, suffer
also from the same cause, particularly tailors,
shoemakers, watchmakers, weavers, jewellers,
&c. In some of these the pressure made upon the
lower part of the sternum and stomach proves
very injurious.
11. .Air. Dop.son furnishes very instructive in-
formation as to the effects of confinement to a
particular posture and in a close atmosphere upon
tailors. Of 334 men, employed by Stultz & Co.,
in London, six are above sixty years of age;
fourteen about fifty ; and the greater number of
the remainder about forty. Three of the six
above sixty have curvature of the spine. Their
most common affections are dyspepsia, diarrhoea,
headache, giddiness, and anal fistula, to which
latter they are so subject that they have a " fistula
club."' They attribute their complaints to the
bent posture of their bodies for thirteen hours a
day, and the heat of the workshop. Tailors are
the most intemperate set of workmen in London.
A large proportion of them die annually of phthi-
sis. (Thackrah, &c. p. 17.) The diseases
most commonly observed amongst shoemakers
are chronic inflammations of the stomach, liver,
and bowels, occasioned bj the pressure of the last
on the lower part of the sternum, where it occa-
sions, in those who are long-lived, a considerable
depression.
12. The sitting posture, when long or habit-
ually continued, is very hurtful in persons of
sedentary habits. M. Patissier remarks, that it
causes the lymphatic to predominate over the
nervous, sanguiferous, and muscular diathesis.
Artisans and others who adopt it early in life,
acquire vigorous constitutions, or reach
old aire, although old age soon overtakes them.
ons with this habit soon become subject to
dyspeptic disorders, to affections of the kidneys
and urinary organs, to constipation, haemorrhoids,
various cachectic affections, obesity, and, in fe-
male-, to fluor albus, and diilicult or irregular
menstruation. When, in addition to a long-
continued sitting posture, the trunk is bent, and
pressure frequently made over the epigastrium
and sternum, as with shoemakers, weavers, at-
124
ARTS AND EMPLOYMENTS — as Causes of Disease.
torneys' or bankers' clerks, &c, gastrodynia,
nervous palpitations, chronic gastritis, pulmonary
consumption, chronic pericarditis, and imperfect
digestion, excretion, and assimilation, amounting
even to complete asthenia, are the not infrequent
results. The hurtful effects of the sitting posture
and bent state of the trunk are much increased by
deficiency of food on the one hand, or by too full
living on the other; and by habitual excesses of
any kind, but particularly in the use of ardent
spirits.
1 3. Literary men who are of sedentary habits
are liable both to the disorders which result there-
from, and to those which depend upon over-
exertion of the mental faculties. Amongst the
latter, melancholy, hypochondriasis, cephalalgia,
paralysis, apoplexy, palsy, inflammation of the
brain or of its membranes, mania, and softening
of the brain, hold a prominent place. All these
evils are, however, in a great measure prevented
by moderate diet and regimen, by avoiding ex-
cesses of every description, by regular and mode-
rate exercise in the open air, by early rising, by
sufficient but not too much sleep, with attention
to the digestive organs, and to the promotion of
the abdominal secretions and excretions.
14. II. Class Second. 1st, The undue exer-
tion of particular organs, with or without insuffi-
cient exercise of other parts, is often productive of
most injurious effects; but much of the evils im-
puted to this cause by MM. Gosse, Merat, and
P atissier, are either imaginary, or merely matter
of occasional coincidence. A. The consequences
of undue muscular exertion are chiefly hernia,
aneurisms of the large vessels, dilatation of the
cavities of the heart, haemorrhages from the lungs
or nose, injuries of the ligament* and intervertebral
spaces, sprains and lacerations of muscles; and
are chiefly met with among those occupations that
are of a laborious kind, as porters, coal-heavers,
draymen, &c. Of all these injurious consequences,
hernia are very much the most frequent. Amongst
nil those persons who bring the back and superior
extremities into frequent energetic exercise, it will
be observed that the muscles of these parts are not
infrequently developed either at the expense of
those of the lower extremities, or to a degree far
beyond them. This partly arises from the shuf-
fling gait of those persons, and from not throwing
the gastrocnemii muscles into action.
15. B. Over-exertion of the vocal organs is
not infrequently productive of disease. The
affections which proceed from this cause are
haemoptysis, laryngeal phthisis, aphonia, a-dema
of the glottis; functional, and subsequently or-
ganic, diseases of the heart and large vessels;
nervous and cerebral affections. The persons
most liable to be affected by this cause are public
singers and orators; but I believe that the ill
ejects resulting from it, in any of the above states
of disease, are not so great nor so frequent as
some writers have stated. Much of the mischief
imputed to this cause is referable rather to the
enthusiasm of singers and orators, to the passions
which are called up during the exercise of their
powers, and to the various dissipations and ex-
posures into which their vocations lead them.
The occurrence of musico-mania from excessive
musical enthusiasm is known to all physicians.
It is obvious that the first signs of the accession
of the above diseases in the persons of singers
and orators, require strict avoidance of the
cause.
16. C. The continued or intense action of light
on the eyes, and application of them to small
objects, as amongst workers at iron forges and
furnaces, engravers, watchmakers, embroiderers,
painters, &c, are often followed by injury to, or
entire loss of sight; persons thus employed being
liable to amaurosis, cataract, inflammation of the
retina, iris, or capsule of the lens, and to short-
sightedness, owing to the more convex form the
eye acquires from continued compression, by the
muscles attached to the eye-balls.
17. 2d, Unnatural or constrained positions are
extremely injurious in the prosecution of any ait
or employment. Occupations that require long-
continued standing have been said to be produc-
tive of varices in the lower extremities; but I am
not aware that such afiections are more common
amongst printers, who usually stand at the frames,
than in other persons. 1 here is no doubt of
undue pressure made upon any particular part of
the body in the exercise of any art or trade, or
even slight pressure when long continued, being
most injurious. '1 bis is remarkably the case when
the pressure is made upon the abdomen, particu-
larly over the epigastrium, and still more so if it
impede the actions of the respiratory muscles.
Various occupations, which are injurious from this
cause, might be pursued with great assiduity by
attending to those circumstances, many of them
trivial, which may remove or counteract it. Thus
clerks, and others, who are often injured by stoop-
ing over a desk, and by pressing the chest against
it, as well as by the sitting posture too long con-
tinued, would be much benefited by frequently,
or even occasionally, standing at a raised desk.
Tailors and shoemakers are also very liable to
suffer from this cause. The stooping posture
is not infrequently productive of cerebral and
nervous affections; hence the frequency of them
in gardeners. Working in constrained positions
shows its effects most decidedly in miners and
colliers, who labour chiefly in the sitting or
kneeling posture, frequently with the body bent
in the greatest degree, in an unnatural atmos-
phere, often containing hydrogen, or carburetted
hydrogen, and carbonic acid gases, and with
artificial light. They are, moreover, exposed to
changes of air, and occasionally work with their
feet in water. They are generally spare men,
with slightly curved spine, and bowed legs.
When the dirt with which their skin is usually
loaded is removed, the complexion seems sallow
and unhealthy. Their complaints are asthma,
rheumatism, disorders of the head, intolerance of
light, &.c, evidently resulting from the circum-
stances just stated, connected with their employ-
ment, and their exclusion from the beneficial
influence of sunshine, light, and air. They are
not generally very intemperate, yet they seldom
live beyond fifty.
18. 3d, Temperature and moisture, and par-
ticularly rapid vicissitudes of them, are extremely
productive of disease among artisans, but chiefly
from negligence, and the want of caution in ex-
posures to them. Forgers, glass-blowers, brass
and iron founders, bak^s, brewers, and various
other classes of artisans, are liable to be affected
by the high temperature in which they work, and
by imprudent exposure to cold, when perspiring,
ARTS AND EMPLOYMENTS — as Causes ok Disease.
12.5
and often without an) additional clothing. The
most frequent consequenoea i ihecked perspir-
ations, producing catarrhs, rheumatism, bronchi-
tis, asthma, and inflammation of the lungs, or of
one of the abdominal viscera.
li». (.'. The bad effects of moisture only are pro-
blematical, or at least not very remarkable. It
in only from the circumstance of its being either
the cause of a greatly depressed temperature, or
the very common vehicle in which oilier agents
of disease are dissolved, and thereby diffused in
the air, or applied in a more active state to the
different organs, particularly the respiratory, that
it becomes a very active agrnt of disease, a< is
demonstrated by the etiology of the intertropical
and malignant diseases. When exposure of the
external surface of' the body to moisture is inju-
rious, the mischief is caused chiefly by the de-
pressing effects of the low temperature which it
■us. The animal heat is less rapidly car-
ried oft by entire submersion in water, than by
aspersion merely. In the former case there is no
evaporation, in the latter more or less evaporation
takes place, and much cold is thereby generated.
The histories of shipwrecks abound in proofs of
this position. Dr. Gukrie, in his well known
work, has adduced a striking example of it. It
is owing to the evaporation which takes place
from damp or moist clothes, and the consequent
rapid reduction of their temperature, that disease
is occasioned by them.
20. Artisans who, from the laborious nature of
their occupations, perspire copiously, and thereby
render their clothes damp, seldom suffer from
this cause while they continue their labours; but
when they relax, or desist altogether, their wear-
ing the moistened clothes, particularly in a state
of exhaustion, is frequently productive of disease.
Inattention to, or inability of, changing damp or
wet clothes, are the most common causes of the
disorders met with in milkmen, gardeners, fish-
ermen, washerwomen, fullers, water carriers,
and persons whose occupations are chiefly out of
d tors. !n marshy or unhealthy localities the ef-
fects of this cause are greatly increased. The
sleepers and cleaners of hemp and flax are ex-
tremely liable to intermittent^, owing to the con-
junction of vegetable effluvia with moisture. Even
p srsons constantly employed in crowded factories,
al air becomes loaded with the
fnil vapours exhaled from the lungs of a number
of persons, may have their clothes so saturated
with moisture as thereby to occasion the usual
consequences of col. I, when exposed to a drier or
aj : It should be kept in recollection, that
cold, when it continues to act for any time upon
t! ■ fram >., is sedative — it depresses the vital influ-
en ■■•: and, when acting partially, or directed to
parts of the body only, that it is one of the most
productive causes of altered energj and sensibility
o!" the nervous system of such part, of irregular
distributions of vital influence and of the blood,
and consequently fruitful of inflammations, and of
morbid discharges and actions.
21. b. The prevention of diseases resulting from
the description of causes adduced under this head
is import ant. Wearing flannel next the skin is
amongst the most efficacious. For those who
are exposed to moisture from out-of-door voca-
tions, the use of external garments of dressed
skins, or of tanned leather, or of oil-skin, during
11*
the time of exposure, is extremely serviceable,
and is generally adopted by the fishermen of
northern countries.
22. III. Class Third. 1st. The mineral
molecules, which, either in the form of vapour or
of minute disintegration, come in contact directly
or immediately with various partsofthe body, are
extremely frequent causes of disease in artisans,
and some of the maladies they produce are pos-
sessed of specific characters.
23. A, Mercury is one of the most common
causes of the diseases of artificers, particularly
workmen in quicksilver mines, glass-platers, gil-
ders of buttons, toys, &c. Dr. Gosse has re-
marked the greatly increased sensibility of those
persons to cold, even to the slightest diminution
of temperature, evidently owing to depression of
the vital energy and organic actions, and conse-
quently of the process of animal calorification.
Persons long or habitually exposed to fumes of
quicksilver are generally affected with ulcerations
of the mouth and fauces ; painful or rheumatic
affections of the periosteum, joints, limbs, and
ligaments, particularly after exposure to cold ;
eruptions on the surface of the body, and all the
affections, to which the term pseudo-syphilis has
been applied; as well as many of those which
are usually denominated cachectic. The effects
are altogether the same, although slower in their
accession and progress, as those which result from
a too long continued, but not violent mercurial
course.
24. a. Amongst the most important of the affec-
tions produced by the fumes or oxides of mercury
in artisans is the mercurial palsy, the tremblement
mercurial of the French pathologists. It is almost,
but certainly not altogether, peculiar to these per-
sons. Its approach is generally gradual, but oc-
casionally sudden ; it usually commences with
slight convulsive snatches, followed by agitations
and tremors of the affected muscles, particularly
those of the arms, which it first attacks, occurring
as it commonly does amongst the workers in mer-
cury. If the person continues his employment,
the affection extends to the lower extremities and
whole body. He becomes incapable of muscular
exertion, and even of the avocations requiring the
least precision of muscular action. Restlessness,
falling out of the teeth, constipation or disorder
of the bowels, a dry and brownish state of the
skin, slight atonic convulsions, cephalalgia, delir-
ium, great depression of the nervous powers, and
of the general health, take place, in which state
the pati snt may continue to live for many years.
(Mi rat and CotsoN.) Although it is chiefly
long-continued exposures to mercurial prepara-
tions which produce this affection, a single ex-
posure to their fumes, even lor a few hours, when
the) float in the air, may occasion it; the effects
being both rapid and violent when their vapours
are inhaled with the atmosphere, and act upon
the extensive surface of the bronchial tubes and
air-cells.
25. b. The habits of the workmen exposed to
the fumes or oxides of mercury, render the. treat-
meni of this affection extremely difficult, owing
chiefly to the circumstances of their frequent re-
course to spirituous liquors, for the temporary ad-
vantage they afford, and to their deferring having
recourse to medical aid until the disease becomes
confirmed. In recent cases, leaving off the trade
126
ARTS AND EMPLOYMENTS — as Causes of Disease.
that occasioned it will alone produce a cure. In
long-continued or confirmed cases, benefit is ob-
tained with much more dilKculty; and, when pro-
cured, the disorder is extremely apt to return after
the slightest exposure to mercurial fumes. De
Haen prescribed electricity in the cases which
occurred to him. Lettsom recommended sul-
phur; and I believe that its good effects are very
considerable. In a case which lately came be-
fore me, of violent cephalalgia, with muscular
tremors, &c, after a severe mercurial course,
large doses of sulphur merely, given every night
in treacle, produced a cure in a few days. Mr.
Pearson chiefly relied upon exposure to a dry
and open air. Sementini states, that he obtain-
ed uniform advantage from the internal use of the
nitrate of silver, beginning with an eighth of a
grain, and gradually increasing the dose to three
grains in the day. I have lately employed the
tincture of iodine in two cases of this affection
With success; and in one case I lately prescribed
strychnine, but lost sight of the patient before its
effects were apparent.
26. c. It is obvious that it is of importance to
be in the possession of plans to prevent the injuri-
ous effects of mercury on tbose employed in the
arts in which it is used. These are sufficiently
simple, and consist chiefly of common attention
to cleanliness, and avoiding the fumes of the min-
eral during the various parts of the processes of
gilding. Workmen should avoid touching the
amalgams that are used with the naked hand ;
and ought to make frequent ablutions, particu-
larly before taking a meal. During the process
of volatilising the mercury by heat, the utmost
caution should be exercised in performing the op-
eration with a stove in which the current of air is
very brisk, so that the fumes may be carried fully
up the flue. In most of the manufactories in this
country, the stoves are now sufficiently well con-
structed for this purpose, the carelessness of the
artisan being the chief cause of danger from his
occupation. M. Jussieu states, that the free
workmen in the large quicksilver mines at Alma-
den, who took care to change their whole dress,
and attended to cleanliness, were but little affect-
ed by their occupation; but that the slaves, who
could not afford a change of raiment, took their
meals in the mine generally without ablutions,
were subject to swellings of the parotids, aphthous
sore throat, salivation, eruptions, and tremors.
(Mem. de VAcad. des Sciences, 1711), p. 474.)
27. B. Lead. a. Injurious effects from lead, in
the various states in which it is used, are very fre-
quent and often fatal. Its oxides may be car-
ried off in a state of vapour, dissolved in volatile
substances, as by turpentine in painting, and thus
be inhaled into the lungs, and act most injuriously
on the frame. It may also pass into the alimen-
tary canal in various ways, or it may be absorbed
from the skin, particularly of the hands, where it
will both act locally, and be carried into the sys-
tem, and produce its effects as when introduced by
the two former channels. These effects are chiefly
lead colic and paralysis. The workmen employ-
ed in lead mines, those who are engaged in pro-
curing it from its ores, who cast it or manufacture
its various preparations, and who use them in the
different arts, as plumbers, glaziers, painters in
oils or water-colours, colour-grinders, type-foun-
ders, printers, are the most liable to be affected
by lead; but all classes, under certain circumstan-
ces, may also experience injurious effects from it.
The deleterious nature of this mineral is certainly
very great; but the fatal results are surely not
one in three annually, as stated by Sir John Sin-
clair.
28. 6. M. Me rat has furnished some very in-
teresting information respecting the frequency of
colica pictonwn in the various classes of artisans
who come in contact with any of the different
preparations of lead. It is derived from the list,
kept at the hospital La Charite, in Paris, in the
years 1776 and 1811. The total number in both
years were 279. Of these 241 were artisans,
whose trades exposed them to the poison of lead,
viz. 148 painters, 28 plumbers, 16 potters, 15
porcelain makers, 12 lapidaries, 9 colour grinders,
3 glass blowers, 2 glaziers, 2 toymen, 2 shoe-
makers, 1 printer, 1 lead miner, 1 shot manufac-
turer. Of the remainder, 17 belonged to trades
exposed to copper. Of the 279 cases, 24 were
under twenty years of age, these being chiefly
painter boys, not above fifteeu; 113 were between
nineteen and thirty ; 66 between twenty-nine and
forty; 38 between thirty-nine and fifty; 28 be-
tween forty-nine and sixty; and 10 older than
sixty. Among the 279 cases, 15 died, or 5.4 per
cent. (See the article Colic, from Lead.)
29. c. The measures of prevention from the ac-
tion of the preparations of lead differ in no respect
from those which have been stated in relation to
mercury (§ 26.). They chiefly consist of strict
attention to personal cleanliness. The instructions
given by M. Me rat are very complete, but are
too particular to be followed by workmen. lie
recommends that the working clothes should be
made of strong compact linen, be changed and
washed once or twice a week, and be worn as
little as possible out of the workshop; a light im-
pervious cap ought always to be worn on the
head. The artisan should never take his meals
in the workshop, or without strict ablution of the
hands, mouth, and face; and he ought to break-
fast before leaving his home.
30. Derangements of the digestive organs ought
to be watched with care. If colicky symptoms
occur, he should leave off work, and take an
aperient. He ought always to guard against con-
stipation. The diet of those exposed to be affect-
ed by the preparations of lead is of consequence.
| It should be light and digestible; and poor acid
drinks ought to be avoided, particularly cider,
I as themselves often containing lead. Various
articles of diet have been recommended as cal-
culated to impede the hurtful action of lead on
the frame. Hoffmann mentions brandy — a
somewhat dangerous recommendation. Fat food
has been accounted preservative. De Hafn
states, that the workers m a lead mine in Styria
I were much affected by colic and pa!sy\ but, by
, being told by a quack doctor to eat a good deal
of fat, particularly at breakfast, they were exempt
from these diseases for three years (Rat. lied.
| p. i. ch. ix.). Similar facts respecting the good
| effects of fat meat, as a preventive of the effects
I of lead, are recorded by Sir George Baker
j (Trans, of Lond. Coll. of Phys. vol. ii. p. 457.),
| and .Mr. Wilson (Edin. Phys. and Lit. Essays.
I. p. 521.). Tbose who work at furnaces in which
I lead is smelted, fused, or oxydised, should be pro-
1 tected by a strong draught through them. Mr.
ARTS AND EMPLOYMENTS — as Causes of Disk ask.
127
Braid, of the extensive mines at Leadhills, in-
formed Professor Chbistison (see his 7no.1t valu-
abk irork on Poisons, kc. p. 506.), that wherever
furnaces of such a construction have been built,
the colic has disappeared.
31. C. Copper, although extensively used in
the arts, is seldom productive of much disease.
Patissier states, that the workmen in copper
become prematurely old, having a meagre and
sickly appearance. This is, however, as much
owing to confinement in ill-ventilated places, and
intemperance, as to the metal. Merat has ad-
duced evidence of their being frequently subject
to colica pictonum. They are likewise liable to
diseases of the respiratory organs, — particularly
those engaged in filing the metal; but this is en-
tirely owing to the mechanical irritation occasion-
ed by the finer particles when inhaled into the
lungs. Asthma is frequent amongst brass-foun-
ders, owing probably to this cause, and partly to
the vaporisation of a portion of the zinc with
which copper is amalgamated.
32. D. Zinc, arsenic, and antimony, are sel-
dom productive of hurtful effects amongst artisans;
owing probably to the first being chiefly employ-
ed in the metallic state, in which it has no elfeet,
although it is deleterious when oxydised; and to
the circumstance of arsenic and antimony being
generally used in small quantities.
33. E. The acrid vapours, which proceed from
the mineral acids often produce violent effects
when respired; chiefly asphyxia, and severe in-
flammation of the. air-passages; but they are eas-
i ' v guarded against, and chiefly by operating in
nearly open places. Persons who prepare arti-
cles for gilding, by cleaning them in aquafortis,
are equally liable to respire the vapours of these
acids, but may avoid them with even a moderate
share of caution. The inflammations of the re-
spiratory organs occasioned by them, differ mere-
ly in respect of their intensity, from the same
diseases proceeding in an acute form from other
causes. Chlorine gas, when respired in consider-
able quantity, produces inflammation of the air-
p iss:iges. The chief effects of habitual exposure
to it are acidities and other complaints of the
stomach. The trades in which workmen are ex-
posed to chlorine do not seem to be unwholesome.
Corpulent men are soon reduced by it to their
natural size. During the epidemic fever that rag-
ed all over Ireland from 1816 to 1819, the people
at the chemical manufactory at Belfast were en-
tirely exempt from it.
34. 2d. Molecules of animal matter in a state
of decay are frequently productive of disease, both
in persons whose avocations expose them fre-
quently to this cause, and in those who approach
it only incidentally. Nightmen are chiefly ex-
posed to this source of disease, particularly in
Paris. The gases evolved when emptying the
fosses d'aisances of that capital are frequently pro-
ductive of serious and even fatal consequences.
The exact nature of these varies with the vapours
evolved. Ammoniacal vapours usually occasion
what the French term la tnitte: sulphuretted hy-
drogen, hydro-sulphuretted ammoniacal gases, and
azote, produce le plomb.
35. A. The symptoms of la mitte are smarting
of the eyes, with the sensation of sharp or pun-
gent odour and uncomfortable feeling about the
nose. To these succeed pain, extending to the
forehead, and discharge from the eyes, occasion-
ally with blindness enduring for two or three days.
These effects, if not very intense, generally pass
off by shading the eyes, and exposure to the open
air: if they are more severe, the application of
cold epithems to the eyes, and protecting them
from the light, are usually efficacious.
36. B. Le plomb is of two kinds: 1st. that oc-
casioned by azote, and which is simply Asphyxy
(which see) from the privation of respirable air,
attended with coma or stupor; 2d, that caused by
sulphuretted hydrogen and hydro-sulphuretted am-
moniacal gases, which is the most dangerous and
common, and is generally attended with convul-
sions. (See Poisons.) The former is common-
ly prevented by a free circulation of air; the latter
is avoided by employing the chlorurets of lime or
of soda, a solution of which is poured in the pri-
vies, and reservoirs or drains, shortly before they
are emptied. (See Treatment of Asphyxy and
of Poisoning by deleterious Gases.)
37. C. The animal effluvia proceeding from
slaughter-houses, dissecting-rooms, chandlery or
adipocire manufactories, and other places where
animal substances are manufactured or employed
in the arts, are seldom so concentrated as to be
productive of disease ; but there can be no ration-
al doubt of their unwholesome influence when con-
centrated, or accumulated in a stagnant atmos-
phere. The liability of butchers and cooks to be
corpulent has been absurdly enough ascribed by
some superficial writers to the absorption of nu-
tritive particles from the air, without attending to
the fact of a much larger quantity of animal food
being taken by them than by any other class of
persons.
38. Dr. Withering had noticed (Letter to
Dr. Beddoes, 1793.) the comparative exemp-
tion of butchers and catgut-makers from phthisis.
M. Patissier has made the same remark; and
Dr. Beddoes has added to these employments
soap-boilers, and the fishermen and fish-wives in
the vicinity of Edinburgh. Glue and size boilers
are exposed to putrid and ammoniacal exhalations
from the decomposition of animal refuse. But
these workmen are generally fresh-looking and
robust. A similar observation is applicable to
buckram manufacturers. Tanners are subject to
animal vapours; but so combined with the odours
of lime and tan as entirely to counteract any in-
jurious effect which the former might produce.
They are much exposed to wet and cold; yet they
are generally healthy, robust, and tolerably ex-
empt from pectoral diseases, particularly consump-
tion. Mr. Thackrah states, that he has care-
fully enquired at several tan-yards, and could not
hear of a single example of this disease.
39. 3d, Vregttable molecules. Corn-millers suf-
fer remarkably from breathing an air loaded with
the particles of flour. They are chiefly affected
by indigestion, asthma, and morning coughs with
expectoration, terminating either jn consumption
or in asthma; and are generally pale, sickly, and
short-lived. This is the case only with those who
work in the mills. Those amongst them who
labour in the open air with the carts are not thus
affected ; but, as other persons raising heavy
weights, are subject to hernia?. Maltsters are
liable to the same diseases, arising from the same
agents, and from the heated and sulphureous air
of the kilns. Bakers are exposed to similar causes,
123
ASPHYXY.
but to a much less extent, and suffer accordingly
— chiefly From cough, asthma, affections of the
stomach', rheumatism, and a peculiar chronic erup-
tion on the skin. Snuff-makers are exposed to
the dust of the tobacco; but they are not so much
afiected by it as may be expected. 'I hey chiefly
complain of disorders of the head, stomach, and
air-tubes: of the former, from the narcotic effect
of this vegetable; and of the last, from its irrita-
tion. The narcotic odour to which tobacco man-
ufacturers are liable is not productive of any very
appreciable mischief, owing to their having be-
come insensible to its influence.
40. 4th, I shall here briefly notice those trades,
the workmen ill which experience the very injuri-
ous effects of inhaling an atmosphere in which
various vegetable, animal, or mineral molecules
are floating, — causes which, although very dis-
similar in themselves, generally act in nearly a sim-
ilar manner — namely, by irritating the bronchial
surface, and superinducing various modifications
of disease, according to peculiarities of constitu-
tion, temperament, and habits of life. a. The ar-
tisans who suffer the most from these causes are
dry grinders and needle-pointers; edge-tool, gun-
barrel, and other grinders; flax-dressers, and pearl
and horn button makers; iron, brass, and other
metal filers; stone-cutters, miners, and quarriers,
particular!} in sand stone; wool-carders and feath-
er-dressers: sawyers, turners, weavers, and starch-
makers. All these suffer more or less, generally
in the order here followed (needle-pointers and
dry-grinders the most, and starch-makers the
least), from chronic bronchitis, in one or other
of its modifications: in some, from the spasm of
the bronchi thereby occasioned, with the symp-
toms of asthma predominating; in others, with
those of chronic inflammation extending to the
lungs; in a few, with pulmonary emphysema;
and in many, with tubercular and cretaceous for-
mations. The most inflammatory effects seem
to result from needle-pointing, dry-grinding, and
stone-cutting; whilst the more asthmatic affections
proceed from the horn and pearl button manufac-
turing. These workmen seldom live above forty
years, and the greater number not beyond thirty or
thirty-five. They often experience but little incon-
venience till some time before the fatal disease takes
place; but they are as often affected in early life,
particularly pearl and horn button makers, the dis-
ease subsequently assuming an asthmatic character.
4!. 6. Various means have been invented in
order to prevent the molecules or dust arising in
these trades from accumulating and being inhaled
into the lungs of the workmen; but nearly every
measure hitherto advised has been neglected by
them. Amongst other contrivances, the muzzle
of damp crape recommended by Dr. Johnstone,
the sponge by Dr. Gosse, and M. D'Arcet's
" fourneau d'appel, " which is, however, not
known in this country, may be named. The best
means yet devised seems to be that invented by
Mr. Abrahams of Sheffield, in which magnetic
attraction is employed to arrest the floating metal-
lic particles. This, as well as the use of the
" damp bag " suspended over the stone, in grind-
ing raid pearl button turning, are most uselul in-
ventions. In mining, quanying, or cutting stones,
dry-grinding, &c, much good would probably re-
sult from having moistened or wet woollen cur-
tains suspended over the heads of the workmen,
and in such a way as to be agitated through the
air of the place. The simpler the means, and the
less trouble required in their use, the more likely
are they to be adopted.
42. c. In respect of the treatment of the pulmo-
nary diseases which result from these causes, very
little difference from that employed under ordina-
ry circumstances is required. The frequent use of
emetics is adopted by the workmen themselves;
and there can be no doubt of their utility in the
most of the diseases of the air-passages. The
other means of cure are fully noticed in their re-
spective places.
BIBLIOGRAPHY. — Rammazini, Opera Omnia Medica.
Gen. 1717. — Merat, in Diction, des Sciences Mtdicales,
t. vi. p. 32. — Patusier, Train'- des Maladies des Artisan*, et
des celles que resultent des diverses Professions, ic, 8vo.
Paris, 1E22. — Merat, Traite de la Coliqne Uetallique,
Svo. Paris, 1812. — Bertrand, Essai Medical sur les Profes-
sions et les Mi' tiers. Paris, 1815. — Speer, in Dublin Hosp.
1!. ports, vol. iii. p. 161.— C. T. Thackrah, The Effects ni
the principal Arts, Trades, and Professions, ice, on Health
and Longevity, he. London, 8vo. 1831. — Cohmi, Sur le
Tremblement Mi'tallique, &c, in Archives Gencr. de M^d.
t. xiv. p. 102., et t. xv. p. 338.
ASCARIS. See Worms.
ASCITES. See Dropsy of the Peritoneal
Cavity.
ASPHYXY. (From the privative a, and nipi'to',
I beat, I leap.) Sy.v. Aaipv&a, Hip. Asphyxia,
Auct. Lat. Apoplexia Snffocata, Cull en. As-
thenia Suffocatio, Young. Asphyxie, Le Pauls
manquant, Fr. Der Scheintod, Pulsstillstand,
Eine todtliche Ohnmacht, Ger. 3Iancamento
di polso, Ital.
Classif. 2. Class, Nervous Diseases; 1.
Order, Comatose Affections (Cullen). 4.
Class, Diseases of the Nervous Functions;
4. Order, Affecting the Sensorial Powers
(Good). I. Class, III. Order (Author,
see Preface).
1. Defin. Suspended animation proceeding
from a primary arrest of the respiratory actions,
the other functions being thereby abolished.
2. Asphyxy, according to its etymology, should
be defined, the cessation of the action of the heart.
In this case it would be synonymous with certain
forms of syncope, from which, however, it most
essentially differs. Yet even in syncope the most
complete, the action of the heart never alto^t ther
ceases; it is only unusually weakened, and pre-
viously to respiration being affected. Attention
to the phenomena to which the term asphyxia
has been so long applied, will inform us that the
actions of respiration are primarily arrested; that
the functions of circulation are subsequently abol-
ished; and that detail is the result of this succes-
sion of events. It may, however, be. stated, i:i
justification of the change of signification which
this term has undergone, that there is no state of
the system from which recovery is possible, that
is characterised by a more complete abolition of
the action of the heart than this, although it takes
place secondarily only from the arrest of the res-
piratory functions.
3. Asphyxy has been very generally viewed as
proceeding from causes which act in various ways:
and the opinions respecting their nature and mode
of operation have been extremely deficient in pre-
cision and accuracy. According to the mean-
ing which I have attached to the term, as stated
above, asphyxy can only occur in a direct or
primary form, from causes which either exclude
ASPHYXY — Causes of.
129
tin- air from the lungs, prevent its renewal, or
abstract thai constituent of it which is requisite
to ill.' respiratory functions. Authors have, how-
ever, included, under the head of asphyxies, those
states of suspended animation which proceed from
the respiration of deleterious gases : and Dr.
Good has comprised under it death or suspended
animation from lightning and from intense cold.
In every case of the action of deleterious gases,
of lightning, and of intense cold upon the system,
the respiratory organs, although one of the chan-
nels for the action of the latter, are not the first
to have their functions arrested. The action
of all these ;iLTi'nt<: is primarily exerted upon the
ganglia! and nervous systems; and, owing to their
effects upon these systems, the function of the
brain, of respiration, circulation, &c. are subse-
quently abolished. As the action of the greater
number of deleterious gases, when respired, is
similar to that of other irritating and narcotic
poisons, I shall consider them under the head of
gaseous poisons (see Poisons). When, how-
ever, they are of such a kind, or are present to
such an extent, as to irritate violently the larynx,
and, by exciting spasm of it, to exclude the air,
or so as to displace, and to occupy the room of,
the respirable atmosphere, their action is similar
to other agents primarily occasioning simple as-
phyxy: and they therefore require no further no-
tice than by adducing them as causes of this
stati'. In respect of the influence of cold and
lightning upon the frame, it may be observed
that, although exciting and concurrent causes of
asphyxy, and producing this, with other changes
in the vital functions, but in very different ways,
they act directly upon the nervous system, and
give rise to asphyxy only secondarily; and, like
the more poisonous gases, chiefly through the
medium of this system, particularly that part of it
which presides over the functions of the brain and
heart. Their action will therefore fall under dif-
ferent heads.
4. I. Causes. — Asphyxy takes place in a pri-
mary and simple form, from whatever excludes,
or prevents the renewal of, air in the lungs of a
healthy person, or consecutively upon other af-
fections or diseases, especially those affecting the
nervous system, and particularly the respiratory
class of nerves. In the former state of the frame
it is an idiopathic or essential affection; in which
light it will be chiefly viewed in this place : in
the latter it is symptomatic, or rather one of the
modes in which disease terminates life. These
state- of asphyxy may proceed,. first, from a pri-
mary cessation of the mechanical phenomena of
respiration, and, secondly, from a primary defi mlt
of the chemical changes which take place during
the respiratory actions.
5. To the first of these is to be referred the
asphyxy which depends upon inaction of the
respiratory muscles (A); and (B.) upon deficient
expansion of the lungs, the inspiratory muscles
performing their functions. A. Deficient or im-
possible action of the inspiratory muscles pro-
ceeds, 1st, from mechanical obstacles applied to
them, as in the instances of death occasioned by
earth falling upon the trunk of the body, and
pressing it so strongly as to prevent them from
expanding the thorax : 2d, from deficient or in-
terrupted influence of the nerves supplying these
muscles, as from injuries or division of the pneu-
mogastric nerve; injury or pressure upon the me-
dulla oblongata or spinal chord, either from frac-
ture or dislocation of the spine, particularly of its
cervical portion; and from the paralysis of the
nervous system occasioned by a stroke of light-
ning, or any other cause abolishing its energy :
and, 3d, from want of activity, or deficient irrita-
bility of the inspiratory muscles themselves, as
from the benumbing influence of cold, and the
suspended animation of new-born infants.
(). B. The asphyxy which proceeds from a
deficient expansion of the lungs, is generally ow-
ing, 1st, to mechanical impediments, as the pas-
sage of some of the abdominal viscera through
the diaphragm, the accumulation of fluids in the
pleura, or similar causes : and, 2d, from paralysis
of the nervous energy of the lungs, as in cases
of death from cold, from lightning, from various
poisonous gases, &c. ; whereby the vital expansi-
bility of the organ is abolished, along with the
other respiratory actions.
7. The second class of causes, or those which
act by impeding or abolishing the chemical chan-
ges effected by respiration, may be referred to
two heads: — 1st, Those which present a me-
chanical obstacle to the entrance of air into the
lungs, as strangulation; submersion; the introduc-
tion of foreign bodies into the larynx, trachea, or
even the large bronchi : and, 2d, Those which
consist of a deficiency of respirable air, as a too
rarified atmosphere, or the presence of azote, hy-
drogen, carburetted hydrogen, protoxide of hy-
drogen, or indeed of any of the deleterious gases.
It is evident, however, that asphyxy is often oc-
casioned by the combined operation of more than
one of its proximate causes. Thus it may pro-
ceed from paralysis of the respiratory muscles,
and of the nervous energy of the lungs them-
selves; and hence be characterised by abolition
of the respiratory efforts, by deficiency of the
expansive power of the organ, and by arrest of
the chemical changes which take place during
respiration : and, on the other hand, several of
the remote causes act by individually producing
more than one of the pathological conditions now-
specified.
8. II. Characteristic phenomena of Asphyxy.
— When asphyxy takes place slowly, especially
from causes which interrupt the nervous influence
actuating the respiratory muscles, it commences
with greater or less difficulty of elevating the tho-
rax; anxiety, with urgent desire to inspire, and
constant attempts to fill the lungs, giving rise to
continued gaspings, or quick, short, and imperfect
respiratory efforts; pandiculation; vertigo; failing
of consciousness and sensation; sometimes to
convulsive movements both of the limbs and
trunk, followed by immobility of the parietes of
the thorax and abdominal muscles, weak and
languid pulsation of the heart, and absence of
pulse at the wrist; the face is coloured, livid, tu-
mid, injected, and its veins distended; the hands
and feet, as well as the face, present a reddish
violet hue; and the cutaneous surface patches of
a similar tint. At last the circulation is entirely
arrested, and asphyxy is complete. The animal
temperature, however, and the absence of rigidity
of the muscles, continue for a long time after-
wards, — almost always for a much longer period
than from death under other circumstances, and
from other proximate causes.
130
ASPHYXY — Pathology of.
9. These phenomena vary, particularly as re-
spects the rapidltv of their progress, according to
the causes whence they proceed, and to the ex-
tent to which air is excluded from the lungs.
Where no obstacle to the action of the inspiratory
muscles is present, — the obstruction to respiration
existing in the air passages, — the efforts to renew
the air in the lungs are much more convulsive and
laborious. The anxiety is extreme, but of short
duration, and rapidly followed by abolition of con-
sciousness, voluntary motion, and of the functions
of circulation. In this case the description of
Shakspf.are is physiologically accurate : —
"Bui, see ! his face is black and full of blood ;
Tlis eyeballs further out than when he lived,
Staring lull ghastly, like a strangled man;
His ha r upreared ; his nostrils stretch'd with struggling ;
His hands abroad displayed, as one (hat grasp'd
And tugg'd for life, and was by strength subdued."
10. In cases where asphyxy arises from a sud-
den abolition of the nervous influence of the re-
spiratory muscles, as from injuries inflicted on the
medulla oblongata, &c, or when the trunk of the
body is so compressed as to prevent all action of
these muscles, but particularly when it proceeds
from the former cause, the phenomena supervene
and sticceed each other with great rapidity ; but
generally in the order in which I have enumerat-
ed them, excepting that all respiratory efforts are
instantly suppressed. In drowning, however, the
progress of the symptoms are less rapid and
somewhat different, as will be shown in the
sequel.
11. III. The duration of life in cases of as-
phyxy is very different, according as the causes
which occasion it act with greater or less prompt-
ness, or more or less perfectly, in preventing the
renewal of air in the lungs. In general, the more
slowly that abolition of the respiratory function
takes place, as in cases of drowning, the longer
does the action of the heart continue, although
feebly and slowly, even after respiration has ceas-
ed; and to this circumstance, as well as to the
fluidity of the blood, which is long preserved, is
owing the power we possess of recalling the as-
phvxied to life; the more slowly the state of as-
phyxy supervenes, the longer the person retains
the ability of being reanimated, and vice versa.
12. The length of time, however, after wliich
resuscitation cannot be accomplished is necessa-
rily \ aried by different circumstances; and not only
by the causes of asphyxy, and their modes of op-
eration, but also the strength of constitution, age,
and previous health of the, person, and the man-
ner in which abstraction of air has taken place.
Much will also depend upon the changes which
the asphyxy has produced in the brain, — the de-
gree of congestion, or the occurrence of extrava-
sation there, — circumstances which, when present
to any very considerable extent, more particularly
the latter, will generally preclude the possibility
of reanimation.
13. IV. Appearances observed on dissection
of asphyxied persons. — A reddish or violet red
hue of the countenance and various parts of the
surface of the body, which continues to retain its
warmth an unusual length of time after death :
this tint does not arise from the position of the
body after death; and is chiefly settled in the
mucous or vascular tissue of the skin, which, up-
on incision, .allows the blood to escape in a state
of fluidity. The eyes are bright and prominent;
the mouth sometimes natural, at other times ex-
pressive of suffering; the limbs are rigid, and
continue in this state unusually long, after having
been late in assuming it. The veins and sinuses
of the brain generally are filled with a dark fluid
or semi-fluid blood; the substance and cavities
of the brain are not otherwise materially altered.
The base of the tongue is generally full or inject-
ed, and even ramified, and its papilla? developed;
the mucous membrane of the larynx, trachea,
and bronchi, is injected and red — the colour
becoming darker as we descend from the larynx
to the bronchial ramifications, where it assumes
a violet or reddish brown tint. Their smaller
branches often contain a little sanguineous frothy
mucus. The lungs are distended, rise around the
pericardium, and present a brown or blackish
brown hue; their parenchyma, when divided,
are of a redder tint, but give out, upon pressure,
large drops of a thick, fluid, and very black
blood. The liver, spleen, and kidneys are gorg-
ed with blood, presenting a similar appearance.
The veins of the heart are congested; and its
right cavities, the vena cava, and other large veins,
are engorged with black and semi-coagulated or
fluid blood.
14. V. Theory of Asphyxy. — It is chiefly to
Goodwin and Bichat that we are indebted for
the near approaches which have recently been
made to a satisfactory and consistent theory of as-
phyxy, upon which a rational mode of treatment
may be based. The venous blood sent by the
right ventricle to the lungs, which contain a di-
minished quantity of air calculated to convert it
into arterial blood, is returned to the left side of
the heart, but slightly changed from its venous
state, from whence it is propelled through the ar-
teries to the different organs. The consequence
of the imperfect changes effected in the blood;
owing to the interruption or cessation of the re-
spiratory actions, is imperfect excitation of the
most important organs of the body; and in pro-
portion as the blood sent from the left side of the
heart is possessed of more of the venous charac-
ters, the absence of excitation is more manifest,
until, as respects the brain, and lungs particularly,
which are the first of all the organs to experience
the effects resulting from the circulation of venous
blood, a sedative or stupifying effect, but negative
in respect of its nature, is produced upon them;
as is frequently evinced on the brain in cases
where asphyxy takes place slowly, and when the
blood sent from the left side of the heart is com-
pletely venous in its characters.
15. In tracing the phenomena it will be ob-
served, that the capillary system of the lungs is
the first to experience a loss of their -\ ital tone
and undergo congestion. This arises from the
following causes : — 1st, The absence of the usual
stimulus of pure air in the air-cells : 2d, The
circumstance of their being the fust to receive the
blood after being returned from other parts of the
body fully charged with venous properties : 3d,
The cessation of the mechanical actions of respi-
ration; and, with them. v( the expansive mo-
tions of the lungs themselves : 4th, Ihe arrest of
those changes which the blood undergoes from
oxygenated air, and the»intluenee of a darker
blood than usual upon the pulmonary vessels :
5th, The loss of nervous influence, arising from
the sedative effect of venous blood upon the
ASPHYXY — Pathology of.
131
nervous centres, when circulating in arterial Tea-
sels: and, 6th, The circumstance of the systemic
capillary vessels retaining their tonicity and pow-
er of reacting, for a longer time, upon their
contents, when circulating venous blood, than
the pulmonary capillaries ; consequently the blood
is returned by them into the veins, and thence
to the righl side of the heart to be sent to
the lungs, which are the lirst. from this and the
foregoing causes, to experience congestion, and to
lose the power of restoring it to the left auricle.
Thus it will be seen, that the interruption to the
circulation commences in the capillary system of
the lungs, in consequence of the slop put to the
mechanical and vital actions of this organ; and
that the heart, which does not cease to contract
until the functions of the lungs and brain have
been abolished, no longer is supplied with blood
from the lungs; the left side of the heart being
thus the ultimum moriens.
1<>. The early and manifest effects of asphyxy
on the brain have been fully proved by the ex-
periments of Bichat. This organ is deprived of
its functions, and the comatose state is rapidly
and profoundly expressed ; the venous blood
conveyed to it. chiefly from its negative effects,
gf\ia^ rise to all the phenqmena usually occa-
sioned by a narcotic poison. Even the heart
itself, although the last of the three organs to ex-
perience the effect produced by the circulation
snons blood, is soon enfeebled in its action.
This evidently arises partly from the abolition of
the functions of the brain, and partly, or even in
n greater degree, from the circulation of dark
blood to the ganglia and nerves, whence the heart
derives its action, and to its proper structure.
!!ut the experiments of Dr. Edwards and Dr.
Kay evidently show that the circulation of dark
blood dues not destroy the irritability of muscles,
but that it is a less powerful supporter of this
property; and consequently that the irritability of
the heart is not abolished, as Bichat supposed,
but only insufficiently excited. Indeed, if this
property were destroyed, resuscitation would be
impossible.
17. The long continuance of the animal heat
after the total cessation of the heart's action can
only be explained by the integrity* of the vital
energies of the frame at the time of the event, by
the continued fluidity of the blood, and the cir-
culatory or oscillatory motion of this fluid in the
systemic capillary system for a considerable time
after the heart had ceased to contract, — phenom-
ena, which have been satisfactorily observed in
cases of asphyxy. The patches of lividitv, and
the dark colour of die surface, depend upon the
injection of the capillaries of the sir lace with dirk
bleed, end the engorgement of the veins. The
slow accession of rigidity of the limbs after death
is referrible to the longer duration of the animal
temperature, and the fluidity of the blood, than
in other cases: and to these causes also are to be
imputed the possibility of resuscitation after a
longer period from the cessation of respiration
than in any other morbid condition of the frame.
'! 1. • marked rigidity of the limbs, niter the
body is quite cold, must be chiefly imputed to
the perfect state of the vital energies when as-
phyxi i took place.
18. It has long been observed that the body of
an asphyxied person appears to contain much
more blood than that of an individual who has
died in a different way. Bichat explains this by
supposing that the organs receiving venous blood,
which is devoid of the materials necessary to
nutrition, yield all the fluids which the\ usually
furnish without appropriating those which they
usually do under other circumstances; so that
the quantity of blood is actually increased, par-
ticularly in cases where the asphyxy takes place
slowly. In proof of the accuracy of this \iew,
it has been stated that, when asphyxy occurs
suddenly, and the functions cease rapidly, less
engorgement of the venous system and of the
lungs is observed, than when death is caused
more slowly, as in the case of asphyxy from
burning charcoal. Perhaps the quantity of blood
in the system seems greater from the circumstance
of its fluidity, or rather the absence of coagula-
tion; for when this takes place, the serum of the
blood partly escapes into the shut cavities after
death, and exudes through the vessels and tis-
sues.
19. From the foregoing, therefore, it may be
concluded that the cessation of the actions of
respiration, — first the mechanical or muscular
actions, next the vital or expansive motions of
the lungs, — is soon followed by an arrest of
the pulmonary circulation, afterwards by abo-
lition of the nervous functions and influence,
and lastly by cessation of the heart's action,
in consequence of the blood not being restored
to the left auricle and ventricle ; the latter of
which, however, continues to contract as long
as blood is sent to it. Hence, as respects the
circulation, first, stagnation of the blood in the
pulmonary capillaries upon the cessation of re-
spiration takes place; next, a deficient supply of
blood to the left side of the heart; and, lastly, an
accumulation of it in the pulmonary arteries, and
right auricle and ventricle, which are no longer
able to overcome the resistance opposed to its pas-
sage in the congested pulmonary vessels. Thus
it will be seen that the left ventricle is actually
the ultimum moriens, and not the right, as suppos-
ed by many. Upon this view of the procession
of phenomena in death from asphyxia, our endea-
vours to restore animation are founded.
20. V. The varieties of Asphyxia, in a practi-
cal as well as physiological point of view, deserve
particular notice. The respiration of several
gases is often followed by fatal consequences ;
but as asphyxy is only one of the deleterious
effects thej occasion, I have considered them in
another place (see Poisons — Gascons.). Of all
gaseous bodies from which asphyxy may arise,
azol ■ and hydrogen alone act simply by produc-
ing asphyxy; and they have this effect only when
ili'v are present in considerable quantity in the
air, or when they are respired for some time. '1 he
w Inch they produce differ in no respect, in
the present state Of our knowledge, from those
des :i ibed above.
21. A. Asphyxy from submersion. — a. There
are various circumstances, both proper to the in-
dividual, and connected with the submersion,
which will modify the resulting asphyxy, and
should betaken into account in our endeavours to
restore animation. When a person is immersed
in water he is seized with an urgent feeling of anx-
ietj at his breast ; his pulse becomes weak and
frequent. lie struggles to relieve his distress, and
132
ASPHYXY — Treatment of.
thereby rises to the surface of the water, and
throws out some air from his lungs. His anxiety
continues to increase, and his pulse becomes
weaker; his struggles are renewed with more vio-
lence; he rises to the surface again, throws out
more air from the lungs, and makes hurried at-
tempts to inspire, and in some of these attempts a
quantity of water goes down the throat with the
air, and excites cough and spasm of the glottis.
These efforts tend to determine blood to the head,
which, owing to the impeded state of respiration,
partakes of the venous properties; and rapidly in-
duces, from this circumstance as well as from the
pressure it occasions, insensibility, loss of volun-
tary motion, slight lividity of the surface of the
body, particularly of the face, loss of pulse, re-
laxation of the sphincters, and as the body sinks
to the bottom, the expulsion of a portion of the
air contained in the chest.
22. b. On dissection, nearly the same appear-
ances as those already described are found. In
addition to these, a frothy fluid is met with in the
trachea, and ramifications of the bronchi, with
some water, the quantity of which varies in dif-
ferent cases. From Dr. Goodwin's very satis-
factory experiments, confirmed by Mr. Coleman
and Professor Meyer, it appears that this small
quantity of water enters during the struggles to
inspire, and, mixing with the mucous of the bron-
chi, forms a frothy fluid, insufficient, however, to
occasion the fatal changes in drowning. A con-
siderable quantity of fluid is found in the stomach.
According to Dr. Curry, the vessels of the
brain are not particularly distended ; but there
are exceptions to this. Dr. Berger, of Ge-
neva, found that the air remaining in the lungs
had lost nearly all its oxygen. Mr. Coleman
states that the left ventricle of the heart is never
entirely empty, it generally containing about half
the quantity of that found in the right ventricle ;
and that a little blood is also found in the
aorta.
23. c. In cases where a person, in falling into
the water, has been struck on the head and stun-
ned, or is intoxicated, or benumbed with the cold
and fright, the efforts at preservation will scarcely
be made, and the case will be more completely
that of simple asphyxia. In cases of this descrip-
tion the countenance is generally pale. The peri-
od after which reanimation may be procured is
extremely various — generally from five minutes to
three quarters of an hour. Of twenty-three per-
sons recovered from drowning, one had been
three-quarters of an hour under water; four, half
an hour ; three, a quarter of an hour ; and the
rest for shorter periods. Dr. Edwards has very
satisfactorily demonstrated that life is more rapid-
ly extinguished by submersion in water of a very-
low temperature than in that of higher grades,
evidently owing to the sedative effects of cold
upon the nervous system. When submersion
takes place during intoxication, there is greater
risk of congestion or extravasation in the brain be-
ing superinduced; and if syncope, by the fright
attending submersion, occurs, fatal congestion and
paralysis of the heart and lungs will chiefly su-
pervene, but in a slower manner than under other
circumstances; and, as M. Leroy (Archiv. Gen.
de Med. t. xvii. p. 469.) supposes, thus admit-
ting of resuscitation at a longer period after sub-
mersion.
24. B. Asphyxy from strangulation. — When
asphyxy is produced by hanging, and if the ex-
clusion of air from ttie lungs is complete, the fol-
lowing appearances are generally observed: — After
loss of sensibility, epileptic convulsions, some-
times slight, at other times marked ; and gener-
ally attended with erections and emissions ; turgid-
ity, suffusion, and lividity of the face, extending
to the shoulders, chest, arms, and hands : the
eyes are open, projecting, and their vessels in-
jected ; the features are distorted, and the tongue
thrust out of the mouth ; the external muscles of
respiration are firmly contracted ; the hands are
clenched, and the sphincters relaxed. When the
air is not perfectly excluded in hanging, the suf-
ferings are prolonged, the engorgement of the
head and face is greater, the lungs are less loaded
with blood, and the vessels of the brain more con-
gested, than when the air is completely excluded.
In the majority of cases of asphyxy from hanging,
the lungs contain more air than after death from
natural causes, or from suffocation by a pillow
when the air is only imperfectly excluded from the
lungs.
25. There can be no doubt, that although
death is caused by asphyxy in cases of strangula-
tion, as proved by De Haen, Monro, and others,
the interruption which the cord occasions to the
return of blood from the bead, and the consequent
congestion of the encephalon, accelerate death.
In some instances, also, there is reason to believe
that fracture, dislocation, or subluxation of the
vertebra; of the neck is produced in the execution
of criminals; but it very rarely, or perhaps never,
occurs in cases of suicide by strangulation. To
these additional effects upon the encephalon and
medulla oblongata is to be partly imputed the
want of success in our attempts to restore anima-
tion after strangulation.
26. VI. General Treatment of Asphyx-
ia. The indications which naturally suggest
themselves from the consideration of the causes of
asphyxia, their mode of operation, and the ultimate
results which they produce, are, ist, to remove
the patient as soon as possible from the causes
which occasioned the asphyxied state ; and, 2d,
to restore the function of respiration, and, through
it, the circulation. The necessity of fulfilling the
former of these is sufficiently obvious, and the
means of doing so will necessarily vary with the
nature of the cause, which should be instantly as-
certained ; but without delaying the employment
of means to restore respiration.
27. The restoration of the function of respira-
tion is to be attempted by various means, calcu-
lated, in the first place, to, dislodge the impure
air contained in the lungs ; secondly, to replace it
with pure air ; thirdly, to excite the remaining
vitality of the nerves and muscles; and, fourthly,
to restore the circulation by measures calculated
to return the blood from the lungs to the left
side of the heart. The simultaneous attainment,
as far as may be, of these objects, is to be attempt-
ed by a judicious combination of means, a. Ihe
patient should be placed on his back, in an open
air of a mild or somewhat high temperature, of
from 65 to 70 deg. of Fahr., with the chest,
shoulders, and head slightly elevated, lie shook!
be stripped of his clothing, and enveloped in a
\\ arm blanket. None but the assistants ought to
be admitted into the room. The body should be
ASPHYXY — Treatment or.
133
placed at a convenient height for the employment
of the measures of reanimation. Pressure should
then be made upon the breast and abdomen, al-
ternating with relaxation, in such a manner as
to simulate the actions of the chesl in respiration.
By this means the foul air will be thrown out of
the lungs; and the restoration of the capacity of
the thorax, upon the removal of the momentary
pressure, by the elasticity of the costal cartilages,
will draw fresh air into the lungs. It will some-
times be of service to apply a hand upon each side
of the thorax below the arm-pits, and by gentle
shocks endeavour to expel the vitiated air. Whilst
this is being performed, bottles of warm water
should be placed to the feet, raider the knee-
joints, between the thighs, and under the arm-
pits. Dry warmth is particularly beneficial when
applied to the epigastric region. Warm stimu-
lating frictions over the surface should also be
employed.
28. b. After having used pressure so as to sim-
ulate respiration for a few moments, insufflation
of the lungs is next to he resorted to. This may
be performed by the mouth, or by a bellows.
When the latter is not at hand, the former must
be adopted. The operator having closed the nos-
tril-, and applied his mouth to that of the patient,
is to blow forcibly into it. pressing the chest after-
wards, in order to expel the air, and again blow-
ing forcibly into the chest. If the lungs cannot
be inflated in this way, the operator should blow
into one nostril, having closed the other and the
mouth; and if a small wooden tube can be pro-
cured, this may be used for the purpose, by in-
serting one end of it into the nostril, and blowing
into the other; or the pipe of a bellows may be
inserted into it.
2t>. c. Insufflation of the lungs by the breath of
the operator has been recommended by some in
preference to the use of the bellows, on account
of the higher temperature of the air thrown into
the lungs by the former mode; whilst others pre-
fer the latter method, on account of the purer air
furnished by it. I believe that the advantage of
the higher temperature of the former nearly coun-
terbalances the disadvantage of less purity. If,
therefore, insufflation by the bellows of a warm
air could be had recourse to, considerable benefit
might be obtained. If the bellows are used, the
pipe is to be introduced into one nostril; and,
whilst the mouth arid other nostril are closed, and
the pomum adami pressed gently backwards and
downwards by an assistant, the bellows are to be
opened and immediately closed, so as to throw air
into the lungs by a single stroke; after which,
allowing the mouth and nostril to open, the chest
i< to be pressed bo as to expel the air: thus air is
to be forced in, and again expelled, about fifteen
or sixteen times in a minute, so as to simulate
respiration.
30. d. The external and internal use of stimu-
lants has been recommended by J. P. Frank and
Devergie. Of this class of "means, galvanism
holds the first place; but it is seldom that an ap-
paratus can be procured. When it can be obtain-
ed, slight shocks may be directed through the
diaphragm or heart; or if an electric apparatus is
at hand, as strong shocks of electrieitv as the ma-
chine can furnish may be tried. Whilst we are
proceeding with insuffial ion of the lungs, frictions
of the surface of the bodv, particularly over the
12 '
chest, on the insides of the thighs, &c, in order to
promote the circulation and the animal heat, should
be continued; and the nostrils may be irritated, or
touched occasionally with a feather dipped in
spirits of hartshorn or of aromatic vinegar. Sub-
Btances which are likely to increase the coldness
of the surface by their evaporation should not be
employed by fiction. The introduction of warm
stimulating fluids into the stomach, by means of
a flexible tube and syringe. Iras been recommend-
ed, and may be tried after insufflation of the lungs
has been performed for a short time. More ad-
vantage, nowever, will probably accrue from the
administration of a clyster of warm spirits and
water than from the injection of stimulants into
the stomach, unless this can be done with an ap-
paratus admitting of easy application. Tobacco-
smoke has also been directed to be thrown up the
rectum; but it is a more uncertain remedy than
the clyster now mentioned.
31. e. Bleeding is one of the measures respect-
ing which the greatest difference of opinion has
existed. In certain circumstances it is often of
great service, and in others detrimental. It is
generally proper when the countenance is swollen,
injected, or purplish ; the veins full or distinct ;
and the skin reddish, or approaching the violet
tint. It is not always, however, possible to obtain
blood; but even when we fail in procuring it, the
opening which had been made should be carefully'
closed and bandaged, ill order to prevent subse-
quent hemorrhage, which may occur when least
expected. Bleeding is also often required during
the progress of recovery, particularly when the
respiration is laborious, the brain loaded or op-
pressed, and when delirium, the not infrequent
attendant on restored animation, is present.
32. f. The means now recommended, partic-
ularly frictions, inflations of the lungs, and the
occasional use of stimulants, should be persisted in
for several hours, unless stiffness of the limbs, and
other indications of death, present themselves.
Convulsive snatches of the respiratory muscles,
with gaspings, followed by sighing, a more natural
respiration, and slight palpitations, are the first
signs of returning animation. When the circu-
lation is restored, convulsions sometimes take
place, and suddenly destroy the patient. Such
seizures may occur even a considerable time after
recovery has apparently been effected. The
patient should therefore be watched for several
days: and if an attack of this kind occur, blood-
letting, and artificial respiration during its con-
tinuance, may save the patient. Delirium, and
all the forms of morbid reaction which occa-
sionally appear on recovery from asphyxy, require
depletion-, with the means usually employed to
restore the secretions and excretions, and to excite
the emunctories to carry off" the hurtful materials
accumulated in the blood during the state of as-
phyxy.
:;::. \ II. Treatment of particular kinds
of Asphyxy. — A. Of asphyxy from submersion.
But little, in addition to what has been stated
above, need be adduced under this head. The
body should be carried from the place of sub-
mersion to where means of restoration are to be
used, in the recumbent posture, with the head
and -boulders elevated; but neither of them bent,
or hanging in an injurious posture. The wet
clothes are to be immediately removed, the
134
ASPHYXY — of New-born Infants.
month and nostrils cleansed, and the body placed
in warm blankets: this should be done as soon
as the body is found, if the weather be cold, and
the distance to the place where resuscitation is
to be attempted be considerable. The directions
given in preceding paragraphs (§ 27. et seq.), are
now to be followed. Some advantage will be
derived from placing the body in a warm sun, or
before a lire, or surrounding it with dry warmth ;
heated substances may likewise be applied to the
epigastrium, the extremities, and insides of the
thighs. Where a warm bath can be readily pro-
cured, the body may be placed in it, and the tem-
perature regulated to about 9S° or 100°. Animal
heat, proceeding from some of the domestic lower
animals or from a healthy person placed by the
side of the body, is, especially in the cases of chil-
dren, a very efficacious mode of resuscitation.
But all these means should not interrupt the per-
formance of artificial respiration. The other mea-
sures recommended in the foregoing section may
also be resorted to, with the exception of bleeding,
which is seldom beneficial until the circulation has
been restored; when it will not infrequently be
required, to subdue morbid reaction, in conjunc-
tion with other remedies calculated to restore the
secretions, &c. (§ 32.)
34. B. Asphyxy from strangulation requires
the same measures which have been described
under the head of general treatment (§ 26'. &.C.),
and particularly bleeding, which may generally be
advantageously performed in the jugular vein.
The head and shoulders ought to be raised as
high as may be consistent with the means used
for resuscitation; and, if a restoration of animation
be effected, the usual means of guarding the brain
from the ill effects of reaction or congestion, to
which this organ is more liable after strangulation
thin after asphyxy from other causes, are to be
put in practice.
35. In cases of asphyxy from obstruction of the
glottis and larynx, or from substances having
passed into this situation, or into the trachea, the
operation of tracheotomy should be resorted to.
Several instances of this description have been
recorded, wherein it has been successfully per-
formed. In all cases of recovery from asphyxy,
the patient should be carefully watched for two
or three days, and every appearance of reaction
affecting any organ, more particularly the brain,
instantly subdued by means appropriate to the
circumstances of the case. Pure air, and the use
of deobstiuent purgatives, and diuretics, are gen-
erally necessary, in order to purify the circulating
fluid, and change it from the unnatural state it
had assumed during the asphyxy.
Bibliography.— J. Louis, Sur la Certitude des Signes
de la Mort, l2mo. Paris, 1752. — Pia, Detail des Succcs
de i'Etablissement que la Ville de Paris a fait en faveur
des NoWs, 8vo. Lyon, 1768. — Gardanne, Sur les Morts
apparenles dites Asphyxies, 8vo. Paris, 1777. — Cail/eau,
Mem. sur PAsphyxie par Submersion, Svo. Bord. 1799.
— Portal, Sur le Traitement des Asphyxies, l2mo. Paris.
lbi l.—Cullen, in Edin. Med. Comment." vol. iii. p. 23.—
J. Hunter, Observations on the Animal Economy, p. 136. ;
and Philos. Trans, for 1776, p. 412. — Goodwyn, Of the
Connexion of Life with Respiration, p. 82, &.c. Loud.
1788. — Bvhal, Sur la Vie et la Mori. Paris, An 8. —
Coleman, On Suspended Respiration, p. 248. — Berger, Sur
la Cause de l'Asphyxie par Submersion. Gen. 1805. —
Curry, Ohserv. on 'Apparent Death from Drowning, &.c.
— Kite, in Duncan's Med. Comment, vol. xiv. p. 107. —
Orfila, Secours a donner aux Person. Empois. ou As-
phyxies, 12mo. Paris, 1818; et Archives Gin r. de M d.
t. xiv. p. 542. — Marini, Del Tratlamento degli Annegati,
£vo. Pesaro, 1826. — l^roy, Recherches sur 1; Asphyxies,
8vo. Paris, 1829. — Edwards, De 1'Influence des Ageru
Physiques sur la Vie, part i. ch. I., et part iv. ch. 4. Paris,
1824. — Piorry, in Journ. Hebdom. de Altd. t. iii. p. 556.
— Deoergie, art. Asphyxie, Oir(. de Med. et Chir. Pratiq.
t. iii. p. 542. — Kay, in Edin. Med. and Surg. Journ.
vol. xxix. p. 42. — M. Bourgeois, in Archives Gener. de
Med. t. xx. p. 220. — Meyer, Lond. Med. Repos. vol. iii.
N. S. p. 436. — Humane Society's Fifty-seventh Annual Re-
port, 1831, p. 62.
1. ASPHYXY of New-born Infants is fre-
quently met with, particularly in those who are
naturally feeble, or weakened by rupture of the
cord or laceration of the placenta, in consequence
of sudden delivery, or of the operation of turning,
especially when required by uterine haemorrhage.
It is also occasioned by compression of the cord,
and a protracted parturition.
2. Besides the absence of respiration and of
muscular motion upon delivery, the surface is
pale; the flesh and limbs are soft and flaccid; the
heat of the body is rapidly diminished, but the
circulation still continues, at least for some time.
Several cases which are viewed as asphyxy, more
properly belong to syncope, or loss of blood, or
participate in those stales as well as in privation
of the respiratory actions. This privation may
depend upon imperfect circulation in the pulmo-
nary arteries, and through the lungs; or upon in-
activity of the respiratory muscles, and torpor of
the nerves which supply them, owing to imperfect
circulation in the brain; 'or upon these causes
conjointly. Care should be taken to distinguish
these cases from apoplexy; as the states of the
vascular system, and of circulation in the brain,
and consequently the treatment which is required
in each, are very different.
3. The treatment of these cases consists of de-
ferring the ligature of the cord for some time;
of taking care that no blood is lost from dividing
it; of enveloping the infant in warm flannel; of
holding it near a warm fire, or plunging it in a
warm bath, rendered exciting by means of salt or
mustard; of removing all obstruction to the pas-
sage of air into the lungs from about the throat
and mouth; warm frictions of the surface of the
chest, with gentle succussation with the palm of
the hand on the shoulders; tickling or irritating
the nostrils and arm-pits with a feather; dropping
a little diluted aromatic, or ammoniated spirit upon
the lips; and most particularly inflation of the
lungs by the breath of the medical attendant, either
blown directly into the mouth, the nostrils being
closed, and the trachea gently pressed backwards;
or through a curved tube introduced into the la-
rynx, as recommended by Chaussif.r. and em-
ployed by him at the " Mtdson d' Accouchement"
in Paris. This latter method is certainly prefera-
ble. Insufflation is to be managed in the same
manner, in other respects, as described in the
foregoing article. But I think that the breath of
the attendant is better suited to infants, than cold
ail- thrown into the lungs bv a bellows.
4. M. Desormeaux complains of his want of
success from inflation of the lungs, even when
carefully and assiduously employed, and places
more dependence upon means calculated to ex-
cite the respiratory muscles to contract. Tor tins
purpose, he recommends a species of spirit douche,
and directs the practitioner to take a mouthful oi'
brandy, and dash it forcibly against the anterioi
parietes of the chest. He states that this is sel-
dom required oftener than twice or thrice. Me-
chanical irritation of the nostrils, or exciting
ASTHMA — Pathology of.
135
powders applied to the pituitary membrane, may-
be c ■uitioiislv tried; a stimulating clyster may
also he thrown up. Galvanism or electricity may
likewise be resorted i<> when within our reach.
We should not relinquish our endeavours at re-
suscitation under two or three hours, or even
longer; and, if we ultimately succeed, the state
of die infant should be carefully watched for two
or three days.
Bibliography. — Burnt, Principles of Midwifery, &c.
:Mi .-lit. p. 592. — Gardien, Traitt Oomplel d'Accouc e-
mi us, v.-. (. ili. p. 135. — Dtsormtavx, art, lYouveaux-nes,
Hi', de Med cine, t. iii. p. 153. — Ifilso/L, in Glasgow
Med. Journ. vol. ii. p. 237.
ASTHMA. DERiv.and Synon. ~Aapp.a, an-
helatio: from «»••, I breathe; aO&fiutaj, I
breathe with difficulty. Suspirium, Celsus,
Seneca. Dyspnoea Spastica, Auct. Var.
Myopathica Spastica, Ploucquet. Asthma
Chroni urn, J. P. Frank. Asthma convul-
sivum, Baglivi, Alberti, Hoffmann, Sauvages.
Asthma Spasticum, Juneker. Pneusis Asthma,
Young. Asma, Bolsaggine, Ital. Pousse,
Asthme, Fr. Die Eagbrustigheit, das Keu-
ehen, Ger.
Classif. 54. G. Asthma; 3. Order, Spas-
mi; 2. Class, Neuroses {Cut lt:n). 4. G.
Asthma; 2. Order; 2. Class(Good). 37. G.
Asthme Convulsif; 4. Order; 4. Class
(Pinel). II. Class, III. Order (Author,
see Preface).
1. Defis. Great difficulty of breathing,
recurring in paroxysms, accompanied with a
wheezing sound, sense of constriction in the tho-
rax, anxiety, and a difficult cough, terminating
in mucous expectoration.
2. There are few diseases, the nature of which
has been a subject of greater doubt and difference
of opinion than asthma. Until the writings of
Flo ye R, Willis, Hoffman, Alberti, and
Jukckbk, directed particular attention to its pa-
thology, it was generally confounded with dysp-
noea, being usually denominated intermittent or
remittent dyspnoea. By these writers, and more
recently by Sauvages, Cullen, Pinel, and
Georget, asthma was considered as essentially
nervous in its nature; and the lesions found upon
the dissection of fata] cases viewed as its conse-
quences, and not as its causes. More recently,
and even at the present day, among many, it has
been considered as a symptom of organic change
of either the heart, large blood vessels, or of the
lungs, air-tubes, &c. I5ut this doctrine, although
generally accurate in respect of Dyspncea, is
quite erroneous as applied to asthma.
:;. Pathology of Asthma. — The depend-
ence of dyspnoea, not only upon organic lesions of
the organs seated within the chest, but upon the
form of the thorax, upon diseases of adjoining vis-
cera, and upon the state of the air-passages, is
anfficiendy obvious. The difficulty of breathing
proceeding from these sources may be either con-
tinued or remittent: but it never is, whilst the
causes on which it depends are in existence, char-
acterised by intervals of perfect ease. True asth-
ma, however, presents intervals of healthy respira-
tion; and although repeated returns of the attack
will generally induce some change in the organ-
ization of either the lungs or the principal organs
of circulation, yet this is not uniformly the case;
and moreover, an attentive examination of the
thoracic viscera, in recent attacks, fails of detect-
ing in them any appreciable change, particularly
during the intervals between the paroxysms.
The disease has even proved rapidly fatal during
the attack, and yet do alteration adequate to ac-
count for the symptoms could be detected on dis-
section. Instances of this description have been
adduced by Wuhmann (Huf eland's Journ. b.
i. p. 18.), Parry, Georget, Andral, Laen-
\i:c, and GuERSENT, and justify the opinions of
those who have referred the disease chiefly to the
nervous system. In some cases, after repeated
returns of the attack, and when they have induc-
ed organic change, the intervals are less distinctly
marked, consist of remissions merely, and the
disease may, at last, pass into confirmed dyspnoea.
4. a. The structure of the air-passages and
bronchi evidently shows that these parts are sus-
ceptible of preternatural or spasmodic constriction.
During 1821 and 1S22, when engaged in some
researches into the pathology of diseases affecting
the trachea and bronchi, I was enabled distinctly
to trace muscular fibres throughout those parts,
both in man and in the lower animals. The dis-
position of those fibres, in many of the lower an-
imals, and the mode of their connection with the
cartilaginous rings, are peculiar, and beautifully
adapted to guard against the contingencies to
which they are liable from varying positions and
habits of life. Upon those, however, I cannot
here enter. About the same time that mv at-
tention was directed to this subject (Loud. Med.
Repository, vol. xxii. p. 41S.), the researches of
Reisseissen of Berlin, and of Laennec and
Cruveilhif.r of Paris, appeared; and the results,
in respect of the structure of the bronchi and larg-
er ramifications of the trachea, upon the whole,
agree with what I had observed. It had been
denied that the membraneous, or any other, part
of the air-passages contain muscular fibres. But
this was asserted chiefly by those who cannot be-
lieve that a part is muscular, unless the fibres are
the same in appearance as those which enter into
the composition of the muscles of voluntary mo-
tion. Other anatomists, who take a more com-
prehensive view of the conformation and functions
of the muscular system, consider, with greater
justice, that the muscles which are acted upon by
the will, form an order by themselves; and that
there is another and a very important order of
muscular parts, which are not directly influenced
by volition, but which contract from stimuli acting
on them, either immediately or mediately, and
which present certain peculiarities in respect of
the appearances of their fibres, of the mode of
their distribution, and of the manner of their con-
nection with internal tissues and organs. Now,
the fibres which are discovered in the trachea,
ami traced to the smaller ramifications of the bron-
chi, are in every respect similar to other involun-
tary muscular fibres, in their organization; in their
connection with a mucous surface, forming, in
many respects, a tunic concentrically with the
mucous coat; in being disposed in circular fibres,
surrounding hollow tubes; and in being supplied
entirely by ganglia! or involuntary nerves. The
ili-pesition of the fibres, therefore, which are de-
tected in the air-passages, being altogether similar
to that which obtains in other canals, the mus-
cular structure of which is not disputed, as in the
alimentary tube and urinary bladder; the organ-
136
ASTHMA — Pathology of.
ization of the fibres being also similar; their con-
nection to a mucous surface, and the circumstance
of their being supplied with the same order of
nerves, being at the same time considered; are
we therefore to be surprised that agents affecting
either the mucous surf ices thus related to them,
or the nerves supplying them, should be followed
with analogous effects to those which we observe
after the action of agents directed to the mucous
surface or nerves of the alimentary canal?
5. 6. The lungs possess a vital power of expan-
sion.— The structure of the air-passages, then,
would lead us, independently of the results of
observation, to infer that the circular fibres are lia-
ble to experience, with all other involuntary mus-
cular fibres, a spasmodic constriction; and it evinc-
es, particularly in the conformation of the cartila-
ginous rings with which the trachea and larger
ramifications of the bronchi are provided, a mark-
ed provision against an inordinate continuance or
degree of this constriction; the rings, by their
permanent elasticity, acting as antagonists to the
circular fibres, preventing extreme constriction,
and at last overcoming long-continued spasm,
particularly in those larger branches, the inordin-
ate constriction of which might have the etlect of
excluding the air from a very large portion of the
lungs. In the larger ramifications of the bronchi,
the muscular fibres connecting the extremities of
the cartilaginous rings are thus antagonised by
these rings; but, in the smaller ramifications,
where the rings cease to be detected even in
the imperfect forms in which they there exist,
and where the fibres are perfectly circular, the
only provision which can prevent an inordinate
constriction of those fibres, is in the structure of
the lungs themselves, which must necessarily un-
dergo a change in bulk, and become more con-
densed by this constriction, in those parts, at
least, to which the spasm extends; unless we be-
lieve that the lungs, like various other organs, are
endowed with an expansive power, — a power
which physiologists and pathologists have too
much overlooked in their exposition of the
healthy and morbid actions of the animal econ-
omy.*
ii. The mechanism of the expansive power is
so little understood, and generally so insufficient
for the explanation of this phenomenon, that we
must refer chiefly to the vital actions of the part,
which must necessarily depend on the energies of
the body generally. The expansile action of the
penis, nipple, heart, uterus, &c. cannot be ex-
plained by their organization only: it is manifest-
ed to us only during life, and the perfection as
well as imperfection of this action are always
accordant with the degree of vital energy with
which these organs are endowed.
7. I have long since had occasion to remark
that the motions and functions of the lungs {Phy-
siological Notes, fyc. to M. Richerand's Phy-
siology, 2d ed. p. 62S.) have been too generally
and exclusively referred to the mechanism of the
* That the lungs, however, really possess this property,
niav be interred from the permanent elasticity of their
structure, which continues for some time after death; and
which is still more marked during life, as shown by exposing
the lungs of a living animal. This state may be with pro-
priety railed the vital expansibility of the lungs, inasmuch
as the decree of this slate is chiefly dependent upon the vital
energy of the system, and partly "on the peculiar organiza-
tion ot the lunirs themselves.
respiratory organs, and to chemical changes pro-
duced in the lungs, to the neglect of a much higher
influence, always controlling, modifying, or alto-
gether changing, the subordinate powers to which
their functions have been thus referred. That
the vital energies of the frame are most power-
fully exerted in the lungs, through the medium,
especially of the organic nerves with which they
are provided, must be evident to "all who will
contemplate the nature and extent of the changes
constantly taking place in these organs upon the
blood circulating through them; and the relation
which subsists between their functions and the
vital energies of the system generally. Now, it
does appear to me that there exists a vital expan-
sion of the lungs independent of that which they
experience from atmospheric pressure, and from
following the dilated parietes of the thorax dur-
ing inspiration. In experiments upon living ani-
mals, where the walls of the chest have been
opened, the lungs are observed to swell and con-
tract alternately. This fact, which was first in-
sisted upon by M. Roux (Mtlanges de Chirurg.
p. 87.), has since been duly appreciated by Prus,
Laennec, and a few others. Even in cases
where the portion of lung has protruded itself
after a wound of the chest, — a circumstance
which could only occur from active expansion
of the lung itself, — this portion has been, although
thus unnaturally placed and subjected to the pres-
sure of the atmosphere, observed to dilate during
inspiration. The not infrequent occurrence of
ossification of the cartilages of the ribs in old
persons, and consequent perfect immobility of
the ribs, even without any evident dyspnoea, fur-
nishes another proof of the inherent expansibility
of the lungs: for without having recourse to this
vital property, we cannot explain the perform-
ance of the actions of inspiration and expiration
by the diaphragm alone.
8. This vital property, therefore, with which
the lungs, in common with some other organs,
seem to be endowed, together with the disposition
and elasticity of the cartilaginous rings of the
bronchi, furnishes an antagonising force to the
unnatural constriction of the tubes from spasm of
their circular fibres; and, while it serves to ex-
plain the natural functions of the organ, with their
modifications from the various influences to which
this property is subjected, is one of the sources to
which we are to impute some of the diseases, and
more especially the one under consideration, to
which the lungs are liable.
9. Having thus shown, from the structure of
the air-passages that theyr, in common with all
other hollow tubes of the body, admit of spasmo-
dic constriction, and that they also present a pro-
vision against the undue extent or continuance of
this state, I should further remark, that a close
observation of the phenomena of disordered res-
piration is sufficient to convince us that they fre-
quently experience this state, owing to the opera-
tion of certain causes acting either directly on the
mucous surface of the tubes, and impressing the
nerves terminating jn it, or originating in and
irritating the nerves themselves, cither at their
origins or in their ramifications and connec-
tions.
10. I. Symptoms and History of Asthma.
— The premonitory symptoms of this disease are
languor, sickness, flatulency, and other dyspeptic
ASTHMA — Symptoms of.
137
disorders; heaviness over the eyes, and headach;
uneasiness and anxiety about the precordia, with
a sense of fulness and straitness in this region
and in the epigastrium. In some cases pain is
complained of in tin; neck, with uncommon drow-
siness and stupor. It is also often preceded by
costiveness ami inefficient calls to stool.
1 1. A. The invasion of the attack of spasmodic
asthma is generally soon after midnight, or about
one or two in the morning, and during the Erst
sleep. Tin' patient wakes suddenly from a sense
of suffocation, lie feels a most distressing tight-
ness at his chest, with great anxiety, dilliculty of
breathing, and impediment to the free admission
of air into the lungs. He assumes with eager-
ness the erect posture, and cannot bear the least
incumbrance about" the chest. The breathing
is wheezing, interrupted, and laborious. The
shoulders ace raised, the elbows directed back-
wards, and every effort made to enlarge the
thorax. Owing to the interrupted circulation
through the lungs and heart, the countenance,
which was at first pale and anxious, becomes,
particularly in plethoric habits, red or bloated,
and covered with perspiration. The eyres are
prominent, and the conjunctiva injected. A con-
siderable quantity of pale urine is usually passed
at the commencement, or previous to the acces-
sion, of the paroxysm; and the lower extremities
are usi "y cold. The pulse is generally acceler-
ated, weak, irregular, and often intermittent.
During the tit, the patient has commonly an in-
stinctive desire for cool fresh air, which always
- him. A small or close room is offensive,
and all warm substances given internally increase
the flatulency of the stomach and bowels, and
te the symptoms. When the fit has con-
tinued from half an hour to one, two, three, or
erven four hours, it leaves the patient; and his
ation, pulse, and feelings assume their nat-
ural state.
12. This is the common course of a first and
moderate attack of the disorder. Sometimes the
patient has but one such fit; but more generally
a slight constriction of the chest is felt through
all the succeeding day, and the paroxysm returns
at the usual period of the night; and this con-
tinues fir three, four, or even seven days; when
the patient is at last altogether relieved from the
attack'. The disease may be suspended for a
month, or several months; hut it is liable to recur
from changes of air, errors of diet, and from the
operation of the other causes productive of it.
13. In some cases the; attack is more severe
from the commencement, and continues, with
slight remissions for several days, accompanied
with a harsh suffocative cough, great distension
nf the abdomen from flatus, and more or less of
the symptoms which characterise the complaint
in the severer states resulting from repeated at-
tacks.
14. When asthma once seizes on the svstem, it
m fails of recurring, though the intervals be-
tween the paroxysms are of very uncertain dura-
tion. In many cases it recurs periodically every
ten days or a fortnight. Sometimes the attack
returns at the full and change of the moon, or at
one of those periods only. It has been observed
to recur in females just after the menstrual
discharge, or to precede this evacuation. Per-
sons who have become subject to the disease
12*
seldom escape an attack in the spring and au-
tumn.
15. After repeated seizures, the disease often
assumes the most violent and distressing features;
the difficulty of breathing in the fit amounts to
the utmost degree, and is attended with the
greatest tightness over the whole chest, the pa-
tient feeling as if he were bound with cords.
His anxiety at this period is inexpressible, .and
he labours in respiration as if every moment
would be his last. Severe vomiting also fre-
quently occurs. The matter discharged is slimy
and frothy, or of a greenish yellow colour. He
is subject to palpitations and faintness; and cool
fresh air becomes absolutely necessary. About
this period a loose stool sometimes takes place.
The eyes are prominent, the face sometimes pale,
sometimes high-coloured, bloated, or livid : the
nose and ears are cold; the face, neck, and chest,
covered with perspiration. The pulse is generally
extremely weak, irregular, and even intermitting:
there is often much difficulty of swallowing. The
patient can scarcely speak, cough, or expectorate,
and the stomach and bowels are much distended
with flatus. As the paroxysm abates, the cough
becomes freer, and is attended with the expec-
toration of a little viscid mucus; and, in proportion
as the cough and expectoration increase, the dis-
tressing symptoms abate; this evacuation, which
had been retained by the spasm of the air-vessels,
indicating a solution of the spasm and a freer
access of air to the cells of the lungs. An easy
and free expectoration, particularly if it be ac-
companied with softness and moisture of the skin,
and a sediment in the urine, is a certain indica-
tion of the subsidence of the attack. Sometimes
when the paroxysm is unusually long, the patient
experiences only a single occurrence of it during
the attack.
16. B. The Humoral form of asthma is gene-
rally gradual in its accession, and attended by
extreme oppression, a suffocative cough, and a
copious secretion and expectoration of mucus
from the commencement of the seizure (§11.).
It is sometimes the consequence of repeated at-
tacks of the preceding variety; and is generally
more severe and of longer duration than it, owing
to the accumulation of viscid mucus in the air-
vessels conspiring with the spasm it occasions to
aggravate the symptoms. There are also less
perfect intervals of ease in this form of the
malady, than in the spasmodic. After the sub-
sidence of the patient's sufferings during the first
night of the attack, and while the expectoration
is easy and copious, the lungs still continue irrita-
ble through the day, and the respiratory function
embarrassed from the slightest causes. At the
approach of night, the fit recommences with the
usual symptoms, and the night is passed nearly as
the former. On the third day the remission is1
more complete, there is some additional expecto-
ration, and bodily motion is performed with less
distress, but still with great inconvenience. After
the paroxysm has been renewed in thus manner
for three or four nights, or for a longer period,
sometimes for several days or even weeks, — for
the duration of an attack varies much, — the ex-
pectoration and cough are more easy and free, the
daily remissions become more perfect, and the
strength of pulse and vigour of action increase.
17. When the chest is examined by the ear or
131
ASTHMA — Symptoms of.
stethoscope, the sound of respiration is weaker
during the fits, than in the intervals, but it is sel-
dom altogether suspended in certain points of the
chest; it is attended by a sonorous rattle, flat or
sibilous, imitating the chirping of birds, the note
of a violoncello, or the cooing of the wood -pigeon.
With this there is frequently intermixed a mucous
rattle; but this conveys the impression of being
produced by a thinner fluid than the mucus of
common catarrh. In the intervals of the attacks,
those various species of rattle exist, but in a much
less degree. The respiratory sound is louder
than during the paroxysms : sometimes it is al-
most puerile. If the complaint have occasioned
dilatation of the bronchi, the respiration assumes
more or less the character of the variety called
bronchial; in all cases it varies in intensity at dif-
ferent points of the chest, and these points change
their situations from day to day (Laennec).
The chest generally sounds well, throughout the
attack, upon percussion.
18. I have stated (§16.), that the Immoral
form of asthma is often consequent upon re-
peated attacks of the spasmodic; but this latter
may also occur, although rareh/, after the former;
or the attacks in some persons present an evident
complication of both forms of the disease. The
stomach and bowels are extremely liable to dis-
order in asthmatic persons, particularly in those
subject to the spasmodic form of the disease.
Colic pains, flatulence, loss of appetite, an irre-
gular state of the bowels, and a disturbed, im-
paired, and unrefreshing sleep, generally harass
the asthmatic patient, even in the intervals be-
tween the seizures. In females, the menses are
generally impaired or irregular, and an attack
often precedes the period of the menstrual dis-
charge, the supervention of which generally acts
as a crisis of the attack.
19. Symptoms of fever are not essential to the
disease, though they often occur, especially when
the humoral asthma, or an attack of catarrh, is
complicated with the convulsive. Hectic fever,
colliquative diarrhoea, faintings, palpitations, vo-
mitings, coldness of the extremities, swelled legs,
and other dropsical symptoms, are common in
the last stage of the disease, and indicate organic
changes in the substance of the lungs or heart,
with obstruction to the circulation in these or-
gans, and effusion of fluid in the chest, — results,
however, which can only be ascertained with pre-
cision by means of auscultation and percussion.
20. C. Terminations. — An attack of asthma
generally terminates in one of three ways: — 1st,
By a return to the healthy function: 2d, By in-
ducing further lesion; in which it either disap-
pears, or becomes complicated : and, 2d, In
death. On each of these I shall offer a few re-
marks.
21. a. Although the paroxysms of asthma fre-
quently terminate in a return to the healthy func-
tions, a perfect immunity from future attacks can
rarely be procured. Yet these attacks may be
frequent, severe, and of long duration, recurring
for a long series of years; the patient, notwith-
standing, arriving at a very advanced age, before
a fatal issue takes place. But they often produce
the following organic lesions.
22. b. The most common consequences of the
>e to which I may now advert, are, chro-
inanimation and dilatation of the bronchi, the
different forms of emphysema and oedema; of the
lungs; haemoptysis; tubercular formations, with
which asthma may also be associated from its
commencement; enlargement, and dilatation, &c
of the cavities of the heart; effusions of fluid in
the pleura or pericardium ; and wasting of the
heart, or polypous concretions, within its cavities.
As the reader will find all those lesions treated of
under their distinctive heads, I shall here only re-
mark respecting them, that, when they supervene
to asthma, many of the distinctive characters of
this disorder entirely disappear in those of the
superinduced disease, and the lesions of the re-
spiratory functions assume the distinctive features
of chronic, continued, or remittent dyspneea.
Severe attacks of asthma may also terminate in
congestions or effusions within the head, giving
rise either to epilepsy, coma, or apoplexy.
23. It was already remarked, that auscultation
and percussion furnished merely negative informa-
tion in the different forms of asthma. But this in-
formation is still important, inasmuch as it inti-
mates the non-existence of any of the foregoing
organic changes; and, when they do exist, those
means of diagnosis enable us not only to recog-
nise them, but also to ascertain with precision
their nature, progress, and extent, and thus to
form an accurate diagnosis and prognosis in re-
spect both of the primary disease and of the con-
secutive organic changes.
24. c. When the disease ends in death, this
event is brought about generally by superinduc-
ing some one of those changes already referred
to as terminations of the disease, or of those
lesions, with which it is frequently associated
(§ 22.). Death may, however, occur, but much
more rarely, from the severity of the attack; the
requisite changes not being effected on the blood
by respiration, owing to the obstructed state of
the air-vessels, either from spasm or the accu-
mulation of viscid mucus, or from both, whereby
the nervous centres are supplied with blood un-
suitable to their functions, and the heart ceases to
contract with sufficient energy to preserve the
circulation in a requisite state of activity through
the lungs and brain.
25. D. The appearances after death may be in-
ferred from what has already been stated. These
appearances are rather the consequences of the
disease, than the disease itself; for it is seldom
that we have an opportunity of examining the
body in recent and uncomplicated cases of
asthma. Where, however, this has been done,
the lesions, even when any have been detected,
have been insufficient to account for the disease,
Willis records a case of protracted asthma, in
which no morbid appearance could be detected;
and similar cases have occurred to Laennec.
Ahdral, Cruveilhier, Bolillacd, Jolly,
and others. Ferkcs, after extensive experience,
states that he h:;< been unable to detect any lesions
which can be attributed to uncomplicated asthma.
The changes which have been noticed, therefore,
by authors, are to be viewed chiefly as accidental
occurrences, or associated maladies: and. perhaps,
more frequently as the remote results of repeat! d
or protracted attacks. The appearances usually
observed in fatal cases are the same as have been
described (§22.).
25. II. Varieties of Asthma, and of their
Pathology. — Sauvages has enumerated no less
ASTHMA — VARIETIES OF.
139
than eighteen forma of this disease, many of them
presenting no modification of the phenomena con-
stituting the disease, but merely peculiarities as
to cause, particularly as respects the occasional
causes. Several of his varieties, also, strictly
belong to the more generally symptomatic com-
plainl to which the term Dyspnoza is usually
applied. The varieties of idiopathic asthma, ac-
cording to Collen, are the Spontaneous, Es-
ANTHEMATIC, and PLETHORIC. Dr. BrEE, who
has given a comprehensive account of the disease,
has divided it into forms which have reference
chiefly to the doctrine which he has espoused re-
specting its pathology. He assigns to it four
species : — 1st, Asthma produced hy the irritation
of effused serum in the lungs; being its most
common form: 2d, That occasioned by the irrita-
tion of aerial acrimony in the lungs: 3d, That
dependent on irritation in the stomach, or some
of the abdominal viscera: and, 4th, That depend-
ent upon habit. Dr. Young has adopted a simi-
lar arrangement.
26. M. Laennec has given a simpler view of
the disease, and assigns it two forms, viz. asthma
attended with puerile respiration, in which the
vital expansibility of the lungs is increased, from
a temporary augmentation of the want of the
system for respiration, occasioned by some un-
known modification of the nervous influence; and
spasmodic asthma, from a spasmodic constriction
of the air-tubes. Dr. Good has divided the dis-
ease into the dry and humid ; but he has en-
cumtiered these two species with nearly as many
varieties as have been assigned by Sauvages.
The dry or nervous asthma he subdivides into
the simple, metastatic, phlegmatic, vaporose, and
organic, — a refinement which is neither founded
in nature, nor can he available in practice; for a
simple nervous asthma may be induced by injuri-
ous vapours, or by repelled eruptions, and hence
we have the first variety produced by either his
second or fourth ; and the second, or the phleg-
matic nervous asthma, may proceed from the
same varieties, I lis tilth variety is certainly not
admissible under asthma, unless as a consequence
of the disease, hut falls more properly under dys-
pno'a, either in its continued or remittent forms.
The Humid or common asthma he subdivides into
the simple, plethoric, and atonic, — a division
much more accurate than the foregoing, but still
objectionable, inasmuch as it is impossible to
draw any line of demarcation between them, and
as the tliree varieties insensibly pass into one
another.
27. By the great majority of authors who have
written on the disease, it has been viewed simply
in respect of its IDIOPATHIC and SYMPTOMATIC
forms ; both, however, presenting modifications
ag from peculiarity of causes, and the cir-
cumstances of the patient, but insufficiently mark-
ed to constitute distinct varieties. In the following
observations I shall observe the same distinction,
and divide the Idiopathic form of the disease
into, 1st, The nervous asthma; 2dly, 'I lie prima-
rily spasmodic asthma; and, 3dly, Tin: piluitous
or humid asthma.
28. 1st, Nervous Asthma. The asthma with
puerile respiration, Laennec. — Char. Anhela-
tioa from a feUing of want of a more complete
respiration than the patient enjoys, the pulmon ry
expansion distinctly taking place with prompti-
tude, completeness, and uniformity, so as to furnish
a general puerile sound on auscultation; usually
accompanied with a slight cough, and with a free
mucous expectoration.
29. This form of the disease was first accurate-
ly described by Laennec, who pointed out the
difference between it and the forms depending on
spasm of the air-tubes. In this variety no spasm
seems to exist in the smaller air-vessels and cells;
for the whole tissue of the lungs is dilated to its
full capacity, and with unusual promptitude and
completeness, so that the puerile respiration is
heard in every part of the chest ; whereas in the
other varieties the respiration is generally some-
what more indistinct than in health. M. Laen-
nec contends, and apparently with justice, that
the wants of the system, in respect of respiration,
may be exactly measured by the intensity of the
respiratory sound; and that the intensity varies
much, according to many circumstances, and par-
ticularly according to the age of the individual,
it being much greater in childhood than in adult
life. There is no morbid affection, he observes,
which can be more satisfactorily referred to sun-
pie disorder of the nervous influence, than this
dyspnoea accompanied with puerile respiration.
Li cases of this kind, the respiratory sound hag
resumed all the intensity which it possessed in
early life. The pulmonary expansion evidently
takes place completely and rapidly in all the air-
cells, and yet the patient feels the want of a more
extensive respiration than he enjoys ; and the
lungs, although dilated to their utmost, have not,
nevertheless, capacity enough to satisfy the wants
of the system. This affection is common in per-
sons affected with chronic mucous catarrhs, at-
tended by a copious and easy expectoration; but
even in them, during the severest attacks, the
completeness with which respiration is performed
is quite astonishing. Nevertheless the patient
feels oppressed, and requires a more extensive
respiration than his organization allows; the wants
of the system in respect of this function being in-
creased beyond the standard of health.
30. In this form of the disease it is not in the
small air-tubes that we are to look for its proxi-
mate cause, but in the trachea and large bronchial
trunks, and particularly in the nervous influence
itself; and this will equally hold good even if we
adopt the chemical theory of respiration, and
refer the affection to an extraordinary want of
oxygen in the blood, arising from impeded func-
tion of the respiratory mucous surface, owing to
the mucous secretion covering it. M. Laennec
believes, as this species occurs only in persons
affected with chronic mucous catarrh, that it can
never amount to asthma, without the catarrhal
complication. Adults and old persons, he re-
marks, who have puerile respiration without ca-
tarrh, are not, properly speaking, asthmatic ; but
they are short-hreathed, and dyspnoea is induced
by the slightest exertion, though when sitting
still they frequently experience no oppression
w hatever.
31. This variety may be considered as depend-
ing upon a temporary augmentation of the want
of the system for respiration, occasioned most
probably by some unknown modification of the
nervous influence; and apparently consisting in
an expansile action of the lungs increased much
beyond the healthy standard. But here a ques-
140
ASTHMA — Spasmodic.
tion suggests itself, viz. can this augmented action
of the lungs be owing solely to the state of this
organ, or is it associated with, or partly depend-
ing upon, increased activity of the respiratory
muscles, particularly the diaphragm? M. Laen-
NEC states that it cannot be produced at will
by a full inspiration; and, therefore, infers that
this state of the lungs is a primary condition of
them, and not depending on increased inspiratory
efforts.
32. From this consideration I am led to infer
that, although the vital expansile action of the
lungs may be increased in this variety of asthma,
it is accompanied with, and much assisted by,
augmented activity of the diaphragm, which per-
forms its office more promptly and completely in
this variety of asthma than in any other; that
instead of the disease being characterised by
spasm of the smaller ramifications of the bronchi
and air-cells, as in the second variety of asthma,
the air penetrates more fully into them than
usual; and that, if any spasm exists, it is limited
to the trachea and large bronchial tubes ; the
exalted state of expansion of the lungs, and of
function of the diaphragm, being an effort to
counteract this morbid condition of the large
tubes, and to supply the wants of the system by
a more forcible inspiration; the increased rapidi-
ty with which the air is thereby made to pass
through the strictured canals making more than
amends for the diminished calibre of the passage.
This form of the disease is frequently symptomatic
of nervous affections, particularly of hysteria
when the globus hystericus atlects the state of
the trachea, and of various diseases, in which the
blood i< imperfectly changed in its circulation
through the lungs. But when thus symptomatic,
it is often slight and evanescent.
33. 2d, Spasmodic Asthma. Svn. Periodic
Asthma. Convulsive Asthma, Willis, Baglivi,
Boerhaave. Asthma Siccum, Musgrave. Occult
dry Asthma, Eimuller. Spasmodic Asthma,
Laennec. Dry Asthma, Good. — Char. Parox-
ysms sudden, violent, and of short duration, at-
tended with hard spasmodic constriction in the
chest; slight, dry, and difficult cough, and with
a scanty expectoration, occurring only towards
their close.
34. I stated that the vital expansive action of
the lungs was increased in the foregoing variety.
In this the ramifications of the air-tubes, and per-
haps the air-cells themselves, seem to be unnat-
urally constricted. The respiration, when exam-
ined by the stethoscope, or by the ear merely,
is heard either very imperfectly even on the most
forcible respiration, or to a small extent only, or
its sound may be but little impaired. The chest,
during the paroxysm, sounds ill on percussion.
These phenomena indicate that there is an im-
perfect entrance of the air into the air-cells. M.
Laennec states, that if the patient, after holding
his breath nearly as long as he can, breathes qui-
etly, the spasm will often be overcome as it were
by surprise, and the entry of the air into the cells
will be heard in a clear or even puerile sound.
This, and various other circumstances, independ-
ently of the proof furnished by the structure of
the air-tubes, indicate that the obstruction to the
entrance of air into the cells is owing to spasm of
the muscular fibres.
35. Dr. Williams believes that spasmodic
asthma may be partial, affecting one lung only,
or one more than the other ; but this is very sel-
dom the case, unless when it is occasioned by,
or complicated with, dry catarrh, which is some-
times partial; or when the spasmodic constriction
is excited by a collection of a pituitous fluid in
some of the bronchi, — a complication of not
infrequent occurrence, but falling more strictly
under the next form of the disease. Although
the paroxysms of the primarily spasmodic asthma
are sudden, and generally of short duration, yet
the disease is often of long continuance, and may,
to a certain extent, become habitual, as shown by
Dr. Brke and others.
36. During the spasm, the lungs seem, from
an attentive examination of the thorax, somewhat
drawn together, owing to the constriction of the
air-tubes; and the parietes of the chest, being ne-
cessarily pressed inwards at the same time, gen-
erally yield a less clear sound on percussion.
The serobiculus cordis is also drawn inwards and
upwards, indicating the manner in whicli the
diaphragm is affected during the paroxysm. '1 his
phenomenon, which was first pointed out by
Scheidemantel (Frtinkische Betruge, No. 5.),
arises either from the diaphragm being prevented
from contracting to its full extent by the spastic
constriction of the air-vessels, or from a temporary
paralysis of this muscle. That the latter state
should take place, and be followed in a short
space of time by a perfect restoration of action,
and that repeated seizures of this description
should be always succeeded by a similarly rapid
return to the healthy state, cannot be admitted by
any person who takes an intimate and com-
prehensive view of the operation of the animal
economy in health and disease. That retraction
of the epigastrium, and even of the hypochondria,
is owing to imperfect descent of the diaphragm
from constriction of the air-cells, seems proved by
the circumstance, that the pleural cavity is per-
fectly closed, and forms nearly a vacuum, and
consequently the capacity of the thorax cannot be
enlarged by the action either of the diaphragm or
of the other respiratory muscles, without the ex-
pansion of the lungs. But this organ is onlv im-
perfectly expanded, owing to the spasm of its
air-vessels ; consequently the diaphragm either
cannot assume its usual place, or does so imper-
fectly, notwithstanding its efforts to accomplish
this end; and the parietes of the thorax are e\erv
where pressed inwards, following the retracted
state of the lungs themselves, and are onlv par-
tially dilated after the most energetic action of the
respiratory muscles, which at last overcomes the
spasm of the air-tubes, as the want of respiration
throws the former into spasmodic action, and
tends to relax the spastic state of the latter.
37. This condition of the air-vessels, and the
antagonising action of the respiratory muscles
during the paroxysm, have a necessary tendency
to form a vacuum in the thoracic cavity : but this
can take place to a very small extent onlv. as the
action of the respiratory muscles is insufficient to
overcome both the pressure of the atmosphere
surrounding the chest, and the spastic stricture of
the air-tuhes, as long as this stricture continues in
full force. The consequeflce, however, of this
antagonising action and tendency to form a va-
cuum is, that a larger quantity of blood is drawn
into the large veins within the thorax, and
ASTHMA — Humid.
141
into the Tenons sinuses and auricles of the heart,
occasioning congestion of those cavities, impeded
circulation through the lungs, congestion within
the head, and inordinate and irregular action of
the heart, with various other injurious effects upon
the central organs of circulation, as well as upon
the cerrbro-spinal centres.
88. In addition also to these effects, which take
place during the antagonising struggle character-
ising the paroxysm, rapture of one or more of the
air-vessels or cells sometimes takes place, in con-
sequence of the violent action of the inspiratory
muscles on the one hand, and the unyielding state
of constriction o\' the air-vessels on the other
(§ 136.); and emphysema of the lungs is super-
induced, forming one of the most common lesions
found upon dissection of fatal cases, and in the
opinion of some pathologists the proximate cause
of the disease. (See Emphysema.)
39. 3d, Common or Humid Asthma. — Syn.
Catarrhal Asthma; Continued Asthma; Humoral
Asthma ; Pituitous Asthma. Spitting Asthma,
Floyer. Asthma Humidum, Riveriua and Mux-
grave. A. Pneumaticum, Willis. A. Humidum,
Baglivi. Pituitous Catarrh, Laennec. — Char.
Gradual accession of the paroxysms, which in-
crease in severity, are protracted, and attended
with heavy and laborious constriction of the tho-
rax, severe suffocative cough, and with expecto-
ration, often commencing early, at first viscid
and scanty, but becoming copious and affording
relief.
40. This common form of asthma may present
various pathological states and relations. It may,
as stated by Cullen and Good, be characterised
by plethora of the vascular system generally, and
of the pulmonary tissue especially, particularly
when it supervenes to the suppression of some ac-
customed evacuation. It may also be associated
with a relaxed or atonic state of the exhalants of
the bronchial surface, particularly when it takes
place after chronic catarrhs, and in aged or phlegm-
atic subjects; and it may be attended with both
these states, namely, with plethora of the san-
guineous system, and atony of the exhalant pores
of the respiratory mucous surface. Besides these
states, it may vary in respect of the acuteness and
chronicity of its symptoms and progress; it being
either acute or chronic, or presenting grades inter-
mediate between both.
41. The chief characteristic of this variety of
asthma is the copious discharge of viscid mucus
accompanying it. Put the questions with several
modern pathologists have been, whether the phe-
nomena of the disease are to he imputed solely to
the accumulation of this fluid in the air-passages,
or in part only; and whether spasm of those pas-
also exist in conjunction with an increased
secretion of mucus, or not. 1 believe that an
attentive observation of the phenomena of the dis-
ease, with the assistance of auscultation and percus-
sion,— which, however, occasionally furnish but
little information, and that of a negative descrip-
tion, in this disease, — will lead to the inference
that it depends upon both those morbid states.
The limits of our enquiry are now narrowed to
the question of the priority of their existence, and
the relation which the one holds to the other. As
to these points it may be remarked, that the early
occurrence of expectoration, as well as its abun-
dance, forbid the inference that the production of
viscid mucus is the consequence of relaxation of
the spasm; whilst they favour the idea that the
spasm is occasioned by this secretion in the irri-
table and morbid air-tubes; the severity and dura-
tion of the paroxysms being occasioned by these
double states of disease, — an abundant secretion
of viscid mucus in, and a spastic constriction of,
the air-passages.
42. But it may be further enquired, are not
those morbid changes the effect merely of a cer-
tain condition of the air-passages still more inti-
mately connected with the disease than they are?
I do not deny the possibility of lesions antecedent
to those now specified; but the difficulty of ascer-
taining their exact nature must be conceded. It
would certainly be advantageous to obtain this
information, inasmuch as on it would be based
the means of cure which might be employed
early in the disease. That it is not inflammation
is proved by concomitant and symptomatic phe-
nomena, by the course of the paroxysms and of
the disease, by the terminations usually charac-
terising it, and by observation of the juvantia and
ladantia during its progress. It seems, however,
extremely probable that the morbidly increased
secretion and spasm are preceded by a congestive
state of the mucous respiratory surface; this state
disposing to the spasm, and being, as well as the
spasm itself, at last relieved by the copious effu-
sion of mucus; the mucus first effused tending,
however, for a time, to increase the spastic con-
striction of the air-passages, and the consequent
strugg'e of the respiratory muscles to overcome it
(§ 3b, 37.), and to procure a fresh supply of air
in the lungs. This antecedent state of vascular
turgescence of the mucous surface of the bronchi
in asthma, is perhaps most marked in that form
of this variety, in which little or no expectoration
accompanies the cough, at least early in the attack,
and which, from this circumstance, and the causes
which induce it, has been called the dry catarrhal
asthma.
43. If it be still further asked, to what cause are
we to impute this congestive state of the respira-
tory surfaces ? I can only answer, to a certain
primary change of the vital energy of the organic
nerves supplying the blood-vessels, and actuating
the muscular fibres of the bronchi ; and hence,
as the morbid changes of the circulation, secre-
tion, and calibre of the air-passages, are merely
effects of one cause, — of a previous change of the
vital manifestations of the nerves of the organ, —
it becomes of the utmost importance to ascertain
the nature of this primary change with as much
accuracy a< possible, in order that remedial agents
may be directed with precision to its removal;
but the prosecution of this very interesting topic
falls under another division of my subject. In
estimating, however, the nature of this, as well as
the other varieties of asthma, the difficulties op-
posed to expiration by the spasm of the air-tubes
and the accumulation of viscid mucus in them,
have been too generally overlooked in our eager-
ness to ascribe all the morbid phenomena to im-
peded inspiration. But I believe that the disease,
particularly this variety of it, is as much occasion-
ed by the obstacle these states of the air-passages
present to free expiration; the air, by the greater
power of the inspiratory over the expiratory
muscles, being drawn in sufficient abundance into
the lungs, from which it is imperfectly expelled.
142
ASTHMA — Diagnosis.
From this circumstance the lungs are often kept
in a state of inordinate dilatation, and the res-
piratory muscles excited to convulsive actions,
occasioning dilatation or rupture of the air-cells,
and consequent emphysema of the lungs. In
the more advanced stages of the disease, in old
and debilitated subjects, this struggle to dilate
the thorax still further, proceeding from the
wants of the system for respiration, and to expel
the air from the lungs through the obstacles
placed in its way, generally terminates unfavour-
ably to the latter part of the respiratory actions;
consequently expectoration is impeded or sup-
pressed, and life is terminated, with the air-
tubes and cells, and even the substance of the
lungs, loaded and infiltrated with mucus, air, and
serum. It is in this state that active stimulants
and emetics, by rousing the energies of the frame,
and by exciting the expiratory efforts during
the process of vomiting, prove so frequently ben-
eficial.
44. This form of asthma may be partial, af-
fecting one lung only, or one more than another;
but it is more commonly general; and in some
constitutions, particularly in aged persons, and
when it has supervened to repeated attacks of
catarrh, the quantity of viscid mucus expectorated
is very great.
45. Its anatomical characters are, slight swell-
ing, or thickening, and softening of, the mucous
membrane, with a slight appearance of redness in
parts, and with marked congestion, and purplish
tint of portions of tills surface in the more severe
or protracted cases. Sometimes these lesions are
accompanied with slight oedema of the membrane,
and the developement of miliary tubercles in the
lungs.
46. As the majority of cases of this disease is
characterised from the commencement by copious
expectoration, it becomes a question how far it
deserves to be considered as a variety of asthma;
but taking all its phenomena into consideration,
particularly the spasm of the air-passages, and
convulsive action of the respiratory muscles, as
well as the circumstance of it having been usually
considered as a species of asthma, and the dif-
ficulty of arranging it otherwise, I was unwilling
either to assign it a different place, or to make it
a distinct disease, to which it scarcely can lay-
claim. M. Laknnec has placed it amongst ca-
tarrhal inflammatory affections of the bronchi :
but I conceive that it is seldom inflammatory
either in its origin or progress; and that, although
occasionally commencing 'in, and always aggra-
vated by, catarrh, it is not necessarily a catarrhal
disease. Besides, inflammations of the bronchi
and catarrhs are not identical affections, although
the latter frequently pass into the former.
47. But, besides these considerations, many of
the phenomena essentially characteristic of asthma
always attend it to a greater or less extent. I pon
an attentive examination, however, of the chest
of a person afflicted with tliis affection, by auscul-
tation and percussion, these phenomena are found
to vary, in different cases, or even in the same
case, at different periods of the attack ; yet they
are essentially the same as those which mark the
preceding varieties, although not so evident to the
senses as in them, inasmuch as they are obscured
by a more prominent symptom — the copious mu-
cous secretion and expectoration. Sometimes it
is manifest that certain parts of the air-tubes are
differently, or even oppositely, affected at different
periods of the attack. When the viscid mucous
secretion proceeds from, and is still present in,
the smaller ramifications of the air-vessels, this
condition, together with some degree of spastic
constriction of their circular fibres, either in a
part only, or more or less throughout the organ,
occasions many of the symptoms which charac-
terise the second or spasmodic variety of the
disease. But in proportion as the secretion rises
to the larger air-tubes, and leaves the smaller
ramifications clear; or when the mucous secre-
tion proceeds chiefly from the former parts, and
excites, or is accompanied with, spasms of these
canals, but not to the extent of preventing the
passage of air into the parts of the lungs which
they supply ; these parts generally expand freely,
owing to the vital activity of the organ, the wants
of the system for the changes effected on the
blood by respiration, and the active contraction
of the inspiratory muscles during the convulsive
efforts of the paroxysm. Hence the part of the
lungs thus affected generally furnish the puerile
respiration, and a clear sound on percussion, with
a full and prompt performance of the inspiratory
actions, — phenomena characteristic of ihe first or
nervous form of asthma.
48. Diagnosis. — From the foregoing account
of the symptoms and forms of asthma, it will
appear obvious that the distinction of it from
every other disease cannot be difficult, particu-
larly if we carefully bring auscultation and per-
cussion to our assistance. The sudden attack of
the paroxysms, the short period of their duration,
the violence of their symptoms, their returning
after intervals of ease and of tolerable health,
are sufficient to characterise the disease. It is
only when asthma is complicated with, or has
induced, other diseases — as chronic or acute
bronchitis, pneumonia, tubercular phthisis, or-
ganic changes of the heart and large vessels, or
effusions of fluid within the thorax — that diffi-
culty can arise in determining the exact state of
parts; and here we have it hi our power to resort
to auscultation and percussion, which, if this
disease be simple and uncomplicated, will furnish
us with no very unnatural sound, at least with
none which will exist with any permanency in
any particular part of the chest; and if it be
complicated, the nature and the extent of the
organic changes will be ascertained by these
means, as pointed out under their respective
heads.
49. A. Spasmodic affections of the larynx may
be mistaken for asthma; but they may readily be
distinguished from it by the sound occasioned" by
the passage of air through the narrowed passage,
which Is very different from the wheezing sound
of the asthmatic respiration. Besides, in all the
affections of the glottis, the patient readily points
to it as the seat of his sufferings. The patient
also betrays much more alarm of impending suf-
focation; whereas in asthma he is seldom appre-
hensive of the result, however severe the attack
may be.
50. B. Severe cases of acute bronchitis, owing
to the viscid and copious expectoration accumulat-
ed in the bronchi and titichea, and to the spasm
excited in these parts and in the glottis during its
expulsion, are often accompanied with fits of
ASTHMA — Prognosis — Causes of.
143
difficult :nui spasmodic respiration, so severe as to
approach nearly to the character of the asthmatic
paroxysm. I>ut the presence of inflammatory
Fever in bronchitis ; and the copious, albuminous,
thick, and glutinous expectoration ; the absenceof
the distressing sense of stricture of the chest and
dyspnoea which attend asthma ; the gradual ac-
cession and increase of bronchitis ; its continued
character, and slow subsidence ; and the varying
appearance of the expectoration, with the differ-
ent stages of the disease ; will be sufficient to dis-
tinguish it from the humoral form of asthma, un-
less both affections are associated, or the one
- into the other, which sometimes occurs, as
when bronchitis seizes the asthmatic subject.
51. C. Angina pectoris may also be mistaken
for a severe tit of asthma. But the circumstances
inducing an attack of both affections, and the
periods of their accession, are different. Besides,
the tit of angina pectoris is attended with a feel-
ing of impending dissolution — a sensation which
never accompanies the asthmatic paroxysm. The
i linSj Iso, under the sternum, and pain
and numbness of the left shoulder, arm, &c, cha-
acterising the former, are not present in the latter
affection. When asthma becomes associated with
disease of the heart and large vessels, these sen-
sations may accompany it, which will render the
diagnosis more, difficult. But still the accession
of the asthmatic tit in the evening or night ; the
comparative immunity from it during the day,
and in the open air ; the history of the case ; and
the antecedent or attendant disturbance of the
functions : will still continue, and serve to
point out the nature of the disease.
52. D. Hydrothorax is frequently attended with
suffocating paroxysms of difficulty of breathing
occurring during the night. But it may readily be
distinguished from asthma by the scanty urine ;
by external o dema, particularly of the extremi-
ties ; und the dead sound furnished by percussion,
and the absence of the respiratory murmur. It
must not, however, be forgotten, that hydrothorax
is not infrequently consecutive of chronic asth-
ma, particularly when the valves and cavities of
the heart have become diseased in the course of
the asthmatic attacks. — The affection denominated
the Aruie Asthma of Infants, by Miller ; False
Croup, by Go ERSEHT; and the Spasmodic Croup,
by WlCHMANN, MlCHAELIS, L>OUBLE,&C, is
nearly allied to spasmodic asthma ; one of the
chief differences being its occurrence in infants.
Its diagnosis, &c. will be found in the article
on Croup — Spasmodic. The practitioner should
also be careful not to confound the disease with
the difficulty of breathing which sometimes ac-
companies hysteria, hypochondriasis, and the pas-
sage of foreign bodies into the trachea.
53. Prognosis. — There are few diseaseswhich
continue longer without shortening life; and which,
therefore, admit of a more favourable prognosis in
t of a fatal result, or a more unfavourable
opinion as regards a perfect recovery. Jt is chief-
ly from the consequences of a severe or protract-
ed state of the disease that we are to apprehend
any danger ; and these are to be ascertained by
dtation and percussion, and our opinions form-
ed accordingly, a. The circumstances which war-
rant a favourable prognosis as to recovery are, a
recent attack, and its occurrence from a decided
cause ; the constitution of the patient being but
little impaired ; the absence of deformity and
malformation of' the chest ; a free and easy state
of the respiration, and a tolerably healthy con-
dition of the various functions, during the intervals
between the attacks. If the occupation of the
patient be not injurious to the lungs ; or, if so,
can be readily relinquished ; i'f the attacks are
not extremely severe, nor of very long duration ;
and more particularly, if auscultation and per-
cussion, as well as the rational symptoms, in-
dicate an uncomplicated state of the disease, we
have still greater reason to give a favourable
opinion as to its issue.
54. I). On the other hand, an unfavourable
idea must be entertained, especially as respects
the perfect recovery of the patient, and his im-
munity from future attacks, if the fits be very se-
vere : the cough difficult, suffocative, and attend-
ed with great expectoration mixed with blood
and purulent mucus, — a state of the expectora-
tion generally indicating rupture or dilatation of
the small air-vessels, or the existence of tubercles
in the lungs. If the occurrence of haemorrhage
from the lungs, of epistaxis, of haemorrhoids, or
of the menses in females, be not followed by a
complete solution of the attack ; — if the disorder
be of long standing, and present remissions mere-
ly, or imperfect relief in the intervals, the attacks
continuing for several days ; — if the means of
cure furnish but little or no relief; — if the patient
be far advanced in life, and his constitution have
suffered much either previously to, or from the
malady ; and if the body evince signs of cachexia;
— if he has neglected his disease, or has been in-
judiciously treated ; — and if the symptoms cha-
racterising any of the organic changes which I
have stated to proceed from, or to be associated
with, asthma (§ 20 — 24.), present themselves,
particularly dropsical effusions in the pleura or
pericardium, and the nature and extent of these
changes are determined by means of auscultation
and percussion, an unfavourable result must be
looked for sooner or later ; yet may this result
be often deferred for a long period by judicious
management. The exact degree or proximity of
danger will depend entirely upon the nature and
extent of the existing organic lesions, and the
state of the vital energies of the frame.
55. If the expectoration become purulent, round,
and globular ; if hectic fever be present, with
irregular or intermittent pulse ; if palpitations oc-
cur, and alternate with leipothymia or syncope ;
if the urine be in small quantity and high colour-
ed, the hands and ancles being oedematous ; if
the countenance continue bloated or livid during
the imperfect intervals between the attacks ; if
the patient become restless, with slight wander-
ing or low delirium ; a fatal termination is not
very far distant, unless under the most favourable
circumstances of regimen and medical treat-
ment, when life may be occasionally protracted
for -nine time.
56. Causes. — 1st, Predisposing causes. Asth-
ma is not a disease of early life, in its primary or
idiopathic form. I hav(! seldom or ever seen it
before the 23d year of age. Some authors state
that they have met with it in infancy and child-
hood ; hut I believe that they have confounded
this affection with oilier diseases of the respira-
tory organs, and particularly with those to which
voung children are liable, and which has been
144
ASTHMA — Causes of.
termed spasmodic croup, Millar's asthma, &c.
by several modern writers, and its nature very
generally misunderstood. The reader will find
them treated under other articles. (See Larynx
— Spasm of; Croup — Spasmodic; and Ca-
tarrh— Suffocative.) I believe that affections
of the respiratory apparatus in children, which
are not connected with inflammation, are general-
ly symptomatic of disease of some other organ.
57. Asthma is evidently sometimes dependent
upon hereditary disposition and conformation. It
invades all temperaments, but especially the mel-
ancholic, the sanguineo-melancholic, the nervous
and irritable. The male sex is much more dis-
posed to it than the female, particularly those of
the former sex who are of a full habit of body
and advanced in life. Joseph Frank surely
reckons the proportion of cases in males some-
what too high, when he states that six are affect-
ed to one female. So far, however, as my own
experience enables me to judge, the proportion is
not much less. Persons endowed naturally with
great sensibility of the nervous system, or who
have acquired this state from indulgence of the
passions — from masturbation, venereal excesses,
the immoderate use of warm bathing, long con-
tinued mental exertions, want of the requisite
sleep, frequent excitement of temper, mental de-
pression, and exhausting discharges, are much
more disposed than others to be affected by the
exciting causes of the disease.
58. The spasmodic form of asthma attacks
most frequently persons of a spare habit, and who
have been weakened or emaciated by the fore-
going causes ; or who have passed a laborious
and anxious existence ; whilst the humoral variety
of the disease is commonly met with in those who
are gross, phlegmatic, corpulent, robust, or full of
blood, and who have been long exposed to the
■causes of chronic and general weakness, and have
led an indolent, luxurious, or sensual life.
59. In addition to the foregoing causes, san-
guineous plethora ; malformation and injuries of
the lungs, chest, or spine ; peculiarities of forma-
tion of the air-passages, of the cavities of the
heart, and large blood-vessels ; constitutional
irritability of the air-passages and lungs ; narrow-
ness of the glottis, and morbid sensibility and ir-
ritability of the nerves and muscles of the larynx;
congestions, enlargements, habitual distensions, or
organic changes, in the large viscera adjoining
the diaphragm, as of the liver, stomach, spleen,
and colon ; previous disease of the lungs and air-
passages, particularly frequent attacks of catarrh,
and neglected winter coughs ; and adhesions of
the pulmonary pleura to the costal or diaphragm-
atic pleura, may be ranked amongst the predis-
posing causes of the disease. It should not, how-
ever, be overlooked, that the foregoing do not
only dispose the system, and particularly the
lungs, to the operation of the exciting causes, but
are also of themselves capable of producing the
disease, when they act intensely, or when their
operation is of long duration.
60. Neglected or confirmed dyspepsia; erratic or
metastatic gout; suppressed eruptions, discharges,
and habitual perspiration of the feet, are also pre-
disposing and concurrent causes of the disease.
In addition to these, I may add, the warmth and
closeness of our apartments, luxurious habits, and
previous diseases affecting the lungs in a particu-
lar manner — as whooping-cough, measles, small-
pox, and typhoid fevers — as having a marked in-
fluence in predisposing to asthma.
61. 2d, The occasional or exciting causes are,
various mental emotions and affections; paroxysms
of anger, vexation, disappointment, anxiety, and
all the violent or depressing passions ; great fa-
tigue ; prolonged watchings ; strong exertions of
the voice, reading long aloud, or long speaking ;
terror, or surprise; sudden refrigeration of the sur-
face of the body; or exposure to, and the respiring
of a cold or hot, or a too moist or too dry air —
these states of the atmosphere acting difierently
in different persons and varieties of the disease.
Thus, the third and first varieties are generally
relieved by a dry and pure air, whilst the second
variety is occasioned or aggravated by it ; and a
very moist and cold air, or a humid, close, and
warm air, whilst it frequently relieves the latter,
always augments the former ; but it is not infre-
quently observed, that states of the atmosphere
which cannot be referred to grades either of tem-
perature or humidity act very differently on dif-
ferent persons labouring under the disease, al-
though the form may be the same. It seems to
me extremely probable that this is owing, in a
great degree, to the electrical states of the atmos-
phere, and the electro-motive condition of the
frame ; as we sometimes see the disease oc-
casioned by close and oppressive states of the
air, particularly when these states precede a
thunder-storm, — thunder and lightning being less
influential in its production than the electrical
states of the atmosphere which terminate in
these phenomena.
62. There are, perhaps, few causes which
more frequently produce asthma, than those
which act directly on the air-tubes through the
medium of the respired air, as various kinds of
dust and irritating particles floating in it (see artir
cle on Arts, as productive of disease); common
coal-smoke, the vapour from lime or brick-kilns,
metallic fumes of every description, mephiiic
gases, every kind of acrid vapour, the fumes
from chemical manipulations ; hydrogen, nitro-
gen, carburetted hydrogen, carbonic acid gas,
and all other gaseous productions floating in the
atmosphere ; employments which lead those
prosecuting them to breathe an air charged with
minute particles of vegetable, animal, or mineral
productions, as manufacturers of cotton.and wool,
furriers, grinders, needle-pointers, &c. Odours
of every description occasionally excite the dis-
ease, particular odours acting differently in differ-
ent persons ; those occasioning it in some, al-
leviating it in others — as the aroma of various
flowers and plants, the smell of tobacco, ipe-
cacuanha, &c.
63. The disease may also be produced, or rather
a paroxysm may be occasioned in those subject to
the disease, by whatever deranges the healthy
function of the digestive organs, and particularly
if it occasion acid or acrid eructations, which irri-
tate the epiglottis and glottis, or cardialgia, flatu-
lent or inordinate distension of the stomach or co-
lon, or impedes the free descent of the diaphragm
(Ast. Sfonitfe/ucum, Baglivi; Ast. F/atuUntum,
Floyer, Schro2der, Balpinger), and by
irritation and spasm of <he glottis and trachea,
(Willis, Lieutaud, Desgranges, &c). It
is also sometimes occasioned in the female by hys-
ASTHMA — Causes of.
1
terical affections (Ast. Hystericum, Horstios,
Baglivi, Sauv \«. i ■ . &c); by misplaced, sup-
pressed, or metastatic gout {Ast. drthriticum,
Musg rave, Hoffmann, Stoli., &.c); by the
syphilitic poison; {Ast. Venereum, Joncker);
h\ the slow introduction of lead into the system
(Williams; Ast. Metallicum of Ettmdxleb
and [tsEMANN);by greal obesity ( Floi er); the
suppression of accustomed discharges and evacu-
ations, and from vascular plethora proceeding from
this cause {Ast. Plethoricum, Dover, Cuxlen,
Sauvages; Ast. Sanguineum, Hoffmann); by
the repulsion of eruptions, the retrocession of ex-
anthematous diseases, and the drying up of issues
and eruptive discharges {Ast. Exdnthematicum,
C\ i li'.x, et Var. Auct.). It may also proceed
from a cachectic habit of bodv (Ast. Cachecti-
aim, Hoffmann, Sat/vages, &c.) ; from ex-
cessive impregnation of the system with mercury
(Schenk, Bonet); and from chronic catarrh
and bronchitis (Laennec, Boissf.au, &c).
64. 3d, Symptomatic Asthma. — But little is re-
quired to be added under this head, further than
to specify in a general way some of the organic
lesions that sometimes excite phenomena, which
either closely resemble, or are the same as, those
which accompany the idiopathic disease. Amongst
those, the disturbance of the pulmonary circula-
tion, and the nervous and muscular irritation,
occasioned by organic lesions of the heart and
large vessels; by aneurismal tumours: by tumours
affecting the diaphragmatic and pulmonic nerves
(Beclard, Andral, and Parry); enlarge-
ment of the cavities of the heart, and obstacles to
the circulation through the openings into the vcn-
trieles or arterial trunk's; by ossific deposits in
these situations, or in the coats of these vessels,
or in the external surface of the heart, or pressing
on the pulmonic plexus of nerves (Ferrus); by
polypi in the cavities of the heart and large ves-
sels (DlEMERBROCK, FlOTER, RoSTAN) J by
adhesions of the pleura, and organic changes of
the pirietes of the chest, diaphragm, or spine; by
curvatures of the spinal column, and lateral con-
traction of the chest, fee.; by hernia of the dia-
phragm (Hecker, Bonet); by tumours and
effusions within the chest and pericardium; by
organic changes in the vicinity of the larynx and
trachea: by enlargement of the lymphatic glands
within the chest and the glands of the bron-
chi; by tumours developed in the mediastinum
(Schjeffer); by foreign substances which have
led into the trachea and bronchi; by organic
changes of the lungs themseh es, especially miliary
tubercles, or similar productions in advanced
• of growth and change; by oedema of the
hmgs, or sera-sanguineous infiltration of their
substance; and frequently by emphysema of the
organ, and pituitous collections in the bronchi,
the emphysema being a verj common consequence
and complication of the severer forms of the dis-
Batllie, Laennec, &<*.). Besides being
sometimes induced by one, or more, of the above
lesions, it may also be symptomatic of congestions
and organic lesions of the liver and spleen; but,
although those, and various other organic lesions
enumerated under Dtspnce \. produce spasmodic
and convulsive states of impeded respiration in
some rare instances, yet they are more commonly
productive of continued or remittent dyspnoea.
Asthma is, moreover, sometimes symptomatic of
13
lesions affecting the mttlulla oblongata and spited
cord, of hypochondriasis, and of diseases of the
colon and rectum.
(>•>. 111. Complications of Asthma. — From
the foregoing statement, it will be readily admit-
ted that asthma very frequently presents itself in
practice in complicated forms. Indeed, when
the disease occurs in consequence of any of the
states of the system described in § 60 — 64., or of
any of the previously existing diseases and organ-
ic lesions of which I have stated it occasionally to
be consecutive and symptomatic, it should be
viewed as complicated with such lesion, and our
attention directed to the whole of the morbid as-
sociation, both pathologically and therapeutically.
I >ur enquiries should likewise be extended even
to the functions of distant organs, as it will occa-
sionally have an intimate relation even with them,
particularly to the functions of the digestive, as-
similative, and generative organs. Amongst the
most common complications of the disease, I may
mention the various forms of catarrh, dyspepsia,
hypochondriasis , hysteria, emphysema, and cedema
of the lungs, hcemoptysis, chronic bronchitis, and
enlargement of the cavities of the heart, as espe-
cially requiring our attention during the treatment.
(See the articles Emphysema, (Edema of the
Lungs, and Bronchitis.)
66. The paroxysm of the third variety of disease
is often occasioned by a common catarrh; and
owing to this circumstance, as well as the presence
of many of the symptoms of this affection, it has
often been denominated catarrhal asthma. It is
sometimes also complicated with active congestion
of the lungs, particularly of its mucous surface.
\)v. 1'arry conceived that this state of the res-
piratory organs constitutes the disease; and in-
stances the case of a person, who died in about
twenty minutes with all the symptoms of spas-
modic asthma, and in whom the only lesion was
complete suffusion, of a damask rose colour,
amounting in parts almost to blackness of the
mucous membrane of the trachea and bronchi.
Dyspepsia not only accompanies asthma, but very
generally precedes an attack. The complication
with bronchitis and haemoptysis is chiefly observed
in the third variety; whilst the association with
hysteria and hypochondriasis Ls most commonly
met with in the nervous and spasmodic forms of
the disease.
67. Organic diseases of the heart and large ves-
sels are very frequently complicated with asthma.
The former seems to be most commonly a con-
sequence of the latter; but, in some cases, an
opposite order of causation obtains. In all such
states of disease, either too little, or too much
blood enters the lungs, and the healthy relation
between respiration and the pulmonic circulation
is changed: if either too much, or too little blood
passes, it is imperfectly purified, and the; wants
oftb i system occasion a sense of anxiety and an-
helation. Hut I believe that the phenomena of
associated disease of the heart, and of the pulmo-
nary functions, may be more correctly explained
by referring them to the state of the nerves sup-
plying the organs. These nerves are so inti-
mately related, anatomically and physiologically,
that disease originating in, or affecting, any one
part of them, will frequently influence the func-
tions of the whole, or of such of them as are
most intimately connected with the originally
146
ASTIIMA — Causes of.
diseased part. When, therefore, we find a por-
tion of the particular order of nerves, which sup-
plies the respiratory and circulating organs, re-
markably affected — whether such portion influ-
ence the state of the bronchi, or the circulation
through the lungs, or the actions of the heart —
can it be a matter of surprise that an analogous
disorder should extend to parts so intimately re-
lated anatomically and functionally as are the air-
passages, the pulmonic circulation, and the heart
and large vessels ?
68. L'pon taking a review of the causes of this
malady, we shall perceive that it may be occa-
sioned, like several other chronic diseases of the
respiratory organs, — 1st, By whatever lowers the
vital energies of the frame, particularly as they are
manifested in the lungs, and increases the suscep-
tibility of the organ to the impression of external
agents, or to internal morbid associations (§ 57.);
— 2d, By mental or moral states deranging the
nervous influence actuating the respiratory and
circulating organs (§ 61.); — 3d, By agents which
disturb the equilibrium existing between the cu-
taneous and respiratory functions (§61.); — 4th,
By causes acting, during respiration, directly on
the seat of disease, either by depressing the vital
and nervous influence of the organ, or by irrita-
ting its mucous surface, and thereby exciting its
fibrous structure to undue contraction (§ 62.); —
5th, By causes acting during respiration, especial-
ly atrial vicissitudes and states which modify or
impede the respiratory functions, and favour con-
gestion of the pulmonary mucous surface, or of
the substance of the lungs; — 6th, By whatever
impedes the action of the respiratory muscles, or
embarrasses the motions of the parietes of the
chest (§ 63.); — 7th, By lesions of the circulating
organs deranging the circulatory function of the
lungs or heart (§ 64.) ; — Sth, By the extension of
irritation from adjoining viscera or parts (§64.);
• — 9th, By the destruction of the equilibrium be-
tween absorption and excretion (§58.); — 10th,
By the transference of morbid action from other
parts of the frame (§ 63.), — 11th, By affections
of the respiratory nerves and plexuses, either at
their origins, or in any part of their distributions
(§ 57. 64. 67.). Hence the propriety of dividing
asthma not only into the nervous, spasmodic,
and humid varieties, but also into two divisions,
as respects its relations to its causes, and to other
diseases; viz. into Idiopathic and Symptom-
atic.
69. Proximate Cause. — The majority of
writers on this disease, from Willis down to the
times of Hoffmann and Cullen, have referred
it to spasm of the bronchial tubes; and the same
opinion has been espoused by many contempo-
rary authors, particularly Laennec, Williams,
&c. Host an and several French pathologists
consider the disease as altogether symptomatic of
organic changes seated chiefly in the heart and
large vessels: but, although this may be conceded
to be the case occasionally, I conceive that they
substitute the effect for the cause; lesions of
these organs necessarily supervening in the man-
ner already explained (§ 67.), after repeated
attacks. The doctrine, moreover, lias been
completely overturned by the post mortem ex-
amination of cases of the disease by Corvisart,
Feiirus, Georget, Laennec, Antral, De-
lens, and Bricheteau, in wliich no such
changes were found. Bree, Parry, and Brous-
sais ascribe asthma to inflammatory congestion
and irritation of the mucous membrane lining the
air-passages; and this doctrine is at present adopt-
ed by many British and continental pathologists.
I do not mean to dispute the existence, to" a cer-
tain extent, of irritative congestion of the respira-
tory mucous surface, particularly- in the third va-
riety into which I have divided the disease, but
still I believe that it is a part only of the changes
from the healthy state, which constitute this mal-
ady. M. Georget contends that it proceeds
from irritation about the base of the brain, and
particularly at the upper part of the medulla ob-
longata, and origin of the respiratory nerves, oc-
casioning convulsive paroxysm of the inspiratory
muscles. MM. Roche and Sanson (Elimens
de Pathologie, §-c. t. ii. p. 642.) ascribe it to ir-
ritation of the nerves supplying the respiratory
surfaces, occasioning convulsive actions of the
respiratory muscles; Zallony to suppressed in-
fluence of the pulmonary nerves, and imperfect
change of the blood in the lungs; Dupuytren
to an affection of the par vagum; and Horn,
Henke, and many others, entirely to spasm of
the bronchi. That the disease, in a great mea-
sure, depends upon the morbid state of the nerves
supplying the lungs and respiratory muscles, is
evinced by the case which occurred to M. Fer-
rus, who found, on the dissection of a female
who had been subject to spasmodic asthma, a con-
siderable ossific deposit in the centre of the pul-
monic plexus, and compressing part of its nerves.
There can be no doubt that irritation of the
nerves, or impeded or interrupted nervous influ-
ence, will produce spasm of those muscular parts
which they supply, and interruption of those
functions which are dependent on their healthy
influence.
70. The proximate cause assigned to the disease
by Cullen, Parr, and other modern authors,
differs but little from that contained in the writ-
ings of Willis, Baglivi, Hoffmann, Bof.r-
haave, Sao v ages, and others of their prede-
cessors, excepting that it is stated by them with
greater precision. It seems to me so correct, in
the majority of cases, as not to admit of dispute.
Doubtless the researches of contemporary pathol-
ogists have tended to show that ninny cases close-
ly resembling this disease, and which would have
been imputed to the same pathological states
by our predecessors, depend on other conditions
of the respiratory organs, and those differing wide-
ly in their nature from each other; thus abridging
the number of purely asthmatic cases, and con-
signing to different organic lesions many that pre-
sent nearly similar functional derangements to
those which are strictly asthmatic.
71. I therefore conclude, with many of my
predecessors, some of them unmeritedlv overlook-
ed at the present day, that asthma depends on a
preternatural or spasmodic constriction of the air-
passage.s, accompanied in many cases, especially
in the humoral or catarrhal variety, and particu-
larly when it assumes what >!. Laennec lias
called the dry catarrhal form, with turgescence
of the vessels of the lungs, particularly those sup-
plving their mucous surface, and an increased se-
cretion of mucus: anfl I would add, that, in this
form of the disease, the spasmodic constriction
of the air-tubes, the turgescence of their niu-
ASTHMA — its Treatment.
147
eoufl lining, and the accumulation of mucus in
them, present an obstacle, not only to inspiration,
but also to expiration; the lungs being thereby
often kept in B state of inordinate dilatation, and
the respiratory muscles excited to convulsive ef-
forts, occasioning, in some cases, dilatation of tlie
air cells, or their rapture, and consequent emphy-
sema of the organ, with effusions into the air-tubes,
and other consequences described in the article on
Organic Diseases of the Longs,
72. IV. Treatment. — The treatment of
asthma is generally directed to the fulfilment of
two intentions; viz. to shorten or alleviate the fit;
and to prevent its return, and thus remove the
disease. The means of cure may therefore be |
divided, 1st, Into those which are to be resorted
to daring the paroxysm, with the view of attaining
the first intention; and, 2d, Such as may be em- j
ployed during the interval, for the accomplishment
of the second. I shall notice successively the
measures which may be resorted to for the fulfil-
ment of these ends, with as strict a reference to
the forms and complications of the disease as my
limits will permit.
7:!. 1st. Treatment of the paroxysm. — In treat-
ins the fit of asthma, the practitioner will take cog-
nisance of certain particulars, which should ma-
terially influence the choice, the combination, and
the extent of the means, which are to be put in
operation. The duration of the paroxysm; the
aire, temperament, and habit of body of the pa-
tient; the period he has been subject to the dis-
ease, the frequency of the attacks, and the par-
ticular form they assume; the state of health in
the interval; and the presence or absence of con-
comitant, functional, or organic lesions of the
lungs, heart, and digestive organs, are all of the
utmost importance to be known; and, without
tolerably accurate ideas respecting them be enter-
tained, the disease cannot lie judiciously treated.
As individual cases vary greatly as to each of
these circumstances, it would be impossible to
describe in connection all the measures which
may be employed in a paroxysm of asthma, so as
to be appropriate to eacli of its numerous states
and complications. Such descriptions, although
thej would be sometimes perfectly suited to a
case, would as often be inappropriate, or even al-
together inapplicable. I shall, therefore, detail
separately the means of cure which have been
found most beneficial, and point out the states
and circumstances of the disease, to which each
of them seems best suited, at the same time ar-
ranging them in such a manner as to fulfil inten-
tions of cure, based on the pathology of the
disease.
74. A. To remove congestion or repletion, when
present. — There are various symptoms which
frequently present themselves during the asth-
matic paroxysm, which would suggest the pro-
priety of blood-letting. Hut it is often either of
little service or positively prejudicial, especially
Li the lirst two varieties of the disease. In the
third variety, however; and in the young, robust,
middle-aged, and plethoric subject; or when the
paroxysms are very severe, and are attended with
signs of much congestion of the longs and brain,
as lividity and fulness of the countenance, stu-
por, extreme dyspno a. &e.; blood-letting is indis-
pensable, and should be performed either from
the feet, or by cupping between the shoulders.
Yet, even in these cases, bleeding will seldom do
more than relieve the more urgent symptoms: it
will seldom or ever put a stop to the paroxysm,
and it should be practised always with much
caution.
75. B. To moderate or relieve spasm by anti-
spasmodics, anodynes, and narcotics, fyc. — These
medicines may be viewed in connection, as a
combination of them are more suited to the asth-
matic lit, than the exhibition of them singly. They
are beneficial chiefly in the first and second vari-
eties of the disease, and in the third, when attend-
ed with severe convulsive and spasmodic fits ol
cough. When the disease occurs in hysterical
females, or is associated with organic change of
the heart or large vessels, these medicines are
generally of much service. In the humoral form
of the disease, and particularly when it commences,
or is complicated with catarrh, they are less ser-
viceable, although sometimes beneficial when ju-
diciously employed. The particular remedies be-
longing to the above classes, which have received
the approbation of the best authors, are camphor,
assafcetida, valerian, castor, musk, ammonia,
athers, coffee, opium, stramonium, tobacco, bella-
donna, hyosciamus, conium, prussic acid, colclii-
cum, digitalis, lactuca virosa, &c. &.C., in various
forms, and modes of combination.
76. a. Camphor is one of the most generally
beneficial of any of this class of remedies, and is,
when judiciously exhibited, applicable to nearly
all the forms and complications of the disease.
In the nervous and spastic varieties it is most ser-
viceable when given in large doses (from three to
ten grains), and combined with musk, castor, assa-
firtida, and the preparations of ffither, opium, or
hyoscyamus (see F. 25. 186. 423. 493.), and the
following : —
No. 34. R Camphors rasa>, cr. iij. — vi.; Amnion. Car-
bon, gr. iij. ; Pulv. Ipecacuanha gr. j. ; Extr. Hvosciami
gr. iij. — v.; Mucilag. Acacia: q. s. M. Fiant Piluhe iij.
statim sumendae cum Hau.stu sequente, et horas post binas
repetends, si sit opus.
No. 35. ft Magnes. Suhcarh. '0 j. ; Aq. Anethi 5 x. ;
Spirit. jElher. Sulph. Comp. ~, j. ; Tinct. Castorei 3 j- j
Old Ani-i Tl) iv. M. Fiat Haustus.
77. In the pituitous or catarrhal form of the
disease, or in cases where blood-letting may be
practised, and where we suspect active congestion
of the mucous surface of the air-tubes, camphor
is best exhibited in moderate doses, and combined
with nitrate of potash, ipecacuanha, kermes min-
eral, James's powder, and other antimonials (see
F. 494—496.).
No. 36. Tl Pulv. Jacobi Veri gr. iij. — vj. ; Camphorae
rasse gr. ij. — iv. ; Pulv. Ipecacuanha; gr.j.; Ext.Hyos-
ciami gr. iij. — ;vj. j Syrup. Papaveris q. s. M. Fiant Pilu-
lae iv., quarum capiat binas statin), et altera post horani, vel
omnes »or& decubitus.
No. 37. |{ Canq>hora> rasa- gr. j. — iij.; Antimonii Tur-
in i/. gr. --. ; Potassas Nitratis gr. v. — virj. ; Moschi gr. ij.:
Extr. Opii gr. ij. — iv. (vd Ext. Lactuca gr. iij. — v.); Olei
Anisi q. s. ul fiant Pilulse iv., quarum capiat binas statim, et
altera* post horani, vel sumal omnes horl souwi.
78. b. Assafcetida, castor, musk, valerian,
myrrh, ammonia ; the balsams, the oxide of bis-
muth, the preparations of zinc, and the athers,
may be severally exhibited in the same states of
the disease. They are more beneficial in the ner-
vous and spasmodic varieties, when unassociated
with mil tmmaton trntat-an, particularly in chroci:
cases, in the debilitated or aged; and in the third
variety, occurring in persons of a relaxed and
leucophlegmatic habit of body, — a conclusion
which is. conformable to the experience of Mill ar,
143
ASTHMA — its Treatment.
Renard, Schlegel, Wolff, Dover, Rejd-
i.in, Bang, Schmidtmann, Wichmann, Len-
tin, Kretschmar, Loebel, Hufkland, and
Bern-hard, and which will be justified by future
observation, notwithstanding the doubts of their
efficacy which have been entertained by some
writers, who consider asthma as merely a form
of inflammation of the mucous surface of the air-
passages. They may lie conjoined with one
another, or with narcotics; and may be advan-
tageously administered, particularly assafcetida and
valerian, in the form of clyster.
79. Although these antispasmodics are indi-
cated cliiefly in the forms of the disease above
alluded to, they need not be restricted to them
entirely. When combined judiciously, as either
with antimonials, or with colchicum, opium, digi-
talis, nitrate of potash, camphor, ipecacuanha,
hyosciamus, conium, &c, and given in suitable
doses, according to the peculiarities of the case,
they will be productive of much benefit, in other
states of asthma, both in the paroxysm and in the
intervals. The external application of them,
especially of camphor, assafcetida, galbanum, ain-
moniacum, &c, in the form of plaster, and par-
ticularly in conjunction with opium or with bella-
donna, will sometimes prove of much service.
(SeeF. 112, 113.)
No. 38. R Extr. Opii, Campbora?, aa 3 ij. ; EmplasL
Galbani Comp. ~ iijss. — 5 ss. Fiat Emplastrum secundum
artem, scuto pec tori admovendum.
80. c. Besides the beneficial effects produced
by it as an emetic, ipecacuanha is, when used
with this or other intentions, one of the best medi-
cines that can be resorted to in asthma, as being
suited to all the states of the disease, particularly
when judiciously combined with other substances.
It may be associated with nitre, or colchicum, or~
digitalis, or with antimony , camphor, and narcotics,
in the more febrile and catarrhal states of the
disease (see F. 39. 394.); and with assafcetida, or
with castor, benzoin, the spirits or oil of aniseed,
valerian, opium, &c. in the more nervous or spas-
modic varieties. (See F. 857. 900.)
81. d. The distilled laurel water, or the prussic
arid, particularly the latter, is often productive of
much benefit in the paroxysm. I have found it
of great advantage when given in from two to
four drops at the accession of the paroxysm, and
in small doses in the intervals, particularly when
the disease is attended with much irritability of
the stomach and flatulence. It may be conjoined
with camphor, ipecacuanha, a'ther, &c, or, indeed,
with any of the medicines already mentioned.
(See F. 344.)
S2. e. Of the narcotics, opium, hyosciamus,
conium, stramonium, and belladonna, are the
most commonly used. The best preparation of
opium in this malady is the compound tincture
(see F. 729.); and it is most advantageously
combined with camphor, aniseed, any of the
aethers, or the wine of antimony or of ipecacu-
anha, according to the circumstances of the case.
I have tried the acetate of morphine in this dis-
ease, as a substitute for opium, but with no bene-
fit, unless when combined with stimulating anti-
spasmodics; in which form, either the sulphate or
the muriate of morphine may occasionally be
employed. Hyosciamus and conium are often
uncertain remedies; but when their preparations
are genuine, they are very useful adjuvants, par-
ticularly the former; and, if judiciouslv prescribed,
applicable to every state of the disease. The com-
bination of hyosciamus with the infusion of vale-
rian has been much praised by Loebel in the
spasmodic form of asthma.
83. /. Belladonna has been found serviceable
when combined with stimulating antispasmodics,
particularly camphor, valerian, or assafcetida; but
it requires caution. In conjunction with ammonia,
galbanum, or assafcetida, &c. in the form of plas-
ter (§ 79.), it will sometimes be productive of
much benefit. The lactuca virosa will be also
employed with advantage, under similar circum-
stances to those in which the above narcotics are
beneficial. Schlesinger and Wolff advise
two or three grains of its extract to be given, either
alone, or with half a grain of digitalis, every two
hours.
84. It may be observed generally, that nar-
cotics can seldom be productive of any effect
under a certain space of time, which will vary
with the susceptibility of the patient. In many
cases they will have no marked influence under
two, or even three or four hours, at which time
the severity of the fit will often subside without
medicine. When given by the stomach, there-
fore, this circumstance should be kept in recol-
lection; and should induce the practitioner to
ascertain the period of accession or aggravation
of the paroxysm, and to regulate the periods at
which these, as well as other remedies, are to be
exhibited, in such a manner as that their antici-
pated action may be contemporaneous with the
commencement of the fit. As the attack consists
generally of a series of paroxysms or exacerba-
tions, medicines should be continued in suitable
doses, and with reference to this circumstance,
until it terminates. It will be found alwa\ s ad-
vantageous to prescribe a full dose of the narcotic
at once, in order that its effects may be secured
as soon as possible. When any one or more of
the stimulating antispasmodics, particularly cam-
phor, ammonia, or musk, are combined with
narcotics, a very large dose of the latter may be
exhibited. Narcotics are most quick in their
operation, when their vapour or smoke is inhaled
into the lungs. Their eri'ects are longest delaved
when they are applied to the external surface;
unless the cuticle has been previously removed,
as in the " endermic " method of medication. The
inhalation of the vapour of certain of this class of
remedies, either alone or in conjunction with some
volatile vapours, is one of the most certain and
quick modes of obtaining relief in the asthmatic
paroxysm.
85. g. Stramonium is one of the best remedies
that can be prescribed in the spasmodic form of
asthma. It is principally used by smoking it as
tobacco. During this process, the patient may
either draw a portion of the smoke into the lungs,
or swallow some of it, or the saliva which has
become impregnated with it. Stramonium is very
advantageously smoked along with aniseed, or
with a small portion of tobacco. It may also be
employed internally during die asthmatic parox-
ysm, as follows : —
No. 39. R Pulv. Fol. Stramonii gT. j-— 'ij- i Soda- Sub-
carbon, exsic. gr. vj. ; Olei Anisj q. 3. ut tiant Pilula; ii.
>taliin -umeudce.
No. 40. )\ Succi lnfpis*»fi Stramonii gr. ss. — ex. j. ;
Potassa1 Sub-carb. gr. vij. ; Olei Cajeputi q. s. M. Fiant
Pilulit' ij. pro dose suuienda;.
ASTHMA — ns Treatment.
149
86. The smoking of tobacco is one of the most
generally employed and efficacious remedies We
possess lor tins disease ; but it. is productive of
marked benefil only when it excites a free ex-
pectoration. The tobacco may be used in this
manner along with aniseed, or with stramonium,
or both. The internal use of preparations of to-
bacco, as ^f its infusion, tincture, wine, &c, so
as to excite nausea, lias also been recommended
in the paroxysms of asthma by IVn yiitli.er,Mi-
< 11 tsLis, and several German writers.
87. h. Lobelia inflata, or Indian tobacco, has
been much employed in America in asthmatic
eases. It is nearly allied in its operation to stra-
monium and tobacco ; and often succeeds in
checking the paroxysm, when given at its inva-
sion, or very shortly before. It sometimes, how-
ever, fails of hiving any good effect, unless it be
taken to the extent of producing nausea and vom-
iting. From six to fifteen or twenty grains of its
powder may be prescribed for a dose, or from
half a drachm to two drachms of a saturated tinc-
ture of its leaves ( 5 j. to O ss.).
88. i. Inhalation of emollient and medicated
vapours, gases, &c. — Next and, perhaps, equal
to smoking is the inhalation of simply emollient,
or of medicated vapours into the lungs. This
method of treatment was recommended by Cje-
uus Aurf.lianus,Alberti,Mudge,Beddoes,
Thilenios, Z vli.onv, IIcfeland, Crichton,
Forbes, Gannal, Scodamore, and Murray.
It is chiefly indicated during the paroxysm, or
shortly before its accession. The vapours arising
from pouring boiling water upon camphor, any-
one of the narcotic extracts or tinctures, or the
balsams, are of great advantage when properly
managed. Thus the vapour from a pint of boil-
ing water poured upon half an ounce of balsam
of tolu ; or that from a solution of camphor, bal-
sam of tolu, and extract of lettuce, or of conium,
in sulphuric aether ; or the fumes proceeding from
camphor, hyosciamus, and aromatic vinegar, mix-
ed together, and quickened by the addition of some
boiling water, may he employed. A solution of
b lUum of tolu in sulphuric aether, the vapour of
boiling tar difthsed in the air of the patient's cham-
ber, chlorine gas much dilated with common air,
and various other medicated vapours, may be
tried ; but these act chiefly by removing the vis-
cid phlegm which collects in the bronchi, and by
exciting the extreme exhaling vessels. I have
prescribed the vapour of the sulphuret of iodine
in two cases : in one of spasmodic asthma, with
no benefit ; and in one of humoral asthma, with
only temporary advantage. Hir C. Scodamore
recommends this formula for the inhalation of
iodine — (R Iodinae gr. viij. ; Potassae llydriodi-
tis gr. v. ; Alcoholis 3 ss. ; Aquae Destil. ~ vss.
M. I'iit Mlstura). To this he adds tincture of
conium. liut his directions as to quantity and
mode of inhalation are, notwithstanding several
attempts to unravel them, perfectly beyond mv
powers. I believe however, that portions only
of the above mixture should be employed for
iion. But the observing practitioner
will generally be able to apportion the quantity,
las to direct the particular materials, for
inhalation, according to the peculiarities of the
: hearing in recollection that the combina-
tion of narcotic and anodyne vapours with vola-
tile fumes and gases will g morally be of more
13*
service in asthma than the use of individual suh-
Stances belonging to one only of these classes of
medicines ; and that the more irritating substan-
ces of this description, such as iodine, chlorine,
and tar vapour, should be ventured upon only m
a very weak or dilute state.
89. C. To remove viscid phlegm, and to pre-
vent its formation. — a. By expectorants, fyc
Squills are amongst the most frequently prescrib-
ed medicines for this purpose, in asthmatic attacks ;
but they are certainly not applicable to all its
states, although they, as well as ammoniacum, in-
ula Helenium, and senega, are very generally re-
commended by some of the best medical writers.
The good effects of these medicines in certain
manifestations of asthma cannot be doubted ; but
I have seen them productive of much mischief in
several cases in which they had been employed.
It should be kept in recollection, that they are
amongst the most active excitants of the respira-
tory mucous surfaces we possess, and are extreme-
ly apt to change active congestion of the bron-
chial lining into inflammatory action, especially
in young, plethoric, or robust subjects ; and, by
their effect upon the expectoration — particularly
by increasing it, rendering it thinner, less viscid,
and more readily expectorated — to occasion a
deceptive appearance of benefit, even when they
are increasing morbid action, with all its ill ef-
fects. In relaxed and leucophlegmatic habits,
however, or when the expectoration is viscid, and
excreted with difficulty ; the skin cool, soft, and
moist ; the pulse soft, slow, or weak, and the
urine scanty ; these medicines may be given with
great benefit (see F. 66,67. 74. 350.) : but when
the pulse is either hard, quick, or full ; or the
expectoration at all puriform ; they cannot be ex-
hibited without risk. They will often, doubtless,
even in cases of active congestion of the respira-
tory mucous surfaces, afford real benefit, by excit-
ing the capillaries to secretion, and thereby un-
loading them ; but they may as readily kindle up
inflammatory action. When combined, however,
with antimonials, refrigerants, diuretics, or ano-
dynes, the risk of mischief from them in doubt-
ful cases is much reduced. Alberti, Floyer,
VyAGNER, Schulze, Lentin, and Brex ad-
vise squills in the pituitous form of the disease,
and found them most serviceable when they pro-
duced nausea or vomiting, — the benefit beinj,
perhaps, moie to be attributed to this operation,
than to the medicine which occasioned it. Un-
der the circumstances in which I have admitted
the use of ammoniacum, squills, inula Helenium,
benzoin, and senega, — namely, in the chronic
pituitous asthma, — the Formulas in the Appendix
above referred to, or the subjoined, may be pro-
scribed : —
No. 41. R Sril] v exsir. jr. xij. ; Mvrrhap ^ 'j. > Extr.
Hyosciami "ss. ; Olei Anisi <\. s. M.Fiant Pilulae xviij.,
■ n binae quarto vcl sextis horis.
No. '-'. R Krillfr Pulv. gr. vj. ; I'ulv. Ipecacuanha; irr.
imphorse ras;e gr. XV. — >) j. ; Pulv. Amiuiuniih.
gr. xij- ; Kxtr. Hyosciami "ss. ; Svrnp. Tnlutan, q. s.
rial in I.- 1 aequalis, et divide in Pilulas xviij., quarum
capiat binas tertiis vel quartis horis ex cvatho decocti Aliha-.-r.
No. 43. II Tiuct. Scill.e IT) xij. — }')j. ; Aeidi Nitricidil.
TT| \iij. — ITJ xxiv. ; Aquas Pulegii " j^s. •, Spirit. vKlher.
Nit. »s. — 1. j Spirit. Pulegii ", j. ; Kxtr. Hyoscyami (rel
Conii) gr. iij. j Syrup. Tolutan. 5j. M. Fiat Haustus ter-
lii- vel nuarua horis capiendu*.
No. -14. R 1\1M. Ammooiaci X ivss. ; Liq. Antimooii
Tei. ", iv. ; Tinct. Camphors Comp. ~. ». ; Syrup. Tolu-
tan. 1 j. II. Capiat cochleare unuui pro re nata.
150
ASTHMA — its Treatment.
No. 45. R Mist, Amm.nii.ici, Aquae Destil. Lauro-C era-
si, aa 51JSS. ; Tiuct. Castorei 5 iij. ; Tinct. Opii Co. (F.
729.) 3 ss. ; Syr. Tolutan. J j. Fiat Mist., cujus sumat
cochleare unum amplum suliinde.
No. 46. R Balsam. Tolutan. 3 j3S- — 'j- 5 Mucilag. Ara-
ciae T. j . : trrc bene et adde, miscendo, Tinct. Benzoini
Oorap., Tinct. Opii Camphoratae Prist., aa 3 iij.; OleiAni-
si T7) n\. j Aquas Pulegii el Aq. Anethi aa g iij. ; Syrup.
Simp. 3 ij. M. Capiat coch. ampla duo quater in die.
90. b. Emetics are amongst the most promptly
beneficial remedies that can be resorted to during
the paroxysm, with the intention of removing
both phlegm and spasm ; and they have been
justly recognised as such by C^elius Aurelia-
nus, Horstius, Mayerne, Floyer, Aken-
side, Bang, Kerbs, Hufeland, Wedel,
Stoll, Bree, Loeffler, and Schmidtmann.
Ipecacuan is, upon the whole, the hest medicine
that can he employed to produce this effect. The
philosophical Akenside recommended a scruple
of it to be given at the commencement of the
paroxysm, and five grains every morning during
the intervals, for some time, so as to occasion nau-
sea. When the paroxysm is excited by an over-
loaded or deranged state of the stomach, emetics
are particularly indicated. It is in such cases that
Schmidtmann, one of the most practical and ex-
perienced of modern writers, recommends them ;
whilst Stoll and Loeffler advise them prin-
cipally in the humoral form of the disease. In the
asthma to which several classes of artisans, par-
ticularly pearl-turners, &c. (see Arts, and the
Causes of Disease,) tire liable, emetics have been
found the most successful remedy in the paroxysm.
But, besides this operation, ipecacuanha has an
especially beneficial effect in asthma, as 1 have
already particularly noticed. Next to it, and even
superior to it in the very humid states of the dis-
ease, are the preparations of zinc, particularly the
sulphate, in suitable doses and forms of combina-
tion (see F. 582 — 587.).
91. c. Nearly allied to emetics are nauseants
and diaphoretics. These are sometimes of ser-
vice, either at the commencement, or shortly be-
fore the fit. The substances that may be employ-
ed to produce this effect are ipecacuanha, and the
different preparations of antimony, particularly the
tartar emetic and kermes. These latter tire prais-
ed by Bang, Vicat, and Hufeland. Ipecacu-
anha, in from one to five grains, or the antimonials
in full doses, may be combined with nitre, cam-
phor, opium, or hyoscyamus, according to the
circumstances of the case (see F. 393. 854.).
92. d. Refrigerants. Of this class of medi-
cines the most useful is the nitrate of potash, in
conjunction with camphor, ipecacuanha, and
hyosciamus (F. 279. 431. 436.), particularly in
the humoral variety of the disease ; in the state
described as requiring blood-letting ; or when
the attack has been induced by, or is compli-
cated with, catarrh. Eeither of the following
draughts may be taken at the commencement of
the paroxysm, and repeated in two hours, if ne-
cessary : —
No. 47. R Potassa; Nitratis gr, x.— xx. ; Spirit, JEther.
Nit. 3 j- i Vini Ipecacuanhas 3 j. ; Tiuct. Hyosciami 3 j.;
Mist. Camphors \ ]■ ; Syrup. Tolutan. i, j. M. Fiat
Haustus statiui sumendus.
No. 48. K Potassae Nitratis gr. x. — svj. ; Vini Ipecacu-
anhas, Tinct. Hyosciami, aa 3 j. ; Liquor. Amnion. Acetat.
3 iij. ; .Mist. Cacuphoras "vj. ; Syr. Tolutan. 3 j. M. Fi- !
at Haustus statim capiendus.
1
93. Besides the internal use of refrigerants.
Loeffler recommends cold epithems to be plac-
ed on the chest, in the spasmodic form of the dis-
ease : and several Continental writers advise clys-
ters of cold water to be administered when asthma
seems to be connected with hysteria. In such
cases, clysters of assafcetida or of infusion of va-
lerian are preferable. Refrigerants act both by
diminishing inordinate secretion, and by allaying
spasm ; and, when the disease is connected with
active congestion, or excitement, are, with deple-
tion, the safest measures that can be employed to
remove, or to prevent the formation of phlegm.
94. D. To transfer irritation to other parts,
or to recall the disease to its original seat, when it
has arisen from the metastasis of gout, rheumat-
ism, or the suppression of discharges, is often an
important indication. The usual means of revul-
sion and derivation, or counter-irritation, partic-
ularly those which produce this effect with the
greatest celerity, as sinapisms, stimulating pedi-
luvia, and the vapour bath, are the chief revul-
sants that are admissible under such circumstances
and at this period. They may be accompanied
with diaphoretics, aperients, diuretics, or even
emmenagogues, in particular cases. They have
also occasionally been found successful in prevent-
ing the accession of the fit ; particularly if em-
ployed when the premonitory signs first appear ;
and if internal derivatives, especially a purgative
combined with antispasmodics and carminatives,
have preceded them, and if they have been fol-
lowed by gentle diaphoretics.
95. E. To remove flatulence, by means of gen-
tle aperients combined with carminatives, is often
necessary during the course of the paroxysm. I
have observed much benefit derived from the ex-
hibition of a purgative, combined with antispas-
modics and carminatives, shortly before the ex-
pected accession of the attack, particularly when
the premonitory signs begin to appear, and the
digestive organs evince disorder — such disorder
often acting as the efficient cause of the seizure.
(See F. 28. 181. 266. 379.) The combination
of diuretics, also, with the medicines prescribed
during the paroxysms, or of carminatives, in order
to relieve the distressing flatulence with which
they are very generally accompanied or preceded,
will be often found of service.
96. F. Besides the means noticed above, there
are several which have been recommended in the
fit — some of them most deservedly, others in a
very indiscrirninating, and hence not a very bene-
ficial manner. Of the former of these, warm cof-
fee is the most important. This dietetic remedy
was used by Floyer in this disease, and more
recently by Thilenius, Percival, and Bree.
It generally affords much relief when made suffi-
ciently strong ; and it seems to resemble the stim-
ulating antispasmodics, particularly camphor, in
its action. 1 have also observed the paroxysm
checked by strong green tea.
97. My limits oblige ine merely to enumerate
the other medicines which may be resorted to in
the paroxysms of asthma. The chief of these are,
dry cupping between the shoulders, a weak solu-
tion of phosphorus in aether, the oxides of bismuth
and zinc, mix vomica, &c bj several Continental
writers ; galvanism, as recommended by Dr. W.
Philip ; electricity, by M. Sigaod La fond ;
the chenopbdium ambrogioides, by Hdfelahd ;
the infusion or spirits ofjuniper, by Bekkkb ;
guaiacum, by Aaskow, particularly when the
ASTHMA — its Tri.atmf.nt.
151
attack occurs iu the gouty or rheumatic diathesis;
c ijepul oil, in the spasmodic form of the disease,
1>\ Whkiiwn; the veratrum album, by Mul-
i.i.k; the muriate of ammonia, by Martios; and
the external application of garlic, by Portal.
98. 2d. Treatment during the interval. — Our
chief objecl during the interval is to prevent the
- in of the attack, by avoiding t lit; remote
causes, and removing the morbid state of the
digestive and respiratory organs which dispose to
it, and whatever disorder of function or of struc-
ture with which the disease may have become
ted. We should, therefore, endeavour to
form a correct opinion respecting the state of the
bronchial mucous surface, the morbid associations
of the affliction, and the consecutive lesions which
may have already supervened to it. The state
of the digestive functions, of the alvine secretions
and excretions, should receive the utmost atten-
tion; and the means which may be most appro-
priately used for their promotion, in particular
cases, ought to be assidudbsly employed.
99. A. Evacuations, S,-c. — Under this head I
will briefly consider blood-letting, emetics, pur-
gatives, blisters, issues, and diaphoretics, a. Bleed-
ing is seldom of service in the uncomplicated state
of the disease. But when it is accompanied with
vascular plethora, or pulmonary congestion; or
when the attack seems to have been produced
by the suppression of an accustomed discharge,
whether sanguineous or of any other description;
a moderate blood-letting, or cupping between the
shoulders, will be of advantage.
101). b. Emetics during the intervals are only
required when the disease is characterised by con-
gestion of the mucous surface of the lungs, obstruc-
tion of the bronchi by a viscid secretion, or torpid
and loaded state of the liver and biliary apparatus.
When prescribed shortly before the expected fit,
they often succeed in preventing its accession.
101. c. Purgatives are often necessary; but
they may also lie detrimental. Those substances
which irritate the digestive mucous surface, with-
out producing a full feculent evacuation, are
always prejudicial. Purgatives also are hurtful
when they are employed so frequently as to lower
the vital energies, and carry oil' a portion of the
chyle which should be absorbed into the circula-
tion. On the other hand, stomachic aperients
and purgatives exhibited in combination with
tomes and antispasmodics, and to the extent
merely of promoting the digestive, assimilating,
secreting, and excreting functions, are particularly
beneficial, lather of Formulas 26b'. 450. to 456.
462., contained iu the Appendix, or the following,
may be prescribed: —
No. 49. R Mo • Socot. gr. iv. ; tere benfc rum Gum.
Maslirh. zr. ij. ; et adile Extr. Gentiana? Comp. et Mass.
Pilul. G i. aa gr. iij.; Olei Anisi <(. b. Fianl
Filulx iij. hora souini quotidie sumenda;.
102. d. Diaphoretics in small doses, in con-
junction with anodynes, deobstruents, or anti-
lodics, are of service merely in as fir as they
may preserve a regular state of an important
function, and prevent the determinations to inter-
nal organs which frequently follow any inter-
ruption to it. Put profuse perspirations and
warm bathing are more generally pn judicial than
otherwise. Indeed, whatever relaxes the cuta-
neous surfaces beyond a certain degree has an
injurious etl'ect upon affections of the lungs which
are not acutely inflammatory, and particularly in
the pituitous chronic asthma. ' Whenthe paroxysm
i> associated with the dry catarrh, diaphoretics
may be carried further with advantage; and when
combined with expectorants and antispasmodics
(§ 91.), they are more generally applicable.
103. B. Expectorants, alterants, attenuants,
and d( obstruents, or substances supposed to have
some one or more of these eifects, have been very
generally recommended in asthma. Several of
these have little or no effect, and others may even
be injurious, a. The expectorants most frequently
employed are those already noticed ; but I believe
that they are seldom productive of much advan-
tage, given in the interval. When the disease is
complicated, as it not infrequently is, with dry
catarrh, or irritation of the bronchial mucous sur-
face, those substances which have the effect of
soothing irritation, relaxing spasm, and softening
the pulse, as James's powder, kermes, ipecacu-
anha, camphor, antimonial wine, are in fact the
best expectorants; inasmuch as they tend more to
render the bronchial secretion less tenacious, where
it is glutinous and obstructing the bronchi, and to
diminish its quantity when too copious, than those
which are of a heating or stimulating kind.
104. b. Amongst those medicines which are
considered as attenuants, deobstruents, and alter-
ants, there are none which possess greater claims
to consideration in this disease than the pure
alkalies and their carbonates, or their combina-
tion with oils, and antispasmodic or narcotic sub-
stances. However the propriety of applying the
above terms to certain medicines in this disease
may be cavilled at, there cannot be the smallest
doubt, in the minds of those who closely observe
the operation of remedies, that certain substances
produce elleets, on the respiratorysurfae.es and
on their secretions, that justify the use of these
terms. The alkalies in various forms of combina-
tion, but particularly with oils, have been much
praised by Wolff, Bache, Sarcone, Mas-
cagm, and Laksnec. Either in the pure state
or ui that of sub-carbonates, combined with the
oils of aniseed or of almonds, with ipecacuanha,
small doses of blue pill, and hyosciamus, the fixed
alkalies are amongst the best remedies to which
we can have recourse, particularly in the catarrhal
or bronchial complications, and when the disease
is connected, as it very often is, with irritability or
other disorder of the digestive organs. I have
experienced the greatest service, in practice, from
the following, and from Formula? No. 348. 457.
No. 50. H Sod* Sub-carbon, exsir. J) ij. ; Pulv. Ipe-
cacuanha gr. vj.j Pilul. Hydrarg. gr. vj.; olei Anisi IT]
xij. vel q. s. ut fiant Pilulae xviij., quarum sumantur binae
lie terve quotidie.
No. 51. R Potass* Sub-carbon. /) ij. ; Pilul. Hvdrarg.
gr. iv. ; Extr. Hyosciami (vel Extr. papaveris Albi) '•) j. •,
Olei Ainydal. Dulc. tj. s. ut fiant Pilulae xviij., quarum
capiat luii.i- ter quotidie.
!().">. Under this head, I may make further
mention of the, balsams, combined with small
doses of rhubarb, or with the addition of mag-
nesia; of a combination of assafcetida, or myrrh,
with galbauum, ipecacuanha, and soap, or the
fixed alkalies (F. 503—510.); frictions with sti-
mulating or antispasmodic liniments in the course
of the spine (see the Liniments in the Appendix);
the nitro-muriatic acid wash, in a tepid state, over
the chest, night and morning, or either the one or
other only; warm clothing, &c.
152
ASTHfMA — rrs Th k ai m est.
106. C. Blisters, issues, and artificial erup-
tions are often extremely beneficial, particularly
when asthma has supervened to suppressed dis-
charge?, to exanthematous diseases, or in the
gouty and rheumatic diathesis. A large blister,
applied between the shoulders or on the chest, a
smaller one kept open, and Issues and setons,
have been recommended by the majority of wri-
ters. Zacutus Lusitanus and Severinus ad-
vise the actual or potential cautery to the nape of
the neck. The production of artificial eruptions
over the chest by the tartar emetic ointment ap-
pears to me, From considerable experience of its
effects for many years (see Lond. Med. Repo-
sitory, vol. xvii. p. 302.), preferable to any other
mode of counter-irritation in asthma, particularly
when the use of the ointment is commenced
during the interval.
107. D. Tonics and astringents. — a. The use
of the preparations of bark during the intervals
lias the support of the best writers on the disease.
Amongst these I may notice Floyer, Bang,
Chapman, Heberden, Feldmann, Ranoe,
Fkank,Withers,Ryan,Bree andLAENNEC.
The states of the disease in which they recommend
it, are, 1st, When the disease assumes a periodic
type, or when it is connected with malaria; 2d, In
the pituitous form of the disease, when the habit is
relaxed and leucophlegmatic; and, 3d, When the
stomach is much debilitated. There can be no
doubt of the preparations of bark or the sulphate
of quinine being indicated in such cases. Indeed,
wherever the powers of the constitution require to
he rallied, and where there exists no inflammatory
irritation to contra-indicate it, bark and other
tonics are frequently beneficial. In these cases,
the decoction or the infusion may be given, with
the liquor ammonia3 acetatis, and vini ipecacuanha?,
or with the subcarbonates of the alkalies.
10S. b. I have derived great service from the
sulphate and oxide of zinc in the humoral form of
asthma, particularly under the circumstances now
described. Either of these preparations may be
combined with ipecacuanha, camphor, myrrh,
hyoscyamus, conium, opium, &c, according to
the peculiarities of the case. Where it is de-
sirable to produce a nauseating or emetic opera-
tion during the fit, or in anticipation of it, the
sulphate of zinc is the next best medicine to ipe-
cacuanha that can be employed.
109. c. The preparations of iron have met with
the approbation of Bree and Stanger, particu-
larly the sulphate. It may be employed in similar
cases to those for which bark and the sulphate
of zinc are prescribed. I can only allude to the
recommendation of the mineral acids with opium,
by Fi.oyer, &c; of the sulphate of barytes, by
Keck and Hufei.and; of arsenical fumes, by
the Arabian physicians, and Ettmuller ; of
Foicler's solution, by Alexander; of the ni-
trate of silver, by Zallony; and of a solution
of phosphorus in tether, by several German writ-
ers. These very active medicines are admissible
only in the most obstinate cases, particularly when
occurring in relaxed or debilitated habits, and
when other active tonics and antispasmodics arc
indicated. Saint Ignatius' s bean, and the extract
of nux vomica, "have also been mentioned by
Stein and Hahnemann. Strychnine, the active
constituent of these substances, seems deserving
of a fair trial in asthmatic cases.
110. d. Sulphur, and its preparations, have
been advised by Diemerbroeck, Gasser,
.Martins, and Hang; and from a few opportu-
nities which have presented themselves of trying
them, I consider them, particularly the balsamum
sulphuris, — a combination of sulphur with the
oils of aniseed, &c. (see F. 21. and 22.), — and
the sulphurets of potpsh and soda, as medicines
of no mean efficacy in several states of the disease.
The sulphur precipitatum or sublimatum, taken
in the form of an electuary (see F. 82. and 89.),
is one of the best aperients to which we can re-
sort in cases of asthma or continued dyspnoea-
It may be also taken as follows : —
No. 52. R Sulphur. Praecip. % ss. ; Semin. Anisi con-
tus. 5 '<}**• i Confect. Sennae et Syr. Tolut. aa 5 vj- M.
Capiat coch. ij. minima pro dose.
111. There are various medicines which have
been recommended hi the paroxysm, which may
also be occasionally employed in the interval,
particularly shortly before the expected accession
of attack, and upon the first intimation of its ap-
proach. Of these, the most important are the
antispasmodics and narcotics already mentioned
(§ 75.), with the smoking of tobacco, stramonium,
and aniseed, and the inhalation of the vapours of
narcotic substances, and certain gases (§ 85. 88.).
112. Flatulence is a very frequent attendant
upon asthmatic cases, chiefly before the invasion
of, and during, the attack. It seems connected
with irritation of the digestive mucous surface,
and deficient vital power. The relief of this
symptom is often a matter of importance. For
this purpose I have sometimes prescribed the
following : —
No. 53. R Olei Anisi TTJ raj. — xij. ; Sodae Sub-carbon.
sr. .\v. ; Sacchari Alhi, Maznesiae Ustae, aa £) j. ; tere et
adde Tinrt. Castorei 5j-> Tinct. Senna; " ij. ; Aquar
Hentb. Virid. et Mist. Camphora1 aa 7, v. ; Syrup. Tolu-
tan. ^ ss. i\I. Fiat Haustus, 3tiis vel 4tis horis ad tertian*
aut quartan] vicem sumendus.
113. 3d. Of the treatment of the various symp-
tomatic and complicated states of the disease. —
But little is required from me on this subject, after
the detailed account of the treatment now given.
When the disease is associated with either of the
usual forms of catarrh, diaphoretics, consisting
chiefly of ipecacuanha, antimonials, &c, com-
bined with narcotics or anodynes, are chiefly in-
dicated; and, if inflammatory irritation seems to
exist in the bronchial lining, local depletions, col-
chicum, or digitalis, counter-irritants and revul-
sants, gentle aperients, and the inhalation of the
vapour of warm water, in which a little camphor
has been thrown, may be added to the above.
114. In the frequent complications of inflam-
matory irritation of the digestive mucous surface,
and disorder of the biliary 'apparatus; or of de-
rangement of the functions of the heart, it will
generally be advisable to commence the treat-
ment with five grains of blue pill on alternate
nights, for three or four times, and with an
aperient draught on the following morning. By
these the secretions will be excited, and the
bowels evacuated. Afterwards the healthy state
of action of the capillaries of the mucous surfaces
generally will be promoted by exhibiting half a
grain of blue pill, three or four times in the twenty-
four hours, combined with two or three grains
of the extract of hyoscfemus, or oi' extract of
hop; vegetable tonics, with the lixed alkalies, or
ASTHMA — its Treatment.
153
other stomachic medicine*, being taken through the
day. If we have reason to suspect the existence
of organic change within the chest, particularly
inflammatory congestion in the lungs, enlarge-
ment ofine structure of the heart, &<■., the inser-
tion of issues, or keeping up an abundant eruption
(in the external surface of the chest by the tartar
emetic ointment, should be added to the above
11 1 cans. This treatment ought, with occasional
variation according to the circumstances of the
to be perseveringly continued for weeks, or
even months ; and it will often succeed, even in
the most unfavourable complications. Theoasjde
of bismuth, combined with tonic or hitter extract-,
will also be found of service in the gastric associ-
ations of the disease.
115. When the disease is associated with affec-
tion of the head, or curvature of the spinal col-
umn, scions, issues, or moxas in the nape of the
neck, or in the course of the spine, may he tried.
If it be attended with disease of the liver, external
irritation, the nitro-muriatic acid hath or lotion,
small doses of mercury, and the plaster, Form.
117., may he prescribed. Organic lesions of the
heart and large vessels, raid dropsical effusions,
require a combination ^l' these measures with the
use of alkalies, digitalis, opiates, &c. When
hysteria, and generally increased sensibility and
ibility, attend the asthmatic affection, ton-
ics with antispasmodics are principally indicated.
In the other complications of asthma, the treat-
ment recommended in Dyspnoea will he general-
ly appropriate.
116. 4th. Of the regimental treatment. — Much
advantage will be derived in asthma from strict
attention to diet and regimen, — comprising bath-
ing, exercise, air, and climate, the use of mineral
waters, &C. A. Cold sponging the surface of the
chest, and cold bathing, are amongst the most
approved means that can he resorted to during
the intervals of asthma. They tend both to
diminish the sensibility and susceptibility of the
patient to the impression of cold, — one of the
mosl frequent exciting causes of the attack ; and
to give a salutary tone to the respiratory mucous
sin faces and vessels ramified in them; and hence
they prove the besl means which can be resorted
to for the prevention not only of the asthmatic at-
tacks, but of catarrhs, and all other affections and
- of the respiratory organs. The patient
should commence this practice with the following
lotion, with which the whole of the chest and
upper part of the abdomen should he sponged, or
rubbed with a towel or piece of flannel Wetted
with it, and afterwards he dried, using smart fric-
tion at the time : —
No. 54. R -Villi Acetici Pyrolignei vel Vini AIM, Liq.
Ammoniac Acetatis, aa 5 iiss. ; \,q. Rosarum 5 v. j Spii it.
Vini Tenuioris 3 'j- M. Fiat Lotto.
This should be used every morning upon getting
out of bed; and if the patient commence with it
during the winter, a fire may be kept in the
dressing-room, and the chill taken off it for the
firsl few days of osing it. Instead of the above
lotion, a solution of common salt in water, in the
proportion of two table spoonsful to a pint, or
one part of vinegar to two of water, may he em-
ployed. After these have been continued for
time, or as long as the patient maj p
and the S3 stem has been thus prepared for it, the
Bhower hath may he substituted with advantage,
particularly if the patient he in that state of health
which will allow him to bear the shock without
risk. Sea or salt water bathing may also he re-
sorted to all the summer and autumn; and the
shower hath, or at least cold sponging the surface
of the trunk of the body, all the winter and spring;
for it will generally he advisable not to discontinue
this practice for any considerable time after it has
been fully adopted and found of service. In ad-
dition to the cold hath, the patient should have
recourse to regular exercise in the open air; and
attend to the state of Ins digestive organs, and the
regular functions of the bowels.
117. If along with the asthmatic affection the
patient ha\e complained of palpitations, irregular-
ity of the action of the heart, oedema of the amies,
severe dyspeptic symptoms, and disorder of the
liveror bowels, these ought to he removed, before
commencing with cold sponging and bathing, hy
local depletions when they are indicated; hy very
small doses of blue pill, or the hydrargyrum cum
creta, with the sub-carbonates of the tixed alka-
lies, and hyosciamus given at bed-time, a gentle
aperient draught the following morning, and bitter
tonics, with the alkalies through the day. The
recommendation of cold bathing in asthma may
startle some; hut when all associated disorder of
an inflammatory kind has been removed by ap-
propriate treatment, and the means now specified,
and when the system has been duly prepared for
it, cold bathing is actually one of the most saluta-
ry measures, and the most permanently beneficial,
that can he prescribed. It has, moreover, received
the sanction of Cjelius Aurelianus, Floyer,
Withers, Millar, Ryan, Brek, and IIufe-
LAHD, — names which should claim our respect
tor whatever they recommend, even if our own
experience did not altogether confirm their opin-
ions, which, however, is in accordance with theirs
as to this practice.
118. B. Mineral waters. — The waters in this
country, which are best suited to asthma, are
those of Cheltenham and Leamington ; and of
Buxton and Bath, to some of its complications,
particularly the arthritic. Dr. J. Clark very
justly remarks (The Influence of Climate, $-c. 2d
ed. Lond. 1830, p. 371. et. seq.), that when asth-
ma is accompanied with chronic irritation of the
bronchial membrane, or with disorder of the di-
gestive organs, and an unhealthy state of the skin,
a course of warm mineral waters will often prove
of benefit. 'J he springs of Kins on the Rhine, of
Carlsbad, of Bonnes and Cauterets in the Pyrenees,
and of Mont d'Or in Auvergne, are those chiefly
esteemed on the Continent. The great difficulty
generally is, that the climate and degree of eleva-
tion of these places will often not suit particular
asthmatic cases. Where the climate of a valley
is likely to suit the patient, Ems and Carlsbad
will he preferred ; and where an elevated sit-
uation is required, the Pyrenees and Mont d'Or
will be chosen. The artificial waters of Fins
and Carlsbad, prepared at Brighton, are but little
inferior to the natural springs. In a case of this
disease, where I directed those of Eins, great
benefit was obtained from them.
1 if). C. Change of air and climate. — Tt is im-
possible to point out the particular climate or
locality which will besl suit the asthmatic patient;
for the state of air or climate which will suit one,
will distress another, and without any very evi-
154
ATROPHY.
dent cause to explain the different effect. In
nearly all cases, however, changes of air are ben-
eficial, chiefly as respects the general health of
the patient, and the disorders with which asthma
is associated. Upon the whole, a temperate,
equable, and moderately moist state of the air is
best borne: but even in 'this, there is much uncer-
tainty. The physician must be guided in his
choice by the kind of asthma with which the
patient is afflicted, and by the ascertained ef-
fects of certain seasons and localities in his
particular case. In general, a moist and warm,
or mild climate, as the south-west extremity of
this island, will suit the spasmodic or dry form of
the disease, and that most commonly associated
with the dry catarrh, much better than any other Sur ]e Systtme Nerveux, t. ii. Paris, 8vo. 1822.— j. j
in this country; whilst the pituitous or humid «■»> j™™ Con.pi. t v.-F«™, Diet de }i«!«i
m ins l'ul1"1 .'.' . r , , j t. in. art. Asthme, p. 101.— Cruvedhier, Nouv. Biblic
variety, occurring in the debilitated or aged and Mi d ( y nL—Bricheteau, Archives G.'nir. de M
in those of a relaxed and leucophlegmatic habit,
and attended with much expectoration, will require
a dry and a somewhat bracing state of the air.
120. D. Diet. — Very little is required to be
stated on this topic. The food should be always
light, digestible, in small quantity, and chiefly
farinaceous ; particularly in those cases which
indicate general or local plethora, inflammatory
irritation, and disorder of the digestive organs.
I'i.oykr particularly insisted upon abstinence, as
to both eating and drinking ; and later writers,
and experience, have confirmed the justice of his
injunction. When the disease is accompanied with
lowered energies of the powers of life generally,
the diet should not be so poor as to furnish insuf-
ficient means whence the mischief may be repair-
ed; but it ought, notwithstanding, to be light or
digestible, and not exceeding the powers of the
digestive organs to manage with facility.
BlBLIOG. and REFER.— Galen, De Di/licult. Respirat.
!. i. ii. iii. ; et De Locis Aiiectis, 1. iv. cap. 7.— Arctaus, De
JWorb. Diut., 1. i. cap. 9. — Celsus, 1. iv. c. 4. — C alius Aure-
lianus, De Morbis Chron. 1. iii. ch. 1. p. i&l.—A-vUxnna,
Canon. 1. iii. tr. 1. c. 7— 42.— Fernelius, C'onsil. xxn. —
BagKvi, De Pract. Med. 1. i. ch. 9. p. 64.— Severinvx, De
Efficac. Medicam. p. 220. — Zacutus Jjusitanus, Prax.
Histor. 1. viii. ob. 25. ; et Prax. Admir. 1. iii. obs. 126.—
Mayerne, Praxis, fcc. p. 184.— Willis, Pathologia Cerebri,
cap. 12. -, et De Morb. Convuls. cap. mi. p. 94.—Floyer,
On the Asthma. Lond. 1698. — Diemerbroeck, Observ. et
Curat. C. ii. 63. — Panthot, Ergo Asthmaticis Tain II..- de
Sulphure. Monsp. 1653.— Dover, Legacy, ice. p. 46 —
Hn//)nam>, De Asthmate Convuls. Opera, vol. m. p. 102.
— Waiver, Diss, de Asthmate. Hafn. 1706.— EttmuZler,
Di«s. de Asthmate. Lips. 1710. ; et Opera, a Zwinguero, t. ii.
p. 109.— Alberti, Diss, de Spirandi Difficultate. Hal. 1726.
—Juncker, De Asthmatis Vera Pathol, et Therapia. Hal.
1752.— Ranoe, in Act. Re-.'. Soc. Med. Ilauu. vol. n.
p. 163., vol. iii. p. 062., et vol. iv. p. 269.— Bang, in Ibid,
vol. i. p. 10. 102. 110.— Aashow, in Ibid., vol. i. p. 308—
Krebs, Medicin. Beobach. b. ii. h. iii. Wo.7.—Akenside,
Medical Transac. of Coll. of Plus. vol. i. No. 7. p. 93.—
What, Works, p. 602.— Withers, Treatise on the Asthma.
Lond. 1786.— Moll, Rat. Medendi, p. iii. p. 36., el p. vii.
p. 231. — Thitenius, Med. uud Chirurg. Bemerk. i. p. 164.
Millar, Observations on the Asthma, &c. Lond. 1769. —
Meyer, De Asthmate et ejus Spec- Oot. 1119.— Ryan, On
the History and Cure of Asthma. Lond. 1793.— Kretsch-
mar, Horn Archiy. b.. i. p. 227.— Chapman, in Medical
Communications, &c. vol. i. No. 22.— fleoerden, Com-
ment, de Morb. &c. cap. 11. — Monro, in Edin. Med.
Essays, vol. iii. p. Sit;. — Simson, in lliiil. vol. vi. p. 121. —
Ritsh, in Edin. Med. Comment, vol. iv. p. 193. — Fother-
gill, Works, vol. ii. — Alexander, in Eilin. Med. Com-
ment, vol. \w.—Perdval, Medical Essays, vol. i. p. 269. ami
vol. iii. p. 270.— Macbride, Med. Observ. and Inquiries,
vi. No. 2. — Michaclis, in Richter Chir. Bibl. b. v. p. 127.
Mascagni, Bull' Uso di Carbonato di Potassa, ,Vr. Mem.
Dell. Soc. Ital. Rom. xii. 1804.— Bree, Practical Inquiry
into disordered Respiration. Lond. 1 1:07. — Zallony, Traite
de l'Asthme, 8vo. Paris, 1809. — Stanger, in Med. i id
Chirurg. Trans, vol. i. — Schmidtmann, Anleitune zu
(jiuiid;ing einer Medicinalvcrfassung, Ih. i. p. 189.— Horn,
Archiv fur Pract. Med. Jan. 1811, p. Sl.—Henke, Ibid,
b. vi. p. 271. — Loebel and Heineckcn, in Ibid. July, 181 >,
p. 187., et May, 18.2, p. 571. — Heinecker, Hufeland
Journ. der Pract. Arzneyk. b. vi. p. 74. — Wichmann, in
Ibid. b. i. p. 18. — Hahnemann, in Ibid. b. iv. p. 755. —
Hufeland, in Ibid. b. iv.—Reil, Fieberlehre, b. iv. p. 820.
p. 62.— Wolf, Hufeland Journ. der Pract. Heilk. xviii.
b. 1st, p. Ai.—Loeffler, in Ibid. xxi. b. 1st, p. dO.—Tol-
berg, in Ibid. x.\vi. b. 3d, p. 26 —Portal, Mem. sur la
Nat. et le Traitement des Pleus. Maladies, t. ii. p. 70. —
J. Frank, Praxeos Medics Univ. Pracept. P. ii. vol. vii.
p. 379.— Rostan, Journ. Giner.de Med. Sept. 1818; et
Nouv. Journ. de Mcdecine, t. iii. p. 1. — Christie, in Edin.
Med. and Surg. Journ. vol. vii. p. 158. — Sch/esinger, Hufe-
land und Himly Journ. der Pr. Heilk. Jan. 1810, p. 115.
— Laennec, De" l'Auscultation Mediate, 2 t. Paris, 1826.
—W. Philip, Philos. Trans. 1817-22.— Reisseissen, Ueber
den Bau der Lungen-Fol. Berl. 1822. — Andral, Revue
Med. t. iii. 1824, p. 330. ; et C Unique Medicale, t. ii. p. 72.
" Forbes, Med. and Phvs. Journ. Oct. 1822. — Georget,
--. — T. Be-
th.
p. ivy. — liruneteau, vucnives vjintr. ae .Utd_
l. ix. p. 334.— Jolly, Diet, de Med. et Chir. Prat, t iii.—
Parry, Elements of Pathology, § 474., and Posthumous
Works, &.C vol. ii. p. 19. — Andrews, in Glasgow Med.
Journ. vol. i. p. 177. — Gannal, On the Inhalation of Chlo-
rine. By Potter. Lond. 1330. — Kreyssig, Encyclopidisches
Wbrteib. der Med. Wissensch. b. iii. p. 575.
ATROPHY. — (From the privative a, and roo^y,
nutrition, or Tgoiptm, I nourish.) Patholo-
gy— Morbid Structure. — Syn. Atropine, Con-
somption, Ft. Ungedeiben, Schicindxucht , Aus-
zehrung, Ger. Voedeloosheit, Dut. Atrofia,
Somma Magrezza, Ital. Wasting, Eng.
1. Defin. Deficient nutrition of a part or
of the whole frame, owing to which its natural
dimensions are necessarily reduced.
2. The healthy proportions of the various parts
of the frame are preserved by their vital endow-
ment, and are intimately dependent upon the
conditions of this influence. When it preserves
its due relations throughout the frame, a con-
tinued vital attraction of molecules from the blood
takes place, to an extent sufficient to supply the
place of those particles, which, having lost their
vital affinity, are removed by absorption. This
slow process, by which animal particles are taken
away, for a time, from the current of the circu-
lation, assimilated in the various tissues, after-
wards detached from them when they no longer
are suited to the purposes of the structure, and
carried back to the circulating current to be
partly eliminated from the frame, and partly
changed into different conditions, is not infre-
quently liable to be disturbed in some one of its
parts or steps. Thus, when the vital influence of
an organ, or of the whole frame, is in a state of
activity, the attraction of molecules from the
blood, similar to those constituting the dk'erent
tissues, is energetic, and extended to a greater
number of such molecules, — they are held in
closer affinity, and the bulk of the part is increas-
ed. But when the state of "the vital endowment
is reversed, when it is weak or depressed, this tit-
traction proceeds slowly and languidly, and, the
existing affinity being also weak, the molecules
composing the tissues are sooner removed by the
process of absorption than in health, and the
part thus circumstanced is wasted, from a more
rapid loss of its molecules than can be supplied
by the low state of vital affinity. Thus, as in the
former case, a double condition of the organi-
zation, but of opposite natures, actually obtains;
namely, the attraction is»extended to fewer mole-
cules, and the ailinit\ between them is more lan-
guidly exerted, they being more rapidly carried,
ATROPHY.
1.35
by the process of absorption, back into the blood,
from whence they came, in order to be partly
changed and partly eliminated from it; and the
part tlms affected, instead of ret lining its healthy
proportions, becomes wasted, deficient in its con-
stituent molecules, or atrophied. Thus we per-
ceive that there is a continued circulation of nu-
tritious particles in the very tissues which they
compose; that this circulation, and the affinity
which preserves them in their spheres, is vital,
influenced by, and fluctuating with, the various
conditions of the vital endowment of the frame,
the nutrition and bulk of a part being intimately
depend ait upon it.
S. .Nutrition being, then, the result of a vital
attraction exerl •<! between the molecules of mat-
tor constituting the elementary tissues, and these
which are similar to them in the blood, and being
co-ordinate with the strength of that attraction.
atrophy necessarily proceeds from a diminution
of this affinity, and the more rapid transit, conse-
quent upon this diminution, of the particles which
have been attracted, back into the current of the
circulation. The he tlthy proportion of the tissues
is therefore continued by a due equilibrium being
preserved betwe sn the attractive influence on the
one hind, and the continuance of Natal affinity on
tire oth ar. When either the attraction is active,
or its duration long, the bulk of the structures
will be 11 :reas d; but when the former is weak,
or the latter of short continuance, atrophy will
irily result
4. The truth of these propositions is evident
from a due consideration of the various pheno-
mena of health and disease, and by the numerous
contia_' ml circumstances which influence the con-
ditions of the different structures of the body.
At this place 1 will briefly describe, first, the ap-
pearances which atrophied structures assume;
secondly, the various causes and circumstances
which, influenced by the vitality of the frame,
produce this change; and, thirdly, the treatment
that may be e nployed to remove it. Thus I will
confine myself, al this place, entirely to the con-
sideration of atrophy, in its generic acceptation;
the species being treated of under distinct and
separate heads.
'). A. Stales or appearances of atrophied parts.
— Atrophy may be confined to particular struc-
tures; it maj affect only a particular constituent
tissue of an organ, whilst its associated tissues are
hypertrophied, and it may extend to various con-
tiguous structures orunconnected organs. A par-
constituent tissue may, however, be wast-
ed, and yet its associated structures may be aug-
mented in bulk', as I hive shown occasionally to
occur, when describing the morbid states of the
liver. When this takes place, either no diminu-
r an actual increase of the whole organ, is
•d. When a compound organ, or part
firmed of various elementary tissues, is atrophied
in all its constituents, the diminution of volume is
then very remarkable; although, in some cases,
as when the atrophy consists chiefly of a rarefac-
tion ol the internal structure of an organ, as of
the lungs and bones, the external surface presents
hange.
6- Tl artiest and most essential change in
an atrophied part is diminution of the qaantit)
of blood sent to it; and next to this, and chief!)
owing to it, is greater paleness of colour. Sub-
sequently the organization is still more complete-
ly changed; so much so, frequently, that all trac-
es of its original conformation are lost, and the
part is reduced to the state of cellular or libro-cel-
lular tissue, generally of small size. In some ca-
ses, the part is not only extremely atrophied, but
at last disappears altogether. When membran-
ous structures are atrophied, they become much
thinner and more diaphanous than natural, or
even perforated.
7. The atrophy of certain organs or parts is a
natural or healthy change, as respects the lietus
in utero, and the newly-born infant. The parts
which experience those changes are too well
known to require notice. Several structures,
especially muscular parts, sometimes have pre-
ternatural quantities of fat deposited on their sur-
faces during the progress of atrophy. This is of-
ten observed in respect of the heart, and appears
to result from the same causes; namely, diminish-
ed vital energy, occasioning insufficient nutrition
or assimilation (§ 2, 3.), and a morbid secretion
of fat, which often is as much a consequence of
diminished vital energy, as insufficient nutrition
of the different structures is the result of this
state; both changes being, in some cases, merely
grades, in others modifications, of the same vital
manifestation.
8. Various parts of the body naturally undergo
marked atrophy during advanced age. Of these
the most remarkable are the generative organs,
particularly the ovaria, mammary glands, testes,
the thyroid gland, the bulbs of the hair, adipose
tissue, the lungs, and bones. Atrophy of these
and other parts has received a more particular
notice under their respective heads. I may, how-
ever, remark, respecting the atrophy which re-
sults from age, that it is very evidently the result
of diminished vitality, especially as those parts
which first experience a loss or diminution of their
functions, either from age or exhaustion, are the
first to be atrophied; and that it often differs from
other forms of atrophy, in consisting merely of a
deficiency of the fluid constituents of the struc-
tures— in a condensation and dying of the organs,
and not of a loss of the molecules constituting
their solid parts.
9. B. The secondary causes which, under the
influence of the vitality of frame, produce atro-
phy, are, 1st, Original deficiency of developement,
constituting congenital atrophy. This state of
atrophy may exist in every grade, and may
amount to a total absence of an organ or part.
When it takes place to this extent, it has evident-
ly arisen from an arrest of the formative process,
or of the developement of the tissues, in conse-
quence of disease of the embryo. If the disease
affeel the nervous centres, the parts supplied with
nerves from (hem are sometimes either much atro-
phied or altogether wanting, as MM. Rostan and
Si i: i;i:s have shown. But this is only an occa-
sional occurrence; for parts of the brain or of the
spinal cord have merely consisted of a serous sac,
and vet the organs of sense and the limbs have
been fully developed: and there have occurred
many cases in which both brain and spinal chord
have been entirely wanting, and yet the nerves
proceeding from them, and the organs which the
nerve- supply, have been fully formed; evincing
the truth of the doctrine stated by the writer
many years since (see London Med. Repos. vol.
156
AUSCULTATION.
xvii. for May, 1322; ;ind Notes to Richerand's
Elements of Physiology, 1st ed. 1824.), that the
nerves are first Conned, and the cerel)ro-spinal
centres subsequently developed.
10. 2d. A diminution of the influence of those
nerves which preside over the circulation of a
part, and its assimilative and proper functions,
rapidly reduces its volume. It is chiefly owing
to this cause that the organs of generation waste
in old persons. The ganglia which supply these
Organs, in both sexes, become, in old age, small
and indistinct; and the nerves which issue from
them to these parts can scarcely be traced. I
have no doubt that a similar result follows injury
or change of the ganglia or ganglial nerves in
other parts of the body. The paralysis attend-
ant upon painters' colic is generally accompanied
with great wasting. In cases of unreduced dislo-
cation, when the head of the bone presses upon
the nerves, wasting is a frequent consequence,
chiefly owing to the incapability of exerting the
voluntary muscles, which are rapidly atrophied
when they remain inactive. Injuries of nerves,
of whatever description, that interfere with their
functions, will, as shown by Bell, Lobstein,
and several others, occasion atrophy. But I may
add, that whilst injuries of ganglial nerves will
produce it directly, by arresting the nutritive ac-
tions, injuries of voluntary nerves occasion it in-
directly only, and chiefly by depriving the mus-
cles of their contractile powers, and reducing
them to that state of inactivity which is more or
less rapidly followed by atrophy. This is proved
in the numerous instances which come before us
of paralysis originating in the brain. The wast-
ing of the paralysed limb in these cases is seldom
great, and it is chiefly limited to the muscles;
the other structures, particularly the cellular and
adipose, being unaffected.
11. 3d. Diminished supply of blood is a very
frequent cause of atrophy. This may be local, as
in cases of obliteration of a large arterial trunk,
and when the functions of an organ cease. In
many such cases, however, the obliteration may
be the consequence of injury of the ganglial nerves
which supply the artery, or of the cessation of
the functions of the part. The general state of
atrophy which occurs after tubercular formations
in the mesenteric glands, or in the lungs, is, gen-
erally, partly owing to the diminution of the en-
tire mass of blood, together with lowered vital
influence; then utritious molecules, and the assimi-
lating or attractive power being both deficient.
A similar inference may also be extended to the
wasting accompanying idiopathic anaemia.
12. 4th. When the functions of a part or or-
gan are arrested, atrophy always results. This
is remarkably the case in respect of the voluntary
muscles (§ 10.). On the other hand, increased
function of an organ contributes to augmented
volume. The urinary and generative organs fur-
nish well-known proofs of those positions, and
illustrate those with which I commenced, namely,
that nutrition, and consequently atrophy, most
intimately depend upon the states of vital mani-
festation of an organ or part. Other organs in-
capacitated from acting also undergo a marked
diminution of their size. Even the lungs, when
the principal bronchial tube of one lobe is ob-
structed, will experience atrophy of that lobe, as
MM. Reynaud and Andral have shown. In
cases of death from hunger, the stomach and
large bowels appear wasted.
1 3. 5th. Atrophy will also present itself as a
consequence of inflammation; and, in some cases,
will amount to obliteration or disappearance of
the part. Such changes are not infrequent in
blood-vessels and excretory ducts. It is some-
times observed in the spleen, liver, and gall-blad-
der; the last of which has been observed to be
wanting or entirely obliterated from this cause.
In the majority of such cases, the atrophy has
proceeded from obstruction to an arterv or vein
having occurred during the disease, probably from
the extension of inflammation to them, or from
the pressure of some of the usual products of the
inflammatory state.
14. C. Treatment of atrophy. — In all these
circumstances under which atrophy occurs, it
will always be observed that the vital energies,
in some one or other of its manifestations, are
diminished or perverted — most frequently the
former. This fact furnishes us with the most ra-
tional indication as to the removal of the morbid
state which it occasions. Having first ascertained
the circumstances and pathological states of the
atrophied organ, we are to direct our attention to
remove them as far as may be possible. We are
next to endeavour to restore the natural vital en-
ergy of the organ by exciting its functions, and
promoting the constitutional powers. Knowing
that, by increasing the natural actions of a part,
we thereby increase its nutrition and bulk, we
should endeavour to apply this principle to the
removal of atrophy, but with a cautious avoid-
ance of fatigue or exhaustion being occasioned by
the means we use for this purpose. When the
atrophy seems to depend upon the developement
of tubercles, or upon engorgements of lacteal
glands or tumours pressing upou nerves or large
vessels, the preparations of iodine are indicated,
on accoimt both of their influence in removing
these tumours, and of their excellent tonic pow-
ers wheu judiciously administered. In many
cases the functions of the digestive organs — stom-
ach, liver, and bowels — are torpid, and conse-
quently the nutritious fluids are not sufficiently
prepared to be assimilated in the different tissues.
Healthy chyle is not supplied in the requisite
quantity, or, if supplied, is not converted into
healthy blood for the nourishment of the struc-
tures. In these cases, although the energy of the
whole frame is deficient, yet our principal means
of medication are to be directed to these organs.
(See art. Consumption, Marasmus, Mesent-
eric Disease, and Tabes Dorsai.is.)
Bibi.ioo. AND Refer. — Desmottlins, in Journ. de Phy-
sique, t. xc. p. 442. — Ribcs, in Bullet, de la Faculte de
Mid. I. vi. p. 299. — Ferrus, Atrophic, in Diet, de M£d. t.
iii. p. 143. — Andral, C Unique Medicale, I. IT. p. 11.; et
Precis d'Anatom. Pathol, t. i. sect. ii. eh. ii. — Bouillaud,
Diet, de Mtd. et Chirurg. Prat. t. iii. p. 629. — Lobsttin.
Traite d'Anatotuie Pathologique, t. i. p. 60.
AUSCULTATION. — (From ausculto, I list-
en). Pathology, Semeiology. — 1. This term
is applied to the methods used to ascertain the
seat and nature of disease, by the signs which may
be recognised by the sehse of hearing. It com-
prises tike study of all sounds indicative of disease,
whether heard by the unassisted ear, or through
the medium of instruments; and whether arising
naturally, or produced artificially. The observ-
ations I have to offer upon this mode of invest!-
AUSCULTATION — of Respiration.
157
gating disease may be arranged in the following
manner ; l>ut I shall confine myself at this place
t.> the consideration of thejurst class of signs, and
devote to the second class a distinct article. (See
Percussion.)
2. I. Signs furnished by Sounds pro-
duced NATURALLY WITHIN THE BODY.
A. Sounds /luring their seat in the chest. — a.
Depending upon the passage of air during re-
spiration. 6. Proceeding from the action of the
vocal organs, c. Depending upon the action of
the heart
Ji. Sounds having their origin in the arteries.
C. Sounds seated within the abdomen. — a.
Proceeding from air in the digestive tube. b.
Depending upon the foetal circulation.
II. Signs furnished by Sounds produced
artificially. (See Percussion.)
8. Hippocrates' remarked that the existence
of fluids in the thoracic cavity might sometimes
he ascertained by applying the ear for some time
to the side of the chest ; and our countryman
Hook (Posthumous IVorks, p. 3f). &c), in sev-
eral very pointed observations, not only stated the
importance of attending to the sounds produced
by the " internal motions and actions of bodies,"
but also of rendering them sensible so as to
distinguish between them ; for the doing of both
which, he thinks, " it is not impossible but
that in many cases there may be helps found."
M. Double, also, was in the habit of applying
the ear closely to all parts of the chest, in order
to examine the signs furnished by the action of
the heart, and by respiration ; and published his
recommendation to cultivate this means of diag-
nosis, in his able work on Semeiology, two years
before the appearance of M. Laennec's cele-
brated production. Although, therefore, M. La-
en nec may not have been the discoverer of the
importance of auscultation in the investigation of
disease, yet is he clearly entitled to the honour
of discovering mediate auscultation — of inventing
the stethoscope — and not only of bringing both
these modes of examination into general use, but
also of strongly recommending percussion, and
of improving, in a very remarkable manner, our
knowledge of the pathology of pectoral diseases.
I. It is unnecessary to occupy mv limits with
a description of the instrument termed the stetho-
scope, as its construction, with the improvements
of M. Piorry, and the acoustic principles on
which it assists the sense of hearing, have been
frequently described, and are so simple, as to be
readily understood, even by those who are not
already acquainted with it. I may remark at this
place, that auscultation, like every other method
of investigation, requires practice for its perfec-
tion. The young practitioner should therefore
early commence the study of the sounds of re-
spiration and of circulation, at first with the un-
aided ear upon the healthy subject, and preferably
on children, from five to twelve years of age, as
in them 'ill these sounds are distinct, and seldom
modified by organic disease. Having made him-
self familiar with these sounds, by frequent re-
COnrse to this practice, he may provide himself
with the cylindrical stethoscope in general use, and
with the one called Piorry 's ; and, with their
aid, continue his study of the sounds produced
within the living body.
5. Having limited myself at this place to the
14
consideration of the Signs furnished by
Sounds produced naturally within the
Body, whether heard by the unassisted ear, or
by the aid of the stethoscope, I proceed, first, to
notice the sounds having their seat in the chest
and throat. These sounds are chiefly produced
by the natural movements of the parietes of this
cavity, and of the organs contained within it, and
consist of, 1st, those of respiration ; 2d, those of
the voice ; and, 3d, those of the heart. These
will be successively considered.
6. I. Auscultation of Respiration. — A.
Of the healthy and simple, respiratory sounds.
The passage of air into, and out of, the lungs
occasions a somewhat different sound in various
parts of the chest, owing to the difference of size
of the tubes through which the air passes. Hence
the respiratory sound has one character in the
small bronchi and air-cells, another in the large
bronchi, and another in the trachea. These
sounds have been respectively denominated, by
Laennec, Andral, and Williams — the best
writers on auscultation — vesicular, bronchial, and
tracheal. The tracheal sound is heard in the an-
terior and lateral parts of the neck, the upper
portion of the sternum, and the sternal part of the
subclavian regions. The bronchial respiration is
heard in the middle portion of the sternum, and
parts of the mammary regions contiguous to it,
and in the axillary and interscapular regions.
Vesicular respiration is perceptible over the re-
maining parts of the chest in health. These
sounds are double ; the one being that of inspira-
tion, the other of expiration. The former is much
stronger than the latter, which is often scarcely to
be heard by the unpractised ear, unless assisted
by the stethoscope.
7. It is difficult to describe these sounds with
accuracy. The vesicular sound is a dull and dif-
fused murmur, or a feeble breathing, resembling
that proceeding from the passage of the air through
the nostrils in a healthy and quiet sleep. The
bronchial respiration is more tubular and blowing,
and is chiefly confined in health to the situation
of the largest bronchi. The tracheal sound
merely conveys the idea of air passing through a
tube of larger calibre, and is more hollow and
blowing.
8. The respiratory sounds vary in their inten-
sity, not only in different persons, but also in the
same person, at different epochs of life, and at va-
rious times. The thickness of the parietes of the
chest does not materially diminish their intensity ;
but the activity of the respiratory function affects
them most materially ; this function presenting
different grades of activity in different persons.
Dr. Williams has remarked that they are more
distinct after meals and moderate exercise. After
excessive exertion they are diminished. Fear,
and the depressing passions, have a similar effect.
9. The respiratory sounds are greatly modified
by age. From birth to the period of puberty, they
are much louder and shriller than in after life, and
the whole respiratory function more active. This
state of the respiration has been called puerile by
1 ,v E H nec; and occurs sometimes in adults, either
generally or partially, from momentary excitation,
or the presence of disease in a part or parts of the
lungs. At puberty the respiration Is less noisy;
and in a few years becomes much deeper, and
assumes the adult character.
158
AUSCULTATION— of Respiration.
10. The vesicular sound being the result of the
perfect penetration of the air into the lungs, its
equal and simple presence is a sign of the healthy
performance of the function. But this sound
may vary in degree. It may be feeble in all
parts, owing to constitutional peculiarity, or only
in particular parts, when we should suspect dis-
ease ; but it is no proof of disease, unless it be
associated with certain peculiarities of sound here-
after to be noticed. The total absence of re-
spiratory sound in a part indicates either the ex-
clusion of the air from the part of the pulmonary
tissue underneath, or effusion of fluids, or the in-
troduction of air into the pleura. Here we must
have recourse to percussion, in order to give pre-
cision to the information. (See Percussion.)
in some cases the natural vesicular sound is ab-
sent, and a bronchial respiration is heard. In
these we must infer that the vesicular murmur is
suppressed by a condensation of the pulmonary
structure, which, owing to this change, becomes
so good a conductor of sound, that the bronchial
respiration either becomes louder or is heard in
unusual places. In other cases, a sound re-
sembling the tracheal is heard in situations where
vesicular respiration alone exists in health. This
is caused by the passage of air into an ulcerated
cavity or cavern communicating with the bronchi,
and from this circumstance is called cavernous
respiration.
11. B. Of the morbid respiratory sounds. —
The respiratory sounds are not only varied in de-
gree, but also in kind, or they are mixed with
different adventitious souiids. These variations of
kind are produced, 1st, by changes in the parie-
tes and vicinity of the tubes, and in their secre-
tions; and, 2d, by morbid states exterior to the
pulmonary tissue. Under the first of these are
ranked the different varieties of sound produced
by the presence of morbid secretions within the
air-tubes, and the lesions producing these secre-
tions. This class of morbid sounds have been
variously denominated. By the French they have
been named rale ; by some of our own writers
the word rattle, and by Dr. Johnson the word
wheeze, have been used. As we have no Eng-
lish tenn which so fully expresses the idea, to
which this morbid sound gives rise, as the word
rhonchus, adopted by Dr. Williams, and some
French pathologists, I shall use it here.
12. a. 3Ioistcrepitous rhonchus, the rale crepi-
tant of Laennec ; the crepitant rhonchus of Dr.
Williams, has its seat in the air-cells and
minute bronchi. It resembles the sound from
rubbing a lock of hair between the finger and
thumb, when held close to the ear; or the crepit-
ation of a piece of lung distended with air when
compressed. It is generally uniform, and con-
tinues to the end of inspiration, and seems to
arise from diminished calibre of the minute bron-
chi, owing to interstitial effusion, and the admixture
of the respired air with the secreted or effused
fluids in the air-cells and tubes. It is charac-
teristic of incipient hepatisation of the lungs from
pneumonia, and of its resolution ; of oedema and
apoplexy of the organ ; sometimes of early
phthisis, of pulmonary catarrh, and bronchitis.
But it is only pathognomonic of the first stage
of pneumonia ; and the more viscid the mucus
that is secreted, the more distinct is the crepitant
character of the rhonchus. In the other diseases
in which it occurs, the crepitation is less perfect
13. b. Dry crepitous rhonchus, the cra^uement
of Laennec, resembles the sound produced by
blowing into a dried bladder, and conveys the
impression of air distending lungs that have been
more or less dried, and whose cells have been
unequally, but much dilated. It is only heard
during inspiration, and occurs only in pulmonary
emphysema.
14. c. Dry bronchial rhonchus. — This is either
sibilous, rale sibilant sec; or sonorous, rale sonore
sec, of Laennec The former is a low or loud,
shrill or bass, and prolonged vMstle, such as
may be produced by air passing through a small
circular aperture, and is owing to some contrac-
tion or constriction of the bronchi. The latter is
a dull, prolonged, snoring sound; sometimes very
loud. It occasionally resembles the bass note of
a violoncello, or bassoon, or the buzzing of an
insect. It seems to be produced by a flattened
contraction in a bronchus of considerable size,
leaving very little aperture ; and arising from
external pressure of the bronchial tube, from
local thickening of its mucous lining, or from
tenacious mucus within its canal. In a modifi-
cation of the rhonchus, which Dr. Williams
calls the dry mucous rhonchus, the sound re-
sembles that of a click-wheel, and is produced
by a portion of very adhesive mucus attached to
the bronchial lining, which, yielding with a jerk-
ing resistance to the air forcing its passage, there-
by occasions a ticking sound.
15. d. The mucous rhonchus, the rale muqueux
of Laennec, the humid rhonchus of Dr. Wil-
liams, takes place in the bronchial tubes, and
is produced by the passage of air through a thick-
ish fluid, giving rise to a kind of bubbling within
the air-tubes. It is most frequent in bronchitis
and pulmonary catarrh, accompanied with mu-
cous secretions ; in haemoptysis, in phthisis, in
pneumonia, and in other diseases which are at-
tended at any period with expectoration. This
rhonchus is more gurgling, loud, irregular, and
coarse, the larger the brouclii in which it is seat-
ed, the bubbles being there larger and more un-
equal. In the trachea, these characters are par-
ticularly marked, and have been denominated
tracheal from this circumstance, by M. Laen-
nec In the smaller bronchi, on the other hand,
this rhonchus is more equal, and its characters
less remarkable, the bubbles being of much
smaller size. The bubbles producing the mu-
cous rhonchus must necessarily vary in their cha-
racters with the varying fluidity of the secretion,
and thus the rhonchi will differ accordingly. If
the fluid be very thin, the bubbles will be nu-
merous, readily formed, and rapidly break : but
if it be viscid, they will be fewer in number, and
will often pass along the tubes for some way be-
fore they break, the sound being diffused, more
regular, and rare. Also the continuance of the
rhonchus will be an indication of the quantitv of
liquid present in the bronchi, as justly remarked
by Dr. Williams. If this rhonchus accon. pan v
only the first part of inspiration and the end of
expiration, the secretion must be scanty. But if
the whole of the respiratory act be attended with
this sound, then we may conclude that the quan-
tity of fluid is considerable, and extends to the
smaller bronchi.
16. e. The cavernous rho/ichus, or gargouille-
AUSCULTATION — of thk Voick.
159
mrii', the mucous rhonchus of morbid excavations
in tlic lungs, occurs when those cavities contain a
Said, and comftiunicate with the bronchi. It gen-
erally exists in the advanced stage of tubercular
f)htliisis, in abscess, and partial gangrene of the
lings. 'This rhonchus is characterised by a strongly
marked mucous gurgling or bubbling sound, con-
fined to a small spot and determinate situation,
and is particularly marked upon the patient taking
a full inspiration, or after coughing.
17. it may lie remarked that this class of mor-
bid respiratory sounds — proceeding from changes
in the parietes of the tubes, and in their secretions
— will sometimes he more or less obscurely heard
through effusions in the pleura, when not very
large. I proceed to consider the second class of
morbid sounds, or those arising from lesions ex-
terior to the pulmonary tissue.
18. a. Metallic resonance, tintement metallique
of Laennec, is observed only when a quantity
of air is accumulated in the pleural cavity, as in
pneumothorax; or rarely in cases where very large
tuberculous excavations are formed in the lungs.
It is most commonly heard when both air and
fluid are effused in the pleural cavity, and when
there is a communication between this cavity and
the bronchi. It is most distinctly heard upon
coughing. Laf.nnf.c has distinguished two vari-
eties of this sound, namely, metallic tinkling, and
amphoric buzzing or resonance. These sounds
are occasioned by the impulse given to the air
accumulated in the pleura, by the vibrations of air
rushing through a fistulous opening in the pul-
menary pleura, or striking against a condensed
part of the pulmonary tissue, or of the pleura
itself:
1 !>. 6. Rubbing sound, the sound of friction, the
brui! dr frottement ascendant et descendant of
La J KNEC. This sound has been particularly in-
vestigated by MM. Honokf and Rf.vnaud. It
is an obscure, dull sound, perfectly distinct from
the respiratory sounds, but synchronous with the
motions of the parietes of the chest during inspir-
ation and expiration, and resembling that produced
by the rubbing of two soft and somewhat rough
bodies on each other. It is loudest, or only heard,
during inspiration. It is sometimes present in in-
terlobular emphysema, hut is more frequently
and sensibly heard in pleuritis, with partial albu-
minous exudation, and with little or no effusion of
serum.
20. II. Auscultation of thf. Voice. — The
voice, although produced chiefly in the larynx,
has its sound partiallj propagated inwards by the
air in the trachea and bronchi, occasioning, in
the -nailer ramifications of the latter, a vibratory
sensation or fremitus, rather than a distinct sound
to the ear through the stethoscope; but, in per-
sons with a large chest and strong voice, a more
distinct vocal resonance. When the instrument
is applied in the situation of the larger bronchi,
as between the si apul;e and under the axillae, the
voice is heard much more distinctly, and the arti-
culation may even be distinguished; but the sound
dees not seem to enter the cylinder, or to traverse
its tube. If we. place the stethoscope on the
trachea or larynx, when the patient is speaking,
we hear the whole of the words, loudly and arti-
culately, and as if passing through the instrument
to the ear. These sounds have been called, from
their site, bronchophony and laryngophony ; and
arise from the vibrations propagated through the
air contained in the trachea ami bronchi, and
which become weaker as they extend in the direc-
tion of the air-cells.
2 1 . The degree of vocal resonance in the chest
differs in different persons. It is loudest and
most extensive in those who tire thin, and have a
strong, sharp, treble voice; so that natural bron-
chophony will extend further in young subjects
and in females, particularly through the upper
regions of the chest. In fit persons with a deep
voice, the natural bronchophony is confined and
obscure, especially during the deeper notes. In all
the lower parts of the thorax, particularly during
the deep tones of the voice, there is either no
resonance, or merely a slight thrill or vibratory
fremitus, which may likewise be felt upon apply-
ing the hand to its parietes. S»'uch are the healthy
sounds of the voice in different parts of the chest;
but in certain states of disease they are very mate-
rially altered, and both the bronchial and laryn-
geal sounds are developed in places where they
never exist in health. Of the various manifesta-
tions of these sounds in disease, 1 now proceed to
take a brief notice.
22. a. Bronchophony is developed in disease by
the same causes that render the bronchial respir-
ation audible, viz. condensation of the substance
of the lungs in the vicinity of large bronchial
tubes, without diminishing their calibres, as in
hepatisation or induration, from the formation
of tubercular matter. From this circumstance
bronchophony is an important symptom in pneu-
monia and phthisis. When the condensation is
seated near the surface of the upper portions of
the lung, and near a large bronchus, the sound
may nearly approach laryngophony. The bron-
chial respiration is generally present with bron-
chophony, excepting when the hepatisation is ex-
tensive.
23. b. JEgophony (from ait, n'yoc, a goat,
the sound resembling the ciy of this animal,) is
merely a modification of bronchophony; and oc-
curs when, with the circumstances which produce
it, there are superadded the existence of a thin
layer of fluid between the surface of the lungs
and the pleura costal is. The bleating sound
of the vore to which the term apgophony has
been applied is variously modified in different
persons, according to the natural tone of their
voice, and the different modifications of the dis-
eases which produce it : thus it will resemble the
squeaking of Punch ; or possess a shriller or
sharper key, and sound more like the echo of the
patient's voice than the voice itself. /Egophony
only exists in pleurisy or slight hydrothorax,
when the quantity of fluid efjrosed is no more
than firms a thin layer between the lungs and
parietes of the chest. Laf.nnec states that he
has found this symptom present in almost every
case of pleurisj ; ami considers it to be owing to
tic natural resonance of the voice in the bronchial
tubes, rendered more distinct by, the compression
of the pulmonary texture, and modified by its
transmission through a thin layer of fluid in a
state of vibration, Dr. Williams ascribes it to
" the successive undulations of the liquid, the
result of an irregular transmission of the. so-
norous vibrations." /F.gophony often co-exists
with bronchophony, and the one passes into the
other.
160
AUSCULTATION — of the Heart.
24. c. Pectorilogy. — The existence, in disease,
of vocal resonance in any part of the chest, to
the extent of laryngophony, has been termed
pectorilogy bv Laennec It may be either im-
perfect or perfect. It is the result of a morbid
cavity, formed in the substance of the lungs, and
communicating with the bronchi; to which cavity
the sound of the voice, or vibrations of the air in
the tubes, is propagated. When the stethoscope
is applied to a part of the chest, under which one
of these cavities is situated, the words which the
patient utters seem to proceed from that spot;
and hence the term pectorilogy. " The distinction
between perfect and imperfect pectorilogy is, as
in the case of natural resonance, whether the
voice seems to traverse the tube, or remain at the
end; and the physical difference producing the
two modifications consists in the size and situa-
tion of the cavity. The most perfect pectorilogy
is produced in cavities of moderate size, which are
situated near the surface of the lung, and freely
communicate with a large bronchial tube. If the
cavitv be deep-seated, or if its communication
with the bronchi be imperfect, the resonance of
the voice will not amount to perfect pectorilogy.
True pectorilogy produced by a cavity, is gener-
ally abruptly circumscribed, so that its limits can
be distinctly traced." — (Williams's Rational
Exposition, fyc. p. 43.). Andral appears to be
correct in considering perfect pectorilogy as not
common, and that the imperfect state of this sound,
or bronchophony, is very frequently mistaken for
it. When present in any part of the chest where
there is naturally no bronchial resonance, it may
be considered as a certain indication of the exist-
ence of a morbid cavity, generally tubercular; and
when heard in situations of natural bronchial re-
sonance, although more doubtful, yet if it be per-
fect, distinctly^circumscribed, and heard on one
side onlv, the same conclusion must be come to.
It may be further -added, that an empty state of the
cavity, its rounded and regular shape, and natural
sharpness of the voice, particularly in women and
children, tend to render pectorilogy perfect.
25. III. Auscultation of the Heart. — A.
In its healthy state. I have always viewed Laen-
nec's explanation of the sounds proceeding from
the heart's contractions as the most defective part
of the exposition of his system; and a similar
opinion seems to have been entertained by Mr.
Turner, Dr. Williams, and several others.
The observations of Mr. Turner, and of Drs.
Stokes and Corrigan, first shook the stability
of the views of Laennec on this subject; and the
recently published researches of Dr. Hope have
almost altogether overthrown them. As I consider
the exposition of the actions and sounds of the
heart, given in Dr. Dope's work, to be the most
accurate, I shall follow it on this occasion.
26. 1st. Of the contractions of the heart in the
order of their occurrence, $~c. — The first motion
of the heart following the interval of repose, is
the systole of the auricle. It is a very brief and
slight contractile movement, most considerable in
the auricular appendix, and propagated toward
the ventricle, in the systole of which it termin-
ates, by a nearly continuous action. The sys-
tole of the ventricle commences suddenly, and
diminishes considerably the volume of the organ.
"Synchronous with the systole are the first sound,
the impulse of the apex against the ribs, and the
pulse of the vessels near the heart;" the pulse at
the radial arteries following at a barely appre-
ciable interval. The diastole of the ventricles
follows their systole; and these compartments
return, by an instantaneous expansive movement,
to the same state as during the previous interval
of repose. The diastole is accompanied with the
second sound, with a rush of blood from the au-
ricle, by a contractile motion of this cavity most
observable at its sinus, and by a retrocession of
the apex of the heart from the ribs. " Next
succeeds the interval of repose, during which the
ventricles remain at rest in a state of fulness,
though not of distension, through the whole
period intervening between the second and the
first sounds ; but the auricle remains at rest
during the first portion only of that period, the
remainder being occupied by its next contraction,
with which recommences the series of actions
described." — (Hope on the Dis. of the Heart,
fyc. p. 40.)
27. The rhythm of the heart, or the duration
of the several parts of this series of actions, con-
stituting what may be called a beat, is the same as
described by Laennec: — 1st, The ventricular
systole occupies half the time of a whole beat;
2d, The ventricular diastole occupies a fourth, or
at most a third; 3d, The interval of ventricular
repose occupies a fourth, or rather less, during
the latter half of which the auricular systole takes
place.
28. 2d. Causes and mechanism of the motion. —
The auricles, being always in a state of fulness,
arrive, during the first half of the period of repose
of the ventricles, at a state of distension, on
which they react and propel a small additional
quantity of blood into the full but not yet dis-
tended ventricles, in order to bring them to this
state, and to cause them to react, and thus expel
a greater or less portion of their contents. Dur-
ing the expulsion of the contents of the ventricles,
Dr. Hope considers that the apex of the heart is
tilted upwards and forwards, and occasions the
impulse against the ribs, in consequence of the
retraction of the ventricles upon their base, and
on the auricles, which, being in a state of extreme
distension, serve as a fulcrum beneath them.
The diastole of the ventricles appears to be oc-
casioned, 1st, by the relaxation of the principal
part of their muscular structure, assisted by an
elastic property; 2d, by the distension of the
auricles, which has arrived at its height, and
brings into action certain lasers of ventricular
fibres having a powerful influence in distending
these cavities; 3d, by the width of the auriculo-
ventricular opening, which allows the blood to
rush instantaneously, and with facility, from the
auricles into the ventricles. T he blood expelled
from the former cavities into the latter being in-
stantly replaced from the vena? cava3, distension
of the auricles immediately recurs, and the same
series of actions is continued.
29. 3d. Causes of the sounds. — There can be
no doubt that the sounds of the heart's actions
are not produced by the mere contraction of its
muscular structure. To what other cause can
we impute them ? I conceive that they can only
be referred to the action of the parietes of the
cavities on the fluid circulating through them,
and to the motions of this fluid. According to
this view, which has been very diligently investi-
AUSCULTATION — of the Heart's Sousns.
161
gated by Dr. HoPK, the systole of the ventricle
is the cause of the first sound, by the impulse it
communicates to the blood, and the di stole of
the ventricle is the cause of tin' second sound;
owing, in the opinion of this writer, to the rash
of blood from the auricles, produced as already
explained (-^ 26.), and the succussion of the
Stream against the walls of the ventricle, when
abruptly arrested by the completion of the dias-
tole.
:i '. I consider that it is clearly made out. 1st,
That the impulse, the pulse, and the first sound,
coincide; 2d, Thai the ventricle is concerned in
the production of the second sound, although the
exact manner, in which the motions of the ven-
tricle and this sound are connected, has not yet
been conclusively ascertained; and, 3d, That the
actions of the auricles are insufficient to produce
either impulse or sound, and that, neither the one
nor the other result from them. With respect to
the production of the second sound, I think that
the opinions of Mr. Turner, Dr. Corrigan,
and Dr. Wir.r.i vms, are untenahle, and therefore
may not he stated; and that the explanation of
Dr. Hope requires further confirmation. From
the third of these facts I believe that it may he
legitimately inferred, that the physical signs of
disease of the auricles are very imperfect, and
therefore uncertain.
31. B. Auscultation of the morbid sounds and
impulse of the heart. — 1st, Of the impulse of the
lira ~t. Although, strictly speaking, the sounds of
this organ are the only objects of auscultation, yet,
;'s the impulse or shock it communicates to a part
of the chest is usually made a matter of enquiry,
although by a different sense, during the time
that auscult ition is being performed, I will briefly
notice it at this place. The impulse necessarily
varies, even in health, in different persons, with
the state of the heart's action, and the habit of
body. It is also greatly modified by mental
'is. and by various affections of the digestive
and other organs. It is always synchronous
with the first sound of the heart; but, in rare
e is s, a sight second impulse also accompanies
the second sound; hut this is felt deeper in the
chest; is more of an obscure tremor, much slight-
er in degree thin the chief impulse or shock, and
is only met with in cases of hypertrophy with
dilatation.
32. When the impulse is prolonged, strong,
and characterised by an extensive heaving move-
ment, thickening of the walls of the ventricles
may he inferred. It should, however, be recol-
lected, tint whatever excites the feelings of the
mind, or hurries the circulation, will occasion a
: impulse; hut, iti such cases, the actions of
the heart are also unusually frequent Morbid im-
pulse of the heart Is present in the states of both
mental and corporeal repose; and is often uncon-
nected with increased frequency, as in hypertro-
p!r. of the ventricles.
33. The impulse may be diminished, even in
h • i th, as by the depressing passions. It is often
Lutionally so small in amount as scarcely to
be i i It is also lowered by diseases of remote
•rgans, as diarThoea, &c, and by abstinence and
blood-letting, and whatever depresses the energies
of the system. It is generally weak in congest ion
of the cavities of the heart, in cases of thinning of
their parietes, in the asthmatic paroxysm, in con-
14*
gestion of the lungs, in some cases of pneumonia,
and in the advanced states of various diseases;
and it may even, although very rarely, accom-
pany certain states of hypertrophy of the heart.
particularly during the operation of debilitating
causes.
34. In health, the impulse is usually limited to
the immediate region of the heart, and chiefly in
the situation of the cartilages of the fourth, fifth,
sixth, and seventh ribs. Its sphere is extended
by increased action of the organ, whether the re-
sult of mental or corporeal excitement or of dis-
ease; by hypertrophy, and by certain organic
changes of organs in the immediate vicinity.
When the muscular parietes of the heart are in-
creased without any dilatation of the cavities, the
sphere of impulse is not extended far beyond its
healthy site; but when dilatation is combined
with hypertrophy, the impulse may often be felt
on the right side of the sternum, below the clavi-
cles, and even on the hack. Diseases of adjoining
organs, as hepatization of parts of the lungs in the
vicinity, effusions of fluids in the pleural or peri-
cardic cavities, tumours in the mediastinum, close
adhesions of the lungs to the costal pleura, adhe-
sion of the pericardium to the heart, displacement
of the heart, and even an enlarged liver or spleen
— when rising into the thoracic cavity, and press-
ing the diaphragm upon the pericardium — will
extend, often to a considerable distance, the im-
pulse of the heart, owing to the increased density
of parts which receive the shock. Much discus-
sion has arisen as to the manner in which the
heart's shock is produced. Further than that it is
occasioned by the muscular actions of the organ,
I beliex'e that the phenomenon has not been satis-
factorily explained, at least in such a way as ac-
cords with the various conditions it presents in
health and disease. The explanation given by
Dr. Mope has been already stated (§2S.).
35. 2d. Of the changes produced in the natu-
ral sounds of the heart by disease. — The sounds
of the heart vary in different persons, even in
health. In some they are loud and distinct; in
others, the reverse: they may also be dull or clear,
in respect of their key. They are generally dis-
tinctly heard by the unaided ear; but more accu-
rately with the stethoscope. The impulse and
sound are never both present in health, to a great
degree, as they depend upon opposite conditions
of the ventricles; the impulse being great in pro-
portion to the thickness of the parietes of the
ventricles, the sound to their, thinness. The
sounds of the left side of the heart are strongest
at the junction of the cartilages of the left fourth,
fifth, sixth, and seventh ribs, with the sternum:
those of the right side, under the sternum and
towards its right edge. The sphere of the heart's
sounds is, in a very few persons, nearly limited
to the sphere of impulse; but it is generally far
more extended, even in health. It should not be
overlooked, that the sphere of sound is much
larger in children and young persons, in females,
in the lean, and in those who have narrow or
small chests; whereas, in persons whose thoracic
cavity is large, and its parietes thick, muscular,
or fat, the sound is heard much less exten-
sively.
3(j. The sphere and loudness of the heart V
sounds are increased by the same moral, physi-
cal, and morbid causes, which liave been stated
162
AUSCULTATION — of the Heart's Sounds.
to augment its impulse (§31.). Therefore, when
frequency of pulse accompanies increase of sound,
no actual disease may exist; but when a natural
or slow state of the pulse is attended with an aug-
mented range of sound, disease may be much
more certainly anticipated. The circumstance of
the sphere of sound being extended by the organic
lesions already noticed as conveying the impulse
of the heart (§34.), and by tuberculous excava-
tions in the lungs, should not be overlooked. In
taking account of the heart's sounds, we should
also be aware that the sounds of respiration \\i\\
occasionally mask them, as the heaving of the
chest during inspiration will, in a slight degree,
mask some of the shocks of the heart. General-
ly, the sounds of the heart are strongest in the
left anterior part of the chest; and progressively
weaker in the sternal, in the right anterior, the
left posterior, and in the right posterior parts suc-
cessively. If this succession be deviated from, or
in any way altered, disease exists; and the de-
gree, state, and order of deviation, become signs
of some importance. It has been remarked by
Laennec, that, when the sounds are heard be-
yond the healthy sphere, in persons with the chest
well formed, and presenting none of the causes
alluded to as giving rise to such extensive range,
these persons will be found to be subject to pal-
pitations, to shortness of breath upon the slightest
exertion, to attacks of asthma, and to congestions
of the internal viscera.
37. 3d. Of the adventitious sounds of the heart.
— The sounds of the heart may not only be
changed in degree, in extent of sphere, and in the
succession of intensity, but entirely new sounds
may be superadded. The most common of these
are the bellows sound (bruit de soufflet), the saw
sound (bruit de scie), and the rasp sound (bruit
de rape). These may either take the place of
the natural sounds, or may be conjoined or super-
added to them; and they may be present with
either the first or second sound, or with both.
The bellows sound resembles the puffing of a
pair of bellows, and conveys the idea of smooth-
ness. The saw and rasp sounds are so named
from their similarity to the sounds occasioned by
the sawing or rasping of wood, and convey the
idea of roughness. But the bellows sound may
insensibly pass into the others; and they all vary
greatly in loudness. They may occupy the place
of the first or the second of the heart's natural
sounds, but more frequently that of the first than
of the second. The saw and rasp sounds are
generally louder, and present a wider range of
intensity, than the bellows sound, which is more
closely limited to the part which occasions it.
They may all be heard in arteries at a distance
from the heart, more particularly the bellows
sound; and often when they do not exist in the
region of the heart. When the saw-sound pro-
ceeds from the heart, it may generally be traced
along the arch of the aorta to the subclavian and
carotid arteries.
38. The causes of these sounds, and the exact
site of the changes which produce them, are ob-
viously the important considerations attached to
them. They have been accounted for in various
ways, even by their eminent discoverer; and, in
general terms, they may be said to arise from
unnatural or morbid motions induced in the cur-
rent of blood circulating through the heart, in-
| stead of those natural motions which contribute to
I the healthy sounds of the organ. Hence, what-
ever produces the morbid change of the motions
of the fluid, will occasion the adventitious sounds;
and we have reason to infer that such change is
; produced either by a permanent alteration of the
I apertures and canals through which the blood is
i propelled, or by a spasmodic or nervous state of
the same parts.
39. The simple bellows sound is more com-
mon, and arises from slighter changes than the
saw or rasp sounds, and is less to be depended
upon in diagnosis. Pressure on an artery will
occasion it; and when present in the heart, it will
sometimes be removed by blood-letting. When
even existing permanently, although it is a very
strong indication of organic change in the heart,
it cannot be implicitly relied on; but when only
occasionally present, although such change may
be its cause, yet it deserves no reliance. The
saw or rasp sounds are much less frequent than
the other; are much more constantly found in
connection with contracted orifices of the heart;
and are very frequently indications of an increased
degree of the same cause that produces the bel-
lows sound. It may, however, be generalh in-
ferred, 1st. That these sounds arise from some
change in the orifices of the heart's cavities, pro-
duced by nervous or temporary causes, or by al-
teration of structure; more frequently the latter.
2d, That these sounds, therefore, although they
indicate the existence of organic disease, are not
conclusive evidence of it, as they sometimes arise
from other causes. 3d, That in proportion as
these sounds possess more of the rasping charac-
ter, the greater is the probability of organic
change. 4th, If the sounds disappear after deple-
tions, upon repose, or without sufficient reason,
their dependence upon functional disturbance may
be inferred, although not implicitly relied on;,
their continued absence, however, strengthening
the conclusion. 5th, The continuance of these
sounds, notwithstanding the means now mention-
ed, or their diminution merely, is nearly conclu-
sive of organic change. 6\h, Intensity of the
sounds is no indication of the degree of valvular
disease, or extent of the contraction of an orifice;
as they may be weak, when these organic chan-
ges are extreme. A moderate contraction and
size of current seem to be requisite to their full
production. The relation of these sounds to the
particular changes which occasion them is con-
sidered in connection with these changes. (See
Heart — Diseases of.)
40. The rasp and saw sounds are often accom-
panied with a phenomenon resembling a species
of impulse, and which can be estimated by the
sense of touch only. This is the thrill or purring
tremor, termed " bruissement " by Corvisart,
and " fn'missement cataire " by Laennetc,
which is felt when the fingers are placed upon
the heart, or on an artery. When existing in
the heart, the feeling excited upon applying the
hand to the region of this organ, is analogous to
the sensation occasioned by the saw or rasp
sounds. The fact is, that the same pathological
condition gives rise merely to modified sensations
as perceived by the medium of different organs,
the object exciting the sensations being one and
the same; the only difference being, that a
stronger current is required to produce the pur-
HARRIERS — Symptoms — Treatment.
1G3
rinu tremor, than is necessary to the production
of the sounds. It ia owing to this circumstance
thai it is strongest in hypertrophy of the ventri-
cle, oi when the circulation is hurried. A firm
pressure of the hand on the region of the heart is
necessary to feel it well ; and a moderate pres-
sure to feel it in the arteries.
41. Tin' last adventitious sound that I have to
notice is that which LaeNNEC has termed the
" rri du Cttir," and which resembles the creaking
of the leather of a new saddle. It seems to bo
chiefly observed in cases of pericarditis, when the
opposing surfaces of the pericardium lose their
lubricity, and when they are rendered rough by
the exudation of coagulable albumen, or are in
an unusual stale of dryness ; and to he occasion-
ed either by their friction whilst in this state, or by
the motions produced in that part of the pericar-
dium reflected over the heart during the systoles
and diastoles of the ventricles.
It is unnecessary to add any thing at this place,
to what has been stated respecting the ausculta-
tory signs in diseases of arteries, and particularly
of the aorta. The employment of auscultation
of the abdomen, in order to ascertain the existence
of pregnancy, is comprised in the article Preg-
nancy.
Biblioo. and Refer. — Douhte, Semeiologie Generale,
t. ii. p. 31. Paris, 1817. — Laennec, De ('Auscultation Midi-
He, L ii. Ire edit. Paris 1819. ; 2.1 edit Paris, 1830. — lie, -tin
el Hnuitlnml, Sur Irs .Maladies du C<uur, &.C. Pari-, I ::_' I.
— Awiriil, Clioique Medicate, I. ii. ct iii. Paris, 1824,
?assim. — Turner, in Tran,. of Med. and Chirurg. Soc. of
Min. mi], ii. — P. Colin, Surl'Exploration de la Poitrine, ir.
3d edit Paris, 1830. — C.J. II. Williams, Rational Expos, of
the Physical Signs of Diseases of the Lungs and Pleura, &c.
8vo. Loud. 1S23.— Rniniiuil, Joiirn. Hebdomad. No. 65.
t. v. p. 516. — Sluices, in Transactions of Irish College of
Physicians, vol. v. p. 305. — Toonwend, Ibid. p. 137.— Cor-
rfaon, in Hub. Med. Trail-. .New .Series, vol. i. pp. 1. 151. —
Ferguson, in Ibid. p. 11. — Hope, in Loud. .Med. (.iaz. 1829,
passim ; and Diseases of the Heart and Great Vessels, 8vo.
1 131, p. 2!:. ct sin.
BARRIERS.
Classif. 4. Class, Nervous Diseases ; 3. Or-
der, Affecting the .Muscles (Good). 1. Class,
IV. Ordkr (Author).
1. Dkkin. Tremor, with pricking, formicating
pain; numbness of the extremities, principally of
the lower, followed by contractions and paralysis
of the limbs, inarticulation or hoarseness of voice,
emaciation, and sinking of all the vital powers.
2. This disease litis been described by various
authors since the appearance of the work of
Bontius. But we have had no satisfactory ac-
count of it until Mr. M \imiai.i. furnished it in
his interesting work on the diseases of Ceylon,
and distinguished it from Beriberi, with which it,
had been confounded by Bontius, and recently
by Dr. Good. Dr. J. Clare had, however, no-
ticed it briefly as a distinct disease, many years
previously ; and the definitions of it given by
Sauvages, LnfN.Eus, Sagar, and Aikik, seem
to indicate that they were not altogether unac-
quainted with its nature. I shall here follow the
accounts! of it by Dr. Clark and .Mr. Mar-
mi \ i.i., as they seem to be the most precise, and
to base been the result of much experience.
3. Symptoms. — The disease generally com-
mences with a formicative pricking pain in the
muscles of the lower extremities, with numbness,
tremors, and an imperfect command of the powers
of locomotion. Both lower limbs are always
equally afl'ected. hi some cases the forearms
and hands, and the powers of articulation, are
subsequently similarly seized. As the disease ad-
vances, the patient is unable to walk steadily.
Standing or walking aggravates the uneasiness of
the limbs, and either is impossible without sup-
port. The superior extremities become incapa-
ble of performing their usual ollices ; and want
of sound sleep, great sluggishness, and inactivity,
are complained of. The limbs afterwards are de-
prived of all feeling, and lose their natural tem-
perature ; the extensor muscles become quite
paralytic, and the limbs contracted. Loss of ap-
petite, indigestion, emaciation, &c. soon follow ;
and the pulse gradually sinks to a frequent, thready,
or fluttering state ; all the vital powers become
depressed, and death supervenes. As respects its
duration, it may be protracted for many months,
and it may present various grades of severity.
Its forms are frequently more mild, the above
description applying to the severer cases. The
diagnosis of barbiers is described in the article
Bkribkri, with which disease it has often been
confounded.
4. Mr. Marshall observed many cases of
this disease, in 1812, amongst the Caffres compos-
ing the 4th Ceylon Regiment. He never noticed
it amongst the indigenous inhabitants of this isl-
and ; and, from every information he could col-
lect, it was only known amongst Africans who
had arrived in the island ; and he believed that
late comers were more disposed to it than accli-
mated residenters. Mr. Marshall also met
with it in Europeans in Ceylon : and he has ob-
served an analogous affection in horses and doos ;
from which, however, he never knew them to
recover.
5. Dr. Lind states that barbiers is a species of
palsy frequent in India, affecting chiefly the lower
classes of Europeans, who frequently sleep, when
intoxicated, in the open air, exposed to the land
winds ; and that its attack is sudden, depriving
the limbs of motion, &c. It appears also to pre-
vail in Java. Dr. Bostock has described a case
which seems to be nearly allied to this affection :
and I have, for several years, been occasionally
consulted by a patient, whose complaints are
very nearly the same as those now described ;
and who had been previously seen by several
medical men, and by some since he was under
my care.
6. The remote Causes of this affection are
cold and moisture applied to the body ; intox-
ication, irregularities, and excessess consequent
upon inebriety ; violent exercise in the sun ; lying
down in the open air during the heat of the day;
exposure to the cold chilling dews of the night,
or sleeping when thus exposed ; suddenly ob-
structed perspiration, by currents of air ; long
fasting, and whatever exhausts the energies of
life. The translator of Bontius 'a work states
that barbiers is frequent on the Malabar coast,
where it attacks those who unwarily sleep ex-
posed to the land winds, particularly in the
months of January, February, and March ; and
that it is seldom cured till after the shifting of the
monsoon, unless the patient changes the climate.
7. Treatment. — This affection appears to
originate in depressing and debilitating causes ; to
be characterised by a gradual and chronic sinking
of the nervous energy ; and therefore to require
a tonic, restorative, and stimulating treatment.
\6i
BERIBERI— Symptoms — Causes.
Frictions, with stimulating liniments along the
course of the spine, and on the limbs ; attention
to the due performance of the secreting and ex-
creting functions ; tonics, combined with warm
cardiacs, gentle aperients, and antispasmodics :
vesication ; stinging with nettles ; electricity ; the
internal use of the extract of nux vomica, or of
strychnine ; the application of external warmth,
and the use of warm clothing ; a nourishing and
digestible diet ; regular habits, and change to a
healthy air or locality ; are the chief means of
cure. Dr. John Clark states, that the few Eu-
ropeans whom he saw ill with this disease were
cured bv a change of climate, and a sea voyage.
In other respects, the treatment is the same as
that recommended in the article Palsy, particu-
larly palsy from lead. (See Colic — -from Lead,
and Palsy.)
Biblioo. and Refer. — Boutins, DeMedicina Indorum,
c. i. — Lind, On the Diseases incidental to European-; in Hot
Climates &.C. 4th ed. Lond. 1788.— John Clark, On the Dis-
eases which prevail in Ions; Voyages to Hot Countries, and
on iho.e in the East Indies, fee. Vol. i. p. 99. Lond. 1792, 8vo.
— Marshal/, Notes on the Medical Topography of Cevlon,
&c. 8vo. 1222, p. 16L — Bisteck, Trans, of the Med! and
Chi] urg. Society, vol. ix. art. i. p. 1. — Good, Study of Med-
icine, vol. iv. p. 493.
BERIBERI. Syn. Beriberia, Synclonus Beri-
beria, Good. Hydrops Asthmaticus, Rogers.
Classif. 4. Clans, Diseases of the Ner-
vous Function ; 3. Order, Affecting the
Muscles (Good). I. Class, V. Order
{Author).
1. Deein. Oppressed breathing ; paralytic
weakness, numbness, and stiffness of the lower
extremities ; general adema, with a swollen and
bloated countenance,
2. Symptoms. — The attack is in some cases
gradual ; in others sudden and severe. When it
is the former, which is more commonly the case,
the patient complains for several days of weak-
ness, and inability or unwillingness to exert him-
self. To these feelings, pain, numbness, and stiff-
ness of the lower extremities, accompanied with
oedema ; muscular weakness, and dyspnoea, par-
ticularly upon motion ; a feeling id' numbness,
fulness, oppression, and weight at the scrobiculus
cordis ; extension of the oedema over the body,
and leucophlegmatic tumescence of the counte-
nance, supervene. As the disease advances, the
dyspnoea increases, and the face is more swollen
and bloated. The lips, which were at first pale,
become bluish and livid ; and the lower extremi-
ties more numb and feeble, or even paralytic.
The stomach is often irritable, especially in the
advanced stages of the disease, when it often re-
jects all ingesta ; the bowels constipated ; the
urine scanty, high-coloured, and sometimes almost
suppressed : the pulse is at first either more or
loss quick, small, and hard, or but little affected ;
subsequently irregular or intermittent ; and the
dyspnoea at last becomes distressing and attended
with great anxiety, and sometimes with a peculiar
fluttering about the heart, and sinking or leipo-
thymia, succeeded by palpitations. In the more
advanced stages of the disease the patient can-
not lie down ; his sleep is uneasy, interrupted,
and always unsound ; and the recumbent posture
induces violent palpitations, sense of suffocation,
and anxiety. The oppression at the pnecordia
and weight at the scrobiculus cordis increase,
and are attended with spasms of the muscles
of the thorax and abdomen ; the countenance
becomes livid, and the extremities cold ; vomit-
ing is either frequent or nearly incessant ; the
pulse sinks, and the patient dies nearly in a state
of suffocation.
3. In this, the most common form of the dis-
ease, it usually runs its course in about three weeks
or a month ; but sometimes, in slighter cases, the
patient experiences several relapses, and is at last
carried off unexpectedly, when the anasarcous
symptoms have nearly disappeared, and he has
been judged convalescent. In some of the mild-
er attacks, several of the above symptoms are
extremely slight, and the disease is altogether of
much longer duration, or consists apparently of
several distinct seizures. Such seem to have
been the form of the majority of cases which Mr.
Marshall has given in his work. In the most
sudden and severe attacks, however, the pain,
numbness, stillness, and oedema of the lower ex-
tremities ; the dyspnoea and anxiety, and all the
more urgent symptoms, are, either present from
nearly the commencement, or they rapidly su-
pervene to each other, and the patient dies in a
few hours, or in a day or two. Such cases ap-
pear to be not so frequent as those which are
more mild.
4. Remote Causes. — This disease is nearly
peculiar to India, and is most prevalent in va-
rious parts of Ceylon, on the Malabar coast, and
in that tract of country which extends from Mad-
ras to Ganjam ; being, according to Mr. Hamil-
ton, confined to these parts, and extending no
further inland than forty miles. It is most preva-
lent during the decline of one monsoon and the
setting in of another, when the air is dan.p, cold,
and loaded with vapours, and the vicissitudes of
temperature greatest. Captain Pe rc i v a i. , in his
" History of Ceylon," ascribes it to low diet and
bad water, and partly to the dampness of the cli-
mate. Mr. Ridley, however, states that the
worst cases he had of it at Trinconialee, where it
was remarkably prevalent, occurred dining the
change from wet to dry weather, when a strong
and hot land wind prevailed ; and that its sever-
est prevalence at Pulitoopane was during dry
weather. In the Indian peninsula it seldom ex-
tends further inland than sixty miles ; but in ( ey-
lon, particularly at Kandy, it has prevailed under
very different circumstances, as respects season,
states of atmosphere, and topography. It seems
to have been much more prevalent in particular
districts, where it may be said to be endemic, in
one year than in another ; and to have assumed,
at distant periods, a nearly epidemic form. Dr.
Christie states, that a residence of several
months in the district where it, prevails is necessa-
ry to its production ; and Dr. Rogers never ob-
served it in any person who had not resided six
months or upwards in Ceylon. Dr. Hex per has
met with it also in Indian seamen, particularly
Lascars, alter exposure to a moist and Aariabie at-
mosphere and privations of food.
5. Opinions respecting both the remote and
proximate causes of the disease differ very mate-
rially among those who have had opportunities of
observing it. Mr. Dick found it most prevalent
amongst soldiers who had taken much mercury for
venereal complaints, and«who were addicted to
spirituous liquors. He never met with it in the
officers. Mr. Ridley, on the other hand, states,
BERIBERI — Diagnosis — Treatment.
165
that, in 1804, " both officers and privates fell vic-
tims to it." Dtb. Christie and Rogers view
it as a consequence of deficient and poor diet, im-
pure and moist air, and of prolonged exposure to
marsh exhalations; and consequently as a disease
of debility j — an opinion which is in accordance
with that of Mr. Dick and Mr. Ridley. Mr.
CoLQUHOON found it to prevail notwithstanding
prophylactic measures founded on these views;
and Air. Marshall did not observe it to occur
amongst the troops in Ceylon, when exposed to
the causes to which Drs. Christie and Rogers
impute it; and froqa that circumstance, as well as
from the effects of medicines, thinks it a disease
of increased vascular action; in which opinion
Mr. Hamilton agrees with him.
6. Appearances on dissection. — There is al-
ways a leucophlegmatic appearance of the surface,
with (Edematous effusion to a greater or less ex-
tent in the sub-cutaneous cellular tissue, and pale-
ness of the muscles; sometimes with a watery
obesity and deposition of fat in the abdominal re-
gions. ( Occasionally there is fluid effused between
the membranes of the brain, and in the ventricles;
with vascularity of the encephalon, and slight ap-
pearances of congestion in the spinal canal. Se-
rum is always found effused in the pleural cavity,
and very frequently in the pericardium. The
longs are gorged with dark blood, and their struc-
ture more or less o'dematous. Old cellular adhe-
sions are sometimes found connecting the oppo-
site surfaces of the pleurae. The heart is general-
Iv soft, enlarged, and flabby. The peritoneal sac
often contains much serum; and the liver is al-
ways found engorged with dark blood, is unusual-
ly large, and of a very deep colour. The spleen
i< generally very soft, large, and is, as well as the
large veins, loaded with black blood. Sometimes
inflammatory appearances are observed in the
diaphragm and serous surfaces; but these are on-
ly occasionally and very loosely noticed. (Chris-
tie. Rogers, Marshall, and Hamilton.)
7. JVature of the disease. — It is evident that
the nature of this disease can be inferred only
from what is known of its exciting causes, and the
appearances presented after death. Of the for-
mer we have very imperfect, loose, and conflict-
ing information : of the latter no precise and mi-
nute account. It is difficult to explain the early
occurrence of the paralytic symptoms. The spin-
al cord, brain, and nerves supplying the lower
extremities, have not been sufficiently investigat-
ed to warrant a positive opinion as to the particu-
lar state of these parts, to which these symptoms
may be referred. They may, however, depend
upon congestion of the veins and effusion of fluid
within the spinal canal. The dyspnoea is evi-
dently owing to congestion of the lungs, and
oedema of their structure; and the feeble and ir-
regular action of the heart may be imputed to the
weakened vital energy and structure of the organ,
in connection with effusion of serum in some
cases into the pericardium. The effusion of fluid
within the serous cavities may, like other effu-
sions, depend upon very different states of the
vessels and serous membranes. By Mr. Mar-
shall and Mr. Hamilton it has been viewed
as the result of inflammatory action. But where
there is merely an effusion of a limpid serum,
without either albuminous flocculi or adhesions,
there evidently can exist no actual inflammation.
Viewing the antecedent symptoms in relation to
the post mortem appearances, as far as both have
been described, it may be inferred that the dis-
ease is more dependent upon active congestion
of the lungs, liver, and spinal cord, than upon
any of the usual states of inflammatory action;
and that this congestion is intimately connected
with weakened power of the nervous' and circu-
lating systems; manifested chiefly in the heart
and extreme capillaries of the cellular and serous
structures, with imperfect function of the liver
and lungs, and with effusion of serum to a great-
er or less extent into the shut cavities and cellu-
lar structures of the body; giving rise to a nearly
universal acute dropsy, and complicated with
more or less of paralysis of the lower extremi-
ties.
8. Diagnosis. — The paralytic symptoms,
constant dyspnoea, universal oedema, and leuco-
phlegmatic intumescence of the countenance,
characterise this disease sufficiently, and distin-
guish it from the cachexia Africana, with which
it has been considered as being allied (see Ca-
chexy — African.). It has been, however,
more commonly confounded with barbiers; but
the history of both diseases show a very obvious
difference between them. Barbiers is a very
chronic disease, in which the paralytic symptoms,
tremors, spasms, and contractions of the limbs,
and emaciation, are the most remarkable symp-
toms; whilst the present malady is extremely
acute, often of very short duration, and is charac-
terised by general oedema, dyspnoea, the sudden-
ness of its fatal termination, and the frequency of
its occurrence. The former is, in fact, a species
of paralysis; whilst the latter is a form of acute
dropsy, very generally diffused throughout the
body, and complicated with slight paralytic symp-
toms.
9. Treatment. — According to this view of
the disease, the discordant accounts given of the
success of treatment will be readily accounted
for. When the disease prevailed very generally'
in the carnatic, during 1782 and 17S3,Mr. Dick,
who appears to have treated a very great number
of cases, found most advantage, during the former
of these two seasons, from a pill, containing a
quarter of a grain of extract of elaterium com-
bined with extract of gentian, given every hour,
until copious watery evacuations were procured;
and this plan was repeated every third or fourth
day, till a cure was accomplished. In the fol-
lowing season this treatment was not so success-
ful. 1 le found most advantage from large doses
of spirit of nitre, antimonial wine, frictions with
warm camphorated oil, aperient medicines, and
wine to support the' strength. Bleeding and mer-
cury were tried without benefit. Dr. Christie
recommended mercury, to excite ptyalism, com-
bined with squills; cordial liquors, consisting
chiefly of gin punch; stimulating pediluvia, with
warm liniments; and when the patient was con-
valescent, tonics, composed of. bark, wine, and
porter. In more urgent cases, he prescribed
blisters to the chest, and brandy, aether, and laud-
anum, to relieve the vomiting, dyspnoea, and
spasms. He found digitalis of no service. Mr.
Hamilton's first cases terminated fatally under
the plan recommended by Dr. Christie; and
Mr. COLO.0HOUN trusted to mercury, but found
that many of the patients who died in hospital of
166
BLOOD — Healthy Relations of.
the disease were in a state of salivation from this
medicine.
10. This want of success led later writers on
the disease to have recourse to other means.
Dr. Hunter had tried blood-letting in one case,
without any apparent effect either one way or
another. Dr. Rogers stated, in his thesis on
the disease, that blood-letting hastened the fatal
termination: but, according to Mr. Hamilton, he
has since prescribed it successfully. Mr. Mar-
shai l appears to have been the first to employ
blood-letting in a decided and successful manner
in the treatment of beriberi; and the same prac-
tice was adopted by Dr. Patf.rson (Marshall,
on Ceylon, §-c. p. 161.), and by Mr. Hamilton.
The bleeding was large, and repeated; and fol-
lowed with The internal and external use of mer-
cury, laud mum, and the vapour bath. To these
were added purgatives of calomel and camboge.
1 1. '! he practice of Mr. Ridley, who expe-
rienced, himself, two very severe attacks; and
who, excepting only Mr. Dick, lias had the most
extensive experience as respects this disease,
basing treated almost a hundred cases in one
year ( 814); recommends a nearly similar treat-
ment to that advised by Mr. Dick. In the early
stage, he directs purgatives of calomel, jalap, and
crystals of tartar; the lower extremities to be
well bathed, afterwards rubbed with camphor
and oil of turpentine, or with the mercurial lim-
ine !, and then rolled in flannel bandages. He
subsequently prescribes a pill, composed of one
or two grains of calomel and two or three of
powdered squills, every third hour; and a solu-
tion of crystals of tartar, as common drink, or
made into punch with geneva or arrack. In the
more advanced stages, he advises blisters to the
back of the neck, or to the seat of pain and tight-
ness the warm bath; frequent fomentations of
the legs and abdomen, followed by frictions with
mercurial ointment, camphor, and oil of turpen-
tine; and clysters with a;ther, and purgatives.
When the dyspnoea, spasms, and vomiting are
urgent, he slates, that he has given large doses
of opium, a?ther, and brandy, with stimulating
diuretics. When they could be retained on the
stomach, small and repeated doses of camboge
were also exhibited.
12. From the above statements, as well as
from the varying character of the disease in Euro-
peans and natives, in different seasons, as observ-
ed by Mr. Dick, and in various localities; — judg-
ing also from the nature and combination of the
remote causes, and from the post mortem appear-
ances;— I should infer, that a depletory treat-
ment may sometimes he required amongst Euro-
peans; and that the means of cure should be
modified according to the characters of the mala-
dy and the state of the vital energies; that, on
some occasions, general blood-letting — in others,
cupping in the course of the spine; blisters; free
purging with calomel, camboge, jalap, elateriuin.
&c; antispasmodics, consisting of opium, aethers,
brandy in some cases, camphor, &c. ; diuretics,
such as squills, cream of tartar, juniper, tere-
binthinate prepara'ions, &c; the vapour bath,
or fomentations, followed by fictions with stimu-
lating liniments, mercurial or camphorated lini-
ments, with oil of turpentine, camphorated oils,
along the spine and lower extremities ; expect-
orants, consisting of ammoniacum, ipecacuanha,
camphor, &c; constitute the chief means that
are likely to remove the internal congestions, to
reduce the circulating fluid to a nearer equality
with the vital power, to restrain effusion, and to
restore the various secretions and excretions of
the body. After these means have been judi-
ciously administered according to the peculiarities
of the case, or when circumstances seem to re-
quire it earlier in the treatment, stimulating and
restorative medicines may either be conjoined
with the above, or be exhibited on such occasions
as may require them.
BinLlOG. and REFElt. — Bontius, De Medicina Indo-
rum, kc. — Dick, in Duncan's Edinb. Medical Commenta-
ries, vol. x. p. 207. — W. Hunter, Diseases incident to In-
dian Seamen on Long Voyages. Calc. 1804. — Rogers, Diss.
de Hydrope Asthmaiico. Edin. 1808. — Ridley, Dublin Hos.
Reports, vol. ii. p. 227. — Marshall, Notes on the Medical
Topography and Diseases of Ceylon, p. 161. Svo. Lond.
1822. — Hamilton, in Transac of the Medical and Chir.
Society of Edin. vol. ii. p. 12.— Good, Study of Medi-
cine, vol. iv. p. 493. (The papers of Mr. Dick and Mr.
Ridley are very- able and instiuclive.)
BLOOD. Syn. jflua, Gr. Sanguis, Lat. Sang,
Fr. Das Blut, Geblut, Ger. Sangue, Ital.
Classif. General Pathology — JEtiol-
ogy, Semeiology. — General Ther-
apeutics.
I. States of the Blood in health. — 1.
A. Of the states of the chyle. In order to ac-
quire accurate ideas respecting the blood in dis-
ease, it is necessary to be acquainted with the
varying conditions and appearances of the chyle,
according to the food, from which it is chiefly
elaborated. To these, however, I can only brief-
ly refer. This fluid, when removed from the
thoracic duct, is usually of an opaque while or
opalescent appearance, and separates into a ser-
ous portion, and more or less firm clot. The for-
mer resembles the serum of the blood, the latter
consists chiefly of fibrine. If the animal have
been fed with fat animal food, the chyle at the
time of coagulation assumes a rose colour, and,
in addition to the separation of the clot, which
falls to the bottom of the vessel, a thin liquid oily
layer forms on the surface of the serum. In ani-
mals fed on vegetable food, the chyle is generally
opaline and nearly transparent, and separates in-
to a serous fluid and a small fibrinous clot only.
According to MM. Prevost and Dumas the
chyle contains globules, similar to those contained
in the blood, but of a smaller size. The fibrinous
coasulum seems to be formed from their aggre-
gation. The serum of the chyle also contains al-
bumen, and the saline ingredients found in the
serum of the blood.
2. B. The globules of the blood, particularly in
respect of their relation to the other constituents
of this fluid, and the changes they experience
when removed from the blood-vessels, excite the
utmost interest in the mind of the pathologist. It
is evident that they are suspended in the serum
by means of the vital influence which the blood
derives from the vessels and organs in which it
circulates. According to the microscopic re-
searches of Sir E. Home, Mr. Bauer, and of
MM. Prevost and Dumas, they consist of a
central colourless spheroid; and of a species of
membranous sac of a red colour, surrounding
this spheroid, from whicji it readily separates after
death. The central bodies are transparent and
spherical in the mammalia; and, when deprived of
their coloured envelopes, are generally disposed
BLOOD — Healthy Relations of.
167
to assume ranges or fibrous meshes. The col-
oured portion appears to be a kind of jelly, easily
divisible ; bet insoluble in water, from which it
may be separated by repose. It is likewise
transparent ; but much less so than the central
corpuscle: and the fragments arising from its
division are not susceptible of regular aggrega-
tion.
3. C. State of the blood in the vessels. — Accor-
ding to the observations of Kolk, Tke viranus,
and others, the globules of the blood possess a
rotatory motion during life, independently of the
motion arising from the impulse of the heart; and
this motion continues till coagulation takes place.
.More recently, this subject has been investigated
bv Professor Schui.tz, of Berlin, who has con-
firmed the tact respecting the intestine motion of
the globules, by virtue of which they move on by
themselves, surrounded by envelopes of colour-
ing matter, and keeping at a distance from one
another. This force, with which the globules of
the blood are endowed whilst circulating in the
vessels, I have, in my physiological notes, im-
puted to the influence exerted by the ganglia!
nerves on the interior of the vessels, which they
everv where so abundantly supply, as stated in
the article on the pathology of the Arteries.
But, besides this force of mutual repulsion, to
which the fluidity of the blood is evidently owing,
under the vital influence exerted by the organic
nerves on the vessels, there is evidently another
force also in action, by which the globules are at-
tracted by the tissues, when they are brought more
intimately in contact with them during their cir-
culation in the minute vessels. Whilst, then, the
former force keeps the globules in a state of con-
stant motion and repulsion, and is exerted in the
stream of the circulation, the latter tends to bring
the globules to a state of repose, and is exerted in
the organic structures themselves, at the point of
contact of the solids and the globules. This lat-
ter force, which was first very minutely examined
by Professor Schultz, and briefly stated by M.
Andral, in his Pathological Anatomy, without
acknowledgment, may be compared to a vortex,
whence globules constantly pass from the arterial
or terminal capillaries, and are lost in the diller-
eut tissues. So that, although the vital endow-
ment of the blood is manifested by its fluidity in
the vessels, it assumes an opposite manifestation
in the capillaries, where this fluid is brought within
the sphere of the vitality of the different struc-
tures; each one attracting fro to it those constitu-
ents of which itself is formed, and which are
always present in healthy blood.
4. 'I hus we see organization commencing in
the chyle, advancing further in the blood, and
reaching its acme in the vital attraction of the
constituents of the tissues from the blood circula-
ting in the capillaries which supply them. At
this part of the circle, where the arterial capil-
laries, with the fluid circulating through them,
become, as it were, confounded with the tissues
in which they are distributed, there appears, ac-
cording to Professor Schultz, to be not only a
constant attraction of particles by the tissues from
the blood, but also an equal extrication of other
parti.-!"- from them into the blood received by the
radicles of the veins. Thus it appears, that as
the proximate constituents of the different tissues
exist in the blood, as was first shown by Dr.
Prout, and subsequently insisted on by Majf.s-
D1E and ANDRAL ; and as these become iden-
tified for a time with them, are afterwards de-
tached, and flow back into the current of tin'
circulation ; the intimate connection and mutual
dependence of the blood and the different solids,
both in health and disease, ought not to be oxer-
looked. But it is at the same time manifest that
these constituents are kept in solution during cir-
culation, and attracted during nutrition, by the
vital influence; that the various parts into which
the blood separates on removal from the vessels
arc only indications of its condition when circu-
lating through the frame; that no such separation
occurs in the healthy body, and never, excepting
very partially, in disease ; that this change pro-
ceeds from the loss of vitality sustained by the
blood when removed from the frame, and that the
phenomena connected with it have an intimate
relation to the vital endowment of this fluid, de-
rived from the vessels and the nerves supplying
them.
5. D. Coagulation of the blood. — This process
is modified by numerous circumstances, and by
various diseases. Generally, however, the blood
soon separates into two portions — tile serum, and
the coagulum or clot; and in this separation the
red globules are principally concerned ; it being
cliieffy the result of the loss of the vital motion
which these globules possess in the vessels, and
of the attraction existing between the colouring
envelopes and central bodies. As the vital at-
traction, which keeps the red substance fixed
around the whitish corpuscles, ceases soon after
the removal of the blood from the vein, these
bodies can then obey the force which tends to
unite them, and they then form a net-work, in
whose meshes the liberated red particles are en-
tangled, and thus produce the phenomena of co-
agulation. If the coagulum be exposed to a
stream of water, the colouring matter is washed
away, while the aggregates formed by the colour-
less corpuscles remain in the form of filaments,
in which may be recognised an analogous struct-
ure to muscular fibre, and constitute the fibrine
of the blood.
6. It seems extremely probable, that the col-
ourless globules observed in the chyle form the
central corpuscles, and, when they have acquired
their coloured envelopes in the progress of san-
guifaction, constitute the red globuics. And it
appears equally reasonable to infer, that both the
suspension of the globules in the serum, and the
attraction between their coloured envelopes and
colourless corpuscles, are entirely vital, inasmuch
as both phenomena cease soon after the blood is
removed from its source of vital endowment: and
that vita! manifestations become first apparent in
the chyle, and still more so in the blood; coagu-
lation being the result of the loss of this endow-
ment, and taking place with a celerity in proportion
to the rapidity of its departure. In cases where
the vital energy, or that manifestation of it exert-
ed by the organic nerves on the vascular system,
is unexhausted, or is in a state of healthy excite-
ment, coagulation is perfect and somewhat slow;
but where it is depressed or exhausted, this pro-
cess is quicker, but much less complete. Besides
these, it presents various other phenomena, which
are intimately connected with the nature of mor-
bid actions, and which I shall notice immediately.
163
BLOOD — Excess of — Plethora.
7. E. Chemical relations of the blood in health.
— The analysis of the blood given by M. Le
Cam;, who obtained the prize given by the Aca-
demie Roy ale de Medicine of Paris, is extremely
minute; and, as respects the principal ingredients,
agrees very closely with the results stated by
Berzelius and Marckt. The oily matter first
detected in the blood by Dr. Trail, and subse-
quently found by Drs. Christison and Babing-
ton, has likewise been recognised by him as con-
stantly present in the serum. The results of the
analysis of the serum by Le Canu, Berzelius,
and Marcet, are as follows : —
LeCanu.
Berz.
Mar.
1st Anal.
2d Anal.
905
Water
906-00
901-00
900-00
Albumen -
78-00
81-20
80
86-80
' Animal matter sol.
in water and alco.
1-69
2-05
—
—
Albumen, combined
*•
with soda
Crystallisable fatty
2-10
2-55
—
—
matter
1-20
2-10
—
—
Oilv matter
1-00
1-30
—
—
*
lluco-extractive mat.
—
—
—
4-00
* Extractive mat. sol. in
alcoh. and acetate of
soda
—
—
4
—
Hvdrochlorate of soda
and potash -
6-00
5-32
6
6-GO
Suh-carb. and phosph.
of soda and sulph.
potassa? -
2-10
2-00
3
2-00
Phosph. of lime, macn.,
and iron, with sub-
cai b. of lime, and mag.
0-91
0-B7
—
0-60
Loss
1-00
1-61
1
—
1000-00
10)0-00
1000.1000-00
8. The blood, according to M. Le Canu, con-
sists of the following constituents : —
Water .... 780-145 786-590
Fibrine - - 2-100 3-565
Alhumen - 65-090 69-415
Colouring matter - - - 133000 119-626
Crvstallisable fattv matter - - 2-430 4-300
Oify matter - 1-310 2-270
Extractive mat. soluble in alcohol and
water - - - - 1-790 1-920
Albumen combined with soda - 1-265 2"0l0
Chloruret of sodium and potassium, alka-
line phosphate, sulphate, and subcar-
bonates .... 8-370 7-304
Subcarbonate of lime and maenesia,
phosphates of lime, maenesia, and iron,
peroxide of iron ... 2-100 1-414
Loss - - 2-400 2-586
1000-000 1000-000
According to some chemists the blood also con-
tains carbonic acid (Vog el and others) ; a yellow
colouring matter, resembling that of the bile and
the urine (Chevreul, Lassaigne, &c.) ; and
a substance analogous to urea (Prevost, Du-
mas, Vauquelin, and Segalas). Vauque-
mn and Chevreul consider the fatty matter to
be similar to that of the brain and nerves.
9. a. The quantity of water in the blood of a
healthy person varies, according to M. Le Canu,
in 1000 parts, from 853-135, the maximum, to
778-625, the minimum. He found the medium
quantity in males to be 791-944, and of females
821-764. The quantity also appears to vary
with the temperament; as the lymphatic temper-
ament in the male furnished 830-566, of the fe-
male 803-716 ; and the sanguineous in the male
786-584, in the female 793-007.
* Probably the same constituents, differently named, and
more minutely examined, by AI. Le Canu.
10. b. The albumen contained in 1000 parts
of blood varies from 78-270, the maximum, to
57-890, the minimum. It is nearly the same in
the male as in the female, being only about one
part more in the former. The difference in the
quantity appears to have no relation to the tem-
perament, nor to the age of the subject, from
twenty to sixty years.
11. c. The quantity of fibrine contained in the
coagulum varies extremely. According to Ber-
zelius it is only -75 for 1000 of the blood. M.
Lassaigne states, that the fibrine of the blood of
a young vigorous man is only ^—^ of its weight.
In the researches of M. Le Canu, who has in-
vestigated the subject more closely than his pre-
decessors, the quantity of dry fibrine contained in
1000 parts of blood varies from 1-360 to 7-236 —
the medium of twenty-two experiments being
4-298. It appeared to be greatest in the young
or middle-aged of the sanguine temperament,
and in the inflammatory state ; and least in the
lymphatic constitution, the aged, and those suffer-
ing under congestion or haemorrhage.
12. d. The proportion of globules varies much
more remarkably in the blood of a healthy per-
son, than that of the albumen ; the maximum
being 148-450, the minimum 68-349., and the
medium 108-399, in 1000 parts of blood. The
medium quantity in males was 132-150, and in
females 99-169. The periods of life intervening
between twenty and sixty years had no influence
on its quantity; but it was found to vary with the
temperament. The medium quantity in the lym-
phatic temperament was 117-300 among females,
and 116-667 among males; and in the sanguine-
ous temperament, 126-174 in females, and 136--
497 in males; giving 19-830 more globules to the
sanguine temperament in 1000 parts of blood. M.
Le Canu found the globules of blood greatly di-
minished in females subject to a copious flow of
the menses. The quantity of globules is also, rel-
atively to the other constituents of the blood, great-
ly diminished by blood-letting, whilst the albumen
is not sensibly affected. Thus, a first bleeding
furnished in 1000 parts of blood 792-897 of water,
70-210 of albumen, 9-163 soluble salts and animal
extractive matters, and 127-73 of globules; but a
third bleeding a few days afterwards in the same
patient (a female), gave 834-053 of water, 71-111
of albumen, 7-329 of soluble salts and extractive
matters, and 87-510 of globules.
Bibliog. and ItEFER. — Marcet, in Transact, of Medico-
Chir. Society of Lond. vol. ii. p. 365. — Berzelius and Mar-
cet, in Ibid. vol. iii. pp. 199.231. — Prout, Inquiry into the
Origin and Properties of the Blood, in the Annals of
Med. and Sins. vol. i. pp. 10. 133. et 277. — Home and
Bauer, Phi los. "Trans, for 1820.— Home, in Ibid, for 1826,
p. 189. — Prevost et Dumas, Mtmoires de la Soc. de
Physiq. et d'Hist. Nat. de Geneve, t. i , et Bibliolheque
Univeis. Juillet, 1821. — Author, Appendix to At Riche-
raruPs Elements of Phvsiol. 2d edit p. 637. — Scudamore^
Essav on the Blood, kc. 8vo. Lond. 1824 — Schult:, Ki-
vue Medicale, t. i. 1825, p. 136 , et Journ. de Pro;, des.
Sc. Med. t. v. — Bostock, in Edin. Med. and Surg. Journ.
vol. \x\i. p. 114. — Adelon, Physiol, de l'Homme, t. iii.
p. 110, et seq. — Le Canu, Nouvelles Recherches sur le
Sane, in Journ. de Pharmacie, Sept. et Oct. 1831.
II. Exuberance of Blood, Plethora
(rrXifidinr, repletion). Syn. Polyecmia (Aoct
Var.). Hyperamia, plethore, Fr. Die Voll-
bliitigheit, Germ. Pletora, Ital. Excessive
Fulness of Blood. »
Classif. Pathology — ^Etiology. IV.
Class, II. Order (Author, see Classif.
in Preface).
BLOOD — Excess of — Plethora.
169
13. Df.fi v. Greater fiilness of the vascular
system than it compatible with the continuance of
health: or repletion of this st/stem.
14. The importance of attending to the varying
states of the circulating system, in respect of both
exuberance and deficiency of the fluid contained
in it, has been acknowledged since the time of
Galen. After the doctrine of nervous influence
had superseded the humoral pathology, the state
of the blood in disease experienced a more gen-
eral neglect, than the part actually performed by
tliis fluid in the causation and perpetuation of
morbid actions ought to have procured for it. Yet
have there always been a succession of able ob-
servers and writers, who have never lost sight of
the influence of the quantity as well as quality
of the blood in producing, as well as in modifying,
disease; and more recently the subject has de-
servedly received an increased and an increasing
attention. Plethora is the opposite of anaimia :
both may be, to a certain extent, compatible with
health; but both predispose more or less to dis-
order, and. beyond certain limits, constitute distinct
and opposite states of disease.
15. A. General plethora. — Galen, Bafllou;
Fern el, Riviere, and others, considered ple-
thora to be of two kinds; to which subsequent
writers added two more. As these distinctions
are still, in several respects, founded in truth.
notwithstanding the neglect into which they had
long fallen, I will here briefly notice them. 1st,
True or absolute plethora — plethora act vasa; 2d,
Apparent or false plethora — plethora ad volumen;
3d, Plethora relative to space — plethora ad spa-
tium; 4th, Plethora in relation to vital power — ■
plethora ad vires. It will be observed that the
first and second of these, the species recognised
by the earliest writers, are still upon the whole
the most important. In the first, the blood is
permanently increased beyond the wants of the
system. La the second, plethora is merely a pass-
ing occurrence, arising from temporary causes, as
the general turgescence occasioned by sudden or
high ranges of temperature, &c. In the third, the
blood may not be increased, but its relative quan-
tity may be too great, as is observed after ampu-
tations of one or two limbs. In the fourth, the
quantity may not be too great, if this fluid were
actuated by a health] state of the vital energy:
but it may be excessive in respect of the influence
by which it is circulated in all parts of the body.
Now. those distinctions are actually founded in
nature; and although they may all be resolved into
one pathological proposition, viz. greater repletion
of the vascular system than the wants and condi-
tions of the economy require, still they must have
become matters of experience to every one whose
range of observation has been such as entitle his
opinions to respect. I shall merely remark upon
such of them as admit of dispute.
Hi. False plethora is very generally observed
to occur in persons suddenly exposed to elevations
of temperature, and depends more upon the effect
of heat in exciting the vita] turgescence of the
capillary vessels, whereby a craving for fluid is
created, and a larger quantity is absorbed, than
upon the expansion of the fluids themselves,
owing to the increase of temperature. A state of
false plethora is very frequently occasioned, — and
is often productive of more serious consequences
than have generally been imputed to it, — by in-
* 15
gurgitation and increased temperature conjoined;
and it should not be overlooked, that these com-
bined influences not infrequently affect those who
are already permanently plethoric. This will be
more forcibly and truly shown by what must
have fallen under the observation of many. A
red faced, full veined, and robust looking person,
ol' from forty to sixty, sits down to dinner with a
good appetite. He eats three times as much as
his body requires, and he excites the stomach to
digest it by drinking stimulating fluids to six times
the quantity that is necessary. All this, moreover,
is dene in a close and overheated apartment. The
vital turgescence and expansibility of the capil-
laries and veins are excited to the utmost; the
whole surface is full and plump, and the extremi-
ties even swollen. Now, a person thus circum-
stanced, particularly from four to eight or more
hours after such ingurgitation, actually has the
quantity of his circulating fluids increased from
one sixth to one third, at a moderate calculation :
but the increase is generally soon diminished by
the pulmonary exhalation; the urinary, the per-
spiratory, and intestinal secretions; which are all
greatly augmented, and are thus the safety valves
of the circulation. But how often, notwithstand-
ing, do we observe the vessels at last yield before
the mass which distends or overloads them, and
apoplexy, and various other haemorrhages and
congestions, result; particularly when any one of
these safety valves are obstructed or tardy in their
action — when the nervous or vital influence is
either depressed or much exhausted by the previ-
ous excitement, and the vessels are irritated, or
their actions otherwise changed by the state of
their contents.
17. That plethora is a not infrequent result of
amputations cannot be disputed, although the
privation of sufficient exercise, which is thereby
occasioned, will partly account for the occurrence;
at the same time we generally observe that the
same quantity of food is taken, and the same
quantity of blood is prepared for the body, when
deprived of one fourth part of the structures re-
quiring support, as was provided for its nourish-
ment when it was in a state of integrity.
18. That plethora may exist in conjunction
with deficient vital or nervous power, aiid that,
although the quantity of blood in the system may
not exceed that of health, and yet be too great for
this power to control, cannot be doubted. We
are constantly observing such pathological condi-
tions, both at the commencement and in the pro-
gress of disease ; and frequently remark their
influence in its advanced states and terminations.
(See article Congestio.n.)
19. The causes of plethora are so manifest as
scarcely to require enumeration. They may op-
erate either singly or in conjunction. They con-
sist, 1st, Of the introduction into the vascular
Bystem of a greater quantity of the nutritious
elements than is necessary to the support of the
organization; and, 2d, Of the retention in the
blood of those parts which are usually removed
by the secreting and excreting organs, it must
be evident that the former is owing to excess of
nourishment and stimulating fluids ; whilst the
latter proceeds most commonly from insufficient
exercise, suppressed natural secretions and ex-
cretions, or accustomed morbid discharges. How
remarkably the habits, indulgences, luxuries, and
170
BLOOD — Excess of — Plethora.
refinement of modern life contribute to these, is
sufficiently apparent. At the same time it should
not be overlooked that there are certain consti-
tutions, and particularly those of a lax fibre,
more disposed to plethora than others, even in-
dependently of temperament; that this disposition
is often hereditary; and that it is frequently so
strong, notwithstanding precautions to overcome
it, as to constitute a distinct diathesis. Plethora,
particularly in conjunction with a rich state of
the blood, is generally most remarkable in those
who live higlily, drink much, and are very often
out in the open air, without taking active exercise.
20. There are also certain epochs of life at
which it is most apt to occur, particularly when
the energies of life are beginning to wane, and
when the balance between sanguifaction and se-
cretion preponderates in favour of the former.
(See article Age.) Plethora is also more frequent
in females than in males, owing to their more
sedentary occupations, and to the wants of the
female economy , particularly during the period of
utero-gestation, and subsequently to the cessation
of the menses. It is justly remarked by various
writers, that the plethora of early life is generally
arterial and capillary; that of advanced age alto-
gether venous.
21. Plethora has been too generally considered
as always existing in fat persons, and as occurring
at least in them most commonly. But obesity is
no sure criterion of plethora; it may even co-
exist with a deficiency of blood. I have known
the supposition, that obesity indicated at least a
sufficiency of this fluid, lead to dangerous results.
Indeed, the opinion entertained by several of the
older writers, that fat persons do not bear deple-
tion, is quite as well founded as its opposite. There
are other circumstances besides this which must
be taken into consideration, when we estimate
either the simple existence of plethora or its ex-
tent. This state of the vascular system is some-
times associated with leanness; but when this is
the case, the pulse is also full and strong, and the
veins very large, full, and rapidly filled upon being
emptied by friction. It is more generally observed
in persons passing middle age, who, with a ruddy,
flesh-like, or lively surface, are beginning to as-
sume greater fulness of the frame without loss of
firmness; and in whom the pulse is full and the
veins well marked.
22. Symptoms. — Plethora, in its slightest
grades, is generally productive of little incon-
venience. There are usually observed merely a
greater disposition to sleep than in health; less
quickness and aptitude to mental or corporeal ex-
ertion; and a more marked disposition to suffer
from and to be affected by the more energetic
causes of disease. In an advanced degree it occa-
sions lassitude, indolence, vertigo, or weight or
pain of the head; heavy, snoring, dreamy, and
often unrefreshing sleep; turgescence of the coun-
tenance, suffusion of the eyes; fulness of the veins,
and of the pulse; occasionally palpitations of the
heart, and slight amaurosis. Such are the usual
signs of plethora, short of actual disease, at least
of such as may alarm the patient. When it pro-
ceeds further, it assumes either the features of
inflammatory fever, with excess of action in some
organ or part, or passes into general visceral con-
gestion, according to the states of vital action and
power. It may moreover occasion, or terminate
in, hemorrhage, visceral inflammations, conges-
tions, and obstructions, activ% dropsy, morbidly
increased secretions, convulsions, spasmodic dis-
eases, morbid states of the vessels, &c.
23. B. Local plethora. — The vessels of an
organ or part may be loaded with blood, and yet
the state of their vital action may be neither
generally or locally exalted to the pitch of active
determination, nor reduced so low as that of pas-
sive congestion. There are, perhaps, few such
cases that are entirely independent of some degree
of excitement, arising either from the condition of
the nerves of the organ, or from an irritating cause
of some description influencing the state of the
capillaries. The best exemplifications of this
state are the plethoric states of the ovaria and
uterus previous to the menstrual discharge ; of the
generative organs during the venereal orgasm;
of secreting glands and parts when their func-
tions are unusually active; of the brain during the
exciting passions and emotions (see Local deter-
minations of Blood), and various internal viscera,
particularly the spleen, during the cold stage of
an ague, &c. These last, however, more nearly
approach to congestion than to simple local ple-
thora. It should not be overlooked, that what-
ever excites the nerves and irritates the tissues of
a part, will occasion turgescence of the capillaries,
increased flux of blood through the arteries sup-
plying them, and a quicker return of this fluid
through the veins. If the part thus excited perform
secreting functions, these will be augmented ;
and thus increased flux and local plethora will
both exist, and constitute local determination of
blood, — a state which will be considered here-
after. But still this is not inflammation; for as
soon as the cause of excitement ceases, this
state disappears, without terminating in any of the
ways in which inflammatory action terminates,
and without having assumed any part of the for-
mative process which in some state or other fol-
lows upon inflammation occurring in a previously
sound frame. It cannot, however, be denied,
that although local plethora does not constitute
either inflammation or passive congestion, it will
often favour the production, not only of these,
but also of hcemonhages, convulsions, &c, accord-
ing to its seat and extent, the state of vital power,
the nature of the exciting causes, and other con-
tingent circumstances. It is evident that local
plethora may occur either with or without general
plethora. It may even coexist with insufficiency
of blood (§ 34.).
24. C. The treatment of general and local
plethora consists almost entirely of avoiding its
causes. Simple plethora does not require, and is
seldom permanently benefited by, vascular de-
pletion alone; indeed, it is more generally in-
creased after a time by this practice, unless more
efficient measures be also employed. Abstinence,
and a free state of the secretions and excretions;
active and regular exercise; abridging the period
of repose; early rising; a moderate use of diluents,
and abstaining entirely from malt and spirituous
liquors; cooling and acidulous beverages, when
thirst requires to be quenched; are the chief
means both of prevention and cure.
Biblioo. and Refer. — Sa/cn, Pe Plenitiuiine, ritte
Opera. Fischer. He Plethora Mult. Horb. Cause. Erf. 112S.
— Hoffmann, Be Plethora insufficiente Morborum Causa,
Opp. sup. ii. pp. 1. 506. — Stahl, Theoria Medica Vera,
BLOOD — Determinations of.
171
Juncker'i ed. Hale, 1737. pp. 303. 483, kc; et De Plethora.
Erf. 1 736. — Junefter, Conspectus Medicine. Halle, 1724,
p. 7. et sea. — Xicolui, De Singular, quibusd. ad I'oly-
.vnii.mi Spectantibus. Jernr, 1790. — Rudolsteller, De
Rlmli. ex Al<und;in(i:i Nanciiinis oriumlis. Helms. 1777.
— Il> itk-anl, Vctiiiisehle S, In il'lcn, I), iii. p. 89. — Gregory,
Conspect. Med. Theoret. ed. vi p 152 — Horn, Beitr&ge
tedic. Klinik. vol. ii. p. 88. — Cn/emard Lafayette,
Kssai sur la Plethora ou Polyemie, 4(o. P;iri>, 1809.—
J'aidtj, Diet, des Sciences Med. t. xliii. p. 178 — Parry,
Element! of Pathology, 2d ed. p. 30. ap. — Roc/wux, Diet.
de Ked. t. ivii. p. 123.
III. Local Determination of Blood.
Syn. Afflux of Blood; increased Momentum
of Blood. Fluxion, l\:
Classif. Pathology. Therapeutics —
(Derivation, Revulsion).
25. The determination of a larger proportion
of the circulating fluid to an organ or part, than
is usually sent io it in health, not infrequently
(.ikes place independently of inflammation. This
state of tlie local circulation has been, singularly
enough, doubted by some writers, and too much
insisted on by others, more particularly by Dr.
Parry, who assigned to it a greater importance
in pathology than it is entitled to, and overlooked
the fact that it is a part only or link in the chain
of morbid causation.
26. i. Pathological Doctrine. — Determin-
ation of blood is intermediate between inflamma-
tion and local plethora. Inflammation is an ac-
tively morbid state of the capillaries; congestion
a passive condition of both them and the veins;
whilst determination is a simply active or excited,
but not otherwise diseased, stats of both the arte-
rial branches and the capillaries, the veins being
unaffected, and readily returning the blood con-
veyed bv the arteries, .More or less determination
of this Said accompanies acute and sub-acute in-
flammations, and hemorrhages; but it never at-
tends congestion, unless this state pass into either
of the former diseases, or be followed by aug-
mented secretion from the congested organ. Local
Plethora (§ 23.) is a lower grade of local deter-
mination, or rather an intermediate state of the
vascular system between determination of blood
and congestion. In other words, (a), Congestion
of blood is repletion of the veins, attended by
depressed vital power — (b) Local plethora, in-
creased fulness of the vessels generally, with in-
tegrity of vital power — (c) Local determination,
augmented circulation and vital functions of the
vessels — and (d) Inflammation, an actively morbid
state of the vessels, and organic nerves supplying
them, tending to change of structure and to disor-
ganization. As these pathological states are often
referred to, and are sometimes improperly con-
founded, it is therefore necessary to attend to the
distinctions now drawn.
27. That determinations of blood actually oc-
cur, and may even be excited at pleasure for a
short time, are matters of daily observation even
in health; and that such changes in the circula-
tion of a part are occasioned by the influence of
the nerves, particularly of the organic nerves sup-
plying the vessels, seems an equally well esta-
blished fact When these nerves are excited,
whether by heat, stimuli, friction, or irritating
bodies, the capillaries experience a degree of ex-
pansion,— a property with which they are na-
turally, or rather vitally endowed. The erythism,
expansibility, or slight erectility, which is evinced
by the capillaries of certain organs in a very re-
markable manner, exists more or less throughout
the frame, especially in mucous or cellular parts.
When, therefore, this property is influenced bv
any agent possessed of the power, the diameter
of the capillaries running between the arteries and
commencement of the veins being increased, an
enlarged stream of blood will necessarily pass
through them, and a correspondent demand will
be made upon the arteries supplying them, owing
to the less resistance opposed to the current, and
freer circulation in the part thus circumstanced,
provided that the return of blood by the veins
be not impeded. If the circulation be thus in-
creased as respects the volume of blood passing
through the vessels, and continue thus facilitated,
the demand thereby made upon the larger vessels
and the heart will ultimately tend also to acce-
lerate it; and hence will result augmented volume
and quickened circulation — the states constituting
determinations of blood.
28. The circulation of an organ or part may
long remain in this state, particularly if its vital
manifestations do not become exhausted, and if
its nervous power continue excited by the agent
or cause which first occasioned this condition, or
by other influences operating in a similar manner.
But if the vital or nervous power become depressed,
or otherwise changed, either congestion, or some
form of inflammation, will generally ensue, or
even haemorrhage may take place, — a result
which is not infrequent when the determination
takes place to membranous viscera or parts, and
to mucous surfaces. These being, therefore, not
unusual terminations of simple determination of
blood, means should generally be employed to
remedy this state. The agent or cause exciting
the vessels should be removed, and other measures
directed that may equalise the circulation and di-
minish its fulness, when the determination is con-
nected with plethora, as it iyt infrequently is.
29. Determinations of blood to an organ are
very frequently occasioned by whatever rouses its
natural actions. If the part thus excited perform
secreting functions, the increased secretion, in
addition to whatever excitement of the vessels
may be produced, will of itself determine a greater
flow of blood to it. Numerous proofs of this are
furnished us by the progress of various diseases,
and the appearances presented by others after
death; and, endeavouring to follow nature, we
attempt to remove determination or inflammations
in vital organs, by inducing artificially an afflux
of blood to parts and surfaces where it cannot be
injurious, as to the skin, mucous digestive surface,
extremities, &c, with the view of assisting other
agents in soliciting or recalling it from the seat
of disease. The exercise, also, of organs which
possess not secreting functions, will likewise fa-
vour an augmented flow of blood to them. Thus,
exertion of the mental faculties and the passions
determine an afflux of blood to the brain; and of
the muscular organs, to the spinal cord, muscles,
and heart. It is of importance to be aware that
the irregular distribution of the blood, whether
of this or of other kinds, may take place either
when this fluid is more abundant and richer than
natural, or when it is deficient as well as poor;
and that the change from the healthy state of the
circulation is to be imputed primarily to the state
of influence exerted by the organic class of nerves
distributed to the vessels, which, thus influenced,
17 2
BLOOD — Deficiency of — Anemia.
control the volume of the blood circulating through
them (§ 27.), as well as modify its states and the
rapidity of its circulation. The particular deter-
minations of blood are noticed in their respective
articles.
BirtLlOQ AND REFER. — Stnhl, De Commotionibus San-
guinis Activia el Passivis. Hals, 1698. ; et De Motu San-
i-uih'- el pendentibua Vitiis, &.C IIala>, 1709. — Fischer, De
Jftotu Sang. Naturali, Non-naturali, et Mixto. Erf. 1720.
— Barthez, Mtmoire sur les Fluxions, qui sont les Ele-
mens essentiels dans divers Genres des Maladies, in i\I -
moires de la Socitte Med. d'Emulation, t. ii. p 1. — Parry,
Elements of Pathology and Therapeutics, 2d ed. Lond.
1 B25. — Author, in Lond. Med. Repos. vol. xxiii. p. 409. —
Barry, Exp. Researches on the Blood. 8vo. Lond. 1826.
30. ii. Therapeutical Doctrine. — De-
rivation — Revulsion. The doctrine of deter-
mination of blood sufficiently indicates the pro-
priety of having recourse to means in the cure of
various diseases, calculated to solicit a flow of
blood to parts where this may he done safely,
and thus to diminish the quantity sent to the seat
of disease. This mode of practice was well
understood, and very generally employed by the
older physicians, upon the well-known pathologi-
cal principle that " ubi irritatig, ibi jluxus." It
must not, however, be overlooked that irritation
will not always procure afflux of blood; and that
it is therefore not altogether identical with deriva-
tion, either in a pathological or a therapeutical
point of view. It does not come within my limits
to point out the difference; but they are so far
alike, that, in order to produce the latter, we fre-
quently have recourse to the former. At the same
time we must recollect that irritation will some-
times be of service even independently of any
afflux of blood that may accompany it, or even
although it should fail of producing this effect.
31. It is almost unnecessary to enumerate the
means, which we occasionally have recourse to
in order to occasion a local determination of
blood, and thus derive it from the seat of disease.
These consist of numerous agents: — a, Such as
increase the circulation in the rete mucosum, as
rubefacients, sinapisms, external heat, &c. : b,
Those which, in addition to augmented circula-
tion, procure a discharge from the surface or part
to which they are applied, as scalding water,
blisters, irritating ointment, &c, purgatives and
cathartics, &.C.: c. Those which, by procuring a
flow of the natural secretions, solicit an afflux of
blood to the secreting organs, as certain purg-
atives, diuretics, and diaphoretics : d. Those
which evacuate the viscera, increase the dis-
charges from their mucous surface, and augment
the secretions in adjoining organs, as emetics,
cholagogue purgatives: e. Those which influence
the circulation in the limbs and extremities, as
frictions, the semicupium, various forms of pedi-
luvia and manuluvia; (distraction of blood from
the feet or hands, by venesection, leeches, or
cupping; stimulating or scalding pediluvia, &c:
and, /. Those which permanently irritate and
procure a continued discharge, as deep scarifi-
cations, incisions, setons, issues; caustic applica-
tions, as the alkalies, the inner bark of mezereon,
moxas, &c.
32. All these occasion, in the first place, irri-
tation in the part to which they are applied, and,
consequent to this, an afflux of the circulating
fluid. Some of them produce the primary, more
remarkably than the secondary effect; and when
this is the case, the pain which is felt is often an
index of the extent of the former. 1 his is the case
with blisters, rubefacient epithems, sinapisms, and
scalding applications; and therefore much advan-
tage is obtained from them in various diseases,
independently of their secondary operation, par-
ticularly when we wish to rouse the torpid or
oppressed functions of an adjoining or subjacent
organ. When derivation is, however, our princi-
pal object, they cannot alwavs be depended upon,
particularly in irritable habits, and in the early-
stages of acute diseases. They ought never to
be employed in the stage of excitement in fever,
unless this stage be irregular, imperfectly de-
veloped, or inefficient; nor in inflammations, until
acute action is subdued by depletions, evacuations,
and other means, — when only artificial derivation
can be expected to have any influence in dimin-
ishing the remaining disorder, and lessening the
risk of effusion. This caution is especially de-
serving of attention in respect of blisters, — the
cantharides of which, particularly if improperly
allowed to remain too long on a place as they
often are in diseases of excitement, being often
absorbed into the circulation, thereby increasing
the general as well as local vascular action.
These applications, also, ought not to be directed
to the vicinity of parts suffering from vascular
excitement. I have often seen mischief produced
by blisters having been directed to the head and
throat in acute diseases of the subjacent parts.
33. The means usually employed in order to
derive the flux of blood from diseased parts are
variously combined, and much discrimination is
requisite both in the choice and in the combination
of them, appropriately to the state and nature of
tlie diseased action at the time. The scope and
limits of this work preclude my entering upon this
important branch of the subject ; but it has received
attention when discussing the treatment of those
diseases in which the various means of derivation
are required : and the appropriation of those
means to the different states of vascular action is
there attempted with some degree of precision.
Bibi.iog and Refer. — Duvias, Nova Constitutio Artis
Revellendi et Derivandi per Vena"sectionem, 4to Tig. 1557.
— Sennert, De Revulsione et Derivatione, 4to. V'it. it'01 —
Bohn,T>e Revulsione Cruenta, 4to. Leip. 1704 — Fi/dar,
De Revulsione. Lugd. Bat. 1731. — Sexier, De Deiivatione
per Ven;esectionem. Goet. 1749 — Bolten, De Revulsione
Gcneratim. 4to. Ilal.e, 1750 — Mrazer, De Lege Revul-
sionis Viiiuni Systematis Nervosi. Prag«e, 1784. — G
Derivationis et Revulsionis Ilistor. el Praesid. 4to. Jena',
1787. — J. H. F. Autenrieth, Ohservationes Veritatem
fflethodi Revulsoriae Spectantes, 8vo. Tubinga?, 1802. —
(Recommend* the tart, antimonial ointment, tile first employ-
ment of which has been incorrectly attributed to Dr. Jen-
NER. It was first recommended by the late Dr. MONRO,
in his Lectures on Morbid Anatomy. I attended these
lectures, and employed it long before the publication of Dr.
Jenner's letter on the subject. See cases adduced by me
illustrative of its e 1 effects, in London Med. Repos. vol.
xvii. p. S10.) — Pinel et Bricheteau, in Diet. Sciences
Medicales, t. xlviii. p. 384. — Jrnner, Letter to C. H. Parry,
on the Influence of Artificial Eruptions in certain Diseases,
&.c. 4to. Loud. 1822.
IV. Deficiency of Blood. Svn. Anatnia
(from the privative a. and aunt, blood).
Bloodlessness. Anemie, Fr. Der Blut-
mangel, Ger. Dyspepsia AruBmia (Young).
Marasmus Anhamia (Good).
Classif. 3. Class, Diseases of the San-
guineous Functions* 4. Order, Cachexies
(Good). I. Class, V. Order (Atithor).
34. Defin. A deficiency of blood in the ichole
BLOOD — Deficiency of — An a: mi a.
173
body or in some important organ, not proceeding
from natural or artificial h/cmorrhage, giving
rise to a waxy, bloodless state of the countenance
and surface, emaciation, feeble quick pulse, and
great languor and debility,
:>."). Defect of blood, bloodlessness, or anccmia,
although not of frequent occurrence, is yet occa-
sionally met with, particularly in its less remark-
able, or local forms. In connection with chlorosis
it is oftener observed. Cases of anosmia have
been recorded by Reiselius, Swhenke, and
others ; and the disease fully described by Beck-
er, Albert, Janson, Hoe fmann, De Haen,
ISENFLAMM, LlEUTAUD, HALLE, AnDRAL,
and several pathologists and practical writers of
the present day. I shall first offer a few general
observations on local anaemia ; and afterwards
describe more fully general anaemia and its com-
plications. The deficiency of blood, occasioned
by natural or artificial losses of it, is considered
under a distinct head.
36. i. Pathology of Anaemia. — 1st, Local
anamia. Deficiency of blood in an organ or part
is evidently the result of one or more of the fol-
lowing pre-existing lesions : — a, Of diminished
influence of that portion of the ganglial or organic
class of nerves which supplies the blood-vessels
of the organ ; b, Of defective vital expansion of
its capillaries, probably owing to the depressed
state of the influence exerted on the vessels by
the nerves supplying them ; c, Of mechanical
impediments in the way of a sufficient supply of
Mood ; d. Of imperfect developement, or dimin-
ished calibre of the arteries by which blood is
conveyed to the organ ; e, Of disease of the or-
gan or part, or an imperfect exercise of its func-
tions ; and, f. Of unusual flux of blood to other
quarters, causing a proportionate diminution of
it in others. It is evident that these states are
merely local, and are capable of co-existing with
other changes affecting the whole mass of the
circulating fluid, as respects both its quantity and
its quality ; and that various disorders of func-
tion, according to the particular state on which
the anaemia depends, and the extent to which it
may exist, will be the consequence.
37. The organs most subject to this condition
of their circulation are, according to M. Andral,
the lungs, the brain, the liver, the substance of
the heart, the stomach and alimentary canal,
and some of the voluntary muscles. To these I
would add, the spleen, the ovaria, and the gene-
rative organs of the male. In many of these, as
in other parts, atrophy is associated with the
anaemia ; and may be considered, in the majority
of cases, as the consequence of it. The symptoms
of local anaemia are not always manifested during
life ; but they frequently are, as I shall have oc-
casion to point out, when considering the morbid
conditions of those organs most subject to this
change. Thus, in the completest of all the states
of local anaemia, as when the obliteration of an
artery cuts oil* all supply of blood to the organ,
gangrene will result ; frequently, when anaemia
is seated on the brain, a form of convulsion is
the consequence, with other symptoms stated in
the article on this subject (see Brain — Ancemia
of); and when the ovaria, at the period of pu-
berty, is not supplied with the requisite quantity
of blood, owing to deficient influence of the gan-
glial nerves distributed to the organs of genera-
15*
tion, chlorosis, sometimes with more or less of
general anaemia, is the constant effect.
38. 2d. General ancemia. — The blood circu-
lating through the body may be most remarkably
deficient, in respect both of its quantity, and of
the relative proportion of red particles. In many
cases in which the absolute quantity of blood in
the body is diminished, the globules are still more
remarkably deficient, they being insufficient to
give the blood its usual deep colour. General
anaemia presents itself in practice, 1st, as a pri-
mary disease; 2d, as a consequence of pre-exist-
ing lesions of some one of those organs which are
concerned in conveying the nutritious fluids into
the blood, or in the processes of sanguifaction ;
3d, associated with other diseases, resulting
equally with it from some antecedent affection,
the nature of which cannot, perhaps, be readily
recognised.
39. A. The primary forms of anaemia, when
closely analysed, seem to proceed, 1st, from
deficient nourishment ; 2d, from deficient vital
power, — from a torpid or depressed state of the
influence of the organic class of nerves on the
digestive, assimilating, sanguifying, and circulat-
ing organs which they supply. — a. The influence
of deficient supply of nourishment in producing
anaemia may be readily imagined, and instances
showing it are numerous ; I will merely allude to
one: — M. Gasparo, whose researches have
tended much to advance the state of the patholo-
gy of the fluids, has illustrated this part of the
subject by obserying the remarkable degree of
anaemia which existed in a large proportion of
the inhabitants of a district devastated by famine,
who lived upon grass. A more common and less
expected form of general anaemia is that which
arises from the injudicious restriction of diet and
regimen, during convalescence from acute dis-
eases, particularly those which have required
large depletions. Several instances of this state
of disease have come before me, and would, Iain
confident, have terminated in dropsical effusions
(§ 44.) or in death, if a different system had not
been adopted.
40. b. A torpid state of the organic class of
nerves, in one of the most influential, if not the
most frequent, antecedent affections to which we
can impute this state of the circulating fluid. It
is extremely probable that those instances of its
occurrence from being shut out from the sun's
influence, and the constant respiration of an un-
wholesome air, arise from the continued priva-
tion of salutary stimuli to this important class of
nerves, upon which the sanguifying processes
depend.
41. The influence of the sun's rays in promot-
ing all the vital actions, particularly those of or-
ganic life, probably from modifying the electro-
motive state of the frame, must be evident to all.
The good effects of light and air are shown in the
vegetable kingdom, the circulating fluids of which
cannot be duly formed without exposure to both.
Tin: sun's rays diffuse a genial influence through
the frames of the aged, and excite the organic and
generative functions of the young. It has been
observed that those persons who are entirely ex-
cluded from the light of the sun, and breathe the
close air of mines, are particularly subject to
general anaemia. M. Chomel has given a very
interesting account of the disease winch affected
174
BLOOD — Deficiency of — Anemia.
the workmen employed in a coal mine at Auzain.
It commenced with colicky pains, meteorismus,
blackish green stools, dyspnoea, palpitations, great
prostration of strength, followed, in ten or twelve
days, bj a yellowish or waxy and bloodless ap-
pearance of the countenance. The capillary
vessels disappeared from the conjunctiva and
mucous surface of the mouth ; and the pulsation
of the arteries could scarcely be felt. The pa-
tients complained of palpitations, anxiety, op-
pression and suffocation on exertion, paroxysms
of fever, profuse perspirations, oedema of the
•countenance, and rapid emaciation. This state
continued for six months or a year ; and in some
cases terminated fatally, with the reappearance of
the invading symptoms. Four of these patients
were sent to Paris for treatment, and were order-
ed light nutritious diet, bitter infusions, &c. One
of them died ; and on dissection, the arteries and
veins were found almost void of blood, contain-
ing merely a little sanguineous serum ; and little
or no blood flowed from the parts divided during
the inspection. The appearances in this case led
Mr. Halle to prescribe iron-filings in the dose
of a drachm daily, with tonics and opium ; and,
under this treatment, all the symptoms gradually
vanished, the capillary vessels reappearing on the
surface.
42. B. It is probable that general anaemia will
not take place, unless consecutively of remark-
able torpor of the vital influence, or of some
other morbid condition of one or more of the or-
gans which contribute to the formation of blood.
Where the digestive powers and the functions of
the liver are weakened, anaemia to a slight de-
gree is not infrequent. Its connection with chlo-
rosis is merely that of an associated effect of pre-
existing depression of the influence of the system
of organic nerves. (See Chlorosis.) The lungs
have been considered by some authors as the or-
gan which is chiefly concerned in the production
of anaemia, and consequently have been viewed
by them as the seat of hsematosis, or at least the
place where this process is completed. Without
disputing that such is the case to a certain extent,
I am disposed to view the liver as being equally,
if not more, concerned in this function, — an opin-
ion long since contended for in my Physiological
Notes (See Appendix to M. Richerand's Ele-
ments of Physiology); and consequently as being
in many cases very influential in the production
of general anaemia, it is probable, however, that
other viscera or parts may also give rise to it.
Thus it may be admitted that total obstruction of
the thoracic duct will occasion it ; and I have
repeatedly observed it in children affected with
various chronic diseases of the viscera of organic
life ; being here, as in most cases, one of the re-
sults of imperfect digestion and sanguif action, as
well as of obstruction to the passage of chyle into
the blood. One of the most remarkable cases
cf general anaemia was recorded by Dr. Combe.
In it all the viscera were found nearly bloodless,
excepting the spleen ; but not diseased in other
respects, at least not to the extent of impeding
their functions. The thoracic duct and absorbent
system were not examined.
43. The symptoms of anamia have been near-
ly all alluded to in the foregoing remarks. 1 may,
however, enumerate them briefly at this place.
They consist of a pale, waxy, or blanched ap-
pearance of the countenance and integuments, in
which the cutaneous veins are scarcely seen ; and
those which appear are pale, apparentlv empty,
do not fill quickly, or scarcely at all, upon pressure
made upon them ; and, when emptied, fill very
slowly. The conjunctiva has lost its red vessels ;
the lips, tongue, and inside of the mouth are pale;
the pulse feeble, small, irregular, and readily
made still quicker or fluttering upon mental emo-
tion ; the patient is languid and very weak ; com-
plains of flatulence, borborigmi, and an irregular
state of the bowels, with want of appetite, and an
occasional nausea ; a sense of sinking and syn-
cope, particularly upon assuming the erect posture,
followed by palpitations ; oppressed, short, hur-
ried, and sometimes gasping respiration ; irregular
convulsive or spasmodic movements ; tremors ;
oedema of the ancles; and in some cases the more
severe symptoms described as following sinking
after large depletions (§ 54.) In the more un-
favourable cases the patient may be carried off by
a fit of syncope upon assuming quickly the erect
posture ; or by a convulsion ; or sink with the
symptoms of exhaustion, or with those of effusion
on the brain, or in the pleural or pericardial cavi-
ties. It most commonly runs into one or more
of the complications about to be noticed.
44. 3d, Complicated anamia. — Deficiency of
blood, as respects both its diminished quantity and
its poor quality, or the defect of red globules, is
often associated with visceral disease, of which it
is generally the consequence ; but it also may
give rise to various affections, both functional and
organic. That anaemia should be complicated
with certain chronic diseases of the Jiver, mesen-
teric glands, and absorbent system, chlorosis. &c.
may be expected ; but that it should give rise to
diarrhoea, and to dropsical effusions in various
parts, particularly in the shut cavities and cellular
tissue, without any alteration of the solid-
not appear so obvious, although admitting of ex-
planation. M. Andral states, that he has ob-
served anaemia in the bodies of persons who had
died dropsical ; and in persons who had com-
plained of diarrhoea, profuse perspirations ; and
very justly considers both the dropsical effusions
into the shut cavities and into the cellular tissue,
and the exhalation from the digestive mucous
surface and skin, as perfectly independent of any
local congestion or irritation, and to be analogous
to the profuse diarrhoea and perspirations w hich
occur in persons who are brought near to disso-
lution by long protracted disease. In all such
cases, whether attended with effusion into shut
cavities or cellular tissue, or with increased ex-
halation from mucous surfaces, we may consider
nearly the same pathological conditions. to exist
as their principal sources, viz. diminished tone of
the exhaling orifices, with lessened vital cohesion
of the tissues in which they open ; a poor and
thin state of the blood, the crasis of which is
much lowered ; and a more rapid circulation of
the remaining fluid.
45. Anaemia, when existing even in a moderate
degree, will often give rise to various functional
disorders, which are. however, of no constant
character, but differing with the temperament,
habit of body, &c. The chief of these are hys-
terical and epileptic convulsions, palpitations, lei-
pothymia or syncope and palpitations alternately,
irregular or anomalous convulsions and spasmB,
BLOOD — Morbid Effects of its Loss.
175
chorea, and various nervous tremors resembling
chorea, dyspnoea, sickness or vomiting, oedema of
the ancles, diarrhoea, headach, &c, with weak,
small, quick pulse; pale, waxy, or dough] state
of the countenance; listlessness, flatulenl state of
the abdomen, gastralgia, colic pains, very weak
ion, Termination, and irregularity of the
and urinal evacuations, it will also be fol-
lowed by atrophy and softening of several of the
internal viscera, and general emaciation.
46. In cases where general anaemia is not ex-
i' ; i;i\ be admitted that both inflamma-
tion and haemorrhages may still occur, particular-
ly the latter, from the causes usually producing
them; and that they will have a remarkable ten-
dency to terminate unfavourably, owing to the
state of the system causing the deficiency of
blood, to this de'.ert itself, and to the want of
vital resistance, as well as to the incompatibility
of most of the means of cure with the state of the
constitutional powers and of local action.
47. Causes. — Several of the causes of anaemia
have been already alluded to (§ 3tf — 42.). There
maj he others which have not yet been ascer-
tained. I may state, however, briefly and gene-
rally, those which have been usually acknowledg-
ed. They consist of insufficient and poor food;
excessive secrections and evacuations; masturba-
tion practised early in life, and long continued;
long exclusion of the body from the direct influ-
ence of solar light and rays ; protracted confine-
ment in crowded apartments, in the stagnant and
impure air of manufactories, especially when af-
fecting children or very young persons; and the
constant respiration of a moist, impure, and
miasma! atmosphere, from which the sun"s rays
are shut out. All these exhaust or depress the
vital and nervous powers; whilst some also either
cut off the necessary supply to the circulating
fluid, or waste its richer constituents. To these
causes may bo added certain malignant organic
diseases, as carcinoma, &c, which, in the latter
stages, is always attended with more or less of
anaemia; impeded developement of organs, par-
ticularly those belonging to the generative func-
tions, whose perfect evolution is requisite to the
salutary excitement of all the organic actions, es-
pecially those of digestion and sanguifaction ; and
lesions which either impede these latter functions,
and interrupt the passage of chyle into the blood,
or vitiate these Quids.
4 3. Ti, i itm BUT. — The most rational and the
most successful means that can be employed con-
sist of such as are calculated gently to excite and
permanently to promote the organic functions.
Of these, the most appropriate appear to be the
various preparations of iron, bark, sulphate of
quinine, camphor, ammonia, small doses of iodine,
aether, &c combined occasionally with opium,
hyosciamus, extract of heps, conium, &c. when
the disease is attended with colicky pains. Con-
joined with these, the chalybeate mineral waters,
Stimulating frictions of the surface, light and di-
gestible food, gentle exercise in the open air,
particularly on borst back, and change of air, will
be found of much service. During the' employ-
ment of tunics, due attention should be paid to
the state of the secretions and excretions; and.
when the bowels are constipated, the more tonic
and less irritating aperients be resorted to. Of
these, perhaps, the best are rhubarb, and aloes,
the aloes and myrrh pill, the compound iron
pill, &c.
i!t. When the state of the system is attended
with hysterical, convulsive, and other nervous
affections, a combination of tonics and chaly-
lu.it. , with antispasmodics, as the preparations
of valerian, ammonia, zinc, myrrh, extract of
hops, galbanum, aether, strychnine, and various
others, is indicated. If we have reason to suspect
that the anaemia is a consequence of obstruction
or of torpor, combined with an enlargement of
some organ or part concerned in the formation of
blood, the preparations of iodine, the liquor po-
tassee alone or combined with tonics, the subcar-
bonate of soda, the boracic acid, and sub-borate
of soda, are the best medicines with which I am
acquainted.
Bibliog. and Refer. — Reiselius, Miscell. Curios, dec.
ii. an. 7. obs. xiv. — SxuhenJce. in Holler's Disput. k.c. vol.
vii. — Becker, Diss. Resol. Casus Pract. Anfemia-, &c. Leid.
[663.— Albt t, Hi--, ill Anaemia. Hal. 1732.— Janson, De
Moi bis ex Defectu Liquidi Vitalis. Lugd. Bat.1748.— Lien-
ttatd, Precis de la Medecine Pratique, p. 71. Paris, 1761.
— IfuIIe, Journ. de Medecine, &c. par M. Corvisart, Sic. t.
ix. ]). 3. — Gaspard. in Journ. de Physiol. Experiment. &.c.
t. i. Octobre 1821. — Chomcl. art. Anemie, Diet, de Med. t.
ii. n. 233. — Roche, art. Entmie, Diet, de Med. et Chirurg.
Pract. t. ii. p. 372. — Anilral, Clinique Medicale, t. iii. p.
558., also his Pathological Anatomy, translated by To-.ensend
and Mist, vol. i. p. 91. — Combe, Trans, of the Med. and
Chirurg. Soc. of Edin. vol. i. p. 194.
V. Morbid Effects of Loss of Blood. —
50. This is a subject of greater practical impor-
tance than has generally been attached to it; and
one which I have had numerous occasions to con-
template, particularly from the years 1816 to 1828,
— an epoch during which blood-letting was either
more generally adopted, or carried further, than
the nature of several diseases, and the constitu-
tions of many patients, warranted. The effects
of large depletions have been well illustrated by
the experiments of Dr. Seeds, which have
shown, what indeed might have been anticipated
from the physical condition of the circulation
within the cranium, viz. that we can never hope
by depletion alone to materially diminish the quan-
tity of blood in the vessels of the brain. Dr. M.
Hall, and the Author, have also shown that
several morbid states may be occasioned by large
losses of blood, or by too large a proportion of
this fluid circulating in the head, relatively to the
rest of the body, as a consequence of large blood-
letting; and M. Piorry has illustrated the same
subject by numerous experiments, and has offered
many instructive and practical observations on it,
particularly in relation to diagnosis.
51. The morbid effects of loss of blood may be
advantageously considered in relation, first, to a
person previously in health, or not affected by
dangerous disease; and. secondly, to persons la-
bouring under different diseases in which loss of
blood may occur, either naturally or from inju-
dicious practice. My observations on both these
branches of the subject must necessarily be brief.
more particularly on the latter, as the topic is not
overlooked in the consideration of the treatment
et' those diseases in which such losses are most
likely to be met with.
52. i. Morbid Effects of Loss of Blood
IN PERSONS .NOT PREVIOUSLY AFFECTED W ITH
serious disease. — These effects will naturally
vary with tie suddenness or rapidity of the loss,
the extent to which it litis proceeded, and the
habit of the person, especially as regards vascular
176
BLOOD — Effects of large Loss of.
plethora, at the time when it occurred. It is evi-
dent that an evacuation which has been rapid will
have a more marked and serious effect, than the
same quantity removed at several times, or in a
slower manner; and that, when blood is discharg-
ed at intervals, a much larger quantity may be lost
without producing the morbid effects often result-
ing from the sudden loss of a smaller quantity; or,
if they occur, they may be of a different kind from
those which follow rapid discharges. The sub-
jects, therefore, which chiefly require considera-
tion are, 1st, The immediate effects of large loss
of blood; 2d, The more remote consequences;
and, 3d, The slow and insidious effects superven-
ing on repeated losses, each occurring to a small
or moderate extent.
53. A. Of the immediate effects of large losses
of blood. — These are, vertigo, leipothymia or a
sense of sinking, syncope; feeble and slow, or
sometimes quick fluttering pulse; slow or appa-
rently suspended respiration for short periods,
interrupted by deep sighs; eructations from, and
sometimes sickness of, stomach; a cold, pale, and
bedewed countenance and general surface; irre-
gular sighing and yawning, generally followed by
a return of the pulse and of consciousness; and,
if the hemorrhage is not renewed upon the re-
storation of the circulation, recovery soon follows.
Where, however, the loss of blood is greater, the
above symptoms are more marked; the syncope
is more profound; the respiration, which is car-
ried on during this state entirely by the diaphragm,
is nearly imperceptible, until it suddenly returns
at intervals, with deep sighs: sickness and vomit-
ing occurs, and restores consciousness for a time,
but the patient again relapses into syncope, which
is broken in a similar manner; and, if the loss of
blood has ceased, a more permanent restoration
follows the sighing and sickness, and recovery
slowly takes place.
54. When, however, the loss is still greater
either absolutely or relatively to the energies of
the patient, or if it continue after the above effects
supervene, the return of consciousness is often at-
tended with some degree of delirium; a difficult
stertorous breathing; dyspnoea; gaspings for
breath; occasionally retchings, and discharge of
the contents of the large bowels; an irregular, in-
termittent, feeble, or imperceptible pulse; loss of
animal heat; great restlessness, violent shudder-
ing*, or general tremors, and jactitation, sometimes
so violent as to shake the bed upon which the
patient lies; a sense of sinking through the floor;
convulsions, or tetanic spasms, and contractions;
terrible gaspings for breath, and death.
55. Such is the common grouping of the mor-
bid effects; but some of them are more marked
than others. Thus, when the loss of blood is
very large, the patient may suddenly and unex-
pectedly expire in one of the fits of syncope which
occur, or he may sink more gradually, without
any appearance of delirium or convulsion, some-
times with the faculties entire to the last. The
former may occur after excessive blood-letting or
haemorrhage, when the patient has been incau-
tiously raised up, or when he has not been in-
stantly placed in the recumbent posture when
syncope occurred: the latter has taken place un-
expectedly when blood-letting has been carried
too far, or too often repeated, in the recumbent
posture.
56. Convulsions are often the most marked
effect, either of excessive haemorrhage or of large
and repeated venesection in the recumbent posi-
tion; particularly if it be carried to leipothymia or
syncope in this position, which ought always to
be avoided. This symptom is very common after
puerperal hemorrhagy, or any large losses of
blood occurring in females, particularly those of
an epileptic or hysterical diathesis, and in children
or young subjects.
57. Delirium is another prominent effect of ex-
cessive evacuation of the vascular system ; but it
usually presents something peculiar. The caro-
tids are often neither full nor strong, the counte-
nance is pale, and the head cool, — symptoms
indicating, with the character of the delirium, im-
paired vital energy of the brain. In some cases
the delirium is associated with convulsions, and
both may ultimately be followed by coma or
lethargy. Delirium more rarely occurs in chil-
dren or young subjects from excessive loss of
blood, than in adult or advanced age; but coma,
as will be shown hereafter, is not infrequent in
the former, particularly when the loss of blood
has occasioned convulsions, which in them usual-
ly terminate in coma.
58. B. Of the more remote effects of large loss
of blood. — When the patient is not carried off by
the more immediate effects of excessive loss of
blood, reaction generally supervenes, and often
becomes excessive. It usually commences with
palpitations, and throbbings through the body,
but particularly in the carotids and arteries of the
head, giving rise to the peculiar noises, of which
patients so often complain after large depletions.
The pulse now becomes quick, sharp, and soft;
and there is sometimes distressing nervous pulsa-
tion of the aorta. In the more marked cases of
reaction, the patient complains also of pain of the
head; intolerance of light and of noise; a sense
of tightness or pressure around the head; harry
of mind, and sometimes delirium, particularly in
the night; restlessness, agitated sleep, often ac-
companied with a sense of sinking or impending
dissolution, fearful dreams, &c. The arteries
throb; and the pulse ranges from 110 to 140, is
jerking, sharp, open, and bounding, but readilv
compressed. The respiration is hurried, panting,
and frequent; often attended with sighing, a desire
of fresh air, great restlessness, and in females for
aromatic perfumes, or the smelling bottle. The
mouth and throat are dry; there is much thirst;
and the skin is usually hot, but the extremities,
particularly the lower, are generally cold.
59. This state has not infrequently been mis-
taken for one requiring depletion; and I have
met with cases in which the idea of inflammatory
action had so taken possession of the mind of the
practitioner, as to induce him to employ large or
repeated depletion, which had been followed by
this state of reaction, for which he was proceed-
ing :iiraiii to deplete, mistaking the morbid effects
of the previous excessive loss of blood for a return
of the inflammation. If this state of reaction be
not judiciously managed, exhaustion rapidly su-
pervenes; and almost as soon as it occurs death
may take place, frequently upon some muscular
effort, or upon getting up from the recumbent
posture. In some cases, particularly in children
and young subjects, the delirium or morbid sen-
sibilitv of the brain, characterising the reaction.
BLOOD — Effects of large Loss of.
177
passes rapidly into a state of lethargy and coma,
which on numerous occasions I have seen mis-
taken for effusion of serum within the cranium,
or hydrocephalus, particularly when it has been
preceded by convulsions, as is often the ease in
children. In many such cases, either no effusion
is (bund, or the effusion is to an extent insuffi-
cient to account for the comatose symptoms.
60. Under more favourable circumstances the
reaction is gradually followed by returning health,
or lapses into a state of chronic exhaustion or as-
thenia, which is variously characterised. In some
cast s it is attended by somnolency, alternating
with slight delirium, ice. : in others, by fits of
dyspnoea, palpitations, frequent cough ; hurried,
laborious breathing; a flatulent, tympanitic state
of the abdomen: in several, by pale, emaciated,
or discoloured countenance and skin; amaurosis,
nervous tremors, or jactitation ; delirium, or
mania : and in puerperal females by a form of
mania which requires to be carefully distinguish-
ed, and which is particularly noticed under the
article on Puerperal Mania. In addition to these
functional disorders following reaction after large
losses of blood, organic changes may supervene;
such as effusion of serum and extravasation of
blood upon the brain, effusion into the bronchi
and air-cells, dropsical effusions in various parts,
and flatulent distension of the stomach and bowels.
When recovery takes place, the pulse always con-
tinues small and frequent for a long time, owing
to the remarkable diminution of the fluid in the
vessels.
61. C. Of the insidious effects produced by
small but often repeated losses of blood. — Loss of
blood occurring in this manner produces efl'ects
different from those now described. They gene-
rally, as may be expected, advance slowly, and
often exist either altogether, or a long time, with-
out detection. They are extremely various, ac-
cording to the age and constitution of the person.
They most frequently occasion a pale, leuco-
phlegmatic, and lax appearance of the counte-
nance and surface; a very quick, weak, and irri-
table pulse; hurried, and oppressed respiration;
frequent palpitations, and sense of sinking; borbo-
rygmi, and hysterical symptoms ; flatulent dis-
i of the colon, and colicky pains; swellings
of the ankles, and dropsical effusions in other
parts: in females, difficult and scanty menstru-
ation, chlorosis, deviations of the spinal column.
epileptic convulsions, pains in the loins, and
various anomalous affections of a painful or
spasmodic kind; tremors, and irregular action of
muscles; chorea; paralysis; dyspeptic disorders,
with irregularity of the bowels; a disposition to
syncope; amaurosis; and all the symptoms of
anaemia, which indeed is the primary or real state
of disease produced, and constitutes the chief
chang ■ detected upon examination alter death;
together with serous effusion in some situations,
and a pale bloodless state of the viscera, and of
the bent itself
> 62. ii. Of kxcf.ssivf. Loss of Blood in the
course of various diseases. — There are two
important considerations which should not be over-
looked in practice; viz. that in many diseases,
apparently attended with excitement, we shall
meet with cases in which the actual quantity of
blood in the body is much less than usual; and
in various others, blood-letting will often not be
borne, although seemingly indicated, and although
the quantity of blood in the frame be not lessened.
In illustration of the former of these, 1 may state
that many years ago I had an opportunity of
remarking minutely the appearances on dissec-
tion of a man of middle age, and somewhat fat,
who had complained of an acute and painful
disease, obviously functional, for which he hail
been blooded only twice on successive days, and
on neither occasion to above thirty ounces; and
yet the symptoms of excessive loss of blood ap-
peared, from which he died in twenty-four hours
after the second depletion. The most careful
examination could detect no organic change, ex-
cepting the remarkably bloodless and pale state
of all the viscera. Even the brain was less
vascular than usual. That in various diseases,
unattended by diminution of the circulating fluid,
depletion will produce marked symptoms of de-
pression and sinking, owing to the state of the
vital power being insufficient to accommodate the
vessels, by their tonic or vital contraction, to the
reduced bulk of the blood, is well known, and
has been fully discussed in the articles on Adyna-
mic Fevers, Erysipelas, and Puerperal Fevers ;
in which, as well as in puerperal mania, and va-
rious other acute diseases, large vascular depletion
is often most injurious.
63. A. Of excessive loss of blood in diseases of
excitement. — The morbid effects of large deple-
tions will necessarily vary with the nature of the
disease in which they are employed. When
carried too far, in cases of excitement, where the
nervous or vital power is not depressed, and the
blood itself rich or healthy, reaction generally
follows each large depletion, and thus often ex-
acerbates or brings back the disease for which it
was employed, and which had been relieved by
the primary effects of the evacuation. This is
more remarkably the case in acute inflammations
of internal viscera, particularly of the brain or its
membranes. Thus, every observing practitioner
must often have noticed, that a large depletion,
when carried to deliquium, will have entirely re-
moved the symptoms of acute inflammation when
the patient has recovered consciousness; and that
he expresses the utmost relief. But it generally
happens that the inordinate depression — the
very full syncope that is thought essential to the
securing of advantage from the depletion — is fol-
lowed by an equally excessive degree of vascular
reaction, with which all the symptoms of inflam-
mation return; and the general reaction is ascribed
entirely, but erroneously, to the return of the in-
flammation, instead of the latter being imputed to
the former, which has rekindled or exasperated
it, when beginning to subside. The consequence
is, that another very large depletion is again pre-
scribed fir its removal; and the patient, recollect-
ing the relief it temporarily afforded him, readily
consents, Blood is taken to full syncope — again
relief is felt — again reaction returns — and again
the local symptoms are reproduced : and thus,
large depletion, full syncope, reaction, and the
supervention on the original malady of some or all
of the phenomena described above as the conse-
quence of excessive loss of blood, are brought
before the practitioner, and he is astonished at
the obstinacy, course, and termination of the
disease; which, under such circumstances, gene-
rally ends in dropsical efl'usion in the cavity in
173
BLOOD — Effects of large Loss of.
which the affected organ is lodged; or in con-
vulsions, or in delirium running into coma ; or in
death either from exhaustion or from one of the
foregoing states; or, more fortunately, in partial
subsidence of the original malady, and protracted
convalescence. Such are the consequences which
but too often result — which I have seen on
numerous occasions to result, when blood-letting
has been looked upon as the only or chief means
of cure — the "sheet anchor" of treatment, as it
too frequently has been called and considered
during the last twenty years.
64. B. Of the mode by which excessive loss of
blood in disease may be best avoided. — Method of
conducting blood-letting. From the above it will
appear obvious, that if blood-letting were better
managed, and directed so as to make an impres-
sion on the local ailment, but in such a manner
as to avoid being so readily followed by the
reaction which reproduces the malady for which
it was employed, great advantage in practice
would result, and much less blood require to be
removed even in the most acute cases, a. In order
to accomplish this, I have long been in the habit,
■ — and have inculcated it in my lectures on the
practice of medicine, from 1824, — of directing the
following mode of practice when large blood-
letting* were required in the treatment of visceral
inflammation : — The patient should be either in
bed, or on a sofa, and in the sitting or semi-
recumbent posture, supported by several pillows.
The blood is to be abstracted in a good-sized
stream, and the quantity should have some re-
lation to the intensity and seat of the disease, and
the habit of body and age of the patient, but
chiefly to its effects; it should flow until a marked
impression is made upon the pulse, and the
countenance begins to change. Further deple-
tion must not now be allowed; but the finger
should be placed on the orifice of the vein, the
pillows removed from behind the patient, the
recumbent posture assumed, and the arm secured.
Thus a large quantity of blood may be abstracted,
when it is required, without producing full syn-
cope, which should always be avoided ; and
when a large loss of this fluid is either unnecessary,
or might be hurtful, the speedy effect produced
upon the pulse and countenance by the abstrac-
tion of a small quantity will indicate the impro-
priety of carrying the practice further. In this
manner I have often removed about forty ounces
of blood, where large depletion was urgently
required, before any effect, was produced upon
the pulse, but always carefully guarding against
syncope; and by the subsequent means used to
prevent reaction, no further depletion has been
required.
65. b. In order, however, to obtain this object,
a treatment varying with the nature of the disease
is required. Repeated doses of tartarized anti-
mony, either given in small quantities at very
short intervals, or in large doses, combined with
opium ; full doses of calomel, antimony, and
opium ; of camphor, nitrate of potash, and col-
chicum; or of ipecacuanha, nitre, and opium, &c,
particularly the first of these, exhibited so as
to excite nausea, but guarding against retching
as being liable to induce reaction; and the in-
dividual antiphlogistic remedies, appropriately
directed, and combined according to the cir-
cumstances of the case, are the chief means
which I have employed to prevent the return of
increased action after blood-letting conducted as
now stated. The particular measures which may
follow blood-letting are fully explained in the
articles on Inflammation of the different Organs;
but I may now mention, that when opium is
given with the view of preventing the recurrence
of reaction, it ought to be exhibited in a large
dose at once, (two or three grains,) either with a
full dose of James's powder, or any other anti-
rnonial, or with two or three of ipecacuanha, con-
joined with some one of the other substances
above mentioned.
66. It should be kept in recollection, however,
that reaction after large depletions is chiefly apt
to occur in idiopathic inflammations, and other
diseases of excitement, in which the constitutional
or vital powers are neither remarkably lowered
nor depraved; and when the circulating fluid is
not vitiated by the retention of those substances
in it which require to be eliminated, nor by the
absorption of matters which are foreign to its na-
ture, and injure its purity. Reaction is very apt
to follow large losses of blood in acute rheuma-
tism; in inflammations of the membranes of the
brain, and, indeed, of all serous or fibro-serous
membranes; and by its recurrence to reanimate
the local action ; so that a person may be blooded
to that state which has been described as the
extreme result of large loss of blood, (§ 54.)
and yet, trusting to this practice alone, the local
disease has either not yielded, or has passed into
one or other of the unfavourable terminations
it is liable to assume, particularly dropsical effu-
sions. In the course of practice I have frequently
seen persons who had experienced attacks either
of pleuritis, pneumonia, peritonitis, enteritis, or of
some other inflammation, and who had recovered
with great difliculty, and after a long convales-
cence. Upon enquiry, I found that they had
always been blooded largely, and to syncope, —
some of them four, five, or even six times, but
scarcely ever less frequently than thrice; and yet,
upon a subsequent attack of inflammation in its
most acuteTorm, in the same or some other organ,
a single depletion, practised as I have recom-
mended above, and followed by the means most
likely to prevent the return of reaction afterwards,
to subdue the local action, to solicit the flow of
blood to other parts, and to equalise its distribu-
tion over the body, has been sufficient; or, at most,
a single repetition of the venisection has been all
that has been required.
67. c. When the chest is dull on percussion,
the heart congested, the liver large, and the veins
distended ; or when the circulation is full and
strong, the capillaries injected, the lips and mu-
cous surface red, the muscles firm and large, or
the respiration oppressed, blood-letting is generally
required, and is well borne. It is also necessarv
even when the pulse is languid, the external
venous circulation difficult, and the surfaces pale,
if these symptoms be conjoined with those in-
dicating internal congestion. (See Congestion.)
On the other hand, persons with an open, soft,
full pulse, florid countenance, lax muscles. &&,
although they may bear moderate loss of blood,
yet sutler more from large depletions than those
of a pale, dry, thin, but muscular and rigid habit
of body.
68. Under no circuit stances ought a patient to
BLOOD — Effects of large Loss of — Treatment.
179
be blooded whilst his head is nearly on the same
level with the trunk ; anil the utmost care should
he taken in having recourse to venisection in ca-
ses of dilatation of the cavities of the heart, par-
ticularly those of a passive nature. It is seldom
■ - try in such eases: and if circumstances
should arise to require it, the blood should he tak-
en, in the manner I have inculcated (§64.), from
a small orifice and to a small extent. In the ma-
jority of eases, the state of the venous circulation,
if duly examined, furnishes some information as
to the quantity of blood in the system, and there-
fore sometimes becomes a valuable guide to blood-
letting in some doubtful eases.
69. When the superficial veins are distended,
of a deep or dark colour, and the blood flows
quickly, and the veins till rapidly on applying fric-
tion and pressure— indicating that their usual state
of fulness does not depend upon interrupted cir-
Culation about the right side of the heart, or in
any part of their course — we may infer that the
system is sufficiently supplied with blood. But if
the veins are small or pale, the body not being
fit ; if they swell slowly upon a ligature being
applied above them ; or are readily emptied by
friction, and very slowly refilled ; we must infer
the existence of a feeble state of the circulation,
H'.ui a deficient as well as poor state of the blood :
and the inference will be further verified if we
find this state associated with a pale sickly ap-
pearance of the countenance and integuments ;
a small, feeble, and quick pulse ; and paleness of
the lips, conjunctiva, tongue, and gums. (See
§43.)
70. C. Of loss of blood in relation to diseases
of depressed vital power, §-c. — There is a numer-
ous class, or rather classes, of diseases, in which
blood-letting, either in small quantity, or carried
too far, is especially injurious. All those in which
the circulating fluid is poorer and thinner, or less
pure, than in health, particularly chronic and ma-
lignant diseases presenting more or less of the
symptoms o( anaemia, and disorders occurring in
ill-fed and emaciated subjects ; those, in which the
vital endowment of the blood-vessels, or their
tonic contractibility, is partly lost, or manifestly
reduced, as various forms of fever, puerperal
and other diseases in which hurtful matters are
apt to pass or to be absorbed into, or not to be
eliminated from, the blood ; all those in which
the vital cohesion of the soft solids is diminished,
and the fibrine of the blood is incapable of Coher-
ing in the manner necessary to form a tolerably
firm coagulum, are injured by large bleedings, or
even by depletion to any extent. In the first of
these, it is obvious that blood cannot be spared :
in the second, although its loss might not be felt
in other respects, the vessels cannot accommodate
themselves to the state of their contents when
any considerable quantity is abstracted : and in
the la~t. as well as in them all, the vital manifest-
ations of the circulating system, and of the solids
generally, of which cohesion is one, is so far in-
jured, that the primary morbid condition from
which they all proceed is increased by the opera-
tion ; and, moreover, a greater disposition to the
absorption of morbid matters is imputed to the ab-
sorbing function, when such matters are within the
sphere of its operation, by the vascular depletion.
71. I may, in conclusion, remark, that all dis-
eases essentially spasmodic, and consisting of
irregular action of muscular parts, or of altered
sensibility of nerves, or of morbid exaltation of
their peculiar sensibilities, even when affecting in-
ternal organs, or the heart itself, and when no con-
clusive evidence of inflammation exists, will eith-
er be aggravated by loss of blood — in some cases
even to a moderate extent — or be readily follow-
ed by the effects which have been described as
consequent upon an excessive evacuation of rhis
fluid. But I may further add, that, in many cases,
where the above reasons for abstaining from
large or repeated depletions, or from venisection,
strictly apply, local depletions, under due restric-
tions, may be resorted to with advantage.
72. iii. Treatment of the Effects of
large Loss of Blood. — This will necessarily
vary with the particular eflect produced, and the
state of the patient and of the disease in which
excessive loss of blood occurred. The more im-
mediate effects of the loss are the first to claim
attention ; the other morbid conditions, which re-
sult from it more remotely, will be considered in
succession.
73. A. Treatment of the primary effects of loss
of blood. — The more immediate effects (§ 53.)
generally require the recumbent posture, free ven-
tilation, and airy apartments ; in the extreme cases,
stimulants, sprinkling the face with volatile and
fragrant fluids, and even the transfusion of blood.
In the worst cases, and particularly when the loss
of blood has occurred from the rectum or vagina,
the head and shoulders should be placed lower
than the pelvis ; and care should be taken to as-
certain whether or no internal haemorrhage is going
on, as far as this may be accomplished (see Uterine
Hemorrhage). In all cases of haemorrhage, the
involuntary discharge of urine and evacuation of
the bowels ought to be considered most dangerous
symptoms — even more so than the occurrence of
convulsions — and the most decided measures should
be instantly adopted. Where we have reason to
suppose that transfusion will be required, it should
not be delayed too long, as the risk from delay is
infinitely greater than that from the operation per-
formed by an expert surgeon, and with a proper
apparatus. In cases where convulsions or delirium
occur, or when these pass into coma or lethargy,
it will be necessary to exhibit, internally, stimuli,
as .ether, spirits of ammonia, and camphor, with
a little tincture of hyoscyatnus ; to sprinkle aether,
or lavender water, or eau de Cologne, over the
face ami head ; to apply a blister to the nape of
tin' neck, or on the epigastrium; to support the
animal heat in the trunk ol* the body and extrem-
ities ; and to administer the lightest and blandest
nourishment. Recovery from large loss of blood
is usually quick, when the functions of digestion
and assimilation have not been greatly injured by
it ; but when they remain imperfect, or remarka-
bly disordered for some time afterwards, we may
dread the formation of visceral disease, and should
direct change of air. voyaging, and travelling, with
the use of tonic and deohstruent mineral waters,
and appropriate internal medicines.
74. B. Treatment of reaction after large loss
of blood. — Careful reference ought to be had by
the inexperienced practitioner to the symptoms
indicating this state (§ 58.), so as to distinguish
between them and the general excitement conse-
quent upon internal inflammation. This state
will require means modified according to the fea-
180
BLOOD' — its Alterations in Disease.
tuves it assumes. But generally the morbid reac-
tion existing in the head, and rendering all the
senses remarkably acute, and the system suscep-
tible of impressions, as well as the distressing pal-
pitations of the heart, require the utmost quiet,
and small doses of hyoscyamus, or extract of
hops, with the preparations of ammonia, and mild
nourishment. Where the throbbings or pains in
the head are urgent, the surface of the head warm,
or delirium exists, cold spirituous lotions, applied
over the head, and full doses of hyoscyamus with
ammonia, or moderate doses of the acetate or the
muriate of morphia, with weak brandy and water,
and warmth applied to the lower extremities, will
be required.
75. C. Treatment of consecutive exhaustion,
or sinking. — Here stimulants are required in
larger doses ; and should be administered by the
mouth, in the form of enema, and externally. It
is possible that transfusion would also be of ser-
vice in this state of the system. If coma be pre-
sent in this stage, large doses of camphor, sther,
and ammonia are required, with the tepid effusion
on the head ; blisters, or mustard cataplasms to
the nape of the neck, or epigastrium, or to the
feet. In more chronic cases of exhaustion or
sinking, gentle nourishment, in small quantities and
often ; warm tonics, combined with gentle ape-
rients, in order to remove morbid secretions, and
relieve flatulence ; nutritious enemata, or injec-
tions of gruel or mutton broth ; and small quan-
tities of weak brandy and water ; are the best
means that can be adopted.
78. D. Treatment of certain effects of deple-
tion in relation to disease. — a. Large loss of blood
during diseases of excitement (§63.) requires a
treatment but little modified from that already re-
commended. When it has occurred during in-
flammations, a certain degree of irritative action
may still continue, notwithstanding the excessive
loss of blood, occasioning dropsical effusion into
shut cavities ; and, when the disease is seated in
die lungs, effusions in the bronchi or air-cells,
which the powers of life are insufficient to throw
off, or to expel. In such cases external deriva-
tives, and a combination of gentle stimuli, with
diuretics, anodynes, and diaphoretics, in order to
equalise the circulation, and to lower the irritative
action in the part affected, often prove of service.
When the primary disease is seated in the head,
the tepid or cold affusion, cold lotions to the head ;
external revulsants applied to the nape of the
neck, or to the lower extremities ; anodynes, cam-
phor, with hyoscyamus, or With acetate of mor-
phine ; and the promotion of the alvine and cu-
taneous secretions and excretions ; constitute the
principal measures, together with those already
enumerated (§74, 75.).
77. 6. Loss of blood occurring during diseases
of vital depression (§70.) requires the most ener-
getic means. The objects very generally are to
restore, as far as may be, the vital endowment —
the tonic contractility, of the vascular system, and
to enable it to act with sufficient energy on the
fluid circulating through it ; to increase the vital
cohesion of the soft solids ; and to excite the se-
creting organs to remove the hurtful ingredients
that may have passed into, or accumulated in, the
remaining fluid, and which tend to vitiate the
whole of the structures, and to sink still lower
the already depressed powers of life. These ends
can be attained only by exhibiting, in frequent
doses, the various tonics and stimuli ; particularly
those which tend to arrest or to counteract the
morbid changes going on in the frame, and to ral-
ly the powers of life. Of this kind are the prep-
arations of bark, or quinine, combined with cam-
phor, the BDthers, particularly muriatic aether, the
preparations of serpentaria, spirits of turpentine,
wine, opium, and various remedies of the same
description, combined according to circumstances,
and generally exhibited in small or moderate doses
frequently repeated. External stimuli, rubefacient
cataplasms and liniments, stimulating and tonic
enemata, injections of mulled port wine,with opium
and camphor, are often of great benefit. When
the secretions require to be carried off, rhubarb and
other tonic aperients may be employed. \\ hen
the disease is attended with coma, blisters or sin-
apisms to the nape of the neck, epigastrium, or
the feet, may be employed ; and either of the fol-
lowing formula, in the Appendix, exhibited (see
F. 423. 496. 845. 906.). If low muttering delirium
be present, the same treatment as is recommend-
ed for this state in typhoid fevers is required.
Bibliog. and Refer.— Montrin, Des Eff'els des Dif-
ferentes Especes d'Evacuations Sanjuines, 4cc. Lyons,
1810.— Seeds, in Lond. Medical Gazette, vol. v p. 433.—
M. Hall, On the Effects of Loss of Blood, in Trans, of Med.
and Chirurg. Society, vol. xiii. p. J21. ; and Researches rel-
ative to the Morbid "and Curative Effects of Loss of Blood
8vO. Lond. 1830. — The Author, in London Medical Re-
pository, voi. xx. p. 15. — Piorry, Memoires sur la Circula-
tion, fcc. Paris, 1831.
VI. Alterations of the Blood in Dis-
ease.
78. It will be necessary to the accurate estima-
tion of the causes and results of the various changes
of the blood in disease, briefly to consider the re-
lation in which the different functions of the body
stand to the blood. These functions are of the fol-
lowing kinds : viz. of sanguij action, nutrition, de-
puration, and secretion; one organ performing, or
contributing to two, or even three, of these offices.
We know that digestion, absorption, arterial cir-
culation, and respiration, are neci ssary to the for-
mation of the blood, and to the nourishment of the
tissues : we also know that absorption, nutrition,
secretion, and venous circulation, are concerned
in rendering the blood impure, by conveying hurt-
ful ingredients into it, or allowing others to accu-
mulate in it, or by destroying the relative propor-
tion of its constituents; and that various organs,
particularly those of secretion and respiration, are
actively concerned in eliminating such matters as
become injurious by excess, or pass into the circu-
lation from the various sources of impurity which
surround it. Hence it must be evident,that changes
in the solids, and particularly in those viscera which
are concerned in the supply and waste of the blood,
as well as in its depuration, must be followed by
changes in the state of this fluid ; unless when one
or two organs merely have their functions inter-
rupted, and others performing analogous actions
to these disorders assume a vicarious office. It
must be evident, therefore, from this, that the doc-
trines of solidism and humorism are, to a certain
extent, both correct ; that, although disorder may
Originate in either, it cannot be long limited to
one or the other, but must extend more or less to
both, according to the nature of the causes, and
the organs or parts where tneir impression is made.
We observe in the course of practice, that certain
morbid or poisonous ingesta make but little im-
BLOOD — its Alterations in Disease.
181
pression on the system, until it is absorbed into
tlie circulation, and by its presence there disor-
ders various organs or puis: whilst other sub-
stances make an h ediate impression on the
nervous system, and, through its medium, impedes
the functions of secretion and depuration, and
thus the blood itself is rendered impure, and the
source whence all the frame is more or less viti-
ated. Various fevi rs furnish most satisfactory
illustrations of this position.
7<». Having already considered changes in the
quantity of the blood, alterations in its qualities
are next to be viewed. The Tacts which have
been observed, connected with this subject, are
few and deficient in precision; and the majority
bf those who have directed their attention to it,
have merely described chemical conditions and
combinations pres'ented by this fluid after it had
been for some time removed from the body, and
had lost whatever vital endowment it may have
received from the vessels and tissues in which it
circulated, or had undergone important changes
incidental to this state; instead of describing at
the same time such vital manifestations as it may
have presented upon its removal, and the relation
of its chemical states to the pathological conditions
of the body.
SO. As we have seen that organization com-
mences in the chyle, and that this fluid is the
chief source whence the blood itself is formed, the
importance of studying the alterations of the blood,
in connection with the state of this fluid, is evi-
dent; but the difficulty of the investigation gene-
rally precludes many from engaging in it. At the
same time it must be admitted, that very important
changes maj take place, not only in the blood,
but also in the fluids which supply it, and are
secreted from it, without being made manifest to
QSes upon the most careful examination.
I shall now, first, furnish proofs of important
changes in the constituents and state of the blood
in various diseases; and next consider the causes
of such changes, and the results to which they
usually lead.
81. i. Proofs of Change. — A. In the pro-
portion of the chief constituents of the blood, a.
cases, the albumen seems either precipitated to
the bottom of the serum, or suspended in it like
a cloud, giving it a turbid opacity.
82. h. The proportion of the watery part of
the blood has been shown to vary in health; but
it varies still more in disease, and even in different
stages of the same malady. This change is not,
however, hunted to one, or even a few, of the
constituents of this fluid; but sometimes is ex-
tended to the most of them. Blood-letting, in
acute diseases, diminishes the proportion of co-
agulum ; and, if diluents be supplied, increases
greatly the proportion of serum, without lessen-
ing the quantity of albumen, unless the depletion
he carried very far. In several chronic diseases
of debility, in the stages of excitement and ex-
haustion in fevers, and in the last period or decline
ot the acute exanthemata, the proportion of serum
is \er\ considerable, owing to the interruption of
the secreting functions; but in acute inflamma-
tions, and the early stages of some of the exan-
themata, the blood is of a deep colour, and rich
in cruor, with an increased proportion of albumen
and of fibrine. In the advanced stages of dis-
ease, attended with fluid evacuations, the watery
part of the blood is diminished. This is remark-
ably the case in the pestilential cholera, dysentery,
and in some forms of dropsy.
83. c. The colouring matter of the blood evi-
dently undergoes some alteration during febrile
and malignant diseases. It has recently been
supposed that such change has an intimate con-
nection with the proportion of the saline constitu-
ents of this fluid, — a diminution of these rendering
the colouring matter dark coloured, whilst an in-
crease of them has an opposite effect; and cer-
tainlj various facts seem to confirm the opinion.
But this alteration is one merely in relation to
colour, which is unquestionably rendered much
more deep or black in the last stages of the dis-
eases now alluded to. But besides alteration of
colour, there are others which may be termed
dynamic, inasmuch as they relate to the vital en-
dowment of the globules, or, if not of the globules,
of the fluid generally. In the diseases referred to,
and after the operation of virulent poisons, the
The quantity of albumen varies considerably in condition of the colouring matter is remarkably
disease. It is not sensibly diminished by large or changed : it separates readily, and almost before
repeated blood-letting, unless the quantity of blood, dissolution, from the central corpuscles which it
in relation to the hulk of the body, be much di
minished. In many inflammatory diseases, and
in a large proportion of cases of active dropsy.
surrounds ; and, passing through the exhalent
vessels of mucous surfaces, with the serous or
watery part of the blood, gives rise to the sanious
the relative proportion of albumen is often very I cruor, and the dissolved blood, which we some-
much increased. This has been shown by times observe issuing from these parts shortly
Blackall, Trail, Gendrin, Bright, and before or after death; and probably to the black
several authors. I have always found it remark- vomit in yellow fever. In cases of infection by
ably increased in most of the exanthemata, par- animal poisons or morbid secretions, this separation
ticularly before the eruption has come out Ge n- of the colouring matter, and solution in the serum,
drin shows that, in inflammatory diseases, the take place very early, indeed almost immediately
serum of the blood often contains twice as much after death; and it is evidently owing to this
albumen as in the healthy state. When this is change in the blood, that the interior surface of
the case, die blood feels remarkably viscid to the the blood-vessels becomes so deeply coloured,
touch. In diseases of debility, and when the without any other appearance of inflammation.
blood is apparently deficient in quantity, and poor Indeed, the evidence adduced by M. Tkoussf.au
in quality, the albumen is generally very much fully proves this to be the case. (Archives Gin.
diminished, being sometimes less than half its usual de Med. t. riv. p. 321.) This further accounts
proportion. M. Gendrin and ftf. Akdr \r. think for the coloration of the interior of arteries in fatal
that it may also he altered in its nature as well as cases of adynamic or malignant fevers. — an ap-
quantity; and I believe, from appearances which pearance first particularly noticed by J. P. Frank,
I have observed in the advanced stages of several and subsequently by many others, and by some
that their opinion is correct. In these incorrectly ascribed to inflammation.
16
182
BLOOD — its Alterations in Disease.
84. d. The fibrine varies greatly in its quan-
tity, and as to the states in which it presents itself
in the blood removed from the body. Its con-
dition will be somewhat modified by the manner
in which blood-letting is performed; but generally
it soon separates from the serum, and, with the
red particles, forms the crassamenturn or clot,
which will vary in its appearances with the de-
gree of nervous energy exerted by the organic
nerves on the vascular system, and the quantity
of fibrine. a. First, the fibrine and red globules
may be in much greater proportion relatively to
the water and albumen, and still the crassamenturn
formed therefrom will be very different, according
to the state of vascular action and nervous energy
at the time when the blood was abstracted. If
the vascular action be increased, or in a healthy
state, and the vital energy unexhausted, the fibrine
will contract into a firm and large coagulum. If
the fibrine retain its relatively large proportion,
and vascular action be exhausted, it will contract
so imperfectly or loosely, as to enclose a large
portion of the serum, and to leave but little of
this fluid surrounding it. In the former case the
coagulum possesses much density: in the latter,
extremely little; indeed, sometimes not sufficient
to separate it sensibly from the serum. In such
cases the blood is rich, although otherwise very
different in appearance, owing to the state of
action and vital power.
85. .1. In the secoiid place, the fibrine may be
in small quantity, and yet present a state of firm
attraction, forming a small coagulum in the midst
of a larger proportion of serum than is usual in
health. Or the proportion being still small, the
cohesion of the fibrine may be so weak as to form
a tolerably large coagulum; whilst, in other cases,
it will scarcely separate from the serum, owing
either to its diminution, or the weak attraction of
its corpuscles. I have met with it in several
cases so nearly wanting, and so deficient in at-
traction in other instances, as not to form any
coagulum; the red particles having been, as it
were, precipitated to the bottom of the vessel in
a dark or blackish sediment, without any cohesion
in the form of clot. From this it will be inferred,
that the quantity of fibrine cannot be reckoned
from the apparent size of the coagulum merely,
but from the size in connection with density or
degree of cohesion. When the blood is deficient
in red globules, and fibrine, it has usually re-
ceived the appellation of poor blood; the degree
of cohesion existing between the particles of fibrine
in it, as well as in rich blood, being the general
index of the degree of nervous power. But there
are apparent exceptions to the indications it pre-
sents. Thus, in acute rheumatism, after repeated
depletions, injudiciously resorted to, — injudicious-
ly, because a frequently injurious, and seldom a
beneficial practice— and during the reaction con-
sequent upon repeated blood-letting, the fibrine,
although much reduced in quantity, will often still
continue to adhere firmly, or even to form, in some
cases, a buffy coat, and yet the powers of life are
reduced very far beyond what the state of the
fibrine would seem to indicate. In these cases,
the cohesion of the coagulum, and the formation
of the buff, are, as well as in many other circum-
stances of disease, principally the result of vascular
reaction, occasioned by morbid excitement of the
nervous influence; and as long as these states exist,
this condition of the coagulum will occur, although
depletion be carried to the utmost extent.
86. -/. Whilst the blood is still circulating in the
body, particularly in the last stages of various
chronic diseases, the repulsion existing between
its existing globules may be so far destroyed as
to admit of the fibrinous corpuscles adhering to
each other, in some part of the vascular system,
or even in one of the cavities of the heart. The
fibrinous concretions thus formed are attributable,
1st, To retarded or obstructed circulation of the
blood in the part. Van Swieten and Haller.
state that flocculent and fibrinous coagula have
formed in the blood of the pulmonary artery during
syncope and the cold stage of agues; and they, as
well as numerous later observers, have found these
productions after exposure to extreme cold, and
when death has been preceded by a very languid,
obstructed, and irregular state of the circulation.
2d, To eliusions of a small portion of coagulable
lymph from the inside of a part of the vascular
lining, during a state of inflammatory irritation;
which lymph may have become the nucleus around
which the fibrinous particles may have collected,
or the bond of cohesion between them in the first
instance : and, 3d, Particularly as respects those
fibrinous concretions, in the centres of which
purulent or tubercular matter has been found, as
in the instances adduced by MM. Legroux,
Marechal, and subsequently by others, to the
absorption of these matters, or to their passage
into the blood from the internal coats of the vessels
on which they may have been formed; and from
becoming nuclei around which the fibrine has
concreted. In some instances, in which these
fibrinous masses have been found, little or no
.connection with the surrounding vessels can be
traced. M. Andral supposes that these con-
cretions are possessed of a separate vitality, and
that the matter detected in their centres is a pro- .
duct of vessels previously formed in them. This
opinion, however, cannot be supported, inasmuch
as the matters formed in their centres have no re-
lation to, nor have they been found often sur-
rounded by, blood-vessels ; and, when -vessels
have been detected, the firm attachment of the
concretions to the inner surface of the vessels at-
tests the manner of their formation to be identical
with that of other productions of a similar kind.
87. (1. But the attraction between the particles
of fibrine, which is usually observed when the
blood is removed from the sphere of vital endow-
ment, in which it participates, instead of being
exerted, as now stated, within some part of the
vascular system, may be entirely lost, or be very
irregular or imperfect. In such cases, the blood
either remains altogether fluid; or its fibrine. and
some part of its albumen, form giumous particles,
or minute fragments, which are either suspended
in the serum or mechanically mixed with it, form-
ing a sanious cruor in the vessels. This latter state
is observed sometimes locally, and often generally,
immediately after death; as in the veins of the
spleen, liver, of the extremities, &c. A thick,
dark, and treacle-like state of the venous blood,
and a venous appearance of the arterial blood, are
not infrequent during life; particularly in pestilen-
tial cholera, in asphyxia, hydrophobia, &c.
88. f . The buffii rout observed to form the upper
part and surface of the coagulum. most frequent-
ly, in cases of inflammation, consists of fibrine,
BLOOD — its Alterations in Disease.
183
according to Deyeux and Parmknetir; of
fibrine, and especially concrete albumen, in the
opinion of Fourcroy, V viijuklin, and 'I'm -
hard; of fibrine and gelatin, according to Or-
>• i i . v ; of fibrine, containing serum between its
fibres, and albumen, or very albuminous serum,
according to Dowlkr and Genjdrin. Berze-
i u - considers thai it may contain all the elements
of the coagulum. It manifestly is produced by
the concretion of the fibrine, which, parting from
the colouring mailer, forms a whitish yellow, or
slightly greenish layer, varying in thickness from
a line to one or two inches; and giving rise to
the cupped appearance of the clot, by the firmness
of attraction between Its particles. The formation
of the buff may be somewhat favoured by the size
of the orifice from which the blood has been drawn,
the rapidity with which it has flowed, and the
form of the vessel in which it has been received;
but the buff itself entirely depends upon the state
of the fibrine, which, in conjunction with a portion
nt* serum and much albumen, not only chiefly
constitutes it, but modifies it in the manner already
noticed, according to the state of vital influence
and vascular action. (See § 84. and art. In-
flammation.)
89. e. Respecting changes in the saline con-
stituents of the blood, we are provided with but
little information, and that by no means of a pre-
cise character. So much difference has existed
amongst chemists respecting the actual saline in-
gredients of healthy blood, and their state of com-
bination in this fluid, that a standard has not
been furnished for comparative observation. Ac-
cording to Dr. Stevens, they are very sensibly
diminished in the blood of patients affected by the
fevers of warm climates; and Dr. O'Shaugh-
NESsv has shown that the blood of those suffering
from pestilential cholera contains much less saline
constituents than in health.
90. /. The electrical condition of the blood may
also be changed by disease. Belling eri states
the electricity of venous blood to be equivalent to
that of antimony; that it is an imperfect conductor
of this agent; and that its electricity is diminished
in inflammatory diseases. According to Rossi,
the blood presents, in severe fevers, modifications
of its electrical states. That electricity, when
acting • nergetically on the frame, affects the
blood (probably through the medium of the nerves
supplying its vessels) in a most intense manner,
is shown by the dissolution and decomposition of
this fluid after death from this agent. '1 he evi-
dent effect of light upon the blood, in rendering it
both more abundant and rich, may be attributed
to the electrical states of the solar rays.
91. g. The temperature of the blood has been
observed to vary, during the course of disease,
from 86" to 104 . It has I n observed as low
as the former grade in pestilential cholera,, and the
cold stage of ague; and as high as the latter in the
6tage of excitement in fevers, and visceral inflam-
mations. Its temperature is evidently owing to
the degree of nervous power in connection with
vascular action.
92. B. Changes in the intimate nature of the
blood, for which mere difference in the proportion
of its convtituents cannot account ; and which are
referrible to the state of vital power. — Important
changes of the blood, which are evidently not re-
ferrible merely to alteration of the healthy propor-
tion of its constituents, although such alteration
may be considered as often co-existing with those
other inappreciable modifications upon which its
mo'rbid effects chiefly depend, occur in the course
of various diseases; and, when once induced,
occasion not only violent or fatal effects as respects
the individual subject of them, but also similar
changes in healths persons inoculated with this dis-
eased blood. Dr. Home communicated measles
by means of blood taken from persons affected by
them. DuHAMEL records a case of a butcher,
u ho. having put in his mouth the knife with which
an over-driven ox had been slaughtered, had his
tongue and throat swollen a few hours afterwards,
and an eruption of blackish pustules over his body.
lie died in four days. Another person, having
wounded himself in the hand with a bone of the
same ox, was seized with inflammation of the
arm, followed by mortification and death. Two
females experienced also gangrenous inflamma-
tion from a few drops of the blood of the same
animal having fallen upon the hand of one, and
on the cheek of the other. Inoculation with, or
even the simple contact of, the blood of diseased
animals, may produce in men the malignant pus-
tule. Of this numerous proofs have been furnished.
MM. Dui'UY and Leuret introduced into the
cellular tissue and veins of a sound horse, blood
taken from a horse affected with malignant car-
buncle (pustule maligne), and thus produced the
disease. The serious effects also observed to
follow wounds in dissection, either of recently
dead bodies, or of those in which decomposition
hascommenced; the changes which take place in
the blood, either primarily or secondarily, in van-
on- maladies; the septic influence of certain ani-
mal secretions and poisons on the tissues to which
they are applied, on the blood, and on the frame
generally; tire among the most important phenom-
ena of disease. I shall, therefore; proceed to a
more minute examination of this department of
pathology than it has recently received. That
these changes are of a most important nature;
that they may arise from various causes, or from
spontaneous alterations taking place in the blood
while circulating in the vessels of the animal, even
whilst those changes are so slight as to escape de-
tection by our senses; and that the blood, when
thus changed, will be the cause of disease pre-
senting a malignant character, when applied to or
inserted into the tissues of healthy animals, are
facts which the preceding, as well as other evi-
dence about to be adduced, fully demonstrate.
The chief of these changes, to which 1 attach the
utmost importance, having observed them to exist
more or less in a large proportion of cases where
blood has been removed, or escaped from a vessel,
in malignant or adynamic diseases, or in the last
Stages of very acute and dangerous maladies, are
the following: —
93. a. The blood has generally a somewhat
salt taste in health, evidently depending chiefly
upon the quantity of muriate fof soda contained in
it. In various maladies, particularly those which
arc malignant, and in the advanced stages of fe-
vers, this taste is not so remarkable, particularly
u hen the blood assumes a darker hue than natural.
h. The peculiar odour of this fluid upon emission
from a vein is also very remarkably changed in
these maladies. Haller has adduced numerous
instances of this in his; great work; and various
184
BLOOD — its Buffy Coat.
authors — and amongst these, Van Swieten,
Hoffmann, Schwencke, Hux ham, Linings,
&c. — have noticed a remarkable foetor of the
blood in adynamic fevers and pestilential maladies.
I have observed a peculiar odour of the blood in
cases of malignant puerperal fever. We are in-
formed by Louis de Castro, that the blood of
two plague patients infected the air of their apart-
ment with a foetid odour; and Zacctus mentions,
that three persons were struck dead by the odour
exhaled from the blood drawn from the vein of a
person infected with plague. Muralt also states
that a cadaverous fator emanates from the blood
of persons afiected with this malady ; and Ba g-
livi mentions that a nearly similar phenomenon
was observed in the blood of patients in the ad-
vanced stages of a very fatal epidemic fever. Hal-
ler prognosticated a fatal issue, chiefly from this
symptom, in a case to which he refers. Zurinus,
Ai.prunner, and Vater, allude to cases where
physicians were dangerously infected by the foetor
of the blood, upon its abstraction from the veins
of persons in malignant and contagious diseases.
Boisseau states, that he has been very disagree-
ably affected by the odour of the blood just ab-
stracted from the veins of persons attacked by
severe disease of the chest or abdomen. Pringle
relates, that an individual was seized with dysen-
tery, after inhaling the odour from the blood of a
dysenteric patient, kept for a long time. The
blood taken from a vein in the arm of a woman
in a malignant fever, was, according to Morton,
so offensive, that the surgeon and assistants fainted
in consequence. It may be therefore inferred that
both the odour and the taste of the human blood
may be very sensibly changed in the advanced
progress of various adynamic, infectious, and ma-
lignant maladies.
94. c. Softness or firmness of the coagulum
has been already noticed, in connection with the
condition of the fibrine; and stated to be often
independent of the quantity of this constituent,
and to be chiefly owing to the degree of nervous
influence and vascular action. In the class of dis-
eases new alluded to, the coagulum is not only
remarkably soft, but, from the want of adhesion,
and from the solubility of the colouring matter in
the serum, is sometimes readily converted into a
reddish fluid by slight agitation with it. In other
cases no coagulum forms, the fibrine being sus-
pended in small albuminous-like fragments in the
serum, and the colouring matter precipitated to
the bottom of the vessel. In several instances,
these constituents are not separated from the
serum, but seem combined with it; the whole
mass remaining more or less fluid, and presenting
a reddish, reddish black, or blackish colour, from
the time of its emission till it furnishes evidence
of decomposition. I have met, in other cases,
with the blood changed into two parts: the upper
and serous part consisting of a remarkably soft
gelatinous mass, sometimes almost fluid, resem-
bling very weak or uncoagulated calves-foot
jelly, and forming from two-thirds to four fifths
of the whole; the colouring matter being spread
over the bottom of the vessel, and presenting a
dirty, black, and muddy appearance. I have also
observed, and very lately, in two cases to which
I had been called by neighbouring practitioners,
the colouring part of the blood, with a portion of
the fibrine and albumen, deposited on the bottom
of the vessel, of a colour between a deep brown
and dirty dark gray, the serum being very abun-
dant and turbid.
95. d. Appearances analogous to the above
are also observed whilst the blood is in the veins
of the dead body. In many cases, it is either
fluid or semifluid, treacly, and of a dark colour.
In others it is apparently decomposed and gru-
mous; and in some, either consisting of perfectly
fluid blood, or resembling water coloured with
a reddish brown matter. In some cases, where
the blood has been partially coagulated or sepa-
rated into a grumous state, the more fluid parts,
generally in the form of a bloody or sanious
serum, have percolated the tissues, and escaped
through the relaxed exhaling pores and extremi-
ties, and passed into the shut cavities; but more
frequently flowed out on the mucous surfaces,
leaving the more consistent parts of the blood in
the vessels in larger propoition than in health.
In all these cases, the blood, whether that drawn
from the veins, or found in them after death,
seems not so deficient of fibrine, as that its state
is changed owing to exhaustion or annihilation of
vitality, by virtue of the possession of which (de-
rived from the influence of the organic nerves on
the blood-vessels and internal viscera) its fibrinous
corpuscles are aggregated into a coagulum when
removed from the veins.
96. ii. Further Proofs 6f Change in the
Blood, and its relation to particular
kinds of disease. — A. The existence of a buff
on blood drawn from a vein has always been re-
garded by practitioners, as a sign, not only of dis-
ease, but also of inflammation. Gendrin (fol-
lowing the path of his predecessors) asserts, that
the blood is in a very inflammatory state, when it
coagulates quickly; is covered by a thick, con-
cave, dense, elastic, bufT, of a yellowish white; and
separates into a truncated, ovoid, dense, elastic
clot, floating in a serum, which bears a proportion
to it of one and a half or two to one; is slimy, col-
ourless, slightly turbid at the bottom of the vessel,
and without any trace of colouring matter. The
clot more rarely is of the shape of a truncated
cone; is very dense at its surface, pretty soft at
its base; does not float; and is more voluminous
than the serum, wliich is of a pale yellow: in this
case the blood is more titan very inflammatory.
97. He observes that the blood is inflammatory,
when the buff is thick, diaphanous, of a dull
white, and covers a rather dense cylindrical clot,
beneath which is the serum, yellowish, and equal
at most to twice the volume of the clot, a slight
colouring deposit being found at the bottom of
the vessel. If there be any buff when the
blood is sub-inflammatory, the clot does not float,
but is suspended in the middle of the liquid, or is
precipitated, and is less dense than in inflamma-
tory blood; the serum is slightly tinted with red
at the bottom of the vessel, where a laver of
colouring matter may be seen. But usually
there is no bufT; the clot is dense, ovoid, floating,
and presenting a red stratum on its surface; the
serum is viscous, limpid, somewhat turbid at the
bottom of the vessel, where no colouring matter
can be observed. The blood in this state coagu-
lates quickly, and yields serum of at least t\\ ice
the volume of the clot. WTien the proportion of
serum is less than twice that of the clot, and the
latter is soft, cylindrical, voluminous, although
BLOOD — Changes of its Vital Relations.
185
floating, the Wood Ls scarcely sub-inflammatory;
it is so in a slight degree, when the clot is dense,
ovoid, and pendent in the middle of the vessel;
when, of 'hose two last mentioned coagula, the
first occupies the middle, and the second the bot-
tom of the vessel, the blood is more inflammatory.
9S. This description is tolerably accurate, par-
ticularly as respects inflammations of serous mem-
branes, pneumonia, and other visceral inflamma-
tions, when the circulation is free and the pulse
not oppressed. But every one must have observ-
ed, that there may be very acute inflammation,
and yet the blood is not buffed, particularly in
children; and, on the other hand, that this ap-
pearance often exists to a greater or less extent
in plethoric persons, in pregnant and puerperal
females, in those who resort frequently to blood-
letting, and in rheumatism, even in its least in-
flammatory tonus. M. Gendrin also errs as
respects the rapidity with which inflamed blood
coagulates. When the powers of life are unim-
paired, and the circulation quick, and particularly
during acute and general vascular reaction and
vital or nervous excitement, coagulation is either
longer in taking place, or, if it commences soon,
it is much later in being completed than in other
cases; but much will depend upon the stream of
blood. If this be full, quick, and large, and the
temperature of the apartment high, coagulation is
delayed, and the hurl' more readily appears. If
the stream be small, slow, and the temperature
low, coagulation is rapid, and no buff is formed.
99. In some cases of intense inflammation, no
butl* appears, the blood coagulates slowly, the
clot is less dense, and less serum is formed than
in health ; but the coagulum is very distinct
from the serum, into which it does not at all
dissolve. This, although another condition of the
blood in a state of inflammation, is observed also
in cases wdiere the inflammation is not excessive,
as every practitioner must have had numerous
opportunities of ascertaining. Two superimposed
layers of buff* are sometimes seen — the one soft or
friable, the inferior more dense, more compact, —
but not (as is asserted) only when suppuration
has taken place in an inflamed organ ; still less
must we receive as a sign of suppuration the
dusky white or opacity of this bull*, and the pres-
ence of a mucous stratum at the bottom of the
serum. In short, it does not always happen that
the bull' shows itself on the blood in chronic
phleg nasia, until the subject has become en-
feebled, and the nutrition deteriorated. A repe-
tition of bleeding, and a tendency to syncope,
causes either a diminution, or the entire disap-
pearance, of the buff*. According to Plenciz,
when the blood is not buffed in inflammations,
the coagulum is always more firm than natural,
— an observation which is tolerably correct in
respect of the state of vital power, but not as
regards the presence of inflammation. It should
not be overlooked, that in many cases of very
acute inflammation, particularly in its early stajre,
the nervous power may be so oppressed, and gen-
eral vascular action consequently so imperfectly
developed, that the coagulum will neither be firm
nor exhibit any butl* on the first and second blood-
lettings: and yet, when this oppression has been
removed, a firm and aizy coagulum will be form-
ed by the blood subsequently drawn. This is par-
ticularly the case when the respiratory function
16*
has been oppressed at the commencement of the
attack.
100. Out of four and twenty cases of peripneu-
monia terminating fatally, Louis found the blood
of nineteen of these patients covered by a buff*,
which was firm and thick at each bleeding in
fourteen cases; soft, and sometimes infiltrated, in
the others. It was cupped only in two fifths
of the whole number of patients. The buff* was
absent in only six cases out of fifty-seven, which
recovered. It was very thick, and cupped, in
twenty-three of them. The blood was covered
by only a slight hutl'in three cases out of five of
hydrocephalus, softening of the brain, or apoplexy;
and in another instance of softening of the brain,
the blood remained semi-liquid, without clot or buff".
101. In four cases of scarlatina, small pox, and
measles, which terminated favourably, the blood
was covered by a thin and not very consistent
butt" ; in one case of scarlatina it was firm and
thick: of the same character in five cases out of
seven of erysipelas of the face, and in four cases
of angina, while in a fifth it was soft ; in nine
tenths of rheumatic patients it was equally firm
and thick ; in two subjects affected by zona it
was not present. It was somewhat thick in four
cases of erythema, where the circulation was
considerably accelerated ; thin, in four out of fif-
teen cases of pulmonary catarrh. According to
Gendrin, the buff" never appears on the blood
of variolous patients until i.f'ter the eruptive fever
begins; it is more strongly marked when the in-
flammation is more intense, and lasts even after
desiccation has taken place. When buff" appears
at the very first, Baglivi is of opinion that the
eruption will he considerable.
102. B. Other states of the blood in various
diseases. — M. Boisseau states, that he has seen
the venous blood of a lively red — now and then
of a clear rosy red — and spouting in a transparent
thread, in patients afflicted with inflammation of
the lungs, and sometimes in those with inflamed
joints. Among those with peripneumonia, but
who were otherwise of sound constitution, he has
noticed it covered by a greenish buff ; yet the
greater part of these patients recovered after re-
peated bleedings. In a very fine young girl, who
had enjoyed good health, "but was attacked by
pain in the side in consequence of a chill, the
blood was of a dirty gray, approaching to violet,
and like lees of wine: after this bleeding she suf-
fered no more, although her skin continued yellow
for some months. M. Boisseau has also seen
blood like turbid tome in several cases of pulmona-
ry inflammation, which were nevertheless cured,
the patient Buffering little more in consequence of
the unusual appearance in the blood.
103. In fact, the hemorrhagic blood, as also
that taken from the veins of subjects attacked by
inflammation, is not always consistent and buffed ;
it is sometimes found dissolved, thin, and serous.
The latter appearance is, indeed, less common
than the former ; but sufficiently so to teach us
not to attach too much importance to the aspect
of the blood in inflammations, and also not to
forget that, whatever may be its condition, phleg-
masia will develope itself when the causes from
which it springs are sufficiently powerful.
104. A whitish appearance of the venous blood
lias been long observed, arising from the presence
of white flakes or streaks. This has been ascribed
186
BLOOD — its Morbid Relations.
to various causes; but with greatest truth to the
existence in it of a large portion of unassimilated
chyle. The separation of the blood into a soft or
natural coaguluni, and a milky serum, is much
more common. This, as well as the foregoing
state of the blood, has been imputed to various
causes. Emmert considered that it was owing
to a substance analogous to buff. Some have as-
cribed it to milk ; others to albumen ; a few
pathologists view it as owing to a matter analo-
gous to tibiine; and several, as proceeding from
the admixture of liquid fit. Uai.t.er imputed it to
liquid chyle. Of these opinions, the two lust are the
most accurate. There can be no doubt that both
the milkiness of the serum, and the whitish streaks
observed in venous blood, are owing in a great
measure to unassimilated chyle; and the more ac-
curate researches of modern chemists, particularly
Christison, Babington, Le Canu, &c. have
detected in this kind of blood an unusual proportion
of oily matter. This state of the serum is occa-
sionally met with in various diseases, functional
as well as organic ; and seerns connected with defi-
cient assimilating power. Sydenham states, that
he observed the blood drawn from a young con-
valescent to resemble pus, — an appearance prob-
ably owing to the great quantity of chyle carried
during convalescence into the blood, which had
been poor and defective, and to the circumstance
of this fluid not having then experienced the pro-
cess of sanguifaction. Nicolas and Guende-
ville have noted, that the blood of diabetic pa-
tients contains an increase of serum, and very little
fibrine: this serum contains, according to Rollo,
a saccharine matter; about the thirtieth part of
what is found in urine, according to Wollaston.
105. During the prevalence of scurvy in Ad-
miral Anson's fleet, the blood taken from the
veins, after the eruption had appeared, was marked
with dark or with vermilion streaks; on first issu-
ing from the veins it was dissolved and very black,
but after standing some time it thickened, and as-
sumed a dark colour ; no regular separation of
its serum took place, and its surf ice was greenish
in several places. When the disease had arrived
at its third stage, the blood was as black as ink;
and although it was kept several hours in a vessel,
its fibrous part precisely resembled wool or hairs
floating in a muddy substance. The blood issu-
ing from the mouth, nose, stomach, intestines, or
any other part, in the last stage of this malady,
was entirely decomposed, black, or yellowish. It
was found after death entirely dissolved in the
veins, so that by cutting some branch of a rather
large vein, it was possible to empty all the neigh-
bouring branches with which it communicated of
the yellowish black fluid they contained. The
extravasated blood was of the same nature. In
a scorbutic patient, opened by order of Cartifr,
the cavities of the heart were stated to have been
entirely filled with corrupted blood.
106. In four cases of scurvy, Rouppe has found
the right cavities of the heart filled with black
and coagulated blood; and a greenish yellow po-
lypus-like matter filling the left cavities of tliis
organ, the aorta, and the pulmonary artery and
vein. Amongst the scorbutic subjects opened at
Paris in 1(599, by Poupart, it was found that
in those who had died suddenly, the auricles of
the heart were dilated by coagulated blood, the
muscles loaded with black and corrupt blood,
and the cellular sub-cutaneous tissun infiltrated by
extravasated, black, coagulated, and congealed
blood, in some cases, and by red blood in others.
107. liicHAT found in a dead body, instead of
venous blood, a greenish sanies, which filled all
the divisions of the splenetic vein, the trunk of
the vena porta, and all its hepatic branches; so
that when cutting the liver, he distinguished by
the flowing of this sanies all the branches of the
vena porta from those of the hepatic vein, which
contained blood in a natural state: this bodv was
remarkable for such an excessive obesity, that
Bichat never remembered seeing any thing equal
to it. Unfortunately he does not give us the s\ mp-
toms of the disease of which this person died.
108. According to Coyter, Gendrin, and
many others, a black pulverised-like substance
deposits itself at the bottom of the vessel con-
taining blood taken from persons aflected with
typhoid, malignant, and gangrenous diseases; the
clot being often either completely dissolved, or not
formed at all. I have seen these appearances,
and various modifications of them alluded to above
(§94.), not only in these diseases, but also in
heematemesis, dysentery, severe infectious erysi-
pelas, phlebitis, the dangerous forms of puerperal
diseases, puerperal mania, and in purpura hemor-
rhagica.
109. Remarkable fluidity of the blood is al-
ways observed after death from severe blows on
the epigastrium, and from lightning. J. Hunter
states, that he has also found it fluid after death
from a violent fit of passion. Morgagni observed
it in a similar state after death from hunger; and
31. Audouard relates, that it was uncom-
monly fluid in a man who died from coup dt so-
ldi, voiding blood from the mouth and nostrils.
In two cases of hydrophobia I found the blood
black; so fluid in the heart and veins, that it
flowed out abundantly from the vessels of the
head and neck, presenting an infinite number of
oily points or particles on its surface; and, when
removed from the vessel, it did not afterwards
coagulate. The same appearances were observ-
ed in a large proportion of the numerous cases
described by 31. 'i rolhet, and other authors on
this disease. M. Troi.liet states, that in several
of his cases, a considerable quantity of gas escaped
from the heart and aorta.
110. iii. The Causes of Changes in the
hfati.hy state of the Blood. — The causes
which occasion morbid changes in the state of the
blood, are either such as are confined in their op-
erations to individuals, or such as influence whole
classes, or the community generally. They may
thus be sporadic, endemic, or epidemic. In re-
spect to their mode of operation, they may be ar-
ranged, 1st, Into such as vitiate the fluids from
which the blood is formed ; 2d, into those which
impede the junctions of secretion and depuration;
3d, Those putrid or septic matters which contam-
inate the tissues and fluids to which they are ap-
plied, and act chiefly by absorption ; 4th, Those
which act upon the vascular system, either direct-
ly or indirectly, through the nerves which supply
it; and, 5th, The passage into the bleed of mor-
bid matters formed in the same body that is the
seat of disease.
111. A. Of vitiation of the blood by the fluids
which form it. — The fluids which supplj the
waste of the blood are not infrequent!) vitiated,
BLOOD — irs Morbid Relations.
187
nn<l (hereby change the state of the circulating
mass. The chief sources of this vitiation are
hurtful of unwholesome ingesta. Man) articles,
even of food, will be hurtful when too lung con-
tinued. The injurious effects of salt provisions on
the blood, when exclusively employed, and par-
tied irl v if depressing causes cooperate with this
diet, are evident, and are fully illustrated in the
article on Scurvy, The influence of diseased
rye, in firsl changing the condition of the blood,
and inducing a state of chronic arteritis, termin-
ating in gangrene of the extremities, is also well
known; and the effects of diseased or putrid flesh
upon the system have been often noticed, although
not always correctly traced to the quarters where
the principal changes are produced. M. Bertin
states that a number of negroes in Guadaloupe,
having eaten the flesh of some animals dead of
an epizooty, were seized with fever, and violent
ileus, of which the greater number died : and nu-
merous cases are on record, where persons shut
up in besieged towns, having partaken of putrid
animal matter, or of the flesh of animals that have
died, have been seized with malignant states of
disease; and the blood has been found fluid, dis-
solved, blackish, grunious, &c. upon examination
after death. In these, and numerous similar in-
stances which might be adduced, although the
state of the blood has been alluded to in general
terms, die information has been deficient in pre-
cision, and has been furnished incidentally, the
attention of the observer having been directed to
other quarters.
112. M. Magendie adduces, in his Journal,
the instance of a man, who, after a long use
of vegetables in which the oxalates abounded,
underwent the operation of lithotomy, and a
large oxalate of lime calculus was removed from
hina. We know that a large proportion of both
our mineral and vegetable medicines operate by
being absorbed into the circulation (see art. Ab-
sorption, &c.); and there is every reason to
suppose that various morbid or foreign matters
may piss with the chyle into the blood, and
modify its condition. The excessive or long con-
tinued use of alkalies, or of alkaline stilts with
excess of base, has the effect of diminishing the
cohesion and the viscosity of the blood, and of
preventing it from coagulating after it has been
removed from the vessels; and while these sub-
stances thus, as it were, dissolve, or attenuate
this fluid, they also diminish the vital cohesion
and tonic contractility of the extreme vessels and
of the tissues, and create a disposition to extrava-
sation of blood in the parenchyma of the organs,
and to exudation of it from tin; mucous surfaces.
On the other hand, the acids — particularly the
mineral acids — turpentine, the superacetale of
lead, and all the salts — especially those with
excess of acid — have the effect of increasing the
healthy crasis of the blood, and of producing an
opposite change to that now stated. When used
in excess, however, or injected into the veins,
they have been conclusively shown to give rise
to fibrinous concretions in the \ esse',-, to coagulate
the albumen of the blood, to darken its colour,
and thus to render it grumous and unfitted for
circulation through the minute capillary vessels,
particularly those of the lungs. The Influence of
salted provisions long and exclusively employed,
in which the soda is generally in excess, in
attenuating the blood, in preventing its coagula-
tion when removed from the vessels, and in re-
laxing the soft solids; and the effect of acids in
removing these morbid states; are well illustrated
by the nature, progress, treatment, and prophy-
laxis of scurvy.
113. That the nature of the food materially
affects the state id' the blood is further shown by
the general character id' the diseases most pre-
valent in various communities, living chiefly on
certain kinds of aliment. The inhabitants of
several places in the north of Europe, who live
principally oafish, a large proportion of which is
usually kept until it has become remarkably stale,
or even ainmoniacal, from incipient decomposi-
tion, who seldom partake of flesh meat unless in
a similar state of change, and who dry or smoke
both these kinds of food, instead of salting them,
are generally subject to diseases which arise from,
or are connected with, an impure state, or weak
cohesion, of the circulating fluid. It should not,
however, be overlooked, that the more complete
changes which respiration affects on the blood m
cold climates, and the active exercise of the func-
tions of depuration, under the influence of the
vital energies, serve to counteract the morbid
alterations which this cause would induce. Yet
still the prevalence of disorder in these eliminating
organs, particularly the mucous and cutaneous
surfaces, which preserve the purity of the blood;
and the marked disposition, which all febrile dis-
eases evince, in persons thus circumstanced, to-
wards vitiation of the circulating fluid; and the
consequently low or adynamic symptoms which
characterise their progress and termination; are
sufficient indications of a change in the constitu-
tion of this fluid. It is worthy of notice, that com-
munities which live in the manner now alluded to,
generally employ remarkably acid beverages, usu-
ally consisting of the fermented whey of butter-
milk, and a fermented farinaceous infusion. I
believe that nothing could be used as common
drink better calculated than these to counteract the
ill effects of their diet on the blood. Besides the
acid existing in these beverages, they also contain
much carbonic acid gas, which likewise contri-
butes to their wholesome influence on the blood.
114. The effects of living upon much fresh
animal food, in increasing the quantity of tihrine,
in rendering the blood rich and abundant, and in
disposing to inflammatory diseases, are too well
known in ;dl their relations to require illustration.
But when we consider the influence of various
kinds of aliments in modifying the state of the
blood, we ought never to overlook that, as its
organization and vital manifestations commence
with the chyle, and depend upon the vital con-
dition of the vessels and tissues, and upon the
it. il' I discharge of till the functions which con-
tribute to its formation and purification, the extent
of mischief produced by unwholesome food will
be commensurate with the deficiency of vital
energy, and the imperfection 'of the various or-
ganic functions, A person of a robust constitution,
breathing a pure air, and assisting the eliminating
functions by regular exercise, will sutler much
less, than the debilitated, the indolent, and those
placed in unhealthy localities, from either un-
wholesome food, or from the accidental ingestion
of injurious substances. A person thus circum-
stanced will also sutler less from the habitual
188
BLOOD — its Morbid Rklations.
indulgence in too much animal food; but more
commonly such indulgence will give rise to a
superabundant secretion of uric acid, and favour
gravel. In such persons, also, there is reason to
suppose that urea, or uric acid, may exist in the
blood, and be deposited from it in various parts of
the body, particularly the small joints. The uric
acid, which becomes thus abundant, is a highly
azotised animal principle, obviously formed from
the excessive use of food which abounds in azote;
and when its appropriate emunctory, the kidneys,
fail of carrying it out of the blood, it is secreted
in other parts.
115. B. Imperfect performance of the functions
of depurution, a chief cause of morbid states of
the blood. — The evident influence of this class of
causes renders it a matter of surprise that it has
been so long overlooked in our estimation of the
causation of disease. When the facts which
have been brought to light by the successful
investigation of the animal functions are duly
weighed, and estimated in connection with the
sources of impurity to which the circulating fluid
is exposed, the importance of assigning a due rank
to this kind of morbid agency will become mani-
fest. When we consider the important changes
that take place in the lungs — the quantity of
carbonaceous fluids constantly discharged through
this organ, and of watery vapour loaded with
various impurities continually exhaled from its
surface, and passing out with the expired air; or
the abundant perspiration, sensible as well as
insensible, constantly issuing from the cutaneous
surface, and holding dissolved in it substances
which require to be eliminated from the circula-
tion, owing either to their excess or their foreign
and hurtful nature; or the varying state of the
urinary secretion, the quantity eliminated, and
the changes it manifests from variations of tem-
perature, atmospheric moisture, and especially
from the abundance and nature of the ingesta;
or the discharges which the female experiences
during the greater part of her average duration of
life; or the secretions formed by the liver, the
internal surface of the bowels, the pancreas, &c.
out of elements which, if not combined into these
new forms, and destined to ulterior purposes,
would become poisonous to the frame, by vitiating
the blood; it must be evident that an interruption
to any one of these several functions, if not com-
pensated for by the vicarious increase or modifi-
cation of some others, must be followed by alter-
ations of the quantity, of the quality, of the relative
proportion of the constituents, and even of the
vitality of this fluid.
116. a. Under the due dominance of the vital
energy of the system — and particularly of that
influence exerted by the organic nerves on the
great secreting viscera, and on the whole vascular
system — no sooner does any substance, which may
have been carried into the circulation, or accu-
mulated in it, become injurious, than it is elimi-
nated bv the appropriate action of some organ,
which often evinces a kind or degree of disorder,
either in its actions, or in the state of its secretions,
according to the nature of the substance which
affects it. Thus, we perceive various substances
and kinds of food, even in health, affect the
actions and secretions of the kidneys, of the skin,
and of the bowels; certain of their constituents
becoming sensible in the halitus of the expired
air, in the perspiration, or in the urine, where
they could be transported through the channel
of the circulation only. The fa-tor, &c. of the
breath, and of the perspiration, &c. consequent
upon interruptions of the abdominal secretions,
also indicates that impurities have accumulated
in the circulation, and that they are being elimi-
nated by means of the lungs and skin. Ho long
as the vital energy is sufficient for the due per-
formance and harmony of the functions, injurious
matters are seldom allowed to accumulate in the
blood to the extent of vitiating its constitution,
without being discharged from it by means of
one or more organs; but as soon as this energy
languishes, or is depressed by external agents and
influences, and the blood is thereby either im-
perfectly formed, or insufficiently animalised and
depurated, some one of its ultimate elements or
proximate constituents becomes excessive, and the
chief cause of disorder, whicli terminates either
in the removal of the morbid accumulation, or in a
train of morbid actions and organic lesions. These
very important pathological facts are so fully
proved by the history of the most prevalent and
serious diseases, and by their terminations and
results, and are so perfectly unopposed by acci-
dental or occasional exceptions, that proofs or
illustrations of their value and uniformity are
superfluous.
117. Thus it will appear that, although changes
in the secretions and in the blood itself are most
influential in the production, perpetuation, and
aggravation of disease; yet such changes are
prevented, controlled, and even in some cases
promoted, by the state of the nervous energy and
vital actions of the frame; to which influence they
are always more or less subject, unless when the
causes of the disorder are so intense, in relation
to its state, as entirely to annihilate it, as is occa-
sionally remarked in respect of the most pesti-
lential diseases, and of the operation of some
virulent poisons. Thus, also, will it appear, not
only that hurtful matters carried into the circula-
tion, and ultimate elements or proximate constitu-
ents allowed to accumulate hi it, owing to the
imperfect performance of some eliminating func-
tion, will be removed from it, when the vital
influence is sufficient for the task; but that both
kinds of injurious agents will, according to their
natures, become productive of a vitiated state of
the blood, of the secretions formed from it, and
even of the various tissues themselves, when the
state of vital manifestation, particularly as displav-
ed in the organic nerves, is insufficient to remove
them from the frame, or to control their combina-
tions, or to direct them to salutary changes.
118. Before leaving this important subject —
important in as far as it involves the fundamental
doctrines of disease, and points to rational indi-
cations of cure — I may briefly illustrate it bv a
reference to two or three facts, which are of every
day occurrence. It has been long known that
affections impeding the functions of the lungs are
frequently attended with an increased secretion
of bile. This I have shown to depend upon the
liver being excited to increased action bv the car-
bonaceous and other elements accumulated in the
blood, owing to their elimination by the lungs
being interrupted; and thus^we readily recognise
the cause of the frequent complication of biliary
disorder with pulmonary disease, particularly in
BLOOD — its Morrid Relations.
189
Borne hot countries. In cases, also, where, ow iog
to asphyxia, or to disease, as pestilential cholera,
&c, the requisite changes by respiration are not
effected in tne blood, it" recovery take place, the
diseased states of the secretions of the liver and
bowels indicate that the favourable result has
been chiefly owing to the increased performance,
under the influence of life, of the functions of
these organs. When death occurs from asphyxia,
and particularly it" ii be occasioned by the vapour
of charcoal, the black, fluid, or dissolved state of
the blood, the presence of yellowish globules like
oil, sometimes observed on its surface, and noticed
by M. Raver, sufficiently indicate the changes
produced in this fluid, and the influence these
changes exert on the chief functions; and if re-
covery is effected, the evacuations evince that the
principal secretin;; organs have been the means of
removing the morbid matters from the blood. A
strict enquiry, also, into the changes which pre-
c ede a favourable termination of the latter stages
of malignant diseases, manifestly delects the in-
fluence of the secreting and eliminating organs
in bringing about this result, and chiefly by their
operation, under the influence of life, upon the
blood.
1 19. b. That high ranges of temperature occa-
sion very important changes in the state of the
blood, had been remarked by several of the an-
cients and by some of the best writers of the
eighteenth century; but the chief mode of its op-
eration was first pointed out in a thesis written
by me in 1815. I there showed that increased
atmospheric warmth, particularly when accom-
panied with moisture and miasma! exhalations,
greatly diminish the changes effected during re-
spiration on the blood in the lungs; and that the
carbonaceous, and other elements and impurities,
are imperfectly discharged from the blood through
this channel. I further showed, both in that pro-
duction, and in my physiological notes, that these
materials are partly combined to form bile, thus
occasioning an increased as well as vitiated secre-
tion of this fluid, and partly excreted by the mu-
cous surface of the intestinal canal, and by the
skin; and that, if the functions of these organs, —
the liver, skin, and intestinal mucous surface, —
which thus compensate the diminished actions in
the kings, he at all impeded under such circum-
stances, the elements, which they should have
eliminated from the blood, necessarily accumulate
in it, and influence the functions of the nerves,
ramified on the blood-vessels, and of the principal
secreting organs and surfaces, ultimately vitiating
the blood and all the soft solids of the body, when
the vital energies become depressed or exhausted,
and the train of morbid phenomena experiences
no change lending to health.
120. Thus, we perceive that, during high ran-
ges of temperature, particularly when the air is
loaded with miasmata, and the liver is inactive,
the elements of the bile will accumulate in the
blood, sometimes even to the extent of giving the
countenance a darker or more dusky tint than
natural, and the blood will be changed, 1st, by the
superabundance of the materials whence bile is
secreted; and, 2d, by the passage of this fluid, or
of certain of its constituents, into the blood, after
its secretion has taken place. In the foregoing
manner (§ 1 19.), I explained the prevalence of
biliary disorders, particularly bilious cholera, diar-
rhcea, dysenterj , increased secretions of bile; and,
in warm climates and seasons, ami when vegeta-
ble and animal miasms an superadded to this in-
fluence, the occurrence oi' fevers of various kinds
— remittent or continued, simple or complicated,
biliary or malignant, inflammatory or dysenteric,
endemic or epidemic, sporadic or pestilential —
according to the circumstances of individuals, the
kind of locality, the nature, combination, and
source of the miasm, and the state of the atmos-
phere. This doctrine, now many years since
contended for, later experience, and the concur-
rent opinions of more recent observers, have fully
confirmed. (See Fever.)
121. c. Several states of disease, which occur
in the puerperal state, may be referred to the ar-
rest of the secretions or discharges incidental to
it. The secretions from the internal surface of
the uterus, and which partly consists of the bloody
serum poured into the uterine cavity from the
open mouths of the vessels which communicated
with the placenta, are not infrequently arrested
or impeded. In such cases, the blood does not
undergo that salutary depuration which this evac-
uation occasions; and, consequently, either expe-
riences further disorder, or it creates a disposition
in the system to the invasion of other causes of
disease. Besides, the fibrinous and albuminous
parts of the blood, which are generally in excess
during pregnancy, not having been discharged by
this route, determine the occurrence of inflamma-
tion of the uterus, peritoneum, &c. upon the co-
operation of exciting causes. Or, if such causes
have produced these diseases, the obstruction or
interruption of the secretions and discharges, which
is generally thereby occasioned, aggravates the
mischief, and the post mortem appearances often
furnish more or less evidence of the suppression
having been concerned in modifying the re-ults;
the matters poured out from the diseased parts
frequently resembling, or containing constituents
of, the secretion which was suppressed, how
are we to account for this ? W e find it demon-
strated, that the materials of both bile and urine,
owing to obstruction of these secretions, may be
mixed with the blood, and give rise to certain
well known symptoms. We may, therefore, ex-
tend the same principle to suppression of the
puerperal secretions; and infer, that the matters
which constitute them, having accumulated in, or
not been eliminated from, the blood, are discharg-
ed along with those effusions of albuminous serum
which frequently follow the diseases of this state,
even although they may not actually be the causes
of these diseases.
122. Graeffe of Berlin (Rev. Mt'd. Jan.
1S27.) states, that a female, in a favourable state,
and suckling her child, experienced a fright on
the eighth day after delivery, which occasioned a
complete suppression of her milk. Febrile ex-
citement followed, and effusion took place in the
peritoneal cavity and cellular tissue. Upon tap-
ping a few weeks afterwards, a bucket of fluid,
resembling whey, and exhaling an acidulous
odour, was drawn off. Upon being boiled with
dilute sulphuric acid, it furnished a substance re-
sembling caseum. When tapped six weeks after-
wards, the fluid was of a greenish yellow, and
without the least trace of caseum.
1 23. That changes in the composition or state
of the blood are also followed by alterations of
190
BLOOD — its Pathology in Fevers.
the natural secretions, is fully shown by both
physiological and pathological facts. It is not,
therefore, unreasonable to suppose, that modifica-
tions or changes of morbid secretions will be oc-
casioned by a similar cause. Indeed, alterations
of the latter are quite as likely to be the conse-
quence of pathological conditions of the blood, as
changes of the former.
124. d. In cases, where the functions of the
skin, or of the kidneys, are interrupted, not only
are the watery parts of the blood frequently in-
creased, but also various irritating matters accu-
mulate in it, unless eliminated by other organs.
These excite more or less disturbance of the whole
vascular system; and if the cause continues, or is
assisted by concurrent causes, the blood itself be-
comes very evidently changed, in respect both of
the state of its eruor and of its serum. The ef-
fects of obstruction of the bile on the blood, and
mediately on the tissues, are sufficiently apparent
to the sight; and the actual presence of this fluid
in the circulation, or, at least, the peculiar matters
which characterise it, has been shown by several
modern chemists, and completely demonstrated
by the recent researches of MM. Proust, Orfi-
la, Gmelin, and Le Canu. Put it is unneces-
sary to prosecute the subject further, as I consider
that the grand pathological inference, that the in-
terruption or obstruction of any important secre-
ting or eliminating function, if not compensated
by the increased or modified action of some other
organs, vitiates the blood more or less; and, if
such vitiation be not soon removed, by the re-
storation of the function primarily affected, or
by the increased exercise of an analogous func-
tion, more important changes are produced in
the blood, if the energies of life are insufficient
to expel the cause of disturbance, to oppose the
progress of change, and to excite actions of a
salutary tendency.
125. e. Illustrations. — The importance of
this conclusion will become still more manifest,
if we illustrate it by reference to the pathology
of fever, and observe the train of morbid phe-
nomena produced by its causes. These, although
modified even still more infinitely than the combi-
nation of causes in which they originate, present
the following almost unvarying characters and
mode of procession : — A person exposed to the
miasmata generated from vegetable or animal
matter in a state of decay, or from persons affect-
ed with fever, inhales such miasmata into the
lungs, where they produce a morbid impression
on the nerves of organic life, followed by depres-
sion of the vital influence: the functions of diges-
tion and secretion languish, and, owing to the im-
perfect performance of secretion and assimilation,
the necessary changes are not fully effected in the
blood; and thus irritating or otherwise injurious
matters accumulate in it. These phenomena gen-
erally proceed gradually, until, owing to the con-
tinued and augmented depression of the vital
powers throughout the frame, and the increasing
change in the state of the blood, marked disorder
is occasioned. The vascular system becomes ex-
cited by the quantity and the quality of its con-
tents; and, when the vital energies are not too far
depressed for its production, the excitement be-
comes general. The accelerated circulation tends
still more to disorder the state of the blood; but it
also has the effect, in the majority of cases, of ex-
citing the organic functions, of restoring the se-
cretions which were impeded or interrupted, and
thereby of removing the morbid state of the cir-
culating fluid; after which the return to health is
rapid. When, however, salutary reaction of the
vascular system is not brought about, owing to
the morbid depression of the vital energy, and to
changes which had taken place in the blood; or,
if reaction occur, but, owing to the state of this
fluid, and of the nervous influence to which it is
subject, it is irregular, imperfect, or excessive: the
vitiation of the blood proceeds; the secretions are
also vitiated; the solids affected; one or more vi-
tal organs suffer in an especial manner; the ener-
gies of life are exhausted; and various organic
lesions are induced, having reference to the pre-
vious state of the system, the kind of change pro-
duced in the blood, and the agencies in operation
during the progress of disease.
126. ^uch is the general procession and char-
acter of the morbid phenomena; and we observe
in them certain prominent features, by means of
which the various species of fever are recognised.
They may be briefly stated to be, — 1st, The im-
pression of the causes on the nerves of organic
life, the depression of their energies, and imperfect
performance of all the functions which thev in-
fluence: 2d, More or less vascular excitement or
change in the state of vascular action, and of the
circulating fluid: 3d, Frequently predominance of
disorder of some one general svstem, or vital or-
gan: 4th, Consequent exhaustion, with either a
gradual restoration of the functions, followed bv a
return to health; or more marked vitiation of the
blood, of the secretions formed from it, and of the
solids of the body, often terminating in organic
changes, or death.
127. Here we observe three different states of
vital action, in each of which the blood generally
presents very different appearances. 1st, The
state of depression and invasion of fever, in which
the blood taken from a vein is of a very deep or
dark colour; flows with difficulty; frequently oc-
casioning syncope, or great depression upon the
loss of a few ounces; and generally coagulates
rapidly, and separates into a very dark, large, and
soft coagulum, which falls low in the serum — the
quantity of which is extremely small in propor-
tion to the clot. Not infrequently the separation
is very imperfect, and the coagulum extremely
large and soft. 2d, The state of reaction, or fe-
brile excitement, in which the blood flows more
freely from the vein, and of a brighter colour, oc-
casioning little immediate depression until a more
considerable quantity is abstracted; is apparently
thinner than natural: coagulates much more slow-
ly, and separates into a somewhat more firm co-
agulum, than in the former state of disease; and
occasionally exhibits a thin fibrinous laver on its
surface: in several malignant cases, however, even
in this stage, either the separation of serum is
very imperfect, consisting chiefly of a deep ge-
latinous layer, beneath which the colouring mat-
ter is deposited in an extremely loose state, and
dark colour; or the blood remains imperfectly
coagulated, and of a gelatinous consistence. 3d,
The state of exhaustion, in which the blood gen-
erally flows readily; but is uncommonly thin.
dissolved or attenuated, and dark coloured; occa-
sions great increase of exhaustion; and either
scarcely coagulates, or separates into a remark-
BLOOD — its Pathology in Fkvers.
191
ably loose coagulum, which lies ;>t the bottom of
the vessel; the serum varying much as to quan-
tity and colour ; being often turbid, clouded,
watery, or slightly viscous, and less saline in its
taste.' Sometimes the coagulum which falls to
the bottom of toe vessel is so loose, that it appears
as a precipitation of the colouring matter, of a
very dark colour, and is readily stirred up into the
supernatant scrum (§ 94. 10S.). In nearly all
the eases where I have seen blood taken, either
in the state of depression or in that of exhaustion,
but particularly in the latter, either little or no
tibrine could be collected from the coagulum; or
what was obtained was scanty, remarkably loose,
and even tlocculent, and nearly albuminous.
Throughout the progress of typhus, the venous
blood is generally watery, and without consist-
ence,— a fact to which my attention was called
mam years ago by the late Professor IIilden-
bkam). at Vienna. In the later stages of typhoid
or malignant levers, it seems nearly altogether
deprived of tibrine. In two or three cases, the
blood was abstracted in these states chiefly with
the view of examining its appearance. But sev-
eral instances have occurred to me, in which I
have found that blood had been drawn, although
the nature of the symptoms, and the state of this
fluid, equally contra-indicated the propriety of the
practice.
128. With respect to the post mortem appear-
ances of the blood in the vessels, 1 stated, many
years ago, when describing the symptoms and
morbid appearances of yellow fever, several cases
of which 1 had an opportunity of examining with-
in five hours after death, in the years lSl6and
IS 17, that it is generally half dissolved, or fluid and
grumous, dark coloured, and speedily undergoes
complete decomposition. (Quarterly Journ. of
Foreign Med. vol. ii. 1820, p. 446.) A similar
state of the blood has been noticed by Arejula,
Bally, Palloni, and others, in the epidemic
yellow fever of Spain; and more recently by Dr.
Stevens, who has described the appearances of
the blood in tropical levers with greater minute-
ness than his predecessors, has referred to most
important changes of the saline constituents of this
fluid, and has folly confirmed some very detailed
observations adduced by myself several years
previously ( Appendix to M. Richerahd's Phy-
siology, p. 640, el. ser/.), comprising the general
results obtained from noting the appearance of the
blood in a number of febrile and malignant dis-
eases. Dr. Stevens states (Paper read to the
College of Physicians in May 1830.), that the
blo "1, in these fevers, loses its property of coagu-
lating, becomes more fluid, and thin or watery, of
a much darker colour, and has its tihrine and saline
ingredients exhausted, — changes which I have as-
certained to obtain in a greater or less degree in
the fevers of this country, particularly in their
latter stages, and have described in my lectures
since 1825. (See Fever.)
12'). Besides other proofs of the diseased state
of the blood in fevers, I may adduce the follow-
ing:— In those who were victims to malignant
fevers, Chirac found the blood in the ventricles
of the heart, and the vena cava, more or less
clotted: and all the ramifications of the vena porta
were filled with grumous blood. In those who died
of typhus, at Brest, in 17.iT, the blood was found
grumous, unnatural, black, and decomposed, par-
ticularly in the liver. Soulier observed blackish
blood coagulated in the vessels; anil extremely
fn lid black blood in the stomach, of those who
fell victims to the plague at .Marseilles. Larkky
found the blood black and liquid in those who
died of the plague in Egypt. After intense fevers,
Andral has found the blood contained in the
heart, and in the larger arterial and venous ves-
sels, remarkable for its great liquidity, and its
black and deep colour: in some subjects it pre-
sented a clear rosy tint, and was like water col-
oured red ; some small fibrous grains were then
dispersed over the internal surface of the vessels.
In one individual, the liquid contained in the larger
vessels was no longer really blood, but a matter
the colour of wine lees, sanious in some parts,
nearly resembling the ill-elaborated fluid contain-
ed in unhealthy abscesses.
130. M. Bouillaud found, in two or three
cases, the blood clear and rosy, after putrid fevers;
but it nearly always appeared blacker and more
liquid than in its normal state : this alteration
varied, from the degree in which the clot was
simply flabby, to that in which the blood formed
only a blackened and liquid mass, without any
trace or clot. This blood, being put into a basin,
was brilliant, shining, and full of micacious specks;
in some cases it has been found mixed with puru-
lent matter, or pure pus; at other times it was so
altered and disorganized that it resembled a putrid
mass. Bouillaud justly adds, that in such in-
stances it is not rare to meet with a quantity of
gas, more or less considerable, in the circulating
canal; and also that, although it be difficult to
describe these changes, they should nevertheless
be taken into consideration, if we wish to explain
satisfactorily the phenomena attendant on putrid
fever.
131. The malignant febrile diseases which very
frequently attack horses and cattle are always at-
tended with a remarkable alteration of the blood,
even early in their progress. These diseases are
less frequently met with in this country, than in
marshy and warm climates. In some of the most
pestilential of those, horses cannot be reared; and
when brought into those places, they generally
experience a febrile attack, with adynamic or
malignant symptoms, and speedily die. This is
constantly the case in some parts of Africa, where
the vegeto-animal miasms from the soil are abun-
dant and concentrated. I bad an opportunity of
observing the examination of a horse brought from
the interior to an unhealthy situation on the coast,
where it died, as all others had done, a few weeks
afterwards. It was not much emaciated; but the
blood was black, decomposed, fluid, and sanie, ■;
and tint liver, spleen, lungs, heart, and, indeed,
all the internal viscera, softened, ecchymosed, and
lacerable with the utmost ease.
132. C. Contamination of the blood by putrid
or septic matters applied to the tissues. — These
substances were not inappropriately said, by the
older writers, to occasion a putrid ferment in the
pari to which they were applied. The ferment
may be disputed, but that they produce change
el' the blood is undeniable. If we examine the
subject closely, we can arrive at this conclusion
only, — that the substance applied changes the part
to a state somewhat similar, as respects sensible
properties, to itself; and that this contamination
I soon extends, either by its immediate effects upon
192
BLOOD — Contamination of — Poisoning of.
the organic nerves supplying the vessels, and con-
secutively on the blood, or by the direct introduc-
tion of the contaminating matter into the divided
vessels, or by its imbibition or absorption, or by
one or more of these channels, to the whole body,
aliening, more or less, the blood, the secretions,
and the solids. That these changes take place is
undeniable, although the precise channel of pri-
mary infection cannot be easily demonstrated;
and "is sufficiently proved by the facts already ad-
duced (§ 92.), and by those which follow (§ 1 33.).
The instances of gangrenous or diffusive inflam-
mation of the cellular tissue, arising from contact
or inoculation of putrid animal matter, as record-
ed by numerous writers, and recently by Drs.
Butter and Duncan; the not infrequent in-
stances of it from injury in the dissecting-room (see
Cellula r Tissue, Diffusive Inflammation of);
and the occurrence of putrid fever, with gangren-
ous pustules and carbuncles, particularly amongst
farriers, flayers, and knackers; furnish proofs and
illustrations of the blood being one of the chief,
although, perhaps, not the primary or only, chan-
nel through which the whole frame becomes more
or less infected in a large and important class of
diseases. A most remarkable instance of this,
and at the same time showing to how great an
extent the fluids and solids of the body may be
contaminated, and yet the patient recover, is re-
corded by M. Genbrin.
133. A flayer was affected with putrid fever,
and gangrenous pustules and carbuncles. His
breath, evacuations, and whole body, were horri-
bly foetid ; and blood taken from a vein was,
three hours and a half alter its emission, unusu-
ally dissolved and black; and gave out an odour
resembling that of putrid flesh. A spontaneous
discharge of a black, dissolved, sanious blood,
also occurred from his mouth and nostrils. M.
Gendrin introduced some of the blood taken
from the arm of this person into the cellular tissue
of a cat, and into the femoral vein of a dog. Both
animals evinced symptoms of putrid fever, and
died in a few hours. The blood throughout their
bodies was dark and fluid ; the heart soft and flac-
cid; the viscera congested, and ecchymosed with
dark spots, and speedily began to exhale a fcetid
odour. M. Gendrin also details some experi-
ments, in which he injected into the veins of dif-
ferent animals, the blood of persons affected with
confluent small pox. Very violent effects, rapidly
terminating in death, followed; and, upon inspect-
ing the bodies, several viscera were found highly
inflamed and congested.
134. D. Contamination of the blood from
causes influencing the state of the vascular system,
either directly, or mediately through the nei'ves
which supply it. — Under this head may be com-
prised a very numerous class of causes: and, in-
deed, many of those which were alluded to in
preceding sections may also act in this way. a.
Infectious and contagious miasms and secretions
may change the state of the blood in a more or
less direct manner, as well as by first affecting the
organic nervous system generally, and therein im-
peding or changing the action of vital and secret-
ing organs. Inordinate acceleration of the circu-
lation appears to be frequently followed by serious
alterations of the blood. The experiments of M.
I. • i in several animals show that the fibrine
is either very much diminished, or otherwise
changed, by their being coursed or hunted; as the
blood remains fluid, or becomes dark coloured
and grumous subsequently: M. Chaussier found
that a portion of blood altered by this cause pro-
duced gangrenous pustules and malignant fever,
when inserted into the cellular tissue of sound an-
imals; and the striking instance recorded bv Du-
hamel, and already alluded to, further proves
that a morbid state of the blood is occasioned by
overdriving animals. Haller and Euchner
remark, that vehement exertion renders the urine
foetid, acrid, and scalding ; the perspiration fcetid
and disagreeable; the boold very fluid, acrid, and
vitiated; and, if long continued, occasions most
ardent fever, terminating rapidly in death, and
dissolution of the fluids and solids. Haller re-
fers to two cases where he observed these effects
produced by intense acceleration of the circulation
by running; and adds, that the blood of hunted
animals is often not only fluid, but foetid ; the
flesh becoming quickly putrid. The attenuation
and subsequent alteration of the blood observed
in ardent or other fevers, attended with inordin-
ate vascular action in their early stages, and the
ecchymosis, petechia?, softening of the mucous
tissues, &c. may doubtless be attributed, in part,
to the rapidity of the circulation, or increased
motion to which it is subjected. If we continue
to agitate healthy blood as it flows from a vein,
it becomes thinner than natural, a small portion
of fibrine collects around the stick with which it
is stirred, and the blood remains fluid, as must be
familiar to every one, and long since demonstrat-
ed by Schwencke.
133. b. If any of the neutral alkaline salts,
particularly those with excess of base, be added
to blood as it is discharged, the coagulation will
either be entirely prevented, or imperfectly pro-
duced; little or no fibrine will be formed, and its
colour will become more florid. These facts have
long since been noticed by Verheyn, Eller,
Rutty, Haller, &c. The injection of acids,
or the metallic salts, particularly those with any
excess of acid, render the blood dark coloured, and
changes it into a grumous fluid, from partially coag-
ulating its albumen and fibrine. The experiments
of Eller, Gianella, Duhamel, Friend,
Courten, Rutty, De Heyde, Sproegel,
Aalsem, Borrich, Petit, and various others,
prove this effect; and further show, that when
these substances are added to blood taken from a
vein they either accelerate its coagulation, render-
ing the coagulum firm; or, if strong solutions are
employed, the coagulation is irregular, the sepa-
ration of the watery portion is more perfect, ar.d
the coagula are of a dirty black or dark brown
colour. The attenuating effects'of the fixed and
volatile alkalies, and of their subcarbonates, both
upon the blood and the secretions formed from it,
particularly when long employed, will be consid-
ered as proved by any one who will peruse the
experiments of Schwencke, Friend, Eller,
Rutty, Courten, Pitcairne, Thackrah,
and Scuda more, without the bias of system; and
they are confirmed in my mind by some observa-
tions I have made of the results when these sub-
stances are mixed with blood immediately after
venaesection, or when exhibited internally in large
doses for sometime previous to abstraction of the
blood; whilst directly opposite effects are observ-
ed to follow the internal use of acids. In the
BLOOD — Nervous Influence on the.
193
latter case, the coagulum is firm, the blood of a
deep or dark colour, and the fibrine abundant :
in die former, the blood is thin, of a brighter
colour, the ceagulum much less firm, and the
quant it \ as well as the cohesion of the fibrine
diminished.
13l>. The effect of the fluid extract or tincture
of opium, alcohol, tonic or astringent tinctures,
and of spirits of turpentine upon the blood, is to
increase its coagulability; and, when injected into
the veins in sufficient quantity, to produce death,
as in similar experiments with acids and the
metallic salts, chiefly from this mode of opera-
tion. The experiments of CoURTEN, Friend,
YOCNGE, SCHWENCKE, De HeYDE, SPROE-
gkl, Silberling, and Fontana, fully prove
these facts. The accuracy of the results as to one
of these substances has been confirmed by the ex-
periments of the writer. That both alkalies, acids,
and salts, act upon the system chiefly from their
being absorbed and carried into the blood, has
been satisfactorily demonstrated by Magendie,
Tiedemann and Gmelin, Mayer, Wes-
TRUMB, and various others, and will not be now
doubled, although the active exercise of the eli-
minating functions, which their very presence in
the blood generally promotes, prevents their ac-
cumulation there to any considerable or dele-
terious extent, unless they have been taken in
poisonous doses. They have, nevertheless, been
absorbed in such quantity as to be detected both
in the blood and in the various secretions by
means of chemical agents, as demonstrated by
M VI. Grognier, Chaussier, Oreila, and bj
Buchner, Krimf.r, Bennerscheidt, Schu-
barth, and Dr. O'Shaughnessy.
137. c. The interesting researches of MM.
Gaspmi!) and Magendie, in order to ascertain
the effects of putrid vegetable and animal matter
when introduced into the cellular tissue or in-
jected into the blood, further illustrate the im-
portance that is to be attached to morbid states
of this fluid, as well as the origin and nature of
various diseases. These physicians have fully
proved that such substances, when thus employ-
ed, produce symptoms very similar to those of
vellow fever, and typhus ; and that, after death,
this fluid h found remarkably altered, being near-
ly altogether fluid, of a very dark colour, and
partially exuded from the capillaries, both into
the parenchyma of the viscera, and from the mu-
cous surfaces. That the blood is really altered
in its nature by this inoculation, is proved not
only by those changes, but also by the circum-
stance of its having lost the power of coagulating
upon removal from a vein soon after it has been
thus infected, and hy its speedy putrefaction.
The more recent experiments of .MM. Leu ret
and 1 1 Amu nt furnish the like results; whilst those
performed by M. Magendie show that dogs con-
fined over, and breathing the effluvium proceeding
from, animal and vegetable matters undergoing
IV, experience similar symptoms to those now
referred to, and the same alterations of the blood,
of the secretions, of the excretions, and of the
viscera, as observed in yellow fever : and, in all
these cases, the morbid changes also extend more
or less to the soft solids, anil particularly to the
mucous surfaces, the Ihul's, the liver, the heart, &c.
138. A most interesting fact Ins been stated by
M. Lr.ui-.i.T, ;uid one which fully illustrates the
17
views T have entertained respecting the nature of
certain forms of puerperal fever. This physician
injected some blood from an artery of a living
horse affected?" with gangrenous boils (pustule
maligne) directly into the veins of a mare five
months with foal. She died live days afterwards.
The heart, lungs, and intestinal canal were stud-
ded with dark eechynioses, the uterus was gan-
grenous, and the blood dissolved and dark colour-
ed. But, in all the cases wdiere poisoning has
resulted from the injection of septic or putrid
matters into the circulation, or from virulent and
rapidly fatal poisons, it must not be overlooked
that, although the more manifest lesions are often
observed in the blood, the injurious agent affects
also the organic nerves terminating in the vessels,
and consequently the vitality of the vessels them-
selves, altering the blood they contain, and there-
by ultimately contaminating all the secretions and
solids of the body ; and that the mode of opera-
tion of the greater number of these septic agents,
whether applied in an aggregate or palpable
form, or from being dissolved in the moisture of
the air, is very different from that of the saline
and mineral substances considered above, which
affect the blood more especially. (See Infec-
tion.)
139. d. The direct influence of the nervous
system upon the blood was long since contended
for by Barthez, and admitted by several phy-
siologists. The chief error, or rather mischiev-
ous fallacy in their theory, however, being, that
this influence was imputed to the cerebro spinal
nerves, and not to the ganglial nerves, to which
it almost entirely belongs. This great mistake
also vitiates the opinions promulgated on the sub-
ject by Mr. Brodie and Dr. W. Phillip. The
opinions, which I have entertained, and frequent-
ly expressed, that the power exerted by the ner-
vous system on the blood is limited to the organ-
ic or ganglial class of nerves, and that their func-
tions are very distinct from those performed by
the cerebro-spinal class of nerves, the influence
of the former having been too generally and er-
roneously imputed to the latter, have been al-
ready aliuded to. Since their promulgation many
years ago, numerous proofs of the accuracy of
these views have been furnished in different coun-
tries. That the effects produced by the organic
nerves take place chiefly in the minute vessels
may be safely assumed ; and that a reciprocative
influence is exerted by the blood upon these
nerves will not be denied : but it. may also be
inferred that the effects produced by the organic
nerves are not limited to the small vessels. Pro-
fessor Mayer's experiments support this opinion.
He found that, when both pneumogastric nerves
were tied, the blood coagulated in all the pulmo-
nary vessels, the colouring matter having sepa-
rated from the fibrine ; and that this change was
not the consequence of death, but its antecedent,
since it was uniformly found upon opening the
bodies the moment they expired. M. Dupuy-
trfn had previously ascertained, that a simple
division of the pneumogastric nerve prevented the
venous from being converted into arterial blood
in the lungs.
110. M. Dupuy found that, when the pneu-
mogastric nerves were divided in the cervical
region, in horses, the quantity of fibrine in the
blood became progressively diminished to a very
194
BLOOD — Operation of Poisons on the.
remarkable extent ; and that a similar result fol-
lowed laborious breathing in disease. lie farther
stairs, that the blood throughout the animal was
entirely dissolved after the pneumogastric nerves
had been divided; and he adds that, when a por-
tion of this blood is injected into the jugular vein
of another horse, a gangrenous affection is pro-
duced (§ 92.). But these effects are compara-
tively slow ; for in order that they may take
place, the division of these nerves must previous-
ly affect the ganglia and plexi supplying the lungs
and heart, and with which they are in intimate
connection. When, however, these ganglia are
immediately impressed, the effect is much more
rapid. Such impression cannot, however, be
readily made upon the ganglia themselves, owing
to the protection their situation affords them from
experiments of a conclusive kind. But as we find
that agents, which do not affect the system when
applied to the voluntary nerves, or the brain it-
self, will act rapidly .when brought in contact
with parts which are especially provided with the
other class of nerves, and manifest the effects of
this mode of operation upon the parts more im-
mediately influenced from this source, we must
necessarily conclude that the morbid impression
of poisonous substances is primarily exerted upon
die latter, and not upon the former ; and hence
the rapidity of their effects upon the blood, —
effects which are productive, no doubt, of most
important consequences throughout the economy,
which I am endeavouring to estimate fully and
fairly, but which should not altogether obscure
our perception of earlier changes, which alone
can account for all the phenomena. A severe
blow over the cceliac ganglion will produce in-
stant death, and the blood will remain dissolved,
and exhibit the same appearances as after death
by lightning and the most virulent poisons. Here
we can attribute these remarkable changes only to
the sudden concussion, and annihilation of the in-
fluence exerted by this important part of the or-
ganic or ganglia) class of nerves — by this central
source of vital power, upon the vascular system,
and to the effect thereby produced upon the blood.
141. Seeing, therefore, that the organic or
ganglia] nerves are chiefly distributed to the very
internal membrane of the blood-vessels for the
purpose of transmitting their vital influence to
the blood itself, it must be inferred that, al-
though various substances or poisons may seem to
act more particularly and immediately upon the
blood, and others more directly on this class of
nerves, according as they are applied within or
without the vessels, the action cannot be restricted
to either ; for whatever changes the state of the
one, must affect the other. That poisons, when
introduced into the blood, will have an almost in-
stantaneous effect, but not in the manner usually
explained, may be readily granted and accounted
for. The views upon the subject frequently stat-
ed by the Author in the Medical Repository, and
in his Physiological Notes, seem more in accord-
ance with the resulting phenomena ; and are
moreover confirmed by experiments and obser-
vations recently made by others ; for when the
poison has been applied to the cerebro-spinal
nerves, it has been found by Orfila, Fontana,
and others, to have no further operation, or even
less, than when applied to other tissues, because
it Is not directed to that particular organization,
upon which the functions of life more immediate-
Ij depend. But when injected into the b!ood, it is
applied to the terminations of the organic nerves
in the blood-vessels — to that particular quarter
where the life of the tissues and of the blood is
either generated or supplied, — to the seat where
the influence of these nerves affects, even if it
does not vitalise, the circulating fluid, and the op-
eration is instant and most manifest. Ihe reader,
who, possessing an intimate acquaintance with
the healthy relations of the organic nerves to the
blood-vessels on the one hand, and to the cere-
bro-spinal system on the other, examines the nu-
merous experiments which have been performed,
— by one class of experimenters to show the ac-
tion of poisons upon the nerves, confounding, as
all have done, the ganglial with the cerebro-spin-
al nerves, — and by another class to demonstrate
the operation of these substances on the blood
solely, both sides leaving reciprocity of action, or
rather the rapid change occasioned by one system
on the other, too much out of the question ; and
is able to detect the fallacies with which they
nearly all more or less abound, chiefly from con-
founding distinct functions, and even different sys-
tems, with one another ; will entertain but few
doubts that the influence of various poisons, al-
though more manifestly indicated in the blood, is
chiefly exerted upon the nerves which terminate
in the blood-vessels ; and that the alterations in
the contents of the vessels arise principally from
previous changes produced upon these nerves,
however rapid the succession of the phenomena
may be.
142. The celebrated and accurate experiments
made by Fontana on the venom of the \ iper
and the ticunas can be justly estimated only in
accordance with this view ; for when these sob-
stances were applied to the cerebro-spinal nerves
no more rapid ellect was produced by them than
upon any oilier tissue: but, when injected into the
veins, a fatal result was almost instantaneous ;
the blood, in the words of this able experimenter,
being suddenly changed to a livid black, and
soon afterwards coagulated in the lungs, heart,
auricles, and liver, as well as in the large veins,
with violent disease of the structure of tiie lungs.
Now, as these substances, when added to blood
as it is drawn from a vein, preserve its fluidity,
they must produce, on the organic nerves ramified
to the blood-vessels, a most intense eriect ; the
alteration in the blood resulting evidently from
antecedent change in the vital influence of these
nerves, since no such alteration is occasioned by
them when added, even much more abundantly,
to blood as it flows from a vein. And there can
be no doubt that virulent poisons introduced into,
or having access to, blood contained in the ves-
sels of a living animal, however the vessel may
he insulated from surrounding nerves, must come
in contact with its interior, and thus have an oc-
casion given them to act upon the independent
class of nerves which is especially devoted to
the blood-vessels. That the very instant and
intense effects which I have, in three instances,
seen produced upon the blood of the human sub-
ject from the bites of serpents, and which have
been minutely described hy Orfila, Font w \.
and many others, cannot arise from the diffu-
sion of the poison in the blood, must be evident
from the rapidity with which they occur, hut
BLOOD — Signs of its Disease.
195
from the morbid impression made by them upon J
tin- vital or ganglia] nerves, and instantly propa-
gated throughout the frame; tl Recta of this
impression Bret appearing as a manifest lesion in
the p url where the injury was inflicted, and in the I
bleed, which, as a part of the vascular system, isj
co-ordinately affected with the class of nerves
supplying both it, and the vessels which contain
it. with vital influence. From the mode of oper-
ation, therefore, of all the most virulent poisons,
as pruasic acid, the venom of the viper, ticunas,
&c, I infer, that, as the organic system of nerves
may be intensely affected, without altering the
state of the brain more than that of any other im-
portant organ, and then secondarily merely, so
may those poisons destroy life by their effects :
upon this system of nerves primarily and chiefly,
lesions being consecutive, amongst which
the alteration of the blood is the next most im-
mediate, and the next most important in its rela-
tions and consequences. (See Poisons.)
i !.!. E. The passage into the blood of morbid
matters formed in the same body that is the seat
of disease, has been particularly noticed in the
articles on Absorption and Inflammation of Veins.
I have shown, when treating of these subjects, as
well as of certain organic and malignant diseases,
that vitiation of the blood, and ultimately of the
soft solids more or less, is a very frequent occur-
rence; that it is hastened or promoted by depres-
sion of the vital energies; and that this fact, as
well as the vitiation of the blood, should be taken
into account in treating these maladies, parti-
cularly in their more advanced stages. It is
probable that morbid matters may sometimes
exist in the blood without very materially affect-
ing its condition; but they much more frequently
occasion very important changes in its constitution,
as must appear fom what has been stated, parti-
cularly when the powers of life begin to languish.
Pus has been often detected in the veins which j
convey blood from parts undergoing the suppu-
rativa process, both by the older physicians and
by recent writers, particularly BlCHAT, Fizeau,
Velpeau, Rocfloos, Gendrin, Andral,
Dance, Breschet, and Ribes; and it seems
very probable that, when thus absorbed, and not
mixed with, or eliminated from, the circulation,
it gives rise to various changes of the blood in the
vessels, not only from attracting the fibrinous cor-
puscles in the manner already noticed (§ 85.),
but also from combining with albuminous or other
constituents of this Quid. 1 further believe, that
the sanies which flows from chronic ulcers, or
from the inside of veins when affected with spread-
ing inflammation of their internal surface (see
Veins.), and from the internal surface of tin;
uterus in certain states of puerperal disease; anil
that the tubercular and enccphaloid matter which
often forms in internal viscera; may all be carried
into, and most sensibly ati'ert, the circulating iluid,
and, through it, all the functions and structures of
the body.
lit. .M. Andral states, that he has often
found in the blood-vessels, instead of blood, a
curdy friable matter, of a dirty gray colour, and
resembling either the semi-concrete pus of chronic
abscesses, or the sanies of malignant ulcers, or
encephaloid matter broken down and mixed with
blood ; and similar instances are recorded by
Bichat,Beclard, and Velpeau. In all these
cases, abscesses, tubercles, or other morbid for-
mations, also existed in some part of the bodj .
(See arts. Absorption, Aiiscess, &c.) in
many of such cases, it is difficult to determine
what may have been the state of the general
mass of blood in the latter stages of the disease,
owing to the period which had (lapsed from the,
dissolution of the patient to the examination; but
it is very probable that the morbid matter found
in the vessels had materially affected, either di-
rectly, or mediately through the organic nerves,
the constitution of the whole fluids and soft solids
of the body.
145. iv. Phenomena materially depend-
ing UPON A VITIATED STATE OF THE BLOOD,
AND SERVING TO INDICATE ITS EXISTENCE.
I have contended that the functions of depuration
are very frequently concerned in occasioning, as
well as in removing, a morbid condition of the
circulating fluid, 'ihese functions will, therefore,
evidently present some modification, when per-
forming this latter purpose, inasmuch as the state
of the blood, and of the impurities requiring
change and elimination, will excite in them, as
well as throughout the soft solids, more or less
disturbance, hi the slighter cases, the disorder
of function will be less apparent ; but even in
these, and still more remarkably in the more
severe cases, the particular function most dis-
turbed will generally evince some relation to the
kind of change existing in the blood. This re-
lation of the change or impurity of the blood to
the functions of viscera is very similar to the
mode of operation and effects of very many
medicinal substances, which, having been carried
into the circulation by the function of absorption,
act upon particular organs according to the cir-
cumstance of their exciting or otherwise changing
the vital condition of these organs, while they are
being circulated through or eliminated by them.
146. As respects, however, this relation of the
pathological states of the blood, much requires to
be ascertained, or rather but little is yet known
beyond a few facts evincing that such relation
sometimes actually exists. Thus we observe that
excess of carbonaceous elements in the blood is
removed chiefly by means of the liver, occasion-
ing an abundant and vitiated secretion of bile.
We may frequently remark, that an imperfectly
elaborated chyle, or the partial absorption of
sordes from the intestinal canal, renders the
breath fetid, and the urine loaded, or otherwise
changed ; that accumulation of the materials
usually eliminated by the kidneys produces copi-
ous urinous perspirations, and the exhalation of a
copious fetid balitus from the lungs ; and thai
putrid vegetable and animal matters, or morbid
secretions carried into the circulation, derange the
digestive mucous surface, and secreting organs, in
a somewhat greater degree than other parts.
147. A. It obviously becomes most important
to enquire if the phenomena resulting from change
in the blood slowly brought about, or proceeding
from pre-existing disease of important functions
are different from, or are nearly the same as,
those which arise from the introduction of putrid
or morbid matters directly into the circulation.
We observe in the last stages of malignant dis-
eases, when the blood undoubtedly becomes
changed, that all the secretions are remarkably
offensive, acrid, and even excoriating. The
196
BLOOD — Signs of its Disease.
breath, perspiration, urine, ar.d stools, aie foetid;
and the surfaces and parts with which the secre-
tions and excretions come in contact, experience
more or less change in their vital actions, and arc
disposed to undergo rapid disorganization. All
the circulating and secreted fluids have acquired
septic and irritating properties ; and discharges
of sanguineous, or black, grumous, fluid matters
sometimes take place from the digestive canal.
The whole soft solids also lose their vital cohesion
and tonic contractility, and are rapid y destroyed
upon accidental injury and pressure. Hence the
frequency and severity of the excoriations, ulcers,
and sphacelating sores, which aflect the promi
nent parts, sustaining the weight of the body in
bed; and to this cause, in some measure, are to
be imputed the ill effects sometia.es following the
use of blisters in the last stages of adynamic
diseases. The whole surface of the body and
countenance also present more or less of the
characters which distinguish chnnge of the other
structures from this all pervading cause: they
lose their vital and animated hue, and become
lurid, murky, or of a dirty pale tint ; in some
cases of a dirty or muddied pale yellow; in others
slightly livid, or even altogether purplish; and in
many instances, besides assuming a lurid and un-
healthy colour, they are dotted with petechia-,
ecchymoses, and blotches of various shades, from
a reddish tint to a reddish brown and deep puiple.
In numerous cases, particularly in the last stages
of yellow fever, the s';in is of di erent shades of
yellow, frequently disposed in large patches, some
of which are deeper than others, but the who'e
surface being more or less changed from its healthy
tint. All these appearances arise from the state
of the colourless parts of the blood, transmitted
by the minute vessels of the integuments ; and
the admission, wheie ecchymosis, &c. occur, of
colouring matter into vessels which did not cir-
culate red blood in health, and the extravasation
or escape of minute portions of a reddish serum,
or attenuated or semi dissolved blood, from the
pores or extremities of the capillaries of the rete
mucosum, — a change, however, which is not
limited to the teguments, but which often exists
still more remarkably in the mucous and sub-
mucous surfaces, and parenchymatous organs.
(§ 149.)
148. B. The rapid or direct introduction of
vegetable or animal putrid matter, purulent sanies,
or animal poisons, into the circulation, generally
occasions, not only changes in the blood, destroy-
in<' its property of coagulating, and imparting to
it a tendency to quick decomposition, but also
most intense disease of the principal organs —
a. The nervous centres are remarkably impressed,
giving rise to great prostration of strength, deli-
rium, convulsions, or death, according to the
intensity of the cause — b. 'J he digestive organs
are atfected by vomiting of morbid, brown,
grumous, or other fluids; with pu ging of san-
guineous, dark, putrid, or black matters; or dis-
tended with foetid gaseous secretions: — c. The
respiratory and circulating functions are remark-
ably deranged — the respiration is quic '•, diffi-
cult, or panting; the action of the heart quick,
weak, or fluttering, and the i,i pu se deficient;
and the pulse, at first full, open, broad, and un-
usually soft and con pressible, soon becomes un-
commonly quick, weak, and ultimately small,
thready, or fluttering : — d. General disease of all
the functions and soft solids, accon p..nied with
speedy death when the cause is intense ; but,
with the symptoms of adynamic, typhoid, or
putrid fever, when acting more slowly, or to a
less extent, and occasioning sphacel tion or gan-
grene of various p irts, gaseous exhalations or
secretions, and various serous, sanguineous, or
sanious exhalations and infiltrations.
149. C. The efiects upon the fluids and soft
solids have been already mentioned incidentally,
and may, indeed, be inferred fiom what has been
stated. These chiefly consist, a. Of a foetid, de-
composed, remarkably morbid, acrid, and dark
or unnatural colour of all the secreted fluids: b.
Of diminished cohesion of the tissues generally,
but most remarkably of the mucous, cellular,
muscular, and glandular parts, — the heait is soft
and flaccid, the blood dissolved, and the internal
surface of the heart and blood vessels tinged of
a more or less deep led colour, owing, as M.
Trousseaux has ful'y proved, to the altered
state of the blood; the muscles are easily torn,
the mucous and eel ular tissues are soft and pu'pv;
all the structures have lost their vital and physical
elasticity, and they all undergo decon position
more rapidly than usual: c. Congestions, infill a-
tions, extravasation, &c. of fluid d rk blood into
the parenchyma of the lungs, liver, kidneys, and
into ihe cellular, mucous, n oscular, and other
parts, with gangrenous spots, aid a foetid odour.
150. Such are the consequences of putrid or
morbid matters conveyed into the circulation,
and the results, in respect both of the phenomena,
and of the remote organic lesions, of changes pro-
duced by these matters in the constitution cf the
whole fluids and structures of the bed v. When
these matters are in a less concentrated state, or
enter the circulation in a more gradual n anner,
they will then act in a relatively slower and 'ess
intense form, and their etie -Is vv i I more nearly
approach those described as consequent upon a
diseased state of the hood in malignant fevers
(§ 125 — 30.). Yet their operation will still
retain nearly the san e distinctive characters, the
symptoms varying chiefly in degree, but not ma-
terially in kind, unless the nature of the c; use has
also varied. Whether we conten plate, therefore,
the character and progress of the phenomena fol-
lowing infection of the blood from these various
sources, or the nature of the lesions which ulti-
mately result, we sha 1 be equally struck by the
marked similarity existing between them.
151. T hat the blood is changed in various other
maladies, although to a much less extert. may be
inferred from the phenomena winch are observed
either essentially or contingently in their cou se.
The secondary fever in so. all pox is apparently
connected with the partial absorption of the n ore
fluid parts of the matter contained in the pustules,
and the change thereby produced on the blood,
and through it upon the economy. Instances
have come before me, where, upon the rapid
disappearance of the small pnx eruption, purulent
matter was secreted suddenly and in large
quantity in the capsules of the joints, aid with-
out any previous or coexistent inflammation of
t! ese parts. In such cas*s the purulent matter
bid evident)} passed though the current of die
circulation. (See Abscess — Consecutive, and
Absorption.) Similar occurrences are not un-
BLOOD — Treatment of its Morbid States.
107
frequent in cases of inflammation of veins, and
in puerperal metritis. (See Veins, &c.)
152. \. Therapeutical Indications and
!\1k \MKi:s IN DISK ASK I) STATES OF THE BLOOD.
— The facts and observations now adduced in il-
lustration of the pathology of the blood must ap-
peal sufficient to attract greater attention to the
state of this fluid in tlie treatment of diseases, than
has been directed to it in modem times. How-
ever scanty well ascertained facts connected with
this subject may seem, they are at least sufficient
to justify us in directing our means of cure to the
removal ^ those changes which may he presum-
ed to exist in this fluid. This indication is the
more safely entertained, as those means are often
at the same time the most etKcacious in removing
pre-existing or concomitant disorder of the nervous
or other systems of the frame. And it should not
be overlooked, in our anticipations of the benefit
resulting from curative indications founded outhese
views, that the most certainly beneficial means of
prevention and cure of a most dangerous disease |
admitted to depend chiefly on the blood, viz. scur-
vy, is a remedy which acts principally on this
fluid, — the citric acid.
153. There are certain facts, which a review
of the foregoing observations will lead us to en-
tertain as useful data for our guide, both in the
recognition of changes in the blood, and in devis-
ing means for their treatment. It will be apparent
from what has been adduced, that remarkable di-
minution or exhaustion of the vital manifestations
of the organic nerves, or of the vital energy gen-
erally, renders the blood dark coloured, prevents
iis fibrinous particles from adhering into a coagu-
lum when removed from the vessels, disposes the
colouring matter to separate from their central cor-
puscles, and occasions a diminution of its saline
ingredients. The effects of various matters, veg-
etable, animal, and mineral, when gradually and
circuitously conveyed, or directly introduced, into
the blood, have been particularly described, not
merely as evidence of the very important changes
produced by them on this fluid, but also as fur-
nishing indications for the removal of similar al-
ms, when they are the results, immediate or
remote, of diseased actions.
154. A. Treatment of blood abounding with
fibrinous and albuminous constituents — of huffy
blood, fyc. — In various diseases, particularly those
which are inflammatory, in the early stages of the
exanthemata, especially in certain epidemic oc-
currences of these maladies, the blood abounds in
these constituents ; and hence partly the copious
albuminous and fibro-albuminous exudations which
are thrown out by the blood-vessels in their pro-
gri -<. The knowledge, which we have already
obtained as to the effects of certain substances on
the blood, indicates the propriety of having re-
course to such as possess the property of dilut-
ing and attenuating these constituents, at the
same time that they diminish the vascular ac-
tion which is instrumental in secreting them ;
and experience fully proves, by its success, the
propriety of the treatment. Blood-letting, and
afterwards the free use of diluents holding in
solution the alkaline carbonates and salts, more
particularly cream of tartar and borax, or the
tartarized antimony ; and digitalis, large doses
of calomel, or other substances which have
been shown to produce an attenuating effect
17*
upon the blood, are especially indicated. Blood-
letting in those cases is of the utmost service, as
it diminishes general action, and removes a por-
tion of the fibnne and albumen which are replac-
ed by tin; thinner fluids absorbed from the prima
via and tissues.
155. B. Treatment of blood with a loose co-
nsilium, S,-c. — Rapid coagulation and deficient ad-
hesion of the clot have been shown to arise from
weak nervous influence and vascular action ; and
indicate the propriety of having recourse to stim-
ulating tonics, particularly when the smallness of
the coagulum, and whey-like, milky, or turbid
state of the serum, evince a poor and imperfectly
elaborated blood. In this case, chalybeates, the
sulphate of quinine, and the more permanent ton-
ics, with the mineral acids, and the metallic salts,
are especially required. \V "hen, in addition to thi-
state,the blood is of a very dark colour, the com-
bination of stimulants with tonics and the alkaline
salts, especially the chlorides of potash or soda,
will be found most advantageous. In cases of this
description, however, the preparations of ammo-
nia, excepting the muriate and acetate of ammo-
nia, although stimulating, will not be found so
serviceable as other saline preparations. When,
however, the muriate and acetate of ammonia are
combined with excess of acid, the use of them
will be advantageous. Camphor, serpentary, and
arnica, the essential oils, the turpentines and bal-
sams, are all beneficial in this state of the circu-
lating fluid.
156. C. The treatment in other morbid states
of the blood will necessarily vary according to the
particular appearances it may present. — a. When
the blood coagulates imperfectly, is dark coloured,
is readily decomposed, or is thin and dissolved as
in scurvy, and various malignant and adynamic.
diseases, especially when the vital cohesion of the
tissues is also impaired, the use of most of the.
remedies recommended above (§ 155.), particular-
ly the chlorides, the preparations of bark, anti-
septic wines, the oil of turpentine, camphor, the
chloric and muriatic acids, with vegetable tonics,
the nitro-muriatic acid, vinegar, citric acid, &c.
The influence of acids in restoring the state of the
blood, particularly when morbidly attenuated, and
deficient in fibnne, appears to have been well
known to the ancients, and the indications there-
by offered put in practice. Vinegar was adopted
by the Carthaginians and Romans in all their cam-
paigns as the chief beverage, as may be gathered
from Vikc.il, Martial, Pliny, Galen, &c. ;
and its advantages have been adverted to in
modern times by Linnaeus. There cannot be a
doubt that both it and citric acid ;ire particularly
serviceable in preventing the attenuation, and ten-
dency to dissolution, of the blood generated, as
has been shown, by excessive fatigue and exer-
tion,— causes which have often been proved (§
134.) powerfully to concur with unwholesome
food, and vegeto-animal miasms, in the produc-
tion of scurvy, dysentery, and typhoid fevers. It
appears that the scurvy, which was found so>
destructive in Admiral Anson's fleet, was in no
small degree promoted by the excessive labour
of the men at the pumps, — a species of exertion
which tends more than any other to acceler-
ate the circulation, and exhaust nervous power,
and consequently to produce a dissolved and
incoagulable state of the blood, and to dimi-
193
BLOOD — Treatment of its Morbid States.
nish its fibrine. When, however, the blood is
morbidly thick and carbonaceous, when the re-
spiratory functions arc imperfectly performed, and
when there appears to be a deficiency of saline
constituents in the blood, as in the advanced st ges
of fevers, the fixed alkaline salts, and chlorides,
are much to be preferred to acids.
157. b. Since the general neglect into which
the humoral pathology has fallen, antiseptics have
almost been discarded from practice ; at least,
medicines have seldom or ever been given with
an intention of preventing a tendency in the fluids
and solids to dissolution. It must have been long
known to every person who considered attentive-
ly the operation of remedies on the frame, that
many of them, either directly or indirectly, pro-
duce this eflect, in conjunction with other opera-
tions ; and that they act in this manner, 1st, by
exciting the organic nerves, and increasing the
vital cohesion of the tissues, to which they are im-
mediately applied ; and, Zdly, by their passage, to
a greater or less extent, into the circulation, and
operation on the blood itself, and, tlirough its me-
dium, on the nerves supplying the vascular sys-
tem, and on the structures generally, — the antisep-
tic effect being the sum of those actions. Amongst
the various antiseptic remedies with which we are
acquainted, there is none more energetic than the
chlorides or chlorurets, the spirits of turpentine,
camphor, the barks, mineral and vegetable acids,
the spices and aromatics, metallic, earthy, and al-
kaline salts, spirits,, and balsams ; and observation
has proved to us, that these are actually the means
which, when appropriately employed, are most
successful in removing morbid states of the blood,
secretions, and solids. Nkkdham and Paulet
found salt most successful in combating an epi-
zooty characterised by a morbid state of the
blood ; and I had an opportunity of ascertaining
that, without a necessary supply of this substance,
the natives of the more insalubrious districts in
intertropical Africa are carried ofl' in great num-
bers by a putrid and liquescent dysentery, for
which salt, lime-juice, and cayenne pepper are
their principal means of cure. It should, how-
ever, be remembered, that all stimulants are not
also antiseptic in their operation on the blood.
The preparations of ammonia have even an op-
posite effect, unless the muriate combined with an
excess of acid.
158. c. During the treatment of all diseases in
which the blood becomes more or less changed,
it will be requisite to have strict reference to the
causes from which the change has arisen. Un-
wholesome food, vegeto-animal miasms, imper-
fect secretion and depuration, and deficient ner-
vous and vital power, have been shown to be the
chief of these. That the first and second of these
should be avoided, need not be stated ; and that
the secreting and eliminating functions ought to be
promoted, in order to purify the blood, is equally
manifest. The nervous and vital energies must
be not only supported, but also promoted and
excited, in order that the power of secretion may
be afforded to the torpid and weakened viscera ;
and that the crasis and vital condition of the
blood may be thereby restored, and the tonicity
of the capillaries, and of the tissues generally, be
increased. In addition to these, also, morbid se-
cretions should be frequently evacuated, in order
that vital power may not be further reduced by
their morbid impression on the nerves and mucous
digestive su face, and that the possibility of the
absorption of any part of them into the circula-
tion may be thereby avoided. 1 ut, in carrying
this indication into execution, care ought to be
had as to the measures which we en. ploy. Gen-
tle means are generally requisite, as rhubarb, &.c.
But those substances, which, with an aperient op-
eration, possess also a stimulating and antiseptic
operation, as the oil of turpentine, should be se-
lected ; or, if other substances be preferred, they
should he combined with tonics, antiseptics, and
stimulants. Formulae 2t>6. 437. 572. in the Ap-
pendix, are good examples of this combination.
159. d. in all the alterations of the blood re-
sulting from the introduction or absorption of mor-
bid matters from parts previously diseased, what-
ever tends to lower nervous and vital power, or
to promote absorption — moie particularly blood-
letting, which operates in both these ways — ought
to be guarded against, and a diametrically oppo-
site plan of cure adopted ; not neglecting at the
same time the promotion of the depurative and
excreting functions.
160. e. In diseases where it seems evident that
the watery and saline parts of the blood are drain-
ed oft', by the continued exudations fiom the mu-
cous surfaces, as in cholera, particularly epidemic
cholera, diarrhoea and dysentery attenued by dan-
gerous symptoms, much advantage might accrue
fiom the injection of warm water into the veins,
holding a very small proportion of saline matter,
particularly the muriate and sub-carbonate of soda,
with a minute quantity of some mi d stimulant and
astringent, in solution ; care being taken that the
latter ingredient be not in nearly such quantity as
to_aff'ect the albumen of the blood. Spirit cf
wine, ammonia, sulphate of quinine, &c. may be
thus employed. (See Poisons, for treatment of
Poisoning of the Blood.)
161. D. Prophylaxis, or the prevention of
morbid states of the blood. — The extended en-
quiry which has been entered into respecting the
causes of the alterations which take place in the
blood, furnish the chief indications for preventing
their occurrence. The primary influence of the
organic nerves upon the blood, and the effect rap-
idly produced upon this fluid by a diminution or
vitiation of this uillueice having been conclusive-
ly shown in respect of changes directly produced
by this class of nerves, both on the blood circu-
lating in the vessels, and on the functions of se-
cretion and depuration, it becomes a matter of the
first moment to preserve the vital manifestations
of this important part of the nervous system from
experiencing depression or exhaustion ; especially
where causes having this eflect are in operation,
and where there is any risk of those morbid mat-
ters, which have been shown in this article to be
the chief sources of vitiation, being carried into
the blood ; particularly those vegeto-animal, or
animal effluvia, which, floating in a moist atmos-
phere, act both by depressing these vital man-
ifestations, and by infecting the blood itself.
Persons exposed to those sources of disease
should live on a due proportion of farinaceous
and other vegetable substances, with a moder-
ate proportion of fresh animal food, and pre-
serve the energies of the digestive and assimi-
lating organs; always attentively promoting the
functions of secretion, depuration, and excre-
BLUE DISEASE — Pathology of.
199
don. At th.' same time many of the substances
mentioned above, may be employed uq beverages,
condi nents, or preventives; more particularly the
medicines formerly denominated antiscorbutics,
tlu> citric acid, lemons, lemon juice with sugar;
vinegar in which the warm spices, as capsicums,
have been infused; the chlorides, camphor, qui-
nine, ice. As it has been satisfactorily shown
that great excitement and acceleration of the cir-
culation, besides exhausting nervous and vital
power, have also the effect of changing, and even
of corrupting, the state of the blood, such excite-
ment should be prevented, and allayed when pres-
ent. I>\ appropriate evacuations, and by refrigerant
saline medicines and beverages.
Bibliog. \xn Refer. — Jessenius, De Sanguine ex
V. nd Vlisso Judicium. 4to. Prag. 1618.— M. Hoffmann, D«
Sanguine el ejus CMttervatione. 4to. Altd. 16'60. — R. Boyle,
Anatom. Observ. on .Milk found in Veins instead of
Blood, Phil, trans. 1665, [>[>. 100. 139.; an. I Natural lli-
torv of the Human blood, 3vo. Lond. Ib84. — Courten,
Experiments on the Blood, bv injecting various Sub-
stances into the Veins, Philos. Trans, vol. xxvii. p. 485.
(abounding in important ft ts.) — Albinos. De Pravitate
Sanguinis. 4to. Franc. 1689. — De Sandris, De Naturali
el Preelernaturali Sanguinis .Statu, 4to. Bon. 1696. —
Rivinus, De Sanguinis Pravitate, 4to. dtraj. 1702.—
Stenerltn, De Morbis ex Crasi Sanguinis Alterato oriuridis.
11. il e, 1706. — r'. Hojfmunn, De Judicio ex Sanguine
pel Venaesectionem emisso. Hale, 1727. — Friend,
iSmmenalogia, Opera Omnia, p. 130. fol. Loud. 1733.
■ i "nber of important experiments.) — Schuri-
g-itu, Haematologia Historico-Medica. 4to. Dresd. 1741. —
Schviencke Hsinatologia, sive Sang, lli-t. Ito. Hags, 1 7 l.J.
— Ykolai, De Spissitudine Sanguinis. 4to. Hate, 1749. —
Buerfmer. De nimia Sanguinis Kliiiditate, et Morb. inde
oriundb. Ito. Halfe, 1749. — Meyer, De Signis ex Sang.
pel Vensect. pefend. Hate, 1763. — Halter, Elementa
Fhvsiologia>, 4to. vol. ii. p, 17. et scq. (A collection of nu-
uiith important nev* observations^ — Heie-
son, Experiment. Inquiry into the Properties of the Blood.
8vo. Lond. 1771.; and Philos. Trans. 1773, p. 303. —Bor-
den, Anilvse Med. du Sang. Paris, 1775. — Mil, mm, in
Trans, of Loud. Col. of Phvs. vol. ii. p. 473. — Lin I. On
Diseases of Hoi Climates. "3d. ed. 8vo. Lond. 1777.—
Pringle, On Diseases of the Army, ;<'-. 8vo. Lond. 1775. —
Hey, Observations on the Blood. Lond. 1779. — Ferris,
iguiuis per Corpus vivura Circul. Putredine. 8vo.
Edin. 1784. — Gruner, He Pathologia Sanguinis. Jen. 1791.
— Deyeax et Parmentier, Mcmoire sur les Alterations du
San,'. Ito. Talis, 1797. — l.fntln, Bevtiage, .Ve. b. iv.
p. 182— 225. — Werlhoff. Opera, p. 748. J. Hunter, On
the Blood, Inflammation, fee. la,. Lond. 1795. — Wells, On
the Colour of the Blood, Phil. Trans. 1797,p. 416. — Beale,
Of the Dbeases arbingfrom vicious Blood. Lond. 1300. —
Bollock, Medico-Cbirurg. Trans, t. i. p. 47. — Tha krah,
On iIih Properties of the Blood, fee. 8vo. Lond. 1819.—
Wilson, Lectures on the Bl od and Vascular Svstem, 8vo.
Lond. 1819, pp. 21. 50. — A tttnreith, Phvsiologie § <s 880.
922. 1034.— Wolff; in H-jfelanoVt Journ. der Pr. Heilk. is.
h. 4 st. p. 97.— Mi -haelis, in tbid. xiv. b. 3 st. p. 65.— Cop-
land, in Appendix to jtf. RicheramPs Elements of Physiol-
ogy, 2d edit. p. 636. — Belhomme, Observations -ur le 8 ing.
Paris, 1823. 4to.— Home, in Philos. Trans, for 1826, p. 189.
— Gendrin, Recherches sui les Fievres, fee. t. i. p. 145 ;
et Tiaite Anat. des 1ml on. t. ii. p. 565, kc.—Bellingeri, in
Annali Dniversali di Wed. \;>. 827. — S-hult:, in -V' l.,!'x
Archiv fur Anat. unci Physiol. 1826, No. iv. p, 1 :7. — Trous-
seaux, in Archives Gen. de Med. t. xiv. p. 323. — Lfuret,
Archives, Vc. t. xi. p. 383. — S 'galas, in Ibid. t. xii. p. 103.
—Dupuy, in Ibid. t. xiv. p. 289.— Raver, Ibid. t. xv. y. Kit;.
—Gaspard, in MajendWi Journ. de Physiol. Exper. t. ii. p.
1., et t. iv. p. 1. — Majendie, in Ibid. t. iii. — Rochoux, m
Nouv. Biblioth.de Mi d. Sep. et Nov. 1823.— Diet. de Med.
t. xvi. p. 206.; et Journ. Hebdom. de Med. I. ii. p. 530. —
Boisseau, Noaographie Organique, t iii. p. 175. — ■ < ,!•,, m,
• Ii'-- -in |, - A 1 1 ei ate, ii- iln Sail-. Hvo. P.irii, 1 82b'. —
Christiaon, in Edin. .Med. and Soil'. Journ. No. ciii. p. 274.
— Rabin^ton, in Trans. Med.-Chir.Soc. t. xvi. — Ribes, Ana-
tomic Pathologique, kc. t. i. p. 308. — Andral, Pathologic il
Anatomv, by TovMiscnd and West, vol. i. p. 632. — Piorry,
Pi ' i' Operatoire, fee., et Collection de Memoires sur
Pathologie, fee. Paris, 1831.; Sur la Circulation, p. 208.
BLUE DISEASE. Sis. Cyanosis, (*»Woc,
blue, and rutuc, disease,) Beaumes. Morbus
Carukus, Cyanopulhia, More. Exangia Cy-
ania, Good. Cyanote, Fr. Die Bluusucht, Ger
Blue Skin, Blue Jaundice;
Classif. 3. Class, Sanguineous Function ;
4. Order, Cachexies (Hood). IV. Class,
11. Order (Author, sic Preface).
1. Df.fin. A blue, violet, or purple colour of
the integuments, particularly of parts usually
prist uting a rose or flesh tint, as the cheeks, lips,
mucous surfaces, 4'c.
2. A blue or purple colour of the integuments
of parts, or nearly the whole of the body, may-
occur as a symptom in the last stage of various
acute diseases. But it is present from the beginning
of this affection, is frequently connected with com-
paratively little disturbance until some sudden
change takes place, and generally results from
chronic organic lesion. In other maladies this
colour is an accidental, occasional, and not the
most important symptom; in this affection it ap-
pears as the only, or the most remarkable, change
observed during life.
3. Its Pathology. — According to 51. G in-
tra c, who has directed much attention to this
affection, it always proceeds from organic change
of the heart or large vessels; the admixture of
venous with arterial blood, and the distribution of
it to the surfaces of the body, being the immediate
or essential cause of the alteration of colour. This
pathology agrees with the opinion of Senac and
5Iorgagni : it has, however, been disputed. 51.
Corvisart first threw out doubts of the constant
origin of cyanosis in this source; and more recent-
ly MM. Ferrus, Brkschet, 51arc, Lor is,
Fouquier, and Crampton, have adduced facts
which seem to militate against it, while it has re-
ceived the able support of M. Bouillaud.
4. 51. Ferrus contends, 1st, That cyanosis
sometimes has existed to an intense degree, and
yet upon post mortem examination no lesion could
be detected admitting of the admixture of venous
blood; nor any organic change of the heart or
respiratory organs : 2d, That the opening of
Botal may continue unclosed for many years
without blueness of the surface being occasioned :
and, 3d, That the admixture and circulation of
venous with arterial blood have been demonstrated
to occur in some cases, without giving rise to
this peculiar appearance. That the second and
third objections tire well founded seems almost
incontrovertible. Numerous instances have been
recorded by Louis, and others, which fully prove
these facts. I have met with cases in children,
where the communication between both sides of
the heart seemed very free, and yet no alteration
of the natural colour existed; and others, in which
the change was evident during the paroxysms
of suffocation only. But I must agree with
Corvisart, Richer and, Cloquet,Gintrac,
and Bouillaud, that the existence of this open-
ing is no certain proof of admixture of the venous
and arterial blood; for if the contractile powers of
both ventricles tire nearly equal, in relation to the
resistance to be overcome, and if the natural open-
ings of the cavities be not obstructed, no admixture
of the blood in both sides of the heart could take
place.
5. The principal force of the objections, there-
fore, urged by 51. Ferrus, evidently rests upon
tin' fact of the non-existence of organic disease of
the heart, large vessels, or lun<;s, in BOme cases
of the disease, — a fact which is still not satis-
200
BLUE DISEASE — Pathology of.
iactorily established. I believe that it may be
safely concluded, that the blue disease of infants
and children is very generally dependent upon a
communication between the opposite sides of the
heart, or some malformation of the heart or large
arteries, particularly contraction of the origin of
the pulmonary artery, or some other change af-
fecting the circulation through the right cavities
of the organ; whilst in older and aged persons, a
similar colour of the surface may proceed from
whatever obstructs the circulation through the
large veins, lungs, or heart, and even from simple
congestion of the venous capillaries from loss of
vital power; and in these latter cases, the affec-
tion more nearly approaches the blueness observed
to occur as a dangerous symptom of various acute
diseases of the lungs and heart, as of asphyxy,
and of pestilential cholera.
6. Symptoms, progress, and terminations of
blue disease. — The bluish tint of the external sur-
faces, whence this malady derives its name, is not
equally deep in every part. It is usually deepest
over the whole of the face, and the lips in partic-
ular, on the hands, feet, and genitals. During any
effort, or when crying, this symptom is much more
marked than during repose: at the same time the
parts presenting a bluish colour, or a violet of the
darkest shade, are more or less puffed. The cir-
culating and respiratory functions are rarely with-
out derangement. The disordered circulation is
characterised by palpitations more or less violent;
sometimes accompanied by a very distinct belloyvs
sound, and by a purring tremor, tendency to
faintings, and serous eHiisions. The breathing is
laboured and panting after the slightest effort. The
warmth of the body is considerably diminished,
and patients are very sensible of cold. The func-
tions in general, and principally those of locomo-
tion, are more or less languid, and, as it were,
benumbed.
7. The symptoms just described do not always
exist in the same degree, during the continuation
of the malady. It may even be said that the
disorder is made up of a succession of paroxysms
and remissions. In the paroxysms alone we ob-
serve those frequent faintings, that tumultuous
palpitation of the heart, and suffocations, which
endanger the life of the patient. No rule can be
relied on as to the recurrence of these paroxysms;
in fact, if it be certain that they are often brought
on by over-exertion, fatigue, and violent mental
agitation, it is equally certain that they occur with-
out any assignable cause, and are more frequent
in winter than in summer. ' The length of the
paroxysm varies: it sometimes lasts several hours,
and generally abates gradually. The termination
of cyanosis is fatal to most patients; but some
appear to recover entirely; others live for many
years. Cases of this kind have been recorded by
MoRGAGNI, SANDIFORT,aild Richerand. The
death caused by this disorder is sometimes very
sudden; but in the majority of cases it is preceded
by an intense suffering, characterised by the most
acute anguish, difficulty of breathing, fainting fits,
and cold sweats. In a case of remarkable blue-
ness from birth, in a girl, who was for some time
under my care, the colour changed, in the course
of two or three years, to dirty yellowish, chlorotic
tint, which is still retained up to the thirteenth
year. The disorder of the heart's action and
respiration, in this case, although more or less
considerable, was never very severe; but the
child was always remarkably delicate, and inca-
pable of any bodily or mental exercise.
8. Lesions observed after death : and their
connection with the symptoms. — 1st, The most
common lesion is the persistence or the re-esta-
blishment of the opening of Eotal. This commu-
nication of the two auricles is generally accom-
panied by an obstacle to the passage of the blood
from the right auricle into the corresponding ven-
tricle, or from the latter into the pulmonary artery.
Twenty-seven cases out of fifty-three reported by
M. Gintrac, presented such an obstacle. In
twenty-six of these cases, the circulation on the
right side of the heart was impeded either by a
contraction or by a total obliteration of the orifice
of the pulmonary artery, and in only one case by
the contraction of the right auriculo-ventricular
orifice. Co-existent with these lesions is usually
a hypertrophy of the right ventricle and auricle,
or of one only of these cavities, with or without
dilatation. Sometimes the ventricular cavity is
itself contracted. 2dly, The ventricular partition
has often presented a solution of continuity of more
or less extent. Sdly, The arterial canal remained
open in some subjects. 4tbly, In one of the cases
reported by M. Gintrac the two auricles (in per-
fectly divided) opened into the right ventricle : the
latter being very large, communicated freely with
the left, which (narrow and- without auricular
orifice) gave origin to the aorta. 5thly, In an-
other case, the aorta and pulmonary "artery sprung
from the left ventricle, the right being almost ob-
literated, and the inter-auricular partition perforat-
ed. 6thly, In another instance, the opening of
Botal was preserved; the aorta disappeared after
having supplied the cephalic and brachial trunks;
the pulmonary artery, receiving the blood from
both ventricles, formed the descending aorta.
Tthly, Such a transposition of the larger arterial
trunks has been witnessed, as the aorta springing
from the right ventricle, and the pulmonary artery
from the left; the opening of Botal and the arte-
rial canal still remaining, or only the latter. Sthly,
In some cases the heart consisted only of one
auricle and one ventricle. 9thly, Two superior
vena? cava? were seen, the one opening into the
left auricle. It is unnecessary here to enlarge
upon the other lesions noticed in persons afflicted
with this complaint, because they do not necessa-
rily belong to the subject.
9. As respects the relation between the symp-
toms and lesions, M. Bouillaud remarks, that
the alterations pointed out in the central organs of
circulation have usually the effect of permitting
the black blood to miugle with the red; but
some of these lesions, as previously observed,
such as the opening of Botal does not necessarily
entail this admixture; for which reason it is not
invariably accompanied by blueness of the tegu-
ments; either the black blood not having mingled
with the red, or the mixture being insufficient to
produce the bluish colour. But when the arterial
canal remains open; when the aorta springs from
both ventricles jointly; or when, to the commu-
nication between the right and left cavities, is
superadded an obstacle to the free current of
blood in the former; a considerable quantity of
black blood must necessarily mix with the red.
Whenever an anormal communication between
the cavities of the right and left divisions of the
BRAIN — Alterations in its Membranes.
201
heart co-exist-! with an obstacle to the circulation
of the blood in the i iiil n ventricle or in the pul-
monary artery, the mixture of the blood is not the
sole cause of the discoloration of the skin, the
pn ling of certain parts, of various .serous conges-
tions, ^c. In fict, it is evident, that the impeded
circulation contributes mainly to the production
of these phenomena. Should we not also attrib-
ute to the contraction of the auriculo-ventrieu-
lar, or ventriculo-pulmonary orifices, the bellows
sound and the purring tremor remarked in some
{mtients? However this may be, some of the
esions coincident with blueness of the teguments
are invariably congenital; while others (such as
the communication between the right and left
regions of the heart) may be either congenital or
accidental.
10. The causes which develope most of the
congenital lesions, from which b ueness may en-
sue, are not easily determined on. Hut a com-
munication between the right and left cavities of
the heart may be occasioned by ulceration of the
auri ular and ventricular partitions, or by the
rupture of these partitions, especially of the au-
ricular, in violent and lengthened efforts. An
obstacle to the course of the blood through the
right auriculo-ventricular, or the ventriculo pul-
monary orifice, may also, particularly in the early
stages of life, induce an anormal communication
between the two auricles, by ungiuing, as it were,
the valvular lamina', which, by their agglutina-
tion, have obliterated the opening of Botal. The
existence of a similar obstacle at an intrauterine
period of life, when the opening still remains, may
I) ■ dso deemed a so (icing cause for its ultimate
non-obliteration. (Diet, de MCd. et Ckirurg.
Prat. t. vi. p. 7.)
11. I am of opinion, not only that such ob-
Btacles have very generally existed during intra-
uterine life, and been the cause of the blueness
observed afterwards, but that they h ive also
occasioned, during foetal existence, a permanent
state of distension; and thence, in some respects,
malformation of the capillary system, particularly
in the cutaneous and mucous surf ices, favouring
Congestion, and languid circulation through them
after birth, and the consequent blueness, and the
puffiness that generally attends it. I may add, as
a matter of diagnosis, that very intense and gen-
eral blueness is not uncommonly produced by the
incautious internal use of the nitrate of silver. I
have observed two or three such cases, and others
are recorded by Alb Kits, Roget, &c. (Med.
Chir. Trans, vol. vii. p. 2S4.)
1 2. Tb e a t M k n t. — Art is of little avail in this
malady. We must chiefly depend upon the ef-
forts of nature in bringing gradually about a change
in the lesions on which it depends; and attempt
to assist her e 'bits, by directing bodily and men-
tal repose, and a pure, mild, dry, equable and
somewhat warm air; by attending strictly to the
state of the biliary and other secretions, and the
digestive functions; and by recommending gently
tonic medicines, with an easily digested and nu-
tritious diet. During the paroxysms, ML Bouil-
lai I) recommends bloodletting, — a practice
which is by no means warranted by mv experi-
ence. Depletions, and all other lowering me ins,
aggravate the sympto us, and se'dom or ever >ue-
ceed in removing die severity of the paroxysms,
for which he advises them. 1 have derived more
advantage from stimulating pediluvia, frictions of
the surface of the body and lower extremities,
and tin? administration of gentle antispasmodics
and stimulants. (See F. 3 is. 424. 663.) In one
or two instances, I conceived that some advantage
was derived from the preparations of iron com-
bined with the fixed alkaline carbonates. (See
also F. 94. C'<i2. 7 i S. 920.)
liiBi.ioo. and Rkfer. — Hunter, Medical Observat. and
Inquiries, vol. vi. p. 299.— Femu, in Diet, de Wed. t. vi. p.
29S._(;W, Study o Med. t. iii. p. 432.— Qintrac, Ohser-
val et Recherches sur la Cvano-e, Itc. Pa' is, 1824. — Louis,
Mem. Mic la Cnmuiiiu. dr. Cavil. Droites du Cceur avec les
cavities Gauches, Archives Gin. de Med. t. iii. pp. 325.
485.; et Mem. et Recherche* Anat. Pathol, p. 301 — Souil-
lemd, Diet, de Med. et Chirurg. Pratiques, t. vi. p. 1. —
Crampton, in Trans, of College of Phvs. Dublin, N. S. vol.
i. p. 31.
BRAIN — its Morbid Structures. Svn.
' ' Ky ■/.''■ i\ ka"c. Gr. Cerebrum, Encepkalon, Lat.
Cerveau, Encdphale, Fr. Das Him, Gehirn,
Ger. Ccrebro, Ital.
Classif. Special Pathology and Mor-
bid Structures. IV. Class, III. Or-
der (Author, see Preface.)
1. With the view of avoiding unnecessary re-
petition, and of furnishing a complete account of
the changes and morbid phenomena connected
with the parts contained within the cranium, al-
terations of structure will be considered in the
first place, and in systematic connection; and, af-
terwards, inflammations affecting either the brain
or its membranes, will receive attention. As
similar lesions develope themselves in the brain,
or its membranes, in the course of a variety of
diseases; and as many of those which are most
commonly found upon dissection give rise to very
different phenomena during life; their arrange-
ment in a separate form will facilitate refe ence to
them, when those specific states of disease, which
they either originate in, or occasion, are being
discussed. 1 hus tumours formed in the brain, or
purulent matter secreted there, or induration or
softening of the cerebral substance, &c. are not
infrequently found in cases of either palsy, epilep-
sy, insanity, or encephalitis, without limitation to
any one of them. Instead, however, of describ-
ing these and various other lesions, when consid-
ering each of these diseases, I shall here give a
minute description of the morbid structures ob-
served in the brain and its membranes, and refer
merely, when discussing these and other diseases
implicating the cerebral functions, to those chan-
ges most commonly found on dissection of fatal
cases, as they are described in this article.
2. Of all the organs of the body, the brain is
the most exquisitely and incomprehensively form-
ed, and presents the least intimacy of connection
between the results of dissection and the phe-
nomena of disease. The most violent symptoms
referrible to this organ often exist during life;
and vet, on the most careful examination, after
death, either no appreciable lesion, or none sulii-
cient to account for the phenomena, can be de-
tected. Whilst, on the other hand, many, and
most important changes are frequently discovered
in both the brain and its membranes, in cases
which betrayed either no cerebral disorder, or
none calculated to excite suspicion during life of
any organic change. It is extremely important
to be aware, not only of this fact, but of the cir-
cumstance just alluded to, that the same morbid
appearances, or, at least, states so nearly alike
OQO
BRAIN — Alterations in its Membranes.
that they cannot be distinguished, will frequently
be found after maladies very dissimilar as regards
their cause, nature, and consequences. Thus, ir-
ritation of the brain occurring in the progress of
levers, and the exanthemata; convulsions, insani-
ty, drunkenness, puerperal derangements, metas-
tasis: of gout, and various other diseases, will be
attended with congestions, injection of the blood-
vessels, secretions of lvmph, or serum, or of air
between the membranes, &c. — states in every
respect similar to those proceeding from idiopathic
inflammation. Nor should it be forgotten, that
the kind of death, the particular circumstances
attending it, and the position and changes to
which the body is subjected immediately after-
wards, tend very materially to influence the ap-
pearance and states of the parts within the cra-
nium. In the view which 1 am about to take of
the principal lesions of structure affecting the
encephalon, I shall first notice the morbid states
of its membranes; next, the lesions presented by
its sinuses: and other blood-vessels; and, lustly,
the diseased appearances of the different parts of
the encephalon itself.
3. I. Morbid States of the Membranes
of the Brain. — The intimate connection which
the membranes of the brain have with the cranial
bones on the one side, and the brain itself on the
other, and their expansion between both, render
them extremely liable to participate in all the
malformations, diseases, and external injuries of
those parts. Whilst they most commonly, with
the limpid fluid exuded between them, separate
those parts, and facilitate the motions of the lat-
ter, they also often prevent the extension of mor-
bid action from the one to the other. But they
do not always succeed in thus limiting disease; for
they frequently become secondarily aflected dur-
ing maladies commencing either in the skull or
the brain; and, when thus involved, they, in some
measure, become the medium of mutual infection.
But the membranes are not only thus secondarily
aflected; they are also not infrequently them-
selves the primarvseat of disease; and when such
is the case, the parts on each side of them, par-
ticularly the brain, seldom fail of participating
more or less in the disturbance. Thus we often
find them the primary seat of congestion, inflam-
mation, with its consequences, as efiusion be-
tween them of various kinds of fluids; and the
source whence disease has extended to the brain
itself. Those changes are presented to our view,
not only in the primary inflammations of the
membranes, but also in several forms of fever; in
morbid arlections of the mind, tetanus, delirium
tremens, convulsions, epilepsy, apoplexy, palsy,
and other diseases, wherein we have reason to
suppose that the brain itself is either primarily and
principally affected, or participates largely in the
morbid states of its envelopes.
4. i. The Dura Mater is often found un-
usually adherent to the cranium, even when the
brain and its membranes have been quite free
from change, but more commonly when chronic
disease has existed in either the one or the other.
It is also sometimes slightly adherent to the
skull, and occasionally this want of adhesion is
very remarkable. In some instances, the dura
mater is separated entirely from it portion of the
cranial bones. In some rare instances, the space
is rilled with a watery fluid; but this has only
been met with in hydropic children. The separa-
tion is generally the result of external injuries; and
either blood or pus, or even both, is usually found
in the space between the bone and the membrane.
In some cases, these effused fluids, particularly
blood, either fluid or in coagula, are in considera-
ble quantity, occasioning the usual symptoms
depending upon pressure. Lymph, in various de-
grees of firmness, is also found between a part of
the dura mater and the skull; and this, as well as
pus, with which the lymph may be partially mix-
ed, are generally the result of inflammations con-
sequent upon external injuries. These appearan-
ces have been sometimes observed in fatal cases
of epilepsy, but only when the patient has receiv-
ed some injury during the paroxysm. They are
often connected with a puffy swelling of a cor-
responding portion of the scalp.
5. The dura mater itself may be here viewed
as two membranes, closely united throughout by
means of fine, close, cellular tissue : the exterior,
or that applied to the cranial bones, resembling in
structure, and performing the office of, periosteum;
the interior, or unattached, being a reflection of
the arachnoid, and having, as respects its functions,
a more intimate relation to the included organs :
the former being a fibrous ; the latter, a serous
membrane.
6. A. The fibrous structure of the dura mater
is frequently more than usually vascular, particu-
larly in fatal cases of apoplexy, paralysis, fever
with cerebral symptoms, epilepsy, and in the con-
gestions which occur in the last stages of whoop-
ing-cough, pulmonary diseases, asphyxia, and
poisoning by narcotics. This state is, however,
very different from inflammation, as the minute
capillaries do not present the same degree of
redness, particularly in the unattached or arach-
noid surface. This structure is sometimes tinged
with bile, and of a deep yellow colour through
its whole extent, as in cases of acute jaundice,
which are attended with comatose symptoms.
After contusions, or when suppurations exist be-
neath or exterior to it, it is either yellow, dusky,
bluish, brownish, or even blackish. It is also
occasionally spotted with black, in some cases of
melanosis. In some instances, this membrane
seems distended from fluids effused in the cavities
of the brain, or between the membranes' in others
it is apparently corrugated or collapsed. This
latter state generally proceeds from it having been
punctured during the separation of the calvarium,
the fluid which it had contained having thereby
escaped. But it is sometimes noticed where no
such accident occurs, particularly in extremely
emaciated bodies, or in the very aged, when little
or no water is collected beneath it. A more than
usual dryness and transparency is occasionally
observed in this as well as in similar structures.
Unusual dryness is also sometimes conjoined with
a shrivelled state, and deficient transparency.
Otto thinks that this is one of the remote effects
of inflammation.
7. It is but rarely irflamed, excepting from
external injuries, and then generally in circum-
scribed patches of greater or less size. In these
cases, the injection and redness are very remark-
able, particularly in the vicinity of purulent form
ations and injuries of' the lunies, or where ulcera-
tion, discoloration, fractures, abscesses. &c. exist
in its vicinity. Suppurations, in which the pus Ls
BRAIN — Alterations in its Membranes.
203
found between its layers, or on its outer surface,
are very Hire. Cases, however, are referred to
by Otto of this occurrence. When suppuration
docs occur, it is generally seated in its inner sur-
face. In sonic oi these cases, the purulent matter
lias eroded, and perforated the skull and layers
of the dura mater exterior to it. Thickening of
the don mater is not an unusual result of chronic
states of inflammation. It varies extremely in
degree, and it is sometimes so great as to occa-
sion symptoms of pressure and irritation. It is
sometimes found in fatal cases of epilepsy and
paralysis ; and is occasionally conjoined to in-
duration of the thickened part. Ossification of
the fibrous structure of the dura mater is a com-
paratively rare occurrence, whilst ossitic deposits
in its free or arachnoid surface are very common.
[n the former case, the bony matter follows the
fibrous arrangement of the membrane, and in-
volves its substance. Two interesting specimens
of this change are referred to by Dr. Bright
(Reports of Medical Cases, fyc. vol. ii. p. 663.).
Ossi ic deposits may likewise be ascribed to slight,
or chronic states of inflammatory action.
8. Tumours also form in the dura mater.
Those which are most intimately connected with
it have a fibrous structure ; whilst the fungoid
rumours sometimes observed seem to be common
to both this membrane and the arachnoid lining it.
Nor are they limited to the dura mater, as sup-
posed by Louis and the Wf.nzels ; but they
may arise also in the bones of the skull, as shown
by W.w.thf.u, Graaff, and Siebold ; and
even in the pericranium, as contended for by
Oiro, Bberhaier, and Croveilhier. Os-
teosarcoma, or fungus cranii, therefore, as stated
by Von Walther, and fungus dura mairis, are
merely different, although often simultaneously
occurring forms of the same disease. (See § 17.)
When fungous tumours originate in the dura ma-
ter, they not infrequently perforate the skull, by
occasioning absorption of the superincumbent por-
tion of hone: but they also often involve the bone
in a similar change, giving rise to fungus cranii as
now stated. They occur in every part of the dura
Dialer, commencing more frequently in its inner
coat, and are found oftener in this situation, than
in the bone itself, or the pericranium. (See CRA-
NIUM.)
9. Other kinds of tumour are occasionally
found in the dura mater. But those of a constitu-
tional origin usually commence either in the arach-
noid covering the dura mater, or in the fine con-
necting cellular tissue. They, however, general-
ly soon involve, not only this latter membrane,
bat also occasionally the cranial bones. Of these
tumours, comprising the scrofulous, scirrhous,
carcinomatous, and the hamaioid, I shall make
more particular mention in the sequel. Although
sometimes found in the inner surface of the dura
mater, they are met with only consecutively upon
their original manifestation in some other part of
the body. More rare than any of the foregoing,
occurrence of fatty and encysted tumours on
the exterior surface, or between the layers of the
dura mater. They have been found in this situa-
tion by Moroagni, Frickk, and Otto; and, in
very rare instances, have been observed to con-
tain hair. Scrofulous tumours are less frequently
found exteriorly to, and between the layers of, the
dura mater, than in its internal surface.
10. Unusual thinness has been observed in
some parts of this mbrane ; and some of its
processes have been wanting, owing to their ab-
sorption ; in some cases, without any obvious
cause, but. more frequently from the pressure of a
tumour of the brain, or some other morbid en-
largement. "The falciform process, and a part
of the sensorium, have been wholly removed, and
large portions of the dura mater and its processes
have been found its thin as silver paper." (Hoop-
er, Morbid Anatomy of the Brain, fyc. p. 29.)
When portions of the dura mater are destroyed
by any internal cause, or even by external injury
affecting the bone, they are rarely or never re-
produced, and never otherwise than by a thick or
dense cellular tissue closely connected with the
newly formed bone; or, if the bone be not produc-
ed, after having been destroyed, it assumes a fibro-
cartilaginous state, and becomes consolidated into
a common cicatrix with the integuments. Rup-
ture, or laceration of the dura mater is generally
the consequence of fractures of the cranium and
concussion. It has, however, proceeded from vio-
lent coughing, after the superincumbent bone has
been removed by fracture, or by trepanning, &c.
11. B. Morbid states of the arachnoid cover-
ing the dura mater. — The internal surface of the
dura mater is lined by a reflected portion of the
arachnoid membrane, the unattached surface of
the dura mater thus consisting of a true serous
membrane, intimately attached to, although differ-
ent in its nature from, the fibrous structure which
it covers. Inflammation, whether originating in
the dura mater itself, or in this surface, chiefly
manifests its distinctive characters and effects on
this lining : and generally presents, especially in
the early stages of the acute disease, a minute-
ly injected state of the capillaries, with a bright
red tinge of the whole surface. This appearance
has been beautifully illustrated in the first of Dr.
Hooper's plates of lesions of the brain. When
acute inflammation attacks this part, it is general-
ly confined to one side, the longitudinal sinus or
the falx furnishing the boundary of the disease.
In very acute attacks, and in the advanced stages
of inflammation of the dura mater, the internal
surface becomes covered by a layer of fibrinous
lymph, into which, as I have shown in respect of
serous membranes generally, minute vessels may
be traced, when the exudation of this substance
has been proceeding for some days. It is usually
diaphanous, very delicate, and forming a complete
adventitious membrane. In other cases, a much
thicker, opaque, and albuminous-like membrane,
of much firmness, less vascular and less intimately
adherent to the dura mater, is formed. Although
the fibrine and albuminous matter exuded may be
both abundant, and thus provided with vessels, it
is seldom the medium of adhesion ; or, indeed, at
all adherent, to the arachnoid covering the con-
volutions : and if adhesions have formed, they are
very slight in respect of this latter duplicature of
the arachnoid, unless very acute inflammation
al-o exists in the pia mater, directly opposite to
the inflamed surface of the dura mater.
12. In more chronic forms of inflammation,
this surface not infrequently assumes a spongy ap-
pearance, with more or less redness and marked
injection of the vessels. In some cases it has ;i
villous aspect, from a slight exudation of albumin-
ous matter, and interstitial effusion of serum in the
204
BRAIN — Alterations in its M.mbranes.
texture of the arachnoid lining. Purulent mat-
ter is seldom formed to any considerable extent ;
but, when it is secreted, it usually spreads thinly
over the membrane. It seems generally to pro-
ceed from the inflamed surface, without any dis-
tinct appearance of ulceration. In some cases,
however, owing to adhesions of the membranes
around it, circumscribed accumulations of pus are
met with ; and these may cause the erosion of
the dura mater and hones exterior to them. Al-
though the productions now noticed sometimes
are observed to follow idiopathic inflammations
of this part, they are more frequently the results
of external injuries ; and are more commonly met
with in the parts which cover the hemispheres,
than in the basis of the skull, unless there be a
very general state of inflammation of the parts
within the cranium.
13. Adhesions of the lining membrane of the
dura mater to the arachnoid and pia mater are
chiefly observed when both reflections of the
arachnoid are inflamed, particularly in chronic
affections of the cranial contents. The medium
of adhesion varies considerably. It is frequently
found to consist of a firm but thin exudation of
fibrinous lymph or of albuminous matter : in some
cases, delicate, diaphanous, and vascular ; in oth-
ers, thick, opaque, and less intimately adherent
to the internal surface of the dura mater than the
preceding. In a few instances, it is formed of fine
filamentous bands passing through a more than
usually copious effusion of serum; and occasional-
ly the membranes are intimately and firmly join-
ed, even without any very apparent medium of
union, particularly at the centre of the part ad-
herent. This is chiefly seen immediately over or
near the situation of severe organic disease of the
brain itself, as abscess, tumours, superficial ulcer-
ations, &c. In some cases, the adhesions are so
firm that, in attempting to raise the dura mater,
the subjacent membranes, with a portion of the
brain, are removed along with it.
14. Ecchjmosis and purple spots arising from
the effusion of blood, in minute patches, beneath
its arachnoid lining, are sometimes observed in
the unattached surface of the dura mater, and
partake of the character of purpura. '1 hey are
most commonly found in cases of cerebral dis-
ease, which has been con. plicated with chronic
change of the biliary organs and deficient energies
of life, — or with general cachexia. Carbonaceous
deposits, or melanosis, have also been sometimes
observed in the situation. Dr. Bright believes
them to be the result of extravasated blood. (See
the art. Melanosis.) Ossific deposils, general-
ly disposed in plates, or much thicker in the cen-
tre than the circumference, and varying much in
number and situation, are also frequently found
towards the surface of the dura mater. They
seem covered by the arachnoid, are closely ad-
herent to the dura mater, and formed between
them. They occasionally present an irregular
surface, or assume a nearly conical form, and are
often connected with nervous diseases, particular-
ly epilepsy. They are most frequently met with
upon the falx, and near the part where the dura
mater separates to form the longitudinal sinus.
15. Tumours not infrequently proceed from
the internal surface of the dura mater. Many
of those productions are actually formed in the
arachnoid lining this surface ; being only adhe-
rent, and often \ery slightly, to the proper struc-
tuie of the dura mater, and in no way changing
its characters. As these tun. ours increase in bulk,
they gradually p.oduce debility of both mind
and body, particularly the former. Much of the
severity and rapidity of these effects will, how-
ever, depend upon the rapidity of their formation.
When small, and sources rather of irritation than
compression, convulsive affections are oftener oc-
casioned by them than paralysis : when large,
they more frequently give rise to paralysis than
convulsions : but either of them may be followed
by any of those affections ; mental weakness
being the more constant, and often the most re-
markable eflect. Many, also, of the tumours
developed in the dura mater can scarcely be said
to originate either in its fibrous membrane, or in
its serous or arachnoidal lining : but should rather
be referred, at their commencement, to the cellu-
lar tissue uniting those layers. Amongst those
which seem more frequently at least to originate
in this latter situation, — although often involving,
and in a very short time, all the lavers of the
dura mater, and even the parts adjoining, — the
scrofulous, the cartilaginous, the ha-matoid, and
the encephaloid or fungous tumours, require the
most particular notice. The scrofulous tumour
is found on the internal surface of the dura mater,
having an organized, fleshy, solid, and bun. id ap-
pearance ; and is but rarely met with, and oniy
in connection with scrofulous disease in some
other part of the body.
16. rl he cartilaginous tumour is generally seat-
ed in close connection with the dura mater, and
under its arachnoid lining. Jt varies as much in
the perfection of the cartilaginous state, as in its
size. It is sometimes perfectly cartilaginous ; at
other times merely gristly. It is ofter.est met
with in the falciform process and tensorium ; and
is occasionally attended with ossific deposits in
the same situations. Indeed, as remarked by Dr.
Hooper and Dr. Monro, some of those tun, ours
are partly ossified, so that the cartilaginous slate
seems to be often an intermediate st;ige between
that of gristly firmness and complete ossification.
A case is described, by Mr. Watson, in J_)r.
Monro's work, of a cartilaginous tun. our, the
size of a walnut, containing bony matter towards
its centre, growing from the dura mater. The
sub-cartilaginous tumours are often tuberculous,
of a dirty white colour, always distinct, but often
numerous, and varying from the size of a pea to
that of a hazel-nut. They generally are found
between the dura mater and its arachnoid lining,
have a broad ba,~e, present a clean smooth surface
when divided, are firm, and devoid of vascularity.
They seldom afiect much the superincumbent
dura mater and bone, but deeply indent the sub-
stance of the brain.
17. The malignant tumours, which are occa-
sionally met with in the dura mater, assume the
sarcomatous, the carcinomatous, and the fungoid
characters. The fungoid disease may be either
encephaloid, ov heematoid. The encephaloid tu-
mour is not common. Its divided surfice is cel-
lular and spongy, and gives out a pap-like matter
when pressed, its structure is more generallv
approaching to the fungoid, than to the tubercu-
lous. It seems to be entirely produced from the
lining membrane of the dura mater, and is almost
always connected with scirrhous or malignant
BRAIN — Alteratioss in its Membrahe*
205
diseases originating in some oilier part of the body.
The futmcUoid tumour is of the colour oi' venous
blood, has a broad base, and a fungous, some-
times a tuberculous, structure, li is soft to the
touch, is covered by a delicately lamellated tissue,
thinner than silver paper. When divided, it ap-
pears spongy, and extremely vascular. It is very
rare, and IS always connected with the primary
Occurrence of the disease in some other part of
the body. The simple cyst, or watery tumour,
the hygroma of Dr. Hooper, is seldom or ever
observed in this situation, although frequently in
other parts of the encephalon. A case of it, how-
ever, occurred to Dr. Duncan. The acepha-
locyst, or headless hydatid, has been found con-
nected with tiie arachnoid of the dura mater, in a
very few cases. .
18. The Causes of malignant, or constitutional
tumours in the dura mater, are generally external
wounds or contusions, concussions, the scrofulous
or syphilitic taint, and most commonly previously
existing disease of a similar nature in other parts
of the body.
19. The Symptoms by which their existence
may be inferred are extremely equivocal. At
the early periods of their growth, they frequently
give rise to little or no disturbance. Much, how-
ever, will depend upon the rapidity with which
they arc formed, and their situation. When they
grow slowly, the portion of brain becomes gra-
dually accustomed to, and, as it. were, insensible
of, the pressure; it see :,s to waste; and, if this
compressed and atrophied part be not indispen-
sable to the free exercise of the sensorial, intellec-
tual, and locomotive functions, the disease pro-
duces no evident or sensible indication of its ex-
istence. But sooner or later the compression
produced by them on the brain, or the irritation
occasioned in the membrane, gives rise to symp-
toms of the most serious nature; frequently in a
very sudden manner, sometimes more gradually.
These chiefly consist of paralysis, epileptic con-
vulsions, ami apoplexy, occasionally occurring as
suddenly as in the sanguineous forms of these
diseas s. Most commonly, however, and espe-
cially when the tumour is situated in or near the
base of the brain, the symptoms, whether those
of compression or of mental disorder, supervene
more rapidly : sensation and volition gradually
disappear from the limbs which correspond with
the compressed portions of brain; the intellectual
powers are obscured, and the patient soon lie-
comes hemiplegic and idiotic. The gradual acces-
sion of hemiplegia, and of the other symptoms of
compression, generally indicate that the paralysis
arises from the developement of a tumour, rather
than from the formation of an apoplectic effusion
of blood. The frequent occurrence, also, of acute
pain in the paralysed limbs, of epileptic move-
ments, antecedent cephalalgia of a violent charac-
ter, with obscuration of the intellectual powers,
somnolency, a cachectic habit of body, or the oc-
currence of disease in other parts of the body cal-
culated to taint the system, as the scrofulous,
syphilitic, carcinomatous, or fungoid diseases, are
also circumstances indicating the formation of tu-
mours in the membranes of the brain.
2d. These tumours usually give rise to further
disease of the brain, or its membranes, before
terminating life; such as inflammation of the parts
adjoining, effusions of fluid beneath or between
18
the membranes, adhesions of their opposite sur-
faces, destruction of the hones, softening and
pulpy destruction, &c. of the cerebral substance;
sanguineous effusion in this situation : and these
i"!!.,;-.,' the severity of the symptoms, and hasten
the fatal termination. It should, however, be kept
in recollection, that the effects produced by these
tumours have in general no relation to their bulk.
One of the circumference of one or two inches
will often occasion (the situation and nature of
the tumour being the same) as violent effects as
another of four or five inches. It is, moreover,
not to the tumour itself that the symptoms are to
be imputed, but to the effects it produces on the
brain and membranes.
21. ii. Morbid Changes of the Arach-
noid and Pia Mater. — A. The Arachnoid is
so delicate, perfectly transparent, and so intimate-
ly adherent to the pia mater, except at the base
of the brain, as to admit with difficulty of sepa-
ration from it. That lesions, therefore, of ilia
latter niefcibrane should affect also the former,
cannot be a matter of surprise. Indeed, the
greater number of changes which I shall have to
notice in this section generally invade both these
membranes simultaneously, although either of
them may be affected in a more or less marked
degree.
22. Inflammatory action gives rise, though
very rarely, about the optic nerves and between
the lobes of the cerebellum, to small patches of
beautiful vascularity in the arachnoid; the sur-
rounding portions of this membrane being opaque,
and adhering to inflamed parts of the pia mater.
It is, however, very uncommon to find, even in
the most intense inflammation of these mem-
branes, red vessels in the arachnoid. The most
frequent results of inflammation in this situation
are, thickening, and the effusion of a watery or
sei-ous fluid under it, raising and separating it,
in places, from the pia mater, particularly in the
intergyral spaces. The fluid secreted in this
situation is generally transparent, but it is some-
times turbid and albuminous, occasionally opa-
que, and tinged with bile in jaundice. In rarer
cases it is tinged with blood. Thickening and
opacity of the arachnoid vary much in degree.
They are occasionally so great as to obscure the
vessels and membrane underneath it. Less fre-
quent than the foregoing is the secretion of a
puriform matter, under the opaque and thickened
membrane, giving the appearance of a diffused
suppuration; and still more rare is the deposit o{
fibrinous lymph, unless in a state nearly approach-
ing to an albuminous substance, or a puriforiii
fluid.
23. The effusion of a serous fluid, in excessive
quantity, exterior to the arachnoid of the pia
mater, and in the bag of the arachnoid coat,
around the encephalon, forming dropsy of the
cerebral membranes, is sometimes observed. It
has been fully demonstrated by M. Majendie,
and confirmed by other enquirers, that this mem-
brane secretes a fluid, in health, varying some-
what in quantity with the state of the brain, and
of its circulation; that this fluid cannot he ma-
terially diminished, or entirely deficient, without
morbid phenomena being produced; and that it
may, in disease, not only he secreted in too large
quantity, but also in modified quality. In some
cases of chronic and congenital hydrocephalus,
206
BRAIN — Alterations in its Membranes.
particularly when accompanied with spina bifida, j
the effusion is chiefly in this situation. In those,
it is usually pellucid, and the arachnoid is not
materially changed in its appearance. In more
rare cases, however, this fluid has heen observed
somewhat turbid, as well as excessive in quan-
tity; and the arachnoid opaque and thickened.
In these, it would seem to have proceeded from
increased vascular action affecting this membrane
and the pia mater. Effusion of a watery fluid,
however, in this situation, is much less frequent
than in the ventricles. It is commonly congenital
and chronic in these latter cases; and it some-
times protrudes the membranes, in large watery
tumours, through apertures in, or between, the
bones of the head. Several cases of this kind
have occurred to me in the Infirmary for Chil-
dren. In dropsy of the ventricles, which is most
common, producing almost all the large watery
heads, the fluid is collected in the bags of the
arachnoid and vascular membranes lining the
cavities of the brain, so that it is contained, either
in all, or the greater number of them, at the same
time, which is most frequently the case; or in one
of them only. Serum effused from the arachnoid
and vascular membrane (pia mater) may thus be
situated : — 1st, In the sub-arachnoid cellular tis-
sue; that is, between the arachnoid of the pia
mater and this vascular membrane : 2d, In the
great cavity of the arachnoid around the encepha-
lon : 3d, In the different ventricles, and even in
the cavity between the two folds of the septum
luciduin (Breschet). The quantity of serum
effused in these situations varies remarkably. In
congenital and chronic cases, it is sometimes un-
commonly great, filling up and distending enor-
mously the cranial cavity; impeding or arresting
the developement, altering the form, and even in-
juring or destroying the texture, of the cerebral
substance, which is expanded in the form of asac;
that part of it above the ventricles sometimes con-
sisting of the meninges merely. In acute hydro-
cephalus, the effusion takes place in a few days,
and to a much less extent ; and in serous apoplexy
it may occur in a few hours. In these latter dis-
eases, however, it is often a matter of dispute,
whether the symptoms are more the result of the
effusion, or of diminished vital endowment, and
the state of circulation of the brain. (See Dropsy
of the Encephalon.)
24. Dryness of the arachnoid is occasionally
found after cases of excessive cerebral irritation,
and where inflammatory action has been suspect-
ed. There can be no reason wherefore deficient
secretion should not sometimes occur here, as
well as in other serous membranes, as a result of
inflammation. An unctuous state of the arachnoid
is sometimes observed, particularly after erysi-
pelas, abscess of the brain, discharges from the
ear, paralysis, &c, and other states of disease, in
which there was reason to infer the existence of
inflammatory irritation of the membranes of the
brain. Adhesions of the arachnoid to the opposite
surface of the dura mater, by means of a cellular
or firm albuminous false membrane, &c. have
been already described (§ 13.). Dark carbona-
ceous deposits, similar to those noticed (§ 14.)
in the internal lining of the dura mater, are also
rarely observed in the arachnoid and pia mater.
Osseous deposits also occur in the arachnoid, and
are likewise rare.
2-5. B. The Pia Mater partakes in all the in-
flammatory states, and their consequences now
described in respect of the arachnoid. The vas-
cularity of this membrane varies greatly. Some-
times it consists chiefly of engorgement of its
veins, imparting to it a dusky or purplish hue,
without any sign of inflammatory or other change.
Occasionally this congestion is attended with in-
jection of the arteries, and increased redness only,
or with these in conjunction with one or more of
the lesions now referred more immediately to the
arachnoid.
26. Slight effusions of blood, and patches of
ecchymoses, varying from the size of a split pea
to that of a half-crown, are occasionally found
lying upon the surface of the convolutions, and re-
tained between the meshes of the pia mater. Tliis
state aries from concussions of the brain, and con-
gestions consequent upon suffocation, poisoning by
narcotics, and the advanced stages of disease;
also from obstructions in the vessels returning the
blood from the brain. A layer of fibrine is
sometimes, but rarely, observed as a consequence
of effusions of blood between the pia mater and
brain; the serum and red particles of the effused
blood having been absorbed, and its fibrine re-
maining.
27. The pia mater and arachnoid are occasion-
ally separated from the convolutions in consequence
of concussion: and in some cases, particularly
after acute or recent inflammations, they may be
removed from the cerebral substance with scarcely
any force, or with much less than in health, the
vessels being loaded with blood. Otto thinks
that the easy separation of the vascular membrane
from the brain originates in the effusion of lymph
beneath the membrane, loosening its connection to
the cortical substance. On the other hand, after
chronic inflammation, occurring without effusion
under the membranes, but with a considerable ef-
fusion into the ventricles, they are often found so
closely adherent to the convolutions, that they can-
not be separated, but in very small fragments,
and then not without bringing away with them
portions of the cineritious substance of the brain.
28. Patches of yellow, albuminous . or albumi-
no-puriform matter, are sometimes found on the
upper surface of the pia mater, between it and
the tunica arachnoidea. These patches are usually
small; but they are occasionally very large, and
diffused over nearly the whole of one hemisphere.
Dr. Hooper has observed them covering nearly
the whole of the base of the brain, so as to en-
velope most of the nerves. Tins appearance
seems to result from a more than usually intense
state of inflammation, as all the membranes are
found inflamed, and the blood-ressels loaded with
dark blood, and to differ but slightly from the
effusion of pus and lymph already described in
connection with changes of the arachnoid. L7-
ceration and mortification are very rare conse-
quences of inflammation of the pia mater. They
may, indeed, be rather considered as superficial
ulceration and gangrene of the brain. Cases,
however, have been met with, sometimes con-
nected with superficial suppuration, affecting
chiefly this membrane. (Buzzi, Morgao.m,
Di'brevil, Otto.)
29. Tumours often grow from the pia meter.
The scrofulous kind of honour or tuba- cits arc
not very rare in tins situation. When they occur,
BRAIN — Alterations in its Membranes.
207
(hey sometimes reach a large size, and break
down into a pariform fluid, forming circumscribed
or encysted abscesses on tbe surface of the brain.
Leu i ii. i. i found them as large as an egg, in
nn idiot. Cases are also described by F.vki.i.,
AbkrcROHBIE, Otto, and others. Tumours
of a tub-cartilaginous structure are very rarely
met with in the pia mater, although occasionally
in the choroid plexus. They are usually of the
size oi' a pea, round or oval, laminated, cartilag-
inous in the centre, exteriorly tuberculous, and
covered with a delicate vascular membrane.
30. True encystid tumours are also sometimes
Diet with in the pia mater. Otto describes one
of immense size, — six inches long by three broad,
— found on the right hemisphere of the brain of
the Duke of Saxe-Gotha. Esq.cirol met with a
tumour of this kind containing fat; and similar
instances have been recorded. Ossific deposits
and earthy concretions have been rarely observed
on the internal surface of the pia mater, dipping
down into the structure of the brain.
31. Serous cysts, the hygroma of Dr; Hooper,
consist of a delicate and transparent membrane,
filled with a clear, limpid serum. There is in
some cases only one, in others two, three, four,
or even more. When solitary, they vary from
the size of an orange-pip to that of a walnut; but
they are seldom much above the bulk of a large
pea. When numerous, they are usually much
smaller. They are very rare in the membranes
of the exterior surfaces of the brain; but they are
very common in the choroid plexus, where they
are frequently in clusters. They have been
mistaken for hydatids, but are merely simple
cv~'.s. containing a serous fluid. They have like-
wise been found in the adventitious membranes
formed on the surface of the brain. They gene-
rally furnish no symptom by which their existence
can even be suspected during life. The acepha-
locyst, or headless hydatid, is seldom or never
found in the pia matter. Five species of the
Cysticercus, or the bladder-tailed worm, namely,
the C. tenuicollis, the C. Fischerianus, the C. di-
cystus, C. punctatus, and the C. Finna, have been
discovered respectively by Brera, Fischer,
Laenni.c, Treuteer, and Werner, either in
the pia mater or choroid plexus. (Art. Cysti-
cercus, Dirt, de Med.)
32. Fungoid, heemutoid, and other malignant
tumours, are sometimes found in the pia mater
and arachnoid; but I believe they are seldom or
never met with as a primary disease, but asso-
ciated, as a consecutive change, with fungoid or
malignant disease in some other part of the body.
When they grow to any considerable size, they
become deeply indented into the convolutions ;
producing at first irritation, and afterwards, as
they increase, symptoms of pressure. When,
then fore, such phenomena present themselves in
persons with fungoid disease, we may suspect its
developemenl also in the brain.
3:5. C. The Choroid I'i.i.xus, and the vascular
plexus of tbe fourth ventricle, which are all pro-
ductions of the pia mater, are often found remark-
ably distended with blood, and their vessels
varicose, particularly when the pia mater lias its
vessels overcharged. The choroid plexus is also
sometimes uncommonly pale and exsanguine.
This generally occurs when considerable effusion
of serum has taken place in the ventricles,
especially when the effu-ion is connected with
debility. Sometimes the plexus contains a number
of transparent vesicles (see § 30.), and it occa-
sionally presents a granulated or fleshy appear-
ance. 'Ibis has been ascribed to a morbidly
enlarged state of tbe glandular apparatus, with
which, in the opinion of some anatomists, this
structure is naturally provided. Gelatinous tu-
mours about the size of a bean, and surrounded
by a cyst, have also, though rarely, been observed
in this situation. Tumours of a cheesy or sub-
cartilaginous consistence, the size of a pea, are
likewise found, in some rare cases; and occasion-
ally these tumours contain ossific deposits in their
centres. Bony and earthy concretions are still
more rarely met with in the choroid plexus than
in the membranes. All these morbid changes
have been most frequently observed in apoplectic,
epileptic, and paralytic cases; but they have also
been frequently detected where no particular
symptom referrible to the nervous system had
manifested itself during life.
34. The membrane ivhich lines the ventricles
is naturally extremely thin and transparent. No
blood-vessels, excepting those which ramify over
the corpora striata and thalami from their trunks,
which pass by the side of the taenia semicircularis,
are usually observed in it. The vessels, however,
of this membrane are sometimes found much en-
larged, and gorged with blood, particularly when
a fluid is collected in the ventricles, so as to distend
them beyond their natural capacity. In this state
the membrane is not only more vascular, but also
much firmer and thicker than natural. The sep-
tum lucidum is sometimes as thick as the dura
mater, and very firm; but more commonly, those
parts of the membrane which are thickened and
rendered opaque, are also soft and pulpy.
35. Coagulated albumen is occasionally found
on the surface of the ventricles. It is sometimes
met with in layers on the corpus striatum and the
thalamus. I have found it of great thickness;
and in one case, which recently occurred to me
at the Children's Infirmary, it nearly filled both
ventricles. Ulceration proceeding from inflam-
mation is occasionally met with in this surface,
particularly in the corpus striatum. It seems
generally to arise from the formation of a small
abscess or purulent collection under the mem-
brane, which it ruptures, the fluid thus escaping
into the ventricle.
36. D. Inflamed states of the pia mater, with
ulceration, puriform secretion, are, as well as
Other lesions of this description in other parts of
the brain, most frequently occasioned by external
injuries. Inflammatory irritation, affecting the
arachnoid and vascular membrane either of the
periphery of the brain or of the cavities, is not an
unusual consequence of injuries of a serious char-
acter sustained in other parts of the body, as after
compound fractures and contusions of the limbs
and joints, severe burns, &c. In these cases, a
similar state of the membranes, as well 03 a nearly
similar kind of delirium to that which has been
called delirium tremens, sometimes occur. In-
flammatory states, either with dryness of the
membranes, but more frequently with effusions
of various kinds, often take place in the progress
of acute diseases, particularly fevers, and the ex-
anthemata; from drunkenness, accidents, concus-
sions, or mental excitement; whilst congestions,
208
BRAIN — Morbid Anatomy of its Sinuses.
effusions, and infiltrations of blood, proceed gen-
erally from interrupted circulation through the
heart and lungs, narcotic poisons, asphyxia, &c,
and frequently are attended with convulsions,
stupor, coma, paralysis, &c The adventitious
formations are usually the result of a cachectic
habit of body, as scrofula, deficient vital power,
and the vitiation of the system by syphilis, and
the cancerous or carcinomatous taint.
37. iii. Diseased States of the Sinuses
of the Dura Mater. — Inflammation of the
sinuses is sometimes observed, in its advanced
stages and consequences, and but rarely at the
early periods. In this latter case, they manifest
chiefly increased vascularity, and redness of their
internal lining, with slight thickening and friability,
sometimes with softening, and occasionally with
abrasion, and give rise to the following changes,
seated immediately within the part of the vessel
which is inflamed: — 1st, To the coagulation of
the blood in contact with, and its adhesion to, the
inflamed surface of the vessel : 2d, Subsequent
discolouration of the coagulum, and its conversion
into a state nearly resembling that of coagulated
lymph : and, 3d, The presence of pus, which is
usually found in the middle of this coagulum,
though not always. Thickening of the mem-
branes forming the parietes of the sinuses is oc-
casionally remarked, and is evidently a result of
a slow state of inflammatory action, affecting
cliiefly the fine cellular tissue connecting the
serous lining to the fibrous membrane. Some-
times their parietes are remarkably thick and
dense, almost approaching to cartilage, this morbid
change being cliiefly seated in their connecting
cellular substance. Finn fibrinous formations, or
coagulated lymph, are also occasionally formed
in these vessels; in some cases, conjointly with
marks of inflammation in them ; the internal
tissues of the vessels being red, injected, con-
gested, and of a dark colour; and in others with-
out any very marked appearance of such disease,
but with evident thickening of their parietes. In
several instances I have observed these formations
disposed in the form of false membranes within
the sinuses, and adherent to their serous lining.
While the more exterior surface of these false
membranes, or that next the vessel, is generally
firm, the interior of the canal which it forms is
soft, and contains a purulent like matter mixed
with a concrete albuminous substance.
38. In other instances, no fibrous concretions
are formed, nor is the vessel perceptibly inflamed,
and yet pus is found in parts of the sinuses, either
distinct and in considerable quantity, or mixed
with firm coagula, or with clots of blood, and in
small quantity. In these cases there is reason to
suppose that pus has been carried by the veins
into this situation from an adjoining part. In
some cases it occurs accompanied with an albu-
minous-like effusion, more or less concrete, or
with firm fibrinous coagula, and an inflamed state
of the internal membrane of the vessel. In many,
die presence of pus is connected with an apparent
abrasion, and even ulceration of the internal
surface of the sinus; but in others, increased vas-
cularity, with patches of deep redness, or of con-
gestion, with a deep lividity, and, occasionally,
blight thickening with diminished cohesion of the
parietes of the vessel, are most remarkable. In
ail these, there can be no doubt that the puriform
fluid is deposited in this situation from the sur-
rounding inflamed parietes of the vessel.
39. The lesions now described are most fre-
quently connected, in adults, with chronic disease
of the bones of the cranium; and, in rarer in-
stances, with disorganization of the brain itself and
of its membranes. They are most frequent after
fractures of the skull, and external injuries: and
I believe that they are occasional consequences of
the worst forms of erysipelas of the head ; a case
of this description having occurred to me, in which
inflammation of the sinuses of the dura mater was
found upon dissection. They are more common
in children, according to my experience, than in
any other class of patients; particularly from the
age of one and a half or two years to ten or
twelve. I have observed the appearances now
described in several cases of cerebral disease ;
or, at least, of cases terminating with the usual
symptoms of pressure on the brain, following
severe states of porrigo, ulcers of the scalp, and
chronic diseases of this structure, particularly in
scrofulous, weak, and ill-fed children. The ob-
servations of. M. Tonnelle and of M. Ribes
fully agree with my experience as to the patholo-
gical relations of these lesions of the sinuses.
40. Ihe sinuses also present a vermilion colour
of their internal membrane, like that which is
sometimes found in the arterial system. This
appearance is most probably caused by a morbid
state of the blood; and it may be, on some oc-
casions, a post mortem change, arising from the
staining of the internal surface of the vessels bv
the colouring part of their contents. In respect of
the state of the blood itself in the sinuses, much
diversity exists : the quantity contained by them
also varies greatly. .Y7ore frequently tbev are
empty, or nearly so. When they contain blood,
it is in some cases dark, semifluid, or thick; in
others, less dark, and more fluid; in the greater
number, either altogether or partly coagulated.
In a few, it is separated into a serous or sero-
sanguineous fluid, and a fibrinous coagulum havir.o-
no connection with the parietes of the vessel, the
coagulum consisting entirely of the fibrine of the
coagulated blood, and not of the albuminous
fibrin, or coagulated lymph, already described
(§ 36.). In some cases, one or more of the
sinuses is filled with a dense, firm, and brown co-
agulum, perfectly continuous throughout; branch-
ing even into the veins which open into the sinuses;
and not interrupted, soft, and forming variously
sized clots, such as are often found after death.
This state o/ the contents of the sinuses is seldom
or never connected with inflammation of its
parietes, unless the inflammation has occasioned,
by means of the albuminous matter efiused, a
complete obstruction of the vessel, and, conse-
quently, the accumulation and gradual coagulation
of the blood beyond it; being a chance in these
fluids independent of organic lesions of the parietes
of the sinus, unless such lesion occasion obstructed
circulation through it.
41. The firm, dense, and continuous coagulum
now described is evidently the result of a slow
coagulation proceeding in the sinuses previous to
death; and, in every instance in which I have
observed it, has arisen from obstruction in the
return of blood from the sinuses, owing to com-
pression of the jugular veins, by tubercles, scro-
fulous tumours, or other organic chances obliter-
BRAIN — Alterations of its Substance.
209
ating tlu1 canals of these vessels, or of the sinuses
themselves; or from a stasis of the blood, follow-
ed by coagulation La these vessels, arising in con-
sequence of great cerebral congestion, joined with
the utmost general adynamia. There is no doubt
that the effusion of lymph, in any of its states,
or even of purulent matter, will, while in connec-
tion with the internal surface of an inflamed ves-
sel, or mixing with the blood in it, dispose this
fluid to coagulation; forming a nucleus around
which coagulation will proceed, or a point from
which it may depart. And such seems to be the
source of the more or less extensive and continu-
ous coagula, which we frequently find in connec-
tion with inflammatory lesions and formations in
the sinuses. But such is not the case here. In
the course of an extended experience at the In-
firmary for Children, I have observed, in several
eases, that this state of dense coagulation of the
blood in the sinuses manifestly supervenes before
death, owing to the general and local conditions
now stated, and gives rise to all the symptoms of
more or less complete and sudden compression of
the brain, owing to the consequences I am now
to notice as arising from it, in common with other
causes of obstruction in the sinuses. In cases of
this description, if no effusion of blood have oc-
curred, the veins are found generally engorged
with dark blood. In some cases, the distension
of the veins had given rise to an exudation of
blood, or rupture of several of their minute distri-
butions, with copious extravasation of this fluid;
and in many, the distension of the veins was ac-
companied with copious effusions of serum in the
ventricles, between the membranes, or in both
situations.
42. The glandula Pacchioni are sometimes so
much increased in number and size as to obstruct
the passage of blood through the sinuses; give
rise to the appearances now described; and thus,
as the other changes in the sinuses, terminate in
some one or other of the apoplectic states. Mr.
Eari.f. (Medico-Chirurg. Trans, vol. iii. p. 66.)
has observed these glands changed to the appear-
ance of grumous blood, in connection with fun-
goid disease in the brain. They are more fre-
quently enlarged and hardened; and, occasionally,
they cause an absorption of the dura mater, with
corresponding depressions in the superincumbent
bone.
4:5. The bands which cross the longitudinal
sinus are occasionally more numerous than natural;
and they are sometimes thickened, particularly in
connection with a similar change of the parietes
of the sinus.
44. The reins on the surface of the brain some-
times contain a few bubbles of air; but it is doubt-
ful whether this is a morbid state or a post mortem
change. They are occasionally filled with_/t&rine,
particularly in those cases which presented a
corresponding state of the sinuses. Pas has also
been observed in them, especially in cases of
inflammation, with secretion of pus under the ar-
achnoid.
45. Ossification is detected only in the arteries;
but it occurs in them very frequently, and to a
very great extent, particularly in advanced life.
The early stages of this change have also been
discovered in youth, although rarely. The arteries
most commonly found ossified are the internal
carotids and the basilar; but the circle of Willis,
18*
and the vessels departing from it, as well as the
arterial ramifications which appear between the
convolutions, and come out upon the surface, often
participate more or less in this morbid state. Car-
tilaginous degeneration is still more extensive,
and seems to precede the ossilic deposits. Car-
tilaginous and oesific formations in the coats of
the arteries of the brain occasion irregular dis-
tributions of blood, and interrupted or imperfect
supplies of this fluid to some parts of the organ;
disposing to aneurismal dilatations, to rupture,
and, consequently, to the production of apoplexy
and paralysis. In most instances of extravasation
of blood in the substance of the brain, this condi-
tion of the arteries exists; and is, most probably,
the cause of the extravasation, by disposing it to
congestion, and rupture from increased action of
the heart.
46. Aneurismal dilatations of the arteries of
the encephalon are by no means very uncom-
mon: they are most frequently met with in the
carotids after they have entered the cranium, in
the large branches, and in the basilar artery.
They may derange the circulation of the brain, or
may occasion effusions of either blood or serum,
without themselves having been ruptured; but
they more frequently break, occasioning apoplexy.
The arteries, particularly those about the base of
the brain, and some part of the branches forming
the circle of Willis, are also occasionally obliter-
ated and reduced to a thin cord.
47. II. Lesions of the Substance of the
Brain. — The morbid states of the brain have
been investigated in modern times with the great-
est success and advantage to practical medicine.
The labours of Reil, Serres, Lallemand,
Wenzel, Gall, Rostan, Abercrombie,
Hooper, Craigie, and Duncan, have chiefly
tended to this advancement; whilst a number of
other enquirers have added much of importance,
as well as confirmed the observations of more
original enquirers.
48. i. Inflammation of the Substance ok
th e Brain , — Encephalitis, — Cerebritis. — A.
Acute inflammation of the brain does not fre-
quently occur as an idiopathic or primary and un-
complicated malady. It is in consequence of pre-
vious disease, as fevers, the exanthemata, inflam-
mations of the ears, extravasated blood, tumours
and tubercles of the brain, of poisons, and external
injury, that it comes most frequently before the pa-
thologist. Resulting from injury, it is generally
limited in extent, although intense in degree. The
whole brain is rarely or never aflected at the same
time, but only a part of it ; and the disease is
seated either in the vascular membrane, or in the
cortical substance, or in the medullary matter of
the interior parts, of the brain, or in them all
simultaneously. The part affected first becomes
vascular, and the injection of the vessels proceeds
till the cerebral substance displays a red tint, deep-
ening, as the disease advances, until it assumes
a reddish brown, and, occasionally, even a brown-
ish or green shade. With this increased intensity
of disease, the part becomes softer than natural.
The formation of matter, however, is not so fre-
quent a consequence of this form of inflammation
as of that of a sub-acute or chronic kind, occur-
ring in persons of a scrofulous diathesis, and un-
healthy habit of body, unless when a foreign sub-
stance, or piece of bone, has been driven into the
210
BRAIN — Alteration's of its Substance — Abscess.
brain. Somewhat similar to inflammation, al-
though decidedly different from it, is that state of
morbid irritation frequently met with in levers,
especially typhus, eruptive diseases, epi!eps\ , de-
lirium tremens, tetanus, convulsions, h\ drophobia,
nostalgia. In these diseases, vascular turgescence
mid red injection of the brain, are usually seen; but
not the general red colouring, the spot-like effusion
of blood, and the change of consistence, which
characterise acute inflammation of this structure.
49. Acute cerebritis occasions violent headach,
intolerance of light, acuteness of all the senses,
delirium rapidly succeeded by convulsions, coma,
and death. When it arises from morbid poisons
affecting the system, as in gaol and camp fevers,
purulent formations are more frequently met with,
as stated by Pringle and others. In these cases
the symptoms are somewhat varied; the prostra-
tion of the powers of life being much greater, and
the delirium of a much lower grade. In those
diseases, the post mortem inspections, when nu-
merous, will furnish examples of the various stages
of lesion, from the first appearances of injection
of the vessels to the formation of matter, or com-
plete destruction of the part chiefly aflected.
50. B. Suppuration of the brain, — Abscess of
the brain, — Apostema cerebri. — Collections of
purulent matter have been often found in the brain,
generally as a consequence of inflammation of a
sub-acute or chronic kind. Of this the writings
of Bonet, Morgagni, Lieutaud, Baader,
Stoll (Rat. Med. i. p. 2S5.). Frank (Acta
Inst. Clin. VTiln. Ann. 1. p. 75.), Prochaska
(Anat. Acad. Fasc. part ii. sect. ii. cap. 2.),
Schaeffer (Huf eland und Himhj, Journ. der
Pr. Heilk. 1809.), Portal (Memoir esde I'Acud.
d-es Sciences, 17S0, p. 315.), Lallemand,
Baillie, Brodie, Powell, Hooper, and Ab-
ercrombie, furnish numerous examples. The
situations of these abscesses vary considerably, as
well as the kinds of abscesses formed, a. Some-
times the purulent collection is lodged in an irregular
cavity, and appears unsurrounded by any distinct
cyst." These take place to a greater or less ex-
tent, and consist most commonly of purulent mat-
ter mixed with flakes of lymph, giving it a slight
curdlv appearance. They are most commonly
found in the anterior lobe of the cerebrum, or in
the centre of the hemisphere. Some of the ab-
scesses of this kind seem to consist of several
small cavities communicating with each other :
these are usually found also in the anterior lobes,
the centres of the Hemispheres, or near the striated
nucleus of Reil. b. The next species of abscess
consists of a distinct, firm cyst, or even cysts, as
observed by Lallemand, and seems to have
been the result of a slower process of formation,
and of a less acute form of inflammation: it con-
tains purulent matter, and is most frequently found
in the centre of the hemispheres, particularly just
above the central oval of Viecssens, or at its
margin. Abscess of the brain has also been met
■with immediately below the cornu ammonis ;
likewise near die parietes of the small posterior
cornu of one of the lateral ventricles, and just
below the unciform eminence which rises into
die interior of this cavity. In one instance only
(North Amer. Med. and Surg. Journ. 1818.),
have the tubercula quadrigemina, and pineal
gland, been the seat of abscess.
51. c. Purulent matter U also found in some part
of the brain, infiltrated, as it were, into the cere-
bral substance in the form of a number of minute
drops, and occupying a considerable extent, but
not lodged in any single distinct cavity: the parts
surrounding the purulent infiltration presenting
scarcely any other appearance of change, except-
ing more or less softening, which is always pre-
sent, and seldom any sign of augmented vascular
action. This morbid state is frequently observed
as the consequence of the transit of purulent
matter into the circulation, which, in some cases,
is secreted from the vessels in the substance of
the brain, giving rise to the infiltration. This
phenomenon takes place much more frequently
in the parenchyma of other organs, as of the
liver, lungs, and spleen, than in the brain. 'I he
infiltration, whether proceeding from this source
or not, often passes into the condition of distinct
collections, varying in number and size; and some-
times they nearly or altogether communicate.
In such cases, the cerebral substance separating
these collections seems as if it were softened, or
broken down into the purulent matter, and often
processes of the cerebral structure, still adhering
to the surfaces surrounding these collections, are
floating in them, appearing as the debris of a
portion of the disorganized brain. In these cases
an approach is made to the formation of a regular
cavity. In other instances, if the disease is less
rapid, or does not destroy life before further local
changes take place, a distinct cavity is effected,
which, at first, consists of the cerebral substance
merely, softened, discoloured, and vascular. M.
Andral thinks that the following characters pre-
sented by the cavities containing purulent n atter
are the result of subsequent changes which the sur-
faces of these cavities undergo, and not the resuit
of an original dissimilarity of structure. As to this
point, I think his reasoning inconclusive, and his
proofs insufficiently strong. It, however, should
be admitted, that the purulent infiltrations, and
collections in either of the forms now noticed, are
those which take place most rapidly, and which
are generally observed in post mortem researches,
in cases of death taking place soon after the s\ mp-
toms of cerebral disease had supervened; whilst
the encysted form, as I have already stated, are
those which manifestly form most s'.owlv.
52. d. The different kinds of parietes sur-
rounding the collections of matter in the brain,
according to this able pathologist, are, — 1st,
The cerebral structure itself, which, in recent
and acute cases, forms the only envelope of the
purulent collection ; but which may assume the
following appearances successively, according to
the duration of the disease. 2d, A cellulo^ascu-
lar substance, extending over the whole of the
internal surface of the cavity, or merely in parts.
3d, A true membrane, which is as yet soft, and
flocculent, but yet admitting of separation from
the adjoining nervous substance. 4th, A fine
membrane, presenting a distinct organization, and
capable of being detached either in pieces or
entire. Once arrived at this stage, their internal
surface often has the appearance of villosities,
whilst sometiir.es the cyst is composed of two or
more distinct layers, which may be detached from
each other. In these cases, the cvsts are thick,
as remarked by Professor Lai i.i m and: the in-
ternal layer, or cyst, being of a reddish white,
and presenting the appearance of a mucous sur-
BRAIN — Alterations of its Substance — Abscf.ss.
211
Face slightly inflamed. In a case noticed by this
author, in which three distinct layers, or cysts,
were observed, the exterior was cellular, adhering
to the cerebral substance; the middle one thick
and linn; the interior layer closely resembled a
mucous suffice. .Mkck ki., however, espouses a
different opinion from An urai., as to the form-
ation of abscesses contained in distinct cysts.
These are not, according to him, owing to ad-
vanced changes in the organization of the walls
of the purulent collection ; nor are they to be
ascribed to suppuration of the cerebral texture
itself; but to inflammation and suppuration of an
adventitious structure, developed in the cerebral
substance. His reasons for this opinion, are, —
1st, That those cysts adhere but very loosely to
the surrounding cerebral texture : 2dlv, That this
texture is not hardened, but, on the contrary,
softened, immediately around them.
53. The cerebral substance iu which the puru-
lent infiltrations and collections of the first grade
are found, is generally softened, and, excepting
when they arise from the absorption of purulent
matter into the circulation, more or less injected.
In cases of purulent collections contained in
more or less distinct cysts, or membranes, the
surrounding structures are often but slightly alter-
ed, and occasionally not even perceptibly so.
But when the collection has much increased, or
continued long, the nervous substance surround-
ing the cyst becomes irritated, inflamed, dis-
coloured, and softened; and then only supervene
those symptoms which evince, unequivocally, the
existence of alis'vss or serious organic lesion:
for, up to this period, the abscess may have been
proceeding, but so slowly as not to disturb the
functions of the organ, until, owing to some de-
termining cause, iu conjunction with the changes
taken place in the cyst, its contents, or with its
size, the substance of the bruin surrounding it
becomes diseased.
54. Abscesses, whether immediately surround-
ed by the cerebral structure, or contained in more
or less distinct cysts, may vary in number from
one to six or seven, each distinct from the other,
and seated in various parts of the brain. They
may present appearances of ulceration in their
parietes; and they may be accompanied by a
variety of other lesions of the brain and its mem-
branes, generally in different subjects, but occa-
sionally even in the same case. Inflammatory
appearances of the membranes; effusions, serous
or albuminous, in either the external or internal
surfaces of the organ; softening of the structure,
tumours, occasionally hardening, &c; are their
usual attendants.
55. e. In respect of appearance, the pus found
in the brain differs in no way from that formed in
other textures of the body. M. Lai.i.emand
(Richerches Anutomico-l'atholog. sur V Enceph.
&c. let. hi. p. 361., let. iv. p. 41.), whose nume-
rous observations of purulent collections in the
brain have enabled him to give much interesting
information on this topic, states, that he has ob-
served it of a yellowish green tint, yellowish,
yellowish white, greenish, grayish, yellowish gray,
whitish gray, dirty white, and altogether white.
lie, as well as Abxkcrombie, has frequently
found it extremely fetid. This fetor of the pus
I have observed in several cases of abscess oc-
curring in young subjects, from the extension of
inflammation of tin; ear to the brain. In a case
of this description, reported in the Medico-Chi-
rurgical Review for Dec. 1830, the fetor of
the purulent collection was extreme ; and the
cerebral substance surrounding it greenish, dis-
organized, and broken down into the contained
matter. Abscesses formed within the substance
of the brain occasionally make their way to some
part either of the external or of the internal sur-
face of the organ : thus they sometimes break into
the ventricles, as iu the case just now alluded to :
when they open upon the periphery of the cere-
brum, they occasionally destroy the bone and
intervening membranes in its immediate vicinity,
before death is occasioned. M. ANDRAL sr.vs,
that he has observed an abscess of the brain
destroy the cribriform plate of the ethmoid bone,
and escape externally through the nasal fossa;:
and MM. Itard, Lalt.km and, and others have
shown, that abscess of the brain, from an exten-
sion of inflammation from the ear, may destroy
the petrous portion of the temporal bone, so fur
as to admit of the evacuation of the abscess by
the ear. In cases originating from this source the
matter is frequently contained in no distinct cyst,
the cerebral structure surrounding it being gene-
rally discoloured, softened, and often appearing
as broken down into it. Sometimes the meatus
externus and interims are shut up by means of
fungous granulations preventing the external exit
of the purulent secretion, and hence probably, in
some cases, diverting it internally. In some cases
more than one abscess, in some instances four or
five, seated in distinct parts of the brain, have
been observed.
56. /. Collections of purulent matter have like-
wise been found by Bianchi, Stoll, Wkick-
ard, J. Plancus, Frank (De Curand. Homin.
Morb. lib. ii. p. 49.), Nannoni, Perrault
(Journ. de Mtd. t. vi. p. 381).), and Abercrom-
bie, in the cerebellum, generally contained in more
or less distinct cysts, "the walls of which were
membranous and vascular." Matter, indistinctly
defined, has been found also in the medulla oblon-
gata, generally in small irregular cavities, " espe-
cially in that part of the olivary body which contains
the corpus dentatum." (Craigik, in opus. tit. p.
386.) Dr. Abercro.mbie mentions a case where
it was met with at the junction of the protuberance.
57. g. These collections are evidently the result
of inflammation, but of a peculiar and slow cha-
racter, probably owing to the constitution of those
in whom they are most frequently found, and who
are generally of the strumous diathesis. The en-
cysted abscess seems to take place very slowly, and
to be analogous to wlmt has been commonly called
chronic or cold abscess. The purulent infiltrations
occasionally met with in the large nervous masses,
as well as in other viscera, from the absorption of
purulent matter into the circulation, evidently lake
place with great rapidity, and are a result rather of
morbid secretion, than of inflammation.
58. h. Abscess of the brain is very frequently
met with as a consequence of purulent discharge
from the ear. This affection of the ear, when it
has not apparently proceeded from inflammatory
sore throat, and the extension of the inflammation
along the Eustachian tube, is very generally con-
nected with a sub-acute or chronic inflammation
of the dura or pia mater of the brain; and is thus
frequently extended to the substance of the bruin
21-2
BRAIN — Alterations of its Substance — Abscess.
itself, terminating at Inst in abscess in this situation.
This has been satisfactorily shown by Moegagni,
Itard, Powell, La llem and, Dun can, Abe r-
crombie, Craigie, and others. Bonet, and,
more recently, Mr. Brodie, supposed that the
affection of the ear was consequent upon that of
the brain, or at least coeval with it; and hence
they ascribe the discharge from the ear to the in-
flammation of the membranes having extended
itself from the dura mater of the temporal bone to
the tympanal cavities. When abscess of the brain
takes place owing to the affection of the ear, they
consider it an extension of the inflammation from
the membranes internally to the substance of the
brain, in consequence either of the unhealthy
habit of the patient, or of improper treatment, by
suddenly suppressing the discharge, " and con-
verting a clu'onic external inflammation into an
acute internal disease;" the external discharge
having been, as it were, arrested and turned in
upon the cerebral substance. The only question
here is in respect of the particular parts in which
the inflammation originates; as to the consecu-
tive phenomena, there seems to be no difference
of opinion : and this point can be decided by the
symptoms only, and the order in which they
occur. If the purulent discharge takes place
without any previous internal and deep-seated
pain, and the dangerous symptoms follow upon
the suppression of the discharge, we may infer
that the disease has commenced in the ear, and
extended itself to the membranes and brain itself.
This is, perhaps, the most frequent procession of
the morbid phenomena. But, occasionally, a
different course is manifest, especially in delicate
children, and patients of a strumous diathesis.
In these, symptoms of disease of the brain or its
membranes are very manifest before the discharge
takes place; and when it does take place, either
the patient recovers under judicious management,
or, upon the disappearance or suppression of the
discharge, a sudden exacerbation of the symptoms
are observed, with delirium, coma, convulsions,
&c. followed by death. Such is the result of my
experience in a very great number of cases which
have come before me; so that I am led to con-
clude that, whilst the opinion adopted by Mor-
gagni and his followers, on this question, is often
correct, that espoused by Bonet and Brodie is
not wholly without foundation.
59. But it is not infrequently observed, (and
I have met with several instances in grown up
persons,) that patients have been occasionally
liable, for years, to a puriform discharge from the
ear, — occasionally from childhood, with little
remission, and with little or no further ailment.
This sometimes gradually diminishes, or sud-
denly disappears; when either soon afterwards,
or not until several months subsequently, or even
after a year or two, dangerous symptoms of dis-
eased brain supervene, and rapidly advance to
a fatal termination; and upon dissection, inflam-
mation of the membranes of the brain of the
same side of the body with the affected ear is
observed, and in the substance of the hemisphere
is found a large purulent collection with inflam-
mation and softening of the cerebral matter sur-
rounding it, the cavity presenting an irregular
soft surface.
60. The following cases strongly illustrate this :
— 1st, A young gentleman had, from childhood, a
slight purulent discharge from the right ear, until
nearly the period of puberty; about which time
it gradually disappeared. He had nearly lost the
sense of hearing on that side. He went into the
public service, in which he continued for several
years, until, about the age of thirty, he was sud-
denly seized with intense pain of the head, fever,
followed by paralysis of the whole left side of the
body, insensibility, involuntary motions, coma,
shortly terminating in death. On examination,
thickening of the membranes of the right side of
the brain, with adhesions, softening of the cere-
bral structure, and a purulent collection nearly in
the centre of the middle lobe of the hemisphere,
were found. I very recently witnessed a nearly
similar case, to which I was called by a neigh-
bouring practitioner; and a third case, in which
I had ventured to predict similar lesions in a per-
son advanced in life, but which we were not
permitted to verify by a post mortem inspection.
61. Abscess of the brain consecutively on pu-
rulent discharge from the ear, is most frequently
observed in young subjects, particularly in those
of a strumous diathesis. From what I have said,
it must not be inferred that abscess of the brain
is the only unfavourable consequence, or even
the most frequent one, owing to an extension of
the inflammatory action from the ear or cerebral
membranes; for other lesions accompany it. But,
whether the abscess proceed from a gradual ex-
tension of disease, as now stated, or be a vicarious
result of the suppression of the external discharge,
— in which light it may sometimes be justly
viewed, — there are generally found, upon exam-
ination of the surrounding parts, increased vascu-
larity, softening of the cerebral substance, and an
irregular, soft, and vascular cavity, containing the
purulent matter. Added to this, there are also
inflammation, thickening, and suppuration of the
membranes; the pia matter being injected, and
covered with lymph; the dura matter thick,
opaque, dark coloured, more readily torn, and
detached from the bone underneath it, which is
also discoloured, and sometimes carious.
62. Abscess of the brain is very often a conse-
quence of external violence; but it is one which
takes place at extremely indefinite periods from
the receipt of injury, and which often has little
or no relation to the extent of the external mis-
chief. The period which elapses from the ex-
ternal violence to that full developement of the
abscess which is incompatible with the duration
of life, according to the observations of Pigray,
Morand, Prochaska, Thilkmis, Home,
Denmark, and others, varies from two or three
months to as many years. A case which I had
an opportunity of observing in a public institution,
and in which the operation of trephining had been
performed, presented a large abscess in the hemi-
sphere, underneath the seat of injury, between
three and four years from the time at which it
had been sustained. The perforation made by
the trephine was completely filled with ossific
matter, which extended in a radiated manner
from the edges of the perforation towards its
centre.
63. Dr. Baillie says, that when suppuration
of the brain takes place from internal causes, it
is generally in the substauc* of the organ; but
when it arises from external violence, it affects
only the surface. But as Dr. Craigie lias very
BRAIN — Alterations of its Substance — Abscess.
213
justly remarked, this distinction does not always
hold good, and requires modification. — 1st, When'
u long interval elapses after the infliction of the
injury, tin? collection of purulent matter is almost
invariably deep-seated. 2d, lit like manner, when
the injury operates in the manner of counter-
si roUe, the collection is also often within the sub-
stance of the organ." 3d, In some instances of
suppuration after injury, the collection does not
take place at the part where the blow struck the
skull, hut either in the line of the force passing
through the brain, or in some of the lines into
which this force may he revoked. 4th, It is chief-
ly when this force has been directly expended on
the part, i. e. when the hone has been immediate-
ly broken, and its membranes injured, that suppu-
ration takes place on the surface of the brain : it
is then the result rather of the injury of the mem-
branes, espe -ially of the pia mater, than of the
cerebral substance itself.
64. Suppuration may occur in any part of the
brain ; but it is most frequently met with in the
hemispheres, as shown above (§ 50.). Its effects
vary exceedingly, according to the situation and
extent of the purulent collection ; but are not es-
sentially different from those which follow upon
the slow effusion of blood, the presence of tu-
mours, or other morbid formations. I have al-
ready hinted at the occurrence of suppuration in
parts M' the brain in the course of fevers, espe-
cially those which are of a malignant character,
or which are complicated with inflammatory ac-
tion of the brain. Such occurrences have been
observed by Pringle, Borsieri, Eisfield,
Pi.ouco.ijet, Clutterbuck, Marcus, .Iack-
s >:•, and Mills, and many others. But this falls
and t the p ithology of, and morbid appearances
iu fevers, where the subject lias received due
attention.
63. C. Ulceration. — To ulceration of the brain
authors have attached no precise idea, they differ-
ing widely as to what should constitute ulceration
of the cerebral texture. According to the opin-
ions of some, those solutions of continuity, some-
times observed in the most advanced degrees of
pulpy destruction of the brain, about to be de-
scribed (§ 72.), are nothing else than ulceration ;
and certainly, if there were appearance of any
considerable loss of substance by absorption, the
lesion would be legitimately ulceration. The case
recorded by Mo lgagni (De Sed. ct Cam. Morb.
cp. xi. pars ii. ), in which he described the corpus
striatum ab relijuo cerebro omnino separatum in-
ventum ed, which is so singular, may be referred
to ulceration. By ulceration of the brain, Dr.
Craig i v. understands destruction of part of either
of its surfaces, " so as to present a hollow or de-
pressed surface, rough, irregular, and covered par-
tially either with bloody or albuminous exudation."
This seems sufficiently precise ; and excludes those
doubtful cases of ulceration sometimes conse-
quent upon effusions of blood, the advanced
st;iges of softening of the organ, and the forma-
tions of abscesses existing in the substance of the
brain, where, although a breach of continuity of
structure is produced, yet the removal of it. by
absorption cannot be demonstrated. Cases of this
description are more legitimately examples of
pulpy destruction, or suppurative disorganization,
than of ulceration. Willi this limitation of ul-
ceration and erosion to the various internal and
external surfaces of the brain, M. AndRAL agrees
with Dr. Craigik. This species of lesion, al-
though not of frequent occurrence, is yet occasion-
ally met with. Besides the case given by Mor-
GAGNi,and already referred to, another is men-
tioned by him in the same epistle. Instances of
this disease have also been recorded by Bonet
( Hist. Anat. Med. part iii. Ob. 108. 138.), Wep-
ff.r (p. 212.), Morgagni (Epist, Jnat. Med.
iv.), I.ieutaud, {Hist. Anat. Med. let. iii.), Se-
nac, Valsalva, Portal {Anat. Mid.t. iv. p.
98.), Howship {Med. and Phys. Journ. March,
1810.), Anderson {Transact, of Royal Soc. of
Edinburgh, vol. ii.), Ridley, IIaller, Stoll
(Ratio Med. pars iii. p. 122.), Powell {Case 6.
Transact, of College of Physicians, vol. v. p. 96.),
andScouTETTEN (Archives Gen. t. vii. p. 31.),
who have met with it on the convoluted surface
of the brain, on the foliated surface of the cere-
bellum, and in the surface of the ventricles, —
parts in which this morbid change is chiefly found.
As shown by IIaller (t. iv. p. 351.), Stoll,
and ScootettEn, ulceration of any part of the
brain's surfaces is always attended with an in-
flamed, or otherwise unsound state of the pia ma-
ter, and occasionally with softening of the parts
underneath, sometimes limited to the gray sub-
stance, but at others proceeding further. In the
two cases recorded by M. Scoutetten, the ad-
jacent brain was somewhat softened, and in one
of them, of a wine lees colour. The ulceration
in the first case existed on the inferior surface of
the right anterior lobe, and presented a hard, dry,
irregular, yellowish surface, thirteen lines long and
eleven broad, with singularly indented edges.
This patient died with symptoms of irritation of
the digestive canal, and of the brain. He ex-
perienced a constant acute pain at the bottom
of the orbits. In the second case, the extremity
of the posterior lobe presented two small uf-
cerated patches, one much larger than the other,
and of an oval form. They penetrated no deep-
er than the cortical substance. This patient had
been seized with gastro-intestinal irritation, and
complained of no pain in the head. During the
latter stage of his disease, he became delirious.
In both these cases the surrounding pia mater wag
injected, and somewhat eroded ; so that we may
infer from these, and other cases upon record, that
ulceration of the brain is a consequence of cir-
cumscribed inflammation of the pia mater.
6b'. The existence of ulceration of the brain is
indicated by headach, partial convulsions, some-
times epilepsy, palsy, loss of memory, hebetude,
coma, and exhaustion. In some cases the head-
aeh is intermittent, and the palsy is generally on
the side opposite to that in which the lesion isj
found. In the case recorded by Dr. T. Ander-
son, and in which most of the symptoms now
noticed were present, there was a superficial losa
of substance from ulceration, two and a half
inches long, one and a half broad, and nearly an
inch iu depth, situated on the upper part of the
right hemisphere of the brain. In the bottom of
tins cavity were found some thin lamina: of a
brownish matter, with stony concretions, some
of which broke into sand upon the slightest
touch.
67. D. Sphacelation or mortification of the
cerebral substance is rarely met with, and chiefly
as a result of external injury, when it has been
214
BRAIN — Alterations of its Substance — Softening.
bruised and acutely inflamed. In this state of dis-
organization, the cerebral substance is dissolved,
of an orange brown colour, or of a grayish black,
and foetid. This alteration seems to be rarely
produced by internal causes, and is to be distin-
guished from the pulpy softening of the organ.
Dr. Abekckombie, however, considers this lat-
ter change to be identical with gangrene.
68. ii. Softening of the Brain. — A. From
serous infiltration, — (Edema of the brain. In-
filtration of the substance of the brain with a
watery fluid has been noticed by Guersent and
An oral, — by the former in children, by the lat-
ter also in adults. In these cases the serum may-
be diffused in the nervous substance, or contained
in more or less distinct cavities. This change is
most frequently observed in the white central
parts of the organ. It has not generally been re-
marked in connection with any particular symp-
tom ; but it has, in a few instances, co-existed
with dropsy of the ventricles ; and, in adult sub-
jects, with general leucophlegmatia and cachexia.
69. B. Simple diminished consistence of the
brain, without change of structure, — Malakence-
phalon (Craigie), — seems to be a different state
of the organ from that which constitutes the ra-
mollissement — softening, or pulpy destruction of
the brain. In this latter more or less disorganiza-
tion is manifest, and generally some change in its
colour; but the former is merely diminished con-
sistence, greater flaccidity, and decrease of its
natural firmness, toughness or tenacity, and of
that clamminess or viscid feeling which it usually
communicates to the touch. This state is com-
monly attendant on low or malignant fever, and
on chronic diseases, particularly pulmonary affec-
tions, marasmus, diabetes, dropsies, mesenteric
and visceral affections. It generally affects the
whole organ, and, indeed, the whole cerebro-
spinal axis ; whereas the pulpy destruction of the
brain is more or less limited in extent, affecting
parts of the organ in a particular manner.
70. In dropsies, the brain is often flaccid, more
easily lacerated, and of diminished consistence
throughout. This state proceeds either from di-
minished nutrition of the organ, or from an inter-
stitial deposit of serous fluid with its minute at-
oms, and defective vital cohesion of its substance.
The proper texture of the part is not otherwise
changed. Diabetes sometimes occasions a simi-
lar state, and most probably from diminished nu-
trition added to a deficient vital cohesion of the
structure. In pulmonary consumption, and in
chronic bronchitis, the brain is very commonly
found softer than natural throughout ; and this
softness is the more marked, the more chronic the
pulmonary affection has been, and the more com-
plete the emaciation. May not this state be con-
sidered as analogous to emaciation of other parts ?
the molecules of matter removed by interstitial
absorption of the texture of this organ being re-
placed by a serous effusion, owing to the cranium
being a shut cavity, which must necessarily, dur-
ing the life of the subject, always be in a state of
repletion. In such a case, the density of the brain
is actually diminished. Meckel states, that he
found a cube of six lines, taken from the brain
of a man dead of phthisis, 1 \ grain lighter than
the same bulk of a sound brain. Dr. Monro
has found the brains of condemned felons ex-
tremely soft, particularly internally, ( The Mor-
bid Anatomy of the Brain, vol. i. p. 35. and
100.). I^ittre, however, states, that the brain
of a felon, who committed suicide, was extreme-
ly dense and firm, (Histoire de I Acadimie Roy-
ale des Sciences, Ann. 1705.) Tulpius, Kerk-
ringius, King, Scheide, Morgagni, Gred-
ing, &c. have found the brain frequently soft and
flaccid in fatuous persons, as well as in epileptics,
and epileptic maniacs. Greding (OnLudwig's
Adversaria, t. ii. part iii. p. 533.) found in about
one half of the last named class of subjects, the
brain very soft throughout, particularly in its cen-
tral parts ; and Dr. Haslam's observations (Ob-
servations on Madness and Melancholy, 2d. edit.
Cases, 4. 10. 18. 25. 28. 30. 37.) in some degree
confirm these statements. But it should not be
overlooked, that the brain of epileptics and ma-
niacs is found also more than usually firm. The
diminished consistence of the brain of condemned
felons has been attributed to confinement, inac-
tivity, and low diet. Whether these may have a
greater influence in causing it than the mental dis-
tress to which these persons are reduced, it may
be difficult to determine ; but if the former be
the cause of this state of the organ in felons, it
may be equally so in maniacs, who are generally
also subjected to confinement and low diet. The
diminished consistence now described, is more or
less universal, although more remarkable in par-
ticular parts, and it generally affects the whole
cerebro-spinal axis. Whereas the morbid soften-
ing, or pulpy destruction, about to be described,
is generally limited in extent. . The former also
seldom presents any very sensible change from
the natural colour of the part ; whereas with
pulpy destruction there is a more or less evident
discoloration.
71. C. Pulpy destruction, — Softening, — Ra-
mollissement, — Encephalitis sub-acutus, — Cere-
britis sub-acutus et chronicus. — Softening of the
substance of the brain has generally been ascribed
to a sub-acute inflammatory action, especially by
Morgagni, Rostan, Lallemand, Bocil-
laud, Pinel, Olivier, and Velpeau, to
whom we are chiefly indebted for having direct-
ed attention to this particular lesion. There are
others, however, asliECAMii.R, who consider this
change as the effect of a morbid nutrition of the
part, rather than as a result of inflammatory ac-
tion. By softening of the brain, must not be un-
derstood that soft state of the organ which is al-
ways present in early infancy, nor the less con-
sistent state of the organ sometimes observed in
some chronic diseases, and in certain forms of
fever, and already described. It should also be
recollected, that all parts of the brain possess not
the same degree of firmuess ; for, if the mesoce-
phalon be as soft as a lobe of the cerebellum, it is
undoubtedly in a morbid state.
72. Softening of the brain presents various de-
grees. The least change of consistence of the
part can be recognised only when it is touched.
In a more advanced degree, the softening is ob-
vious to the sight. In a still farther advanced
grade, the cerebral substance is nearly liquid, and
has almost entirely lost its organization ; and in
its place there is a mere loose cellular substance,
soft and gelatinous, appearing as the original
matrix of the structure ; and in the last and most
advanced stage of all, there is a perfect disso-
lution of the part, and breach of continuity.
BRAIN — Alterations of its Substance — Softening.
215
In the cases of this description published by MM.
Eli i urn and Velpeao, the disorganization was
so complete, that the filaments of the delicate cel-
lular substance, forming, as it were, the matrix of
the structure, were suspended in the middle of the
diffluent matter into which the cerebral substance
was changed. In the case observed by M. Vel-
PEAU, the solution of continuity was still more
complete. From the inferior margin ofthemeso-
cephalon to the base of the pyramidal bodies, a
substance entirely liquid, which no longer retained
the appearance of nervous substance, occupied the
place of the bulb of the cord; and through the
whole of this space there existed neither arachnoid
nor pia mater.
7:5. The softened portion of brain presents va-
rious shades of colour. 1st, It may be of the
natural or healthy colour of the part, — even al-
though the softening has advanced to such a degree
as to form a diffluent pulp, (Andral, Lalle-
manii). 2d, It may be perfectly colourless; of
a dull white resembling milk; and occasionally
the whiteness of the part assumes a clear, or bril-
liant hue. 3d, The shades of colour sometimes
are the following: — a rose tint, an amaranthine
red, reddish brown, the colour of wine lees, violet,
yellowish, greenish yellow, light gray, and dark
gray. Besides the above appearances, tbe softened
part of the brain may be, — 1st, The seat of effu-
sions of blood, which are sometimes small, rela-
tively to the degree of softening, or to its extent;
at other times very considerable compared with
the softening itself: 2d, Pus may be infiltrated
throughout the part which is softened; or the pus
may exist in it in the form of one or more distinct
collections. M. Lallemand considers, that in
all softenings of the brain of a white colour, this
appearance is owing to the infiltration of purulent
matter through the softened structure. MM. Ros-
tan and Andral espouse an opposite opinion,
on the grounds that, in many softened portions of
the brain of this shade, no pus could be detected.
The softened part of the brain is generally inodo-
rous; but M. Billard has remarked, in the
case of an infant, the smell of sulphuretted hydro-
gen. Softening, attended with the odour observ-
ed by this author, seems to have constituted what
was called by the older writers, gangrene of the
brain.
74. There is no part of the brain or cerebellum
in which softening has not at some time or other
been detected. Generally those parts which are
most obnoxious to hemorrhage are most liable to
softening, such as the optic thalaini, and the cor-
pora striata, and the parts in their. vicinity. It
also as frequently affects the cortical substance,
as the medullary texture. In the cerebral hemi-
spheres, the softening may be seated in the corti-
cal substance of the convolutions, the white me-
dullary structure remaining unchanged, where it
may often escape detection, owing to such limit-
ation; and it is usually an attendant upon active
inflammation of the membranes of the brain.
When the gray part is softened, it generally sepa-
rates along with the pia mater, on attempting to
raise this membrane. When softened, this por-
tion Is commonly also redder than natural; some-
times, on the contrary, it Ls paler than common.
The medullary structure situated above the lateral
ventricles is very often the seat of this Bpecies of
lesion. This mass may be altogether softened,
or in a few small points merely, each point being
quite isolated from the other." The symptoms,
however, resulting from this smaller extent of
morbid change may be as severe as those arising
from the more extensive and more intense lesion.
When one of the hemispheres is softened near to
its external surface, the circumvolutions are flat-
tened, and often evince a species of fluctuation.
M. ANDRAL has remarked, in some cases, the
existence of softening of the parietes of the ven-
tricles, with the presence of a turbid fluid effused
into them. (Anat. Pathol, t. ii. p. 802.)
75. The optic thalami, the striated bodies, and
parts in the vicinity of these; the cornu ammonis,
and the eminences in the interior of the digitated
cavities of the lateral ventricles, the commissures
of the hemispheres {corpora callosum, septum
lucidum, fyc), have all been observed the fre-
quent seats of softening; sometimes limited to one
or other of them only, at other times extending
to two or more, and occasionally co-existing with
signs of inflammatory action, or with effusion of
a serous fluid into the ventricles. Softening of
the other parts of the encephalon is not so often
met with, as of those now enumerated; yet has it
been seen in the mesocephalon, in the various
parts of the cerebellum, in the medulla oblongata,
and spinal cord.
76. Softening of the brain may be limited to
one part, or it may exist in several parts, even in
both hemispheres, in the same case; and it may
affect these different parts at the same time, or
successively, either as respects the brain merely,
or as regards the whole cerebro-spinal axis. In-
stead of being partial, which is its usual form, the
softening may be so general, and to so intense a
degree, that the brain is almost reduced to a pulpy
matter, evincing scarcely any appearance of or-
ganization. So general and great a change is very
rarely met with in the adult; but it is occasionally
observed in infants. M. Billard has met with
ten instances of it, and I have also found it in
some cases of young children: the odour of sul-
phuretted hydrogen, first noticed by M. Billard,
was sensible in these; and he found it present in
all his cases, which were chiefly of infants only a
few days old.
77. Softening of the cerebro-spinal axis is met
with in patients of all ages. According to M.
Rostan (Rtcherches sur Ramollisscment du Cer-
veau, 2d edit. p. 155.), whose attention has been
directed, at the Salpetriere, to this lesion in a
special manner, it is very common in old subjects;
even more so than sanguineous apoplexy. The
researches of Lallemand, Andral, and others
go to confirm this opinion, and to show that it i3
also common during early and middle age, al-
though less so than in old age. And I perfectly
agree with M. Billard in considering it common
in children, especially infants. lie believes, and
I think with justice, that it commences in some
cases even before birth.
78. There still remains an important question
to be discussed, namely, what is the origin and
nature of the softening which has now been de-
scribed ? M. Lallemand' conceives that it is a
constant and necessary result of an acute, sub-
acute, or chronic inflammatory irritation of the
part. M. Rostan, who has examined this sub-
ject witli great care, and viewed it in various
lights, as respects both the morbid appearances
216
BRAIN — Alterations of jts Substance — Hemorrhage.
and the symptoms accompanying them, concludes
at last by confessing its difficulty, and considering
this change as analogous to senile gangrene. Be-
fore the question can be entertained with precision,
we should previously enquire with what other
morbid states of the system generally, and of the
lirain in particular, has softening been found al-
lied ? 1st, it has been observed by Jemina,
Black, myself, and others, to supervene during
fevers, especially those of an epidemic and malig-
nant character. 2d, It has been seen connected
with puerperal disease of a malignant nature; and
with epidemic and infectious erysipelas. 3d, It
lias been found in cases of scorbutus, and to occur
in persons of an unhealthy and cachectic habit;
also in those whose powers of life have been ex-
hausted by bad living and excesses.
79. As to its relation to other lesions of the
brain, I may state that it is often found surround-
ing extravusated blood in the brain, and intimately
connected with this effusion. The softened part
is then generally of the color of wine lees, of a
brownish hue, sometimes tending to green, or of
a gray or ash tint. But what is the nature of this
connection ? M. Rostan contends, that the soft-
ening precedes and is always the cause of the ef-
fusion, owing to the destruction of the minute
capillaries at the point where the softening is
greatest; whilst Dr. Craigie and others consider
the softening surrounding the effused blood as the
consequences of such effusion; and chiefly be-
cause, " in cases in which death takes place
early, the pulpy disorganization is less complete
than those in which it takes place at a later
period. In short, the extent of the disorganiza-
tion is proportionate to the interval which elapses
between the effusion of the blood and the period
of death." But is this the fact? It certainly
is not in accordance with my experience, for I
have observed no such relation; but have found
recent effusions surrounded by as great, and even
a greater, extent of softening as effusions of an
older date.
80. Pulpy softening may be the attendant upon
a coup dc sang, or sudden congestion of the ve-
nous capillaries of some part of the brain. This
is considered to be the case in softenings with
the reddish, amaranthine, crimson, or reddish
brown shades of colour. But is the softening a
consequence, or a cause of the injection ? May
it not be a state of the vessels preceding that of
effusion ? These are questions which large ex-
perience and deep thought will not readily de-
cide. Dr. Craigie thinks that the softening is
a consequence of the blood-stroke; but I cannot
agree with him, merely because the reasons for
a contrary opinion are quire as strong as those
which rnay be urged in its favour. It has been
often found accompanying hydrocephalic effu-
sions, by Rostan, Lallemand, Billard,
Otto, Anoral, and by the author. It is then
generally of the lighter shades of colour, and not
great in degree. Is it here a consequence or a
cause of the serous effusion ? It may be either.
I am more inclined to consider both lesions as
being often coeval, and, whether consecutive or
not, depending upon a similar state of the vessels
and vital manifestations of the organ and system
generally.
81. Softening, or pulpy destruction of a portion
of the brain, has likewise been found surrounding
tumours and abscesses, by Morgagni, Sanbi-
iort, Meckel, Lallemand, Blane, Yel-
lowlev, Powell,. &c, and presenting almost
every variety and depth of shade already noticed.
In these cases, especially in those where purulent
matter is lodged in the substance of the brain,
without any intervening cyst or membrane, the
softening often amounts to disorganization, and is
more clearly attributable to inflammatory irrita-
tion. When it is found subsequently to injury of
the brain, external violence, and inflammation of
the brain and its membranes, its nature and origin
are most manifest. That it does supervene in this
way, is shown by Fantoni, Morgagni, Le
Dran, Schmucker, O'Halloran, Dease,
Abernethv, Thomson, Hennen, Aber-
crombie, and others. The apparently unequiv-
ocal origin of this lesion in inflammation, under
these latter circumstances, induced Morgagni,
Lieutaud, Jemina, and more recently Baillie
and Abercro.mbie, to consider it as analogous
to gangrene in other structures.
82. But it should be kept in recollection that
this state of the cerebral structure, although often
preceded by signs of inflammation, and exhibiting
in the parts surrounding it inflammatory appear-
ances, is often neither preceded by the one, nor
accompanied by the other, but, on the contrary,
with a directly opposite train of phenomena and
state of parts. In these opposing cases, what is
the origin of the disease ? Are we to infer, with
Recamier, an entirely opposite^ origin to that of
inflammatory action, and that, as the softenings
observed in the brain betray a variety of charac-
ters, therefore they ought not strictly to be refer-
red to a single unvarying source ?
83. From what I have seen of, or read concern-
ing this lesion, I should infer, in respect of either
of its most manifest conditions, that it is an effect
of different states of morbid action, but most fre-
quently of a form of sub-acute inflammation, cha-
racterised by deficient power and loss of the vital
tone and cohesion of both the vessels and the
substance of the brain, — that it is the result of
deficient vitality of the extreme capillaries and
cerebral structure, occurring either primarily, or
in consequence of previously excited action. The
circumstances in which it is observed; its occur-
rence after injuries and bruises, from the pressure
of tumours, &c, and during the progress of ma-
lignant diseases, show that it is not produced bv
a sthenic or healthy form of inflammatory action;
but by that unhealthy, disorganizing and diffusive
kind observed in cachectic habits, or in persons
whose vital powers are much reduced. At the
same time, I think it cannot be denied, that it
sometimes originates in a different way, being
preceded by no signs of inflammatory irritation,
nor attended with inflammatory appearances, and
is a simple consequence of diminished, or alto-
gether lost, vital power and cohesion of the part
affected.
84. iii. Hemorrhage. — Sanguineous effu-
sion may occur in a primary form, but more com-
monly from some morbid state of the vessels, or
of the substance of the brain itself. It may take
place in any part of the organ, but much more
frequently in some situations than in others, a.
Blood is effused on the external surface of the
brain, either in small quantities, beneath the pia
mater, in one or two aufractuosities; or in an
BRAIN — Alterations of its Substance — Hypertrophy.
217
uniform layer, even extending over the whole of
an hemisphere in rare cases. !>. It is Bometi s
found in large quantities in the ventricles; bnl it
generally lias escaped into them, owing to lacer-
ation of the cerebral substance in which tin: ex-
travasation takes place, c. The haemorrhage most
frequently is in this substance. M. Andral
states, that in 392 cases of haemorrhage in the
brain, its actual seat was in some pari of the cer-
ebral substance in as many as 386. Of these,
202 occurred in the corpora striata, and thalami
optiri, and parts in the hemispheres, on a level
with these places. The cavities formed by the
extravasated blood vary in size, from that of a
small pea, to the greater part of the extent of a
whole hemisphere. When the effusion is very
large, it generally ruptures the parietes of the
lateral ventricles, sometimes tearing the septum
Iucidum, and destroying the fornix. In other
cases it may make its way to the exterior of the
brain, and spread itself over the cavity of the
arachnoid.
85. The number of haemonhagic cavities found
in the brain vary from one to many. When
several are found in the same brain, they gener-
ally present different appearances, owing to their
ha\ ing been formed at different periods. This is
generally the case when the patient has experi-
enced several attacks of apoplexy or palsy. M.
Andral remarks that effusion of blood sel-
dom occurs in the cerebellum without appearing
also in the cerebrum, whereas it may take place
in any part of the cerebral hemispheres without
occurring elsewhere. I have stated in the article
on Apoplexy, the periods of life at which haemor-
rhage in the brain is most frequently met with.
Instances have occurred to MM. Rochoux, Bil-
i.ard, Serres, Guersent, and myself, in
which it has taken place at the unusual periods of
infancy and childhood. The changes that take
place in the effused blood, in the cavity contain-
ing it, and in the substance of the brain after
haemorrhage, comprising the reparative processes
consequent upon it. are fully described in the ar-
ticle Apoplexy (§ 35 — 39.). I have there shown
that the cysts remaining after the coagula have
been absorbed, sometimes disappear altogether
by adhesion of their parietes. Some pathologists
suppose that the cerebral fibres in those cases are
directly united, and refer to the experiments of
Fontana, Haighton, Michaelis, and May-
er, who had shown, in opposition to Arnemann,
that the filaments of divided nerves are, after a
time, directly produced in the direction of their
axis across the cicatrix. But intimate examination
of the cicatrix of a lacerated portion of brain, or
of a hemorrhagic cyst, shows that this does not
take place in the medullary structure of the brain.
(See Apoplexy, § 53.)
86. iv. Hypertrophy and Atrophy of
the Brain. — A. The brain occasionally presents
lesions evidently connected with a modification of
the nutritive process. In such cases, the con-
sistence and size, either of the whole, or of cer-
tain of its parts merely, are altered. Changes of
its consistence are more frequent than of its size,
and both are occasionally conjoined. It should
not be overlooked, however, that the consistence
and size of the organ are modified from tin; usual
standard of middle age, at both the earliest and
most advanced epochs of life; and that these
19
modifications, as being its natural conditions at
those terms, are to bo distinguished from the al-
teratibns occasioned by disease. One hemisphere
may also differ from The other, in respect both of
its volume, and the form and size of its convo-
lutions, owing to original conformation, without
occasioning any appreciable disorder of function.
87. The brain continues to increase in size
until manhood; from this period until old age its
volume continues the same; but with extreme
age it somewhat diminishes in bulk. This is,
however, not an uniform occurrence, for disease
may have cut short existence before the period
had arrived at which the organ would have un-
dergone this change. According to Cazan-
vieilh, the longitudinal diameter of the brain of
an old man, compared with that of one in early
life, is 6 inches 1 line French measure for the
former, and 6 inches 4 lines for the latter; whilst
the transverse diameter is 4 inches 10 lines, and
5 inches, respectively. M. Desmoulins (Anat.
des Syst. Nerv. fyc. t. ii. p. 620.) found, that in
persons above seventy years of age, the specific
gravity of the brain was from one twentieth to
one fifteenth less than that of the brain of persons
just arrived at manhood.
88. The convolutions of the brain are scarcely
developed at birth, or even until the expiration
of the first year. In old age they again become
less distinct and prominent. In the brain of the
full grown young subject, they vary in thickness
from three to five lines, whilst they are usually
about two or three lines in old persons. They
present the greatest diversity in respect to their
number and length, and the depth of their an-
fractuosities in the adult: in general they are the
most marked and developed in the largest brains.
Several physiologists in France are of opinion that
the developement of the faculties of the mind
has a very intimate relation with the extent and
number of the convolutions of the hemispheres,
and the depth of their anfractuosities.
89. But it is important for the physician to
know that not only may the whole encephalon
experience a diminution of its bulk and specific
gravity with old age, but that this diminution may
be particularly apparent in certain parts of it in
preference to others; and it is presumed, that this
change may sometimes commence in one portion
previously to others, or may affect it alone, so as
to disturb its functions without being so evident
upon dissection as to attract notice. The com-
parative length of the following parts of the ence-
phalon of subjects just arrived at puberty, of those
in the prime of life, and of aged persons, is here
given, as furnished by M. Cazanvieilh in
French measure : —
Thai, optici
Corp. striata
Corp. catlosum
Mesoeephulon <
Cerebellum )
In
the
Puberty.
1'v
me of
in.
lines.
L
in.
ife.
lines.
in
1
5*
t
6
1
2
6"
2
6
2
3
Q
3
5
2
leneth 0
10
0
11
0
breadth I
0
1
I
1
lensth 2
2.
2
3
2
breadth 3
9
3
9
3
In Old
Age.
lines.
41
4l
7"
lOi
0"
90. From these data it will appear, that the
cerebellum is the only part of the encephalon
which is not diminished by old age. Hut it may
' ed, do the large nervous masses experience
218
BRAIN ALTERATIONS OF ITS SUBSTANCE AtROPHT.
any diminution of volume analogous to that which
the muscular textures and other parts experience
in chronic diseases ? In answer to this, M. Des-
jhoumns states that the brain, although atrophied
in the manner stated above by old age, sutlers no
diminution of its hulk, whatever may be the de-
gree of marasmus to which the individual may
have been reduced. In all such cases he has
also found the brain of the same specific gravity;
and, to this predominancy of developement which
the brain thus has acquired over all other organs,
he is inclined partly to impute that nervous sus-
ceptibility and excitation, which are common
to the last stages of those maladies. It ought,
however, to be borne in recollection, that, al-
though the nervous centres may not undergo any
change in bulk or specific gravity in consequence
of those diseases, they often experience a very
marked diminution of their consistence, as we
shall have to show in the sequel. Having been
made acquainted with these modifications of the
nutrition of the encephalon which it undergoes
at the different epochs of life, we are the better
able to recognise those which are the result of
disease.
91. B. Hypertrophy, or morbidly increased
bulk of the brain, is very rarely met with. This
state of the organ is to be distinguished from the
apparently augmented bulk, arising either from in-
creased vascular action, or congestion of the ves-
sels. It appears to consist of an actual increase
of the molecules of matter composing the proper
tissue of the organ, and not of an injection of the
minute vessels distending its structure. Although
this condition of the brain seems to have been
known to Morgagni, it is to Laennec that we
are indebted for precise information respecting it.
He stated (Journ. de Corvisart, fyc. t. ii. p. 66'9.),
that, upon opening the heads of patients who had
been thought to have died of hydrocephalus, he
found no fluid effused; but the brain presented
appearances of great compression, which he could
attribute to no other cause, than to a too active
nutrition of its structure, giving it a bulk too great
for the bony case containing it. In children es-
pecially, who had died in convulsions, or who
had been subject to epilepsy, this disproportion
between the capacity of the cranium and the
bulk of the encephalon has been witnessed by him
on several occasions, the convolutions of the hem-
ispheres being flattened, and apparently squeezed
against each other. M. Dance has also describ-
ed this state of the brain (Repertoire d' 'Anato-
mic, t. v. 1828.), and furnished some cases in
which it was observed. It is chiefly met with in
children or young subjects, and is, I conceive, of
very rare Occurrence, since, from amongst the
great many thousand cases of children's diseases
which have come before me, I have only remark-
ed three cases in which it was unequivocally pre-
sent. In these it presented the following charac-
ters:— The convolutions of the hemispheres were
extremely flat, and closely pressed against each
other, so that the separations between them were
scarcely apparent. The cerebral structure was
firm, and, when incised, was dry, and more than
commonly destitute of blood. The ventricles
seemed small, were closely pressed together, and
almost dry. The bones of the cranium were either
natural or thicker than usual, as if they had parti-
cipated, as regarded their thickness, in the increas-
ed nutrition of their contents: the dura mater ad-
hered closely to the cranium. A similar augmen-
tation of the thickness of the cranial bones, but to
a greater degree than I have remarked it, has
been recorded by M. Scoutetten, who met
with it in a girl five years of age, who died of ab-
dominal disease, and who had never complained
of any disorder of the head, or of disturbance of
the mental faculties, which were those common to
children at her age.
92. Rickety hypertrophy of the brain is more
frequent. It commences soon after birth, and often
attains a great extent. Otto supposes that brains
which have been much expanded by dropsy in
youth, become subsequently, in rare instances,
cured by increased deposition of cerebral matter;
and thus retain their size and weight. The dis-
tension of the cerebral substance by the accumu-
lation of fluid in the ventricles, cannot be compre-
hended under hypertrophy of the organ.
93. M. Andrai. (Anat. Path. t. ii. p. 776.)
says, that, although hypertrophy of the brain is
usually general, and extends to the whole of both
hemispheres, it is sometimes also partial : thus
he has seen the thalamus opticus of one side of
its natural dimensions, whilst that of the opposite
side was one fourth larger. This extraordinary
developement of the thalamus of one side was not
attended with any particular symptom during the
patient's life. Otto refers to a number of cases
of hypertrophy confined to a single part of the
brain, chiefly to the thalami and the corpora qua-
drigemina. I am not aware that- any well authen-
ticated cases of marked hypertrophy of the cere-
bellum are upon record. The spinal cord, how-
ever, is not infrequently subjected to this change.
94. Morbid enlargement of the pineal glaiid
has been observed by Drelincourt, Morgag-
ni, LlEUTAUD, DESPORTES, SOEMMERING, A\-
geei, Greding, Meckel, and Blane. The
pituitary gland has also been found enlarged, in-
flamed, and otherwise ciianged, by Greiuxg,
Baillie, Chaussier, Oppert, Ward, Rul-
lier, De Haen, Rayer, Neumann, Aser-
crombie, Otto, the Wenzel's, and Meckel.
95. C. Imperfect developement and atrophy of
the brain, — Agenisie cerebrate (Cazax vieilh),
— is met with in every degree, from a slight dim-
inution of the usual bulk of the whole organ, or
of any of its parts, to their almost entire disappear-
ance. Atrophy, although occurring in all situa-
tions of the cerebro-spinal axis, is most frequently
observed in those which are the last formed: thus
the spinal cord is formed before the brain, and
atrophy of it is much rarer than that of the ence-
phalon. Of the brain, the convolutions are the
last developed, and they are most frequently atro-
phied. It should, however, be noticed, that the
majority of those cases which are denominated
atrophy of the brain by Andral, and other French
pathologists, are, strictly speaking, imperfect or
arrested developement of the organ. The hemi-
spheres are most frequently the seat of atrophy
and imperfect developement; and they may be
thus affected, either partially, or altogether. Im-
perfect growth of particular lobes, especially the
anterior, is common in idiots, and may exist even
although the cranium is well formed, the void
being tilled up with water, the congenital effusion
of which is the probable cause of the arrest of
developement. When the hemispheres are par-
BRAIN — Alterations of its Substance — Induration.
219
tially affected, the lesirfh is most commonly ob-
served in the convolutions.
96. a. Atrophy of the convolutions. — These
parts are sometimes only smaller and less numer-
ous than usual, either in respect of one or both
hemispheres, or in a portion of a hemisphere
merely ; and they may be altogether wanting in
one, or in both. M. Jadelot lately found the
hemispheres of the brain of an idiotic child, aged
six years, without convolutions, and consisting of
an uniform layer of medullary substance covered
by a thin coat of cineritious matter.
97. b. Sometimes the greater part of the hemi-
spheres of the brain, especially their superior por-
tions, from the vault of the ventricles upwards,
are found in a state of atrophy, or altogether
wanting. Most of the cases of this description,
which have been adduced by the French patholo-
gists, as well as the case of Jadelot, are merely
instances .of imperfect developement of the part.
Sometimes this portion of the encephalon is re-
placed by a sac containing a serous tiuid, having
no communication with the ventricles. In other
cases, no such body replaces the deficient hemi-
spheres ; but the different parts of the anterior and
superior aspects of the ventricles, as the thalami
optici, corpora striata, &c, may be seen through
the membranes, no substance intervening between
them and those portions of the floors of the ven-
tricles. These occurrences are, however, not
cases of atrophy, but of arrest of the formative
process as respects the hemispheres of the brain.
Cases of diminished size merely, of one or both
hemispheres, are more common than those now
instanced ; and are generally to be considered as
being congenital ; or, at least, the result of a di-
minished nutrition of the part, in the process of
the growth of the organs. Instances of extreme
smallness, or an entire absence of a part of the
hemisphere, are most frequently met with in its
posterior or anterior lobes : either of which may
be altogether wanting, in one or both sides of the
brain. Diminished size of the anterior or pos-
terior lobes are a much more frequent occurrence
than their entire absence.
98. c. The thalami optici, and corpora striata,
may be also much diminished in volume, either
singly or together. The diminution may proceed
from a defect either of the gray matter, or of the
white substance ; and from this cause of diminish-
ed bulk, the accompanying symptoms will derive
their chief characters. Not only may those bodies
be simply diminished in volume, they may be
even altogether wanting, either being replaced by
a serous cyst, or having no other body as a sub-
stitute : in "the former case, the hemisphere of that
,side may be, or not, also entirely wanting ; in the
latter it Is always absent, and, from the cerebral
peduncles, nothing more is found than a few scat-
tered fibres, which are spread out into a mem-
branous tissue, resembling that which, at the
earliest epochs of foetal existence, forms the ru-
diments of the hemispheres. It is evident, that
hi such cases, the white central portions of the
brain being absent, and both sides of the cere-
brum being thus circumstanced, there can scarce-
ly be said to be any brain in existence. This,
however, does not prevent the other parts con-
tained within the cranium, as the mesocephalon,
cerebellum, &c, from being fully formed.
99. d. The central while parts of the brain
may be imperfectly developed, even when no al-
teration is remarked in the hemispheres. In some
such cases the corpus callosum is so small as to
for lerely a thin membrane. Rkii. remarked
its entire absence in a female idiot, who died at
thirty : the two hemispheres communicated only
through the medium of the anterior and posterior
commissures. It is remarkable, that when the
cerebral lobes are wanting, two small masses of
nervous substance, whence the olfactory nerves
arise, are sometimes found in the anterior part of
the cranium ; thus displaying in man, in the mor-
bid state, the independent existence of the olfac-
tory lobes, naturally shown in animals.
100. It will be seen from the above, that all
the parts of the brain may present a state of im-
perfect developement to a greater or less extent ;
that either of them may be entirely wanting,
while the others remain : and that all of them
may be absent, so that there exists no brain : a
circumstance not infrequently observed in foetuses,
and evidently owing to the process of develope-
ment having been suddenly arrested.
101. But not only may the brain be in part, or
entirely, deficient at birth; it may be also remark-
ably small at advanced age, particularly in idiots.
It may be generally, but more frequently only
locally, diminished by external pressure, as in
meningeal hydrocephalus. Although the brain,
as well as the other parts of the nervous system,
wastes so little in general consumption, it is, how-
ever, somewhat diminished, although rarely, in
the course of certain diseases : Savaresy states,
that he has found it atrophied in yellow fever.
Horn remarked a similar state in diabetes ; and
Otto, after venereal excesses. Atrophy, is, how-
ever, more frequently observed in particular parts
of the brain. The lateral lobes of the cerebellum
have been occasionally found atrophied. M. Ru-
tin observed the medullary centre of the cerebel-
lum reduced one third of its natural size. Mob.
gagni, Wenzel, and Biermayer have de-
scribed atrophy of the corpora striata. The op-
tic beds have been found greatly reduced in size
after blindness, by Soemmering, Michaelis,
Rudolphi, &c. ; and in idiots, by Otto, Ram-
say, and Romberg. The quadrigeminal bodies,
and the tubercles of the brain, have likewise been
severally found atrophied. The pressure occa-
sioned by tumours, collections of lymph, pus, or
blood, or even dropsy of the ventricles, may give
rise to atrophy, interstitial absorption, or destruc-
tion of particular parts of the brain. The want
of exercise of the functions of the nervous system
may also occasion atrophy, by diminishing nu-
trition, as an unexercised muscle soon wastes.
Thus, the wasting of the brain so generally ob-
served in idiots, may be the effect and not the
cause of idiotcy. The pineal gland, and the
pituitary gland or appendage of the brain, have
both been seen remarkably atrophied, particular-
ly the latter. According to Otto, this change
has been most frequently remarked in idiots, and
in hydrocephalic cases.
102. V. INDURATION} OR HARDENING OF
the Brain, — Selerencephalia (Craigie). —
The cerebro spinal axis sometimes presents, eith-
er throughout its extent, or in particular parts, a
remarkable increase of consistence. This increase
varies in grade. In its first degree, it is nearly
of the consistence of a brain which has been kept
220
BRAIN — Alterations of its Substance — Induration.
some time in dilute nitric acid. The second de-
gree of increased hardness resembles the con-
sistence of cheese. In this state, the cerebral
substance, when exposed to the action of fire, in-
stead of swelling up, without emitting any mark-
ed odour, and leaving a brownish light residue,
assumes a horny hardness, emits a strong heavy
smell, and leaves a compact blackish residue.
Nitrous acid also imparts to it a horny hardness,
— circumstances evincing a great increase ol the
albuminous constituent of the structure. The
third degree of hardening equals the firmness of
wax, frequently also conjoined with elasticity, so
that the indurated portion resembles fibro-cartilage.
103. a, The first grade of induration may affect
the whole or the greater part of the cerebrospinal
axis. The two greater degrees of this change are
commonly of more or less limited extent. Gen-
eral hardening of the brain is usually attended
with augmented vascularity, numerous drops of
blood becoming effused when the cerebral struc-
ture is incised. This increased vascularity, al-
though general, is not constant ; for, in some few
instances, little or no injection of the capillaries is
observed, the brain being rather exsanguineous
than vascular. Even in the general induration of
the brain, the hardening is not equal throughout
every part. It is least remarkable in the cortical
structure and convolutions ; and more manifest in
the white, particularly the central medullary parts,
than in the gray substance.
104. b. Partial induration of the brain is most
frequently found in its central parts, and some-
times in the convolutions. M. Andral has ob-
served it in this latter situation, at as early an
age as three years, which is extremely unusual.
Sometimes the convolutions of the convexity of
the hemispheres are unaltered, whilst those of the
base are hardened ; occasionally, in such cases,
especially when the induration is considerable,
the cortical can scarcely be distinguished from
the medullary structure. In a case recorded by
Lallemand, the induration was limited to a cir-
cumscribed portion of cortical substance, and,
under it, the medullary texture was manifestly
softened. M. Pinel found, in one of the hemi-
spheres of a female who had died in a state of
idiotcy, a portion of the medullary structure ex-
tremely hardened ; and, in the same individual,
there existed, in the whole posterior and inferior
border of the cerebellum, an induration of a fibro-
cartilaginous description. The hardened por-
tion was yellowish, elastic, resembling a piece of
whitish-yellow leather. Mr. Pa yen found, in a
girl six years of age, near the posterior third por-
tion of the left hemisphere of the brain, a de-
pression, owing to hardening of one of the con-
volutions, which seemed externally as if it were
shrivelled. It was rose-coloured on its surface,
slightly yellowish in its substance, and almost
concealed from view by two convolutions, which
were healthy. The membranes covering this
hardened convolution were white and thickened.
Hardening was here joined to diminution of vol-
ume ; or, perhaps, the disease of this portion of
the brain was congenital, and, whilst the growth
of the rest of the organ had proceeded, the de-
velopement of this was interrupted. The intel-
ligence of this child was well advanced ; but she
had, from birth, a contraction of the right wrist
and foot, with slight atrophy, and incomplete
hemiplegia of this side. Similar cases of harden-
ing of portions of the lobes of the brain are de-
scribed by Monro, Lallemand, and Hutchin-
son. In a case recorded by Joeger, the indu-
ration was limited to the parietes of the posterior
cornua of both lateral ventricles, and amounted al-
most to that of cartilage. Bergman found both
optic beds hardened in a paralytic and squinting
girl : and Castellier and Anderson observed
excessive hardening of the lobes of the cerebel-
lum. Partial induration of the nervous centres
frequently co-exist with other lesions of those or-
gans, especially around old sanguineous effusions
and morbid productions formed in the cerebral
substance : they are also occasionally found ac-
companying the usual results of chronic inflam-
mation of the membranes ; these being firmly ag-
glutinated together, to an extent of surface more
or less considerable, and closely adherent to a
subjacent hardened portion of brain. (Portal,
Analomie Med. t. iv. p. 91.)
105. Cause of hardening of the brain. — The
first degree of induration has been frequently
found in persons who have died of fevers, gener-
ally.of an ataxic or typhoid type, and in maniacs.
M. Andral observed it in two patients afflicted
with convulsions from working in lead. MM.
Gaudet (Recherches sur V Endurcissement gen.
de V Enc.iph. eomme tine des Causes des Fievres
Atuxiques. Paris, 1825.) and Bouillaud [Ar-
chives Gintr. t. iii. p. 477.) consider it as the
consequence of acute inflammatory action of the
brain and its membranes, they having found it in
persons who have died of encephalitis occurring
either primarily, or as a complication in fevers ;
and M. Andral (Anat. Path. t. ii. p. 810.) seems
to coincide with this opinion. Rudolphi ob-
served it in thirty cases of typhus : and Otto
found, during the epidemic typhus of 1809 and
1812-13, hardening of the brain frequent in those
who died within the first week ; and softening in
many who died at a later period. But, in these
cases, granting the induration to have been the
consequence of the disease which destroyed life,
it must have taken place in the short space of a
very few days ; whereas, I am much more inclin-
ed to impute it to inflammatory action of a lower
grade and of a much slower progress. M. Brous-
sais regards it as the result of meningo-encephalic
inflammation, of a sub-acute or chronic nature.
As being generally found in connection with in-
creased vascularity of the substance of the organ,
and with this and other signs of inflammatory ac-
tion of the membranes, the relation of this change
to inflammation seems established ; but I am in-
clined to adopt the inference of Dr. Craigie, in
respect of the opinions of MM. Gaudet and
Bouillaud, that, in those cases in which they
observed this lesion, it had existed previous to the
acute disease which occasioned death.
106. Induration of the brain has been long fa-
miliar to pathologists, in relation to mental derange-
ment. The writings of Littre, Geoffroy, Bo-
erhaave, Lancisi, Morgagni (Epist. Anat.
Bled. viii. 4— IS.), J. F. Meckel {Mem. de I'
Acad. Roy. de Berlin, t. vii. p. 306.) Lieutaud,
■Santorini, Greding (Ludwig's Advers. Bled.
Pract. t. ii. pars 3. p. 533.), Portal, Mar-
shall (Morbid Anat. of the Brain, §-c. Loud.
1S15.), Haslam (Observ. on Madness and Me-
lancholy. Lond. 1809.), SErres (Arm. Medico-
BRAIN — Alterations of its Substance — Tumours.
221
Chirurg. Paris, 1S19.), Lallemand {Richer dies
Anut. I'cilli. let. ii.), Lkrminier, Bouii.i.aud
{Traitt- Clinit/tie de I'Encephalite. Paris, 1S25.),
Pi.mi., jun. (Rev. Mid. t. vi.), Fovii.t.k, and
Pin ki .-( Ikandchamp, furnish numerous instances
of it, thus related: and, from the history of the
cases, as well as the generally augmented vascu-
larity of the membranes and of the indurated
brain itself, I infer that it is a consequence of
chronic inflammatory action, conjoined with some
change in the nutrition of the cerebral substance;
and that it proceeds from a less intense and more
chronic state of the vascular action than that
which occasions softening, or pulpy destruction
of the cerebral texture. That such is the case,
is proved, not only by my own experience, but
also by the observations of the authors enumerated
above; for, in the majority of those cases, even
when presenting the appearances and conse-
quences of cephalo-meningeal congestion and
inflammation, the symptoms of cerebral disease
were of much longer duration, than thos'e depend-
ing upon morbid softening of the organ.
107. It has already been stated, that induration
of the cerebral substances, amounting to either
the second or the third degree, is generally cir-
cumscribed in extent. Whatever doubts may be
entertained of the first degree of hardening being
the result of chronic rather than of acute disease,
there can be no doubt of the second and third
being always a chronic affection — perhaps, of a
still more chronic state of capillary action than
that giving rise to the first form of increased hard-
ness; the morbid action, affecting in the former
cases a portion of the brain only, may be com-
patible with a longer duration of life, and hence
give rise to ulterior or more advanced stages of
change than those presented when the whole or-
gan is affected, and all its functions and energies
thereby involved. That this change is one of the
consequences of chronic irritation, or inflamma-
tory action, may be conceded, as well as the sup-
position entertained by Andral and Craigie,
that the morbid irritation is connected with a
perversion of the nutritive action. Indeed, the
numerous cases detailed by Portal, Serrf.s,
Lallemand, Bouillaud, Pinel, and others,
furnish satisfactory evidence, both in the symp-
toms during life, and in the co-existent lesions in
the membranes and other parts of the brain, of
the existence of a chronic inflammatory action,
or of a state of irritative erythism of its capillaries.
But to say that this state is in such cases accom-
panied by a perversion of its nutritive actions, is
ascribing to it what always is an attendant upon
inflammatory action, of whatever grade, or in
whatever texture it may be seated. It should,
however, be mentioned, that M. Lallemand
considers partial induration to occur occasionally
as a favourable termination of morbid softening
of the brain; but this is a mere supposition.
108. As to the phenomena to which induration
of the brain gives rise, every practical man must
feel considerable interest. The first and more
general induration of the brain generally occa-
sions loss of memory, confusion of thought, and
derangement of the mental manifestations — caus-
ing insanity without lucid intervals. When the
induration Ls advanced in degree, or considerable
as to its extent, or both, and especially when its
long duration has been indicated by continued
19*
mental derangement, a complete obliteration of
the mental faculties, or fatuity, is frequently its
attendant towards the last periods of life, and may
therefore be considered as the consequence of the
most advanced degrees of this lesion. The signs
of partial induration of the brain, in any of the
grades to which I have referred, will vary accord-
ing to the extent and seat of the lesion. They
consist chiefly of a progressive defect of memory,
inattention, or an inability to pursue a long train
of ideas, indifference to momentary impressions,
and to present or future occurrences, dilhculty of
articulation, derangement of ideas, with partial
or total loss of the affections, appetites, and de-
sires ; and ultimately increased loss of speech,
palsy, convulsions, or want of power over the
muscles, futuity, general or partial wasting, and
death.
109. Lallemand found, in a patient who had
complained of fixed pain of the forehead, palsy
of the face, and confusion of memory; the mem-
branes firmly matted together, for the extent of a
thirty sous piece, at the anterior extremity of the
left hemisphere; the subjacent cerebral substance
hardened to a scirrhous or cartilaginous firmness,
and adhering closely to the membranes. Bouil-
laud states, that of a man, aged sixty-eight,
who, after symptoms of cerebral disease, had im-
paired memory, headach, difficulty of expressing
his ideas, followed by muscular weakness and
convulsions. The cerebral substance was found
injected, and induration was seen " passing from
the striated body of the left hemisphere, through
the nucleus, at the upper region of which it formed
a cavity with hard yellow walls; a similar hard-
ened portion also existed in the posterior lobe.
According to M. Pinel, induration confined to
the brain causes fatuity, with more or less of
palsy; but, if it extend to the annular protuber-
ance, the crura cerebri, the corpora olivaria, or
cord itself, epilepsy, followed by palsy, and death
by marasmus, are generally superadded. In these
advanced degrees of hardening, which are some-
times attended with a shrunk, depressed, and con-
densed appearance, — a species of atropine hard-
ening of the part, — there are usually remarked
palsy and idiotcy, which are either congenital, or
occurring subsequently to birth.
110. vi. Morbid Growths. — Tumours of the
brain. Tumours of various kinds have been
found to originate in the substance of the brain;
but as Dr. Craigie {Anat. p. 447.) has observed,
they have not been distinguished with sufficient
precision by authors, from. those which, originat-
ing in the membranes, affect the brain only secon-
darily. The first form of tumour which he has
described, and denominated " cerebral tumour,'"
entirely agrees with those partial indurations al-
ready considered; differing from them in no re-
spect, but in the extreme degree of firmness it
presents, which is similar to the second and third
(the latter particularly) degrees of hardening,
arising in the manner I have endeavoured to ex-
plain (§104.), and affecting all parts of the ner-
vous masses, — the cerebellum and medullary
cord, as well as the various parts of the brain
itself. (See Hardening, &c.)
111. A. Tubercular secretion, — Tyroma
(Craigie). — Tubercles of the brain have been
described in recent times with much accuracy by
Ge.ndrin, Leveille, Ollivier, Aeercrom-
222
BRAIN — Alterations of its Substance — Tumours.
bie, Anpral, and Craigie. They are formed
of a white, or pale yellow, opaque, firm, cheese-
like, sometimes granular and finable substance,
consisting of a large proportion of albuminous
matter, and varying in size, from that of a millet
seed to the bulk of a hen's egg. This substance
is deposited in various forms in the brain, but
usually as follows: — 1st, One, two, or more,
homogeneous, distinct masses, of considerable
size ; 2d, Several, or many, separate, minute,
spherical, or spheroidal masses. Cases of the
first form of tubercular formations are to be
found in the writings of Manget, Rochoux
(Rt'eherches sur VApoplcxie, p. 151.), Powell
(Trans, of Coll. of Phys. vol. v. p. 222.), Blane
(Trans, of a Society, fyc. vol. ii.), Baillie
(Fasc. of Eng. No. 10. plate vii.), Coindet
(Mem. sur V Hydrociph. p. 106.), Bouillaud
(Truite, fyc. p. 161.), Abercrombie, (Bis. of
the Brain, fyc. p. 42S.); Chambers (Med. and
Phys. Journ. vol. It. 1826, p. 5.), Piedagnel
(Journ. de Phys. t. iii. p. 247.), Berard (Ibid.
t. v. p. 17.), and Hooper (Morbid Anat. of the
Brain, p. xi. and xii. fig. 1.). Tubercles of this
class vary in number from one to five or six, and
in size from that of a pea to the bulk of a hen's
egg. In form they closely resemble tubercles in
other parts of the body. According to Leveille,
they are often of an unequal surface, so as to ap-
pear lobulated, particularly when they are very
large. If only one or two are present, their size
is generally considerable. M. Andral mentions
their existence in the cerebellum, of so large a
volume as to destroy nearly the whole of one of
its hemispheres. Even when of this bulk, they
consist of the opaque, cheese-like substance
already described, and are always destitute of
vessels, or any trace of organic structure. They
are albuminous, friable, and generally surrounded
by a cyst. MM. Gendrin and Leveille are
of opinion that they always have cysts, but of
variable thickness, which are sometimes remark-
ably thin, at other times, especially in old tuber-
cles, thick and fibrous. The cyst adheres exter-
ally to the surrounding cerebral structure; and
its internal surface sends oft" delicate filaments,
which traverse the continued tubercular matter,
and, in the large and old tubercles with thick
cysts, seem like small fibres or partitions passing
between the lobules of the contained substance,
which is disposed in cellules formed by these fila-
ments. In some large and old tubercles, the cyst is
fibrous, cartilaginous, or even osseous (Gendkin),
and is sometimes partially separated from the sur-
rounding cerebral structure by a minute quantity
of serous fluid. In proportion as the tubercle
softens, the cyst becomes more apparent.
112. The surrounding cerebral substance is
often perfectly natural, and sometimes variously
altered; — occasionally inflamed, or softened, or
atrophied, or even destroyed, especially when the
tubercles are very large. Upon these lesions, the
svmptoms during life are often chiefly dependent.
Very frequently, especially in children, tubercles
varying as to number and size may exist in the
brain, without occasioning any symptoms suffi-
cient to lead to the suspicion of cerebral disease :
but this seems to be the case only when the
nervous substance around them has been but little
changed from the healthy state. When nervous
symptoms have appeared without such change,
they have generally assumed an intermittent
character.
113. It is very probable that tubercles are
formed in the brain, as elsewhere, at first in a
fluid state; and that they afterwards either un-
dergo a slow coagulation, or have their aqueous
portions partly absorbed, the albuminous and
other more solid constituents forming the tuber-
cular substance. M. Bouillaud believes that
they are the product of an inflammatory process;
and the tendency of inflammation to produce an
albuminous secretion certainly countenances this
opinion. Whatever may be the origin, they ap-
pear to experience in the brain a similar softening
to that which they undergo when formed in other
organs. When this is advanced to more or less
partial fluidity, tubercles may be mistaken for
other formations; and when amounting to lique-
faction, the tubercular production can, with diffi-
culty, he distinguished from a small encysted
abscess. (See art. Tubercles.)
114. The second form in which tubercular
productions are found in the brain, is that of
spheroidal bodies, disseminated through its sub-
stance. Professor Re il (Memorab. Clinica,t. ii.
fas. iii. No. 2. p. 39.) describes them, in a case
which occurred to him, to have consisted of about
two hundred spheroidal bodies lodged in the gray
matter of the brain and cerebellum. Thev were
a little firmer than the brain itself, mostly of a
pale yellow, some of a pale blue, of the size of a
lentil or pea, and consisting of an - adipose-like
substance. From some, which were marked in
the centre with a dark point, and seemed covered
by a thin cyst, a slight incision discharged a mat-
ter like vermicelli. These bodies were confined
entirely to the cortical substance of the brain,
chiefly near the deep anfractuosities, and but very
few were in the prominent parts of the convolu-
tions. They were most numerous in the superior
aspect of the hemispheres, less so in the cerebel-
lum, and least numerous in the base of the cere-
brum. The pia mater was remarkably injected
with blood, and the ventricles contained very
much fluid. This patient had never complained
of pain in his head, although long afflicted with
scrofulous sores, until eight days previous to
death. In a case recorded by M. Chomel
(Nouv. Journ. de Med. t. i. p. 191.), similar
bodies were found disseminated through the brain
of a woman aged thirty, who died with symptoms
of cerebral disease. Two such productions were
also found in the cerebellum, and one in the spinal
cord. Cases similar to the above have likewise
been recorded by other writers. Tubercles, even
in the form now being considered, are seldom or
ever found in greater number than in the case
just quoted from Reil; and, as Gendrin has
remarked, they are never found in the brain in so
very great numbers as in the lungs; nor, in my
opinion, do they assume, in the cerebral struc-
ture, the agglomerated form, in which thev are so
often met with in other viscera, and in the lungs
especially.
115. Tubercles are often met with in the brains
of children, and those especially of a strumous
diathesis, and upwards of one or two years
of age. They occur most frequently from tins
age to puberty; after which they are rarely met
with, even in scrofulous and phthisical subjects,
where tubercles exist not only in the lungs, but
BRAIN — Alterations of its Substance — Tumours.
223
also in other organs. They are most common in
the hemispheres of the brain, and there occupy
indifferently either the cortical or the medullary
texture ! sometimes they appear, as it were, placed
between both. In some cases in which they have
been found in the more exterior layer of the
cineritious structure, they seem not to have heen
originally formed in it, but to have sprung from
the internal surface of the pia mater, and to have
pressed inwards the cerebral tissue as they in-
creased in size, forming, as it were, a superficial
cavity in it, without any intimate union with it
beyond tint of close contact. The parts of the
brain, after the hemispheres, where tubercles are
most commonly found, are, according to M. An-
DRAL, the cerebellum, the mesocephalon, the
medulla oblongata, various parts of the spinal
cord, the peduncles of the cerebrum and cere-
bellum, the thalami optici, corpora striata, the
commissures of the thalami, and pituitary body.
According to the order of frequency here indicated,
it will be observed, that those parts of the cerebro-
spinal axis which are most frequently the seats of
inflammation, softening, or haemorrhage, are not
those which are oftenest the seat of tubercles.
116. B. Adipose tumour (Wen/.el), — Fatty
productions (Andral), — Lardaceous degenera-
tion (llKBKT.AB.T,Annuaire Mid. Chirurg. Paris,
1829. p. 579.), — Ceroma (Craigie). — This
morbid formation has been noticed, under the
above designations, by the authors whose names
are respectively noticed, and also by Rudolphi,
Braus, Cruveilhier, Merat, Leprestre
(Archives Ginir. de Mid. t. xviii. p. 19.), and
Dai. mas (Joum. Hebdom. de Mid. t. i. p. 332.).
Borelli states that he has found, behind the
upper part o( the medulla oblongata, n fatty, ho-
mogeneous, reddish, or rose-coloured substance,
the size of a nut, apparently traversed by reddish
lines, and contained within a thin envelope. A
similar tumour, though smaller, was found in the
left cerebellic hemisphere. Amongst the great
number of brains examined by the Wenzei.s,
only two presented this change; which they de-
scribe as having been smooth, of a yellow colour,
and consisting of a solid, adipose, ash-coloured
substance; and, although found near the exterior
surface of the hemisphere, penetrating deep into
the substanee of the organ.
117. According to M. Hebreart, this disease
is not so rare as the Wknzels lead us to suppose.
He had met with four cases of it; two in which
the tumour was seated in the brain, and two in
the cerebellum. " In the first of the former, a
distinct tumour, consisting of matter of a yellow
colour, and lard-like consistence, the size of a nut,
in the anterior part of the anterior lobe of the
right hemisphere, gave rise to idiotcy. In the
second, a square inch of the posterior lobe of the
left hemisphere was converted into a yellowish
pulpy matter, which was separated from the con-
tiguous sound brain by hardened cerebral sub-
stance. This, in a man aged forty, caused epi-
leptic paroxysms, occurring once or twice a month,
which at last proved fatal, by causing asphyxia.
In the first of the cerebellic cases, in a \ouiig
man who had been idiotic for six years, the cere-
bral substance, forming the walls of the fourth
ventricle, had been converted into a yellowish
lardaceous matter. In the second, that of an
incurable maniac, a space, six lines in diameter,
of the lower part of the right hemisphere of the
cerebellum, bud become bard, yellowish, and
lardaceous, both in the gray substance, and also in
the white." The membranes also participated in
this change. If. Hebre \kt considers that this
lesion may occur in two forms, — 1st, As a de-
generation of the cerebral structure into a matter
of a yellowish colour and lardaceous consistence;
and, 2d, in the shape of a distinct tumour situated
in the cerebral substance.
118. Closely allied to the above, although
materially different in some respects, jet still more
strictly deserving the term adipose, are the tu-
mours described by Leprestre and Dalmas.
M. Leprestre found, in the left side of the me-
socephalon of an adult subject, a large tumour,
with a brilliant lobulated surface, consisting of
concentric layers, united by means of fine cellular
tissue, but without any trace of blood-vessels. It
was denser in its structure than the brain, and
closely resembled a mass of adipocire. This
resemblance is remarkable, inasmuch as MM.
Barruel and Gmelin have demonstrated, in the
healthy human brain, a certain quantity of fatty
matter and cholesterine. The tumour found by
M. Dal mas nearly resembled the foregoing. It
was situated in the base of the brain, and was as
large as a hen's egg. It rose upwards into the
third ventricle, separated the parts which contri-
bute to the formation of this cavity, and disap-
peared in the medullary substance of the striated
bodies, the thalami optici, the anterior commis-
sure, &c. Its superior surface closely resembled
spermaceti. Its inferior surface was transparent,
polished, and studded with a number of pearl-
like granulations, from a line to a line and a half
in diameter, which were, like the whole of the
mass, perfectly homogeneous, and devoid of every
trace of organization. When analyzed by M.
Barruel, this tumour was found to contain a
very large portion of fatty matter, and a substance
which seemed to be cholesterine. The description
of a similar tumour is recorded in the first volume
of the Journal Clinique dcs Hopitaux. Otto also
found a fatty tumour, which contained hair, pro-
truding through an aperture in the hemisphere into
the ventricle, its cyst shining like mother-of-pearl.
119. C. Flesh-like tumour, — Adenoidea ( ( ' r a i-
gie). — This production has been described by
the vague names of scirrhous and scrofulous tu-
mour; but it cannot be admitted to possess un-
equivocal characters of either. It is generally
stated to be similar to a mass of flesh, or an en-
larged absorbent gland. Its colour is light pink,
or pale flesh-colour; its firmness is considerable;
and, in some instances, it is compared to the
kidney. Cases of this description of lesion may
be found in the writings of Plater (Ubser. 1. L
p. 13.), T. Bonet (Sepulchetum, t. i. p. 283.),
Rhodius (Cent. Obs. I. No. 55.), J. J. Washes
(Misccll. Curios. Dec. II. Ann. 10.), J. G. Zinn
(Comment. Soc. Reg. Scient. Gott. t. ii. 1752.),
J. J. I [o B E R ( Nova Acta Phtjsico-Medico Acad.
Cas. Leap. Cur. t. iii. p. 533.; et Comment, de
Rebus in Scient. Nat. t. xviii. p. 335.), Hai.ler
(Opusc. Path. Obs. i.), J. E. Greding (Ludwig's
Advers. Med. Prac. t. ii. part ii. p. 492.), H.
Earle (Med. Chirurg. Trans, vol. iii. p. 59.),
Powell (Trans, of Coll. of Phys. vol. v. p.
211.), &c. .Most of those cases appear to have
occurred in strumous habits; and, besides signs of
224
BRAIN — Alterations of its Substance — Tumours.
glandular disease, many of them were affected
with palsy, apoplexy, or mental derangement;
and others with convulsions and epilepsy, shortly
before death. M. Andral (Anat. Putholog. t.'u.
p. 84S.) mentions his having found, in the middle
of one of the hemispheres of the brain of a person
who had died of apoplexy, a fleshy fibrous tumour
of the size of a walnut.
120. D. Fibrocartilaginous tumour, — Scirr-
hus, Chondroma (Hoofer and Craigie), — is
probably, in its slighter grades of change, merely
an advanced state of the third variety of partial
induration of the brain (§ 103.). It is distinguish-
ed from the surrounding cerebral substance by its
great firmuess ; its irregular and lobulated form ;
its yellqwish, hard, and fibrous structure; and, in
its advanced stages, by the presence of a semi-
fluid, gelatinous matter, occasionally tinged with
blood, contained in small cavities, disseminated
through it; and by a tendency to softening; death,
however, generally taking place before complete
softening, or cancerous ulceration, has supervened.
This tumour is not often met with in the substance
of the brain, and very seldom as a primary affec-
tion. It seems to consist of a change in the
structure of the part affected, rather than of a
deposition of adventitious matter; and it is not
enveloped by any cyst; but gradually disappears
in the surrounding substance, which is sometimes
softened. All the cases which have been recorded
of scirrhus of the brain, are not in every respect
similar to the above description, but an approx-
imation to it merely; some, according to the loose
accounts given of them, being intermediate be-
tween this and the cartilaginous conditions. The
best illustrations of this form of tumour have been
furnished by Cruveilhier (Anat. Pathol, t.
ii. p. SO.), Rostan (Rt'chtrches sur le Ramol-
lissement du Cerveau, fyc. Ire. ed. p. 80.),
Andral ( Journ. dc Physiol, t. ii. p. 105.),
Bouillaud (Trailc Clinique de t'Enci'phalite,
fyc. 1S25.), Lerminier (Ann. Mid.-Chirurg.
1819, p. 225.), Monro (Marb. Anat. of the
Brain, p. 55.), Wade (Medic, and Phys. Journ.
vol. lv. p. 369.), Bayle (Rcch. sur la Phthisie
Fulmon. fyc. p. 305.), and Copland Hutchison
(Trans, of Med. and Chir. Soc. vol. ii. and iv.).
All these cases were characterised by acute pain
in the head, stupor, palsy, idiotcy, convulsive
movements, and, at last, insensibility, coma, or
complete apoplexy, and death; or by one or more
of these symptoms; and several of them seemed
to originate in external injury received at a more
or less remote period.
121. E. Bony tumours and calcareous con-
cretions,— Osteoma (Hooper), — are rarely ob-
served in the substance of the brain. Cases have,
however, been furnished of their formation, in
more or less considerable masses, — near the right
ventricle, in an idiot, by Kerkringius (Obs.
Anai.-p.l35.); inthecorpus striatum, byDEiDiER
(Des Tumeurs, fyc. p. 351.), and Kentmann
(De Calc. in Hominib.r£\g. 1536.); in one of the
corpora quadrigemina, by Tyson (Phil. Trans.
No. 228.); in the union of the optic nerves, by
Bi.egny (Zodiac. Gall. Obs. xiv. p. 81.);
where they were attended by violent pain in the
occiput, by Boyer (Cruveilhier' s Anat. Path.
t. ii. p. 84.) ; in the cerebellum, by Littre
(Mini, de V Acad, de Paris, 1705, p. 55.); in
the cerebellum of an epileptic, by Lieutaud
(Hist. Anat. Med. I. iii. Obs. 179.); in the pons
varolii, by Metzger (Obs. Anat. Reg. 1792, p.
3.) ; in the optic beds, by Caldani (Opusc. Anat.
Path. 1803, p. 51.); in one hemisphere of an
epileptic, by Otto (Comp. Anat. Path. p. 415.);
in the cerebellic peduncles and protuberance of an
idiot, by Home (Phil. Trans. 1S14.); in the left
hemisphere, by Andral (Journ. de Physiol, t.
ii. p. 110.); in the cerebellum, with violent pain
at a determinate part of the occiput, by Nasse
(Abercrombie on Dis. of the Brain, p. 426.);
in the centre of the medullary substance of the
anterior lobe, with pulpy destruction of the sur-
rounding part in one case, and in the cerebellum
in another, by Dr. Hooper (Morb. Anat. of the
Brain, p. 39.). Besides these, other instances are
referred to in the Repertorium of Ploucquet,
and the Compendium of Otto. In more numer-
ous cases, the chalky, calcareous, or bony matter,
is disseminated like sand in a diseased portion of
brain, and can be detected only by squeezing or
rubbing the part between the ringers. In some
cases, the bony matter appears like minute spi-
cules, or particles; and Dr. Hooper states that
he has found each of them attached to a filament-
ous vessel.
122. Sabulous concretions are so constantly
found in the pineal gland, or its peduncles, even
of those whose cerebral functions were most
healthy, that Soemmering conceived them to
form a part of its natural structure in adults. But
this part may be greatly enlarged, and contain
calcareous matter to an excessive amount A
case of this description is given by Mas get
( Theat. Anat. 1. iv. c. ii. p. 309.) and Salzma.nn
(De Gland. Pineal. Lapid. Arg. 1733.).
123. F. Hygromatous tumours, or cysts, con-
taining a serous or albuminous fluid, — Hygrcma
of Hooper), — are not infrequently found in some
part or other of the brain. Dr. Hooper has de-
scribed four varieties of these cysts: — a. 1 hat
consisting of a simple cell, or cavity, containing a
transparent, yellowish, or yellowish red, serous
fluid. Their sides are somewhat harder than
healthy brain, occasionally rough, and of a brown-
ish hue internally, but mostly smooth and shining.
They present no appearance of membrane lining
the cell, nor of vascularity; are of the size of
peas or nuts, and are most frequently met with
near the external surface of the brain. They
appear to be the remains of cavities formed by
extravasated blood, b. Another variety is a dis-
tinctly encysted tumour, consisting of a membran-
ous cyst, or vesicle, filled with a serous fluid.
This cvst is delicate, is formed of a single mem-
brane, and is provided with vessels coming from
the surrounding brain, and which may sometimes
be seen ramified over it. The fluid which fills
it is colourless and limpid. This variety varies
from a very small size to that of. a small orange.
It is sometimes solitary; but occasionally two or
more may be embedded close together, c. Dr.
Hooper describes two other varieties, one of '•
which is formed of a cyst, which is opaque in some
parts, and transparent in others, and distended
with a sero-albuminous fluid. The cyst is not
apparently vascular, but is much thicker than the
preceding; and its contents coagulate by heat:
d. The other is characterised by the remarkable
thickness of its cyst, and the thick albuminous
nature of its contents. It is generally found
BRAIN Alterations of its Substance — Rupture.
embedded in the medullary substance of the
brain.
12 I. C. Hydatids. — The existence of true hy-
datids, — both the acephalocyst, or headless hyda-
tid, and tin' cysticercus, or bladder-tailed hyd itid,
— in the substance of the brain, lias been doubt-
ed. Several cases of hydatids in this part have
been adduced by authors; and instances have oc-
curred to A :< dual and (' ai.meil (Anat. Pathol.
t. ii. p. 779.)j which they considered to belong to
the latter of the above species of entozoa; but
whether they actually were such, or some one of
the cysts described above, rests upon the patholo-
gical reputation of these physicians. Those ad-
duced by Home, Hkadington, Morrah, and
Rostan, seem to have been merely varieties of
hygroma. Dr. Hooper never met with hyda-
tids in this situation, in his numerous dissections.
Brer a states that he has found them in the cho-
roid plexus; and Dr. Monro relatesa case, where
a cyst, which he considered as a true hydatid, was
found in one of the ventricles. But their con-
nection with the membranes of the brain (§ 31.)
has already been shown.
125. H. The Hamatomatous tumour, — the
Hamatoma of Hooper, — is not common. It is
mostly fungous, arising from a small base, sepa-
rating the convolutions and cerebral substance
about it, as it enlarges and rises towards the sur-
face "I' the brain. It is soft to the touch; is elas-
tic, and covered with a vascular and shaggy mem-
branous tissue. When divided, its inner structure
Is vascular, mottled, of a whity brown, and, in
some parts, of a bloody colour; and a humid sub-
stance adheres to the knife like cream. Interest-
ing cases hive been detailed by Rochoux {Rich,
sur VApoplexie, Ob. 38. p. 14*).), Hooper (Op.
Cit. pi. x.), .Monro (Op. Oil. p. 56.), and G.
Gregory (Med. and Phys. Journ. vol. liv. p.
4b'2.), in which these tumours were, exteriorly,
of a reddish or reddish brown colour, lobulated,
and surrounded by pulpy destruction of the cere-
bral substance. In two of the patients, violent
headach and epilepsy, and, in one, palsy, follow-
ed by coma, preceded dissolution. This tumour
must not be confounded with the solid nodules of
extravasated blood, often found after ap'oplectic
seizures.
12(1. / Eneephaloid or cerebriform tumours,
— Medullary sarcom, — Fungus hamatoides, —
Cephaloma, Hooper. — These tumours are not
frequent. Delineations of them have been given
in Dr. Baillie's and Dr. Hooper's illustrations.
They occur chiefly in young subjects; and are en-
cysted, soft, compressible, and spongy, resembling
the gray cerebral substance, with a tinge of red,
and of the consistence of the foetal brain. They
are frequently divided into lobulated masses.
When cut with a knife, the surface is smooth, and
the knife is covered with an unctuous substance.
I have met with one case in a boy of eleven -sears
of age. M. Bayle found it in the cerebellum of
a middle-aged man. {Rev. Mid, Avr. 1824, p. 77.)
127. K. The Melanoid tumour, — Melanosis, —
Melanoma, of Hooper. — .Melanosis has rarely
been found in the brain. Dr. Hooper has, how-
ever, observed it in a tuberculous form, both in
the cineritious and medullary structure. These
tumours were of a jet-black colour, soft, distinctly
circumscribed, and closely surrounded by healthy
brain. Dr. II. has found them of all sizes, from
that of a mustard seed to that of a walnut. "They
are so soft as to require a very sharp knife to cut
them, which they soil. They are easily taken out
of the brain with a forceps, and leave a clean
cavity, without any cyst apparent to the naked
eye; autl if shaken in water, they colour it black,
and a flocculent substance remains. In one in-
stance, in which there were several of these tu-
mours, some of them were of a blood or liver
color, and resembled hematoma (§ 125.); others
were perfectly melanoniutous; and several were
of ' an intermediate colour, — a circumstance
which is very much in favour of the hsematoma
and melanoma having an intimate connection, if
they be not one and the same disease, modified by
particular circumstances." (p. 41.)
128. All the tumours now described occasion
alterations, generally of an inflammatory nature,
with softening in the substance of the brain conti-
guous to them; and until those alterations have
been in some measure produced, they often give
rise to but little disturbance of the functions of
the organ. However, when these changes be-
come developed, the usual symptoms of circum-
scribed inflammation of the substance of the brain,
with softening; epilepsy; loss, or perversion of
one or more of the mental faculties — amounting
often to insanity; idiotcy; palsy; coma, and apo-
plexy; are the usual effects. (See the Articles on
these diseases.)
129. vii. Rupture of the Brain. — Hernia
cerebri, — Encephalocele, — is occasionally met
with. It consists of the protrusion externally of a
portion of the bruin through openings in the cranial
bones. This lesion either may be congenital, or
may arise subsequently to birth. In the former
case it is generally connected with effusion of
fluid in the ventricles. The protrusion of brain
varies with the size of the aperture in the skull,
and the quantity of effusion causing it. In some
cases a large portion of the skull is wanting, and
the protruding part of the brain has a wide base :
in other cases, the opening in the cranium is small,
and the protrusion is either very small, or attach-
ed to a narrow neck. Otto states, that in every
case which he has observed, the lesion was owing
to effusion, and not to hypertrophy of the sub-
stance of the brain; and that the aperture arising
from deficient developement of the bones of the
cranium was one of the consequences of the effu-
sion. This agrees with my experience, and con-
stitutes hydrenctphalocele or watery rupture of
the brain. In some cases large portions of the
brain are protruded, in others but small. Fre-
quently the protrusion consists only of the mem-
branes forming hydrencephalocelc meningea, and
the water which they contain. Otto describes
this as a rare occurrence. I have met with seve-
ral case's at the Infirmary for Children, and in
unusual situations, namely, through clefts in the
parietal bones. In rare cases of hernia cerebri,
the water is found both within the ventricles and
between the membranes.
130. Congenital rupture, of the brain occurs
most frequently on the back of the head, through
the enlarged occipital foramen, and the cleft upper
cervical vertebra, or through a cleft in the upper
part of the occipital bone, or in the lambdoidal
suture. It is not frequent at the top of the head,
especially at the great fontanel; and Otto says
it is still more rare in the sides of the skull and
226
BRAIN — Cerebral Plethora.
forehead, and the rarest of all in the orbits and
sphenoidal sinuses. Two cases, however, of its
occurrence at the sides of the skull have come
before me. Rupture of the brain, occurring after
birth, arises from the expansion of the brain by
its own elasticity, or by increased determinations
of blood, and its consequent detrusion through
apertures naturally or artificially made in the cra-
nium. I have met with cases, however, in which
no protrusion of the brain had been observed af-
ter birth; and yet apertures, through which it
might have occurred, were found in the middle
or squamous parts of the bones, and must have
been congenital. The inference is, in these cases,
that a watery tumour of the brain had arrested
the formation of the bone immediately over it,
and that this tumour had subsequently disappear-
ed, probably from the absorption of the aqueous
effusion; but that the bone had not yet been form-
ed in the situation where the ossiiic process had
been interrupted.
131. viii. Laceration. — The continuity of the
brain may be destroyed by external violence, or
injuries penetrating the cranium, either with or
without loss of substance. Concussions also will
lacerate the brain, without the skull being pene-
trated or even fractured. The substance of the
organ, particularly the septum and fornix, may be
torn by large collections of water in the ventricles.
There is every reason to suppose that, when the
solution of continuity is simple, adhesions will
take place. When there is loss of substance, the
injury can be repaired only by granulation. If
the laceration be accompanied with the effusion
of blood, so as to form a large coagulum, requir-
ing to be absorbed, the reunion of the opposite
sides of the lacerated brain is effected by means
of a fine cellular tissue; permanent paralysis being
the usual consequence. When the granulations
of the lacerated brain protrude through the frac-
tured skull, owing to their luxuriance, or rather
to the elasticity of the brain ; and when the pro-
trusion proceeds from the distension arising from
the fulness of its vessels, the morbid condition has
been improperly called fungus cerebri, — impro-
perly, inasmuch as the term fungus is applied to
a malignant and constitutional malady.
132. ix. Ecchymoses, and Alterations
of Colour. — Besides the lesions now described,
there are others of a less remarkable kind, of
which a brief notice may be taken, a. The cine-
ritious substance may be extremely pale, and even
approximating to white; and it may also be of a
very deep colour, and almost approaching to black,
particularly in some cases of asphyxia and fevers,
owing probably to the dark apd imperfectly de-
carbonised state of the blood. Ihe different
layers composing this substance are sometimes
also more than usually distinct, and separate easily
from each other (M. Foville and Dr. Bright).
In other cases they are very thin, as if in a great
measure absorbed. This" part of the cerebral
substance likewise, in some instances, presents
numerous ecchymosed spots of various sizes and
depth of colour, b. The medullary structure
is also sometimes ecchymosed, particularly after
concussion; and variously marbled, and present-
ing blotches of a pink, purplish, grayish, or of a
grayish yellow. These changes seem to proceed
from excessive injection of the minute capillaries
of the organs, and probably from partial extrava-
sation of their contents, owing to over-distension,
or a morbid state of the blood which had circu-
lated in them shortly before death, and are most
commonly observed after death from convulsions
and malignant diseases.
133. As respects the colour of the brain gene-
rally, I may state that it is sometimes found un-
usually pale from deficiency of blood, in cases of
anaemia and cachexia. But it is more commonly
of a deep or pink colour, particularly in those
who have died from apoplexy, strangulation,
narcotic poisons, asphyxia; and in the" insane,
or those given to drunkenness. In some cases
resulting from those diseases, or attended with
cerebral congestion, dark red, bluish, or purple
coloured spots, or even streaks, have been found
in both the cortical and medullary structure. In
cases of inflammatory irritation, a reddish or pink
hue is observed. A red colour is rarely met with,
but more commonly a pale rose tint, unless effu-
sion of blood have occurred. I may also state,
at this place, that if, in severe diseases of the
brain, the blood be decomposed, or if the colour-
ing particles be secreted in various proportions,
the brain will present different shades of colour,
both in its cineritious and in its medullary sub-
stance : it will thus be either a pale or dusky
yellow, an orange, a brown, grayish green, a slate
colour, and even here and there soot-coloured.
Occasionally, also, in different changes of texture,
although even without these, a deposition of a
melanotic pigment takes place, chiefly in the
course of the larger vessels, independently of the
melanoid tumour (§ 127.). Otto never observ-
ed the brain generally tinged yellow in cases of
jaundice, and doubts it having ever occurred,
although Stoll says that he has seen it. I
should add, that the above changes of colour are
independent of marked softening or pulpy' des-
truction of the cerebral substance.
Brain. — Asejiiaof the. — See § 132., and
art. Convulsions.
Brain. — Cerebral Plethora. — Deter-
mination of Blood to the Head. Classif.
II. Class, I. Order (Author).
134. When the blood is determined in too
great quantity to the brain, although the patient
may not be altogether incapable of his usual avo-
cations, yet much disorder may be present, which,
if neglected, may lead to serious diseases, more
especially to those which will be considered in
the sequel of this article.
135. Causes. — The causes of general vascular
plethora likewise occasion this affection. Those
which are more peculiar to it, are inactivity of the
secreting and excreting functions, mental exertion,
retention of accustomed evacuations and dis-
charges, full living, sedentary occupations, and
want of exercise in the open air; organic diseases
of the heart, particularly hypertrophy of the left
ventricle, and those causes which are enumerated
under the article Apoplexy.
136. Symptoms. — Cerebral plethora, and de-
termination of blood to the head, differ in many
respects from cerebral congestion, or coup de sang
(§ 131.), but the symptoms accompanying them
vary chiefly in degree. Where the disorder consists
merely of plethora from local determination, som-
nolency, cephalalgia attended with scintillations,
and objects appearing of a red colour, vertigo, noises
in the ears, sometimes sleeplessness, moral and
BRAIN — Congestion of the.
227
physical excitation, intellectual activity ; or, on
tlie contrary, inactivity, inability of continued at-
tention, stiffness, cramps, twitcliings, &c. of the
limbS ; animation of the countenance and eyes,
win -li arc sometimes red or injected, with strong
pulsation of the carotid and temporal arteries, full
and somewhat frequent pulse, and slightly in-
il temperature about the head, are the usual
symptoms.
137. Morbid appearances. — This state of dis-
order never of itself occasions death ; but, as it
sometimes occurs in the advanced stages of fatal
diseases, it has been observed to consist of increas-
ed vascularity in the brain and its membranes,
without further organic change ; but it is some-
times accompanied with a slight serous effusion
into the ventricles and between the membranes,
particularly towards the base of the brain. This
effusion seldom amounts to more than may be
present in the healthy state of the organ, the
excess being probably rather a consequence of
death, than its antecedent.
13S. Treatment. — Cerebral plethora may gen-
erally be removed by avoiding the causes induc-
ing it ; by promoting the abdominal secretions and
excretions by the usual means ; by the affusion of
cold water on the head, and the daily use of the
shower-bath, or by sponging the head with cold
lotions ; by clothing the lower extremities warm-
ly, and promoting the cutaneous perspiration ; by
regular daily exercise ; by due attention to the
quantity and quality of the food ; and by changes
of air in obstinate cases, and sea voyages.
Brain. — Congestion of Blood in the. —
Coup de Sang. — Cerebral Congestion.
("lassie. II. Class, I. Order (Author).
13;). Congestion is an advanced as well as a
modified state of cerebral plethora, and consists
in too great an accumulation of blood in the ves-
sels of the head, particularly in the venous capil-
laries and sinuses, occasioned either by too great
a flux of this fluid to the brain, an exhausted tone
of the capillaries and smaller vessels, or impeded
return of it by the veins. This state of circula-
tion in so important an organ as this is, necessa-
rily occasions marked lesion, not only of the func-
tions which it performs, but also of other func-
tions throughout the system.
140. Symptoms. — Cerebral congestion is char-
acterised by numbness, vertigo, noises in the ears,
somnolency, brilliancy or watering of the eyes,
cephalalgia, redness of the countenance, beating
of the carotids and temporal arteries, loss of re-
collection, kc. These symptoms continue for
some time in different degrees, sometimes disap-
pearing, and after awhile returning, accompanied
wiih cramps, twitcliings of the limbs, generally
of both sides : at last the patient loses sense and
voluntary motion, in a more or less sudden man-
ner. But usually in the course of a few minutes,
or, at furthest, some hours, the more urgent of
1 these symptoms disappear ; leaving, however,
numbness of the limbs, which generally disap-
pears in a short time, or in the course of one or
two days.
141. In the more severe cases, and those which
more nearly approach complete apoplexy, the
attack is preceded by disorder of the stomach, or
accompanied by nausea, or vomitings ; and some-
times, during ih". loss of sense and voluntary
motion, the stools and urine are voided involun-
tarily ; respiration is more or less embarrassed,
but not stertorous ; the pulse is strong, frequent,
and full ; the temporal and carotid arteries, beat
strongly ; and the skin is generally warm and nat-
ural. Cerebral congestion is almost always gen-
eral throughout, the brain, but it is also, although
rarely, local, affecting only one hemisphere ; ami,
owing to the numbness and temporary paralysis
thereby occasioned, is confined either to one limb
or to one side of the body ; .simulating apoplexy,
or paralysis from haemorrhage in the brain. That
these local symptoms are, however, owing to par-
tial congestion, and not to haemorrhage, is evinced
by the celerity with which they disappear under
judicious treatment. When the cerebral conges-
tion is very great, it constitutes a form of apoplexy,
noticed in the article on that disease, and may oc-
casion death without any further lesion than con-
gestion merely.
142. Appearances on dissection. — The scalp,
and even the bones of the cranium, in some cases,
are of a red violet colour, and allow of a consid-
erable quantity of blood to escape upon being di-
vided. The vessels, and particularly the sinuses,
are rilled with dark blood. When the arachnoid
of the pia mater is separated from the brain, a
reddish patch, more or less deep, is formed, the
vessels running through it being gorged with blood.
The surface of the convolutions are of a more or
less dark colour ; and, when the cortical sub-
stance of the brain is divided, it is of a deeper
hue than natural, the orifices of the cut vessels
giving out drops of blood proportionate to their
size. Upon dividing the medullary structure,
which is usually not so white as in health, myriads
of minute specks, becoming small bloody drops,
rapidly form on the surface. The large vessels,
and particularly the veins of the brain, are gorged
with blood. When a person cured of repeated
attacks of cerebral congestion, dies of a different
disease, morbid appearances are seldom detected
in the brain.
143. Terminations and complications. — Cere-
bral congestion may occasion meningitis ; or in-
flammation and softening of the substance of the
brain ; or hamorrliage in some situation within
the cranium, giving rise to complete apoplexy, or
palsy, or both ; and serous effusion in the ven-
tricles, or between the membranes ; many of the
cases of apoplexy, attended with extravasation of
blood, thus commencing in congestion, the extra-
vasation being a consecutive change. It may also
supervene on organic changes of the heart and
lungs, and in the progress of various fevers, and
thus be complicated with these diseases.
144. Causes. — The causes of this state of the
cerebral circulation, are those which have been
already detailed in the articles Apoplexy and
Cerebral Plethora (§ 134.).
145. Treatment. — Blood-letting, general, lo-
cal, or both, to an extent which the constitution,
habit, and symptoms of the patient indicate, are
requisite. Next to blood-letting, active purging
by calomel, followed by a dose of senna, croton
oil, or some other active cathartic, and promoted
by Strong cathartic injections, such as the oleum
terebintliinae, oleum ricini, extr. colocynth. comp.,
&c. are required, and should be repeated, so as to
procure copious evacuations, and keep up suffi-
cient action in the alimentary canal. The affu-
sion of cold water on, or cold sponging the head,
228
BRAIN — Inflammation of its Membranes.
is generally beneficial ; and when the temperature
is increased, and the countenance and conjunctiva
flushed, a thick oilskin should he placed under the
patient's head, which ought always to be kept el-
evated, and covered with cold epithems. Due
attention should be constantly paid to the state of
t'.ie evacuations. Accumulations of bile in the gall
bladder or hepatic duets, and of fecal matter and
morbid secretions in the alimentary canal, fre-
quently predispose to or induce an attack, which
will seldom altogether yield to the means em-
ployed, unless these morbid collections are remov-
ed by appropriate means : and as long as the
evacuations continue unhealthy, we may infer that
the chief cause of disorder is not altogether re-
moved. (See Treatment o/Apoplexy.)
Brain — Inflammation of the. Clas-
sif. 1. Class, Febrile Diseases ; 2. Order,
Inflammations (Cullen). 3. Class, Diseases
of Sanguineous Function ; 2. Order, Inflam-
mation, (Good). III. Class, I. Order
(Author, see Preface).
146. Nosol. Defin. — Pain of the head more
or less violent, with suffusion or prominence of
the eyes ; generally tumid or flushed countenance,
delirium, or sopor, or both, or a marked pre-
dominance of either ; with symptomatic fever ;
and frequently with lesion of the senses and
functions of relation.
Pathol. Defin. — Inflammation of either the
membranes or the substance of the brain, or of
both, generally with predominating lesion of
either the one or the other.
147. The recent researches of anatomists and
pathologists have tended to advance our knowledge
of the phenomena of inflammations of this import-
ant organ. The investigations of M. Ma gkkdie,
who has shown that its membranes exhale in
health a limpid serum for the purposes of protect-
big the parts they surround, of facilitating the
movements to which they may be subjected, and
of accommodating and imparting a certain degree
of superficial pressure, so that they may not suf-
fer from the varying positions and states of vas-
cular plethora to which they are obnoxious, have
indirectly thrown considerable light on the pa-
thology of the brain. Much, however, is still re-
quired to be known, not only as to the further re-
lations which these membranes hold to the cere-
bral organs, in the performance of their healthy
functions, but more particularly as respects the
connection which subsists between their organic
lesions and their symptomatic or functional dis-
orders.
148. We know that the more internal and the
most vascular of these membranes are chiefly ap-
propriated to the distribution of the circulating
fluid by means of the minute capillaries which it
transmits to the external surface of the brain.
We may thence infer that the functions, and even
the organic conditions of the brain, in these situ-
ations especially, will be greatly modified, or even
altogether changed, by the varying condition of
the circulation in this membrane. When, there-
fore, it is the seat of inflammation, disease will
be more or less extended to the substance of the
brain ; and will more or less influence the func-
tions of this organ, particularly in the parts which
it supplies with blood. The membranes, how-
ever, exterior to the pia mater, may be affected
to a considerable extent without this latter par-
ticipating much in the disorder : and here our
knowledge is both imperfect and deficient in pre-
cision : for we are not enabled to state that in
such cases the functions of the brain itself are
undisturbed, or, if disturbed, in what manner the
lesion of these exterior membranes affects this
organ ; and, being imperfectly informed respect-
ing all the offices of these membranes, we are
less able to trace the relation between healthy
function and the phenomena which inflammation
of them present. Surrounded thus with dhficul-
ties, which the advances of science will doubt-
less diminish, are we therefore to leave the sub-
ject without investigation, or relinquish the at-
tempt to place in order and explain those facts
which we have already obtained, and which may
be made subservient to a further elucidation of
the subject ?
149. In no other organ of the body is it so diffi-
cult as in the brain, to trace the relation between
demonstrable change of structure and morbid
manifestations of function. This is partly ow-
ing, no doubt, to the circumstance of its being a
double or symmetrical organ ; lesions seated only
in one half or side of the brain, when unattend-
ed by absolute disorganization, not occasioning a
corresponding degree of disorder as long as the
same part of the other side is% unaffected. Deli-
rium has been conceived to be a symptom indi-
cating the existence of inflammation of the mem-
branes of the brain ; yet delirium is a disorder of
those functions which we conceive to be perform-
ed by the cerebral substance itself ; and every
experienced practitioner must have observed, and
numerous are the cases on record, in which in-
flammation to a great extent, and all its conse-
quences— as thickening, adhesions, effusions of
lymph, or even of purulent matter — have been
observed, and yet there had been no delirium.
It is, therefore, to be inferred, that, when menin-
gitis is accompanied with delirium, the disease
extends more or less to the pia mater or parts
enclosed by it. This inference, however, might
lead to a conclusion which seems not well found-
ed, viz. that it is impossible to distinguish menin-
gitis as a disease independent of inflammation of
the substance of the brain. Ibis, doubtless, is
often ditficult, because both diseases frequently
co-exist in different degrees, or co-ordinately ;
yet still an extensive experience will show that
they often exist separately : and hence the neces-
sity of ascertaining what are the characters which
are proper to each. In respect of diagnosis, the
subject possesses interest ; and although the treat-
ment in both is, in its principal points, the same,
yet on some occasions it requires to be mod-
ified.
Brain — Inflammation of its Mem-
branes. Syn. Meningitis, Paraphren-
ias ct Phrenitis, Auct. Var. Recent. Arach-
nitis, Parent and Martinet. 'Cephalitis Me-
ningica, Good. Phrents'ie, Pinel. JMinin-
gite, Fr. Die Hirnhautcntzundung, Ger.
Brain Fever.
150. Defin. Acute pain in the head, with in-
tolerance of light and sound ; watchfulness, de-
lirium ; flushed countenance, and redness of the
conjunctiva, or a heavy suffused state of the
eyes ; quick pidse ; frequently spasmodic iiritch-
ings or convulsions, passing into somnolency,
coma, and complete relaxation of the limbs.
BRAIN — Inflammation of its Membranes.
229
151. We are rarely enabled to distinguish be-
tween inflammation of the arachnoid membrane
and that ofthepia mater by the symptoms (luring
lite. 1 shall therefore comprise under the head of
meningitis, inflammations affecting one or more
of the membranes of the brain.
152. Symptoms. — As the uses of the cerebral
membranes are not rendered sensible by manifest
functions, it may be concluded that diseases of
these puts mav exist to a considerable extent,
without any Distinctive symptoms. The justness
of this observation is but too frequently confirmed
bv experience ; for there are few practitioners
who have diligently employed their opportunities
of post mortem research, and have not observed
appearances of inflammation, without much dis-
order of the intellectual faculties, or of the move-
ments of the body, having been manifested almost
up to the moment of death. Such instances are
not rare, particularly in persons advanced in life.
More frequently, however, when the membranes
are inflamed, the adjoining portions of the brain,
the functions of which they are probably intend-
ed to facilitate, evince some sort of disorder, par-
ticularly of their usual functions. These symp-
toms, although indirect, are generally similar to
those of the inflammation of the cerebral sub-
stance itself, and are the chief guides to lead us to
the recognition of meningitis.
153. The symptoms vary according to the seat
of the inflammation, the stage at which it has ar-
rived, the, severity of the attack, and the celerity
of its progress. The disease in its usual form pre-
sents three periods : 1st, that of invasion ; 2d,
that of fully developed inflammation ; and, 3d,
that of compression. Some one of these periods,
however, does not always exist, particularly when
the inflammation is very general or very circum-
scribed, or when it is very acute or very chronic
in its progress. Meningitis affects more frequent-
ly that put of the membranes which covers the
convexity of the cerebral lobes, in adult subjects;
and the portions about the base of the brain, in
young children.
154. A. Acute meningitis of the convexity of
the cerebral lobes is attended with violent pain,
which is exasperated at intervals, and often with
stupor or somnolency. It occupies various re-
gions of the cranium, the frontal, occipital, synei-
pital, &c, and is augmented by motion, particu-
larly by rotation of the head, which in children is
often drawn backwards. In this class of patients
the pain is expressed, particularly upon being
roused, bv a peculiar cry, which the experienced
observer recognises as a diagnostic sign of the dis-
ease, and after uttering which the infant sinks into
a somnolent stupor, in which it grinds its teeth
frequently. The functional derangements occa-
sioned by meningitis are usually of a general
character, although the inflammation is more fre-
quently of limited extent. This is owing to both
sides being attacked at the same time; cases
where the meninges are inflamed on one side only
be in 2 very rare.
155. a. Pain in the head is generally preceded
by chills or rigors, which may be viewed as the
result and indication of the formation of the iiis-
ease; but cases not infrequently occur, wherein
the foregoing signs in a greater or less degree pre-
cede the rigors even for a considerable time. The
face at first is often pale; but, as the disease
20
becomes fully developed it is more frequently
slightly tumid, flushed, and expressive of pain,
and the eye-brows knit or contracted; the eyes
are heavy or brilliant, injected and watery, gen-
erally nearly shut, incapable of bearing the light,
and the pupils contracted. The patient thinks
he sees fire, or scintillations of light; and some-
times the colours of bodies appear differently
shaded. The slightest noise is insupportable, and
all the senses are in a state of morbid activity.
His answers are brief and quick, and there is an
evident activity of mind, but as yet no delirium.
His disposition, however, seems changed; and he
becomes impatient, irritable, abrupt, and quick
in his manner, and his countenance is expressive
of irritation and pain. The temperature of the
bead is now greatly increased; the pulse is fre-
quent and developed; the tongue rather dry, its
papillae more or less erect and distinct; thirst is
complained of; the urine is scanty and high-col-
oured, and the bowels are obstinately constipated;
but in some instances, in children, either relaxed
or irregular, and the evacuations morbid and of-
fensive. From the commencement of the attack
there is generally vomiting, particularly in chil-
dren, which recurs at intervals, is unattended
with tenderness or pain at the epigastrium, and
is manifestly sympathetic of disease within the
head. In adult subjects, vomiting is sometimes
absent. It is not infrequently remarked, that this
stage either does not occur or passes unobserved
in aged persons. The patient loses suddenly bis
recollection, as in congestion only of the brain;
but to this succeed febrile symptoms, distinguish-
ing it from this latter affection.
156. 6. After an indeterminate period, com-
monly varying from one to three or four days,
according to the intensity of the attack, violent
delirium comes on, but not constantly. If the
pain in the head continues, it is not complained
of by the delirious patient; and the senses are no
longer intolerant of their natural excitants ; the
pupils commence to dilate or to contract, and
strabismus supervenes ; the countenance has a
convulsed appearance; the lips are drawn some-
what to one or both sides; the pulse is more
or less developed, sometimes irregular and trem-
bling, and is rarely at this period feebler or
slower than natural ; the tongue presents the
same appearances already noted ; the thirst, and
frequently the vomiting, still continue. The tem-
perature of the head continues excessive, but oc-
casionally fluctuates, whilst that of the rest of the
body is often not materially augmented.
157. c. To this state succeeds more or less
marked exhaustion, which should not be taken
for commencing resolution of the disease. The
patient ceases to scream; and the symptoms of
violence subside; but to these succeed startings
of the tendons, carphologia, convulsive motions,
and sometimes cramps, chiefly in the upper ex
tremities. The pupils are dilated, contract with
dkficulty on exposure to light; the eyes are rolled
in their orbits, become insensible, as well as the
other senses, to the ordinary excitants ; and a
complete calm takes the place of the violent
delirium; the patient even not answering ques-
tions put to him. lie has had no sound sleep
excepting a fatiguing stupor ; he is now plunged
in a profound coma. The limbs are, up to this
time, rigid and contracted, but soon become
230
BRAIN — Inflammation of its Substance.
completely relaxed. This state is owing, gener-
ally, to the effusion of serum, which has now
taken place; hut it sometimes may exist without
increased effusion; injection and congestion of
the vessels of the brain, or compression, from
whatever other cause, also producing it. At this
period of the disease the face is pale, the eyes in-
expressive, dim, half open, and drawn upwards;
the cheek bones prominent, the temples hollow,
the nose pinched, the ears cold; the lips dry,
applied closely to the teeth, which are covered
with a fuliginous coating at their base; the tongue
is dry, hard, and brown; deglutition difficult, the
abdomen distended with flatus, and the fa>ces and
urine voided involuntarily. The skin is either
cold, or covered by a viscid sweat; the pulse is
small, unequal, or irregular; the respiration slow,
sometimes stertorous; the expired air is cold and
foetid; and the patient dies generally in the course
of a very few days, or from two to three weeks,
and but rarely later.
158. These are the principal symptoms of acute
meningitis of the cerebral hemispheres. They
present irregular periods of exacerbation ; the
heat of skin and character of countenance vary-
ing at different times without any evident cause.
The stages of the disease are not precisely mark-
ed; either of them may be wanting, and some-
times they seem as if confounded with each other.
When the disease terminates favourably, the
symptoms subside gradually ; resolution taking
place, sometimes with, but as frequently without,
critical phenomena.
159. According to the observations of MM.
Parent, Martinet, and Rostan, when the
membranes of the base of the brain, or of the ven-
tricles, are the seat of the inflammation, the symp-
toms are somewhat different. The patient then
experiences less delirium, or even preserves his
intelligence almost entire; his faculty of attention,
arid some of the other intellectual powers, being
only diminished. He answers slowly, but ration-
ally, to questions put to him ; somnolency is al-
most continued, and coma more quickly super-
venes. In other respects the symptoms are the
same. Cephalalgia is complained of chiefly at
the bottom and above the orbits; in general, the
symptoms of irritation and excitement are less
strongly pronounced than in the preceding form
of the disease.
160. B. Chronic meningitis differs from the
acute chiefly in the less intensity of the symp-
toms, and slow progress of the disease. In many
cases the functions of sense and locomotion are
but slightly disturbed, and usually the intelligence
is unimpaired; at least, as long as the inflamma-
tion does not affect the membranes of the convex-
ity of the hemispheres. When seated, however,
in this place, according to M. Bayle, who has
devoted considerable research to this subject, de-
lirium frequently is also present, but it is seldom
violent ; sometimes it is taciturn ; and the pa-
tient generally is engaged with lofty or ambitious
ideas.
161. Chronic meningitis commonly succeeds
to the acute form of the disease ; but it often pre-
sents the chronic characters from the commence-
ment. There is generally continued headach,
with slight somnolency, sluggisluiess, incapacity
and want of desire for intellectual exertion, mo-
roseness, irritability of temper, sometimes con-
fusion of ideas, embarrassment of speech, and
delirium, terminating in confirmed mania or ma-
niacal idiotcy. The motions of the limbs are
slow, difficult, or painful, and their muscles are
subject to involuntary motions and twitching*,
and sometimes are not under the controul of
volition, or are altogether paralytic. Vomiting
and convulsions are rarely present, excepting in
infants, where they are often the chief or almost
only signs. In children, the peculiar knitting of
the eye-brows, retraction of the angles of the
mouth, whining or peevish cry, stupor, grinding
of the teeth, scanty urine, obstinate costiveness,
and increased heat of the head, are the chief
symptoms; these being similar in kind, but much
milder in degree than those accompanying the
acute or sub-acute states of the disease. In many
cases, both in children and adults, the functions
of organic life present but few lesions of a marked
description until towards the last period of dis-
ease, or shortly before death. It will be perceived
that many of the phenomena here stated, belong
to disease of the brain, — a circumstance which
must necessarily obtain; for as the membranes
surround the whole of this organ, and are one of
the chief media of distributing the blood-vessels
to it, any disease affecting its structure, or modify-
ing the quantity or properties of the fluid secre-
tion furnished by these membranes, for its protec-
tion, &c, must necessarily implicate the state of
its functions.
162. C. The duration of meningitis necessarily
varies with its intensity. In its acute form it ex-
tends from three to four dajs to twenty-eight, and
even thirty ; but more frequently from seven to
fourteen days. In many cases it is difficult to
assign the period of invasion; pain and somno-
lency having been complained of even for days
before the occurrence of chills or rigors. The
disease also not infrequently supervenes on other
affections, and occasionally becomes complicated
with them, particularly in the course of hooping-
cough, and diseases of the prima via, when its
invasion may be overlooked, or with difficulty
ascertained. The more chronic states of men-
ingitis have no determinate duration : they may
proceed gradually and in a slight form, when,
unexpectedly, from some exciting cause, or even
without any evidence of such occurrence, they
may assume an acute character, and terminate
more or less rapidly.
163. D. The organic changes consequent upon
inflammation of the cerebral membranes are ob-
served chiefly in the pia mater, the arachnoid,
and the reflection of the arachnoid covering the
dura mater ; and not infrequently, also, in the
cineritious substance of the brain. These consist
principally of injection and impregnation of the
pia mater with blood, &e; loss of the transpa-
rency of the arachnoid; effusion of "serous or sero-
albuminous fluids; and the various lesions partic-
ularly described in the preceding sections (§ 22— »"
28.).
Brain — Inflammation of itsSubstancf..
Syn. Phrenesis, Phrenismus, Auct. Var
Encephalitis, En/cephalitis, Hildenbrand.
Cephalitis, Auct. Var. Recent. Enciphalite,
Bouillaud and other French Pathologists.
Cerebrite, Foville. Cephalitis Profunda,
Good. Gehirnentziindung, Ger.
164. Defin. Pain oftheheadj vertigo; altered
BRAIN — Inflammation of its Substance.
2.31
sensibility : spasms, or contractions, of one or more
iimbs ; excited or deranged functions of sense
and intellectual power; rapidly terminating in
coma. "
165. I have stated that meningitis manifests
itself to our senses chiefly by the lesion of the
cerebral functions ; and that this is occasioned in
two ways, viz. by deranging and impeding the
functions of the brain, which these membranes
are intended to facilitate; and by imparting the
inflammatory action to those parts of the brain
contiguous to them. But although the relative
connection of parts thus necessarily increases the
difficulty oi" distinguishing the symptoms proper
to the membranes, or to the brain itself, still there
are certain signs which enable us to infer the
degree to which either may be separately affected.
We shall see in the sequel, that, in cerebritis, the
organs of- voluntary motion exhibit frequently
morbid phenomena which are generally limited
in extent ; whilst we have seen, in meningitis,
these organs are affected generally, and seldom
or ever partially, excepting when complicated
with inflammation of some portion of the brain ;
and if, in cerebritis, all the voluntary actions are
affected, the inflammation has commenced in the
membranes, and extended itself to the substance
of the brain, — the disease existing as meningitis
and cerebritis conjoined, which is, perhaps, its
most common state, and in which I shall presently
consider it.
11)6. Symptoms. — A. The more immediate
functional derangements. The functions of the
brain consisting of sensation, volition, instinctive
desires, intelligence, and moral sentiments, it is
evident that the phenomena of the disease should
be sought after in this series of manifestations;
and that they will vary, in respect of their par-
ticular states, their intensity, and progress, ac-
cording to the seat, the nature, and extent of the
organic change.
167. a. When cerebritis is general, it often
presents the same functional disturbances, and
the same progress and stages, as meningitis: it is,
indeed, very probable that both diseases co-exist,
and that the inflammation commences in the pia
mater. However, when the whole cerebral mass
is inflamed, coma, with relaxation of all the limbs,
takes place much earlier than in meningitis; and
the disease developes itself with extreme rapidity ;
the symptoms of vascular excitement scarcely
showing themselves, or, at least, for a very short
time ; and being frequently altogether absent.
This difference is readily explained, when we con-
sider that, in meningitis, the brain beinj only
secondarily and slightly affected, it may still ex-
ercise its functions, although in a deranged man-
ner; whilst in general cerebritis, the change being
extensive, its functions must necessarily be sus-
_Bended. The patient, after a rigor, which ushers
Si this as well as the majority of other inflam-
mations, sometimes loses recollection; but he has
generally experienced other symptoms previously,
such as obstinate pain of the head, twitchings,
pricking sensations, slight numbness or diminu-
tion of the sensibility, with painful muscular
action, vertigo, sudden want of recollection, and
tinnitus auriuui. Sometimes the sensibility is
morbidly increased at this stage, as well as the
functions of sense; the intellects are active, or
excited; and there is watchfulness, with other
analogous symptoms, for a longer or shorter
period before the patient is seized with rigors and
insensibility.
168. b. These precursory symptoms M.Rostan
considers as the result of an incipient disorder,
which he conceives to be local congestion, and
that inflammation has not then taken place; but
they are, more obviously, signs of an early period
of inflammatory action. These symptoms are
frequently accompanied with general signs of
plethora or determination of blood to the head:
the pulse, particularly of the carotids, is hard, or
full and developed ; the countenance is injected;
the skin hot, &c. The same precursory signs
are likewise observed in softening of the brain;
but in this affection the pulse is not augmented in
frequency or fulness, the skin is cold and pale,
and the countenance pale or shrunk. The symp-
toms now described indicate, at least, that morbid
action has commenced in the brain; and that it is
not so extensive or intense as not to subside
under judicious treatment. But when the pa-
tient has had rigors, the functional disturbance,
especially of locomotion, is particularly marked :
then ensue clonic or tonic spasms of the muscles,
such as starlings of the tendons, carphologia,
convulsions, cramps, rigid contraction of the
limbs, &c. At a more advanced period, par-
ticularly when effusion supervenes, paralysis or
relaxation, and loss of sensibility of a lunb or
limbs, take place.
169. c. When cerebritis is general (which is
never the case without the pia mater being in-
flamed), these symptoms affect all the limbs
simultaneously; when local, only some of them,
according to the seat of inflammation. Spasms,
convulsions, or paralysis, affect also the muscles
of the face; there is a falling down of the upper
eyelid ; the eyelids are shut and contracted ; the
commissures of the lips are drawn to one side,
either by their natural tonicity, when the antago-
nist muscles are paralysed, or from a morbidly
increased action. Sometimes this exists on both
sides, producing retraction of the angles of the
mouth. Very frequently the muscles and limbs
are remarkably painful ; so that, when attempts
are made to move them, or to straighten those
that are contracted, or upon attempting to move
himself, the patient screams out.
170. d. In partial cerebritis, the action of the
muscles and the sensibility of the surface are also
partially, but not permanently, affected; some parts
being less disordered, whilst the affection extends
to others; or they all become more severely and
permanently diseased ; the spastic contractions,
which existed at first owing to inflammatory irri-
tation, giving place to paralysis, in consequence
of pressure or disorganization. The intellectual
faculties are also frequently disturbed. The
patient's answers are abrupt, rapid, sometimes
incoherent, and at other times made very slowly.
When merely one hemisphere is affected, it has
been supposed that the functions of the other
will proceed so as to prevent the appearance of
much disturbance of the mental faculties; but this
may or may not be the case; and, at least, can
only occasionally obtain. The mental disturbance,
which is extremely various in its forms and states,
according to the part of the brain affected, exists
only during the first days of the disease, and is
soon displaced by coma.
030
BRAIN — Inflammation of the — Symptoms.
171. e. At the commencement, particularly
when cerebritis is general, or affects the periphery
or more superficial parts of the brain, as in me-
ningitis, or meningitis complicated with superficial
cerebritis, the functions of the senses are morbidly
increased, the least light or noise, or the slightest
touch, being insupportable; but when the disease
Ls seated in the centre of the brain, where the
senses transmit their impressions, there is either
perversion, or complete loss, of these functions.
The pupils are then frequently dilated and insen-
sible ; the eyes unaffected by light, the ear by
sounds; and the other senses are similarly dis-
turbed; the patient is either watchful, or is op-
pressed by a somnolency intermediate between
sleeping and waking; and numbness, with twitch-
ings, or local convulsions, are generally observed.
172. In the course of a period, varying from
one to three or four days, or sometimes earlier,
and occasionally later, the symptoms are changed,
owing to the local affection having advanced to
disorganization. At this period, copious effusion
of serum often takes place, occasioning symptoms
of compression. The spasms and convulsions are
replaced by relaxation and immobility; and the
senses are paralysed, not only on the side oppo-
site to the cerebral lesion, but on both sides si-
multaneously, owing to the healthy parts of the
brain being compressed by the effused serum, or
by the tumefaction of the parts inflamed. Sensibi-
lity diminishes rapidly, and is at last abolished; the
intellects are obscured, and at last overwhelmed,
and the patient becomes profoundly comatose;
or, in the less acute or chronic cases, hemiplegic,
and sometimes ultimately apoplectic, or epileptic.
173. B. The mediate symptoms. — During the
first, days of the disease, the countenance is full
and coloured ; the eyes brilliant and animated,
their expression unusual; the temporal arteries,
as well as the carotids, beat strongly ; there is no
ai'mefiie: the tongue is white, loaded, red at its
margins and point, and the papillae developed;
there are nausea and vomiting; the bowels are
costive; but occasionally in children there is diar-
rhoea from the commencement, and the evacu-
ations are morbid and offensive; the skin is warm,
the pulse strong and frequent, and the respiration
accelerated. At a later period, a very manifest
change ensues : the countenance is expressive of
pain, irritation, and chagrin; the features begin to
sink, and become pale; the eyes dull and half
closed; and thirst is no longer complained of;
deglutition is difficult, or cannot be accomplished;
vomiting is produced with difficulty; the abdomen
is distended with flatus; and the feces are passed
involuntarily, as well as the urine, which some-
times accumulates in the bladder from paralysis
of this organ; the skin becomes cold, or covered
by clammy sweat; the pulse is unequal, irregular,
or variable; the respiration laboured, or stertorous;
and the patient sinks. In rare cases, at this stage
of the disease, the symptoms diminish, and the
functions gradually assume their natural states,
either with or without the occurrence of phenom-
ena which may be regarded critical. 'I he alter-
ations of structure produced by cerebritis are
fully described in preceding sections of this article
(§ 48, el seq.).
Brain — Inflammation of the Mem-
branes and Substance of the. Syn.
Phrenitis (from ifq^r, the mind); Encepha-
litis, Cephalitis (from xtya/.t], the head)
Frank and Hildf.nbrand. Phre'nesie,
Enciphalite , Fr. Hirnentzitndung , Ger.
174. Defin. Violent pain in the head; pro-
minent suffused eyes; flushed countenance; violent
delirium, folloioed by profound sopor.
175. Having described inflammation affecting
chiefly either the membranes, or the substance of
the brain, I now proceed to consider inflamma-
tion attacking these structures simultaneously, or
rapidly extending from the one to the other,
chiefly from the former to the latter. This is cer-
tainly the more common form in which inflam-
mation seated within the cranium manifests itself
in adults, particularly in hot countries, and in
temperate climates during hot seasons. In chil-
dren, however, a more or less evident limitation
of the inflammatory action to either the mem-
branes, or the cerebral substance, especially the
former, is frequently perceived ; and the same re-
mark may be extended to aged persons, in whom
the substance of the brain is more liable to be
affected, chiefly in a sub-acute or chronic form.
That the division which I have made of inflam-
mations of the brain, is founded in truth and
that their diagnosis may be established in prac-
tice by a judicious and experienced physician, I
have had numerous opportunities of proving at the
Infirmary for Children, where the cases admitted
with inflammations seated within the head have
been entered as cases of meningitis, cerebritis, or
encephalitis, as the membranes, the substance of
the brain, or both, respectively, were considered
chiefly affected.
176. It may be supposed, that the distinctions
argued for, granting their accuracy, tend to little
practical advantage. This is, however, a very
serious mistake; and I cannot more fully demon-
strate it, than by the following fact : — About ten
years since, I was requested to see a child, at-
tended bv an ah! 6 »pd scientific "^'-'sctitionsr, v>*hs
considered the case as meningitis, which had
terminated in effusion; or, in other words, of
acute hydrocephalus in its advanced stage, and
perfectly beyond the reach of art. After an atten-
tive consideration of its history and existing state,
I expressed the opinion, that the disease was in-
flammation, chiefly affecting the substance of the
brain, and that a decided treatment founded on
these views might still be successful. Leeches
applied behind the ears, and around the occiput,
with the means which will be hereafter detailed,
succeeded in restoring the child to health in a
few days. Since this instance, I have witnessed
similar mistakes. The diagnosis, prognosis, and
the treatment adopted in these cases proceeded
on the important fact already stated (§ 167.),
that cerebritis will, owing to the turgescence
of the inflamed organ, give rise at a very
early stage of the disease to the most profound
coma, relaxation of the limbs, and many of
the symptoms occasioned by effusion of serum ;
wliilst the greater temperature of the head, and
strength of the pulsation of the carotids in the
former, will often, independently of other signs
connected with the history of the case, evince its
real nature.
177. Seat. — In the greater number of cases,
inflammation commences in the pia mater, and
extends itself to the arachnoid on one side, and
to the cortical substance of the brain on the other;
BRAIN — Inflammation of the — Causes.
233
and not infrequently also to the arachnoid cover-
ing the dura mater, and the deep-seated structures
of the brain. It is also very probable, that more
than one of these different structures may lie
nearly simultaneously allerted. It may, how-
ever, originate differently when it arises from ex-
ternal injury; as in the dura mater, the substance
of the brain itself, or the arachnoid.
ITS. I. Symptoms. — A. Premonitory. Ence-
phalitis generally commences with a sense of heat
and fulness in the head; frightful dreams, and
unquiet sleep; forgetfulness; confusion of ideas;
dimness of sight; vertigo; turgidity of the face,
and eyes; and moroseness of temper. These
symptoms generally precede the occurrence of j
chills or rigors, and are entirely absent when the
disease proceeds from external injuries. In chil-
dren, unusual somnolency, or wakefulness; start-
ing^ in sleep, 'or fretfulness; aversion from sudden
or quick motion; dryness of the mouth and nostrils;
and not infrequently a voracious appetite; are the
chief precursory symptoms.
179. B. The invasion, or first stage of ence- i
phalitis, is indicated by severe chills or rigors; to
which succeed a burning heat of the head; urgent
thirst; sometimes, even thus early, an unnatural
absence of thirst, and violent delirium; jactitation
of the body; intolerance of light; fixed, pulsating,
heavy, compressing, and most severe pain of the
head, alternating frequently with stupor. Febrile
heat rapidly increases; and the head becomes
more turgid, and hotter; the eyes more promi-
nent, suffused, watery, and intolerant of light;
the pupils are contracted ; the eyelids are gen-
erally shut, or imperfectly open; the eyebrows
are knit ; and the countenance is threatening and
fierce. Hearing is quicker, is attended with ring-
ing in the ears, and intolerance of sound. Epis-
taxis sometimes occurs, generally to a small ex-
tent, and with only transitory benefit. Insomnia,
and delirium of various forms — morose, taciturn,
furious, &c. — supervene; and, in proportion as
the cerebral organs are excited, those viscera
which are supplied with the ganglial nerves are
rendered torpid, the patient being insensible to
the wants of the digestive organs.
180. C. The second, or advanced stage, is ge-
nerally characterised by a marked diminution of
the sensibility, which was in the preceding period
morbidly increased. The pulse, which was at
first frequent, hard, and full, becomes slower,
fuller, and softer; and, in some cases, quicker,
smaller, or harder. The skin is dry; the urine
scanty, and high coloured ; the tongue is dry,
and loaded at the root; the bowels constipated.
In some cases, particularly those in which the
cerebral substance is early and generally in-
flamed and turgid, instead of phrenetic delirium,
an apoplectic sopor, often preceded by convul-
sions, quickly supervenes ; with a slow pulse ;
Stertorous, slow, or laborious breathing; turgid or
-weated countenance; startings of the tendons; in-
Voluntary evacuations; torpor of the senses; and
flaccidity of the limbs. In those cases in which
delirium is present, and the pulse quick and
hard, a similar state of coma to that now men-
tioned takes place sooner or later, if not averted
by medical aid. In the one, the first stage is
short and indistinctly marked; in the other, it is
long, and often continuing the greatest part of
the whole duration of the disease ; the second
20*
stage sometimes appearing suddenly, and ter-
minating rapidly. In both these states of the
disease, the difficulty of swallowing is great, so
that fluids are sometimes regurgitated by the
nose ; and when the substance of the brain is
chiefly affected, deglutition is often nearly, or
altogether abolished in the most intense cases.
In this stage, the pupil becomes at first dilated,
and occasionally again contracted; the patient, in
some cases, squints, or has double vision ; his
speech is often much affected; and his mouth is
drawn to one side. Deafness also comes on, or
increases; and the sopor, or coma, is more pro-
found— most probably owing either to incipient
effusion of fluid, or to greater turgidity of the
capillaries and veins, or to both these combined,
in a part or the whole of the encephalon. The
comatose symptoms appear early or late, accord-
ing to the intensity of the disease, the extent to
which the cerebral structure is affected, and the
tone and energy of system. They sometimes
partially subside, again recur, or alternate with
convulsions. As the disease advances to an
unfavourable termination, the pulse becomes re-
markably quick, irregular, or intermittent.
151. D. Duration. — Encephalitis usually reaches
its acme about the third or fourth day. It then
continues in full strength for several days, exhibit-
ing slight remissions and exacerbations, and sim-
ulating continued fevers. In favourable cases, a
change is sometimes observed on the fifth, seventh,
or some other critical day, unless a fatal termina-
tion occur; and is generally attended with either
copious perspiration, or haemorrhage from the nose,
free evacuations from the bowels, or a discharge
of urine depositing a copious sediment. The
disease may assume a sub-acute or a chronic
form, presenting a diversity of symptoms, espe-
cially in its chronic state, according to the partic-
ular part of the brain affected; or it may proceed
in a very slow, slight, and insidious manner, and
escape detection until a dangerous or fatal change
has taken place. The more chronic states may
follow an imperfectly cured acute attack; and the
latter may suddenly supervene on the former.
152. II. Causes. — A. Predisposing. The san-
guineous and nervous temperaments; the epochs
of infancy, childhood, and youth — particularly to
meningitis ; the period of dentition ; advanced
age — especially to cerebritis in a sub-acute or
chronic form ; the male sex ; a large head and
short neck ; children of scrofulous parents, and
those who evince precocious talent or acquire-
ments; persons subject to perspirations or erup-
tions on the head; early or habitual exertions of
the mental powers; the indulgence of the more
active passions and affections; encouragement of
vindictive feelings; anger; continued watchings;
venereal excesses; the use of spirits, and narcotics,
as opium, tobacco, &c. ; a too warm state of the
head; suppression of epistaxis, haemorrhoids, or
of any other accustomed secretion or evacuation ;
the neglect of sanguineous depletion after the
habit has been established ; the healing up of
chronic ulcers and eruptions; and other disorders
of the brain, — are most frequently the predispos-
ing circumstances and causes of the disease.
183. B. The exciting causes. — a. Those which
act more directly on the encephalon, are blows,
fractures, falls, counter-strokes or concussions of
the head, all which may not be followed, for
234
BRAIN — Inflammation of the — Diagnosis-
many days, by any evident symptoms; whirling
children iu the air, or tossing them in order to
quiet them, or rocking them rudely in cradles;
the improper use of narcotics and stimulants in
order to quiet them; the action of the sun's rays;
protracted study; excessive joy; violent fits of
anger, excessive desire, jealousy, and all the ex-
citing passions; unusual exertion or irritation of
the senses of sight and hearing; exostoses on the
inner table of the skull ; and the absorption of
purulent or morbid matters into the circulation.
b. The causes which act more remotely or indi-
rectly, are the diseases with which I have stated
encephalitis to be sometimes complicated (§ 186.) ;
nervous or bilious headachs; all painful affections;
mania; inflammations of the ear; disorders of the
stomach, diaphragm, liver, and bowels; affections
of the sexual organs; ingurgitation and intoxica-
tion; the exanthemata, particularly when imper-
fectly developed on the external surface, or upon
the disappearance of the eruption; the metastasis
of gout, rheumatism, and erysipelas; suppressed
haemorrhages and evacuations, particularly the
menses and the urinary secretion ; the accumula-
tion of sordes and morbid secretions in the prima
via and gall bladder ; the ingestion of irritating
and narcotic poisons ; indulging in cold punch
(Frank); violent fits of coughing; long exposure
to great cold; and, according to Goelis, the two
free use of belladonna, and other narcotics, in the
cure of hooping-cough.
184. III. Diagnosis. — A. Characteristic
symptoms, a. Pain is an early sign, but the
patient often ceases to complain of it very soon,
particularly if the cerebral substance be chiefly
inflamed; when it is also gravative, and attended
with stupor from the commencement. It is most
acute when the membranes are affected, and is
always aggravated by shaking the head, and the
erect position. When the disease supervenes in
the progress of fevers and bronchial affections,
pain may not be complained of, owing to the
impure state of the blood having blunted the sen-
sibility, b. Watchfulness and sleep. — Insomnia is
generally present during the first days, when the
membranes are affected; and, in children, starting
from sleep, and screaming. Heaviness, somno-
lency, sopor, or even coma, often preceded by
convulsions, are early present when the substance
of the organ is the chief seat, or the membranes
extensively affected ; and supervene early, but
without convulsions, when the disease occurs in
the course of fevers and bronchial affections; but
a refreshing sleep is never enjoyed, unless after a
favourable change, c. The senses, particularly
sight, hearing and touch, are all morbidly active
in the first stage, especially when the meninges
are inflamed ; but they are nearly abolished at
this period, when the cerebral substance is chiefly
affected. The eye often indicates mental oppres-
sion, even when bright and staring. The sensi-
bility of the surface is unnaturally increased in
meningitis or superficial cerebritis, but is dimin-
ished when the substance of the brain is deeply
affected, and in the advanced stage, when the
membranes generally are inflamed. In partial
cerebritis, the sensibility of a limb, or part only,
is often lost, and it may be conjoined with spastic
rigidity, or paralysis, of the same or of another
part. d. The intellectual and moral faculties are
more or less disordered; they are unusually ex-
cited, or violently deranged, early in the disease;
but sopor frequently supervenes without being
preceded by this state, when the cerebral structure
is inflamed. Reverie or wandering of the mind
during night, is the least important form of mental
disturbance, indicating a slight affection of the pia
mater, extending to the cineritious substance ;
delirium through the day, and watchfulness in the
night, are the most dangerous, and attend a severe
affection of the membranes, d. The respiration
is often quicker in proportion to the pulse in the
first stage, and slower in the second; and in the
torpid or somnolent state, when the substance of
the organ seems chiefly to be affected, is often
attended by deep-drawn sighs, e. The digestive
organs are much affected, particularly in children.
There are nausea and vomiting, especially at the
commencement, and torpor of* the bowels. As
the disease advances, however, the bowels often
become free, or even relaxed, f. The muscles
and limbs are more or less pained, contracted,
convulsed, particularly in the first stage, and
when the cerebral structure is inflamed. The
convulsions are often general or severe, on the
supervention of the disease, in young subjects.
They may be soon followed by coma, which
may pass off, and the convulsions again recur,
and terminate life. When the cerebral substance
is partially affected, the spasms and contractions
may be confined to one or more limbs, whilst
the rest are relaxed; or complete paralysis may
ensue. In the last stage, muscular power is gen-
erally lost, and the limbs are flaccid, g. The
pulse is extremely variable. At first it is not re-
markably frequent; but it often becomes slower,
and again quicker than ever, and at the same
time weak, small, irregular, or intermittent. It
may be at one time either slow or frequent, and
in a few minutes the reverse ; but it is never
natural in respect of fulness, regularity, or
strength. It is generally stronger and fuller in
the carotids than elsewhere; and in this situation
it ought always to be felt.
185. B. Encephalitis may be mistaken for other
diseases; but if attention be paid to the history
of the case, and the descriptions now given, this
can scarcely happen. It may, however, be con-
founded with fevers, apoplexy, delirium tremens,
mania, and nervous headachs. a. In fevers, the
disturbance of the cerebral functions, when pro-
minently marked, generally occurs in their pro-
gress, as a complication or consecutive affection.
The pulse is always more uniformly frequent and
regular than in encephalitis; spasms, convulsions,
or paralysis, seldom occur, unless the brain be-
comes inflamed; respiration is not laborious, nor
deglutition difficult ; nor are the eyes, coun-
tenance, and speech affected, as in encephalitis.
In idiopathic fever, the muscular power is de-
pressed from the commencement, but is neither
generally nor partially affected by spasms, con-
tractions, or paralysis ; and the stomach is less re-
markably disordered. There is not observed that "
falling of the pulse from its former frequency,
afterwards followed by great rapidity, trembling,
or irregularity, which take place in encephalitis.
In fever, the general febrile symptoms are the
earliest and most apparent disease; in encephalitis,
the functions of the brain, of sense, and of the
organs of volition, are prominently and early dis-
ordered, and the febrile symptoms much less re-
BRAIN — Inflammation of the — Termination.
235
markable in proportion to the severity of the cere-
bral disease. When the coma is profound in en-
cephalitis, the beat of the whole body, excepting
the head, is either not augmented, or depressed.
The delirium in fevers also occurs at a remoter
period, and is much less violent in its character,
than in encephalitis, b. The disturbance of the
organic, and particularly the digestive functions,
the presence of fever, anil the acute character of
the disease, distinguish it from maniacal insanity.
c. The same symptoms, with the frequent addition
of delirium, of disturbance of the senses and gen-
eral sensibility, spasms or convulsions, somnolen-
cy, sopor, and paralysis, preclude the possibility of
confounding it with bilious or nervous headachs.
d. Somnolency, sopor, convulsions, and slowness
of the pulse, distinguish it from delirium tremens,
in which the spectral illusions, the remarkable
tremors, timidity; copious, clammy, fetid perspir-
ations; and the specific cause of the affection;
sufficiently characterise the latter, when occurring
in a distinct and uncomplicated form. e. The
spasmodic or convulsive symptoms, antecedent
delirium, the mode of attack, and progress of dis-
ease; the absence of paralysis, or its slower ac-
cession when the brain is inflamed, distinguish
encephalitis from apoplexy, in which the invasion
is sudden, or more rapid, and the paralysis a
simultaneous or consecutive symptom. The rela-
tion, however, between apoplexy and encephalitis
is often intimate, particularly in cases of partial
inflammation, or inflammatory softening, of the
substance of the organ.
186. IV. States, Forms, and Complica-
tions.— Besides the more or less perfect limita-
tion of inflammation to either the membranes or
the substance of the encephalon, other states may
present themselves deserving of remark, a. En-
cephalitis may result from the metastasis of gout,
rheumatism, and erysipelas, or it may arise from
the extension of the last-named disease to the
brain. In these cases the membranes are chiefly
affected; stupor and coma come on early, and
are attended with general flaccidity of the limbs,
subsultus tendinum, involuntary evacuations, and
slowness of pulse; but local cramps, convulsions,
or paralysis, are seldom present, b. The disease
may be also consecutive of other diseases, as of in-
flammation of the ears (§ 58.), of the bones of the
head or pericranium. In these cases it Ls first ex-
tended to the membranes, and afterwards to the
substance of the organ; occasioning contraction,
spasms, or paralysis of one or more limbs, or
muscles of the face, terminating in coma, or al-
ternating with stupor and general convulsions.
It may also be consecutive of severe ophthalmia,
inflammation of the parotids or testes, of the kid-
neys, of inflammation of the mucous surface of
the bowels, especially in infants, and of the dis-
eases of the lungs, c. Encephalitis may likewise
supervene on, and be complicated with, the ad-
vanced stages of continued and remittent fe-
.vers, bronchial and pulmonary affections, hooping
cough, exanthematous fevers, particularly scarlet
fever, and small pox. In all these cases the
membranes and superficial parts of the brain are
principally affected, generally in a more or less
diffused manner, occasioning first delirium, gene-
ral convulsions in young children, great pain in
the limbs, sensibility and soreness of the surface,
followed more or less rapidly by sopor, coma;
more rarely by local spasms and paralysis, in-
voluntary evacuations, rapid irregular pulse, &C.
The complication with typhoid, continued and
exanthematous fevers, especially those of certain
epidemic constitutions, is extremely frequent and
important; and have given occasion for the opin-
ions entertained by Willis, Chirac, Werl-
hoe, Reil, Ploucquet, Clutterbuck, and
Marcus, respecting the proximate cause of fe-
vers. To this complication also Turti attributes
the malignancy occasionally assumed by the re-
mittents and intermittents of the south of Europe.
When it thus supervenes on fevers and bronchial
diseases, the symptoms are often more insidious,
and of a less violent character, although the dis-
ease is equally rapid and disorganizing. This is
probably owing to the depressed state of the vital
manifestations, particularly of the organic nerves
and vascular system. Owing also to this circum-
stance, encephalitis, when thus complicated, re-
quires a modified and less depletory treatment.
Inflammation of the brain is also not infrequent
after apoplectic seizures, particularly in the part
of the organ surrounding extravasated blood. In
these cases the disease generally occurs from five
or six to ten or twelve days after the attack, and
is attended with many of the symptoms of partial
encephalitis, particularly spasms, paralysis, deli-
rium, &c.
1S7. V. Terminations and Prognosis. —
a. This is always a dangerous disease, and there-
fore a very cautious prognosis ought to be given.
The termination of encephalitis in health occurs
most frequently in persons of a sound constitution,
and who have no hereditary disposition to the
diseases affecting the encephalon. This change
often occurs on critical days, when it is generally
attended by some favourable occurrence, as a co-
pious discharge from the bowels; a genial and
universal perspiration ; a copious discharge of urine,
depositing a sediment; haemorrhage from the nose,
or the presence of the menses; a more natural
state of the pulse and respiration; a quiet undis-
turbed sleep, distinct from the oppressive somno-
lency or sopor which is one of the chief signs of
the severity of the disease; a more moist, natural,
and clean state of the tongue and gums; a decline
of the temperature of the head, and of all the
other symptoms.
188. b. A fatal termination may take place,
1st, In the inflammatory stage, owing to the very
general extension of the disease to the membranes
and substance of the organ; the pressure and in-
terrupted circulation arising from the turgescence
of the inflamed organ annihilating its functions
(§48. 167.): 2d, In a further advanced stage, from
an effusion of serum, sero-albuminous fluid, or the
deposition of false membranes (§ 21 — 28.): 3d, In
the less acute cases, and at a still more advanced
period, from suppuration or inflammatory soften-
in;; of a portion of the brain (§50 — 76.): and,
4th, This issue may proceed from any two, or the
whole, of these changes being conjoined in the
same case. The indications of an unfavourable
termination are, the persistence of the urgent symp-
toms after treatment ; violent delirium, watchful-
ness, and restlessness; profound lethargy or coma,
or the alternation of these states; violent general
convulsions, followed by coma, or alternating
with it; a morose delirium; retraction of the head;
severe pains of the limbs, followed by cramps,
236
BRAIN — Inflammation of the — Treatment.
contractions, or palsy; hemorrhage from the ears;
difficulty or impossibility of deglutition; strabismus,
or double vision; loss of speech; slowness of pulse,
followed by a sudden increase of frequency; a
trembling or irregularity of pulse; obstinate vom-
iting, particularly of a greenish fluid; singultus,
continued or recurrent; the rapid healing of chro-
nic ulcers; the appearance of the disease in the
course of other maladies, particularly pneumonia,
the exanthemata, and after apoplexy, and in the
scrofulous habit, or in persons having an heredi-
tary disposition to cerebral affections, or who
have been recently affected by other maladies.
18.9. c. The disease may pass into an obscurely
chronic form, which, together with the effects
produced by its antecedent state, may give rise to
paralysis, epilepsy, various states of mania or
mental disturbance, idiotcy, &c. In these cases,
many of the chronic changes which have been
described as occasionally found in either the
membranes or the substance of the brain, particu-
larly those which affect parts only of these struc-
tures, have taken place, as softening, abscess, in-
duration, tumours, ossific formations, &c. (§ 50.
71. 102, &c).
190. d. When encephalitis arises from rheu-
matism (Encephalitis liheumaticu, J. Frank),
the membranes, particularly the dura and arach-
noid, are chiefly affected; and the danger has
been considered, upon the whole, less than in
other states or relations of the disease. The dis-
position, however, to effusion, and to many of the
chronic organic changes described as frequently
found in the membranes, is great. It often as-
sumes a sub-acute or chronic form, and is usually
attended with great distress, but is without deliri-
um. The gouty form of encephalitis generally is
observed in older persons than the rheumatic; is
accompanied with much disorder of the stomach,
liver, and bowels, and with deficient vital powi-r;
and is hence a more dangerous state of the dis-
ease. The same remark is applicable to its oc-
currence from the extension or suppression of
erysipelas. In these, the re-appearance of rheu-
matism or gout in a joint or extremity; the erup-
tion of the erysipelatous inflammation in any part
of the surface, even in the face (J. P. Frank);
the supervention of diarrhoea, the hemorrhoidal
flux, or any other discharge; are favourable cir-
cumstances. Encephalitis,, occurring after the
disappearance of the eruption in the exanthemata,
or during the course of typhoid or epidemic fe-
vers, or pulmonary diseases, or after attacks of
apoplexy, paralysis, epilepsy, or mania, is much
more dangerous than when appearing in a primary
form, owing, 1st, to the depression of the vital and
nervous powers; 2d, to the vitiated state of tlite
circulating fluids; and, 3d, to the silent and in-
sidious manner in which the disease of the brain
often advances to disorganization in these compli-
cations. According to Hufeland, encephalitis,
supervening on the disappearance of the variolous
eruption, is generally fatal. The alterations of
s'rurture occasioned by encephalitis are fully de-
scribed in preceding sections of this article (§11,
et seq.).
191. VI. Treatment. — A. Of the idiopathic
and simple encephalitis. It must be evident that
the treatment should be the same, whether the
membranes or the substance of the brain be chief-
ly, or entirely, the seat of disease. The causes,
the age, the habit of body, and apparent state of
vital power, are circumstances which ought to be
duly considered when adopting the means of
cure, or determining upon the extent to which
they ought to be carried, a. The antiphlogistic
treatment, in all its departments, must be rigor-
ously enforced. Some discretion is, however,
required as to the extent to which it should be
carried, and the direction, choice, and adaptation
of the individual means of which it consists. In
ordinary cases, bleeding from the jugular vein;
cupping between the shoulders, nape of the neck,
behind the ears, or occiput; leeches applied in
those latter situations, and bleeding from the arm,
are upon the whole the preferable modes. Ar-
teriotomy 1 consider to be attended with no ad-
vantages; and in this I am supported by the opin-
ion of Hildenbrand and others; but bleeding
from the feet, from the hemorrhoidal vessels, and
from the groins and insides of the thighs, are
undoubtedly preferable when the disease arises
from metastasis or the interruption of discharges,
especially when conjoined with the treatment I
shall presently describe as appropriate to those
states. Hildenbrand, and several other Ger-
man physicians, recommend the application of
leeches to the insides of the nostrils, when the pa-
tient has been subject to epistaxis, or if a dispo-
sition to critical epistaxis be evinced. As to the
extent to which depletion should be carried, no
precise opinion can be given, ft should be regu-
lated according to the circumstances of the case,
and its effects upon the circulation, and be con-
ducted in the manner I have recommended in the
article on the Pathology of the Blood (§ 64.).
It ought never to be relied on alone : other means
should be simultaneously, or subsequently, em-
ployed, with the view of diminishing local and
general action, and thereby preventing the re-
moval of more blood than may be indispensable.
192. b. The hair should be removed from the
head as soon as possible, and a stream of cold
water poured upon it from time to time, or every
second or third hour, until the temperature be re-
duced to the natural standard; and, as morbid
heat soon returns, cold epithems, or evaporating
lotions, or even pounded ice enclosed in a blad-
der, should be constantly applied in the intervals
between the cold affusions, and the head be kept
elevated, and placed upon a thick oil-skin, or,
what is still better, upon a piece of common
painted floor-cloth, as long as increased action
continues, (.'old applications or affusions may,
however, be injurious if too long persisted in.
They ought never to be continued after the tem-
perature is depressed to the natural standard, or
a little below it, particularly if sopor or coma be
present; and as soon as the heat returns, they
should be again resumed. Simultaneously with
the affusion, the feet and legs should be immersed
in warm water, or in warm water made irritating
by means of salt and mustard, and the saphena
vein be opened. In some cases, particularly
when suppression of the menstrual or hemor-
rhoidal discharge has preceded the attack, the
semicupium, or hip-bath, may be substituted for
pediluvia.
193. c. The immediate exhibition of cathartics
should not be neglected. From ten to twenty
grains of calomel may be given at once, and,
three or four hours afterwards, an active purgative
BRAIN — Inflammation of the — Treatment.
237
draught, which shouid he followed by cathartic
enemata, particularly the En. Cathart. and the
En. Terebinth. (F. 141, and 150.). By these, or
similar means, a copious action of the bowels
should be procured and continued. With this
latter intention, pills calculated to promote the
abdominal secretions may be given each night, a
purgative draught the following morning, and an
enema subsequently, if it be necessary. Calomel
combined with digitalis, or with antimony, should
be prescribed in full and frequent doses, in addi-
tion to the above, so as to change the state of
morbid action, particularly when the membranes
are chiefly affected. The following, or similar
medicines, may be used, and their effects carefully
watched : —
No. 55. K Calomel, gr. iij. — x. ", Pulv. Jacobi Veri gr.
iij.; Pulv. Digitalis (vel Pulv. Colchici) gr. j. — ij. ; Syrup.
Simp. q. s. HI. 1'iaut Pihilse ij. vel iij. tertia, quinta, vel
iexla qudque hora porri°:enda;.
No. 56. 1\ Hvdrarg. Submur. gr. iij. — vj. ; Pulv. Jacobi
Veri gr. iij. — vj. ; Extr. Colocynlli. Comp. gr. vj. ; Syrup.
Simp. q. s. Fiaut Pilula? iij. hora somni sumantur.
No. 57. ]< Infus. Senna; Comp. % j-is. ; Magnes. Sul-
phatU " ij. (vel Potassa* Tart. " jss.) ; Villi Antimon. Tart.
^ ss. ; Tinct. Jalap. •" j. ; Tinct. Cardam. Co. 3 j- M.
Kiat Ilaustus, primo mane sumeudus.
194. d. In addition to these means, the fre-
quent exhibition of refrigerants and saline medi-
cines, especially those consisting of the liquor
ammon. acet., potassa nit., antimonials, &c, will
be of much service. The preparations of anti-
mony, judiciously exhibited, have a remarkable
influence in diminishing determination of blood
to, and inflammatory action in, the brain; and I
believe that the effect will be more decidedly
beneficial, if their operation as an emetic be
carefully avoided. Form. 24. 359. 406. 436. 456.
and 854. are of the ahove description, and, as
well as others of a refrigerant and diaphoretic
nature, may be employed, in small or moderate,
and frequently repeated doses. I may state, as
the result of considerable experience, that I have
found the saline refrigerants and antimonials
most beneficial during the early stage of the
disease, and where the membranes were chiefly
inflamed. In the stage of coma, or when the
substance of the brain itself is affected, and the
pulse quick, weak, small, trembling, or irregular,
antimonials are not admissible; the preparations
of camphor, with liquor ammon. acet. and spirit,
(ether, nit., being preferable. (See F. 405. 436.
441.)
195. e. Sedative and diuretic medicines, parti-
cularly colchicum and digitalis, combined with
the liquor ummonicE acet. and moderate doses
of camphor (F. 395. 400. 514.), are extremely
useful in the early stage of the disease, after de-
pletion and the free evacuation of the bowels.
In the advanced stage, however, much less ad-
vantage will be derived from them. After blood-
letting has been carried as far us may be thought
judicious, and if much restlessness and jactitation
be present, great advantage will be derived from
the exhibition of a moderate dose of camphor,
hyoscyamus, and James's powder, in this or any
Other appropriate form : —
No. 58. K Pulv. Jacobi Veri gr. iij. — v. ; Camphora?
rasa;, gr. ij.— iv. ; K\tr. Hyoscyami gr. iv. — vij. ; Svr. Pa-
pav. q. s. ut fiant Pilulae iij. statiin sumend.e et. h'. s. re-
petend.
No. 59. R Mist. Camphora- % j. ; Liq. Ammon. Acet.
5 >j- ; Spirit. ./Ether. Nit. T, ,,. ■ Tinct. Colchici Semin.
axij. — xx.; Syrup. Papavciis g j. Fiat Ilaustus, tertiis
quaxtis horis capiendus.
196. /. Derivatives and counter-irritants are
useful in many cases, when judiciously prescribed.
In the early stage of the disease, and Whilst great
irritability or delirium is present, they are often
prejudicial, excepting simple pediluvia, the semi-
cupium and hip-bath, employed simultaneously
with cold applications to the head. Great mis-
chief has arisen from ordering blisters and mus-
tard poultices too early in inflammations, but
more particularly in encephalitis, when, instead
of deriving the circulation from the inflamed part,
they excite the nervous and vascular systems ge-
nerally, and thus react upon the disease. It is
chiefly in the latter stage, when sopor or coma is
present, that benefit is derived from them. Some
difference of opinion has existed as to the part to
which they — ■ particularly blisters — ought to be
applied, if the coma be profound, some writers
have advocated the application of blisters directly
to the scalp. Without denying the possibility
of circumstances arising to justify this practice, I
believe-that they will seldom occur. The most
profound sopor, weak action of the carotids, a
not remarkably frequent pulse, and a temperature
of the head much and permanently below the
natural standard, would only induce me to apply
blisters to the scalp. When derivation can be
attempted with safety, — when sopor is present,
and morbid sensibility and irritability has nearly
disappeared, and depletion has been carried as far
as seems judicious, — a large blister to the nape
of the neck, or between the shoulders, or over the
epigastrium, mustard poultices to the insides of
the legs or thighs, or irritating liniments (see the
Liniments in the Appendix) in the latter situa-
tions, will often be used with advantage. The
semicupium, warm bath, or pediluvia, are seldom
of service when there is much general febrile
excitement, particularly in children, unless when
used simultaneously with cold affusion on the
head. But when the lower parts of the body
have their temperature reduced below the natural
standard, and when the disease has appeared
after suppressed discharges, &c.,they are often of
service, and may be made more revulsive by salt
or mustard.
197. g. Various remedies have been recom-
mended in the treatment of this disease, in a more
particular manner than others. Amongst these,
the most general I v employed and most beneficial
is calomel, when given in large and repeated doses,
and judiciously combined, and until an impression
is made upon the disease, or state of the circula-
tion. In the meningitis of children, this practice
is particularly requisite, as, without it, but little
impression will often be made on the disease;
and, with due attention, but little risk will be run
of experiencing unp'easant results from it. Where
we dread impending exhaustion, the calomel may
be combined with small doses of camphor and
ammonia, and a less restricted regimen allowed.
Marcus recommends strongly very large doses
of nitre, which may be combined with antimony,
or with diuretics; Hedgewisch, the prepara-
tions of mercury carried to the extent of saliva-
tion; Chaussier, the boracic acid, very nearly
as prescribed in F. 343.; several physicians in
Italy and in Switzerland, especially Brera,
Tom ma si ni, Peschier, Laennec, &c, large
and frequently repeated doses of the tartar-
ised antimony, so as to act upon the bowels;
238
BRAIN — Inflammation of the — Treatment.
Loefler (Hufeland's Journ. der Pract. Arz-
neik, b. iii. p. 694.), free incisions of the scalp;
and Arf.tjeus (Curat. Acut. 1. i. ch. 1.), Cel-
sus (1. iii. ch. IS.), Celius Aurf.lianus (p.
30.), and Zacutus Lusitanus (Med. Pr. Hist.
1. i. p. 85.), scarifications and cupping in the same
situation. All these are undoubtedly advantage-
ous, when judiciously prescribed. Besides these,
there are remedies which are very generally em-
ployed, and which are beneficial in certain states
of the disease only : these are, camphor, digitalis,
hyoscyamus, opium, &c. In the early stage,
camphor, unless in very minute doses, is prejudi-
cial; but when sopor or coma is present, when
depletion has been duly practised, the heat of the
head has subsided, the energies of life are depres-
sed or exhausted, and the symptoms are apparent-
ly the consequence of the lost tone of the capilla-
ries of the brain, moderate and frequently repeat-
ed doses of this medicine are almost indispensable;
particularly in the complications of the disease
with typhus, or epidemic fevers, with gout or
rheumatism. Digitalis as well as colchicum are
principally required in the early stage, when either
of them may be combined with calomel : if ex-
hibited subsequently, they should be given with
camphor, and their effects carefully watched.
Botli these medicines may be advantageously
combined with aperients or with diuretics.
Br era recommends digitalis as follows in the
earlier stages of the disease : —
No. 60. V. Pulv. Fol. Digitalis gr. xvj. ; Ilvdrarg. Sub-
nuir. gr. n. ; Pulv. Had. Glvcyrrh. ■> j. ; Olei Jnnip. q. s.
M. I'tant Pilula: viij. Capiat binas tertiis vel quarlis horis.
The combination of camphor with colchicum is
often of service in the gouty and rheumatic forms
of the disease. I found it recently of much ad-
vantage in a severe case of the latter.
8. Narcotics ought generally to be avoided;
yet there are states of the disease, chiefly in adult
and aged subjects, which are benefited by them.
\\ hen lethargy or coma, or an obvious disposition
to either, is present, narcotics are injurious, par-
ticularly in cerebritis; but when the membranes
are obviously most affected, and the disease pre-
sents much of the phrenitic character; when great
irritability, mental excitement, or exhausting
watchfulness is present, particularly after deple-
tions and other evacuations have been carried as
far its seems judicious, and the pulse has been
reduced, or become less febrile; a full dose of
hyoscyamus, or even the preparations of opium,
particularly the acetate or muriate of morphine
(F. 315. 674.), the compound, tincture of opium
(F. 728, 729.), or Battley's sedative liquor, may
be exhibited. In cases where the propriety of
having recourse to these medicines admits of
doubt, they should be combined with moderate or
full doses of camphor (F. 554. 787.), or the Spi-
ritus JEther. Sulph. Comp. (F. 375.)
No. 61. R Camphorae rasa? gr. j. — iv. ; Gum. Acacia',
Sacchar. Albi, fia ", ss. ; Magnes. Garb. })j. ; Decocti Al-
tb;ea; 5 jss. ; Spirit. yEtber. Sulpb. Comp. Tinct. Hyoscv-
ami, aa ^ j. (vel. Tinct. Opii Comp. (F. 729.) 5 ss. fit.
Fiat Ilaustus.
199. B. Treatment of the complicated states. —
There are certain consecutive and complicated
forms of the disease which require a somewhat
modified treatment, a. The rheumatic encepha-
litis, according to J. Frank, does not admit of
cold applications to the head; in other respects,
the means of cure do not differ from those already
stated. I believe that, in its advanced stage, the
application of a blister to the scalp is more likely
to be of service in this than in any other form of
the disease; and the same remark may be extend-
ed to the use of colchicum and camphor — the
latter of which may sometimes be advantageously
combined with the tartrate of antimony or James's
powder.
200. b. In the arthritic complication, after ge-
neral and local depletions, ■ — the latter chiefly on
the right hypochondrium, hemorrhoidal vessels,
and insides of the legs, — followed by active purg-
ing, stimulating and irritating pediluvia, sinapisms
and blisters applied to the lower extremities, and
colchicum combined with the sub-carbonates of
the fixed alkalies, and diuretics, are chiefly indi-
cated.
201. c. When encephalitis occurs in the course
of fevers, or when it is seated chiefly in the sub-
stance of the brain, and assumes a typhoid cha-
racter, from the depressed state of the vital powers,
either at the commencement or in consequence of
treatment, the infusions or decoctions of arnica,
senega, or serpentaria, have been recommended
by the German writers, after depletions have been
carried as far as seems prudent. When the dis-
ease is thus complicated, depletions should be em-
ployed with caution; and those which are local
and derivative ought to be preferred, revulsants
being simultaneously prescribed': cold applications
to the head require equal caution. In the early
stage of this complication, J. Frank recommends
a combination of camphor, cinnabar, and nitre,
every two hours. The first of these is amongst
the best medicines we possess in every stage of
such cases; but it should, in the advanced periods,
be exhibited in larger doses than early in the dis-
ease; and it may often be advantageously com-
bined with calomel. A similar treatment is ap-
plicable when the disease appears in the course of
bronchitis and other pulmonary diseases.
202. d. The erysipelatous complication of en-
cephalitis often requires a more antiphlogistic and
depletory treatment than the typhoid form of the
disease; but such is not uniformly the case. I
conceive that deep and large incisions into the
scalp, particularly over the occiput, as recom-
mended by Loefler, would be more applicable
to this state of the malady than to any other,
especially if there be much tumefaction of the
scalp or countenance. When encephalitis fol-
lows, or is complicated with apoplexy, the treat-
ment differs in no respect from that which has
been recommended for the primary form of the
disease. Incisions or scarifications of the scalp
may be also practised in this complication.
203. e. The supervention of encephalitis on in-
flammations of the digestive mucous surface is
not infrequent in children; and in diseases of the
liver in persons of middle age, or advanced in
life. In these cases the treatment is not mate-
rially different from that already advised. Local
depletions over the region of the liver; full doses
of calomel, so as to affect the mouth ; cold af-
fusions on the head, particularly in the former
state of complication ; external and internal revul-
sants, and diuretics; are generally indicated.
204. /. The appearance of the disease after
irritating and narcotic poiwns, particularly after
opium, aconitum, belladonna, &c, is not infre-
BRAIN — Inflammation of the — Treatment.
239
orient These occasion, first, congestion, and
afterwards mflammatory action. In encephalitis
from these substances, vascular depletions, cold
affusion on tin; head; emetics, or the introduction
of the stomach-pump; camphor or arnica, com-
bined with antimonials or aperients ; external
derivatives, and active purging; are amongst the
chief means of cure.
205. C. Of the treatment of the more unfa-
vourable and anomalous states of the disease. —
The practitioner, although he will very fre-
quently, or even generally, find the treatment
described above successful, may sometimes meet
with cases in which the symptoms persist, not-
withstanding repeated depletions and the other
remedies prescribed : the energies of life being
more or less depressed; the pulse becoming very
rapid, irregular, trembling; the coma or stupor
more profound; and the temperature, even of the
head, much diminished, lie may or may not
have had recourse to derivatives; but, in either
case, they may be continued or varied ; and
camphor, musk, valerian, ammonia, Hoffmann's
anodvne, and other restorative medicines, vari-
ously combined, maybe exhibited. If the pulsa-
tion of the carotid-, and temperature of the head,
be not in such cases increased; or if they be
diminished, and the energies of life be obviously
depressed or exhausted, both in the affected organ
arid throughout the system; the above diffusible
gtimul tnts will often be inefficacious. In this
the infusion of the flowers of arnica, or the
infusion of serpentaria, either simply or com-
bined with cinchona; camphor in larger doses,
and given occasionally with calomel and small
<1 '- - of opium : active frictions of the surface
and lower extremities with rubefacient liniments;
and in some instances, particularly if effusions
betw mi t lie membranes be suspected, with mer-
curial liniments, or inunction of the scalp ; are
the principal means that can be adopted. But if,
notwithstanding those, the above symptoms con-
tinue or increase, — the evacuations being invo-
luntary, and the patient unconscious of them ;
a vomiting, or rather a pumping up, of whatever
is taken into the stomach, with singultus, and an
intermitting, trembling pulse, that cannot be dis-
tinctly counted, being also present, — are we to
continue to give the medicines which we have
found inefficacious, thus leaving the patient to his
fate ? or are we to resort to still more active means ?
There can surely be no hesitation as to the part
which ought to be taken. In a case of this descrip-
tion, consecutive of bronchitis, in a robust man of
middle age, who was attended by Mr. Faxon, Dr.
Br e f., and myself, after depletions and cold appli-
cations had been carried as far as it was judged
prudent, and blisters were applied on the epigas-
trium and nape of the neck, without benefit, full
doses of calomel and camphor were given, the
following medicines prescribed, and their action
promoted by the enema terebinth. (F. 151.) : —
No. 62. R Mist. Camphors rasae gr. iij. ; Ammonia
Carbon, gr. it. ; htucilag. Acacia; q. s. Fiaat Pilula; ij.,
omni lecunda bora, cum Haustu sequente, sumendae.
N... 63. iv Mist. Camphors g j. ; Liq. Amnion. Acet.
~ ij--. ; Spirit. /Elher. Sulph. Coinp. 5 ss- > Tinct. Capsici
TT) vij. ; Syrup. Croci 3 s3- M.
The following draught was also given, four hours
after the exhibition of a large dose of calomel and
camphor, with the view of deriving the circulation
from the head, and of acting decidedly on the
abdominal secretions ; and was repeated every
hour until three were taken.
No. G4. R Olei Terebinth., Olei. Ricini, aa ~ ij. ; Tinct.
Capsici TT) xij. ; Olei Cajepul. TT) vj.; Aqu:e Meuth.
Virid. $ ju. M.
The pulse soon afterwards became more distinct
and regular, the bloated cast of countenance
subsided, and all the symptoms improved. The
patient afterwards quickly recovered, and is now
in perfect health. At the time the above treat-
ment was suggested by me, his recovery was
considered almost impossible. Several years ago,
1 was consulted by Mr. Harry Cox respecting
a very similar case, which was consecutive of ery-
sipelas. In this a similar treatment to that now
noticed was adopted, and the patient recovered
from an extreme state of danger. This case is
published in the twenty-third volume of the London
Medical Repository. In those states of the dis-
ease which are characterised by profound sopor,
depression of vital power, and the symptoms
above referred to (§ 180. 205.), other means
having proved insufficient, a judicious exhibition
of the oleum terebinthinae has very frequently
a decidedly beneficial effect, particularly in the
typhoid, erysipelatous, and other complications
of the disease ; and, when suitably prescribed,
will generally allay the irritable state of the sto-
mach, with which the worst forms of the malady
are often attended even during their advanced
stages.
206. The inexperienced practitioner should be
aware that the existence of profound sopor or
coma does not contra-indicate sanguineous deple-
tions or cold applications to the head, if, conjoined
with this state, the temperature of the head be at
all increased, or the pulsations of the carotids
strong or full. If these evidences of increased ac-
tion be present, those important parts of the treats
meat ought not to be omitted; but the depletions
should often be moderate or local merely; and, in
my opinion, preferably from the scalp of the occi-
put or nape of the neck, by cupping, or by deep
incisions of the former. When the disease is con-
sequent upon suppressed discharges, a derivative
intention may be had in view, and the lower ex-
tremities, the groins, the vicinity of the anus, &c...
may be selected as the situations for depletion.
In traumatic encephalitis, the fact that the dis-
ease either does not appear whilst the wound in
the scalp remains open, or is averted by a long-
continued discharge from it ; and that the worst
states of cerebritis often arise after injuries of the
head, when the external wound has readily and
prematurely healed, furnish a striking indication
of the propriety of having recourse to incisions of
the scalp in the other forms of the disease, and
to Issues and setons in the same situation subse-
quently, when their sequelaMiidicate the propriety
of having recourse to permanent irritation, with
puriform discharge, for their removal.
207. D. Treatment of the subacute and chronic
states of encephalitis, particularly in children. —
a. < die of the most frequent forms of sub-acute
inflammation of the brain is dbserved in infants,
principally affecting the substance of the organ,
and often terminating in dropsy of the ventricles.
It is chiefly characterised by want of animation,
by slight sopor, indifference to all objects, absence
of sound sleep, and a state that is different from
waking. The child is dull, but fretful and irri-
240
BRAIN — Inflammation of the. — Treatment.
table upon being roused or handled. The head
generally droops, or reclines on one side; the
countenance is usually pallid, but occasionally
irregularly flushed ; the eyes are dull, rolled
about, or turned np ; the pupils sometimes di-
lated, at other times contracted; and the infant
often utters a plaintive moaning, and occasionally
starts soon after having fallen asleep, as if pained
or frightened. The hands are tossed about or
raised to the head; the lower extremities alter-
nately extended and drawn up to the abdomen;
the head thrown backwards; and occasionally its
temperature is slightly increased, whilst the heat
of the rest of the body is either natural, or some-
what diminished. This grade of disease may con-
tinue for a long time; sometimes fluctuating, at
other times passing into either a more acute or more
chronic form, or at last terminating in dropsy;
the bowels being either relaxed or irregular, but
in either case with a morbid and offensive state
of the motions. The shades of difference observed
in this form of disease are numerous: the pulse
is very variable, as well as the appearance of the
tongue; which is, however, most frequently red
at its point and edges, and white or loaded at its
middle and base : in some of the more chronic
cases, particularly when the disease is compli-
cated with chronic disorder of the digestive mucous
surface, it has what may be called a strawberry
appearance, from the number of bright red dots
scattered over it. This variety of the disease is
often associated with torpor or imperfect func-
tion of the liver, with disease of the mucous sur-
face of the stomach or bowels, or with both ;
and occasionally with bronchitis, especially dur-
ing the period of dentition, when it often super-
venes.
208. b. Another variety of this affection is also
frequent in infants and children, and seems to be
chiefly seated in the arachnoid. Dr. W. Nicholls
has termed it sensitive erythism of the brain. It
is characterised by a morbidly increased sensi-
bility, which distinguishes it from the foregoing
variety. The child often cries without any ob-
vious reason ; is generally wakeful, lively, but
irritable; all the senses, even that of touch, are
morbidly acute, particularly the senses of sight
and hearing : it frowns, winks its eyes, or closes
them upon exposure to light; it sometimes shrieks,
clenches its hands with the thumb bent across
the palms, tosses backwards its head, and pre-
sents many of the symptoms of the preceding
form of disease; and not infrequently terminates
in effusion; but, more frequently than the fore-
going, between the membranes exterior to the
hemispheres. ,
209. c. The Treatment chiefly consists of leech-
ing behind the ears or on the occiput; frequent
scarifications of the gums ; the afiiision of cold
water on the head, or cold sponging ; calomel
purges, followed by castor oil or other cathartics,
and occasionally promoted by terebinthinate en-
eina'a ; frequent warm semicupia ; the use of
saline aperients combined with diuretics, and
strict attention to diet and regimen, with change
of air After the several active calomel purges
have been exhibited, and the evacuations have
improved, and the more obvious symptoms are
abated, small doses of hydra rg. cum creta may be
given at night, either alone or combined with a
little of the sub-carb. of soda or potash, and a
weak saline mixture through the day, similar to
the following, or to F. 440. and 441. : —
No. 65. K Magnesia; Sulphalis (vel Soda? Sulph.) 3 ij'. ;
Potassa? Fulphatis 5 j-i Aqua? Fteniculi 5 ivss. ; Spirit.
.'Ether. Nit., Viiii Antimonii Tart., Spirit. Juniper. Co.,
aa " j. ; Syrup. Srills 3 ij. M. Capiat Infans 5 j. — 5 iij.
ter quaterve quotidie.
210. When the morbid sensibility or irritability
continue notwithstanding the above treatment,
and if the child be not very young, small doses
of James's powder, and, if that fail of procuring
quiet, of the pulv. ipecacuan. conrp. may be con-
joined with the hvdr. cum creta, and given every
night ; or a little tinct. of hyoscyam., or of the
extr. conii, may be added to the above mixture.
In the soporose form of the affection, narcotics
must be avoided, but the rest of the treatment
strictly adhered to. Small doses of camphor and
nitrate of potash may also be exhibited, — if in
solution, with the spirit. a?ther. nit., and blisters
applied either to the nape of the neck or behind
the ears.
211. E. Treatment of the sequela of encepha-
litis.— After an attack of this disease, the patient
may complain of vertigo, more or less torpor or
weakness of the mental powers, cephalalgia, &c;
or of increased sensibility, and marked erythism
of the brain and whole nervous system, watch-
fulness, incapacity for mental exertion, tinnitus
aurium, languor, and pain in the limbs, &c. In all
such or similar cases, the diet should be carefully
restricted to food of easy digestion, in moderate
quantity, and consisting chiefly of the farinacea?.
Change of air, easy travelling, avoidance of all
mental exertion and anxiety, and attention to the
secreting and excreting functions of the abdominal
viscera and of the skin, will generally bring about
perfect recovery. If these fail ; or if the patient
have irregular flushings, or increased heat of
head ; or if the carotids pulsate more strongly
than usual ; the shower-bath, cold sponging the
head night and morning, and wearing the hair
closely cut, occasional local depletions, the in-
sertion of a seton in the neck; or keeping out an
eruption, in the same situation, with the tartarised
antimonial ointment; or blisters kept open behind
the ears for some time; may be prescribed.
212. When the more severe sequela? of the
disease are present, — such as cramps, pains, or
spasms of the extremities, hebetude or derange-
ment of the mental faculties, obstinate headach,
&.c, — we should suspect the existence of a chronic
state of the disease, and resort to occasional local
depletions, cold affusions, or sponging of the head;
followed by issues in the scalp of the occiput, or
the inunction of the tartar emetic ointment in this
situation; and to the mercurial preparation at bed-
time, with cooling and deobstruent aperients on
the following morning; and to the other means
above recommended. When we apprehend, from
the marked character of the ab'ove symptoms, or
from the paralysed state of particular muscles or
parts, that organic lesion has been produced, the
means now recommended should be strenuously
persisted in; and the mercurial medicines may be
pushed to slight salivation, under the favourable
circumstances of pure air and mental quiet; after
which, gentle tonics, and a more invigorating
treatment and regimen, may be cautiously tried.
213. F. The regimen during the disease should
be strictly antiphlogistic. '1 he patient's drink or
beverage may consist of either of the formula,
BRAIN — Softening or the
SYMPTOMS.
241
No. 590 — 595. 915. contained in tho Appendix;
and attention sliould be paid to the state of the
urinary dbcharge; particularly to tlie prevention
of accumulations of urine in the bladder, which
ou'dit to be removed by the catheter whenever
any interruption oi' its evacuation occurs. The
diet, and regimen generally, should be as carefully
regulated timing convalescence, as in the progress
of the disease; and attention ought to be directed
no less to the mental occupation-;, and moral
emotions, than to the natural functions, and phys-
ical employments. Care should be taken not to
carry abstinence too far in the meningitis or en-
cephalitis of infants or children, particularly after
large sanguineous depletions and doses of calomel
have been employed. The exhaustion arising
from too great abstinence, and from the treat-
ment, will often simulate effusion into the ventri-
cles; and be .mistaken for it, if the history of the
case be not carefully attended to in connection
with existing symptoms.
214. Brain — Softening of the. — Ramol-
lissement. Classif. Class, Order (Author,
see Preface.) — I have considered this change,
apart from those proceeding from inflammation,
although it is frequently a consequence of inflam-
matory action, occurring either in an acute, sub-
acute, or chronic form, and characterised by defi-
cient vital power; chiefly because I agree with
MM. Rostan, Recamier, and others, in con-
sidering that it occasionally is unconnected with
inflammation, particularly in aged persons.
215. Symptoms. — This disease takes place
slowly, and wc may distinguish in it two stages,
the recognition of which is of much importance
in the diagnosis, inasmuch as when the first period
does not exist, or when the physician cannot
obtain a satisfactory knowledge of it, it is ditlicult
to determine the particular kind of disease pres-
ent. 1st, The first period. — A. Direct symptoms,
a. of non-inflammatory softening. A continued,
and more or less severe, pain in the head is gen-
erally complained of. To some, the existence of
pain may 'appear pathognomonic of inflammation;
but, as M. Rostan has justly said, this is an in-
ference not borne out by close observation ; for
pains frequently occur, of a most severe descrip-
tion, unconnected with any form of increased
vascular action, or capillary injection. Cephalal-
gia is, however, not always present. At this pe-
riod, vertigo is oftencr complained of, and there
is generally a more or less marked diminution of
the intellectual and moral faculties. The per-
ceptions, attention, judgment, memory, and im-
agination, are more or less enfeebled ; and the
patient sinks into a species of senile mental alien-
ation. Sometimes the mental disturbance is
partial or slight, owing to the seat and limited
extent of the softening. There are observed,
moreover, slowness in the answers; some degree
of embarrassment in the motions of the tongue;
dejection and sadness of spirits ; hypochondriasis,
or an extreme indifference as to events ; great in-
clination to sleep, with prickings, twitchings, and
numbness in the limbs ; and much difficulty of
lay ing hold of objects, particularly those of small
size. The sensibility is generally diminished ;
vision is often affected, being less distinct than
usual, or partially or altogether abolished. It
very rarely happens, that unequal dilatation of
the pupils, or strabismus, occurs. The sense of
21
hearing is generally impaired. These are the chief
symptoms of non-inflammatory softening of the
brain.
216. b. If the softening proceeds from inflam-
matory action, \\v\s period is more acute, of longer
duration, and presents also certain important dis-
tinctions. The pain in the head is then more
acute and sharp ; the answers are abrupt and
quick, and there is frequently delirium: the sensi-
bility of the limbs is often increased, and the pa-
tient complains of pain in them, with stiffness,
contractions, and cramps. This affection of the
limbs may be mistaken for rheumatism, but is to
be distinguished from it by the existence of cere-
bral symptoms, and the absence of increased heat,
redness, or tumefaction. The senses evince ex-
cessive sensibility, and cannot tolerate their natu-
ral stimuli. (Rostan.)
217. B. Indirect symptoms. — a. The functions
of organic life do not present undeviating symp-
toms, and assist but little the diagnosis; the appe-
tite may be diminished, the thirst somewhat in-
creased, and digestion more or less disturbed, and
the mouth and tongue white and clammy. Some-
times there is nausea, or even vomiting, with epi-
gastric tenderness; and there may be either con-
stipation or slight diarrhoea; micturition is more or
less difficult, or involuntary ; or all these symptoms
may be absent. The following are more constant
in this non-inflammatory form of the disease : the
pulse is slower and feebler than natural, a symp-
tom which is not observed in inflammatory soften-
ing of the brain; the skin is pale, its temperature
is lower than natural, and the respiration slow and
gentle, b. In inflammatory softening, the pulse
is strong, full, or frequent ; skin hot; and there is
much thirst, with many of the symptoms describ-
ed in the section on Cerebritis (§ 164.), but gen-
erally in a sub-acute or chronic and slight form.
Thus far, the symptoms do not seem very urgent;
and they may be so slight, or so obscure, that the
patient is not induced to have recourse to medical
aid, or the physician overlooks the nature of his
ailments.
2iS. 2d, Secondperiod. — A. Direct symptoins.
a. The patient now loses the use of some limb,
or even one half of the body, either gradually or
suddenly, but generally the latter. The greater
part of the time his intelligence is but little disturb-
ed, but he answers with extreme slowness, and
is often incapable of making himself understood,
excepting by the aid of painful gesticulation. In
certain cases, either complete coma supervenes on
the paralysis, or both coine on simultaneous!}*. If
the latter, the patient often regains his recollection
in a day or two afterwards. This change seems
attributable to temporary congestion of the brain.
The symptoms, particularly the coma and para-
lysis, are increased, the mental faculties and the
powers of sense become entirely abolished, and
the patient sinks under the most complete coma.
(Rostan.)
219. b. In the inflammatory softening, in the
place of paralysis, there exist' pains, more or les*
violent, shootings in the limbs, with contractions,
cramps, or convulsions, and severe headach. In
either the inflammatory or non-inflammatory form
of the disease, when the patient complains of
pain in the head, and is asked its situation, he
carries the unaffected hand slowly to his head,
and indicates generally the side opposite to that
242
BRAIN — Softening of the — Treatment.
paralysed. In encephalitis, there is generally de-
lirium; in the non-inflammatory form of soften-
ing, the intellectual faculties are enfeebled, or
much weakened; the countenance is generally
pale, colourless, or sometimes even sunk; where-
as in inflammatory softening it is red, or more or
lo<s injected, or even tumid.
220. B. Indirect symptoms. — a. In this second
sta<*e of the disease, the organic functions are
mole or less affected: there is no appetite; the
teeth and gums are dry, the tongue rough, brown,
blackish, chopped or "traversed by small fissures:
deglutition is difficult: sometimes there is vomit-
ing, first of the ingesta, and afterwards of bile: all
the excretions are involuntary ; frequently there is
constipation : respiration is laboured, and at last
stertorous; the pulse feeble, frequently irregular
or unequal, or even intermittent, and the skin is
cold. b. In inflammatory softening there is
great thirst, redness of the tongue, sensibility of
the epigastrium and abdomen, hot skin, a strong
and frequent pulse, &c. (See § 170.)
221. The second period may be of longer or
shorter duration. The morbid phenomena often
continues stationary for a considerable period, and
then make rapid progress; at other times the pro-
gress is slight, but constant ; in some cases it is
constant and remarkable. This disease very rare-
ly retrogrades or evinces much amelioration; its
progress is essentially continued and increasing.
The anaiomical characters of softening have been
already fully described (§ 70, ct seq.). It may
be stated in general, that when it is the result of
inflammatory action, as it most frequently is, 1st,
The colour of the softened part is, more or less,
deeper than natural, or of a rose tint; 2d, It con-
tained a certain quantity of pus, sometimes infil-
trated through the softened tissue; and, 3d, Febrile
symptoms have existed previously to the death of
the patient.
222. Treatment. — It is unnecessary to add
any thing to what has been already advanced re-
specting the treatment of the inflammatory states
of softening, which are essentially the consequence
of partial cerebritis (see § 191, et seq.). When,
however, the disease does not present an inflam-
matory character, it becomes necessary not only
to enjoin abstinence from all debilitating means.
but from the commencement to apply rubefa-
cients, to throw irritants into the great intestines
(see Enem. F. 141. 150.), and to have recourse to
tonics, aromatics, &c, of which the sulphates of
zinc, iron, or quinine, in small doses, with sul-
phuric acid, or the less heating astringent tonics
belonging to the vegetable kingdom, are the most
eligible; preserving, at the same time, a regular
state of the alvine secretions and evacuations, and
of the other digestive functions.
223. Regimen. — The gently tonic, chalybeate,
and aperient mineral waters are of service in the
non-inflammatory form of the disease ; whilst
those only which are aperient and deobstruent
should be ventured upon in its inflammatory
states, when they may be tried and varied ; local
evacuations, revulsives, particularly setons, issues,
&c, being kept discharging at the same time.
In both forms of the disease, gentle travelling, and
change of air, and agreeable and quiet amuse-
ment, without undue mental excitement of any
kind, will be of much service. M. Rostan's in-
junctions under this head may be summed up as
follows: — Those alimentary and medicinal gab-
stances which exert a strong and speedy action
on the encephalon, should be strictly shunned.
Wine, spirits, cofl'ee, and spices, are of this num-
ber. Excess at the table is dangerous. The diet
should be mild and moderate, and the food easy
of digestion, but not too nutritious. The impres-
sion of cold air on the head may be favourable :
sudden passage into a heated place must be
avoided: the patient should inhabit a cool situa-
tion. Whatever, by compressing the limbs or
the organs contained in cavities, may favour
cerebral congestion, must be rigidly proscribed.
Warm, as well as cold bathing should be inter-
dicted: tepid bathing alone may be permitted, al-
though with much caution. Cold lotions to the
head are advantageous in the inflammatory form
of the disease, provided we do not permit reaction
to be established; at the same sime pediiuvia con-
taining mustard may be prescribed. The oidina-
ry excretions should be kept up; but sexual indul-
gence, too violent exercise, strong emotions, long
study, and watching, should be carefully avoided.
The age, strength, constitution, habits, and state
of the patient, and the character cf the symptoms,
must modify these precepts.
Biblioc. and Refer. — I. Diseases of the Mem-
BRANES OF THE BRAIN, tc. i. ALTERATIONS OF THE
Dura Mater. — Holler, Opera Minora, vol. iii. p. 863. —
Burdock, Beitrage. b. i. p. 87. — Gilbert, in Eilin. Med. and
Surg. Journ. No. 95. (Dura mater absorbed and wasted.).
— Otto, Anat. Pathol, ice. ; and Bonetus, Sepulchret. Ana-
tom. vol. i. p. 41. (Dura mater thickened, to half an inch.).
— Lieutaud, Hist. Anatom. Med. vol. ii. I. iii. obs. 3. 16.76.
165.; et Trecourt,3 urn. de Med. t. vi. p. 189.; and B.
Brcr.cn, Lond. Med. Repos. edit, by Copland, vol. xvii. p.
108. (Dura mater dry, shrivelled fyc.). — Gendrin, Histoire
Anat. des Inflam. 8vo. Paris, 1826. (Melunoid deposit in
dura mater.). — Ludnrig, Adversaria Med. Piact. vol. ii. p.
459. ;etj. P. Frank, DeCurand. Horn. Morli. 1. vi. p. 161.;
et Voigtel, Handbuch, kc. h. ii. p. 9. (Water between the
bon*s and dura mater in hydropic children.). — Biermayer,
Museum Anatom. Palholog. No. 94.; et Kilian, Anat.
Untersuchung, &c. p. 127. ; and Lobstein, Comple rendu
sur les Travaux Anatom. t. i. p. 56. (Layers of dura matt r
separated by blood, coagula, and pas.). — Stanley, Med.
C hiring. Society's Trans, vol. iii. p. 24. (Duru mater burst
during coughing seven months after trepanning.) — Boeh-
mer, De Ossificatione Duras Matris, &c. 4:o. Hafa>, 1704. — •
Velten, Casus aliquot Ossificat. in Merabr. Cerebri invent.
Linn. 1825. — Loder, Observat. Anatom. Tumoris S
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\
BRAIN — Diseases of the — Bibliog. and Refer.
243
Brain, ic. Edm. 1828. — Men™, Morbid Anatomy of the
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'hit r, Anatomie Pathologiquc, 8ierue livr. Paris, 1830.
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CEREBRitis. Inflammation, and its Consequences, $c —
,/. ('. Brendelii, Resp. Ellenbergeri ds Phrenitide. Goet,
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— (.'. G. Frank, in Ephenj. Nat. Cur. dec. ii. an. vi. obs.
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— Syme, in Ed. Med. and Surg. Journ. July, 1828. (On the
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to abscess in different parts of the brain, some of them in
connection with inflammation of the internal ear, othei • p iss-
ing through fistulous openings in the skull, see the article
urn in Ploucquet's Medicina Digesta, and Otto's
Compendium of Pathological Anatomy.
iii. SOFTENING. Rostan, Rcch. sur un Maludie encore
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ii. Paris, 1827. — Cruveilhier, La Med. Eclairee par ['Anat.
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Prat. t. vii.
iv. Sphacelus. Lysa-us, De Sphacelo Cerebri. Lips.
1656.— M. Cristin, Revue .Med. t. ii. p. 302. 1825.— Greet-
ing, Sanuntl. .Medic. Schrift. b. i. p. 306. Gangrene is ob-
piouslj a post mortem change, as death must take place before
it could supervene as a consequence of acute inflammation,
v. Hypertrophy. Holler, Element Physiol, vol. iv. p.
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p. 335. — Penchienati, in M. m. de Turin, vol. iv. p. 118. —
Meckel's Handbiich iter Pathol. Anat. b. i. p. 29.:. — A' oil-
in Archives Gen. de Mid. t. vii. p. 31. — Otto, in
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Sri, -a. Med. t. xi. p. 232.— Jadelot, in Journ. de Mi ;d. t.
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\i. Hypertrophy of Pineal Gland. Manget, Theat.
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x\i. 24.— Lu.utaud, Hist. Anat. Med. 1. iii. obs. 177—210.
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— Blane, Trans, of Soc. for Impi ov. Sic. Loud. vol. ii. p. lti.
\\i. Hypertrophy, Sec. of Pituitary Gland. De
Haen, Rat. Med. vol. vi. p. 271.— Greding, p. 282.— Horn'*
Archiv. f. Med. Erfahrung, 1815, par. iii. p. 463. — Baittie,
.Morbid Anat. 4to ed. p. 160.— Oppert, De Vitiis Nervorum
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den Hirnanhang fallsiichtiger Personen, 4to. Mainz, 1810,
p. 74.; el de Penit. Struct. Cerebri, p. 114.
viii. ATROPHY. Willis, Cerebri Anatom. in Opera Omnia,
4lo. Amst. p. 14. — Morgagni, Epist. ix. 20., xi. 11., lx. 4. —
Roederer, Observ. de Cerebro, p. 5. Got. 1758. — Sandifbrl,
Museum Anatomicum, vol. iii. p. 365. — Otto, Selt. Beob.
part i. p. 106. — Kaltschmid, in Holler's Disput. Pathol, vol.
vii. p. 484, — Mier, in Samml. Auserl. Abhandl. Ii. xi. p. 214.
— Meckel, Anal. Phys, Beobach. und Lfntersuch. he. p.
135. 1822.— Glover, in Philad. Med. Journ. vol. ii. p. 1.—
Saversey, De la Fievre Jaune, p. 158. — Horn, Archiv. f,
Med. Erfahrung, b. xxii. — Biermayer, Mus. Anat. Path.
No. 247. — Wenzel, De Penit. Cerebri Structure, p. 102. et
136. — Cazanvieilh, Ai chives Gen. de Med. t. xiv. p. 582.
ix. Induration. Morgagni, Epist. viii. et seq., Epist.
Ixi. 8. — Meckel, in Mem. de I'Academ. de Ber in, 1766. —
Lallemand, Opus Cit. lclt. ii. et iii. — Portal, Cours d' Ana-
tomie Medicale, t. iv. p. 90. — Pinel, fils, Recherches d' Ana-
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veux. Paris, 1822. ; et Recherches sur les Causes Physique
de 1' Aberration Mentale, in Magendie's Journ. de Physiolo-
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Physik. p. 332. April, 1828.— Bouillaud, Sur l'lnduratiou
Generate de la Substance de Cerveau, consideree comme
un des Ell'ets de l'Encephalite Generale Aigue, in Archives
Gener. de Med. 1825. — Abercrombie, On the Diseases of the
Brain, -^c. 2d edit. Case 18. — Craigie, Elements of General
and Pathological Anatomy, p. 438. Edin. 1828.— Andral,
Anatomie Pathologiquc, he. t. ii. — Hooper, Morbid Anato-
my of the Human Braiii, 4lo. p. 16. Lond. 1828.— Bright,
Medical Reports, vol. ii.; and Diseases of the Brain and Ner-
vous System, p. 664. Lond. 1831.
x. TUMOURS. In the Substance of the Brain. — Mor-
gagni, Epist. Iii. 15. (Scirrhus in cerebellum.). — Meckel, in
Mem. de 1'Acad. de Berlin, 1754. p. 74. (Scirrhus); Ibid.
1761, p. 61. (Scirrhus cerebelli); Ibid. 1764, p. 84. (Stir-
rhus.).— Hatter, Oper. Minora, vol. iii. p. 282. (Scirrhus
cerebri/:.). — -Bauder, in Sandifbrt's Thesaurus, vol. iii. p. 33.
(Fatty.). — Gendrin, Sur les Tubercles du Cerveau et de la
Moelle, i.c. 8vo. Broch. Pari-. — Zinn, in Com. Soc. Reg.
Scient. Gutt. vol. ii. 1752. — Liveitte, Recherches sur les
Tubercle- du Cerveau. Paris, 1824. — Burdach, Vom Baue
u. Leben des Gehirns, b. iii. p. 543. — Chomel, in N uv.
Journ. de Med. Mars, 1818. p. 1.— .Rose, in Lond. Med. Re-
pos. i\o. Ixi. p. 12. — Datham, in Med. and Phvsical Journ.
Julv, 1826. — Bouillaud, Traite de l'Encephalite. Paris,
1325. (Scirrhus.). — Cruveilhier, in Nouv. Biblioth. de Med.
Nov. 1825.; ct Anatom. Patholog. liv ii. pL vi. (Fatty tu-
mours.).— Hawkins, in Med. and Phys. Journ. Julv, 1826.
— Horn, in Archiv. f. Med. Erfah. March and April, 1313,
p. 238.— JYysten, in Bullet, de la Facult. de Med. 1316, p.
133. — Biermayer, Mus. Anat. Patholog. No. 74. (Scirrhus.).
—Meckel, in Archiv. f. d. Physiol b. iii. p. 190. (Fatty.).—
Tueheron, Rech. Anat. Path. vol. iii. p. 45. and 381. (Tu-
bercles).— Ward, in Lond. Med. Repository, vol. xx. p. 217.,
and April and June, 1824. (Pituitary gland, and in cere-
bellum.).— Bellmer, De Cerebelli Degeneratioiiibus. Bon.
1325. (Tubercles, (f.). — Berg. De Tumor, et Ossificat.
Cerebelli. Lips. 1826. (Osseous, 4fC.). — Bergmann, in Mcn-
de's Be ib und Bemerk. &c. b. iii. Gutt. 1826. (Calcareous.).
—Mayer, De Tumoribus Cerebri, 4to. plates. Berol. 1829.
—Otto, Selt. Beobach. parti, p. 107., part ii. p. 9 1. Stc,
(Fight instan &s, scrofulous anasteatomatous.). — Scheidcr,
De Encephali Destructione, Jtc. Berol. 1823. (Steatomatus.).
— Fantoni, Opuscul. Med. et Phvs. p. 22. (Hygroma.). —
Berdot, Acta Helvet. Phys. .Med. vol. v. p. 183. (Hygroma.).
— Portal, Anatom. Med. vol. iv. p. 41. (Hygroma.). — Rent-
dorf, De Hydatidibus i i Corp. Human, praes.in Cerebro re-
pertis, p. 36. Ber. 1822, — Bailey, in Lond. Med. Repos.
Feb. 1826.— Olio, Verzeichu. No. 2891. (Fatty tumour in.
the hemisphere, containing hair.). — Ozanam, in Journ.
Compl. in. du Diet, des Scien. .Mid. t. xix. p. 189. (2V
bercles.). — Wardrop, On Fungus ILemalodes, tac. passim.
(Fungus hamatodes.). — Hunter, Trans, Med. Chirurg. Soc.
vol. xiii. p. 1. and 38. (Medullary sarcom.). — Rambelli,
Archives Gen. de Mid. t. xvii. pi 97. (Scirrhus.). — Dufour,
in Ibid. t. xvii. p.242. — We lemeyer, in Rev. Med, t i. p. 134.
1826.— Bally, in Ibid. t. iii. p. 35. 1224. (Cysts in.).— Otto,
SelL Beobach. part ii. p, 90.; and Verzeichu. &c. (Three
eases of fungus hamatodes.). — Height, Medical Reports,
vol. ii. p. 688. — Abercrombie, On the Diseases of the Brain,
he. p. 428.— Calmiel, Journ. Hebdom. de Med. t. i. p. 44.
(Hydatids.). -
xi. Rupture of the Brain. Meckel, Vora Hirnhruche,
244
BRONCHI AND AIR-PASSAGES — Alterations of the.
in Haadb. der Pathol. Anatom. t. i. p. 302.; Ibid, in Archiv.
Cur die Physiologie, vol. vii. p. 139.; el Rat/tire, in Ibid. t.
vii. p. 431. — Walter, Museum Anatom. Berol. 1803. p. 275.—
Osiandt -.'(■, in Gutting. Gelchst. Anzeiger, 1812, No. cxxxix.
Beclard, Bulletin de la Faculte de .Med. t. iii. p. 292.—
Autenreitlu in Tubinger Blattern, vol. ii. p. 273.— Palleita,
Exercitatioues Pathologic*, t. i. p. 127. — Ehrmann, in Re-
pertoire Gen. d'Anat. &c. Phvs. Pathol, t. iv. p. 25. — Mar-
tini, in R.'pertorio Medico-Chirurgico di Torino, No. lix. —
Otto, iii Sell. Beobach. part ii. p. 157. — Billurd, Traite des
Maladies des Enfans Nouveau-nes, &c. 8vo. Paris, 1828. —
Merye, in Archives Gen. de Med. Jul. 1827. — Geoffrey St.
Hi! aire, in Ibid. Julv, 1827. ; et Philosophic Anatomique.
Paris, 1822.— Me kef, in Pathol. Anatom. vol. i. p. 292. ; et
Archiv. f. d. Physiol, b. vii. p. 99,— JEarle, in Medico-
Chirurg. Soc. Trans, vol. vii. p. 427. — Stanley, in Ibid. vol.
viii. p. 12.— Thompson, in Loud. Med. Rcpos. Nov. 1824.—
Workman, in Ibid. vol. iii. No. xviii. — Spalding, in New
Eng. Journ. of Med. and Surgery, Jan. 1820.
xii. Laceration. Arnemann, Versuche iiber das Gebirn
und RQchenmark. Got. 1787.— Burdach, Vom Baue und Le-
beo des Gehirns, b. iii. p. 501. — Cop/and Hutchison, Pract.
Observat. on Surgery, Treat. 4. — Brodie, in Med. Chirurg.
Trans, vol. xiv. Lond. 1828.— Otto, Verzeichn. No. 2891. _
xiii. Alterations of Colour. Sto//, Ratio Medendi,
vol. iii. p. 11. — Lallemand, Recherches Anat. Patholog. sur
l'Encephale et ses Depend. Paris, 1 824-29.— Billurd, in
Archives Gen. de Med. t. ix. Dec. 1825. p. 492.— Bright,
Medical Reports, vol. ii. part ii. p. 670.
BRONCHI, Diseases of the. Syn. Boov/o:,
Gr. Bronchus, Bronchia, Lat. Bronche, Fr.
Die Luftrohreniiste, Gei\ Bronchi, Ital. Air-
passages, Air-tubes, Eng.
1. Bronchi and Air-tubes — their Altera-
tions. Under this head, the alterations of struc-
ture usually found in the air-tubes, from the la-
rynx to the smallest subdivisions of the bronchi
will be first considered, and subsequently the his-
tory of such of them as are more immediately
seated in the bronchi, and are not treated under
distinct heads, where some of them are placed,
owing to their specific nature, and their relations
to other parts.
2. I. Alterations of Structure in the
Bronchi. — As the same lesions are found in the
larynx and trachea, as in the bronchi, although
certain of them are more frequent in one part
than in another, no particular distinction depend-
ing on locality merely will be made, in order that
repetitions may be avoided.
8. i. Alterations of the Mucous Mem-
brane of the Air-passages. — 'These are
the same in kind from the glottis to the air-cells,
whether the vascularity, the structure, or the se-
cretions of this membrane, be individually or col-
lectively changed. A. Passive or simple conges-
lion of this surface is not unfrequently found after
death ; and there is every reason to believe that
it may take place during life, or at the moment of
death, or even be a post mortem change. When
occurring during life, it is most frequently met
with in the debilitated, and when the return of
blood to the left side of the heart has been im-
peded. Simple congestion of this membrane may
be either partial or general. When general, and
at the same time suddenly and intensely formed,
it may terminate life with all the symptoms of
asphyxy. (See Congestion of the Bronchi.)
In a slighter form it accompanies various diseases,
particularly the febrile exanthemata ; but it is sel-
dom found in a chronic form. Congestion of this
membrane presents various depths of shade,
varying from a dirty pale red, or a brick red, to
a brownish or purplish hue ; being sometimes
equally deep throughout, in others of a different
shade in different situations.
4. B. Inflammatory injection, or active conges-
tion of the bronchial surface is generally partial,
or affects one part of the air-passages more than
another. It is also of a livelier colour, and is
usually attended with some of the changes here-
after to be noticed. Partial or inflammatory
redness of the mucous membrane is very much
more common than general congestion. It may
be limited to the trachea and larynx, whilst the
bronchi are pale ; and in this case it may be con-
fined to one side of the tube. M. Andral has
seen it cease abruptly at the medium line, par-
ticularly when one lung was affected ; and then
the inflamed side of the trachea has corresponded
with the diseased lung. The redness may also
be confined to the large bronchi, the mucous
surface of the passages above and below its seat
being pale ; or it may be limited to the smaller
bronchi, where it often occasions great dyspnoea
and fever, with little or no cough. According to
M. Broussais, the bronchi of the upper lobes are
most frequently congested and inflamed. Con-
gestion and inflammatory injection of the bron-
chial mucous membrane, although very often
connected with diseases of the substance of the
lungs, are not necessarily dependent on any of
them ; for this membrane may be pale from the
glottis downwards in cases of acute, and still
more in chronic, pneumonia. The same obtains
in respect of tubercles, previously to their soften-
ing. In many cases, however, where tubercles
exist in the lungs, the surface of the smaller bron-
chi are more or less inflamed or congested ; and
when the tubercles have advanced to softening,
the bronchi nearest them are almost always red.
Where tubercular excavations exist, the redness
is still more marked and extensive, sometimes
proceeding along the trachea to the larynx :
bronchitis thus supervening to tubercular phthisis.
In these and various other diseases, the inflam-
matory state of the mucous surface commences in
the smaller ramifications, and spreads upwards to
the glottis. But in other maladies, particularly
those which first affect the Schneiderian mem-
brane, throat, fauces, pharynx, &c, the injection
of the bronchial surface is chiefly an extension
of these ; inflammatory action more frequently
originating in some one of these situations, and
extending itself more or less rapidly, according to
the state of the patient, along the surface of the
larynx, trachea, and large bronchi successively,
until it at last reaches the minute bronchi, or even
the air-cells and structure of the lungs. This is
the usual direction in which inflammation of the
mucous membrane of the air-passages commences
and extends itself ; but most frequently without
reaching the smaller bronchial ramifications, and
pulmonary parenchyma.
5. C. Thickening of the mucous membrane of
the air-passages is a very common lesion, arising,
1st, from its congested or injected. state ; and, 2d,
from its increased nutrition or hypertrophy, a.
The former is most frequently observed in the
larynx and small bronchi : it is sometimes found
in children about the margin of the glottis, giving
rise to a form of croup, b. True thickening, or
hypertrophy of this membrane, occurs in various
situations, occasioning very different phenomena
accordingly, particularly in those who had been
affected with chronic coughs. This form of thick-
ening may extend throughout the larynx, or may
be limited to the epiglottis, to the entrance of the
glottis, to the chorda.1 vocales,or to the ventricles.
BRONCHI AND AIR-PASSAGES — Alterations of the.
245
In the trachea it may occasion no marked symp-
tom; but in the bronchi, particularly the smaller,
it wives rise to sensible alterations of the sound of
the pulmonary expansion. It may, when exten-
sive, very materially impede the changes produced
bv respiration on the blood. Hypertrophy of this
membrane may also be confined to a circumscrib-
ed point, forming thus a tumour rising above the
surrounding surface. This form of thickening may
assume a nearly cauliflower appearance, from its
exuberance. These excrescences have been found
in the larynx by MM. Andrai. and Fkrrus.
(i. The mucous follicles may be enlarged inde-
pendently of the membrane in which they are
seated. When this is the case, a number of
round granular bodies, of either a white, red, or
dark brown colour, are found on the internal
surface of the membrane, surrounded by two
coloured circles — one round the centre, the other
round the base. M. Andral thinks that they
have often been mistaken for tubercles, and for
die variolous eruption.
7. C Other alterations of structure in the re-
spiratory mucous membrane. — a. Atrophy is said
by Andrai. sometimes to be observed in this
membrane, b. Softening is much more frequent;
and is most common in the larynx, especially in
the situation of the chorda? vocales and ventricles,
where it is sometimes very remarkable, and lias
been the only change of these parts observed in
persons who had either Lost their voice or been
hoarse long before death, c. Ulceration is not
infrequently found in this membrane. Ulcers
may be seated in any part of the air-passages,
but are more common in the larynx than in the
trachea or bronchi. They rarely, however, occur
in the larynx, without tubercular ulceration exist-
ing also in the substance of the lungs. They
occasion various modifications of the voice, ac-
cording to the parts of the larynx in which they
are situated; being found in every point of its in-
ternal surface. Their size and number vary ex-
ceedinglv. Sometimes only one very small ulcer
is found, the rest of the larynx being in all other
respects quite natural. In other cases, this part
is nearly destroyed by numerous ulcers of various
shapes and sizes; and in some cases, one large
ulcer extends over one half or more of the larynx.
i leers, when seated in the trachea, are chiefly
found in its posterior or membranous part. M.
Andral states, that in some cases they are con-
fined to one side of the trachea, which invariably
corresponds to the diseased lung; or, if both lungs
be diseased, to that which is most atiected. Ulcers
are not so frequent in the bronchi as in the larynx,
but more so than in the trachea.
8. Ulcers in the internal surface of the air-
passages sometimes extend no deeper than the
cellular tissue connecting the mucous membrane
to the subjacent parts. In this case the con-
necting tissue is much thickened at the bottom of
the ulcer. But they frequently proceed deeper,
destroying successively the different tissues, until
tin' parietes of the tube are at last perforated, and
a fistulous opening is formed between it and some
neighbouring organ or part, as the oesophagus,
aorta, parenchyma of the lungs, large blood-
vessels, the pleural cavity, &c., or even the ex-
ternal surface; forming, in this last case, a direct
communication between its interior and the ex-
ternal air. When a fistulous opening extends into
2i*
an excavation in the parenchyma of the lungs, it
is difficult to determine whether it produced, or
was itself occasioned by, the excavation. When
it is connected with a cavity arising from the
liquefaction of tubercular masses, there can sel-
dom be much difficulty in determining the prece-
dency; but every cavity found in the lungs has
not tins origin. There can be no doubt that ul-
cers perforating a bronchial tube may excite in-
flammation of the substance of the lungs, and
occasion either small abscesses, or ulcerations,
which enlarge into considerable excavations.
But, in the majority of cases, excavations com-
municating with the bronchi arise from the soft-
ening of tubercles; the bronchi being perforated
from without inwards, instead of from within
outwards, as in the case of ulceration commenc-
ing in their mucous surface. The bronchi or
trachea may be also perforated from without in-
wards, by aneurisms, &c of the aorta, and not
infrequently by ulceration commencing in the
oesophagus and extending through the membran-
ous part of the trachea; an instance of which I
lately had an opportunity of seeing in a patient
of my friend, Mr. Byam. Suppurated bronchial
glands may also perforate the bronchi which they
surround, and pour their contents into them. A
similar result may likewise occur from purulent
collections, hydatid formations, &c. of adjoining
parts, as of the thyroid gland; instances of which
are recorded by Portal and Andral.
9. D. Alterations of the secretions of the air-
lubes.— M. Andral has very justly stated that
alterations may occur, 1st, in the gaseous secre-
tion; 2d, in "the perspiratory exhalations; and,
3d, in the mucous secretion, a. Changes of the
gaseous exhalations are but little understood, and
are more matters of inference than of demonstra-
tion. There can be no doubt, however, that not
only in various diseases, but also in certain states
of the system and of the atmosphere, a very ma-
terial alteration occurs in the proportions of the
different gases naturally exhaled by the mucous
surface of the lungs. That the successive changes
in the system, certain conditions of temperature
and of the air, different states of vital energv,
and the constitutional differences in the various
races of our species, modify very materially the
quantity of carbonic acid gas and of azote exhaled
from the lungs, may be considered amongst the
surest established facts in physiology. (See my
Notes, fyc. p. 620*. ) Such being the case, it may
reasonably be inferred that marked alterations of
the gaseous exhalations also take place in disease.
10. b. The perspiratory exhalations evidentlv
undergo changes in disease; but their nature and
extent are but little known. The vapour exhaled
from the respiratory mucous surface very probably
may, when excessive, be condensed into a liquid
state, and increase the watery fluid sometimes
discharged from the lungs. M. Alibert states
that he has seen, in certain diseases of the skin in
which the cutaneous transpiration is suppressed,
the pulmonary vapour issuing like steam from the
chest, and descending again like an abundant dew.
M. Andral adduces, in his Clinique Medicate,
the case of a person who suddenly discharged,
whilst suffering from hvdrothorax, an enormous
quantity of a serous fluid from the bronchi, at the
same time that the fluid which had been effused
in the chest was absorbed.
246
BRONCHI AND AIR-PASSAGES— Alterations of the.
11. c. Alterations of the mucous secretion of
the bronchi have been successfully studied by a
number of modern pathologists, but more par-
ticularly by M. Andral. This secretion is mo-
dified both in its quantity and quality. It is often
very greatly increased in acute and chronic affec-
tions, particularly those immediately affecting the
respiratory passages; under which heads the prin-
cipal changes of this secretion, with the different
states and stages of disease, are described. The
quantity of the mucous secretion may be so ex-
cessive as to nearly fill up the bronchi, trachea,
and larynx, and to suffocate the patient. This
sometimes occurs in adults; but, I believe, still
more frequently in children, forming in one of its
states a species of croup intermediate between
true croup and bronchitis; and, in another state,
the disease hereafter described as asthenic bron-
chitis. M. Blaud considers the former, or that
seated chiefly in the large bronchi, in which the
secretion is consistent and glairy, a " form of
croup, and calls it croup myxagene." This ex-
cessive secretion of mucus is sometimes unattend-
ed by any alteration of the air-pnssages. The
mucous secretion may become so viscid as to
adhere to the sides of the bronchi; where it may
accumulate so as to occasion a fatal dyspnoea, by
preventing the passage of the air. In other cases,
the mucus is transformed into a puriform fluid;
sometimes without any trace of ulceration, or
even of redness, in any of the bronchi ; the
alteration of the secretion being independent of
any perceptible change of structure. More com-
monly, however, patches, streaks, or points of
inflammatory injection of the mucous membrane
accompany this state of secretion.
12. d. J\Iemhraniform concretions, or false
membranes, form more frequently upon the in-
ternal surface of the air-passages than in any other
mucous canal. Some pathologists have supposed
them to be consequent on the most intense states
of inflammatory action in mucous membranes ;
but this is evidently not the case: they are rather
a result of a certain state of the system, probably
connected with excess of the albuminous con-
stituents in the blood, together with a disposition
in the inflamed vessels to secrete it. (See art.
Croup.) These membranes are generally un-
organized, and vary in thickness and consistence
in different parts as well as in different cases.
According to Schwilguf, they consist of albu-
men, with a small portion of carbonate of soda
and sulphate of lime. M. Bketonneau has de-
tected fibrine in them. They may exist in patches,
or in continuous layers, or in perfect tubes; and
extend from the larynx, where they usually com-
mence, to the minute divisions of the bronchi.
They rarely originate in this latter situation, and
advance upwards; but they often commence in
the pharynx, fauces, &c, and extend through the
glottis, and down the trachea and bronchi. They
are most frequently met with in children from
two years of age to puberty; and are not con-
fined to, although most frequent in, acute diseases.
In some cases they assume, in children, a chronic
character, but only when confined to the trachea;
whilst a chronic state is most common in adults,
when they are usually formed in the bronchi.
When, however, they occur in the larynx, the
tumefaction of the subjacent membrane, the
spasms of the muscles, and their own thickness,
often give rise to an acute or fatal disease. When
seated in many of the small bronchi, they may oc-
casion asphyxy by interrupting the changes pro-
duced by the air on the blood. It is probable
that fibrinous or polypous concretions may some-
times form in the bronchi, from the coagulation
of a portion of blood exhaled from its mucous sur-
face. Laennec has described (Riv. Mid. 1824,
t. i. p. 384.) a case which appears to be of this
description. Such formations differ from the albu-
minous exudations, in their containing much fibrine,
and being of a darker colour than the latter.
13. e. Earthy or calcareous concretions occa-
sionally are found in the air-passages, and are
sometimes coughed up. They consist chiefly of
phosphate of lime; and are formed either in the
substance of the lungs, and escape into the bronchi,
or in the latter; but more probably in the air-cells.
They have also been found impacted in the ven-
tricles of the larynx. The cause of their forma-
tion is not well understood. They have been
ascribed to chronic irritation of the small bronchi
and air-cells; but this source is by no means well
established. I have met with them in gouty
persons, by whom particularly they are often ex-
pectorated during life, recovery generally taking
place. Hydatids have also been found in the air-
tubes. In some cases they may have been de-
veloped in this situation; but they much oftener
escape into it from contiguous parts.
14. f. Hemorrhage from the respiratory sur-
faces are amongst the most frequent changes to
which it is subject. In the greatest number of
cases of hemoptysis, the blood is exuded without
any ulceration or breach of surface: a slight redness
of the mucous membrane being the onlv change
that can be detected. When the haemorrhage oc-
curs-in the smaller bronchi, the blood sometimes
accumulates and coagulates in them; imparting
a blackish or brownish black appearance to the
lobules, and constituting the pulmonary apoplexy
of Laennec. The occurrence of haemorrhage
into the parenchyma of the lungs is, however,
more strictly deserving of this appellation. The
extravasation and coagulation of blood in the small
bronchi, giving to portions of the lung a blackish
and indurated appearance, are most commonly,
but not always, found in persons who have ex-
pectorated blood, or died from an attack of hae-
moptysis; and are most frequent in those cases
which supervene in the progress of diseases of the
heart. M. Andral considers, however, that the
haemoptysis is not from those sources which have
been called apoplectic; but from a larger extent of
mucous surface, and from larger tubes. (See art.
Lungs — Alterations of, and Hemorrhage from.)
15. ii. Alterations of the other Struc-
tures COMPOSING THE AlR-TU.BES. A. The
fibrous and muscular tissues of the air-passages
experience various changes, a. The fibrous struc-
ture of the bronchi are sometimes found either
softened or hypertrophied. The thyroarytenoid
ligament is occasionally softened. It has then
lost its brilliant colour, become opaque, or even
changed into a cellular-like tissue, or an unorgan-
ized pulpy substance, leaving the thyro-an tenoid
muscle exposed. In this case the voice is remark-
ably altered. When the fibrous tissue is hypertro-
phied, increase of thickness is the chief appearance.
(Andral.) b. The muscular structure, as it ex-
ists in the trachea, &c, may be either atrophied
BRONCHI AND AIR-PASSAGES — Alterations ov the.
247
or hypertrophied; it may also be softened and
destroyed partially or in points by ulceration (§7,
8.)- Cut it is chiefly when- this structure as-
Bamea a different state and function, as in the
larynx, that it undergoes marked alterations, giv-
ing rise to the most formidable and fatal diseases.
The muscles of the larynx are, in some of those
cases, softened, more or less atrophied, or even al-
together destroyed; and, in others, infiltrated with
either purulent or tubercular matter. (Bouil-
laud, Andral, and others.) M. Andral
states, that he has more than once observed, on
examining the larynx of persons who had been
long completely without voice, the thyro-arytenoid
muscle either remarkably atrophied, or its fibres
infiltrated by different morbid secretions; this
being the only lesion that could be detected.
16. B. Thecartilaginous structures of the air-
passages are most frequently diseased in the
larynx. The cartilage of the epiglottis sometimes
loses its natural form : it is scarcely ever ossified ;
but it is occasionally somewhat indurated, so that
it imperfectly protects the opening of the larynx.
It is not infrequently destroyed altogether by ul-
ceration, commencing either in itself, or in the
tissues enveloping it. Similar changes to these
sometimes take place in the other cartilages of the
larynx. Ulceration of these cartilages may be
superficial only; or it may destroy more or less
of their structure. It generally commences in
the soft parts covering them; but in some cases,
particularly of constitutional taint, there is reason
to suppose that it originates in inflammation of
the cartilages themselves, terminating in the ul-
cerative process, and the formation of purulent
matter in the soft parts adjoining, which escapes
by a fistulous opening, generally through the mu-
cous surface into the larynx, and rarely externally.
Ulceration may also commence in the articula-
tions of the cartilages; filling them with pus, and
destroying their ligaments and articulating sur-
faces. The thyroid and cricoid cartilages are
naturally ossified in old age; and in consequence
of disease, in earlier life. M. An deal states, that
the arytenoid cartilages have never been ossified.
The rings of the trachea are sometimes ossified,
but seldom or ever otherwise altered. The car-
tilages of the bronchi are often hypertrophied,
becoming more apparent, and forming more com-
plete rings, than natural. They are also sometimes
ossified. MM. Reynaud and Andral found the
ultimate ramifications of the bronchi changed into
osseous spicule, with minute canals (the cavities
of the bronchi) running through them, in very old
subjects. M. Andral states, that the bronchial
cartilages may become so brittle from disease, a*
to break into fragments, project into the canal of
the bronchi, or become altogether detached, and
be ultimately expectorated.
17. C. The cellular tissue connecting the above
structures is often the seat of disease. In the
larynx, it is very frequently the seat of inflam-
mation and congestion; and, in consequence of a
chronic state of inflammatory action, it sometimes
becomes indurated and thickened; diminishing
remarkably the calibre of the glottis, impeding
the action of the muscles, and affecting the form
and movements of the epiglottis. This tissue, in
the situation of the larynx and epiglottis, is occa-
sionally infiltrated with serum, which, when con-
siderable, constitutes the a>dcma of the glottis,
fust accurately described by Birrr.. The infil-
tration may distend the folds ofmuoous membrane,
surrounding the rima of the glottis, so as to ob-
struct more or less the passage through it. Tliis
change is generally consecutive of inflammation
of the mucous membrane of the larynx, or of
chronic affections of this organ. In some cases
it is very chronic; in others very acute, quickly
producing asphyxy. Instances of this latter form
are to be found in the sixth volume of the Ar-
chives Gmerale de Medicine, and twenty-second
volume of the London Medical Repository. Pu-
rulent matter is sometimes found in the cellular
tissue of the air-vessels, either in the state of small
abscesses, or infiltrating it to a greater or less ex-
tent; and either in the ventricles of the larynx, or
in any other situation in the course of the air-pas-
sages. Tubercular matter has also been found in
various parts of tins tissue. Different kinds of tu-
mours occasionally compress the nerves supplying
the air-vessels, and give rise to symptoms similar
to those caused by disease of their parietes. They
are sometimes formed in the larynx, or in its im-
mediate vicinity, occasioning more or less com-
plete occlusion of the glottis. M. Ferrus has
recorded a case where this result followed the de-
velopement of two fungous tumours in the larynx
(Archives Gemr. Aout 1824.). Several writers
have made mention of a varicose state of the
veins of the air-passages amongst the causes of
hemoptysis; but M. Andral states that he has
never met with this appearance in Ids numerous
post mortem inspections.
18. hi. Alterations of the Size oe
Calibre of the Air-vessels. — The chan-
ges already described very often cause marked
change in the air-tubes, either diminishing or in-
creasing their calibre. A. Diminution of their
canals are occasioned, a. by the formation of false
membranes, chiefly in the larynx and trachea of
children, and in the bronchi of adults: b. by thick-
ening of the mucous membrane; occurring princi-
pally in the glottis and bronchi: c. by infiltrations
of fluids into the sub-mucous cellular tissue, chiefly
in the larynx and vicinity: d. by various substan-
ces formed hi some part of these tubes, such as
hydatids, coagula-of blood, concrete mucus, &c:
e. by compression by some tumour situated exter-
nally to some portion of them, as by the thyroid
gland, an aneurismal tumour, or enlarged bron-
chial glands. /. Lastly, there is every reason to
conclude, that diminution or constriction of some
part of these passages very often arises, although
seldom in so permanent a' manner as to be ob-
served after death, from spastic contraction of the
fibres or muscles belonging to them; particularly
when foreign bodies escape into the trachea, or
when it, the larynx, and even the bronchi, are ir-
ritated by morbid productions; — the larynx more
especially.
19. B. Dilatation of the bronchi was first de-
scribed by Lakn.nkc, and afterwards illustrated
by Andral and others. It. is most frequently
observed in the smaller ramifications; and may
be so great as to be mistaken for tuberculous ex-
cavations, a. In some cases, the bronchi may be
uniformly dilated throughout one or more of their
ramifications, some of those which could not nat-
urally receive a fine probe, having attained the
size of a goose-quill; and, in some instances, even
admitting the finger. These dilated branches aro
243
BRONCHI — Congestion of the — Treatment.
sometimes visible on the surface of the lung,
where they terminate abruptly. They occasion-
ally also terminate, particularly near the top of
the lung, in an indurated black portion of its sub-
stance, or in a cartilaginous mass, or in a calca-
reous concretion, either exterior or interior to the
dilated bronchi, 6. In other cases, the dilatation
is limited to a particular point of the tube, and has
the appearance of an excavated cavity in the sub-
stance of the lung, for which it may be mistaken,
especially when it is met with in the upper lobe.
The size of cavities arising from this species of
dilatation varies from that of a hemp-seed to that
of an egg. Several of these may co-exist. When
they are placed near each other, they form, by
their communication, a complicated sinus filled
with puriforiii mucus, and closely resemble some
kinds of tuberculous excavations, c. Occasional-
ly they present a third form, consisting of a suc-
cession of dilatations, between each of which the
bronchus recovers its natural diameter, the walls
of the dilated portion being generally thin and
transparent. One lung may contain a number of
these dilatations, d. The parietes of the dilated
bronchi are, in some cases, hypertrophied, or
more fully developed than in the natural state;
in other cases they are reduced to a delicate
membrane, presenting neither fibrous nor carti-
laginous tissue. (Andral.) The dilated por-
tions generally contain much mucus, or a puriform
mucus.
20. These changes of the bronchi are seldom
found, unless in persons who had suffered attacks
of chronic bronchitis. They are most common
in persons of middle or advanced age. But they
are also sometimes met with in children who had
died of hooping-cough, particularly in its more
chronic states, and when complicated with bron-
chitis. I have occasionally found them in this
class of subjects; but only consequent upon this
disease. Dilatations of the bronchi, unless when
very considerable, seldom occasion any change of
the parenchyma of the lungs, beyond compressing
and condensing it : they are frequently associated
with either gray or dark induration of the adjoin-
ing pulmonary substance. (See Chronic Bron-
chitis, § 52. 61.).
II. Congestion of the Bronchi. Clas-
sif. I. Class, III. Order (Author).
21. Df.fin. Urgent continued dyspnaa; little
or no cough, and no expectoration ; with an
anxious, pale, or livid countenance. — This ailec-
tion is not often seen in a primary, severe, and gen-
eral form; but ii isVery common in more slight and
partial states; and as an attendant on typhoid, ma-
lignant, and pestilential diseases, and on exanthe-
matous fevers, especially measles, scarlatina, and
small pox, either shortly before the breaking out,
or upon the premature disappearance of the erup-
tion, when it often assumes a very general and
severe form: and it not infrequently, in slighter
grades, ushers in other diseases of the bronchi,
particularly ha morrhage, bronchitis, humoral
asthma, &c. General idiopathic congestion of
the bronchi to such an extent and degree as to
destroy life, although rare, is sometimes met with.
Several cases have been recorded of persons who,
without any apparent cause, were seized with
urgent dyspnoea, increasing until it terminated in
death; and, on dissection, the only morbid ap-
pearance observed was general congestion of
blood in the capillary vessels of the mucous and
sub-mucous respiratory tissues. (See § 3. for a
description of its anatomical characters.)
22. The symptoms of this affection have not
been sufficiently investigated; but they may be
stated to consist of continued dyspnoea, more or
less urgent; sometimes fever, little or no cough,
and no expectoration; the sibillous or sonorous
rbonchus in the large tubes, and absence of the
respiratory murmur over the chest; diminished
resonance on percussion; anxious, pale, bloated,
or slightly livid countenance; purplish tint of the
lips and nails of the fingers; anhelation, &c.
When the congestion takes place in the course of
fibrile or exanthematous diseases, in addition to
these, the pulse becomes very quick, small, irre-
gular, or intermittent, and the oppression at the
chest extreme.
23. The causes of these congestions are not
well known. They appear, however, to be most
frequently occasioned by the inhalation of poison-
ous gases or effluvia; by close, overheated, and
crowded apartments; by the ingestion of sedative
or narcotic substances, or indigestible or poisonous
animal or vegetable matters; by inordinate disten-
sion or oppletion of the stomach; and by the tran-
sition or metastasis of other diseases, or by their
determination to the bronchial surface in a more
especial manner, as in the instances above referred
to (§21.). When this affection proceeds from
poisonous or indigestible substances, and not in-
frequently also when it arises from other causes,
it is evidently associated with more or less con-
gestion of the substance of the lungs. It often
precedes other pulmonary complaints, as hae-
morrhage, and that modification of asthma, call-
ed dry catarrh by Laennec. Congestion of
the "bronchi sometimes also occurs in the pro-
gress of several diseases of the heart attended
with obstructed or impeded circulation tluough
its cavities, particularly those of its left side;
and is often one of those changes which super-
vene in the advanced stages of several acute
diseases, especially the exanthemata, and to
which death is more immediately owing. (See §
21.)
24. The Treatment must depend upon the
state of the vital energies at the time, upon the
nature of the causes to which the congestion is
owing, and on the evidence of existing general
plethora. The state of the pulse, in respect of
frequency aud fulness, will indicate the degree of
activity characterising the attack; but generally,
when the congestion is considerable, the changes
which take place in the lungs during respiration
being impeded, the vital energies become propor-
tionately reduced, and the pulse weak, quick, and
small. In the majority of cases, it will be neces-
sary, notwithstanding, to abstract blood either by
venaisection or cupping; and if the depression of
vital power be urgent, to exhibit simultaneously,
stimulants by the month, and in enemata: to em-
ploy frictions with irritating liniments (see F. 305.
30S. 311.), and revulsants, such as sinapisms,
blisters, mustard pediluvia, &c. ; and to inhale, at
brief intervals, and for a very short time, stim-
ulating vapours, particularly those of ammonia,
camphor, aromatic vinegar, &c, with the view of
exciting the nerves of the bronchi, and thereby
removmg the distension of the capillaries, and ac-
celerating the circulation through them. When,
BRONCHI — Inflammation of the.
249
however, the patient, in addition to the symptoms
indicating congestion, complains of a sense of
heat, trickling, &c. in the course of the trachea,
or under the sternum; and if the pulse retains
its volume, and still more especially if it he
sharp, full, or rebounding; we should infer (hit
the fulness of the bronchial vessels is of an active
description and most probably amounts to deter-
mination of blood; and, possibly, constitutes the
early stage of haemorrhage or of inflammation.
In cases of this description, full blood-letting,
either generally or locally, or both; and after-
wards, counter-irritation and revulsion, irritating
cathartic injections, the strict avoidance of internal
stimuli, and the antiphlogistic regimen; must be
prescribed.
'!'). In every case a strict reference should be
had to the cause, associated circumstances, and
the complications of the attack, and the treat-
ment should be varied accordingly. When it
seems to have been induced, or aggravated, by
hurtful substances taken into the stomach, the ex-
hibition of emetics, particularly No. 402. in the Ap-
pendix, ought not to be omitted; and, if they fail
of operating, the stomach-pump should be used.
The bronchial congestion preceding, accompany-
ing or consequent on the eruptive fevers, is to be
combated by cupping, revulsants, rubefacients, sti-
mulating frictions of the surface, and by emetics.
III. HEMORRHAGE FROM THE BRONCHI.
Hemoptysis (from auia, blood, and nrvaic,
sputum) frequently occurs, and often consists, as
already stated (§ 14.), of a simple exhalation
from the mucous surface. It is seldom, however,
owing merely to the pathological state of the
bronchi; but is either connected with some change
in the substance of the lungs, or with impeded
circulation through the heart; although the bron-
chial surface is generally its more immediate
source. Being, therefore, intimately related to
various changes of the lungs themselves, and
oi'ten occurring in consequence of these changes,
it will be considered in connection with them.
(See Lungs — Hemorrhage from, fyc.)
IV. Bronchi, Inflammation of the. Syn.
Bronchitis, Badham, Hastings. Erysipelas
Pulmonis, Lommius. Catarrhus pituitosus,
Angina bronchialis, Stoll. Catarrhus suffo-
cative, Auct. Var. Bronchitis Catarrhosa,
Hildenbrand. Peripneumonia Bronchitis, J.
Frank. Bronchite, Fr. Die Entzundung der
Luftrohrenuste, Bronchialentzundung , Ger.
Cl assif. 3. Class, Diseases of the Sangui-
neous Function; 2. Order, Inflamma-
tions (Good). III. Class, I. Order
(Author, see Preface).
26. Defin. Cough with, or without rigors,
often preceded by coryza, and folloioed by expec-
toration of a transparent, pale, glairy, and watery
fluid; more or less febrile commotion , dyspnaa,
and slight soreness, heat, or tightness of the chest,
which are diminished as the expectoration becomes
more abundant and opaque.
27. This important disease, until Dr. Badham
directed particular attention to it, was, according
to the particular form it assumed, confounded
with common catarrh, with pneumonia, under the
appellation of peripneumonia notha, and with
other diseases of the lungs and air-passages, more
especially tubercular consumption, dyspnrea, &c.
Dr. Young seems to have viewed it as a modifi-
cation or extension of inflammation of the trachea,
or even as synonymous with that disease, proba-
bly from their occasional complication, or succes-
sion to each other. J. 1*. Frank appears to
have been among the first who directed attention
to the frequency and importance of inflammation
of the bronchial surface. '-Cum vero," he ob-
serves, " profundius per tracheam penetrat, ac in
bronchia descendit inflammatio ; tunc in primo
casu tracheitidis speciem, in altero peripneumo-
nia? imaginem refert, in qua ultima vix non con-
stantem internorum bronchiorum phlogosin in
centenis cadaveribus deteximus." (Interp. Clin.
p. 110.) " Rectam habebis febrium catarrha-
lium saltern fortioreui ideam, si eas pro iifflam-
mulioue bronchiorum, sive pro bronchitide con-
sideies." (De Cur. Horn. IMorb. p. i. t. i. c. vi.)
Buoussais also noticed the frequency and im-
portance of inflammation of the mucous surface
of the bronchi (Hist, des Phlegmas. Chron. t. L
p. 75. Paris, 1800.). But it is chiefly to the
writings of Badham, Broussais, Hastings,
L/AENNEC, VlLLERME, AlCOCK, ANDRAL,alld
Chomel, that we are indebted for our knowledge
of it as a specific disease.
2S. Bronchitis commences variously, and as-
sumes different forms and states, according to the
intensity of the exciting causes, the severity of
the attack, and the constitution of the patient.
I shall consider it chiefly with reference to its
activity and duration, to the states of vital energy
and age of the patient, to its forms and compli-
cations, and to its results. Its general prevalence,
severity, and not infrequent fatality, require for
it a more particular notice than it has received,
even recently, from several systematic writers.
This will appear somewhat singular, when I state
that I know of no disease that is more frequent,
or productive of a greater number of deaths, in
children, than it, in its different states and com-
plications.
29. i. Acute Bronchitis assumes different
grades of severity, and a modified type, according
to the habit of body and vital energy of the pa-
tient, and the extent to which the inflammatory
action advances along the bronchial tubes. It
presents itself in practice, as a primary disease,
in three forms: — 1st, Common catarrhal bron-
chitis, in which only the mucous membrane of
the large bronchi and trachea are affected by the
specific and often infectious inflammatory irri-
tation constituting catarrh : 2d, Sthenic or true
bronchitis, in which the inflammatory action is
more acutely marked — is of a more phlogistic
description, probably from its further extension
along the bronchi, and from both the mucous
and the sub-mucous tissue of the tubes being
affected : and, 3d, Asthenic bronchitis, where,
owing to weak vital energy, the inflammatory
irritation assumes a lower and more asthenic
grade, and extends still more generally, or affects
especially the minute bronchi, interrupting their
functions, and preventing those changes from
taking place in the blood which are requisite to
the support of the nervous and vital manifesta-
tions.
30. A. Catarrhal Bronchitis (B. Calarrhalis) ;
Mild Bronchitis (B. 3Iitis) ; Pulmonary Catarrh,
Bronchial Catarrh, Catarrhal Fever; Bronchitis
serosa, fyc. — This is the most common form of
the disease, and generally commences with coryza,
250
BRONCHI — Acute Inflammation of the.
or with slight hoarseness or sore throat, and other
symptoms of catarrh extending down the larynx,
along the trachea, to the large bronchi ; the af-
fection of the former parts generally subsiding as
the latter become diseased. But it sometimes
appears without any signs of irritation, either of
the Scfaneiderian membrane, or of the tonsils or
fauces, evidently originating in the trachea or
large bronchi themselves, particularly in delicate
persons, or in those disposed to coughs, pulmonary
disease, and habitual expectoration.
31. A sense of roughness, with frequent
attempts to clear the throat, is generally the first
symptom of the disease. This is accompanied
with, or followed by, titillation of the larynx, ex-
citing a dry hard cough; hoarseness of voice,
with a sense of tightness across the chest, and
sometimes slight pain or soreness upon coughing
or breathing deeply. Accompanying- these local
symptoms, more or less constitutional disturbance
is generally present. The patient complains of
lassitude, pain in the limbs and back, slight
shiveriugs, or cold chills, quickness of pulse, and
increased warmth, with dryness of the skin.
The cough, which was at fust dry, is now accom-
panied with a slight expectoration of a somewhat
saline, glairy, and thin fluid; and as it rises to-
wards the glottis, increases the cough, and ren-
ders the fits more frequent, probably owing to its
irritating quality; in this resembling the secretion
in coryza, with which it so often originates. In
the slighter forms of the disease, the expectora-
tion becomes in two, three, or four days thicker,
more abundant and tenacious, less irritating, and
somewhat more opaque; and with this change,
the constriction, pain, and soreness, are diminish-
ed, or very much relieved; the pulse also is less
frequent; the skin cooler and more moist; the
urine less scanty, paler, and deposits a sediment;
and the cough less frequent, although often in lon-
ger paroxysms. As the amendment advances, the
sputum decreases in quantity, but is more opaque,
tenacious, and deeper coloured, being frequently
greenish white. This amelioration is most remark-
able at first in the morning, and, as convalescence
proceeds, continues throughout the day. At last
but little expectoration takes place, and is observ-
ed, as well as the cough, only morning and eve-
ning. In slighter cases, the dullness continues
throughout, or alternates, with some increase of
heat and perspiration; the pulse is scarcely affect-
ed unless towards evening; the expectoration is
neither abundant nor very viscid; the fits of cough
not severe, and chiefly in the night and morning.
Such are the usual symptoms and course of ca-
tarrhal bronchitis, constituting what is usually
named a cold upon the chest. But it sometimes
assumes other characters; and then pulmonary
catarrh is no more applicable to it than to inflam-
mation of the substance of the lungs, in which,
also, it occasionally terminates.
32. 'J his form of bronchitis appears to consist
of catarrhal irritation extending to, or originating
in, the mucous membrane of the trachea and
large bronchi, to which it is chiefly limited, with-
out materially affecting the sub-mucous tissue.
It seems not to be actual inflammation, or, if in-
flammatory action be present, it is of a peculiar
or specific kind, probably owing to its being
seated in, or rather limited to, the mucous mem-
brane; in which light it is viewed by Hilden-
brand, who very justly considers catarrhal irri-
tation to be distinct from true inflammation. This
variety may assume an epidemic form, when its
symptoms become somewhat modified (see In-
fluenza.); and repeated or prolonged attacks
of it often favour the developement of tubercles
in the lungs, or even originate them, in scrofulous
and delicate subjects. It may also pass more or
less rapidly into either true acute bronchitis, or into
the chronic form of the disease, owing to the ex-
tension of inflammatory action more generally
through the bronchi, and to their sub-mucous cel-
lular tissue.
33. B. True Bronchitis (B. Vera); Sthenic
Bronchitis (B. Gravis Sthenica); the Acute
Mucous Catarrh of Laennec — This more de-
cidedly inflammatory form of the disease is some-
times preceded by coryza or sore throat; and as
these begin to yield, the morbid action extends
along the mucous membrane to the trachea and
bronchi. But it frequently also commences in
this last situation, particularly in those who are
liable to pulmonary disease, and to chronic
coughs, and assumes a severe form. After these
preliminary signs, sometimes hoarseness, or loss
of voice, and always a dry hard cough, with a
sense of soreness, rawness, dryness, and heat, are
complained of under the sternum, preceded by
marked chills or complete rigors. The chills at
first alternate with increased heat and dryness of
the skin; and are soon followed by quickened and
somewhat laborious respiration; dyspnoea or op-
pression at the chest; sometimes a dull pain on
coughing; quick, full, and often strong pulse;
sickness or loss of appetite; pain in the forehead,
back, and limbs; loss of animal strength, with
an inability to leave the couch or bed ; foul
loaded tongue; constipated bowels, and scanty
high coloured urine. As the disease advances,
the frequency of pulse, the cough, expectoration,
and general febrile symptoms, increase, as well
as the tightness and soreness of chest ; the latter
sensation often amounting to an obtuse pain ex-
tending between the shoulders, to the back, and
to the attachments of the diaphragm to the false
ribs, sometimes with pale anxious countenance,
and great oppression and anxiety. As expectora-
tion comes on and increases, the sense of heat
below the sternum diminishes. The cough is
generally excited by a full inspiration; and from
being short and dry, or attended by but little ex-
pectoration, becomes longer, more severe, and
convulsive, accompanied with a more copious
expectoration; and subsequently, in some cases,
terminates in scanty vomiting, which promotes
the discharge of a watery or serous and frothy
mucus, sometimes in considerable quantity,
which had accumulated in the bronchi and
trachea. The febrile and other symptoms are
aggravated towards night, which is generally
sleepless and disturbed, the position of the body
being on the back; but the posture is often
changed. In some cases, particularly those
which are not remarkably severe, each exacer-
bation of the fever is attended by chills; and
throughout the disease, the sensibility of the sur-
face to cold is very great. In the more phlogistic
cases, especially in plethoric subjects, the dys-
pnoea and oppression are very urgent, the face is
flushed, and sometimes slightly tumid, and the
eyes injected. At a still luore advanced period.
BRONCHI — Acute Inflammation of the.
251
the tongue is often red at its sides and point, and
deeply loaded in the middle and base; the breath-
ing becomes rattling or wheezing, owing to the
air strugirhn" through the miieous accumulation
in the bronchi, and the exertions to expectorate
greater. In extreme cases of this description,
collapse, with diminished expectoration, purple
li|>s. orthopnea, quick depressed pulse, cold
perspirations and extremities, with threatening
suffocation, occur as early as the sixth or eighth
day.
:> I. The chief characteristic of this true form of
bronchitis h the state of the sputum, which ought
always to be carefully examined. When the
disease attacks a person who never expectorates
whilst i:i health, the cough remains dry for a
considerable time ; and those who expectorate
habitually, cease to do so when the inflammatory
attack is very acute. If the disease be slight, the
sputum is often increased from the commence-
ment, and its quality changed. As long as the
cough continues dry, the disease may be said to
be in its first stage. In the course of a period
which varies with the constitution of the patient
and the treatment employed, each fit of coughing
is followed by the excretion of a clear, transpa-
rent, serous or watery mucosity, which is at first
slightly saline, but afterwards becomes tasteless.
It is without odour. As the disease advances, it is
a glairy mucus, resembling white of e<;g. When
it is poured into one vessel from another, it flows
with extreme viscidity. The more it can be
drawn out into a tine thread, and the greater its
tenacity, the more marked is the irritation of the
surface secreting it ; the greater also being the
oppression, heat, and anxiety in the chest, the
violence of the cough, and the general febrile
symptoms. In these very acute cases, it adheres
closely to the sides of the vessel containing it by
long stria'. When the fits of coughing are severe,
there is a froth or sort of lather on its surface;
and, in some cases, it is streaked with a little red
blood, which, however, is not combined with the
mucus as in pneumonia. Early in the disease,
whilst the expectoration is fluid, transparent, or
watery, it often contains small whitish flocculi,
proceeding from the mucous cryptae of the pharynx
and fauces.
33. In proportion as the inflammation advances
to resolution, the sputum loses its transparency,
and is mixed with opaque, yellowish, whitish, or
greenish matter, which increases until it forms
nearly the whole of the expectorated mass, and is
attended by a marked diminution of the symptoms:
its quantity also is lessened. The inspection of
the sputa thus not only serves to indicate the na-
ture of the disease, but also its various stages.
In cases of a relapse or aggravation of the in-
flammatory action, the sputum again becomes
transparent; frothy, more abundant, and \iscid;
and the other symptoms increase. In several in-
stances the disease will continue to fluctuate for
several day-, exhibiting symptoms of slight ameli-
oration, soon followed by slight relapse or exacer-
bations, often occurring on alternate days, or at
the tertian period, and assuming from this circum-
stance a remittent character, until either a more
decided improvement takes place, or a more
marked aggravation terminating in some one of
• , the ways hereafter to be detailed (§ 39.).
3(5. hi the two forms of the disease now de-
scribed, the minute bronchi so far escape, during
the favourable course of the disease, as that no
material interruption to the functions of the lungs,
in respect of the changes effected on the blood
during respiration, takes place in them; the air
still passing through them and reaching the air-
cells : but, in certain of their very severe forma
and complications, and of their unfavourable ter-
minations, and in the variety next to be noticed,
obstruction to the free circulation of air, and to
the changes produced on the blood, in the lungs,
occurs to a greater or less extent.
37. C. Asthenic Bronchitis (B. Asthenica) ;
Peripneumonia Not/ta* of Authors; Acute Suf-
focative Catarrh of Laennec. — This variety of
the disease- generally occurs in very young, or in
aged persons, in those of a phlegmatic or cachectic
habit, and of lax fibres and exhausted powers of
constitution, or who have been liable to chronic
coughs, and to copious expectoration of a thin
watery phlegm. Severe paroxysms of cough, with
wheezing and oppressed breathing; foul loaded
tongue; scanty urine; complete loss of aopetite;
very quick, small, or irregular pulse; little or no
increase of heat, excepting at night; cold extre-
mities ; vertigo ; pain in the head ; exacerbating
fits of dyspnoea, with a scanty expectoration at
the commencement, gradually becoming abundant
and frothy ; are its chief symptoms in persons
advanced in life. It is much less acute or phlo-
gistic in its character than the preceding variety;
and its duration is longer. In the more severe
cases, the countenance is pallid and anxious; the
oppression of the pracordia extremely great; and
a full breath taken to relieve it brings on a severe
fit of coughing, which sometimes terminates in
vomiting, and relieves for a time the symptoms by
favouring the excretion of the accumulated mu-
cosites. The tongue is often dry, and brownish
red at its point and edges, and sometimes covered
at its base with a dark coating; the breathing is
much more difficult ; the lips and nails assume a
blue livid appearance; the face becomes lurid or
dusky; the patient cannot lie down in bed, or,
if he does, starts up, after falling asleep, with a
sense of suffocation; and the symptoms indicate
either collapse, and obstruction of the air-passages,
or effusion of fluid in the thoracic cavities, or even
both: stupor or sopor; weak, wiry, and xevy fre-
quent pulse ; marked diminution of the sputa,
cold extremities, orthopneca, clammy sweats about
the face and neck, suppressed urine, &c. ushering
in a fatal termination.
3?. This is, upon the whole, the most common
form of bronchii is which is met with in children,
particularly in the metropolis, and among the
children of the poor, ill \'rd, and ill clothed, and
those living in cellars, ground-floors, and badly
ventilated lanes and apartments, and is often re-
markably prevalent during the winter and spring.
In this class of patients its approach is often insi-
dious ; and it usually commences with coryza,
but not infrequently also with chills, febrile symp-
toms towards evening, wheezing, quick breathing,
* " Peripneumonia notha fortior nobis bronchiorura ca-
tarrhus est, quo in nil uitosis, obi is, ii nibus, c
laxisnu fri ;ida 1 1 humid i ub I
luucos i hi i- c; nales invesl ientis irri-
copiosior, tenaxque pituita celeriori passu secreta
broncliiorum fines oppleudo, suflbcationein sat cito mina-
tur." (J. P. Frank.)
BRONCHI — Acute Inflammation of the — Terminations.
and cough. There is at first little or no dyspnoea;
but the tongue is loaded, the pulse accelerated
and full, the face pallid or tumid, and the child
has lost its animation. As the disease advances,
the breathing becomes more quick and laborious;
and fits of dyspnoea come on, generally followed
by severe attacks of cough, which often terminate
in vomiting; on which occasion only the bronchial
secretion is presented for examination, and is
found to consist at first of a viscid, watery mucus,
and afterwards of a yellowish white, or a tena-
cious matter. These exacerbations are followed
by remissions, during winch the child dozes, and
appears relieved, and the pulse becomes less fre-
quent. Thus the disease may continue, with al-
ternate remissions and exacerbations, for many
davs, until either a permanent diminution of the
symptoms takes place, or an increased frequency
of pulse, stupor, lividity of the lips, nails of the
fingers, convulsions, &c. supervene, and indicate
impending suffocation, with congestion or watery
effusion on the brain.
39. Terminations. — A. Duration. The
sthenic variety of the disease usually runs its course
in about seven or nine days; but it may terminate
either way as early as the fifth; or it may be pro-
longed to the 21st, or even the 28th day. Its
duration will, however, chiefly depend upon the
treatment employed, the complication it may pre-
sent, the severity of the symptoms, and on the age
and constitution of the patient. The asthenic
form of bronchitis generally runs its course in a
slower manner; it seldom terminates either way
in less than fourteen days, and generally continues
for several weeks (§ 37.).
40. B. In favourable cases, the sthenic form of
the disease begins to decline from the fifth to the
ninth day. 'ihe change is first evinced by the
state of the sputum, as above described (§ 35.);
by an amelioration of the cough, dyspnoea, and
febrile symptoms : in rare instances, by copious
epistaxis; by a more general and copious perspir-
ation than that which frequently terminated the
febrile exacerbations; by a more copious discharge
of a paler urine, depositing a sediment; and by a
diminution of the dyspnoea, of the frequency and
severity of the cough, and of the quantity of the
expectoration, which becomes pearly, opaque,
thick, yellowish, or greenish yellow ; at last,
febrile symptoms recur only towards evening,
and the disease disappears as in the first variety
(§31.).
41. C. This favourable change is not, however,
always observed, particularly when the attack is
very severe, when treatment has either not been
soon employed, or lias not been sufficient to re-
move the disease, or when the secretion into the
bronchi has been very profuse, and expectorated
with much difficulty. In such cases, it either
lapses into the chronic state about to be described;
or, owing to the extension of the inflammation, to
the air-cells and substance of the lungs, gives
origin to pneumonitis, and even to pneumonitis
combined with pleuritis, which is thus superadded
to the original disease; or, from the great extent
of surface affected, the consequent irritative fever,
and interruption to the pulmonary functions, and
the profuse viscid fluid filling up the bronchi, col-
lapse of the powers of life supervenes, and the
patient dies, either with cerebral affection, or
with the usual symptoms of asphyxy, consequent
upon diminished discharge of the morbid secretion,
and its accumulation in the air-tubes.
42. a. When the disease thus terminates in
pneumonia, the sputum becomes more rounded,
thick, tenacious, and streaked with blood, which
is more or less intimately mixed with it, and some-
times of a dark colour, giving it a rusty appear-
ance ; and the cough is more tight, hard, and
deep. The oppression also increases; the cheeks
are flushed with circumscribed red; the pain of
chest is more severe, or is now complained of for
the first time ; the skin is partially covered with
moisture, sometimes very abundant in parts; the
chest, which was hitherto sonorous throughout, is
dull, in some part or other, upon percussion; and
the auscultatory signs of severe and dangerous
pneumonia appear, on which delirium and other
unfavourable symptoms often supervene, and ter-
minate, with coma, the life of the patient.
43. 6. Bronchitis, as it occurs either in the
sthenic or asthenic form, may also terminate in
chronic pleuritis, and in effusion of serum into the
pleural cavity, and in some instances also into the
pericardium, particularly in persons advanced in
life, and in those who have experienced difficulty
in the circulation through the cavities of the
heart. In some instances of this description, the
expectoration, and many of the other symptoms,
are suddenly or quickly diminished; but the dvs-
pnoea continues, and signs of effusion become
more apparent as those of bronchitis disappear.
In these, the consecutive effusion occurs in the form
of a translation or metastasis of the morbid action
from the mucous to the serous surface. In other
cases, symptoms of pneumonitis, or pleuritis, in-
tervene between the change in the bronchitic
symptoms and the occurrence of effusion, with
pain, more or less severe, loss of resonance in
some part of the chest, and other auscultatory
signs, indicating the extension of the inflammatory
action first to the small bronchi, and thence to
the substance of the lungs and the pleura. Dr.
Hastings has detailed some cases of this termi-
nation in his work, and I have treated several
instances at the Children's Infirmary; but it is
chiefly the aged who are liable to this unfavoura-
ble occurrence.
44. c. In other unfavourable cases, the disease
becomes, in the course of a few days, charac-
terised by failure of the energies of life ; oppres-
sion and uneasiness increase; the cough is more
frequent, laborious, and convulsive; the sputum
is either more abundant, frothy, tenacious, and
glairy, or gelatinous, and excreted with great dif-
ficulty, or much diminished in quantity from want
of power to excrete it; the pulse is more rapid,
small, weak, and irregular, or intermittent ; the
pain of head more distressing; the countenance
is pale, and the face and neck covered with a
clammy sweat; the respiratkm'very frequent and
wheezing, sometimes with an audible rattle; and,
at last, delirium, lividity, at first of the lips,
afterwards of the countenance, great pin$tration
of strength, and coma, supervene, and lhp*pat ient
sinks with all the signs of imperfectly^tehgi d
blood. In some cases, cerebral symptoms- "come
on much earlier, with either violent or WSKji.ut-
tering delirium, which soon terminates ~"ih ;fb06t
profound coma. In a few cases, this early acces-
sion of delirium, or of violent headach, with other
symptoms of consecutive ^inflammatory action,
BRONCHI — Acute Inflammation of the — Complications.
203
ending in serous effusion on the brain, altogether
removes the original bronchial inflammation, or
in others moderates it greatly and masks it. I
have observed this in children, and once or twice
in robust adult persons; bnt in both classes of
subjects it is a dangerous occurrence. More com-
monly, however, the cerebral symptoms continue
increasing, with those referrible to the bronchi, till
life is extinguished.
45. In other cases of very acute bronchitis,
with very high fever and severe local symptoms,
particularly with quick, laborious, short respira-
tion, dyspnoea; anxiety, great sense of heat under
the sternum, and bloated countenance, collapse
takes place rapidly, particularly if an appropriate
treatment have not been early employed ; and
either delirium, coma, and other cerebral symp-
toms, or those more directly depending on the
circulation of venous blood, appear, and the
patient is speedily cut off. In weak and nervous
patients, and during unfavourable states of the air,
the inflammatory action sometimes seems to in-
vade nearly all the respiratory mucous surface,
and is soon productive of a copious mucous secre-
tion, which, either from its difficult excretion or
rapid secretion, in some cases, speedily suffocates
the patient.
4ij. In children, and rarely in adults, cases
occur, in which the inflammatory action extends
upwards, to the trachea and larynx, occasioning
all the symptoms of laryngitis in addition to those
of bronchitis, and frequently terminating fatally
with convulsions and the signs of congestion in
the head. In many of the unfavourable cases of
bronchitis in children, the extent of the disease,
anil the copious secretion, occasion suffocation
more or less rapidly, with somnolency, bloated,
or livid countenance, convulsions, coma, and, at
unplete asphyxy: and, on dissection, con-
gestion of blood, with watery effiision, is found
within the cranium; the bronchi are filled with a
nvuco-purulent matter, and the vessels of the lung's
are loaded with blood.
47. Complications. — The most common
states of complication, in which bronchitis pre-
sents itself in practice, are, 1st, With catarrhal
sore throat, coryza, &c. of which it is generally
■ utive, and with catarrhal inflammation of
tla/ pharynx and oesophagus. 2d, With inflam-
mation of the trachea, or larynx, or both, of
which it is most frequently consecutive; but also
sometimes antecedent, as I have occasionally
observed in children. Indeed, we have seldom
croup in London uncomplicated with bronchitis
in some one of its forms or states. 3d, With
measles, scarlatina, or small pox, on which it very
frequently supervenes; particularly in measles,
sometimes verj early in the disease, and before the
eruption breaks out; but oftener in consequence
of its premature disappearance, or retro.
4th, Very commonly witli hooping-cough, espe-
cially during certain seasons and epidemics. 5th,
NociftiBueutly with continued fevers, particularly
i.i its iMieiiie form, fith, Often with disorder, or
•i *A-. cute inflammation, of the digestive mu-
cou^urfice, and diarrho'a, in children, when ii
alsjojiittimi is this form; the -tools being offensive,
ail^r nje tongue red at its point, &c* 7th, With
•^tluring some seasons I have occasional!) admitted in one
the Infirmary for Children, several cases, in which it
Bcult to determine whether the digestive or the re-
22
disease of the liver, and accumulations of bile in
the gall-bladder, chieflj in adults; the tongue then
being very deeply loaded with a yellowish brown
crust, or fur; and the stools dark coloured, and
most offensive. 8th, In some cases with erysi-
pelas, particularly its epidemic and infectious
form. 9th, With pneumonia, or pleuritis; these
being either consecutive of the bronchitis, or sim-
ultaneous with it. 10th, With dropsical effusion
into the pleura or pericardium, especially in a<>-ed
persons: and, 11th, With inflammatory irritation
in the substance of the brain, or in its membranes,
with disposition to effusion, — a complication most
commonly met with in children.
48. All these diseases are greatly aggravated,
and their danger increased, from being associated
with bronchitis ; and they frequently terminate
fatally by one or other of the unfavourable states
which the bronchial affection assumes. Bronchitis
thus complicated also presents, in consequence,
either a more acute character, or the asthenic
form ; and, being attended by a more marked
disposition to invade the smaller ramifications and
air-cells, or by a more profuse secretion of mucus,
and a rapid depression "of the powers of life, the
unfavourable terminations above described quickly
supervene. In several of these complications, par-
ticularly with pertussis, measles, scarlatina, con-
tinued fever, cerebral affections, and diseases of
the lungs or pleura-, bronchitis often escapes de-
tection, until it becomes either one of the most
important, or the most dangerous, or an actually
fatal lesion. When thus complicated with measles
or other exanthematous diseases, the eruption, if
it still continue on the surface, often assumes, as
the powers of life sink-, a dark or purplish hue;
and a slight dirty blueness of the skin, particularly
of the face, hands, &c. is generally observed in
other eases, indicating the impeded functions of
respiration, and the consequent changes in the
blood. The frequency and importance of the
complication of bronchitis with measles, especially
before the appearance of the eruption, during its
progress, and after its decline; and the occurrence
of the former complaint, both during and after
convalescence from the latter; are deserving of
the careful attention of the practitioner.
49. ii. Sub-acute Bronchitis is character-
ised by the symptoms of the sthenic form of the
disease in a milder and more chronic form. The
cough continues longer dry, and the expectora-
tion scanty, or thick, viscid, gelatinous, or albu-
minous, with tightness of chest, and oppressed
.breathing. In this form of the disease, a plastic
albuminous exudation sometimes forms in the
large bronchi, and lower part of the trachea, or
in the large bronchi of only one lung, and is
moulded in the form of the air-tubes ; and is
either expectorated in fragments, or in large tub-
ular branches and ramifications. Cases of this
description are detailed under the appellation of
bronchia] polypi by the older writers, and figures
given of them by Tulpius and others. Mr.
[liff has published {Lond. Med. Kepos. vol.
xviii. p. 207.) a case of this .description, wherein
tin-' production retained its ramified and tubular
form. I have met with two cases where the
albuminous exudation had been formed in the
spiratory mucouS Burface was most affected. This compli-
Dol infrequeni from the exan-
themata, particularly mi 1- and soarlet lever.
254
BRONCHI — Chronic Inflammation of the.
bronchi, and expectorated in fragments. It gen-
erally occurs in an uncomplicated state.
50. iii. Chronic Bronchitis often follows
severe attacks of catarrh; and is also frequently
consecutive of acute bronchitis; but it sometimes
occurs primarily in the chronic state, particularly
in aged persons. It differs in nothing from the
acute or sab-acute forms, excepting in as far as
the symptoms are altogether milder, and their
continuance longer; there heing no distinct line
of demarcation between its grades of activity and
chronicity. The chief means, by which we are
enabled to infer, that the disease has assumed a
chronic form, when it is consequent on the acute,
is the continuance of the sputum for several days,
in undiminished quantity, and the persistence of
the opaque, whitish yellow, or yellowish green
appearance, which it assumed upon passing from
the transparent, fluid, and viscid condition charac-
terising the acute form.
51. Chronic bronchitis assumes various grades
of severity, and presents different phenomena,
according to the changes which have taken place
in the bronchi. In its slighter states, and primary
form, as it is often met with in persons advanced
in life, and as it prevails during winter and spring,
or variable seasons, it consists chiefly of a fre-
quent and almost habitual cough, with scarcely
any pain in the chest, continuing for weeks, or
even months, or recurring every autumn, winter,
and spring; being most severe in the mornings,
and much easier through the day, with slight
dyspnoea on exertion, and copious viscid mucous
expectoration ; but without any marked febrile
symptoms, excepting slight acceleration of pulse.
Its severer forms are met with in young or middle
aged persons, after catarrh or acute bronchitis;
and are attended with fits of coughing, and copi-
ous expectoration; with oppression at the chest
and preecordia; with febrile symptoms, particu-
larly towards night; with copious perspirations in
the morning, which often seem to increase the
cough instead of relieving it; with loss of strength,
emaciation, and slight disorder of the digestive
organs. The cough is increased after getting into
bed, and very early in the morning. The breath-
ing is quick and laborious, particularly on any
exertion ; and the patient complains of slight
tightness of the chest. The pulse generally
ranges from 90 to 120; being the former whilst
quiet in bed, and the latter towards evening.
52. Attention to the expectoration is very im-
portant, in order to enable us to judge both of the
accession of this state of the disease, or of its ag-
gravation or change into the acute form, which
is not infrequent, and of the concurrent or con-
secutive alterations which often take place. The
sputum occasionally continues long in the state
now described. It is generally then inodorous,
and without taste. But it oftener becomes green-
ish, or yellowish white, or muco-purulent ; is
mixed with a colourless watery phlegm, and is
more or less abundant. In cases of a worse char-
acter, particularly when hectic symptoms are pre-
sent, it assumes a more purulent appearance; is
sometimes streaked with blood, or mixed with
dark specks of blood, or consists chiefly of pus.
These changes, however, seldom occur without
much antecedent fever, and attendant emaciation,
night sweats, occasional diarrhoea, and the symp-
toms of confirmed hectic. In rarer cases, the
sputum becomes remarkably foetid ; but this
change cannot be imputed to any particular
lesion of the bronchi or lungs, excepting some-
times to considerable dilatation of the former.
The whole of the symptoms in this class of cases
so very nearly resemble tubercular consumption,
as to be distinguished from it with much difficulty,
and only by attending to the appearances of the
sputum, and by examining the chest with the
stethoscope.
53. The sputum generally partially swims on the
surface of water. When it is thin, transparent,
viscid, and frothy, it usually altogether swims; but
when it is thick, in tenacious, opaque lun ps, or
in fragments resembling portions of albuminous
exudation, it generally sinks. In all these states it
cannot be diffused in the water. When it consists
of yellowish white, or greenish vellow matter, it
partly sinks, and by agitation is broken into ragged
portions, and is partially diffused; and the more it
approaches a purulent state, the more completely
and readily is it diffused, imparting to the water,
by agitation, a yellowish white appearance.
54. Chronic bronchitis is also sometimes co?:se-
cutive of the eruptive diseases; but these diseases
have generally altogether or very nearly subsided
before the bronchial affection supervened. It
occurs primarily from the irritation of minute par-
ticles of mineral or vegetable substances floating
in the air, as is shown in the article on Arts. It
is sometimes also complicated with other chronic
diseases of the lungs and pleura, more especially
with tubercles; with diseases of the liver; with
chronic inflammation, or other disorders of the
mucous surface of the digestive tube, particularly
of the oesophagus, stomach, and large bowels.
In all these consecutive and con plicated states,
it presents no certain or unvarying forms ; its
chief character, its duration, progress, and ter-
mination, being modified by its severity, by the
constitutional powers of the patient, by his dia-
thesis, and by the quantity of expectoration. In
some cases, the secretion from the bronchial sur-
face is so profuse as to be the chief cause of the
exhaustion and death of the patient.
55. iv. Anatomical Characters of
Bronchitis. — A. When the body of a patient
is opened, that has sunk under any disease whilst
affected at the same time with a mild and recent
bronchitis, some redness is found, generallv in a
circumscribed portion of the mucous membrane,
and usually towards the end of the trachea, and
in the first divisions of the bronchi. If the in-
flammation have been more intense, the redness
extends to a greater number of these tubes, and
exists, moreover, in the smaller ramifications. It
sometimes happens that this redness is exactly
limited to the bronchi of one lobe only; and it is
the bronchi of the superior lobe which seen.s to
be more particularly disposed to inflammation.
The red colour of the bronchi presents itself
occasionally under the form of a fine injection,
which seems to exist both in the sub-mucous cel-
lular tissue, and in the mucous membrane itself,
and is usually attended by slight tumefaction.
Sometimes the vessels cannot be distfngtn'shed,
but only a number of small, crowded, red "points,
which are agglomerated the one around the' "other.
Finally, an uniform red colour is occasionally ob-
served. In some cases, the redness diminishes
progressively from the large bronchi to the
BRONCHI — Inflammation of the — Diagnosis.
255
small ones ; in others, an opposite disposition is
remarked. Occasionally the redness only exists
in intervals, in the form of bands or of isolated
spot-, forming, aa it were, as many circumscribed
phlegmasia], between which the mucous coat is
white and healthy.
5t>. B. When the inflammation is chronic, the
mucous membrane generally loses its lively red-
ness: it presents a livid, violet-coloured, or brown-
ish tint Finally, and what is very remarkable,
in individuals offering all the symptoms of invete-
rate chronic bronchitis, with puriform expectora-
tion, the mucous membrane of the lungs has been
found scarcely rose-coloured, and even perfectly
pale through its whole extent. Hayle and An-
DKAL have particular! v noticed this fact. 1 would
not wish to conclude that there is not, and least
of all, that there has not been, inflammation in
these cases; but I think a very copious secre-
tion will often take place from mucous surfaces,
and assume even a purulent appearance during its
retention in the bronchi, from lost tone of the
extreme capillary vessels, with, perhaps, an in-
creased flux or determination of the circulating
fluid in order to supply the discharge, all vascu-
larity disappearing with the cessation of circula-
tion. The other changes observed on post mor-
tem inspection, particularly in the more chronic
states of bronchitis, consist chiefly of thickening,
softening, ulceration, &c. of the mucous mem-
brane, dilatation of the bronchi, &c. (See § 7,
et seq.).
57. v. Diagnosis. — The characters of the
Cough, and of the sputa, and the physical signs,
are our chief guides in the diagnosis of bronchitis.
The history 1 have given of the disease will be
generally sulricient to enable even the inexperi-
enced to recognise it: but it will often be necessa-
ry to arrive at more precise and certain informa-
tion as to the extent of lesion, and its existence
either in a simple or in a complicated form.
58. A. Of the acute. — a. By auscultation. In
the first stage of the disease, the inflammation
causes tumefaction of the mucous bronchial sur-
face, and consequent diminution of the calibre of
the tubes. This state occasions a modification of
the respiratory sound in them: and, hence, either
with the unaided ear, or with the stethoscope,
we hear at first the " dry bronchial rhonchus j"
consisting chiefly of a sibilous or whistling sound;
occasionally with a deeper tone, resembling the
note of a violoncello, or the cooing of a pigeon,
particularly when the large bronchi are atiected.
These sounds (see Auscultation, § 14.), de-
nominated the sibilous and sonorous rhonchi, are
present chiefly in the early stage, and before ex-
pectoration takes place ; and prove the accuracy
of the rational inference of Dr. I5a dh am, that the
dilHcult breathing of this period is owing to the
state of the mucous membrane; and I would add,
of its sub-mucous cellular tissue also. To these
sounds is added the mucous rhonchus; and in
proportion as the bronchial secretion, to which it
is owing, augments, this sound becomes predomi-
nant". • When the inflammation is seated in the
large Tabes, the bubbles of mucous rhonchus are
large ftud uneven ; and the respiration may be
still arellril over the chest. Hut when the mucous
rhonchus is tine, and is heard constantly, it may
be inferred that the small bronchi are invaded.
When this is the case in a severe degree, there is
also slightly diminished resonance of the chiefly
affected part upon percussion. As the disease
proceeds, and the secretion passes into an opaque
and thickened state, the mucous rhonchus be-
comes interrupted, sometimes with obstruction of
the respiratory sound in a portion of the lungs, and
passes into a sibilant or clicking sound. These
changes arise from the entire or partial obstruc-
tion of one or more tubes by the thickened mu-
cus, and are generally of temporary continuance :
occurring now in one part of the chest, and dis-
appearing; and now in another. This state of
the bronchi fully explains the dyspnoea of this
stage.
59. b. Rational diagnosis. — «. The cough in
bronchitis is loose, diilused, and deep; in pa-
roxysms, and attended with fever, often with
wheezing. In pertussis, it is in severe paroxysms,
unattended' by fever or wheezing; is accompanied
with a distinct whoop; and terminates in vomiting.
In croup it is sonorous, clanging, and harsh. In
laryngitis, it is suffocating, shrill, or grunting;
and, on inspiration, attended with a drawing down
of the pomum Adam', to the sternum, and retrac-
tion of the epigastrium and hypochondria. In
pneumonia, it is deep in the chest ; frequent and
short, often hard; and gives a metallic sort of
noise. And, in pleuritis, it is short, dry, hard;
sometimes slight, but always suppressed and pain-
ful, ft. The expectoration in bronchitis is abundant
after the second or third day, or even from the
first: in pertussis, it only follows the vomiting:
in pneumonia, it is more rounded, distinct, thick-
ened, purulent, rusty, and intimately streaked
with blood: in pleuritis, croup, and laryngitis, it
is scanty, thin, frothy in the latter ; sometimes
with shreds or pieces of lymph, and entirely
different in appearance from that of bronchitis.
)'. Pain in bronchitis is scarcely complained of;
and consists merely of a sense of soreness, heat,
and tightness in the chest, particularly beneath
the sternum, and is not increased on full inspira-
tion: in pneumonia, it is more marked, especially
in certain parts of the chest, generally nearer the
lateral regions, and is increased on inspiration
or prolonged expiration : in pleuritis, it is very
acute, and a full inspiration is impossible: in
croup and laryngitis, the pain is increased upon
pressing the trachea and larynx, ti. The counte-
nance in bronchitis is more frequently pallid or
bloated; in pneumonia, it is generally flushed;
and dyspnoea is greater in the former than in the
latter. The breathing is wheezing and hurried
in acute bronchitis; in pneumonia it is less so,
and generally without the bronchial wheeze. The
pulse, in the former, is frequent, full, free, de-
veloped, and soft; in the latter, full, hard, bound-
ing or vibrating, and sometimes oppressed and un-
developed. The general febrile symptoms are
more continued in pneumonia than in bronchitis;
morning remissions, with free perspiration, being
more frequent in the latter than in the former.
The physical signs in pneumonia, pleuritis, &c,
are the surest means of their diagnosis. (See ait.
Lungs — Inflammation of. ),
60. Some cases of asthenic bronchitis may be
mistaken for humoral asthma ; and occasionally
no very distinct line of demarcation can be drawn,
both affections either insensibly passing into each
other, or being complicated with one another.
But, generally, the slow accession of the former,
256
BRONCHI — Inflammation of the — Prognosis.
the more continued and less urgent dyspnoea and
tightness of the chest, and the presence of febrile
symptoms, particularly great quickness of pulse,
will distinguish it from humoral asthma; which is
commonly characterised by the sudden accession
of the paroxysms, their severity during the night,
and the attendant orthopnceu, the more or less
complete and prolonged intermissions, and espe-
cially by the absence of fever, and by the much
more marked integrity of the vital and animal
powers, than in asthenic bronchitis. In this
latter disease, the patient is incapable of leaving
his bed or his apartment : in asthma, he may
attend to his avocations; or may, at least, change
his room in the intervals between the fits. The
diagnosis between the sthenic bronchitis and asth-
ma is attended with no difficulty. (See Asthma,
§50.)
61. B. Of the chronic. — a. By auscultation.
The physical signs of this form of bronchitis are
not materially different from the acute. The re-
spiration is extremely varied : being sometimes
louder, at other times more obscure than natural,
and generally accompanied with the mucous rlton-
ckus ; which, however, is not heard over the
chest, but now chiefly in one part and then in
another, and seldom during the whole of the
respiratory act. The occasional occurrence of
the sibilous and sonorous rhonchi indicates that
the tubes are sometimes partially obstructed; but
this is much less frequent than at the commence-
ment of acute bronchitis; and it rarely happens
that the respiration is entirely interrupted in a part
of the lung. Very often, also, when the dyspnoea
is considerable, or even urgent, the air is heard to
enter the lungs as well as usual, the respiratory
sound being either distinct or puerile. The re-
sonance of the chest on percussion is scarcely di-
minished. When the bronchitis is very chronic,
the tubes sometimes become dilated, from being
weakened by the inflammation and strained by
the paroxysms of coughing. When this state of
the bronchi exists, the sputum is often foetid, and
several of the auscultatory signs of tuberculous
excavations of the substance of the lungs are pres-
ent. If the dilatations be large and rounded, it
may furnish pectriloquy and the cavernous rhon-
chus ; but if, as is more generally the case, it
extend to several tubes, or if they be dilated
along a considerable portion of their axis, a loud
bronchophony is only heard. If this dilatation
be extensive, bronchophony, bronchial respiration,
sometimes with a "veiled blovaing," and even
slight pectriloquy, will be heard in corresponding
parts of the thorax. On percussion, the sound is
often somewhat less than natural, owing to the
compression of the surrounding pulmonary tissue;
and owing, also, to this cause, the dyspnoea is
often great. Dilated bronchi remain long station-
ary; tuberculous excavations generally increase
rapidly. The former are most frequently situated
in the scapular, mammary, and lateral regions ;
the latter in the sub-clavian and sub-acromian
regions of the chest. (See the diagnosis in Tu-
bercles in the Lungs.)
6*2. b. Rational diagnosis. — It is chiefly with
tubercles in the lungs that chronic bronchitis is
liable to be confounded; and, indeed, without the
aid of auscultation, the diagnosis between them is
very difficult. When they both co-exist, and es-
pecially when the latter k attended with dilata-
tion, we have seen that even auscultation docs
not easily enable us to ascertain the exact state of
disease: however, by a careful comparison of the
physical and rational symptoms of both, we may
generally form a tolerably correct opinion. Early
m chronic bronchitis, the absence of pain during
inspiration, the capability of resting on either side,
the pallidity of the lips and countenance, the ap-
pearance of the sputum (§ 34, 35.), and the
wheezing noise on respiration, may readily distin-
guish it from tubercular phthisis. As the disease
advances, the symptoms more nearly resemble
tubercular consumption ; but the pallor of coun-
tenance and absence of pain generally continue;
or, if the latter be present, it is diffused over the
chest, and the patient can draw a larger volume
of air into the chest, and retain it longer, than in
phthisis. The dyspnoea, is less on exertion, consists
more of a stuffing sensation, and is more relieved
by expectoration; the sputum generally consists
of a more considerable portion of mucus, and is
more regularly abundant ; and the perspirations
are much more partial, the emaciation less, and
the paroxysms of hectic much less regular, than
in tubercular disease. The cough is very differ-
rent. In chronic bronchitis, it is generally deep
and sonorous, and in paroxysms; in phthisis, it is
short and tickling. When we find copious puru-
lent expectoration, but without broken-down por-
tions of softened tubercles or of the pulmonary
tissues; night sweats; hectic fever, with full deep
cough, and absence of the physical signs of phthi-
sis ; — if, after repeated examinations, there can
be detected neither a constant absence of the re-
spiratory murmur, nor gurgling cavernous rhon-
chus, nor pectriloquy, nor marked defect of reso-
nance on percussion, — we may safely conclude
the disease to be chronic bronchitis. When this
disease depends upon the inhalation of irritating
substances, as Dr. Hastings very justly remarks,
the cough and copious muco-puruient expectora-
tion often continues for months, or even years,
without much suffering, with pale countenance,
slight lividity of the lips, &c. In these cases
there can be no difficulty in the diagnosis.
63. vi. Prognosis. — A. In the acute. When
the disease is slight, or limited to a few bronchi
only, the disease generally terminates favourably.
The change is indicated by a more perfect apy-
rexia in the mornings, less severe and less fre-
quent cough, easier expectoration, and a thicker
and more opaque sputum; which, however, gen-
erally assumes a more fluid and glairy appearance
for a few evenings during the febrile exacerbation.
A relapse of the disease is indicated by increase
of the fever and cough, and a more transparent,
fluid, and glairy expectoration. When the in-
flammation is very severe and general, as indi-
cated by high fever, dyspnoea, &c, the prognosis
should be unfavourable, or givey with caution.
If symptoms of collapse have appeared, and the
mucous rhonchus be heard universally, and with
little or no respiratory murmur upon auscultation ;
if the pulse become very frequent, small or weak,
irregular or intermittent ; and if the countenance
be at the same time pallid and anxious, slightly
livid, or the nails of the fingers and lips tending
to purple ; the danger from asphyxia is extreme.
When the disease occurs in the course of contin-
ued or exanthematous fevers, in some epidemic
states of hooping-cough, and in the other severe
BRONCHI — Acute Inflammation of — Treatment.
257
forms of complication (§47,48.); and when
the si"ns indicating the unfavourable terminations
already enumerated appear, the danger is also
great, although it may not be extreme. The
supervention of pneumonia or pleuritis, or of
tracheitis or laryngitis ; a sudden diminution of
the expectoration ; the occurrence of cerebral
symptoms, of orthopncea, or even continued
dvspiuea, with expansion of the nostrils ; a dark
red colour of the tongue ; are all unfavourable
circumstances, and indicate imminent danger.
On the other hand, when spontaneous evacua-
tions occur, with a favourable change in the
cough and expectoration, particularly on one of
the critical days, although the attack has been
extremely severe, a favourable result may be
looked for ; more particularly if the disease pro-
ceeded from cold, and was uncomplicated.
64. The asthenic form of the disease is very
dangerous, when occurring at the extremes of
age ; but less so when it is unattended by marked
depression of the powers of life, and by signs of
the circulation of venous blood, — circumstances
which, in connection with the frequency, weak-
ness, and irregularity of the pulse, the quantity
and appearance of the sputa, and with the dirh-
culty of expectoration, constitute the danger.
65. B. In the sub-acute and chronic. — If it
have arisen from catarrhal affection, and be un-
attended by much emaciation or hectic, this form
of the disease will generally terminate favourably,
although the expectoration present a puriform
appearance. The more purulent, however, this
excretion, and the more marked the symptoms
of hectic, the greater the danger. But when the
sputum seems to consist chiefly of mucus, al-
though the quantity expectorated be great, a fa-
vourable issue may take place ; and this will be
more frequently the case when the chronic bron-
chitis has been consecutive of the acute. When
there are constant dyspnoea, very frequent pulse,
profuse sweats, and copious purulent expectora-
tion, with emaciation, hectic fever, colliquative
ftiarrhcea, associated symptoms of disease of the
liver, or of the mucous surface of the bowels,
with a smooth, glossy, or chopped, a dark red,
or raw appearance of the tongue, a most un-
favourable prognosis should be given ; and if to
these succeed aphthous eruptions about the mouth
and tongue or fauces, little hope of recovery can
be entertained. The causes and complications
of the djsease should also materially influence our
prognosis. When it has arisen from mechanical
irritation of the bronchi, patients often recover
from a very unfavourable state, when the irri-
tating cause has altogether been removed. The
occurrence of bronchitis in the scrofulous diathe-
sis, and its association with tubercles in the lungs,
are dangerous circumstances. This complica-
tion is to be ascertained chiefly by means of
tin- physical signs. If these indicate the existence
of tubercles, or do not establish with certainty
their absence, a very cautious opinion should be
given. The mucous rhonchus, and dulncss on
percussion, with the rational symptoms of tu-
bercles, are indications of a very dangerous mala-
dy. The rapid developement of symptoms of
the acute, in the course of chronic bronchitis,
must be viewed as an unfavourable circumstance.
The extremes of age also increase the risk in this
as well as in the acute state of the disease.
22*
66. Causes. — A. The predisposing causes are,
whatever lowers the energies of the frame, more
particularly too warm or crowded apartments ;
sleeping with too many clothes ; late rising, late
hours, and too great sexual indulgence; very early,
and far advanced age ; the lymphatic and san-
guineous temperaments ; relaxed habits of body;
febrile and exanthematous diseases, and the sup-
pression of accustomed eruptions and discharges.
67. B. The exciting causes arc, exposure to a
cold and moist atmosphere, or to currents of air,
particularly when perspiring : rapid vicissitudes
of weather and season ; wearing damp clothes or
shoes, or sleeping in damp beds or linen ; con-
tinued exposure to dry cold ; quick refrigeration
of the body after being over-heated and fatigued,
or upon coming from crowded apartments and
assemblies ; wearing too low or very thin dress,
with exposure of the neck and chest ; rapid at-
mospherical changes, particularly during autumn,
winter, and spring, and especially from cold to
heat ; epidemic constitutions of the atmosphere ;
easterly and north-east winds ; exposure to the
night air after rain ; the inhalation of irritating
gases, vapours, or mineral or vegetable particles
(see Arts and Employments, as Causes of
Disease, § 40.) ; sudden passage from the cold air
into over-heated apartments ; catarrhal infection;
miasmal exhalations in cold and moist states of
the air; the imperfect irruption or retrocession of
the exanthematous diseases ; and the translation
or metastasis of gout, rheumatism, erysipelas, &c.
68. vii. Treatment. — 1st, Of Acute Bron-
chitis.— A. In its simple states. M, Broussais
gives a very concise view of the indications of cure
in this form of the disease, which has been adopted,
verbatim, by Dr. Hastings ; without, however,
referring to the original writer. M. Broussais
very justly recommends that the excitement of
the sanguiferous system should be moderated, by
general blood-letting, acidulated and mucilaginous
fluids, and abstinence from stimulating food ; that
perspiration be favoured, by saline and antimonial
medicines, and by emollients, both internally and
externally employed ; and that the irritation and
congestion of the diseased vessels be relieved by
local depletions and emollient revulsants when
erythism of the capillaries predominates, and by
rubefacients and vesicatories when the nervous
powers are depressed.
69. a. In the first variety of the disease, blood-
letting is seldom requisite ; saline and antimonial
medicines, with demulcents, emollients, &c. being
generally sufficient. When, however, fever is con-
siderable, and the patient complains of soreness
or slight pain in the chest, a moderate bleeding —
preferably by cupping — will be serviceable ; and
full doses of antimony, or as much as the stomach
will bear of the solution of tartarised antimony, in
frequently repeated doses, will soon remove all
febrile disturbance. The following mixture has
generally answered this purpose in my practice
(see also F. 393. 854.):—
No. 66. R Mist. Camphors, Mist. Amvgilal. Dulc, ar«
% ij.; Liq. Ammonia; Acet. ^ jss.; Spirit. Mthrr. Nit., Vint
Aniimon. Tart., aa 3 'j,s-i Syrup Tolutan. 3jss. M- Capiat,
coch. ij. larga secunda quaque nora.
70. In the third variety, or the asthenic form
of the malady, blood-letting is generally required;
but it ought to be resorted to with much caution,
and early in the disease, as recommended by Sy-
denham and most practical writers of the present
233
BRONCHI — Acute Inflammation of the — Treatment.
day. From eight to ten ounces may be taken
from a vein, but, I think, preferably from betw een
the shoulders bj cupping ; and afterwards, revul-
sants, counter-irritants, and expectorants, maj I"'
employed. The admissibility of depletion, or of
antimonials, or the extent to which they should be
[, and the propriety of having recourse to
stimulating expectorants, necessarily depend, in
this form of the disease, upon the degree of mor-
bid action and of vital power presented by indi-
vidual cases, and upon the quantity of the expec-
toration and the difficulty to excrete it. Moderate
local depletions are more generally required when
this state of disease occurs in children, than when
it is met with in aged persons ; whilst the latter
are more benefited by expectorants, diaphoretics,
counter-irritants, an diuretics, than the former
class of subjects.
71. In the second variety of bronchitis, particu-
larly when the patient is young, plethoric, or ro-
bust, blood-letting should be early and energetical-
ly employed, and be directed as recommended in
the art. on the Blood (§ 64.); and a full impres-
sion made upon the circulation, short, however,
of syncope. Immediately afterwards, the pre-
parations of antimony, combined according to cir-
cumstances, should be given in full and frequently
repeated doses, so as to prevent the return of ex-
cessive local or general action, and to promote a
free and universal perspiration. The preparations
of antimony that may be selected for this pur-
pose are the ant. tartar., James's powder, or the
kermes mineral (F. 637.); and the first doses of
them may be advantageously combined with calo-
mel. The following may be exhibited ; or F. 24.
513. 530. 638., or other similar formulae contain-
ed in the Appendix : —
No. 67. ft Hydfarg. Suhniur. gr. vj.; Pulv. Jacobi Veri
gr. v.; Camphors? rasa? gr. j.; Exlr. Hyoscyami gr. v.; I mi-
sery. Rosar. q. s. ut fiat Bolus slalim post venajseclioueiu
sumenclu*.
No. 68. R Mist. Camphors 5 j. ; Liq. Amnion. Acct.
o ij. ; Polassae Nitratis gr. vj. — x. ; Spirit. .Titlier. Nit.
TT) xx. ; Vini Antiinon. Tart, (vel Vini Ipecacuanha:)
TT) xx. — xxx.; Tract. Hyoacyami TT) xv. ; Syrup. Tolutan.
~ j. M. Fiat Haustus, terliis lioris capiendus.
When antimonials are given in as large doses as
the stomach will bear, and frequently repeated
after the first full depletion, a second will not
often be necessary ; or local blood-letting will be
sufficient. But if the febrile excitement and the
state of the pulse and of the blood drawn indicate
it, venisection may, in robust subjects, be again
repeated to the extent already indicated. When
litis variety of the disease affects children, blood-
letting, either general or local, according to the
R're, should be prescribed, with saline diaphoretics,
followed by the semicupium or pediluvia. In all
classes of subjects, blood-letting must be regulated
according to the state of the pulse, heat of skin,
the character and quantity of the expectoration,
the presence of pain, and the prevailing charac-
ter of diseases ; attention to these circumstances
being especially required in children and aged
persons.
72. b. The choice of diaphoretics in this dis-
ease is deserving of notice. Early in the first
and second varieties I have usually preferred tar-
tarised antimony, generally in solution, and con-
joined with the vin. ipecacuanha', or with the
spirit, aether, nit., small doses of camphor, &c.
Bnt in infants or very young children, in the aged,
and ia the third or asthenic form of the disease,
ipecacuanha seems preferable, — in the latter class
of subjects particularly, combined with camphor.
In the more catarrhal, or less acute, forms of the
complaint, ipecacuanha, combined with nitrate
of potash and opium ; and, in the more sthenic
states of the disease, the same medicines, in larger
doses ; will often prove equally serviceable as
the preceding. While febrile excitement con-
tinues much increased, diaphoretics or diuretics
are often exhibited with little advantage, as the
restoration of these secretions is rather the conse-
quence, than the cause, of diminished or exhaust-
ed febrile commotion. The object, therefore,
should be, first to lessen the excitement by deple-
tion, alvine evacuations, and sedatives ; and then
to make choice of those diaphoretics which pro-
duce a lowering and refrigerant operation, until
the strength of pulse and heat of skin are reduced.
Hence the propriety of adopting the medicines
already recommended, and combining them with
the nitrate of potash, and with each other.
73. c. Emetics are amongst the most beneficial
remedies we can resort to in certain states of
bronchitis, particularly in the third variety ; and,
in the second, after blood-letting: in children they
are often remarkably useful. They have the
effect of unloading the bronchi of the mucus ac-
cumulated in them, of relaxing the surface, and
afterwards of promoting perspiration. For cliil-
dren, ipecacuanha should be preferred ; and for
aged persons, and the third variety of the disease,
the sulphate of zinc. In the second form, and in
all other subjects, the tartarised' antimony is the
best emetic that can be prescribed, its it operates
both by vomiting, by lowering vascular action,
and promoting perspiration. Emetics are more
particularly required when the expectoration is
difficult or suppressed, the cough severe and suf-
focating, and when the disorder depends upon the
inhalation of irritating particles. They more-
over tend to promote the operation of purgatives,
which are generally much required in this disease.
In cases of extreme depression, with suppressed
excretion of the secretion, the stimulating emetics
in the Appendix (F. 402, 403.) should be selected.
74. d. Purgatives and cathartics have been
considered by several writers as of doubtful ef-
ficacy in pulmonic inflammations ; and, when
expectoration is established, as being even pre-
judicial. Such appears also to be partly the
opinion of an able reviewer in the Medico-
Chirurgical Review for Dec. 1S20. But it is not
quite in accordance with my experience, which,
at the Infirmary for Children alone, must have
amounted to some thousand cases of the differ-
ent forms of the disease. It should be kept in
recbllection, that the expectoration in broiu I
not a salutary discharge from the lungs, the pro-
motion of which is a beneficial indication of cure;
but that it is the product of a morbid state, of the
nature of which it is an index : that this state
is generally inflammatory, and always attended
with determination of the circulating fluids, there-
in- keeping up the discharge. It is obvious, that
v> hateyer tends to increase the morbid determina-
tion to the bronchial surface will increase the dis-
ease, and, consequently the expectoration ; and
that whatever derives from this situation will pro-
portionately diminish both. That purgatives or
cathartics, judiciously combined, have the effect
of deriving from the lungs, by increasing the se-
BRONCHI — Acute Inflammation op the —-Treatment.
259
cretions of the liver and digestive mucous surface,
most be evident; and I have accordingly found
them serviceable when thus prescribed. Severe
attacks of bronchitis, moreover, arc favoured by
congestions and accumulations of bile in the bilia-
ry organs, and I >v sordes retained on the mucous
Burface of the bowels. In all those cases more
iHy — wherein the stools are generally very
offensive — and at the commencement of all the
tonus of the disease, these i licines ought to be
exhibited, with the view nol only of promoting
the abdominal secretions, and of removing fecal
matters and sordes, bul also of deriving the circu-
lation from the seat of disease; and the bowels
should be kepi very freely open throughout the
treatment. It is, of course, understood that we
arc not to prescribe cathartics to the extent of de-
pressing the energies of the frame too low, espe-
cially when they are already weak. Indeed,
purgatives may he as much required, and as ben-
eficiallv employed, in asthenic cases, as in others
of a more phlogistic description, particularly if the
bowels have been neglected; effects of a very
different nature from that of mere evacuation
arising from a judicious choice and combination
of them. Thus, when prescribed with hitters,
tonics, stimulants, or antispasmodics (F. 266.
471. 572. 880, 8S1. 887.), in the asthenic or
suffocative states of the disease, not only will full
alvine evacuations be procured, but also a tonic
effect on the digestive organs; and, consecutively,
a more moderate secretion in the bronchi, with an
easier expectoration, will he produced. I have
observed that the combination of purgatives, espe-
cially calomel, or those of the resinous class, with
camphor, antimony, and hyoscyamus, according
to the circumstances of the case, is particularly
serviceable in bronchial diseases.
75. e. Expectorants have been much abused
in inflammations of the bronchi; chiefly from the
circumstance of the expectoration being too gen-
erally viewed as a salutary discharge which ought
to be promoted, instead of its being a product of
the inflammatory state, or of active determination
to the surface of the air-vessels. I consider them
quite inadmissible when there is much fever or
fa : of skin, or when the sputum is abundant and
fluid, the patient having sufficient strength to bring
it up; and generally in the second variety of the
disease. On the other hand, in the third variety,
or when the expectoration is arrested evidently
from want of power to throw it off", or to excrete
it, or from its great viscidity, expectorants will he
of much service. In such cases, ammonia and
camphor should be first tried, as being generally
least detrimental in doubtful cases, and most
quickly beneficial. Where the admissibility of
expectorants is evident, especially in the asthenic
form of the disease, and in aged persons, squills,
ammoniacum, galbanum, or senega, may be di-
rected; with the precautions, and in the forms,
recommended when treating of them with refer-
ence to humoral asthma. (See Asthma, § 89.
103.; and II No. 41 — 46.) When expectoration
is tendered dillicult, and the cough suffocative,
from tlie tenacity and consistence of the sputum,
sometimes the case, attenuants and altera-
tives, as the fixed alkalies combined with ipeca-
cuanha, &c, or as prescribed in the article on
Asthma (§ 103. R No. 50, 51.), and exhibited
with camphor or ammonia, will be found of much
service. I safly all states of bronchitis, cam-
phor is a most valuable medicine. Its virtues
have been singularly overlooked by the writers
on this disease; bat, when combined with colchi-
ewm, or with antimony, nitrate of potash, ipeca-
cuanha, &C, and given in small doses, in the
more inflammatory and febrile states of the dis-
ease; or when prescribed in progressive^ larger
quantities, with diuretics, the spirit, aether, nit.,
opium, &c, as the vascular excitement subsides,
and febrile heat disappears; and in large doses
(from five to ten grains), with ammonia, ammo-
niac-urn, senega, opium, &c., when exhaustion and
difficulty of expectoration from deficient power are
urgent; it is one of the most valuable remedies we
possess in this, as well as in several other diseases.
76. /. The inhalation of emollient and medi-
cated vapours are occasionally of much benefit in
the sthenic form of the disease, but chiefly in its
first and second stages. The vapour arising from
a decoction of marsh mallows, or from linseed tea,
or from simple warm water, is the best suited to
(his state; and should be employed from time to
time, the temperature of the apartment being du-
ly regulated through the treatment, and constant-
ly preserved from about 66^ of Fahr. to 75^.
Dr. Paris recommends, during the dry easterly
winds of spring (when the disease is so preva-
lent), the vapour of warm water to be diffused in
the patient's apartment. In the early stage it may
be of advantage. In the case of the son of an
eminent medical writer, attended by Dr. Gordon,
Mr. Annesle y, and myself, this was tried in the
state of the air alluded to, but with no benefit.
The case terminated fatally, from extension of the
disease to the air-cells and substance of the lungs.
When the expectoration becomes whitish, opaque,
and thick, the vapour may be rendered somewhat
more resolvent by adding a solution of camphor
in vinegar, and extract of conium or hyoscyamus
to the hot water, or to the emollient infusions
now mentioned; and in the asthenic variety, par-
ticularly when the difficulty of expectoration, and
the fits of dyspnoea, are distressing, or when the
excretion of the morbid matter is impeded or sup-
pressed from want of power, the medicated va-
pours and gases recommended in the chronic state
of the disease (§ 9S.), and in humoral Asthma
(§ 88.) may be tried.
77. g. There are various medicines which are
occasionally useful, when exhibited in appropriate
states and periods of the disease. Amongst these,
narcotics and sedatives deserve an especial notice.
Opium should not be exhibited alone, as long as
febrile action is great; but, in combination with
antimony, or ipecacuanha, and nitre, it is often a
most valuable medicine. It is best given in small
or moderate doses, in conjunction with camphor
and expectorants, where vital power is reduced
and expectoration difficult (§ 37.). In general,
when the skin becomes cool, the bowels are well
evacuated, and the air-tubes remain irritable,
opium, or some other narcotic or anodyne, is in-
dispensable. Opium, and others of this class of
medicines, particularly when judiciously prescrib-
ed, are then of service, not* only in diminishing
the irritability of the system and of the air-pas-
sages, and in lessening the cough, the frequency or
sev< nty of which often aggravates the inflamma-
tory irritation of, and determination to, the bron-
chial surface, but also in equalising the circulation,
260
BRONCHI — Acute Inflammation of the — Treatment.
in determining to the skin, nnd promoting per-
spiration. In the more phlogistic states of the
disease, and at its commencement, colchicum or
digitalis will he often of advantage, in diminish-
ing vascular action, local determination, and mor-
bid irritability. They ought, however, seldom to
be used at the same time. In the more sthenic
cases, digitalis is very beneficially associated with
the preparations of antimony. When the sputum
is thick and opaque, colchicum is generally less
beneficial than at an earlier period, e\cepting in
conjunction with diuretics and camphor. When
the skin has become cool, it is no longer of use.
In the third variety, it is seldom indicated, unless
at the commencement of the disease, or when
combined with ammonia and camphor. Upon
the whole, both colchicum and digitalis are less to
be depended upon in acute bronchitis, than a ju-
dicious combination of antimonials with anodynes,
&c. Hyoscyamus, conium, and the extracts of
lmPl"J and of lettuce, are also very generally ser-
viceable in the different forms of bronchitis. But
with them, likewise, the amount of advantage will
entirely depend upon the manner in which they
are prescribed. In the sthenic and febrile states
of the disease, and at its commencement, they
should be associated with antimonials, ipecacuan-
ha, refrigerants, demulcents, and emollients (F.
24. 20S. 427. 554.); with diaphoretics (F. 394.
568. 809.); and with diuretics (F. 818. 865.
S93.); or in other similar forms, of which there
are several in the Appendix. When the disorder
assumes an asthenic state, or when expectoration
is difficult, the cough distressing, and the skin cool,
any of the sedatives particularised may be con-
joined with either ammonia, camphor, or the fix-
ed alkalies, or with other attenuants (F. 835.),
and with expectorants, &c. (F. 356. 555. 558.
811. 895.) according to circumstances.
78. h. When the acute form of the complaint
seems to be about lapsing into the chronic, the
combination of gentle tonics with emollients and
diaphoretics is often of service, as was first point-
ed out by M. Broussais, who allowed also red
wines much diluted w ith water in this state. The
infusion or decoction of cinchona, or the infusion
of uva ursi, may be thus prescribed: —
No. 69. R Dccocti vel Infusi Cinchonae % iijss. ; Liq.
Amnion. Acet. ? jss. ; Mucilag. Acaciae *ss. ; Spirit.
Oilier. Nit. 5i.iss-i Tinct. Camphor* Comp. 5ss-i Extr.
Conii gr. xx. ; Syrup. Tolutan. ^ss. M. Capiat Cochleare
iinuin amplum secunda vel tertia quaque hora, vel Coch. ij.
quiutis velsextis horis.
79. i. External measures ought not to be over-
looked during the course of the disease. In re-
spect of local or general depletions nothing need
be added to what has been already stated. The
former of these should always be preferred when
doubts are entertained as to the propriety of tak-
ing any considerable quantity of blood; and, in
the sthenic form of the disease, may be resorted
to at an advanced stage, particularly when the
change in the expectoration, and other symptoms
(§ 35.), indicate a return or exacerbation of the
inflammatory action. Blisters are not admissible
in the early stages of sthenic bronchitis. But, in
the asthenic disease, or when inflammatory ac-
tion and febrile heat have been subdued by deple-
tions, &c, blisters are of much service, and may
be applied either between the shoulders or on the
breast; and, in some severe cases, re-applied or
kept discharging for some time. In young child-
ren, and in adult or aged persons, when the secre-
tion of the bronchia] surface is profuse, and the
powers of life much exhausted, I have derived
more permanent advantage from the use of the
rubefacient liniments in the Appendix (F. 295,
296. 311.), rubbed assiduously twice a day over
the chest or back, than from blisters. When blis-
ters are employed, much benefit will sometimes
arise from removing them as soon as slight redness
of the skin is produced, and covering the part with
a large warm bread and water poultice, which
ought to be frequently renewed; or by applying a
succession of warm fomentations. In some ex-
treme cases of this description, I have seen much
advantage derived from applying over the epigas-
trium and lower part of the chest, a flannel wrung
out of hot water, and immediately afterwards
soaked with the spir. terebinth., and allowing it to
remain until severe burning heat of the skin is pro-
duced by it. If suffocation be threatened either by
the profuseness of the secretion, by its difficult ex-
pectoration, or by exhaustion of the vital energy;
and if we be, as we then unfortunately are, at a
loss for any probable means of success; this will
sometimes have a remarkable effect, and save the
life of the patient, particularly when assisted by
the internal use of camphor, ammonia, &c. At
the time of my writing this, a case occurred, at-
tended by Mr. Faxon and myself, where imme-
diate relief and a speedy recovery followed this
almost dernier resort. And I have often wit-
nessed a similar result, in other most dangerous
cases of this description, from tlte internal as well
as the external use of this most valuable remedy,
particularly at the Infirmary for Children, where
I have for many years had recourse to it in cases
of danger.
SO. The tepid bath, or semicupium, will often
be of service early in the disease; and in its course
sponging the surface of the chest, or of the whole
trunk, with warm water and vinegar, and after-
wards with the warm nitro-muriatic acid lotion (F.
834.), particularly towards the decline of the dis-
ease, when we dread its lapsing into the chronic,
and in the asthenic variety, will often prove of es-
sential service. The common beverage of the
patient during the treatment should be regulated
according to the state of febrile action, and its
compatibility with the treatment directed. Bailey
water, with any of the vegetable acids, tamarind
water, or any of the formula? or drinks (vide Po-
tus), contained in the Appendix, may be directed.
81. B. Of the complicated states. — a. Bron-
chitis is not infrequently associated, particularly
at its commencement, with sore throat; inflam-
mation existing not only in the fauces, but extend-
ing to the pharynx, and through the larynx down
the trachea and bronchi. This state of disorder
sometimes obtains in scarlet fever, forming a com-
plication of remarkable danger. I have also ob-
served it, in a very severe form, affect six members
of one family, and three of another, both living in
the vicinity of the metropolis, in a low damp situ-
ation, all of whom had long previously had scar-
latina. In some of these cases the danger was
great, and all were severe and of the asthenic
type. Purgatives, first consisting of calomel and
James's powder, and subsequently combined with
stimulants and tonics, were actively exhibited.
Demulcent linctures (see Linctus, in the Appen-
dix), or astringent, cooling, and antiseptic gargles;
external revulsants, and rubefacients ; the inter-
BRONCHI — Co M r 1. 1 c a t k u I S v i. a u nations o r the — Tk e a i u i m.
261
iial exhibition oC camphor, combined with anti-
monials, byoscyanaus, diuretics, ami afterwards
whh amniouia, mild attenuants, expectorants,
and tonics; the liquor ammonias acetatis, with
infos, , , spirit. anher. nit, or spirit, am-
nion, arom., &c, formed also the chief means of
cure. All the cases terminated favourably.
82. 6. When the disease is complicated with
I fever, the treatment will altogether depend
upon the character of the prevailing epidemic,
and the circumstances of the ease. Early in the
complication, local depletions are sometimes re-
quired; and afterwards, roll doses of camphor or
ammonia, or of both, — particularly if the eruption
prematurely disappear, or present a dark tint, or
it' the anginous affection assume an ash-colour,
ora dark red, or brownish hue. — are amongst the
chief remedies to be depended on. I have mel
with severe cases in which the bronchial disease
either preceded, or followed, the efflorescence and
decline of the eruption in scarlet liner; and in the
course of this association most violent cerebral
symptoms have supervened; thus forming a dou-
implication. These cases, although ex-
tremely dangerous, are not necessarily fatal. Lo-
cal depletion, sometimes to a very considerable
extent, may he practised, chiefly by leeches ap-
p'ied over the sternum, behind the ears, or below
the occiput, or by cupping on the nape of the
neck; and calomel, antimony, revulsants, purga-
tives, camphor, ammonia, &c, according to the
circumstances of the case, should be prescribed.
Counter-irritation by rubefacient liniments is par-
ly required in complications of the disease
with scarlatina or measles. Formula: No. 299.
aud 300. may be used for this purpose, or the
following : —
R Camphors ~ j.; Pulv. Capsici " *s. ; Olei
Mm i- TT) x>:\. ; Olei Oliv.e 3 jss. 5 Liq. Amnion. 5 vj.
. Fiat Liniiiicntum.
83. c. The appearance of the disease with
measles, either previous to, in the course of, or
subsequently to, the eruption; or even its accession
during convalescence, is a very frequent occur-
rence. This association was very common in the
winter and spring seasons of 1829, 1830, 1831,
and 1832; during which epoch, blood-letting was
not so generally indicated, nor so well home, as in
former years, the bronchial affection being more
frequently of the asthenic type. In general,
however, local depletions are required early in
the disease, and, in some eases, may be carried
to a considerable extent; often much further than
in its association with scarlatina. I have some-
times found ii uecessarj to deplete locally in both
states of complication, at the very time
when I judged it proper to exhibit camphor or
ammonia in considerable doses. But in many
instances, particularly during the years above
specified, patients have recovered as readily when
no sanguineous depletion has been employed, as
where it has. Bronchitis occurring either in the
course of scarlatina, measles, or small pox, re-
qnires active counter-irritation and revulsion; and
the means recommended for this purpose (§ 79.)
to be decidedly enforced. The observations I
have already made respecting the use of inhala-
tion (§ 76.) also apply to such cases. When
these exanthemata commence with bronchial
symptoms, emetics are then of decided advantage.
.And, if they be accompanied with sore throat,
purgatives oughl to be given in decided doses, the
bowels freely acted upon throughout, and enemata
occasional!) thrown up, particularly F. 140. 149.
794.
84. d. When bronchitis occurs in the course of
continual fivers, the same general principles of
treatment are required, as have been specified in
respect of scarlatina end measles. In all these
States of complication, this disease should lie
viewed as a marked manifestation, in a particular
organ, of the morbid stale prevailing more or less
throughout the frame; and it should be kept in
recollection, thai this affection always, in some
measure, impedes the changes effected by respir-
ation on the blood, thereby increasing the morbid
condition of this fluid existing more Or less in all
severe eases of exanthematous fevers, and at least
the disposition to it that obtains even in simple
continued fever. The extent to which depletion
should be carried in this complication, or the
propriety of employing ii at all must depend upon
the character of the fever, of the prevailing epi-
demics, and the particular symptoms and circum-
stances of the case. I have seen a strong, and
regular-living man, with fever thus complicated,
very dangerously depressed by a single small de-
pletion. Purgatives are, however, better borne,
particularly when combined with camphor or
ammonia; and occasional large doses of calomel
combined with camphor, and followed in a few
hours by a cathartic draught, will be found of
much service in promoting the functions of the
liver, and enabling it to remove those elements
[Voe; the blood, which so readily accumulate in
it to a hurtful extent, when their elimination by
the lungs is impeded. Much advantage will also
arise from the use of blisters applied for a few-
hours, and often repeated; from the use of the
rubefacient liniments above specified; and from
the inhalation of the vapour of warm water, with
a solution of camphor in vinegar added to it.
85. d. The association of the sthenic form of
bronchitis with tracheitis and laryngitis, either
affection preceding the other, requires full deple-
tion, general or local, or both; large and repeat-
ed doses of calomel, with antimony; the tepid or
warm bath, semicupium; internal and external
revulsion, by cathartics, purgative enemata, &c;
emetics, particularly when the paroxysms of suf-
focation and stridulous respiration are urgent;
the inhalation of watery, emollient, and anodyne
vapours; and a free use of diluents, emollients,
&c, with the sub-carbonate of soda, the sulphu-
ret of potash, small doses of the sulpburet of
ammonia, or of the sulpburet of copper, in ex-
treme cases, until nausea or vomiting is occasion-
ed, &.c. Blisters are seldom of much service
in this state of disease, particularly whilst the
symptoms of croup are present. They ought
never to be applied over the throat, as occasion-
ally directed, and, in some eases, not without mis-
chief; although recovery has taken place in others,
notwithstanding the risk they occasioned of in-
creasing the local irritation.
8b. e. One of the most frequent complications
presented to us in practice is that of bronchitis
with hooping cough. In some eases, this com-
plication commences with the usual symptoms of
catarrh, on which those of bronchitis supervene;
the characteristic signs of hooping cough, par-
ticularly the convulsive fits of coughing, with the
262
BRONCHI — Chronic Inflammation of the — Treatment.
inspiratory whoop, and vomitings, not appearing
for some days subsequently. In other cases — and
those, perhaps the most numerous, — the inflam-
matory affection has not appeared until after the
invasion of pertussis. When thus associated,
bronchitis may be either sthenic or asthenic; the
one or the other being more generally prevalent
in some seasons than in others. During the
years specified above (§ 83.), the asthenic state
was most common; and I have seen several cases
in which sanguineous depletion had been injudi-
ciously practised, particularly as respectsquantity.
Cerebral symptoms are apt to occur during this
complication, and also infiltration or hepatisation
of a part of the substance of the lungs. These
unfavourable terminations should be anticipated
and prevented by small local depletions, — by
leeches applied behind the ears; by the exhibi-
tion of camphor combined with ipecacuanha or
antimonials, and narcotics, particularly conium
or byoscyamus; by diaphoretics with diuretics;
and more especially by the use of the liniments
and revulsants already recommended (§ 79.).
(See Hooping Cough.)
87. /. The simultaneous occurrence of inflam-
matory action in both the digestive and respiratory
mucous surfaces is not infrequent, particularly in
children ; and means calculated to benefit the one,
generally aggravates the other, or risks the ac-
cession of cerebral disease. I have found small
local depletions, followed by the pulv. ipecacu-
anha? comp., combined with small doses of calo-
mel, or hydrarg. cum creta and camphor; the
warm baiii and frictions, with the stimulating
liniments already specified (§ 79.) ; the applica-
tion of blisters for a few hours only, and often re-
peated; the liq. ammonias acet., with spirit, aether,
nit., camphor mixture, diuretics, &c, constitute
the principal means of cure.
88. g. The association of hepatic disorder
with bronchitis is not rare. But the affection of
the biliary organs does not always precede the
bronchial disease : it often occurs in its progress;
an increased, as well as a morbid, secretion of
bile supervening, probably in consequence of the
vicarious increase of function of the liver, and its
irritation by, and elimination of, the morbid ele-
ments accumulated in the blood owing to the
impeded function of the lungs. This complica-
tion requires the use of mercurial purges com-
bined with camphor and antimony, particularly
James's or kermes powder (F. 637.); external
irritants and revulsants, cathartic enemata (F.
151.), &c. A similar treatment is indicated when
the disease is connected with the translation of
erysipelas, gout, or rheumatism.
89. h. If the inflammation extend to the sub-
stance of the lungs or pleura, the antiphlogistic
treatment should be rigorously enforced : the
solution of tartarised antimony ought to be given
in frequent doses, and carried as far as circum-
stances will permit; internal and external revul-
sants resorted to at the same time; and diapho-
retics and diuretics suited to individual cases pre-
scribed. In some instances, either colchicum or
digitalis, or both, may be substituted for the an-
timony; but they answer better, particularly the
digitalis, after this medicine has previously been
used. If we have reason to suppose that effusion
of serum has taken place in the thoracic cavities,
diuretics, and, amongst others, digitalis, should be
employed; recollecting, however, that the accu-
mulative and sinking effects of either digitalis or
colchicum sometimes appear very rapidly, and in
an alarming degree, when they are given either
at the same time or after the exhibition of tartar-
ised antimony. Disease of the brain or its mem-
branes supervening in the course of bronchitis has
been considered in the article Brain (§ 186.).
90. The sub-acute form of bronchitis re-
quires in all respects the same treatment as the
acute uncomplicated disease, but not carried so
far; the activity of the means should have due
relation to the acuteness of the attack, and the
effects they produce.
91. 2d. Of Chronic Bronchitis. — M.
Broussais has very justly stated the indications
of cure in chronic bronchitis to be, 1st, to diminish
the general excitability, and to keep the circulation
quiet; 2d, to solicit the excitement and the fluids to
other organs, particularly towards the skin ; and, to
these I would add a 3d, viz., to restore the healthy
tone and functions of the bronchial surface, by
means which seem to have this effect either directly
or indirectly. It is obvious, however, that the ac-
complishmentofthefirstand second intentions have
an indirect influence in bringing about the third.
92. a. General blood-letting- is inadmissible in
this state of the disease; and even local bleedings
should in many cases be employed with caution.
Cupping, however, to a moderate extent, is very
frequently required; and it is evidently more ad-
vantageous to repeat the operation to a small ex-
tent, than to abstract a large' quantity at once.
When the disease has existed long, and is at-
tended with a copious discharge, much general
debility, and absence of pain upon full inspiration,
even local depletion cannot be ventured on. Next
in importance to depletion is counter-irritation;
and for this purpose several means are presented
to US. When there is a tendency to acute action,
or when the cough is at all painful, and the spu-
tum puriform, either the tartarised antimonial
ointment, or a large issue or seton in the side, is
preferable; but when there is very marked relax-
ation of the bronchial mucous surfaces, blisters,
and rubefacients, or a succession of them, seem
more appropriate. I have, however, found, in a
number of cases, the liniments, No. 296, 297.
311. in the Appendix, productive of much greater
advantage, and more generally applicable, than
either blisters or the ointments, 'ihey may be
employed once or twice daily. The vapour aris-
ing from them, and diffusing itself around, has
also a direct and beneficial effect, by being inhaled,
upon the diseased mucous membrane. M. Brous-
sais is very favourable to the use of setons and
issues; and I have seen several instances of nark-
ed benefit from them, particularly in the obstinate
state of the disease which simulates tubercular
phthisis. He also recommends warm cataplasms
to the chest, made rubefacient by the addition of
mustard. I have seen advantage produced by
warm bread and water poultices applied over blis-
tered surfaces, and the seats of issues formed by the
mezereon bark, and by the same kind of poultices,
to each of which one or two table-spoonsful of the
nitro-muriatic lotion (F. S34.) had been added.
But it is chiefly early in the chronic disease, or
when it has recently passed into this state from
the acute, that issues and setons prove successful.
They exhaust the energies of the system too
BRONCHI — Chronic Inflammation of the — Treatment.
263
much to be of service in the latter stages, or when
the discharge from the lungs is profuse, and the
vital energies much depressed.
93. !>. Expectorants have been much employ-
ed in this state of disease; and though more ap-
propriate in it, than in the acute, they are often
hurtful from their too exciting operation on the
vessels of the bronchial surface. This is especi-
ally the case with squills, ammoniacum, and se-
nega, which ought to be used with much caution,
and never whilst the sputum is purulent, and
pain or soreness complained of in the chest, with
lever, heat of skin, &c. The best expectorants
are those which are also astringent, or at least
not very heating: amongst these, the sulphate or
oxide of zinc, with small doses of myrrh or gal-
banum, and extract of coiiium; or small doses of
sulphate of quinine, or of the sulphate of iron,
with ipecacuanha and opium; or the sulphuret of
potash, and the Buhamum Sulphuris (F. 21, 22.),
are the most eligible, when the state of the ex-
pectoration, of the skin, and pulse, indicates the
propriety of having recourse to tonic expectorants.
Opium has been too much reprobated in cases of
this description, as well as in acute bronchitis,
owing to the dogma that it suppresses expecto-
ration. I believe, however, that, when judicious-
ly combined, particularly with ipecacuanha, with
the muriate of lime, or either of the sulphates of
potash, of alumina, or of zinc; or with the nitrate
of potash; with camphor, with kermes mineral,
or James's powder, according to the circumstan-
ces of the case, it is a valuable medicine; and that
the diminution of the expectoration produced by
it, and which has been unaccountably dreaded,
is. when it occurs, a consequence of its changing
the morbid state of the vesse's forming the ex-
creted matter. If it be the object — as necessarily
follows from the doctrine of some writers — to
preserve a copious and free expectoration in this
disease, how can it ever be cured? Frequently
have I seen this end pursued, as if it constituted
all that was required, and squills, ammoniacum,
senega, &c. given accordingly; and the more
abundant and easy the expectoration thereby
produced, the more rapidly did the powers of life
give way, or complete hectic, with all its attend-
ants, manifest itself. The following have proved
serviceable when the pulse was soft, and not re-
markably frequent; the skin cool and moist; the
sputum very abundant, and consisting chiefly of
mucus; and the weakness and emaciation con-
siderable : —
No. 71. Pulv. Ipecacuanha; it. j. ; Camphora; raw sr.
H. — j. ; Extr. Conii gr. iv. — vj. ; Mucil. Acaciee q. s. 5l.
Fiant i'il. ij. ter die capiendae.
No. 12. R Zinci Sulphatu gr. vj. ; Masse Pilul. Calbnn
Co. :) j. ; Extr. Conii 3 ?s. ; Svrup. q. s. M. Fiant Pilu-
le xij., quaruin capiat unam terilia horis.
No. "3. K Pulv. [pecacuan. Comp. gr. xxv. ; Quininae
SulphaUi gr, vj. ; Pulv. Acacia; }) j. ; Extr. Lacluce ;) j. ;
Syrup. Papaveris q. %. M. Fiant Pilule xviij., quaruin ca-
piat liill is l»r qlloliilir.
No. 74, li Quinine Sulphatis gr. vj.; Pulv. Ipccacuan-
K _ i . i v: ; Camphors rase gr. iv. ; Opii Purigr. vj. ; Pulv.
Hal GlycyTrh. (vel Extr.) 3 ss- i Mucilag Acacie q. s.
Jttisce bene, el fiant Pilulie xx., quaruin capiat binas ter qua-
No. 7 j. [{ Balsam. Sulphuris 3 53- i Pulv. Ipecac, gr.
> i. j Extr! Bonii .) ij.; Pulv. et Mucilag. Acacie q. s. Jil.
i undum artem, Pil. xx., quaruin capiat binas quartii
q-daqite lima.
.No. 76. II Soltlt. ^Turiatis Calcis IT] xx.— xxxv. ; Mist.
faoijiliora- ", x. ; Tinct. Opii Comp. ({•". 729.) TT| x. — xx ;
(vel. Tinct. (amphorae Comp. 5 jss.) M. Fiat Haustus ter
die- capiendus.
94. c. In cases of this description, any of the
formula; given under the head Balsams, in the
Appendix, may be employed. Dr. Armstrong
strongly recommended tin; balsam of copaiva in
chronic bronchitis; but it is seldom beneficial, and
is certainly inferior to the other balsams and ter-
ebiuthinates in this affection (F. 486, 487. 538.
571.). In the more advanced stages of chronic
bronchitis, particularly when the colliquative
sweats or diarrhtea occur, the most essential ben-
efit has been derived from the following mixture,
in several cases in which I prescribed it; but even
where the bowels are regular, I have found it by
no means productive of costiveness. At the time
that I was giving this medicine to the third patient
on whom 1 had tried it, a case, showing the suc-
cess of a nearly similar treatment, was published
by Dr. Hastings (Midland Med. Repor. vol.
ii. p. 376.), — a coincidence fully evincing the
propriety of the practice.
No. 77. |{ .Mist. Crete ^ vjss. ; Villi Ipecac. 3 jss. ;
Tinct. Opii 3j. ; (ve' Tinct. Camphors Comp. 3 vj.);
Syrup. Tolutan. 3 iij. M. Capiat Cochleaiia duo larga ter
quaterve in die.
The cretaceous mixture will often be of service
when used alone, or with a little of the muriate
of lime, or with the addition of mucilage, or of
hyoscyamus, or conium, or extr. lactuca;, or the
extr. papaveris, according to circumstances. In
this state of the disease, also, I have seen sulphur
given with advantage in mucilaginous electuaries.
Dr. L. Kerckhoffs states, that he has adminis-
tered it with success, in conjunction with the pow-
der of the white willow bark. M. Broussais
relies chiefly upon mucilages and demulcents,
combined with ipecacuanha and opium, and cer-
tainly with great justice. (See F. 2S4, et seq.).
The extr. lactucse, as recommended by Dr. Dun-
can, may occasionally be substituted for the
opium. The decoctions of Iceland moss, and the
infusions of conium, of marrubium, of the uva
ursi, or of the melissa (F. 230. 237, 23S. 245.
267.), with mucilages, anodynes, and ipecacuan-
ha, are also very serviceable. I have given the
preparations of iodine in a few cases, in small do-
ses; and, in some instances, especially when there
was little or no febrile action, nor much emacia-
tion, benefit appeared to be derived from them.
95. d. When the disease is attended with
dyspnoea, and profuse or difficult expectoration,
emetics are of great, although often of temporary
advantage, particularly in aged persons. Ipecac-
uanha, or sulphate of zinc, with the addition of
diffusive stimulants (F. 402.), are the most ap-
propriate in the majority of cases. After their
operation, and if the strength be not very much
reduced, the digitalis or colchicnm may be pre-
scribed, in conjunction with diuretics and gentle
astringents (F. 203.). These active medicines
are chiefly suited to the more febrile states of the
disease, or when soreness or slight pain of chest
are complained of, with a puriform expectoration;
and are best combined with small doses of blue
pill, camphor, and opium, — with pectoral infu-
sions and nurtures (see A pp. F. 244. 426. 4:>7.)
with demulcents (F. 389.), and with diuretics (F.
194, 195. 236, 237.). Dr. Hastings recom-
mends a combination of digitalis and colchicum;
but i have seen more harm than benefit occasion-
ed bv it in some cases of chronic bronchitis,— a
result which might, a priori, be expected from
the associated operation of two most depressing
264
BRONCHI — Chronic Inflammation of the —Treatment.
medicines, given in a state of disease character-
bed by irritative, rather than by acute, vascular
action.' 1 have found them most beneficial when
exhibited singly with diuretics, or diaphoretics,
in the chronic forms of bronchitis consecutive
of exanthematous fevers (§54.); sometimes re-
sorting also to the warm bath, followed by fric-
tions of the surface with the liniments F. 297. or
oil. The combination of colchicum and digita-
lis, in small or moderate doses, has proved more
serviceable, in my practice, in tubercular disease
of the lungs, or when bronchitis has been com-
plicated with tubercles. Iu cases where the pro-
priety of giving these medicines is doubtful, a com-
bination of them with the alkalies, or their carbon-
ates, and with tonic infusions or decoctions, or F.
515 — 517., or the following, may be prescribed: —
No. 7a. V Pulv. Oolchici (vet Pulv. Digitalis) ::r. j.—
ij. ; Massae Pilul. Hydrarg.gr. ij. ; Massae Pilul. Galban.
I'omp. gr. v. : Extr. Opii gr. ss. ; Syrup, q. s. M. Fiant
Pi], ij. liis terve quotidit sumendae.
No. 79. R Infus. Uvae Ursi 3 xij. ; Acidi Sulph. Dil.
Tt| xx.; Tinct. Digitalis IT] x.— xv. ; Tinct. Camphorae
Comp. 5 j.; Syrup. Papaveris 3 ss. M. Fiat Hauslus, bis
terve in die sumendus.
No. SO. R Soda? Sub-carbon; (vel Liq. Potass*) Z j. ;
Infus. Calumbae (vel Decocti Cinchona?) § vj. ; Tinct. Ool-
chici Seniin. ~, j. — " jss. ; Tinct. Digitalis TI| xxx. JYI.
Capiat Coch. ij. larga ter in die.
No. 81. R Mist. Diosmae Crenata; (F. 396.) 5VSS.; Tinct.
Digitalis H| xxxv. (vel Tinct. Semin. Oolchici "ij. — 3'j-i)
Extr. Oonii gr. xxvj. (vel Extr. Lactueae 5 ss.) ; Syrup To-
lutan. 5 ss. M. Fiat Mist., Cujus sumat Coch. ij. larga ter
quaterve in die.
No. £2. R Pulv. Acacia? " ij. ; Mist. Amvedal. Dulc.
et Camphora :ia ~ iij»;. ; Acidi Hydrocyanici TT| vj. — xij.;
Spir. .Ether. Sulph.' Comp. ~, ij. — iij. ; Oxymellis Scillae
g ss. M. Coch. ij. vel. iij. larga tor in die.
96. Prussic acid is often of much service in
the chronic forms of bronchitis, especially in their
complications with disorder of the digestive or-
gans, and may be exhibited with demulcents,
gentle tonics, astringents, or expectorants, or as
prescribed in the Appendix (F. 344. S5S.).
When the disease is associated with derangement
of the hepatic functions, or even of the stomach
and bowels, it will be necessary to give small
doses of blue pill, or of the hydrarg. cum creta,
with deobstruents and gentle tonics; and, on some
occasions, full doses of calomel from time to time,
either alone, or in suitable forms of combination,
followed by a purgative.
No. S3. K Pilul. Hydrarg. gr. vj. (vel. Hydr. cum Cre-
ta gr. xviij.) ; Pulv. Tp. <■;<< uanli 1 ■ zv. viij. ; Extr. Sarsae et
Kxt. Taraxaci fin ~, j. ; Gum. Assaftutida? et Saponis Casril.
aa H) j. M. Fiant Pilulae -xlviij., quaium capiat binas ter
quaterve in die.
No. 84. j; Hydrarg. Submur. gr. vj. ; Kermes Mineral,
gr. xij. ; Camphorae rasas gr. xij. : Extr. Taraxaci 3 ijss. ;
Extr. Humuli g jss. M. Divide in Pilulas lxiv., quarum
capiat ij. vel iij. ter cpiaterve in die.
97. The treatment which has been already re-
commended for Humoral Asthma (see par-
ticularly § 100, ct omn. scq.), and the tonics and
astringents, especially the sulphates of zinc, iron,
or quinine, already noticed (§ 93.), are applicable,
with but little variation, to the more chronic and
humoral states of the disease, especially in per-
sons advanced in life, and in children, when it
lias assumed a chronic form after hooping-cough
and the exanthemata. 1 hive also occasionally
seen benefit derived, in those states of chronic
bronchitis, from the chlorate of potash, given to
adults, in from two to six grains, three or four
times a day. '1 his medicine was often prescribed
by myself and one of my colleagues, at the In-
firmary lor Children, during the years 1S20 —
1S2S, and subsequently, in the more chronic
forms of bronchitis, and in various disorders of
debility; in which latter it was generally beneficial:
but little advantage was frequently derived from
it in this disease, unless in those forms of it now
mentioned, where it was often of great use, par-
ticularly when the morbid action seemed connect-
ed with deficient tone of the bronchial vessels,
and of the system generally. Mr. Murray, in
a recent publication, states, that he has employed
it successfully in consumption, — a name which
has usually comprised most of the cases of this
form of bronchitis.
98. e. Inhalations of medicated or tar vapours
have been recommended by Crichton, Pagen-
STECHER, IJUFELAND, FORBES, HASTINGS,
Elliotson, Cannae, and others noticed in the
article on Asthma, and been disapproved of by
some. I believe that they have frequently been
used in too concentrated a state ; or too much of
the vapour has been diffused in the respired air,
occasioning irritation of the bronchial membrane,
instead of a gently tonic and healing effect.
Whenever any of the vapours advised in this dis-
ease produce an increase of the cough, either its use
should be left- off, or its strength greatly reduced
The manner of having recourse to such vapours,
as well as the choice of substances emitting them,
have not, in my opinion, always been judicious.
The tar vapour is occasionally of service, chiefly
from the quantity of turpentine it contains; while
the acrid empyreumatic fumes which it also emits,
counteract whatever good effect the former con-
stituent might produce. Would it not, therefore,
be preferable to try the effects of the substance
from which the advantage is obviously derived ? I
have done so in a few cases oi' this disease, and seen
marked benefit result from it ; and therefore recom-
mend it to the notice of other practitioners. Iu
former times, medication by fumigations and va-
pours was much resorted to; and it is probable, that
the early use of incense and various balsamic and
aromatic fumes in religious rites had some relation
to their prophylactic effect against disease, or even
to their curative influence; the more especially, as
the priests of antiquity also exercised the healing
art. Iu several of the productions attributed to
Hippocrates, the inhalation of vapours and
fumes of various resinous and balsamic substances
is recommended; and a number of writers in the
16th, 17th, and 18th centuries, have advised a
nearly similar method, and employed camphor,
benzoin, amber, frankincense, myrrh, storax, as-
safcetida, sulphur, cloves, the balsams, &c. for
this purpose. Tills practice was employed by
Benedict (see his Theatrum Tabidorum) in
consumptive diseases: and Boerhaave gives
several formula, in his Materia Medica, for fumi-
gations with the above substances. Mead, in his
Monita << Pfecepta, oilers several judicious re-
marks on this subject. He observes — " that fumi-
gations with balsamics, &c. is of vast service in
some cases: which is to be done by throwing the
ingredients on red coals, and receiving the fumes
through a proper tube directed to the windpipe."
After noticing the undeserved neglect of this
practice, and the propriety of thus applying me-
dicinal substances directly to the seat of disease,
he states, that the smoke of the balsam of Tola
convex cd into the lungs, or the smoking this
substance like tobacco, is of signal service in
BRONCHI — Chronic Inflammation of the — Treatment.
265
diseases of this organ, (p. 58.) It appears from
the writing of Fa*CASTORi that the fumes of
cinnabar were much employed by inhalation in
the treatment ofthe constitutional forms of syphilis,
at an early period ol* the histof) of that disease,
when it assumed a pestilential form.
99. Notwithstanding the unsuccessful attempts
of Beddoes to revive the practice, by employ-
infthe elementary and permanently elastic gases,
but according to views too exclusively chemical,
the practice of inhalation has long been neg-
lected, or undeservedly fallen into the hands ol'
empirics. Very recently, however, it has been
brought again into notice by M. Gannat., Mr.
Murray, and Sir ('. Scudamore ; and chlorine
gas, the fumes of iodine, and watery vapour
holding in solution various narcotics, have been
recommended to be inhaled. I have tried those
substances in a few cases of chronic bronchitis;
but in not more- than two or three cases of tuber-
cular phthisis. The chlorine was used in so di-
luted a state as not to excite irritation or cough.
The sulphuret of iodine, and the liquor hydriodatis
potassec concentratus (F. 32S.) were also employ-
ed; one or two drachms ofthe latter being added
to about a pint of water at the temperature of 130J,
and tho fumes inhaled for ten or twelve minutes,
twice or thrice daily. The tinctures or extracts
of hyoscyamus and coniumj with camphor, added
to water at about the above temperature, were
likewise made trial of; and, although the cases
have been few in which these substances have
been thus used by me, yet sufficient evidence of
advantage has been furnished to warrant I hi'
recommendation of them in this state of the
disease.
100. Inhalations also of the fumes of the bal-
sams, of the terebinthindtes, of the odoriferous
resins, &c. are evidently, from what I have seen
of their effects, of much service in the chronic
forms of bronchitis : and I believe that they have
fallen into disuse, from having been inhaled as
they arise in a column or current from the sub-
stances yielding them, and before they have been
sufficiently diffused in the air. When thus em-
ployed, they not only occasion too great excite-
ment of ill-' bronchial surface, but also intercept
an equal portion of respirable air, and thereby
interfere with the already sufficiently impeded
function of respiration. M. Nysten has shown
(Z)iW. des Scim. Mid. t. xvii. p. 143.) that am-
moniacal and other stimulating fumes, when
inhaled into the lungs in too poncentrated a
state, produce most acute inflammation of the
air-tubes, generally terminating in death; and re-
fers to a case in which he observed this result
from an incautious trial of this practice. I con-
ceive, therefore, that the vapours emitted by the
more fluid balsams, terebinthinat.es, the resins,
camphor, vinegar, &c.,and from chlorine and the
preparations of iodine, should be more diluted
by admixture with the atmosphere, previously to
being inhaled, than they usually are. According
to this view, I have directed them to be diffused
in the air of the patient's apartment, regulating
the quantity of the fumes, the continuance of
the process, and the frequency of its repetition, by
the effects produced on the cough, on the quan-
tity and state ofthe sputa, and on the respiration.
The objects had in view have been gradually to
diminish the quantity of the sputum, by changing
23
the action of the vessels secreting it ; without
exciting cough, or increasing the tightness of the
chest, or otherwise disordering respiration. From
this it will appear, that the prolonged respir-
ation of air containing a weak dose of medicated
fumes or vapours, is to hi; preferred to a short
inhalation of them in their more concentrated
states. The want of success which Dr. Hast-
ings and others have experienced, evidently
has been partly owing to the mode of adminis-
tering them, and partly to having prescribed
them inappropriately. When the patient com-
plains of acute pain in any part of the chest,
as in some of Dr. Hastings's cases, they are as
likely to be mischievous as beneficial. Where
benefit has been obtained, it will be found that
it was when the fumes ofthe more stimulating of
those substances were diffused, in moderate quan-
tity, in the air of the patient's apartments ; or
when he passed, at several periods daily, some
time in a room moderately charged with the
vapour or fumes of the substance or substances
selected for use. (See the remarks on Inhalation
in Humoral Asthma, § 88. for an account of
various medicines that may be employed in this
manner.)
101. f. Sponging the surface of the chest, and
trunk ofthe body, first with tepid, and afterwards
with cold lotions, has often been practised by me
with advantage in several states of this disease.
When the expectoration has been profuse, the
debility great, and little or no febrile heat pre-
sent, I have preferred for this purpose the nitro-
muriatic acid lotion (F. 83-1.), in a warm or tepid
state, night or morning, or both. When the dis-
ease is more active, the habit of body being,
nevertheless, relaxed and debilitated, a solution
of common salt in water, or the lotion, R 54.,
seems preferable ; and the directions given re-
specting this treatment in the article Asthma
(§ 116, 117.) should be strictly followed. I have
observed much benefit derived from the appli-
cation, for a considerable time, of one of the
plasters, F. 111. 115. 118, 119., between the
shoulders; whilst cold sponging the anterior of
the trunk with the lotions referred to has also
been directed.
102. g. The complications of chronic bronchitis
require generally no particular modification of
treatment from that now detailed : indeed, some
of them have been already noticed. I may, how-
ever, add, that, in the chronic asthenic states of
tin; disease frequently met with in aged persons,
and often occurring in children after exanthema-
tous diseases, hooping-cough, and bowel com-
plaints, the flowers of sulphur, the preparations
of zinc, the oxide of bismuth, and the chlorates of
potardi and of lime, have severally been of great
service, especially when combined with narcotics
— with opium in the aged, and conium in the
young, — their constipating effects upon the
bowels being duly obviated by the occasional
exhibition of purgatives. The chronic bronchitis
complicated with, or consecutive of, hooping-
cough, the characteristic cough of the latter
i either still continuing, or having altogether dis-
appeared, is frequently attended with dilatation
of the bronchi. In these cases, balsams, inhal-
ation, the use of tonics, particularly the sulphate
of iron, quinine, the liniments already noticed,
frequent doses of sulphur, or moderate doses of
266
BRONCHI — Dilatation or the — Treatment.
the chlorate of potash, are required. If the child I the red Bordeaux wines, or the wines of Bur-
he not very young, either of these latter may be I gundy — the former generally reduced bv one
combined with belladonna, or with conium, and
given in honey or syrup of squills; or with simple
fyrup, sugar, powdered liquorice root, or with the
compound tragacanth powder. When the disease
is associated with chronic irritation of the mucous
surface of the bowels, the chlorate of lime will be
of much service, and will soon restrain the latter
affection; the use of the liniments already recom-
mended (F. 296. 311.), in addition, generally con-
tributing to cure the bronchial disease. Either of
these liniments has often been sufficient of itself
to remove all disorder, both in the consecutive
states, and in the different complications noticed
at this place; and, when bronchitis seems to have
a tendency to terminate, or has actually termi-
third or one half water ; or beer or ale', also
reduced, to which a little of the liquor potassse,
or of Brandish 's alkaline solution, has been added,
may also be tried at meals; and either of these,
or of the more cooling beverages, adopted, that
may be found to agree best with the patient. If
the disease evince a disposition to terminate in
dropsy, the imperial drink, with the addition of a
little borax, or F. 590, 591., will be most service-
able. In the advanced period of chronic, or duruic
convalescence from acute, bronchitis, the sulphu-
reous mineral waters will often be beneficial.
Those of Harrowgate, Leamington, or Moffat,
may be tried; or of Enghein, Bonnes, Bareges,
or Cauterets (Roche) ; or the artificial waters of
nated, in effusion, they have powerfully assisted i Ems or Carlsbad.
the treatment. When, however, dropsies super- 105. c. Few diseases are more benefited than
vene, in addition to them, colchicum or digitalis, chronic bronchitis by change of air. A resid-
with astringent tonics; squills, with blue pill, ta- ence on the southern coast, particularly at Tor-
raxacum, or extract of sarsaparilla; the prepar- quay, and in various other parts of Devonshire,
ations of iodine, alone or with narcotics ; super- | during the winter and spring months, guarding
tartrate of potash, with the sub-borate of soda, j against vicissitudes of climate, — which, how-
particularly this last ; and various other diuretic I ever, is milder and less variable in this part of
and deobstruent medicines in different forms of the island than any where else; wearing fhmnel
combination — of which numerous examples are I next the skin, especially during winter and spring;
given in the Appendix — and the general plan of I gentle exercise on horseback, or the use of the
treatment recommended in the article Dropsy; I swing; and constant attention to the state of the
should be employed. bowels; are severally of great importance. During
103. C. The regimenal treatment of bronchitis ■ the progress of convalescence, as well as in the
requires strict attention. — a. In the sthenic acute j earlier stages of disease, particularly if the secre-
disease it should be strictly antiphlogistic; and, at i tion from the bronchi continue, it will be neces-
the commencement of convalescence, a farina- ! sary to resort occasionally to an emetic; and in
ceous diet adopted, until out-of-door exercise may a day or two subsequently, notwithstanding the
be taken, or shortly before. In the asthenic states I bowels may be freely open, to an active cathartic.
of acute bronchitis, this regimen is chiefly appli- I In these cases, the addition of a vegetable bitter
cable to the commencement of the disease : sub- ! or tonic to a purgative medicine, — as the sul-
sequentiy, nourishment in small quantities, suited, ' jihate of quinine to aloes, or the infusion or ex-
in kind and frequency of partaking of it, to the tract of gentian to senna, — will have a decidedly
atate of the symptoms, the powers of the digestive ', cathartic operation, without lowering the energies
organs, and feelings of the patient, should be j of the frame. There are few diseases more Dene-
permitted; and even animal food of a digestible i fited, either in their progress or decline, than those
nature, in moderate quantity, may in some cases, | now discussed, by active purging ; but it will
particularly in the aged, be permitted once a day. ! often be requisite to combine the purgatives with
The decoction of Iceland moss, jellies, mucilagin- I stimulants or tonics, in order that an active or
ous and emollient soups; shell-fish ; the different ' continued operation on the bowels may not ex-
kinds of white fish, dressed either with sweet oil j haust the patient. During convalescence, the
or the oil obtained by boiling their fresh livers; I free use of purgatives requires a liberal and in-
the lighter kinds of animal food; and, in the case ! vigorating diet.
of infants, attention to the milk of the mother, or
a healthy wet-nurse; are all occasionally of ser-
vice during early convalescence from the acute
forms of bronchitis, and in the progress of the more
febrile states of the chronic disease. In the more
asthenic cases of this latter, or when the expec-
toration is profuse, the skin cool and moist, and the
habit of body lymphatic, relaxed, or wasted, ani-
mal food, especially fresh beef or mutton, under
106. V. Dilatation of the Bronchi. —
The anatomical characters and physical signs
of this change of the bronchi have been already
described (§ 19.). It is almost entirely a con-
sequence of, or an attendant upon, the more
chronic cases of bronchitis, or of hooping-cough
complicated with bronchitis. The expectoration,
besides being copious and puriform, is often fa^tid,
a diagnostic symptom of this alteration, with-
done, and in moderate quantity ; new-laid raw j out which, M. Louis, and other pathologists, who
eggs ; or a due proportion of digestible and sti-
mulating food ; will be found most serviceable.
In nearly all the chronic states of the disease,
particularly in their advanced stages, a light nu-
tritious diet is necessary.
104. b. The patient's beverage should receive
particular attention. Lemonade, imperial, barley-
water, and the cooling and aperient drinks pre-
scribed in the Appendix (F. 5S8 — 595. 916.),
should be employed in the sthenic form of the
acute disease, hi the asthenic and chronic states,
have devoted much attention to pulmonary di
eases, has sometimes failed of distinguishing it
from phthisis.
107. The Tre atm E kt of this alteration is near-
ly the same as that which has been recommended in
the more chronic states of bronchitis. The means
which are especially indicated consist of the in-
halation of balsamic and terebinthinate fumes; of
those of chlorine, iodine, &c. (§ 99, 100.) ; the in-
ternal use of balsams, tonics, arid bitters, particu-
larly the sulphates of quinine, or of zinc, or iron;
BRONCHIAL FLUX— Diagnosis.
267
and other preparations of cinchona or steel; with
the use of the liniments already noticed (§ 102.);
or the niiro-iuurintie lotion on the chest. The chlo-
rate of potash, or of lime, seems indicated in this
form of the disease. An open state of the bowels,
an occasional cathartic, nutritious diet, and change
of air, are also evidently requited. In other re-
Bpects, the treatment already detailed (§ 101, et.
seq.) may be followed ; or modified according to
the peculiarities of the case.
10f<. VI, Ulceration of thk Bronchi
(see § 7, S.) is another alteration which is pro-
duced by, or is attendant on the advanced stages
of, chronic bronchitis; most frequently, however,
when complicated with tubercular phthisis. It is
not infrequently met with, particularly after bron-
chitis occasioned by the mechanical irritation of
mineral, vegetable, or animal molecules. The
existence of ulceration, when seated in the bron-
chi, is not indibated by any sign in addition to
those which accompany the most chronic states
of bronchitis, or tubercular disease, when it arises
from, or is complicated with, this change. When
affecting the Larynx or Trachka (see these
articles), it may frequently be suspected, or oc-
casionally prognosticated, in a case which occur-
red in the trachea, a prognosis to this etiect was
given by me long before death.
10). The Treatment of this lesion, even
could its existence be ascertained during life,
cannot he different from that required in some
other states of chronic bronchitis. That ulcera-
tion may take place in the bronchi, and heal, as
evinced by the appearance of cicatrices, has been
ascertained h\ M. Laknnkc, and other patholo-
gists. In addition to the means of cure already
described, the establishment of local drains of the
most active kind is obviously required. Blisters
and issues applied to a distant part have not been
found of use by M. Laknnkc. He prefers the
repeated application of small moxas as near the
seat of disease as possible, and the preservation
of absolute rest and silence. The inhalation of
emollient, anodyne and balsamic vapours and
fumes may likewise be tried; and, if the disease
be devoid of marked febrile excitement, the ex-
pectoration abundant, and the powers of life con-
sequently reduced, the treatment advised for dila-
tation of the bronchi (§ 19.) may be employed
in all its parts. (For the treatment of other
organic changes of the air-passages, see aits.
Croup, Larynx, Lungs — Hamorrhage from,
and Trachea).
VII. Bronchial Flux. — Bronchorrhtea
(from linuy/uc and (/*•-.) Syn. Bron-
rhorrh.'e (Roche). Catarrhe Pituiteu.x
(Laennec). Mucous Flux.
Classik. I. Class. III. Order (Author).
110. Dkein. A flux of watery mucus, or
phlegm, from the chest, with more or less cough,
but without fever ; frequently occasioning exhaus-
tion.
111. This affection varies considerably. It is
often a variety of chronic hronchitis; being con-
secutive of it in persons advanced in life, or those
of a relaxed and phlegmatic or pituitous habit of
body. In other cases it appears from the com-
mencement, or consecutively of slight catarrh, as
intermediate between chronic bronchitis and hu-
moral asthma. This appellation may, upon the
whole, therefore, be viewed as applicable to those
cases which are attended with a more abundant,
fluid, and transparent expectoration, than is ob-
served in chronic bronchitis, and are devoid of
fever and all other signs of inflammatory action;
whilst they are equally without the severe dys-
pnoea, the paroxysms of suffocation and cough, and
the intermissions, characterising humid asthma.
112. Broncborrhcpa proceeds generally from
similar causes to those which produce common
catarrh, or bronchitis, even although it be not
consecutive of some one of the forms of bronchial
inflammation. It is very frequently, either at its
commencement, or recurrence, connected with
cold and moist states of the atmosphere, or occa-
sioned by exposure to cold in some one or other
of its forms. When it occurs as a sequela of
bronchitis, it may be viewed as arising from lost
tone of the vessels and of the bronchial surface,
the flux or determination to this part still continu-
ing, from peculiarity of habit or some other cause,
after all inflammatory and febrile symptoms have,
been removed. '1 bus it is very frequent in aged
persons of relaxed fibres, who have experienced
repeated attacks of pulmonary catarrh.
113. Diagnostic symptoms. — Bronchorrhcea
may be distinguished from chronic bronchitis,
tubercular phthisis, and humoral asthma, by the
following characters : — The quantity of fluid ex-
pectorated is very great ; being, in some cases,
as much as four or five pounds in the twenty-
four hours. The sputum is colourless, ropy,
transparent,' slightly iiothy on the surface, and
resembling the white of egg mixed with water.
It is without the thickened sputa generally ac-
companying chronic bronchitis. 'I here is con-
siderable dyspnoea, but the chest sounds well
throughout upon percussion; aid the cough in
slight comparatively to the quantity of the expec-
toration, being evidently no more than is occa-
sioned by the discharge of the secreted fluid.
The pulse and temperature of the skin are natu-
ral, and there are no night sweats. The appetite
is generally unimpaired; and emaciation is not
remarkable, or not at all observed, unless the
quantity of the sputum be extremely great. M.
Nauche states, that the expectoration in this
state of disease is always more or less acid, and
reddens turnsole paper, whilst that proceeding
from inflammatory action restores the blue tint
to this paper after being reddened by acids. On
auscultation, the respiratory murmur is common-
ly weak, but is very rarely suspended. The sib-
ilous rhonchus is heard more or less distinctly,
and often mixed with the sonorous, and occasion-
ally with the mucous rhonchus, the bubbles of
which seem to burst upon the surface of a fluid
of less consistence than in bronchitis.
114. Bronchorrhosa usually commences with
catarrhal symptoms, and frequently without fever.
In other cases, after bronchitis has continued
chronic for a longer or shorter period, the expec-
toration becomes less consistent and less opaque,
more abundant, and similar to that described; and
the affection becomes established, — aggravated at
times by disorder of the stomach or bowels, or
by changes of the air, especially by cold and
moisture, or by arrest of the cutaneous transpira-
tion from any cause,— and ameliorated at other
times by a warm dry air, an open state of the
bowels, and light nourishing diet, taken in mod-
erate quantity. Vacillating in this manner, tha
268
BRONCHIAL FLUX— Treatment.
disease may continue for years if it be not severe,
without materially affecting the strength. But
more frequently the discharge increases, after
irregularly prolonged, and more or less slight in-
tervals; the patient loses his flesh, and becomes
paler; liis strength is impaired; dyspnoea increases;
and, in some cases, the aflection either runs into
humoral asthma, or the quantity nf expectoration
is augmented so as to exhaust his energies, and
to occasion suffocating paroxysms of cough. In
rarer cases, the quantity of the bronchial dis-
charge has been so great as to occasion the ex-
haustion and death of the patient. INT. Andral
has detailed two cases of this description, wherein,
upon dissection, no evidence of inflammation or
congestion could be found in the air-tubes. M.
Roche lias described, what he has designated an
acute form of this aflection, which other French
pathologists have named catarrh e suffocant'; but
it differs in no respects f um the more humoral
states of asthma, described in its more appropriate
place, and presenting ali the symptoms of spasm
of the air-passages, with a copious viscid expec-
toration; the spasm and other symptoms subsiding
after the bronchi and trachea are unloaded of the
secretion accumulated in them. Bronchorrhcea
has, in rare instances, been the means of remov-
ing other diseases. M. Andral states that he
has seen hydrothorax disappear after the establish-
ment of a copious bronchial flux.
115. Treatment. — After the full exposition
that has been given of the means of cure in the
different states of chronic bronchitis, to some of
which bronchorrhcea is closely allied, it will be
sufficient to enumerate succinctly the various
means which are applicable to this aflection. As
the disease essentially consists of an increased
secretion and exhalation from the respiratory
mucous membrane, with a determination of the
circulation to that quarter, and deficient tone of
the vessels distributed to it, the obvious indica-
tions are, to increase the secretions from other
surfaces and organs, thereby to derive from the
lungs, and to restore the lost tone of this mem-
brane and its vessels. In some cases, accord-
ingly, it will be advantageous to commence with
an ipecacuanha or sulphate of zinc emetic, and
afterwards to act freely upon the secretions and
alvine excretions by purgatives. 1 have never
seen a case of the disease which has not been
much relieved by purgatives ; taking care, how-
ever, that they should not lower the energies of
the constitution, by combining them with tonics,
bitters, or stimulants, and allowing sufficient light
nourishment to admit of this mode of deriva-
tion being satisfactorily employed. In the inter-
vals between the exhibition of purgatives, diuret-
ics and diaphoretics may be exhibited, and the
cutaneous functions promoted by wearing flannel
next the skin during the winter and spring months.
1 lb'. Expectorants are very much employed in
this aflection; but some of this class of medicines
are seldom of benefit in it, unless combined with
opium. The balsams and terebinthinates (F. -184
— 487. 489.); the sulphate of zinc, with myrrh,
or the compound galbanum pill; and either of
these, with camphor and opium ; are often of
service. In addition to these, inhalations, as
recommended in another part (5 99, 100.), may
be employed. Although astringents and inhala-
tions are often required, yet we should be cau-
tious in using them when the disease has been
of very long continuance, particularly in persons
advanced in age, or when there is any irregulari-
ty of the action of the heart, or physical sign of
organic change about this organ, con. plicated
with it; inasmuch as the arrest of an habitual
discharge will, in such circumstances, lisk the
supervention of effusion in the cavities of the
thorax, it wiil be n, ore judicious, in these cases,
to confide in purgatives combined with bitter
tonics; in diuretics, and in diaphoretics, so as to
moderate the dischaige, and p. event its increase,
or its exhausting e! ects upon the system. At
the same time the vital energies should be pro-
moted by a light nutritious diet, moderate exer-
cise, and chai ge of air, with the sulphureous or
gently tonic mine al waters. In other cases,
where the age of the patient, the regular or heal-
thy state of the heart s action, the absence of leu-
cophlegu.asia, and the circumstances of the case
altogether, are such as to pieclude dre d of the
consequences of suppressing this dischaige. cold
sponging the surface of the lx;dv by the nitro-
muriatic lotion, &.C (§ 101.), and the liniments
already noticed (F. 21^6. 3 1.), with the inter-
nal use of the more astringent tonics, particularly
the sulphates of iron or of quinine, in addition to
the measures already recommended, may also be
practised.
BlF.LIOG. and. REFER. — Morh f, -Piinceps Medicus,
4to. Host. 1665.— Ra t er, Disser.de Catanho Phlhisin
Mentienlc, 4lo. Goet. 1758. — Riehter, On Mucous Con-
sumption, in Med. and Sugical Observations. Edinburgh,
1794. — Be I'll is, On the Medicinal Use of Factitious Airs,
&c. Brist. 1795. — En^lehart, De Catanho InAammalorio,
4to. Lund. 179'J. — Ln Ro lie, Kssai sur le Catai.be Pul-
monaire Aigu, Svo. Paris, 1802. — Bertrand, Sur la Dis-
tinction du Cat an he, de ia Pleiirisie, el Peripneuin. kc.
4to. Paris, 1804. — Cub, mis, Ohserv. -nr les Affect. Catarrh.
Svo. Paiis, 1807. — Bwihtan, On the Inflammatory Affec-
tions of the Mucous Memh. of the Bronchia", Svo. Loud.
1810.— J. P. Frank, Interp. Clinic, p. 110. Tuh. 1812.—
J.Frank, Piaxis Medica, L.C. pari Ii. vol. vi. p. 359. — Ftr-
rittr, On the Effects of Pneumatic Medicine, .Medical His-
tories, &c. vol. ii. p. 261. Loud. 1 810. — Broussais, Ilistoire
des Phlegmasies, on Inflammations Cbioniques, 5lc. t. i.
p. 69. 3d "edit. Paris, 1822.— Ckeyr-e, On the Pathol, of the
Laivnx and Bionchia. Kdinh. 1 809. — Alarrl, Du Si.' ire et
de la Nature des Maladies, 2 t. Pari-. 1821. — / illermi,
Diet, des Scien. Mfcd. I. xxxii. p. 208. — Hastings, On In-
flain. of the Mucous Membrane of the Lung*, kc. 6vo.
Lond. 1820.; and Midland Medical Reporter, vol. ii. p.
397. — Roc At el Sanson, Nouveaux Hitmen* de Pathol.
Medico-Chit in gi.ale, t. i. p. 560. ; el t'ict. de Mtd. et thir.
Prat. t. iv. p. 258. — Armstrong, On Scarlet Fever, ";
and Consumption, 2d edit. Lond. 1818. — Bouillattd, in
Journ. Complement, de Diet, de Sciences Med. t. xix.
p. 5. — Duncan, Observations on Pulmonary Consump-
tion. 2d edit. p. 162. — Laennec, Train- de rAu*ciiltation
Mediate, et des Maladies des Poumons, &c. 2d edit.
Paris, 1826.; et Rev. M. d. t. i. p. 384. 1824.— Andral,
Clinique Medicale, Aic. t. ii. p. 1. ; et Anatomic Patho-
logique, t. ii. p. 465.; et Archives (j mi. de Mtdicine,
t. i\. p. 314.— Roye> -Co/lard, Nouv. Biblioth. Mtd. t. i.
p. 196. 1826.— Smin, Rev. Medicale, t. ii. p. 520. 1826.—
Mills, Account of Morbid Appearances from Disorders of
the Limns anil Heart, Svo. Lond. 1!30. — Alcock, On In-
flammation of the Mucous Memb. of the Organs of. Re-
spiration, Medical Intelligencer, 5<os. vii. and viii. p. 151.
— R. Harrison', in Medical and Physical Journ. Julv,
1820. — Johnsm.'s Medico-Chhurg. Review, Dec. 1820.
p. 341. — Chomel, Diet, de Mtd. I. iv. p. 41". art. Catarrk*
Pulmonaire.) — ffildenbrand, Inslitut Pn>.:ti. n-Mcdics-,
t. iii. p. 470. — Patrenstecher, in Hvfelnnd's Journ. der
Pract Heilk. Nov. 1827. — Crichtrn, On the Treatment of
several Varieties ol Pulmonary Consumption, and on the
Vapour of Tar in that Disease,' Svo. Lond. 1 223. — Elliot-
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vol. xvii. p. 467. — Bayle, Recherches sur la Phthisie in
some cases of cftronic oroncAtCu found the bron hint sur-
f n- pale, and vrithout change , obs. \h\. p. S90. Paris,
1810. — Aber-'-onilie, in Edin. "Medical and Surgical Jour-
nal, vol. xvii. p. 39. (Ulceration cf the bronchi. — J.
BRONCHOCELE — Causes and Morbid Relations.
269
Forbfs, On Tar Vapour in Diseases of llic Lungs, &c, in
Medical and Physical Journ. vol. xlviii. p. 2iil.— Wil-
liams, On (lie Pnyaical Signs of Diseases of the Lungs,
tic. p. 60. Bvo. Lond. 1829.— Forbes, Original Cases, illus-
trating the Use of the Stethoscope and Percussion, BVO.
Lond. 1824. — Qendrin, Histoire Anatom. des [nflammaV
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M< ileal Cases, &.C. p. 127. 4lo. Lond. 1827.
BRONCHOCELE (from »?«/*<>?. throat, and
xi'^i], a swelling). Syn. Hernia Gutluralis,
Gossum, LuftrJhrenbruch, Kropf, Get. Goi-
tre, Fr. Broncocele, Gozzo, Ital. Thyro-
phraxia, Alibert Cynanche Thyroidea, Con-
radi. Goitre, •' Derbyshire Neck.'"
Ci.assif. 4. Class, Local Diseases; 6. Or-
der, Tumours (Cullen). 6. Class, Ex-
cement Function; 1. Order, Atlecting the
Parenchyma (Good). IV. Class, IV.
Order (Author, see Preface).
1. Deiin. Chronic enlargement of the thy-
roid gland, sometimes with change in the sur-
rounding parts, generally increasing slowly, of-
ten continuing for years, and depending upon
constitutional causes.
2. I. Causes, and Morbid Relations. —
This disease is endemical in Derbyshire, and some
other parts of this country; but most remarkably
so in Switzerland, various adjoining districts, and
in some places in South America. It usually oc-
curs during the early epochs of life, most frequent-
ly about the period of puberty, in persons of a
weak and lax fibre, and generally in females; it
very seldom being observed in Great Britain in
males: but the comparative frequency of it in the
latter sex is greater in Switzerland, and other
parts where it is very prevalent, and is connected
with cretinism. In a considerable number of
cast's which have come before me in females, I
have never met with any before the period of
commencing puberty, — not even at the Infirma-
ry for Children; although the menses have often
been delayed for a year or two, or even longer,
when the tumour has appeared at this epoch; and
I have seldom observed an instance in this sex
unconnected with some kind of irregularity of
the menstrual discharge, or disorder of the uterine
functions. In two cases, occurring in married
females, who were under my care, unhealthy or
irregular menstruation had existed during the
continuance of the goitre; in one case for eight
years, in the other for five: upon its disappear-
ance, pregnancy took place in both. Suppres-
sion of the menses has sometimes caused its sud-
den appearance and rapid developement; and it
more rarely has originated during pregnancy and
the puerperal states. Authors have adduced con-
clusive proofs of its occurrence hereditarily, inde-
pendently of endemic influence.
3. Dr. Good has attributed the disease, in a
great measure, to poverty, and the nature of the
food: the rich being exempt from it. This is,
bowever, very far from being the case. I have
Been several cases of bronchocele in the richest in
this metropolis. He is also wrong in attributing
it to the use, in Derbyshire, of oaten cakes. In
Scotland, when- this article of diet is in general
us', bronchocele is rare.
4. That it chiefly depends upon certain phy-
sical causes is shown by its prevalence in certain
districts in preference to others, and by the cir-
cumstance of its disappearance when persons af-
fected by it endemical I y have changed their resi-
'23*
dence. M. Alibert mentions his having seen
it disappear after a residence in Paris. It has
been very generally imputed to the water used
by those affected. Since the time of Pliny, it
has been attributed to the use of snow water.
But it prevails in several places where this cause
does not exist, as in Sumatra, and several parts
of South America. The Swiss v ho drink snow
water are free from the disease, while those who
use hard spring water are most commonly affect-
ed. Captain Franklin states, that at a part in
his journey to the Polar Sea, where bronchocele
prevails, it is confined to those who drink river
water, and that those who use melted snow es-
cape. Mr. Bally ascribes its frequency, in a
district in Switzerland, to the use of spring water
! impregnated with calcareous or mineral substan-
ces; and he states, that those who use not this wa-
ter are free from both goitre and cretinism. Dr.
Coindet observed that the inhabitants of Gene-
va, who drink the hard pump waters, are those
most liable to bronchocele. Its prevalence in Not-
tingham is ascribed by Dr. Manson to the same
cause; which also seems to occasion it in Sussex
and Hampshire, in the valleys of which counties
it is frequently met with.
5. That this is, however, not the only cause,
may be inferred from other physical circumstanc-
es connected with its endemical prevalence. Its
great frequency in low, moist, marshy, and warm
valleys, and the exemption of the inhabitants of
dry and elevated situations, have been shown
by Larrey, Fgdere, Saussure, Reeves,
Clark, Valentin, Postiglione, and J.
Johnson, as respects various districts in Switzer-
land, the Tyrol, Carinthia, the Vallais, and the
north of Italy. Similar facts have been adduced
by Dr. Gibson, and Humboldt, in regard to
the V/nited States, and South America. It is
most probable, however, that the exhalations
from the soil of those localities are not the only,
but a concurrent cause, cooperating with others
possessing equal influence in the production of the
disease, and particularly with the nature of the
water. But it as certainly sometimes appears
where neither of those causes can be traced, as
in London; disorder of some kind in the uterine
functions being the most frequent morbid relation
it has presented, as far as my experience has
gone, its connection with cretinism id the dis-
tricts on the Continent above alluded to, and the
occasional appearance of the disease at very early
periods of life — it being even sometimes congen-
ital, in these countries, as well as being more
common there in the male sex than in this
country — are matters of some interest, and not
readily admitting of explanation; since poverty,
close, confined, and ill-ventilated apartments, are
not the chief causes of those phenomena, as
shown by their absence in the poorest classes
in this metropolis. Dr. Parry has seen goitre
follow diseases of the heart, and epilepsy. Fi.a-
jani has noticed the common occurrence of pal-
pitations and affections of the lungs from the dis-
order it has occasioned of the respiratory func-
tion. When the tumour is very large, or hard,
or when it has increased suddenly, it not infre-
quently occasions most argent symptoms, by its
pressure on the trachea, oesophagus, and jugular
veins.
6. As respects the External and internal ap-
270
BRONCHOCELE — Diagnosis— Treatment.
pearanccs of this tumour, I may briefly observe
that it affects generally the whole gland; but is
also sometimes confined to the lateral or to the
middle lobes: it is more rarely larger on one side
than another. At first it is commonly compact,
rounded, and equal; but, as it increases, it is
cither soft and flabby to the touch, or unequal,
irregular, hard, and obscurely lobulated. It is
usually free from pain, and is not discoloured.
When it is greatly increased in size, and is soft,
it appears pendulous, chiefly owing to its lower
parts being most enlarged. When the tumour is
<livided, the cells of the gland are found, accord-
ing to Hunter, Baii.lie, and B. Bell, filled
with a more or less viscid fluid; and are of vari-
ous sizes, generally from that of a pea down-
wards, not only in different cases, but even in the
same gland. In the older, harder, and more ir-
regular forms of the tumour, melicerous, steatom-
atous, cartilaginous, and ossific deposits have been
met with in parts of it, by Celsus, De Haen,
Freytag, Giraud, Hedenus, and others.
The usual state in which this disease presents it-
self, obviously, is that of an increased secretion
into the cells of the gland, distending them more
or less; the other changes sometimes observed,
being consequences of obscure irritation induced
in parts of it during its continuance or growth.
7. II. Diagnosis. — It is necessary to be
aware that other diseases of either a more acute
or malignant character may affect the thyroid
gland and its vicinity, and be mistaken for bron-
chocele. 1st, The gland may be either healthy,
or but little enlarged; the tumour consisting chief-
ly of thickened surrounding cellular tissue, some-
times containing cysts filled either with a serous,
albuminous, or purulent matter. Large encysted
tumours may also form in the course of the tra-
chea. But these may be readily distinguished by
their situation, form, and fluctuation. 2d, The
gland itself may be the seat of/ chronic or acute
inflammation. In this case the swelling increases
more rapidly, but seldom attains a large size; and
is generally attended by redness of hs surface, and
increased temperature. It is also painful, parti-
cularly on pressure, and is very hard. I lately
saw a case of this description, in a married female
of about thirty, who was also seen by Mr. Lloyd,
where the inflammation had proceeded to suppu-
ration, and had terminated in an external opening.
I believe that inflammation of the gland never
occurs but in scrofulous habits. 3d, The gland
may also be the seat of scirrhus, which may ul-
timately go on to carcinomatous ulceration; but
this is a rare occurrence. .In this case the gland
is very hard, seldom large, sometimes scarcely
increased in bulk, and is the seat of sharp darting
pains. It is only met with in persons advanced
in age. Alibert states, that he has observed a
case of goitre pass into cancer; but I doubt the
fact; cancer having a very wide and indetermin-
ate signification with this writer. The disease
can scarcely be mistaken for aneurism of any of
the thyroidal arteries, if any share of attention be
directed to the subject. Bronchocele has been
considered in the light of a strumous disease —
as a form of scrofula. Dr. Pos tk.lione, how-
oner, contends that no connection exists between
thfise diseases. As respects the state of morbid
jictiou in the gland, the concomitant phenomena,
and the respective terminations of both diseases,
there, is certainly no ultimate relation between
them.
8. III. Treatment. — Previous to the use of
iodine in the cure of bronchocele, numerous rem-
edial means were recommended by writers. Of
these, the most common were fiictions with vari-
ous liniments; dry rubbing; stimulating and astrin-
gent lotions; cold bathing, and cold douches;
mercurial applications; plasters with cicuta and
ammoniacum, or with ammoniacum and hvdrarg. ;
repeated blistering; leeches applied to the tu-
mour; electricity and galvanism; mo.xas, issues,
and setons; ligature of the arteries supplying
l he gland; and extirpation of the gland it.-elf.
Amongst the internal remedies recommended, I
may notice the various preparations of mercury;
digitalis combined with camphor (Ossiahder);
' sulpburet of potash; muriate of barytes (Posti-
I glione); cicuta or belladonna, either alone, or
with the muriate of baryta; the muriate of lime;
' preparations of potash and soda; various mineral
springs; the use of sea water, and of distilled
Water; the ammoniated muriate of iron; burnt
sponge, given either alone, or with mercury; and
the ashes of the funis vesiculosus (Russell).
9. Of all these, the most celebrated was burnt
sponge; and, after the discovery of iodine, this
substance, which, having been found bv Dr.
Straub, of Berne, to be contained in officinal
sponge, was recommended by him in 1829. aid
adopted by Dr. Coindet, of Geneva: and so
successful has this medicine' proved in the treat-
: ment of bronchocele, that, of a hundred and twen-
ty cases treated with it by Dr. Man son, of .Not-
tingham, seventy-nine were cured, eleven great-
ly relieved, and two only were not benefited by
it. Of several cases of the disease which have
come before me since the introduction of this
remedy into practice, there has not been one
which has not either been cured or remarkably
improved by it. I believe, however, that al-
though it has been found the most certainly ben-
eficial of any medicine ever en ploved in bron-
chocele, some other practitioners have not deriv-
ed an equally uniform advantage from its use.
1 I can account foi this only by considering that it
has been given in too large and irritating doses,
I or in an improper form; and without due atten-
tion having been paid to certain morbid and con-
stitutional relations of the disease during the treat-
ment. The cases of two females who were late-
ly completely cured by the remedy confirm this
inference. They had both had the tumour for
several years, one for nine years; and had. on
former occasions, gone through long courses of
iodine, prescribed by judicious and eminent prac-
titioners, but without advantage. When this med-
icine was ordered by me, it was, therefore, with
great difficulty that they were' induced to have re-
course to it again. It was ordered in very small
doses, often repeated, and strict attention was
paid to the state of the secretions, and to the
uterine functions. In the course of a fortnight an
improvement was manifest; and of a few weeks
longer, a great decrease of the tumours had
taken place. One of these females, a married
woman, who had been once pregnant nine years
before, upon the disappearance of the tun. our
came with child; soon after which it somewhat
suddenly reappeared, bufcthe resumption of the
iodine again dispersed it. The preparations given
271
id the Vppendix (F. 204. 277, 278. 302. 3 3,
:> 4.) ore those which an extensive expe ienceof
its effects in \ ;nious diseases, as well as in this,
has led ine to adopt.
10. hi respect of the use of iodine in bron-
cho :ele, the weaker preparations should be at first
preferred ; and care should be taken never to
exhibit them to the extent of irritating the stomach
or bow,' s : when this effect is produced, little or
no benefit will be derived from them. 'I he suo
cess which Dr. Mansos and M. Lugol have de-
rived from this valuable dicine, 1 know from
experience to be chiefly owing to the small and
soluble doses in which they exhibited it. In some
of the more obstinate cases, it u ill be often requisite
to assist the operation of iodine by other means.
Sometimes the occasional use of emmenagogue
aperients will be of much service; and when the
uterine functions evince disorder, as they very
frequently do iii cases occurring in females, I
have usually directed either the sub-borate of soda,
or milk of sulphur, to be taken, in the form of
electuary, every night (F. 89. 281.). A calomel
purge will also be sometimes of service. I have
generally preferred the internal to the external
use of the medicine in this disease. In some more
obstinate cases, they may be both employed; but
its external application should be of the mildest
kind. In some cases, a moderate blood-letting
may he premised; and souie writers recommend
that leeches should he applied to the tumour
itself. .Nearly all the cases which I have seen,
having occurred in females, in whom it appeared
requisite cither to promote the menstrual discharge
or to subdue uterine irritation, I have usually di-
rected the bleeding, when practised, to be per-
formed in the feet, or leeches to be applied to the
groins. Dr. Coster has adduced a case in which
galvanism materially assisted the iodine in remov-
ing bronchocele.
1 !. Dr. Ivoi.r.F.Y has stated, that iodine should
not be exhibited where there is a disposition to
congestion in the head and internal viscera; when
febrile and inflammatory symptoms are present;
when gastric, hepatic, or intestinal disorder exists;
and when there is a disposition either to hydro-
cephalus or to pulmonary consumption. This is
in some respects just ; but after depletions, and
when the more marked symptoms of these dis-
orders are subdued, iodine may, notwithstanding,
be exhibited, if its effects be carefully watched,
and if the mildest and weakest preparations be
selected, and these be combined with anodynes
and narcotics. I have observed that a continued
course of iodine has sometimes had the effect,
particularly during cold weather, of producing
pains in the limbs or joints resembling rheum-
atism, which have continued to increase if the
medicine was not for a time relinquished. This
effect has never appeared during a course of less
than six weeks. It has general!) soon disappeared
after an aperient operation from sulphur, and one
or two warm baths. A change to warm weather
has also removed it.
12. If iodine fail of reducing the tumour, and
if its pressure occasion urgent symptoms, recourse
must be bad to surgical aid. For a full exposi-
tion of this part of the treatment, I must refer the
reader to Mr. Coopkk's Surgical Dictionary, and
limit myself to a brief enumeration of this class
of measures. The first and most important of
* ' ii fion of setons in the tumour.
I In- pry itice was recommended by Dr. (.Iuadki,
of n'iiples; and practised first in this country by
Mr, » upland ile i , niMi\, and with success.
According, however, to the experience of Mr.
James, Mr. Cooper, ami Mr. Gunning, this
practice is liable to occasion dangerous haemor-
rhage, sloughing of the tumour, and irritation and
inflammation of the trachea or larynx. Mr. Lt-
ford has, however, employ ed setons successfully;
whilst IIkdkmjs states, that he has seen tetanus
occasioned by their introduction. It has been
recommended to cut off' the supply of blood to the
gland liv t_\ ing its arteries; and the advice has been
followed by Blizard, Walther, Coates,
[jKtiniE, and Carle. The cases thus treated by
Blizard, Coates, and Brodie, terminated
unfavourably ; whilst those by Walther and
Earle succeeded. Lastly, the tumour has been
altogether removed by excision. Dessaui.t first
performed this operation successfully; Gooch at-
tempted it in two cases, but filled; Dupuvtren
and Klein also failed; whilst Vogel, Theden,
and (jraefee, performed it with success; and
Hedenus, of Dresden, succeeded in six cases ia
which he resorted to this operation.
Birci.iOG. and Refer. — Pliny, lib. ii. rap. 37. — Cehus7
lih. vii. cap. 13. — De Hnen, Ratio Meaendi, pars vh. p. 285.
— Rush, Medical and Physical Jonrn. vol. ivi. p. OS. —
Frjflcri; Train' Mir It- Goitre et lc Cr^Uoisme, Svo. Paris,
An 8. — Flajani, Collez. d'Osservazioni eRefless.de- Chirurg.
t. iii. p. 270. Roma, 1800. — Baillie, Morbid Anatomy, 8vo.
p. 87. — Larrey, Memoires de Chirurg. Hilit. t. i. p. 123. — -
lidlij, in Diction, des Sciences Med. t. Kit — fTemel, Ueb.
den Cretinismus. Wien. 1802. — Wijlie, i» HufehnvPs Jonrn.
1809, 2d st. Febr. p. 118. — Maas, Piss. Sistens Gland.
Thvroideoideam tarn Sanam tamMorbosan. Wire. 1810, Svo.
— Postiglione, Mem. Patholog. Practfca nulla Natnra di
Gozzo. Flor. 1811. — Alibert, Nosologic- Nature-lie, t. i. p.
•164. fol. Paris, 1817. — Straub, in Naorwissenchafllicher
Auz. der Allgenuiner Schweiz. Gcsell. ic. von rV. Meisner,
4lo. Bern. 1820. — Coindet, Decouverte eTur/ Noavean lic-
mede contre le Goitre, in Bibl. Univers. Juil. 1820, pi 190. j
et Feb. 1821, p. 140.— Cnn-o, in Ibid, jttai, 1821. — Brera,
Saggio Clinico sull' Iodio, &c. Pad. 1322. — QuciriW, in.
Medico-Chirurgical Society's Transac:. vol. x. p. 16. —
Coates, in Ibid. vol. x. p. 312. — 'dat-hisonT in Ibid,
vol. xi. p. 235. — Roots, in Ibid. vol. xil p, 310. — Kenne hi.
in Lond. Medical Repos. vol. xvii. p. 177. Humbol<lt,\a
Magendie, Journ. de Physiol. Exper. t. iv. p. 10Jf. — He-
denus, Tractat. de Gland. Thyroid, ic. Lips. 1-822. —CosterT
Arcbivis Gt'ntr. de Medecine, Juillei, 1823. — GairdnerT
(In the Effects of Iodine, &c. 8vo. lond. 1824. — Kollty,
Medico-Chirurgical Review, vol. vi. p. 229.— Tail, Jomii.
Complement d is Sciences Med. t. xxiii. Nov. 1825. — Pes-
chier, Biblioth. Univers. Oct. 1824, p. 146.— Mansoa.Medi-
cal Researches on the Effects oflocnoe in Biviu-hocele,. &c.
8vo. 1825. — Georgian:, De Pracipuis Thvroplu axiaro. Cu-
randi Methodis, Svo Pavia, 1825. — Krugehtem, Die Kunst
d. Krankh. d. Schilddriise u. d. Kropf znHeilen, lie. Gotha.
Svo. 1826. — Eai-le, in Lond. Med. and Phys. Jonrn, Sept.
1826. — Lawrence, Lectures by, Medical Gazette, voL vi. p.
719. — J. Johnson, On Change of Air, &c.
BTJLIMIA. (See Appetite.)
BULL.£.— Blains. Syn. <I>h'xrcttrai, Gr.
Phlyctena, Ampulla, Auct. Lat. Bulla,
Plenck. Ecphlysu, Good. Dartre Phlycten-
oide, Alibert. Bulles, Ampoule%, Fr. Blasen,
ll'asserblattern, Ger. Blebs, Eng.
Classit. 6. Class, 3. Order (Good). 4. Or-
der (Willan). IV. Class, IV. Order
(Author).
1. Dee in. An eruption of large vesicles con-
taining a serous or sero-puriform fluid ; frequent-
ly succeeded by yellowish or yellowish brotnn
scabs, and sometimes by ulcerations.
2. Plenck fust separated the individual erup-
tions belonging to this order from the vesicular
272
CACHEXY.
eruptions, to which they are intimately related,
and formed them into a distinct class. Willan
afterwards adopted a nearly similar arrangement,
comprising under this head erysipelas, hut leaving
out rupia. M. Biktt has, however, with stricter
propriety, excluded from it the former disease,
and introduced the latter. Adopting, therefore,
his classification, this order of erruptions embrace
pemphigus, pompholyx, and rupia. These forms
of bullae proceed from internal causes; but various
irritants, applied externally, will also give rise to a
similar eruption. '1 he influence of cantharides
and other rubefacients, of excessive heat or cold,
of friction, of poisons, &c, in occasioning vesi-
cations, is well known. In a pathological point
of view, both the bulla produced by internal
causes, and the vesications formed by external
causes, depend upon very nearly the same state
of the rete mucosum. This tissue is more or less
inflamed, or affected in such a way as to secrete a
greater quantity of serous fluid than can be exhaled
through the cuticle, which is thereby separated from
the vascular tissue, ;md, by the increase of this
fluid, elevated into blisters, or bulke, of various
dimensions.
3. The eruptions of this class are both acute
and chronic. The parts affected are often pre-
ceded by more or less redness, and occasionally
by a very slight elevation. But, in many in-
stances, no suck inflammatory appearances are
observed before the serous effusion beneath the
cuticle takes plate. After an indefinite period,
varying from a 'ew hours to four and twenty, a
small vesicle appeirs, and gradually eidarges, until
it reaches, generally within eight and forty hours,
a great size. The bulla? thus formed are at first
tense, and the fhid contained in them serous and
transparent; but t sometimes becomes, especially
at a later stage, sero-purulent, and rarely sero-
sanguineous. After an uncertain time the bulla?
pass from a tense to a flaccid state, the included
fluid, at the same time, assuming a very slightly
opaque and thickened condition. If they be situ-
ated where the epidermis is very thin, or occur in
very young infants, they often break before this
change in the fluid takes place. But where they
are more persistent, the humour becomes thicker,
and often forms sct.bs of a light yellowish colour.
The affected parts of the skin are afterwards either
provided with a new cuticle, or are affected with
more or less severe ulceration. Bulla; may thus
appear in any part of the surface, and even in the
scalp, and be more or less numerous, or thickly
scattered over the body. I have observed them
so extensive, as respects both number and size, as
to occasion death, obviously from the constitutional
disturbance and irritation resulting from the loss
of the cuticle over more than two thirds of the
whole surface of the body.
4. These eruptions are also either idiopathic or
symptomatic — most frequently the latter. They
may also be infectious, or dependent upon the
air of an hospital. Thus I have seen them pre-
vail (chiefly in the form of pemphigus) at one
time, in Queen Charlotte's Lying-in Hospital, to
the extent of affecting nearly all the infants born
there during several months', notwithstanding fu-
migation and whitewashing were resorted to; no
other disease having occurred there during that
period. In a chronic state, they are usually
symptomatic of irritation or other disorder of the
digestive organs, more especially of the alimenta-
ry canal ; of chronic bronchitis, and of general
cachexy. They are sometimes observed as an
attendant upon small pox, and very rarely in the
other exanthemata.
Biblioo. and Refer. — Bateman, Synopsis of Cut.
Diseases, &c. 7th ed. p. 193.; and Med. aiid Phvs. Journ.
vol. xi. p. 230. — Ti/i:sius, in Marlens's Parodoxien, tic.
Leips. 1802, h. ii. heft. i. p. 18.—- Rmjer, Traite des Mala-
dies dc la Peau, he. 1. i. p. 142. Cuzenave et Scheilef,
Abrege Pratique de Maladies de la Peau, kc. Paris, 1828,
p. 125.
CACHEXY. Syn. Cachexia (from y.ay.oc, ill or
bad, and iiig, a habit). A bad Habit of Body.
Classif. Constitutes the 3d Class in Dr.
Cullen's Nosology ; and the 4th Order in
the Class, Diseases of the Sanguineous
Function, in Dr. Good's Arrangement. I.
Class, V. Order (Author , see Preface).
1. Dekin. Depravity of the constitution, with-
out fever, affecting more or less the solids, the
circulating fluids, and the secretions.
2. The chief characteristics of this state are,
want of vigour and vital cohesion of the soft
solids, with defective digestion and assimilation,
diminished animal warmth, universal languor,
and deficient strength or activity. The skin is
usually pale, yellowish, or lurid; and the white of
the eyes in some cases almost transparent. As
this state advances, the countenance becomes
pale, white, or bloated; the skin loses its vital tint,
and changes either to a dirty white, or to a yellow
hue. The muscles tire flaccid, and deprived of
their healthy elasticity; the mind is inactive; the
breathing difficult upon exertion ; the feet and
ankles swollen ; the pulse slow and soft ; the eyelids
cedematous; the urine turbid; the alvine evacua-
tions irregular and offensive; the sleep oppressed,
and all the vital manifestations are enfeebled ;:nd
languid. In females, more or less of these syn p-
toms are associated with suppressed, returned,
morbid, or irregular menstruation; pains in the
forehead, back, ioins, or limbs; palpitations; and
longings for noxious or unwholesome articles of
food, or for what is not food. (See Appetite — ■
Morbid, and Chlorosis.)
3. This state of disease appears to be chiefly
the result of diminished vital energy, produced
by various mental and physical causes; in conse-
quence of which state the food is not sufficiently
elaborated and assimilated, the circulating fluid
does not experience the requisite degree of change
resulting from nervous influence, and the action
of the viscera, and the secreting functions are im-
perfectly executed, whereby the whole n.ass of
blood is impoverished or depraved, the manifest-
ation of the nervous and muscular systems are
feebly performed, and, ultimately, the whole of
the structures more or less vitiated. (See Blood
— Alterations of , in Disease.) Cachectic maladies
are very frequently associated with, or preceded
by, obstruction, or other disease of some important
viscus. If the pulse does not exceed SO or S4,
particularly towards evening, we may conclude
that the lungs are sound; and if the pulse be re-
gular, and the sleep undisturbed, we may infer
that the heart and its capsule are not, at least,
seriously affected. The viscera most frequently
diseased are the liver, mesenteric and lymphatic
glands, the spleen, pancreas, kidneys, uterine or-
gans, stomach and bowels; and the affection of
these is sometimes a cause»of. at other times an
CACHEXY — African — Causes.
273
attendant on, or even consecutive of, the cachectic
state; the vital endowment of the frame being the
first to experience the morbid change. It would
appeal th it thee irliesl manifestation of this change
lakes place in the ganglia] system; the internal
and circulatory organs, whose functions
are actuated by this syste u, becoming next disor-
de ''il. generally in such a manner as to attract the
attention of the observer to the nature and source
of disturbance.
4. The Treatmemt of cachexies chiefly con-
sists of lighl nutritious food, taken in such quan-
tity as the digestive organs can easily dispose of;
healthy air, or change of air, with gentle and reg-
ular exercise, short of fatigue; of tonics combined
with deobstruents and gent e aperients, in order
permanently to excite the languid powers of life,
and to promote the functions of the secreting
orgttis; and of the use of chalybeate and deob-
■truettt mineral waters, with frictions with stimu-
lating iai nents, and pleasant mental occupation.
The sulphate of quinine, or the preparations of
ebinchooa, particularly its compound tincture,
with s nail doses of the oxymuriate of [uicksilver;
ill • vi ions v eg 't ib !e to 'ii:s, bitters and aro n..ti<\s,
with the mineral acids, especially the ch oric
acid ; the preparations of iron ; the ch orates of
potash, soda, and lime; s arsap irilla, with gu il-
eum, &c.; the balsamic and terebinthinate sub-
stances; camphor, and the esseniiil oils, and the
preparations of iodine; are most serviceable in
ictic diseases, either exhibited singly, or com-
bined with laxatives or purgatives sons to p o-
inote the secreting and excreting functions. Vs
the various disorders of this description are often
connected with obstru sted function, or infai
of some important viscus, it will frequently be
requisite to exhibit at the same tine, or in con-
junction with so ne of the above remedies, small
doses of blue pill, or of the hydrargyrum ' "in
creta; or to combine thorn with rhubarb, aloes,
or other purgatives, and often to add to them ar-
omatics or warm gum resins. The object in
these cases is to pro note a regular action of the
viscera, by increasing their vital energy; and this
Ls belter attained by adopting measures calculated
to benefit the general health, and to increase the
action of the stomach and bowels, than by the oc-
il use of active and debilitating cathartics;
which, however, operate more efficiently and
much more beneficially in those cases, when com-
bined with bitters and tonics, — a fact long since
insisted on by Hoffmann, and others. (See
also .Mercurial Cachexy, Scrofula, and
Syphilitic Cachexy.)
BlBLIOG. AND REFER. — Binrtus, Sepulchretum, I. iii.
i. xx. oli«. 1 — 1 4. — We let, De Cachexia. Jen. 1715.—
Stahl, Diss, cle Cachexia. Hal*, 1710. — Hoffmann, De
Cachexia. Opera, t. iii. p. 318.— Nicol it, Diss. Sistem Ge-
nuinain Cachexiap indolem. Jen't*, 1760. —Voj^ttl^ Hi".
Si-ten- Cogoilionem Morborum. Goct. 1763. — JV<
Uelier die Kachexie iin Allgeincinei), Ate. 8vo. Leips. 1796.
Cachexy, African. Syn. Cachexia Afri-
cana, Negro Cachexy, Dirt-eating. Mai
(I " Ext.omar, Fr.
Classif. 1. Class, V. Order {Author,
see Preface. )
1. Df. fin. General cachexy, with vitiated
functions of the stomach and bowels, and a pro-
pensity to eat chalk, clay, or other dirty and un-
wholesome substances , generally affecting the ab-
origines of intertropical countries, $*c.
2. This disease is a complication of cachexy
with anaemia and pica, or depraved appetite (see
Appetite — Depraved), at least in its advanced
stages, it isverv common amongst the natives
of Africa, and the slaves in the West Indian col-
onies ; and is attended with loss of appetite,
continued pain of stomach, whiteness of tongue,
di ticu'ty of breathing upon the slightest exertion,
drowsiness, inactivity, and general debility, de-
spondency, with fondness of solitude, paleness of
the f ice, lips, and palms of the hands, coldness,
and often oedema of the extremities, glassy state
of the tunica adnata, weakness and smallness of
pulse, scanty, pale, or milky urine, whitish or
clay-coloured stools, with other signs of depressed
vital power and deficient assimilation. Owing to
the dep essed energies of the frame, and partic-
ularly of the digestive organs, a vitiated state of
the juices of the stomach, with morbid acidity of
the prima via, evidently prevails ; occasioning
sensations which p obably excite the patient to
have recourse to chalk, clay, or other absorbent
matters to relieve them, and which occasion what-
ever viti tion of appetite may be additionally ob-
served. rJ his morbid condition appears, however,
not to be limited to the stomach, but to be ex-
t aided along the alimentary canal : the mucous
surface of the bowels are in a state of morbid ir-
ritation, giving rise to offensive evacuations ; the
lacteal and mesenteric ghuids become irritated and
obstructed, owing to the passage through them of
unhealthy chyle and morbid secretions, and sub-
sequently incapable of conveying sufficient nour-
ish tient into the circulation ; the blood is thus
rendered poor, pale, and in all respects such as is
desciibed in the article on the Blood (§ 34. et
sea.): and the liver, pancreas, spleen, lungs, and
heart, become pale, at ophied, and sometimes
soil ■ ed, from being deprived of the requisite
nourishment, and supply of the circulating fluid.
And at last the patient sinks, from depression of
the vital power and anaemia, presenting the fol-
lowing appearances on examination —
3. The stomach is often flabby, softened, appa-
rently distended, and pale. 'J he liver is some-
times enlarged; occasionally atrophied, hardened,
and generally very pale. The bile is usually
w ne v. pale, oi si aw coloured: the gall-bladder
has contained biliary concretions in a few cases.
The mesenteric glands are always enlarged and
hardened. The mucous follicles of the intestines
are often morbidly developed. The heart is soft
and flabby; the blood in its cavities and large
veins is watery and thin; and sometimes fibrinous
concretions are found in these situations. Serous
effusions, to a greater or less extent, are also fre-
quently found in the thoracic and abdominal cav-
ities.
4. Causes. — This affection is very nearly allied
to chlorosis: hut whilst the latter affects females,
and most commonly about the period of puberty,
the former occurs in both sexes, and sometimes
at as early an age as six or seven years. It is
generally attributable to depressing or debilitating
causes — mental or physical. The despondency
and grief occasioned by separation from the place
of nativity and friends, and by a state of bondage,
often dispose to it; and thus it is not infrequently
accompanied with nostalgia. 'I he lax and weak
j habit of body, and the indolent disposition of the
I negro, seem also to favour the appearance of the
274
CAECUM — its Diseases.
disease, particularly in those who have been badly
nursed and neglected in early life. The chief ex-
citing causes are, poor diet, hard labour, harsh
treatment, exposure to cold and moisture, insuffi-
cient clothing, and venereal excesses early indulg-
ed in. The causes of the disease, the symptoms
it presents in its progress, and the appearances
observed after death, are altogether irrefragable
evidence that it proceeds from great depression of
the vital energies, especially of the digestive or-
gans ; occasioning, in its more advanced states,
anaemia, imperfect nutrition, and vitiation of the
fluids and soft solids of the frame.
5. The Treatment is in no respects different
from what has been recommended in general
terms in respect of Cachexia and Depraved
Appetite (see these articles). Warm clothing,
and a digestible nourishing diet, are indispensable
to recovery: and to these should he added, regular
but moderate exercise; bathing, followed by fric-
tions of the surface; tonic, aromatic, and saline
medicines; the use of the carbonates of the alka-
lies, con. bined with tonics and hot spices. Warm
stimulating laxatives, such as the compound tinct-
ures of rhubarb or aloes, or the bitter aperient
tincture (F. 69.9.); the elixirs prescribed in the
Appendix (F. 103— 06.); the preparations of
iron, cinchona, and myrrh ; are severally of the
greatest benefit, especially in coi junction with
warmth, a residence in a warm dry situation, and
sufficient nourishment. Care also ought to be
taken to preclude any access to the substances for
which the moibid propensity is entertained.
Bibliog. and Refer. — Duvihov, New York Med.
Repos. 1799, vol. ii. No. iii/ art. 6. — Chisholme, in Ibid.,
and Med. and Phvs. Journ. 1300, p. 6li.—Tf nter, On the
Diseases of the At mv in Jamaica; and in Edinburgh Medi-
cal Commentaries, vol. xiii. p. 194.
CAECUM. — Its Diseases. 1. This viscus is
not infrequently the scut nf dangerous and fatal
diseases, without any other part of the digestive
tube being affected; and it is evidently concerned
in the production of other disorders, in which it
has usually been considered as merely accidental-
ly to participate. If we consider its anaton ical
relations and functions in man and the lower
animals, we shall be justified in viewing it as a
distinct organ, performing offices modified in their
nature fom those of the rest of the alimentary
tube. Notwithstanding this individuality, both its
functions and its diseases have not generally at-
tracled that degree of attention, nor received the
investigation, they evidently deserve; and, hith-
erto, the latter have not even obtained a place in
practical or systematic works. Some years ago,
I took occasion to notice the importance of the
offices and pathological states of this viscus, and
detailed some cases in which it was remarkably
diseased. Several facts illustrating the practical
part of this subject have been recently accumulat-
ed, and some have since been observed by myself.
From these sources, 1 shall arrange all that is
known respecting the diseuses of this organ, after
having premised a few remarks on its functions.
2. The resemblance of the ca:cum to the stom-
ach in most of the graminivorous, and particu-
larly the ruminating, animals, as well as its form
and situation throughout all the higher classes of
the animal kingdom, are circumstances showing
that it is an important viscus, and one in which
the last act of digestion is performed. M. Vi-
kidet appears to have been the first who enter-
tained correct ideas of the actions of this viscus.
" Sed de intestino caeeo," he states, " quidquam
dicere prastat, cum in quibusdam animalibus sit
summe necessarium, nempe quibus et amplissi-
mum, forsanque vicem alterius ventriculi gerit;
nam glandulis crassioribus donatur, quorum suc-
cus solutione heliotropii rubescit, et solutioue
sublimati albescit, suisijuesalibus acidis et volatili-
bus praditum est." (De Prima Coctione, p. 270.)
This view has been recently confirmed by the
able researches of Tiedemann and Gmelin,
professors at Heidelberg. The situation of this
organ, its capacity, its attachment to the parietes
of the abdomen, and the circumstance of its con-
tents being propelled in opposition to their gravi-
ty, are proofs of their longer retention than those
of any other part of the digestive tube; and con-
firm the view that has been taken as to its being,
in some respects, a reservoir, wherein is poured
that pottion of the materials remaining in the ile-
um, in order to undergo the latter st;:ges of diges-
tion, and the first of faecation. Besides other
proofs of these functions, it may be stated, that it
is very abundantly supplied with large follicular
glands, which, according to the experiments of
Tiedemann and Gmelin, secrete an acid, al-
buminous, and solvent fluid, which mixes with,
and promotes the digestion of, those portions of
aliments which have withstood the actions of the
stomach and small intestines, or been insufficient-
ly changed by them. In order that this office may
be the more completely performed, the anatomi-
cal relations of the caecum admit of the remora,
for a longer or shorter time, of the matters which
pass into it; so that a last effort is here made to
obtain the remaining nourishment from the inges-
ta: and thus it performs, if not the very last act
of digestion, at least the last important part of it.
Put ii also seems to fill an additional office, name-
ly, that of secreting, cliiefly from its numerous
fo Nicies, an unctuous or oily fluid for the protec-
tion of the surface of the large bowels from the
irritating effect of the fatcal matters passing along
them; and it is probable that the constituents
both of this fluid, and of the other secretions
poured out from its surface, consist of elements
that require to be eliminated from the blood; so
that, in addition to its other functions, it is also a
depurating organ.
3, rI he usual contents of the co?cum are of the
consistence of a soft bouillie, or gruel, of a brown-
ish yellow colour, and here first acquire their
faeculent odour; which, according to Tiede-
mann and Gmelin, proceeds from the volatile
oily substance secreted by its follicles. During
the changes that are ejected by the ca-cum
on its contents, an acid and hydro sulphuret-
ted hydrogen gas is disengaged. 1 his gas seems
to be generated only in small quantities during
the healthy functions of the organ ; but when
its vital energies are diminished, and when,
consequently, a greater remora than usual of
its contents takes place, air is disengaged in
much greater quantities, and sometimes to the
extent of injuring its healthy tone. Whilst the
caecum reacts energetically on the distending
power, this flatus, along with a portion of its
contents, are thereby propelled along the colon :
but on many occasions, and under particu-
lar circumstances, considerable opposition about
CAECUM — Functional Disorder of.
275
the right flexure of this bowel is offered to their
transit; and hence, pain and uneasiness in this
part of the colon, as well as in the ca'cum, are
complained of; giving rise to the idea of the ex-
istence of either hepatic or nephritic disease.
4. Under other circumstances of protracted dis-
order of the digestive organs, as when acidity is
generated in the stomach and small intestines,
and the food imperfectly digested; or when the
ingests are of a stimulating, irritating, or other-
wise unwholesome kind; or when the secretions
of the liver, pancreas, and mucous surface of the
gmail intestines, are of a morbid or excoriating
nature, — then the accumulation and remora of
these matters in the cacum are productive of
disorder of its functions, of inflammation, and
even of change of its structure.
I. Disord k red Functions of thk Caecum.
Classif. I. Class, I. Order (Author).
5. When the vital energies are weakened, and
the alimentary canal debilitated, the caecum often
betrays greater disorder than any other part of
the digestive system. Its situation and functions
will, from what has already been stated, account
for the frequency and importance of its diseases.
In some cases, the irritation produced by morbid
or accumulated matters in it is slight, and readily
productive of sufficient reaction of its muscular
coats to propel them along the colon. In other
instances, the efforts made to accomplish this
end, owing to the obstructions occasioned by the
liul.' i. cut of flatus about the right flexure of the
colon, or by irregular spasmodic contractions of
this bowel, are ineffectual, and give rise to colicky
pains. If the interruption is removed, disorder
soon subsides ; but if it continue for any con-
side able time, the more violent forms of colic or
ileus supervene. When the internal surface of
the cspcuiii is in an irritable state, disorders of
this description are readily produced by the accu-
mulation, even to a small extent, of the intestinal
m. Iters poured into it from the ileum, especially
when they are of a more than usually stimulating
kind, or if the secretions be morbid. In young,
ir, iu.ble, or nervous persons, and in those who
partake of much acid or unripe fruit, or who
neglect their bowels, particularly females who
wear very close cinctures around the upper part
of the abdomen, diseases affecting the alimentary
canal, and, sympathetically, some other parts of
the frame, not infrequently thus originate in this
viscus. Accumulations, however, of alimentary
and faecal natters sometimes take place in it to a
great extent, without producing much disorder,
until the distension and irritation thereby occa-
sioned give rise to disease of its internal surface,
of its follicles, or its parietes generally. Persons
advanced in life, of a phlegmatic temperament,
or lax and torpid habit of body; those who take
little exercise, or whose occupations are seden-
tary; and especially aged females; are very liable
to be thus affected. During this state of infarction,
the retained matters are more or less changed,
partially decomposed, become acrid, excoriating,
and a source of irritation both to the mucous sur-
face itself, and to its follicles; which are thereby
obstructed, and ultimately inflamed and ulcerated.
In this way, most of the morbid states about to
be described originate.
(j. Several instances have been recorded by
the older writers, where the stones of fruits,
biliary and intestinal concretions, and hardened
frrcal matters lodged in the ca'cum, have occa-
sioned severe colic, and even fatal ileus. Some
cases of this kind are referred to in Dr. Monro's
instructive work on Morbid Anatomy, as ha\ing
occurred in his and his father's practice. In one
of these, a concretion upwards of seven inches in
circumference filled up this viscus. Fontanus
found an earthy concretion in it, as the only
morbid appearance after death from ileus ; and
Helm, nearly three hundred cherry stones in the
same situation, and in the ileum before it opens
into the caecum, in a fatal case of this disease.
In some instances, accumulations of faecal mat-
ters with great distension occur, without much
suffering referrible immediately to the ca;cutn
being experienced ; the organs affected second-
arily evincing the most marked disorder. This
was shown by the case detailed by M. Odier,
of Geneva, of the celebrated M. de Saussure,
in whom this viscus was very greatly dilated.
When very much distended, it is generally dis-
eased in other respects; its coats are more or less
thickened, inflamed, and ulcerated, or its follicles
enlarged. Monro, Nacquart, and others,
have adduced instances in which its engorgement
and enlargement were accompanied with chronic
inflammation and thickening. Mr. Wilmot re-
lates a case in which it was dilated to the extent
of containing a gallon, filled with fecal tnatters,
and perforated by a circular ulceration. When
the distension by accumulated matter is great, it
may, from rising high in the abdomen, and press-
ing upon the nerves, vessels, and ducts in its
vicinity, occasion numbness, and oedema of the
right lower extremity, retraction of the testicle,
and derangement of the urinary secretion ; and
thus be mistaken for disease of the kidney. M.
Ducos has detailed an instructive case of this
kind ; and two similar instances have been ob-
served by me. In general, the seat of the tumour
arising from collections of morbid matters in the
caecum, and the disorders connected with it,
readily lead to the recognition of its nature, us in
the case recorded by Dr. Barlow. When,
however, there is little or no tumour formed, and
the symptoms are of a chronic and less violent
kind, the cause of disorder may long exist in this
situation, and escape detection. In a case of
a young lady whom I attended with Mr. Annes-
ley, this part was considered as the seat of dis-
order, from its fulness and hardness upon an ex-
amination made when the patient was semi-
recumbent, and the thigh slightly bent, and a
treatment in accordance with this view strenuously
insisted upon. She had been attended by several
eminent physicians during the preceding three or
four years, and very different opinions entertained
of the nature of her ailments. After persistence
in the treatment about to be recommended, an
evacuation of baldened balls, containing indiges-
tible substances which she had chewed many
months previously, were evacuated, the fulness
and hardness in the right iliac region disappeared,
and the patient perfectly recovered. Two nearly
similar cases to this were detailed by me in a,
work referred to below.
7. Substances incapable of digestion, either
taken accidentally or from a depraved appetite,
also frequently lodge in the cacum, and remain
in it for a very long period, sometimes without
27 G
CAECUM — Functional Disorder of.
producing much disorder, at other times occasion-
ing the most violent effects. In other cases, in
addition to various morbid matters, large halls of
worn s, both lombrici and* ascarides, collect in
this viscus, and occasion much local irritation, or
even inflammation of its inner surface, and con-
stitutional disturbance. Mr. Blackadder has
detailed some interesting instances of this occur-
rence, lie found, in a patient who had com-
plained of disorder of various organs, and of
a gnawing soreness in the right iliac region,
ragged ulceration of the inner surface of the
csBCum, which contained an immense number
of worms. The rest of the alimentary canal
was sound.
8. When the caecum is much enlarged, or
otherwise diseased, it may also be displaced.
Cases are recorded by Salzmann and Annes-
LF.y, in which its attachment to the internal iliac
muscle had yielded so far that it had passed over
to the left side; and others, in which it had de-
scended very low into the middle of the pelvis,
and pressed upon the urinary bladder.
9. Not only may indigestible substances and
morbid concretions sometimes lodge in the caecum,
producing much local irritation and general dis-
turbance, but they may, when small, sometimes
pass into the vermiform appendage, where they
occasion, as will be shown in the sequel, the
most dangerous effects. It does not, however,
appear that the simple presence of any of these
substances in this process is always followed by
such results. Mr. Blackadder relates a case
in which he found a small concretion in this part,
and yet the patient had not complained of any
symptom referrible to the right iliac region. I
have treated, or been consulted respecting, four
cases, in which foreign bodies and concretions
were found in the appendix after death; and in
all, the symptoms were those of the most violent
peritonitis complicated with ileus, and termin-
ating in sphacelation of this process itself. Two
of these I attended with Mr. Fainter, of Craw-
ford-street, by whom the inspections were made;
and who ascertained that the substance found in
the appendix, in one case, consisted chiefly of
cholesterine.
10. The phenomena usually occasioned by
faecal matters collected in the caecum, and by dis-
tension, enlargement, or irritation of this viscus,
will necessarily vary with the nature of the
offending substances, the extent to which they
may have accumulated, and the age, tempera-
ment, and habit of body of the patient. Ihe dis-
orders which result are, 1st, Local; 2d, Symp-
tomatic, and 3d, Constitutional, a. The local
signs are more or less fulness, hardness, or dis-
tension in the right iliac region : sometimes, on
examination careful! with the points of the
fingers, the abdominal muscles being relaxed, a
doughy hardness is felt. In other cases little or
no pain, even upon a minute examination, is
complained of; but occasionally, especially if the
disorder be about inducing inflammation, both
tenderness and pain either exist more or less con-
stantly, or come on in paroxysms; and the patient
generally reposes on the right side. When the
bowels are constipated, and interruption of the
passage of matters through the ca'Cum occurs,
the paroxysms of pain are very acute, and some-
times attended by vomiting, and all the symp-
toms of the most severe colic, or even those of
ileus. In such cases, upon examination, si<ms
of obstruction either in the cacum or in its
vicinity are detected, unless general peritonitis
may have come on; and then the origin of disease
is very generally referred to the caecal region, or
the tenderness and pain are most acute in that
situation.
11. b. The symptomatic disorders, when this
viscus is much distended, either by fecal or other
matters, or by flatus, or by both, as is most com-
monly the case, are, numbness of the right thigh,
oedema of the right foot and ankle ; sometimes
retraction of the testicle, or frequent calls to
empty the bladder, and sometimes haemorrhoids;
uneasiness or pain in the right iliac region, often
extending to the hvpochondrium ; various dys-
peptic symptoms, costive or irregular state of the
bowels; occasionally diarrhoea, with scanty, of-
fensive, and mucous stools; and, if irritation be
excited in the mucous surface and follicles of the
organ, the efforts made to evacuate the bowels
are attended by severe tormina, and even by-
retching. I have seen several cases of varicose
veins of the leg, or indolent ulcers, and a case of
disease of the bones of the foot, the occurrence
of which was evidently connected with great
distension and accumulations in the caecum; the
symptoms of this disorder, with more or less
tumefaction and hardness in the iliac region,
having been found on examination. The just-
ness of this view was fully shown bv the success
of the treatment, which was based upon it.
12. c. As long as the states of disorder have
not advanced to inflammation or ulceration, the
effects are often not very manifest upon the con-
stitution. The countenance and skin, however,
are pale and lax; the complexion is deficient of
clearness, and, with the surface generally, often
covered with an oily or dirty moisture; the per-
spiration is foetid, and the breath offensive; the
soft solids lose their elasticity, and are slightly
emaciated; the lips are usually pale, the tongue
white or loaded at its centre and base, sometimes
red at its point and edges; the pulse is weak,
soft, or small, frequently slow, but easily acceler-
ated; and, at an advanced stage, the symptoms
more clearly manifest that the blood is imper-
fectly depurated, or that it is affected by the
absorption of a portion of the excrementitious
matters retained in the cacum. In addition to
these symptoms, general debility, and disincli-
nation to any physical or mental exertion, are
often complained of. The above states of disor-
der continue for a longer or shorter period; when
at last the local irritation either produces increased
action of the muscular coat of the caecum, and
ultimately the dislodgment of the offending mat-
ters, or gives rise to acute or chronic states of
inflammation, and various consecutive organic
changes. In some instances, the accumulation
in this viscus, and the spasm of the adjoining
parte, amount to complete obstruction of the
passage through the alimentary canal, even with-
out inflammation or any disorganization of the
cacum itself having taken place; causing violent
colic and ileus, as in the cases already noticed
(§ U).); the most marked symptoms during life
being referrible to the superior portions of the
tube, and the lesions after death being most re-
markable in those parts,, particularly about the
('.!'.( 'I IM — Infix m mation of — Causes.
277
termination of the ileum, and the ileo-crccal
valve.
13. Treatment. — The intentions in this state
of disorder are very obvious; namely, 1st, to
evacuate morbid collections; and. 2d, to prevenl
their re-accumulation, by preserving a regular
tonic action of the vis. -us, and by strengthening
the digestive organs generally. «. The evacua-
tion of the accumulated or retained matters is to
lie attempted by means appropriate to the cir-
cumstances ot" the cases. If there exist irrita-
bility of stomach, or even any tendency to it, or
to febrile action; or if there be any pain or sore-
ness in the iliac region; full doses of calomel
should be first exhibited, the enemata about to be
suggested administered, and die liniments pre-
scribed in the Appendix (F. 296. 311.) assidu-
ously rubbed over the caecal region, with the
view of exciting the healthy action of the viscus.
If, ou the other hand, the stomach and bowels
he torpid, and the former can retain purgative
er cathartic medicines, they may be given, select-
ing those which are the least irritating in their
1 have seen inattention to this caution,
the most stimulating cathartics having been ex-
hibited, productive of the worst consequences; a
state of disorder simply functional, or colic from
distension and obstruction of the caecum, being
converted into either inflammation of the bowels
or dangerous ileus. When, therefore, an irritable
state of the stomach supervenes in our attempts
to remove obstructions of this viscus, we should
desisl from the exhibition of purgatives, or even
oi' aperients by the mouth, excepting full doses
of calomel, or calomel combined with hvoscyamus
or opium, and moderate doses of nitrate of potash,
or sub-carbonate of soda, or of both, which will
dly be retained, and will allay the sicUness
and retchings. But we ought strenuously to per-
sist in the administration of enemata — preferring
those which are oleaginous, saponaceous, and
solvent — and in the use of the liniments. The
a should be always large, and injected
by means of the valve-syringe now in use, so that
they may reach the seat of obstruction. In ob-
-. this object will be facilitated by
placing the patient upon his knees and elbows
during their administration, and elevating the
pelvis as much as possible above the rest of the
trunk. The practitioner should not be discour-
aged by the ineffectual administration of several
injections, but repeat them according to circum-
stances, employing at the same time frictions over
the abdomen with the liniments already advised.
If flatulent distension of the abdomen be present,
they will assist in removing it; but in such eases
the terebinthinate enemata ought to be preferred.
When we suspect the presence of worms, in ad-
dition to other morbid matters, aloes and the al-
kaline solutions, assafiEtida, camphor, lime-water,
&c. may be used in the injections. In the slight-
er and more usual cases, the aperients in common
particularly castor oil, the compound decoc-
tion of aloes, the combination of the compound in-
fusions of senna and of gentian, or the infusion of
senna with decoction of cinchona, or the several
formulae of this description contained in the Ap-
pendix (F. 215. 266. 562. 575.), may be pre-
scribed, as they may appear appropriate to the
circumstances of the case.
14. b. Having apparently removed whatever
24
obstruction may have existed, — the caecal region
being soft and natural, and the actions of the
bowels free, — the object is next to prevent the
recurrence of disorder, and to strengthen the di-
gestive organs, by vegetable tonics and bitters
combined with aperients; by sulphate of quinine
with aloes; by small doses of blue pill with the
alkaline carbonates and other deobstruents, and
given occasionally with the view of promoting
and correcting the secretion; by the occasional
use of the liniments above referred to, or hy wear-
ing a warm stimulating plaster (see F. 109. 115.
117.) over the right inferior regions of the abdo-
men. In every case, attention should be paid to
the state of the digestive, assimilating, and secre-
ting functions; regular evacuations of the bowels
promoted, by the occasional use of enemata; and
the diet strictly attended to.
II. Inflammation of the Cecum. Clas-
sif. III. Class, I. Order (Author).
15. Although inflammations of this viscus have
been generally overlooked or confounded with
those affecting either the colon, the small intes-
tines, or the peritoneum, there are few diseases
more defined in their character, or more distinctly
limited in the great proportion of the instances of
their ocurrence, than they are. In respect of
its seat, inflammation may affect chiefly the mu-
cous surface, or the follicles, or all the coats of
the organ more or less : or it may attack the ver-
miform appendix only, or the cellular tissue con-
necting the caecum to the internal iliac muscle.
As to the character of the inflammatory action,
it may be sthenic and acute; or acute, asthenic,
and spreading, as in dysentery and fever: it may
also be more or less chronic. Cases of all these
states of disease are to be found scattered through
the works of modern medical authors, and most
of them have come before me. The first case
which attracted my attention to the importance
of attending to the state of tliis viscus in various
abdominal diseases, occurred in 1S16, in a hot
climate. The patient had the usual symptoms
of inflammatory dysentery, with violent pain, and
subsequently tumefaction in the cacical region.
The disease had been neglected in its early sta-
ges; and it was only shortly before the sudden
subsidence of this tumour that I observed it.
Upon straining at stool, a sensation of something
having burst internally was felt; and very soon
afterwards above a pint of purulent matter, mixed
with a little blood, was discharged. Upon exa-
mination six hours after death, the caecum was
found ulcerated, discoloured, and nearly sphace-
lated, with an opening through the part attached
to the abdominal parietes leading to the nearly
empty sac of an abscess which had formed in the
cellular tissue connecting this viscus to the side;
the mucous membrane of the colon was inflamed
in parts, and excoriated.
16. i. The Causes of inflammations of the ca>-
cum are chiefly the functional disorders already
described. A morbid state of the abdominal se-
cretions, and particularly an increased secretion of
vitiated acrid bile; the irritation of foreign bodies,
indigestible substances, and of worms; a strangu-
lated hernia, or the pressure of an ill-constructed
tru<s: the suppression of the haemorrhoidal and
menstrual discharges; and the presence of biliary
or intestinal concretions, hardened feces, or the
stones of fruits, or their escape into the vermiform
278
CECUM — Inflammation of the Appehdii of.
appendage. Inflammatory irritation of the mu-
cous membrane and follicles of the viscus is not
infrequent after child-birth, and as an attendant
upon some of the diseases which affect chiefly
the bowels of females at this period. In connec-
tion with the accumulation and retention of mor-
bid matters, it very often constitutes the earliest
pathological state in dysentery and diarrhoea, and
consequently then arises from the same causes
that produce those diseases.
17. ii. Symptoms. — A. Of inflammation of the
mucous surface of the ccecum. These chiefly con-
sist of an irregular, mucous, offensive, and some-
times slightly bloody appearance of the stools,
with tenderness upon pressure or examination of
the coecal region. The evacuations are generally
preceded by tormina or griping pain, extending
from this part upwards to the right side, and
down towards the pelvis. The tongue is slightly
loaded or furred; and more or less symptomatic
fever is present. This state of disorder is liable
to lapse into a chronic form, and to continue for
a long period; or it occurs primarily, from the
functional disorders already described, and some-
times fluctuates as to the degree of severity. In
the more slight or chronic states of inflammation
of this surface, the patient often complains of
little beyond irregularity of the bowels and co-
licky pains in the abdomen, with slight emacia-
tion, and loss of the healthy complexion; till, at
last, an acute attack of the disease supervenes,
from the extension of the inflammatory action to
the more exterior coats; or the chronic organic
change has proceeded so far as to implicate ad-
joining parts, and to occasion a train of severe
symptoms. In this manner, the more dangerous
forms of dysentery not infrequently take place.
During the earlier states of inflammation of the
internal surface of the caecum, ulceration may
have commenced, or the follicles become diseased,
and the coats successively perforated, until the
peritoneal covering is attacked; when the inflam-
mation assumes more serious features, owing both
to its extension, and to the nature of the tissues
which are now invaded by it. The perforation
may, however, take place in that part of the pa-
rietes of the viscus where it is attached to the
iliac muscle; and thus inflammation be extended
to, and abscess form in, the cellular tissue exterior
to it, and break either externally, or into the cae-
cum, or both; a sinuous communication being thus
formed between the cavity of the organ and the
surface of the body. In the manner now de-
scribed, the more acute states of inflammation of
the caecum, and its connecting tissue, may arise;
or these states may primarily affect the different
structures composing its parietes, or may originate
in its vermiform appendage.
18. S. Acute inflammation of the coats of the
ceecum generally commences with violent pain in
the right iliac region, frequently attended with a
burning sensation, and most exquisite tenderness,
particularly when the serous coat of the viscus
is affected. It is accompanied with the most
severe tormina, extending from the above region
upwards to the right hypechondrium, across the
abdomen, down into the pelvis, and along the
thigh of that side. If the disease be attended
by distension of, or faecal collections in, the
caecum, the testicle is retracted, and the thigh
either very painful or numb. While the pain
occurs in paroxysms, and shoots in various direc-
tions throughout the abdominal cavity, it is con-
stant and fixed in the situation of the caecum.
The regions of the abdomen, although sometimes
distended and tense, bear examination, excepting
in the caecal region and its immediate vicinity,
where the least pressure cannot be tolerated.
The pain is usually increased when the body is
erect; and the patient reclines on the right side,
with the trunk slightly bent, and the thiglis
drawn upwards, so as to relax the parts in the
vicinity of the disease. The bowels are generally
torpid; but vomiting is not complained of, un-
less obstinate constipation exists, or drastic purga-
tives have been given early in the disease. rlhe
pulse is usually quicker than natural; but it is
occasionally not much affected; and the temper-
ature of the surface is increased. In some cases,
the above constitute the chief symptoms; but in
others much more disturbance ensues, particu-
larly if the disease advances, or is neglected in
its early stages, and the peritoneal surface of the
caecum is affected. When such is the case, the
local symptoms increase in severity; the abdo-
men becomes more generally tense and painful,
owing to the extension of the inflammation over
the peritoneal covering of the viscus and the ad-
joining parts; and the symptoms of peritonitis,
often attended by obstinate vomiting, supervene,
with great frequency of pulse, and general fever.
If the appendix participate in the disease, the
symptoms are still more acute; general peritonitis
is very quickly produced; adhesions are formed
between it and the adjoining peritoneal surface;
and the appendix soon sphacelates; a fatal result
taking place, usually in a very short time. In
other cases the disease assumes a somewhat less
violent character, and terminates in suppuration,
owing to the cellular tissue connecting the coats
of the intestine to one another and to the ab-
dominal parietes being chiefly affected. When
this occurs, the issue is not so rapid as in the
former instances, but is sometimes prolonged for
a considerable period; and, in some cases, re-
covery is at last brought about. The foregoing
history applies more strictly to inflammation ori-
ginating in the caecum ; but when it commences
in the appendix, or in the external connecting
cellular tissue, the symptoms are often much
modified.
19. C. Inflammation of the appendix caci ap-
pears to be attended from its commencement with
more acute symptoms than that of the caecnm
itself. In four cases of this description which I
have seen, this part was primarily and chiefly in-
flamed, owing to hard substances having escaped
into it, and had occasioned general peritonitis,
and gangrene of the appendix itself. In all of
these, obstructions of the bowels, with obstiuate
retchings, was present at the -time when I first
saw them; and in the latter stages of the disease,
vomiting was attended by violent tormina, and
the discharge of matters evidently from the
small intestines. Thus the svmptoms of ileus
were superadded to those of peritonitis. Upon
dissection, the ca>cum was found inflamed only
in its peritoneal surface, in three of the cases; in
the fourth, inflammation was observed also in its
inner surface. In one, where the appendix con-
tained a small biliary concretion, its extremity
adhered to the surface of the caecum after passing
CECUM — Chronic Inflammation of.
279
around a convolution of the ileum, which it had
evidently strangulated; bul at the time of the in-
spection it was quite gangrenous on each side of
the concretion. In another case, appearances of
strangulation were manifested in a less satisfactory
manner ; the surrounding parts being so agglu-
tinated by albuminous exudations, that their re-
spective relations were not obvious. It does not
appear, however, that inflammation originating in
the appendix always arises from substances having
escaped into it. M. Louyer Vii.lermay has
detailed two cases of a similar state and termina-
tion of disease to the above; one occurring with-
out any apparent cause, the other seemingly from
the pressure of a bandage in hernia. In one, pub-
lished by Mr. Parkinson, ulceration and per-
foration of the appendix had taken place from the
lodgment of a small portion of indurated fasces
in it. A very interesting case, where violent
abdominal symptoms were occasioned by a large
lumbricus, which had passed into the caeca) ap-
pendage of a person otherwise diseased, is record-
ed by Mr. Blackadder. M. Thif.ry found
this part engorged with faecal matters, and in-
flamed, in a fatal case of ileus; the caecum being
narrowed, but not otherwise diseased. Hf.ister
met with the appendix inflamed and ulcerated
after death, with similar symptoms. Amyand
detected a small nail in this part after fatal ileus.
Moreao and Kloeckhoff record instances of
this disease produced by strangulation of the ileum
by the coecal appendage. Mr. Waldron dis-
covered a small concretion in it after fatal perito-
nitis; and Morcagsi,VanDi)everen,Sandi-
fort, and several others, have detailed cases of
both peritonitis and ileus, in which this part had
adhered to adjoining parts; and, in some instances,
a loop of intestine had been enclosed by it, and
strictured. From the history of these and other
cases, which have occurred to several of my
medical friends, it may be inferred, that inflam-
mation affecting primarily the caecal appendage is
most frequently brought on by hard substances
having escaped into it; and that the inflammation
rapidly extends to the peritoneum; giving rise to
the exudation of albuminous lymph, to adhesion
of its opposite surfaces, and of the appendix to
adjoining parts, and to gangrene of this process.
20. Very acute pain, tumefaction, and tender-
are complained of upon the invasion of this
form of the disease, first in the right iliac region,
and subsequently more or less over the abdomen;
with excruciating tormina, obstinate constipation
of the bowels, a very frequent, small, or con-
tracted pulse, heat of skin, dry tongue, great
thirst, sometimes with numbness of the right leg,
or pain shooting down the thigh, and retraction of
the testicle. \ omiting funics on sooner or later,
and is often, at one period or another, attended
by the discharge of matters from the small in-
testines— at least, in the cases which I have seen.
The patient at last becomes restless, his coun-
tenance sunk, and a fatal termination takes place,
generally from the third to the sixth day, pre-
ceded by the symptoms ushering in dissolution
from intestinal peritonitis.
21. D. Inflammation of the pericecal tissue IS
occasionally met with. Several interesting cases
of it have been published by French writers, es-
pecially by MM. Dupuytren and Meniere.
Mr. Co p E E. a n d has detailed a case where a urinary
calculus was extracted from an abscess which
opened externally, and communicated internally
with the cavity of the caecum. It is probable
that the calculus, in passing along the ureter, had
produced inflammation, extending to the cellular
tissue exterior to the caecum, and terminating in
abscess, which had opened in both directions. In a
case contained in Dr. Johnson's Journal, abscess
had formed in the cellular tissue, external to the
cascum, had also burst into this viscus, and pointed
externally: and a similar instance is recorded by
M. Duplay. In all these a sinuous communi-
cation between the cavity of the intestine and
external surface was formed. Several of the cases
of inflammation of the caxuin and connecting
tissue, detailed or referred to by M. Meniere,
terminated in suppuration, and opened either in-
ternally or in the right iliac fossa. In some of
those published by M. Dupuytren, the purulent
matter had infiltrated itself as high as the kidney,
and as low in the pelvis as to collect between the
rectum and bladder.
22. The precursory symptoms of this state
of disease belong to pathological changes in the
functions or coats of the cascum itself, and are
often similar to those already described as in-
dicating acute or chronic inflammation of its
mucous surface and follicles ; the disease in such
cases most probably arising from ulcerative per-
foration of the coats of the organ, or the extension
of inflammation from its mucous surface. The
patient frequently is first affected with either
diarrhoea or constipation, or by both alternately,
with colicky pains shooting in various directions,
but generally radiating from the right iliac region;
and he complains of pain or tenderness on pres-
sure. To the above symptoms, others sooner or
later are added, especially tumefaction, and con-
stant pain in this part, and in the right iliac fossa,
with anorexia, nausea, fever, and an irregular
state of the bowels. As soon as suppuration
commences, the disease presents the local and
constitutional characters usually accompanying
the formation of matter, with more or less tu-
mour, which is generally situated deep in the
iliac fossa.
23. Inflammation in this situation will, if re-
cognised early and treated judiciously, terminate
by resolution, in perhaps the majority of cases.
But suppuration is almost as common a termin-
ation as resolution; and when it takes place, the
abscess formed most frequently opens internally.
In several instances, peritonitis has supervened,
cither previously or subsequently to suppuration,
but more usually the latter. The abscess may
also open externally, as in the cases already re-
ferred to; hut seldom without it having also pre-
viously established a communication with the
cavity of the caecum.
24. hi. Chronic Inflammation of the
Cecum generally comes on primarily, slowly,
and insidiously, and may be long limited to the
internal surface and follicles of the intestine, as
noticed above (§ 17.). It more rarely remains
after acute attacks. In the former mode of ap-
pearance, it often advances' imperceptibly, until
serious organic changes have taken place in the
coats of the organ; the general health, although
more or less affected, not being so far injured as
to alarm the patient. In its progress, it sometimes
presents occasional accessions of severity , and even
280
CAECUM — Inflammation of the — Complications.
assumes a sub-acute form. In other cases, an
acute attack is superinduced, which may terminate
in peritonitis, or in suppuration, or even in gan-
grene. Chronic inflammation is the most common
organic state of disease by which the caecum is
afleeted.
25. A. Causes. — This form of inflammation of
the caecum is, I believe, most frequent in females,
probably owing to contingencies connected with
the uterine functions and child-bearing, and to
their modes of dress. It often occurs among them
previously to menstruation, or soon after the cli-
macteric epoch. The use of unripe or acerb
fruits; sedentary occupations, or want of exercise;
the depressing passions; previous disorder of the
digestive organs, particularly costiveness, and ha-
bitually, or occasionally, deferring the earlier in-
timations to evacuate the bowels ; suppression of
accustomed discharges, especially the hemorrhoi-
dal, the menstrual, and lochia!; the pressure of
an ill-constructed bandage for hernia; blows or
contusions on the caecal region; and occasionally
too violent exercise on foot or on horseback; are
its most usual exciting causes.
26. B. Symptoms. — At first the general health
and strength are not much injured; but the pa-
tient loses his healthy appearance, and activity.
He complains of colicky pains occurring occa-
sionally, or even periodically, in the right iliac
region, shooting through the abdomen, and recur-
ring soon after a meal. The appetite is not
materially affected, and flatulence is the most
constant gastric symptom. Ihe tongue is gene-
rally red at its point and edges, and loaded at its
root; sickness and vomiting are not present; the
pulse is often little affected, or it is quick and
small ; the patient lies on the right side, with the
body bent and the thighs drawn up, and feels
pain or uneasiness in the iliac region on turning
to the left side, which is increased by continuing
the position. The alvine evacuations are irre-
gular and offensive, being at one time frequent, at
another retained, generally muco-feculent, fluid,
preceded by colic or slight tormina, and affording
little relief. The abdomen, on examination, pre-
sents little remarkable, until we reach the ca>
cal region, where pressure occasions uneasiness,
and a deeply seated fulness and hardness are
usually detected. If much fulness or distension
be present, the urine is generally voided fre-
quently, and slight pain or numbness of the right
thigh, with oedema of the right ankle, is often felt.
If the disease go on to ulceration, blood will ap-
pear in the stools, which will also be of a more or
less dark colour. Such are the usual symptoms,
until some one of the acute states of the disease
supervenes, when their attendant phenomena will
indicate the change.
27. C. The chronic state of the disease may give
rise to very great thickening of the parietes of the
caecum, either with or without dilatation of its ca-
vity, and ulcerations in its internal surface. Fa-
bricius Hildanus describes a case of this kind
as one of cancerous ulceration; but it seems rather
to have been chronic inflammation, with thickening
and ulceration. Dr. Beezeley has detailed an
interesting case very nearly of this description,
wherein these changes were very remarkable. The
patient complained of colic, constipation, flatu-
lence, mucous bloody stools, and of a large tumour
in the iliac region, which was mistaken for aneu-
rism of the iliac artery. On inspection, post mor-
tem, the coats of the carcum were found above an
inch in thickness, scirrhous, inflamed, ulcerated,
perforated, and its cavity enlarged. When the
disease has gone on to thickening, as indicated by
the obscure hardness, and tumour, uneasiness, kr.
in the iliac region, particularly if it be attended
with ulceration, as may be inferred from the pre-
sence of small quantities of blood or pus mixed in
fluid, or but little consistent, muco-feculent and
offensive stools, amendment is procured with great
difficulty, under the most favourable circumstances;
but it should not be despaired of, although it may
be long in appearing. I have met with severe
cases, obviously of this description, where medical
treatment was persisted in for many months, and
one or two for some years, yet ultimately the health
was re-established. In a case recorded by M.
Emery, the caecum was remarkably constricted,
and the appendix filled with faeces. The patient
died of ileus.
28. iv. Complications. — Inflammations of
the caecum, particularly of its internal surface, and
in their sub-acute and chronic forms, with morbid
enlargement and fungous ulceration of its follicles,
are very frequently associated with dysentery and
fever, in both temperate and warn) climates. In-
flammation of its external connecting tissue is
much less common in these complications. I
ascertained the fact of the intimate connection of
inflammations of the caecum with dysentery, in
1816, my attention having been first directed to
it by the case already allude'd to (§ 15.). In-
deed, they generally constitute the original dis-
ease in dysentery; the irritative state of inflam-
mation of the mucous surface and follicles of this
\ iscus, together with the acrid secretions and
other matters retained in it, producing an es-
coriating state of the discharges, whereby the
caecum itself is first affected, and subsequently
those parts of the colon and rectum where they are
the longest retained; an opposite morbid relation,
however, obtains in respect of its complications
with fevers, particularly those of a typhoid na-
ture; for, while in dysentery it is frequently the
primary affection, in fevers it is commonly a
consecuth e lesion arising from the morbid states
of the secretions and matters, either retained in
or passing through it, and from the disposition to
change possessed by the mucous tissues and fol-
licles during these diseases, particularly those of
an asthenic character. It should not, however,
be overlooked, that lesions of the caecum may also
arise in the course of dysentery, owing to similar
states of the secretions and mucous surface of the
intestines as are present in fevers ; and that the
caeca] disease will very generally escape detection
during life, particularly in fevers, unless the atten-
tion of the practitioner is alive to its occurrence.
In every case, therefore, should the region of this
\ iscus be attentively examined; and, if symptoms
indicating an affection of it be present, the means
of cure should be directed accordingly.
29. v. Laceration, or rupture of the caecum
occurs in rare cases, either in consequence of pre-
vious disease and infarction of its cavity, or of
external injury. Some instances of this occur-
rence arc to be found in early volumes of the
Philosophical Transactions, and in the Transac-
tions of foreign medical societies. Soemmering,
in his notes to the translation of Dr. Baillie's
C/ECUM — Inflammation of the — Treatment.
281
3[t»'lii<! Anatomy, mentions ;i case wherein it
was produced by vomiting, which may have
arisen from accumulation of morbid matters in
the cecum, with obstruction of its canal, and ul-
ceration of its internal surface. Mr. Spf.f.r and
Mr. SHKWARD record instances of its rupture
from contusion, — an event which is very likely
to occur when an injury is sustained over it during
distension of its cavity, from whatever cause.
The consequence of its laceration generally is
rapidly developed, and speedily fatal, peritonitis.
Introsusri pliuiis vl' this part, itself having passed
into the colon, or portions of bowel having passed
into it, are not infrequent, particularly in young
Subjects ; but they require no particular notice,
farther than as a cause of ileus, inflammation of
intestines, &c.
30. vi. The Prognosis in disease of the caecum
is very different in each of its forms. — a. When
the internal surface is chiefly affected, recovery
will take place in most of the cases, unless ulcer-
ation has commenced ; and even then a favour-
able issue will sometimes follow judicious medical
treatment and regimen, b. In the acute states of
inflammation affectiDg the more external coats of
the viscus, the prognosis is upon the whole un-
favourable, at least it should be stated as such to
the friends of the patient ; and in every case it
should be given with caution, c. If we suspect,
from the severity of the symptoms, or from the
rapid extension of inflammation from the caecal
region over the abdomen, that the appendix is
inflamed, it is still more unfavourable ; if, in ad-
dition to this circumstance, the retching be fre-
quent, and more particularly if the matters eject-
ed appear as having come from the small intes-
tines, we may infer, not only that the caecum or
its appendage is most acutely inflamed, but also
that either its canal is obstructed, or some adjoin-
ing part of the tube is strangulated ; — in either
case the prognosis is most unfavourable. The
subsequent appearance of the symptoms usual-
lv indicating gangrene of the intestines leaves
no hope, and is soon followed by dissolution.
d. When considerable tumour, seated in the iliac
fossa, and the signs of inflammation of the peri-
cecal tissues, are present (§22.), a favourable
opinion of the issue may be entertained, if active
treatment have been employed early in the disease,
and the patient's constitution be not in fault. But
in very many such cases, the general health has
been much impaired previously to this disease,
and has even predisposed to the attack. In such
cases, as well as when evidence of the formation
of abscess is observed, a very unfavourable, or at
least a very cautious, prognosis ought to be given.
e. In the chronic states of the disease any opinion
should be offered with much reservation. If the
disease have come on slowly, continued long, and
the stools present the appearances indicating ul-
ceration (§ 26.), an unfavourable state of disease
exists ; thickening of the coats of the viscus mere-
ly ( § 27.) is more favourable, but is not readily
removed. /. The complications of this disease
(I 2s.), particularly with typhoid fever, are at-
tended by considerable danger. The association
of it with dysentery is productive of the worst
forms of that disease, as well as its complication
with fever, of its most dangerous states ; and
causes the former to assume a chronic and obsti-
nate form. g. Laceration, or rupture of the
24*
coats of the caecum, is generally fatal in its results.
31. vii. Treatment. — A. Inflammation of
the internal surface of the caecum, and the
chronic stales of the disease (§17. 24.), require
the application of a number of leeches either
near the iliac region, or on the inside of the right
thigh, and a repetition of them according to the
circumstances of the case. In robust, or plethoric
persons, general depletion may precede the local.
After the leeches are removed, fomentations and
a succession of poultices will be found service-
able ; after which, a full dose of calomel with
James's powder, and, a few hours subsequently,
a mild aperient medicine, should be exhibited,
and an aperient action promoted by the ad-
ministration, and frequent repetition, of demul-
cent, oleaginous, or saponaceous enemata (§13.).
Drastic purgatives are seldom more efficacious
than those of a milder kind, but are often attend-
ed with risk. I have generally found the infusion
of rhubarb, with tartrate of potash, and the elec-
tuaries prescribed in the Appendix (F. 82. S9.
98.), most serviceable. In the majority of cases,
the above means will remove all ailment. The
treatment in other respects should be the same
as is recommended in chronic Diarrhoza and in
Dysentery. If functional disorder remain after the
more inflammatory symptoms have subsided, a
blister may be applied, or a deobstruent liniment
(§ 13.) rubbed over the caecal region night and
morning ; or a rubefacient and deobstruent plas-
ter (§ 14.), worn for some months in this situa-
tion.
32. B. In the more acute states of the disease,
general blood-letting, repeated according to the
circumstances of the case, or followed by local
depletions, and the same treatment subsequently
as described above, must be early and decidedly
employed. If there be vomiting, or retchings
upon taking substances into the stomach, a large
dose of calomel, — generally from 10 to 20 grains
given either alone or with one or two grains of
opium, — will allay this disorder. If the symptoms
still continue, or if they be but slightly mitigated,
blood-letting, general and local, followed by fo-
mentations, poultices, and oleaginous enemata,
having been carried as far as may be deemed pru-
dent, the turpentine embrocation, (flannel cloths
wrung dry out of very hot water, and immediate-
ly soaked with spirits of turpentine,) should be
applied over the abdomen and retained there as
long as it can be borne by the patient. If the
tormina be severe, or if peritonitis have super-
vened, this is, after depletions have been practised
with decision, the most efficacious means we
possess. In a case of this disease, which had be-
come complicated with peritonitis, in a member
of the family of a medical friend, this means gave
almost instant relief, after other measures had
been carried to the utmost limits, and the patient
soon afterwards recovered. In another instance
of extreme danger similarly complicated, which
very recently occurred, the repetition of this treat-
ment removed all complaint, although resorted to
in despair of success from it.
33. C. I have stated that inflammation of the
appendix cmci, particularly when occasioned by
hard bodies having passed into it, often does not
extend to the caecum itself, or, at most, only to
its peritoneal coat, in common with the adjoining
portions of this surface; but that the superveution,
o go
CANCER — Pathology of.
the extension, and fatal termination of peritonitis
in such eases are most rapid and dangerous, the
appendix itself generally soon becoming gangren-
ous. It therefore behoves the practitioner to have
recourse to the most derided measures, when he
finds the symptoms of peritonitis originate in the
cecal region, and when retellings come on. Vas-
cular depletion, and all the remedies already no-
ticed, must be energetically and early employed ;
but premature attempts should not be made to
evacuate the bowels, otherwise their action will
be inverted, and decided symptoms of ileus will
be produced. Fomentations should follow the
leeches ; and afterwards hot poultices should fol-
low ; which in their turn ought to give place to
the terebinthinate embrocation, if requisite. A
large dose of calomel and opium should, how-
ever, be given after the first full blood-letting ;
this will generally be retained, even in the worst
cases ; and it ought to be repeated according to
circumstances, without fear of affecting the system
by it, — an effect which it is even very desirable
to produce. Little other medicine need be ex-
hibited by the mouth, excepting draughts with
nitrate of potash, or sub-carbonate of soda, or
both, with agreeable demulcents and emollients,
if the stomach will retain them. But the assidu-
ous administration of enemata must not be neglect-
ed. It is entirely by their agency in this state of
disease, that the bowels are to be evacuated, when
it is judged prudent to fulfil this intention, which
should seldom be omitted as far as they are cal-
culated to accomplish it ; more especially after
depletions have been practised. The enemata
prescribed in the Appendix (F. 130. — 151.), as
they may appear suited to particular cases, may-
be employed. Pain, tormina, nausea, or vomit-
ing, having been relieved, gentle cooling aperients,
and in the interval diaphoretic medicines, may be
exhibited by the mouth. Warm baths are sel-
dom of much use in this malady : but when
they will not interfere with the treatment pre-
scribed, they may be tried, particularly in the
more advanced periods. After the disease has
been removed, and merely functional disorder
remains, the measures already advised may be
put in practice.
34. D. The treatment now described is also
applicable to the early stages of inflammation
affecting the pericecal tissues. If suppuration
takes place, the treatment recommended for Abs-
cess must be resorted to ; taking care to support
the energies of life under it, particularly when
the constitution or general health is in fault. If
we suspect either the existence of ulceration or
of thickening of the coats of the viscus (§ 27.),
the assiduous employment of the liniments notic-
ed above ; of gentle aperients and deobstruents.
particularly the infusion of rhubarb with soda or
potash ; of electuaries, with sulphur, cream of
tartar and soda, or the sub-borate of soda ; small
doses of blue pill or bydr. cum creta, with ipeca-
cuanha, hyoscyamus, . and camphor; repeated
blistering, and subsequently the deobstruent plas-
ters ; the frequent use of large oleaginous, sapo-
naceous, and demulcent enemata, with the treat-
ment recommended in chronic dysentery; are the
measures most to be depended upon ; with strict
attention to diet, which should be chiefly farina-
ceous, to the state of the digestive organs general-
ly, and to the secretions and excretions.
35. E. The complication of the disease with
dysentery requires, in addition to the measures
used for that disease, the application of leeches
near the right iliac region, and the other external
measures already noticed, with rhubarb aperients,
combined with camphor, narcotics, and ipeca-
cuanha ; laxatives, with demulcents and ano-
dynes ; the frequent administration of oleaginous
and emollient enemata ; and the usual means of
correcting the secretions, and diluting and carry-
ing oil" the acrid and excoriating fluids, and faecal
matters in the intestinal canal, (See Dvsentiry
— its Treatment.) A similar treatment to the
above is necessary when the disease occurs in
the progress of fever. Depletions, however, are
generally not so well borne in this complication
as in the former, and should therefore be carried
to a less extent ; but all the external remedies,
and the use of laxatives, particularly those im-
parting a tonic effect to the intestinal mucous sur-
face, should be often employed. Camphor, with
hydrarg. cum creta and opium, or with ipeca-
cuanha and rhubarb, terebinthinate injections, or
even a terebinthinate draught in the worst cases,
have proved most serviceable in this state of
complication, in my practice. During recoverv,
the occasional use of the liniments and plasters
above referred to, attention to the secreting and
digestive functions, particularly to the state of the
bowels, which should be occasionally assisted by
emollient and laxative injections ; and a regula-
ted diet, easy travelling, change of air and of
scene ; are the chief measures* requiring attention.
(See the treatment of Fever.)
Bibliog. AND REFER. — Fc.bricius Hildanus, Cent. i.
olis. G. — Amyand, in Philog. Trans. No. 443. — Cuntxvc//, in
Ibid. No. 416. — ffeister, Wahrnehmungen, vol. i. n. 111. ;
Nov. Act. Curio*. Nat. vol. ii. obs. 93. — Moreau, Journ. de
Wed. 1790, n. 4.— Salzmatm, Observ. Anatom. p. 53.—
JYuequart, Journ. Gtcer. do Med. t. xxxi. p. SS4. — Ifc.hr.
Zvv.'v Krankenz. &c. p. 21. — Tiedemunn et Gmelin, Rech.
Experiment. Physiol, et Chim^ues sur la Digestion, &c.
Svo. Paris, 1826. — Author, Appendix to M. Ricfurrcmd'i
Elements of Physiology, p. 591. 2d edit. Lond. 1829.—
Parkinson, in Mcdico-Chirurg. Transact, vol. iii. p. 57. —
Copeland, in Ibid. vol. iii. p."l91.— Odier, in Ibid. vol. vii.
p. 221. — Johnson's Medico-Chirurg. Review, vol. iv. p. 739.
— Barlow, in Ibid. vol. iii. p. 181.— Monro, Morbid Anato-
my, ftc. Evo. 2d edit. p. 26. — En:ery, in Revue Mt'dic. t.
iii. p. 273. 1825. — Lovyer Viltermay, in Archives Gen. de
Med. t. v. p. 246.— Blaclcadder, Edin. Med. and Surg.
Journ. vol. xxii. p. 19. — Wilmot, Trans, ot' Assoc, of Irish
Coll. of Physic, vol. ii. p. 12. — Speer, Dublin Hospit. Re-
ports, vol. iv. p. 3-19.— Bttzt ley, in Philad. Med. and rhv<.
Journ. vol. vi. p. 3.50. — Kloelchoff", in Auserl. Abbandl. fur
Pract. Aerzt. 1>. i. st. ii. p. 124. — Anncsley and Author, in
Researches on the Diseases of India and Warm Climates,
vol. ii. p. 54, it scq.—Ducos, in Archives Gin. de Vied. t.
xx. p. 581.— Meniere, in Ibid. t. xvii. p. 188. 513.— In -
Ir.ii. in Journ. Hebdom. I. ii. p. 302. — She-ward and Wal-
diuv. Midi. Med. Reporter, vol. ii. p. 50. 463. — Aler-
crombie, On the Abdominal Viscera, &.C. p. 237.
CALCULI. See Concretions, Biliary
and Intestinal; also Urinary Calculi, and
I'll INK.)
CANCER. Svn. Scirrhus. .Carcinus, Schir-
ro-Cancer, Carcinoma, Auct. Var. Cancer, Fr.
Das Krebsgesclnvitr, Ger. Scii ro, Canchero,
Cancro, Ital.
Classif. 4. Class, Local Diseases ; 6. Or-
der, Tumours (Cullen). 3. Class, San-
guineous Diseases ; 4. Order, Cachexies
((iood). IV. Class, IV. Order (Au-
thor, see Preface).
1. Defin. A disease often arising from he-
reditary predisposition, in the middle or advanced
periods of life; commencing with a local hardness,
CANCER — Patholog* of — Scirrhous Stage.
283
which subsequently so/lefts in its centre, infects
the adjoining parts, and ultimately contaminates
the frame.
2. Cancel consists of two states or stages : the
first, in which it presents the appearances usually
denominated scirrhus ; the second, in which it
softens, ulcerates, &c, and degenerates into true
ca n cer, or carcinoma. I shall describe each of
these successively.
3. I. Scirrhous Stage. — Occult cancer.
It commences with a tumour, a limited local hard-
:, ■--: i> usual!} single; is very rarely, al its com-
mencement, detected in different parts at once;
and is not surrounded by a cyst. Several authors
have stated the occurrence "fa cyst; but Otto
more accurately excludes it from this structure.
li is of importance to attend to tin; appearances
of the disease at its commencement, as serving to
indicate its nature. It is distinguished, at this
period, by hardness, coldness, whiteness or pale-
ness, insensibility, and deficiency of red blood
Is; — a state indicating the low grade of vi-
tal endowment of the part.
4. The scirrhous structure, when fully develop-
ed,consists ofa firm, hard, rugged, incompressible,
and unequal mass, the limits of which are not
distinctly defined. Its colour is generally of a light
gray, and, when cut into thin sliees, it is semi-
transparent. Upon close inspection, it is found
to consist of two distinct substances; — the one
hud, fibrous, and organized; the other soft, and
apparently inorganic. The former composes the
chief part of the diseased mass, and consists of
which are opaque, of a paler colour than
ft part, unequal in their length, breadth,
and thickness, disposed in various directions;
sometimes forming a nearly solid mass; in other
instances, a number of cells or irregular cavities,
which contain the soft part. This latter is some-
times semi-transparent of a bluish colour, and of
the consistence of softened glue; at other times
more opaque, softer, somewhat oleaginous, and
like cream in colour and consistence.
5. The fibrous structure seems to be the cel-
lular, or proper tissue of the part, in a state of
ion and hypertrophy; assuming, in con-
LCe of its increased density and bulk, an
appearance similar to the fibrous or fibro-cartilagi-
nous structures; whilst the softer portion, contain-
ed in the meshes and cells of the former, appears
to be merely a morbid secretion poured out by
tiie vessels nourishing the organized fibrous tissue,
and is probably the exhalation of the part, either
ited in a modified state, or accumulated and
changed by the disease of its containing structure.
If this view be correct, the former, or organized
part, may be considered as chiefly resulting from
an altered state of nutrition in the seat of disease;
whilst the latter, or inorganized portion, may be
viewed as proceeding from a morbid secretion,
— the diseased structure thus being a product
of a disordered state of both the nutritive and
secreting functions, most probably in conse-
quence of alteration of the vital influence exert-
ed by the ganglial nerves on the capillaries of
the part.
fi. The proportion of each of those two sub-
stances, and the modes of their distribution, vary-
very considerably in different scirrhous masses.
This diversity seems to be owing to the different
tissues in which they are developed, and to the
modifications arising from temperament, local irri-
tation, ami various concurrent circumstances to
which the patient may have hero exposed. It
has been attempted by Air. Abernetht to ar-
range these varieties el' scirrhus into species, and
to designate them according to the natural struc-
tures which they most resemble. Thus he di-
vides them into .Mammary, Pancreatic, Tubercu-
lous, &c; but these different slates of structure
glide so insensibly into each other, and are so
perfectly similar as respects their origin and con-
sequences, that little practical advantage is deriv-
ed from thus distinguishing them.
7. In some scirrhous tumours, the fibrous part
of their structure is both most conspicuous and
abundant, and is condensed into a solid mass,
having the appearance of a centre or nucleus,
whence radiate numerous septa in every direction.
This is the most common appearance of the dis-
ease. In other instances, the tumour forms an
uniformly hard mass, of tin irregular shape, and
of no very defined structure. In some cases, the
organized part approaches more nearly to the
cellular structure, its cells being filled with a soft
matter which may be pressed out. Occasionally,
cysts are formed within the tumour, of various
sizes, containing a reddish, reddish brown, or a
chocolate-coloured fluid. These cysts are lined
by a smooth membrane, from which a fungous
tumour sometimes sprouts out. In some instanc-
es, portions of the scirrhous mass are converted
into a hard substance resembling cartilage, in
which bony or calcareous depositions are occa-
sionally found. When the scirrhous structure is
formed in the substance of a gland, its limits can-
not generally be accurately determined, the two
structures apparently being inseparably connected.
In some cases, the scirrhous tumour condenses
the cellular tissue surrounding it, and hence it
acquires a somewhat sacculated appearance.
(Wardrop.)
8. At the commencement of scirrhous disease,
the structure of the tissue or organ in which it is
seated preserves for some time its aspect and
colour, being changed merely in volume and den-
sity : sometimes, however, its volume is but little
augmented, whilst its density is very much in-
creased. . As the disease advances, the proper
tissue of the organ becomes more obscure, and
verges nearer to that already described.
9. M. Hecht, of Strasbourg, analysed a por-
tion of fully developed scirrhus of the mamma,
and found 72 grains composed of 2 grains of al-
bumen, 20 of gelatine, 20 of fibrine, 10 ofa fluid
fatty matter, and 20 of water and loss. He like-
wise analysed, by a similar process, 72 grains of
scirrhous uterus, and found it to consist of 15
grains of gelatine, 10 of fibrine, 10 of oily or fatty
matter, and 35 of water and loss. (LorjsTiiK,
Anal. Path. t. i. p. 403.)
10. Scirrhous tumours do not always remain
in the state now described; and the period during
which they thus continue is not determinate.
\\ lien once they commence, they seldom retro-
grade, and the part affected never is restored to
its healthy state. It is chiefly in this respect that
the early stages of scirrhus differ from simple in-
duration proceeding from chronic inflammation.
Scirrhus may remain Dearly stationary for several
years, occasioning but little constitutional disturb-
ance; but generally an important change takes
284
CANCER — Pathology of — Carcinomatous Stage.
place in its structure, anil the disease afterwards
makes rapid progress.
11. IF. Carcinomatous, or Cancerous
Stage. — Open or ulcerated cancer. After a
time, portions of the scirrhous mass begin to soft-
en, and pass into a state of unhealthy suppuration
and ulceration, — unhealthy as respects the cha-
racters and progress of these processes, and their
contaminating influence upon the whole frame.
The soft or inorganic substance resolves itself into
a thin ichorous matter, very different from pus;
and disorganization commences, generally about
the centre of the mass, and extending towards
that part of it which is nearest either the surface
of the body or any of the natural openings. When
this process commences, it is in that state which
has been denominated Carcinoma, or Cancer.
When this change takes place, the diseased mass
seldom increases much in bulk, but is destroyed
by an ulcerative process. The disease now makes
rapid progress, owing to the contamination of the
adjoining structures by the morbid matter secret-
ed by the ulcerating part, a portion of which
matter is evidently absorbed, irritating the lym-
phatic glands, and vitiating the whole frame. In
consequence of this infection, the powers of life
sink, the soft solids become cachexied, and the
progress of the local affection accelerated. At
last the patient sinks from the contamination of
the circulating fluids, and the different textures of
the body; the blood being diminished in quantity,
as well as otherwise altered.
12. When the skin covering a scirrhous tumour
ulcerates, a fungus of a cauliflower appearance,
and hard gristly structure, sometimes proceeds
from the surface of the mass. In some cases, ul-
ceration destroys both the fungus and the primary
tumour. It has been observed by Sir E. Home,
that some cancerous sores have suddenly changed
from a painful and malignant character, to a more
healthy aspect at some part, and even have begun
to cicatrize. This apparent amendment is never
permanent, for, sooner or later, the ulcerative
process is renewed, and the disease pursues its
usual course. Dr. Parr (Diet. vol. i.) states,
that he has seen several cases thus terminate
spontaneously; but the patients were all soon af-
terwards cut oil" by internal disease; probably
consisting of the internal developement, or metas-
tasis of the malady, cases of which occurrence are
not infrequent. (See Journ. Hebclom. t. i. p. 323.
for a case wherein internal cancer appeared after
the removal of the external disease by compres-
sion.)
13. Cancerous tumours generally contaminate
the glands in the vicinity, particularly after ulcer-
ation has commenced. But these glands are sel-
dom primarily affected. Mr. War drop states,
in his excellent description of this disease, that he
has only met with two cases of primary affection
of the lymphatic glands. Besides these glands,
various other organs and parts, sometimes far re-
moved from the seat of the primary disease, be-
come secondarily affected. This is most probably
occasioned by contamination of the frame, from
absorption of the morbid matter of the disease.
Sometimes the existence of cancer in distant or-
gans is not successive or secondary, but seemingly
coeval. In this case the cause must be looked
for in the originally morbid state of the system.
Indeed, this state always obtains, to a certain ex-
tent; the disease being strictly constitutional even
in its origin; the consecutive contamination, aris-
ing from the absorption of morbid matter from
the primary tumour, merely augmenting the ori-
ginal vice, and accelerating its noxious effects.
14. Scirrho-cancer most commonly originates
in glands whose functions have been interrupted,
or that have never performed the offices intended
for them; or it affects parts which have been pre-
viously diseased, or have received at some period
an external injury. Thus it attacks the mammae,
the uterus, the ovaria, the testes, the thyToid
glands. It also very frequently commences in
the tegumental, and the digestive, and urinogenit-
al mucous surfaces; more particularly in the skin
of the face; in the mucous membrane of the nose,
lips, mouth, pharynx, and oesophagus; in the
stomach, especially the pylorus and cardia; in
the intestinal canal, the ileo-cmcal valve, rectum,
and anus, and in the urinary bladder. The vis-
cera which are secondarily affected, are com-
monly the lungs, bronchial glands, the liver, the
omentum, the mesentery, the spleen, the pancreas,
the brain, the medulla of the bones, and the skin.
Several of these, particularly the liver, pancreas,
mesentery, brain, &c. may also be primarily or
coevally affected with other parts. Scirrhus af-
fects the skin in two forms; — the one is that of
wart, the other that of tubercle — the former be-
ing primary, the latter secondary.
15. III. Diagnosis. — It is of great import-
ance to be able to distinguish between this disease
and various others, for which it is liable to be
mistaken. For instance, the simple induration
proceeding from chronic inflammation has, in
several instances which have come to my know-
ledge, been mistaken for scirrhus. This mistake
not infrequently occurs in respect of induration of
the neck of the uterus.
"16. A. In simple induration, the part affected
is redder, more injected, retains more of its ori-
ginal structure, is less indurated, and less lobu-
lated, than scirrhus. The parts also surrounding
the indurated portion are frequently slightly infil-
trated with serum. Induration, the result of in-
flammatory action, admits of resolution, and en-
tirely disappears, sometimes in consequence of a
natural flux or evacuation, of active exercise, the
return of accustomed discharges, or pregnancy.
Thus the menstrual flux sometimes dissipates in-
flammatory induration of the mamma?, or of the
neck of the uterus.
17. B. The fibrous production generally ap-
pears in the form of a rounded body, implanted,
but isolated, in the proper structure of the organ,
and adhering to it merely by means of laminaled
tissue. Upon dividing this structure, it grates un-
der the scalpel; and it sometimes presents dilated
vessels, which are never observed in scirrhous
masses: moreover, it occasions- little or no pain,
and never passes into the cancerous state.
18. C. Compared with tubercular or lardaceous
productions, scirrho-cancer offers remarkable dif-
ferences : — 1st, This latter is never found isolated
in the cellular tissue, or in the parenchyma of
organs, in the form of granulations, or of small
rounded tumours, as the tubercular formations
are; nor in largely diffused masses, as the lard-
aceous substance : 2d, It is never enclosed in a
cvst: 3d, It does not greatly increase the volume
of the part it affects; sometimes the part is even
CANCER — Cancerous Cachexy — Causes of.
285
diminished, but much more dense: 4th, It is not
susceptible of the same kind of softening as the
tubercular and lordaceous productions; bul rather
of a peculiar rarefaction, passing into a peculiar
form of fungus, followed by the developemenl of
blood-vessels: 5th, Its vital properties are excited,
and its sensibility becomes exalted, as the disease
advances, — circumstances which are never ob-
served in connection with these productions.
19. D. Cancerous ulceration is characterised
by a jagged, thick, soft edge, which is turned out-
wards. The surface of the nicer is grayish, or
grayish brown, sometimes livid brown, elevated
into loose, fungous vegetations, discharging a
foetid, corroding sanies or ichor, and bleeding
slightly upon irritation, a. Chronic inflammatory
ulcers differ from the former in the absence of a
foetid corroding ichor ; in the hardness of their
margin, which turns inwards; and in the reddish
and more healthy appearance of their bottoms,
which in cancer is colourless, or a livid brown,
hard, irregular, fungous, sometimes with cauliform
:es, and extremely offensive, b. Local
tumours sometimes appear, particularly on the
tongue, on.-ii1 .te.g in irril tion, and exasperated
by the continuance of this cause. These usually
commence with a small pimple or wart, becoming
more and more hard and irritable as they increase,
until the_\ assume a scirrhus-like induration, 'ihey
seldom endanger the constitution, yet appear
sometimes to assume a malignant character.
(Mr. Caki.k, in Trans, of Med. Cliir. Soc.
vol. xii. art. 22.)
20. E. As soon as the carcinomatous change
takes place in the scirrhous mass, the disease in-
volves adjoining parts, and the System generally.
The local suffering is more fully developed, and
the vital actions of the part are changed greatly
from the healthy course. The sensibility i-; mor-
bidly augmented in short paroxysms ; the pain
violent; and what is usually called lan-
^ or stinging during the exacerbations, but
often slight, or almost altogether absent in the
intervals. If the surface be exposed, the pain is
burning, and the part is always sore. As the dis-
ease advances, and particularly as the ulceration
proceeds, the paroxysms of lancinating and burn-
ing pains increase in violence, and the remissions
e nunc imperfect, and of shorter duration.
The cancerous sanies is generally very fluid; but
pearance varies with the treatment, the
id of the disease, and with the diet of the
patient. It is generally of a grayish white, or
reddish gray; it slightly effervesces with sulphuric
acid, and turns syrop of violets to green.
21. jF. The extension and contamination of the
i characterising cancerous ulceration appear
to be owing, 1st, to the' corroding influence of the
secretion on the parts with which it is in contact :
2d, to the absorption of a portion of the morbid
secretion by the lymphatic vessels : this is evinced
by the swelling and aflection of the glands in the
vicinity of the primary disease. But the affection
of the glands may not be altogether owing to the
absorption of the morbid matter, but partly to the
irritation of the lymphatic vessels occ;isioned by
the disease of the part in which they originate :
and, 3d, to the absorbing function of the veins,
according to the researches of Mayer, Magen-
i>iF.,Tir dkmann,<;.-wki.in, &c. These di ferent
sources of contamination seem more than sufficient
to account for the general cancerous cachexia
characterising the advanced stages of the disease.
22. G. 'I be characters of this cancerous ca-
chexia are, emaciation; sof as and flaccidity of
the soft solids; oedema of tl xtremities; hectic
fever; a peculiar change of the complexion and
colour of the whole surface of the body, which
become of a pale leaden, or pale straw colour,
or waxy hue ; and general depravation of the
functions. This state of cachexia increase's with
the progress of the disease, and augments at the
same time the primary local change. It is rapid]]
developed and increased when the scirrhous mass
ulcerates, when also carcinomatous tumours fre-
quently manifest themselves in various parts of
the body. Ultimately the circulating fluid is de-
ficient in quantity, and is poor and morbid; and
the vital cohesion of the soft solids, and even of
the bones, is diminished.
23. IV. Causes. — Scirrhus, like scrofula, is
undoubtedly an hereditary malady. Instances
are numerous of several individuals in the same
family having been affected by it. It is almost
altogether confined to persons advanced in life.
Cases of the disease are very rare before the age
of thirty, Sir A. Cooper met with it only twice
previously to this age. Mr. Warurop has seen
one instance of it in the skin of a git 1 of twelve
years. Females, owing to the liability of their
appropriate organs to be attacked, are more sub-
ject to it than males; especially those who have
not borne children, the disease generally appear-
ing in them upon the cessation of the catamenia.
'I he disease seems commonly to result from an
original or acquired diathesis, existing previously
to the developement of morbid structure, and very
often connected with the lymphatic temperament.
MM. BREscHETandFERRus found 23 instances
of this temperament prominently marked, out of
44 cases of the disease. Anxiety and distress of
mind, and all the depressing passions, are most
disposing causes, particularly to cancer of the
breast. An inactive state of the part for a con-
siderable time previously; a poor, unwholesome
diet ; laborious and exhausting occupations, and
an unhealthy locality; also dispose to it.
24. It is generally excited by blows and exter-
nal injuries; by repeated or continued irritation;
the abuse of spirituous liquors; and by low and
poor diet. It is not liable to be propagated by
contagion; the experiments of MM. Aliukrt,
Biett, and Dupuytren, having shown that the
matter discharged from a cancerous ulcer cannot
produce the disease in another person. Although
irritating agents of any description may give oc-
casion to its appearance, yet there must have pre-
viously existed cancerous diathesis, or constitutional
disposition, in which it almost always originates.
2"). The proximate cause of this dreadful disease
is extremely obscure; and opinions respecting it
have consequently been numerous. Schaeffer
and (> a M ft consider it to be caused by a singular
depravation of the nervous fluid. Dr. Adams and
Dr. Baron impute it to the existence of an by-
datiform body, which they call the hydatis car-
cinomatosa; and Mr. Carmichael, to a body
enjoying an independent state of existence de-
veloped in those parts of the frame, the vitality
of which is enfeebled, and the organized matter
of which begins to be decomposed, lie supposes
that, at fust, this constituent of cancer occupies
286
CANCER— Treatment of.
but a minute spot, consists of a substance nearly
similar to cartilage; and that it afterwards extends
itself in the form of radiations, resembling liga-
ments formed by thickened cellular tissue. These
opinions, which are not essentially different from
each other, have been completely refuted by
Burrs, Cleri, and Himly. According to M.
Broussais, scirrho-cancer is the result of an
inflammatory or sub-inflammatory state of the
vessels {Examen des Doctrines Med. t. i. prop.
93 — 95.); and the opinions of M.M. Begin,
Breschet, and Ferrus (Diet, de Mid. t. iv.
p. 133.), differ but little from that of M. Brous-
sais. They impute the disease to irritation of
an inflammatory nature, occasioning the secretion
of a coagulable lymph that becomes condensed
into a scirrhous substance, which may remain sta-
tionary for a longer or shorter period, but which
sooner or later undergoes a secondary inflamma-
tory process, and experiences softening and dis-
organization, with various other changes, as these
processes proceed. To this doctrine of the mod-
ern French pathologists it may be objected, that
scirrhus furnishes no sign, local or general, of in-
flammation, and yet it goes on increasing; and if
it can increase rapidly without inflammation, may
it not also originate independently of this cause ?
Where, therefore, neither the local appearances,
nor the usual consequences, nor the constitutional
symptoms, of inflammation can be perceived, ought
we to impute disease to this state of vascular ac-
tion ? The inference is obvious; but it is only one
of many arguments, which, if they were not su-
perfluous, might be adduced against the doctrine.
26. According to M. Andral, cancer is not
a specific alteration, but a state of disease arising
from lesions of nutrition and secretion, which have
reached the period of their termination in ulcera-
tion ; the ulcer thus arising, constantly increasing
either in depth or extent of surface, without any
disposition to cicatrisation. Thus, M. Andral
considers cancer in a generic acceptation, and com-
prises under it the ulcerative process in various
species of disease of a constitutional origin and
malignant nature, which, although always consid-
ered as closely allied, in their origin, nature, and
tendency, to scirrhus, have usually been viewed
as distinct maladies. This opinion is more in ac-
cordance with the wide signification of the term
cancer, in the writings of French pathologists, but
is very deficient in precision and applicability; in-
asmuch as it embraces the advanced states only
of several organic changes, which, in their earlier
periods especially, are very distinct from one
another — distinct in causes, origin, the structures
they principally attack, and in their appearances
and properties. I have, therefore, adopted the
more accurate views of British pathologists re-
specting this disease, which I consider in relation
to its predisposing and exciting causes, to the states
of the system in which it occurs, to its local ap-
pearances, and constitutional effects, to the results
of treatment, and to the ultimate change*- produc-
ed in the blood, and in the various structures, as
essentially depending upon a weakened and other-
wise morbid slide of the system generally ; and
arising from depravation of the vital conditions
of the part affected, whereby its nutrition, ner-
vous sensibility, and secreting function, become
specifically changed, and all the fluids and so/ids
ultimately contaminated.
27. V. Treatment. — The conclusion now
drawn respecting the nature and morbid relations
of scirrho-cancer must render very apparent the
futility of various measures which have been em-
ployed to remove it. Some writers have too ex-
clusively viewed the disease as local; and thus,
even in its advanced stages, resorted to most dan-
gerous and painful operations to extirpate an evil,
which, instead of being local, proceeds from the
morbid state of the system generally, and which
all depressing causes (the surgical operation itself
being one) rapidly increase, disposing not only to
its extension in its primary seat, but also to its ap-
pearance in new situations and more vital organs.
The means of cure, therefore, should have especial
reference to the state of the constitution favouring
its developement and progress ; for, when the
malady is advanced, local measures can, at the
best, only be palliative, and are therefore subsidi-
ary to judiciously devised means employed inter-
nally, and assisted by suitable diet and regimen.
28. Before I proceed to state the indications
which should guide the treatment of this disease,
and the medicines which seem best calculated to
fulfil them, as far as this is possible, I will take a
brief view of the means which have been recom-
mended or tried by preceding writers. The real
importance of this subject to the physician will be
the more obvious, when he reflects, that cancerous
diseases are often — indeed most legitimately on all
occasions — within his province, more particularly
when they invade, as they frequently do, internal
organs; and that the life of the patient may be
greatly prolonged, and his sufferings much allevi-
ated, by judicous medical treatment.
29. A. At the commencement of the scirrhous
stage, various means have been employed, and
sometimes with some advantage, according to the
showing of those who employed them. Conium
has, upon the whole, found the greatest number
of supporters; and 1 think that, when it has been
combined with the alkaline tonic and stomachic
preparations, it has been often of considerable
benefit. This seems to be nearly the opinion of
several writers, and amongst others, of Gesner
(Beobacht. b. i. p. 213., hi. p. 242.), Girard,
Hufeland, (Journ. der Pract. Heilk. b. ix. 3
st. p. 86.), Hahnemann (in Ibid.b. ii. p. 473.),
and Thilenius (3Ied. und Chir. Bemerk. p.
100.). Electricity and Galvanism have
been employed by Brisbane (Select Cases, $-c.
p. 36.) and Walihir ( Ueber die Thar. Jnd. der
Galv. Oper. <§-c. c. 12.); the muriate of baryta,
by Hufeland; antimonials, by Rowley and
Dowmann; aconitum, by Greding; digitalis,
by Mayer (Richtei-'s Chirur. Bibl. b. v. p.
531.); laurel-water, by Thilenius; mercury,
particularly the corrosive sublimate, by RtJYSCH,
Thilenius, and Harris; sal-ammoniacnm, by
Justamond; belladonna by Gataker-; and the
mezereon, by Home (Clin. Exper. and Hist. p.
428.), with more or less benefit, chiefly of a tempo-
rary kind in those cases which were obviously scirr-
hous, and with permanent service in those which
were only supposed to be of this description.
30. B. In the more fully developed and less
doubtful states of the disease, as well as in its
earliest stage, a number of medicines have been
recommended, and for awhile have obtained some
credit, which few of them have long retained.
The great majority, however, of them have been
CANCER — Treatment op.
287
brought forward rather as palliatives, and with the
view of keeping the disease in check, than as pos-
sessing the power of curing it; yet some have been
exhibited with more sanguine expectations, par-
ticularly arsenic, conium, hyoscyamus, and bella-
donna, a. That conium is productive (if benefit,
when judiciously combined with other remedies,
is manifest, notwithstanding the contradictory evi-
dence respecting it. While we find Stoerck
(Lib.de (Scut. Vind. 1761. 8vo.), Fothergill
(Works, vol. ii. p. 47.), HAMILTON, Francke
(De Cancro. Fen. 1778.), Nicolson (Med. Obs.
and Enquir. vol. iv. n. 31.), Quvrin (De Cicu-
ta, ch. -I. 5.), Fearon, 15k i.i. (On Ulcers, pt. ii.
sect 8.), Gruelmann (De Usu Cicuta, fyc.
Goet. 1785.), Ren a no (Journ. de M,d. t. xxiii.
p. 411.), Sen a E fk ER, and several other writers,
in fivour of it, we observe, SlEBOLD (Chir.
Tageb. n. 74.), Lange, Hill (Ed. Med. Cora-
mi n>. vol. i. p. 146.), Akenside ( Trans, of Col.
of Phijs. vol. i. n. 6.) Oberteuffer, (Hufe-
land's Journ. b. ix. St. 3. p. SI.), Schneider
Chirurg. Gesch. b. iv. n. 19.), and Burns, ex-
pressing opinions as to either its little eiHcacy, or
its entire want of effect. This discrepancy may
be accounted for upon the supposition of want of
virtue in the preparations prescribed; the extract
generally losing the virtues of the plant during the
modes of preparing it formerly in use: and I find,
upon referring to most of the authors now quoted,
and to others not referred to, that the extract and
decoction were usually employed by those who
found it productive of no benefit; whilst the
powdered leaves, the expressed juice of the
plant, or an infusion of it, had been preferred by
those who have expressed themselves in favour
of it. I have prescribed the inspissated juice and
powdered leaves of this plant, in several cases of
internal scirrho-cancer, in combination with the
alkalies and tonics, and have always found them
much more beneficial when associated with it.
31. b. Belladonna was first exhibited by Al-
bert i (De Bel lad. tanquam Specif, in Cancro,
fyc. Halse, 1739.), who highly praised it in the
occult stage of the disease. It was afterwards re-
commended by Lambergen (Haller's Disp.
Pract. ii. n. 41.), Bf.llot, Lentin (Beobacht.
<Vc. ii. 2. and 3.), Amoureux (Journ. de Med. t.
xiii. p. 47.), Camperdon (Ibid. t. Iv. p. 342.
423 — 502.), Sul/.er (in Ibid, txxiv. p. 68.), and
by Gr A ND villiers ( Ibid. t. xvi. p. 449. ) ; and
declared of little use by Zimmermaxn and De
Ha en (Rat. Med. pt. ii. p. 37.). I believe, how-
ever, thai some advantage will be procured from
its internal and external use, particularly as a pal-
liative, and when combined with medicines which
are calculated to support the energies of life, and
improve the secreting and digestive functions. A
similar opinion may be offered respecting hyoscy-
amus.
32. c. There is, perhaps, no medicine which has
been so commonly prescribed in this malady as
arsenic. It forms the base of the several secret
remedies, internal as well as external, employed
byempirirs: and has been very generally used by
them as an escharotic, sometimes with very inju-
rious effects, from being absorbed 'argely into the
system. There can be no doubt, however, of its
beneficial influence, in many cases, when cau-
tiously prescribed, and judiciously combined with
other medicines; but chiefly as a most energetic
tonic and excitant of the capillary vessels, and
powerful detergent in the ulcerative stage of the
disease. JesTAMOND prescribed it both internal-
ly and externally, with opium and various Other
medicines; Stark (Archiv.f d. Geburtsh. b. ii.
p. 673.), Rush (Edin. Med. Comment, vol. xi. p.
312.), and Oohki.ius, state that they have found
it cure incipient cancer, when applied in solu-
tion to the part; Collenbusch (in Huf eland's
Journ. d. Pract. Arzn. §-c. b. iii. p. 103.) found
it beneficial when employed externally, tonic ex-
tracts having been given internally at the same
time; Fischer (in Richter's Chir. Bibliog. b.
viii. p. 76.), Michaehs (in Ibid. b. v. p. 132.),
and Reusner, prescribed it in the form of the
powder of Guy * (composed of arsenic, sulphur,
ranunculus sylvest., Sac), with marked benefit;
S a i. made (Mem. de la Soc. d'Emulat. t. i. p.
152.) cured a case with the powder of Rousselot,
the twenty-fifth part of which, he says, consists
of arsenic; Balascon de Tarare gave it with
the expressed juice of the solanum, and Hornung
with serpentary and soot. This evidence, how-
ever, in its favour, is not without powerful oppo-
sition. Fabricius Hildanus ( Cent.\i. obs. 8 1 .)
says, that arsenic was introduced into practice by
a monk named Theodoric, in the tenth or
eleventh century (having probably been made
acquainted with it in the West), and details cases
in which he considered it detrimental. A similar
opinion has been entertained of it by Schneider,
Thilenius (Med. und Chir. Bemerk. p. 101.),
Acr el, Murray (Med. Pr. Bib I. b. iii. p. 485.),
Adams, Oberteuffer (Stark's JV. Archiv, b.
iv. p. 673.), and Delius. Mr. Hill, however,
expresses a very favourable opinion as to the ef-
fects of this mineral, and states that it will retard
the progress of the true scirrhous tumour, in the
great majority of cases, and often prevent it from
becoming cancer (Ed. Med. and Surg. Journ.
vol. yi. p. 58.). I believe that, when this medi-
cine is cautiously employed, both internally and
externally, in conjunction with narcotics and al-
kalies, or otherwise judiciously combined, Mr.
Hill's opinion in its favour is not much too
highly coloured.
33. d. The preparations of mercury are always
injurious in this disease, when exhibited in any
other manner than as an alterative, and, externally,
as an astringent and stimulating wash. The oxy-
muriate, in minute doses internally, with the mu-
riate of ammonia, or the compound sarsaparilla
decoction, the tinctures of cinchona, with guiacum,
&c, is often of service, at least in retarding the
progress of its early stage; and when the disease
has advanced to ulceration, the external use of the
oxymuriate, with the muriate of ammonia, lime
water, &c. may occasionally be of some service.
Reipein (Car. Med: Millen. n. 408.), states,
that the preparations of this mineral are always
injurious when productive of salivation. Of the
accuracy of this opinion, there can be no doubt.
Prescribed, however, as now recommended,
it has received the approbation of Moseeev,
GooCH, GMELIN (Method. Cancrum Sanaudi,
Tub. 1756.), Hagen, Gataker, Chapois,
BiicHNER (De Med. Mercur. Usu in Cancro.
Hal. 1755.), CHAMPELLE (Sur le traitem. du
* A secret remedy, recommended by Richard Guv, in a
production, entitled* Essays on Scirrhous Tumours and Can-
cers, Rvo. Lond. 1759.
288
CANCER — Treatment of.
Cancer. Par. an viii.), and by Sir A. Cooper
(Lectures, in Lancet, vol. iii. p. 190.)
34. c. The preparations of iron have been
recommended by .Iustamond and Dk Make
( True!. M<d. Chirurg. de Cancro, Src. Vien. 8vo.
1767.). who gave them variously combined, par-
ticularly with muriate of ammonia, and in the
state of neutral salts. Mr. Carmichael strenu-
ously ad\ ises the sub-phosphate, combined with a
little pure fixed alkali, lie prefers this prepara-
tion, but occasionally also employs the carbonate,
the tartrate of iron and potash, the phosphate and
ox\ phosphate of the metal. If it occasion cos-
tiveness, he combines with it a little aloes; and, if
it produce head ich, fever, or full pulse, he leaves
it off, and gives four grains of camphor every five
hours. He prescribes it as follows; directing
externally to ulcerated cancers, the carbonates,
phosphates, or arseniate of iron, made into a thin
paste with water; and to occult cancer a lotion
constantly applied, consisting of a strong solution
of some one of the salts of this metal.
No. 85. R Sub-phosph. Ferri gr. xxx. — 'f) ij. ; Potassae
vcl Sottne Pura> gr. iij. — v.; Extr. Aloes gr. iv. ; Pulv. |Grly-
cyrrh. V) j. ; JQbumenis Ovi q. s. ut riant Pilula; xij. Capiat
biuas terliis vet quarlia hoiis.
Besides these preparations, the ferrum ammonia-
turn is entitled to notice. It was considered the
best medicine that could be directed against this
disease by Dr. Denman (Observ. on the Cure of
Cancer, p. 77.).
35. /. The preparations of lead have also been
used, chiefly externally, when the disease has ad-
vanced to ulceration. Gesner (Beobach. b. v.
p. 141.) recommends the acetate in the form of
liniment with turpentine, and Schoenheyder
(Soc. Med. Harm. Coll. vol. i. n. 4.), advises the
continued application of lotions of this salt in a
decoction of conium. It has also been used in
thin sheets constantly pressed upon the scirrhous
tumour. Of the various other remedies brought
forwards by authors at different periods, and stated
by them to" have proved serviceable, I may briefly
notice the following: — Horstius (Observ. 1. ix.
ob. 3.) prescribed internally, and externally, sul-
phur, with spirit of turpentine; Ruland (Cur.
Amnir. i. n. 92.), the balsamum sulphuris; and
various other writers, the oleum sulphuris ( F. 21.).
The sulphur ets have also been employed, both
internally and externally, either alone, or with
narcotics, and sometimes with benefit. Gata-
ker (Obser. on the Intern. Use of the Solanum.
Lond. 1757.) used the solanum nigrum; and
Paulus /EgiNj-e (I. iv. c. 25.),Oribasius (Syn-
op. 1. vii. c. 13.), and Carere, the expressed
juice of the solatium dulcamara, externally; the
last-named author exhibiting it internally at the
same time. Opium, as well as other narcotics, is
often necessary in order to alleviate the patient's
sufferings, and with this view has chiefly been
employed. I believe, however, that, when com-
bined with suitable remedies, it is otherwise pro-
ductive of benefit. The volatile and fixed alka-
lies have been exhibited by Barker (Neio York
Med. Repos. vol. iv. n. 4.), Martinet and Bar-
bette (Journ. de Med. t. lvi. p. 559.); antimo-
nials] by Row ley and The den (Betnerk. b. ii.
p. 86.) ; barytcs, by Cb uvkdrd (Duncan's Med.
Comment, vol. xiv. p. 433.); cinchona, by Hom-
burg, Vi t.ussens, and Plenk (Samml. von
Bsobacht. i. n. 6.) ; the expressed juice of the che-
lidonium and the sulphate of zinc, by Berchel-
mann; lime-water by Vogel (De Curat. Cancir.
per Aquam Calcis Viva potam, Sec. Goet. 1 769.) ;
the orobanche Virginiana, by Barton and Bfn-
sell (Philad. Med. Journ.); an ointment with
the juice of the bardana and acetate of lead, by
Percy (Huf eland N. Anna/en, i. p. 3sl.); cam-
phor, by several authors; the sedum acre, by Bu-
choz and Quesnai; the onopordum acunthium,
by Goelicke (De Onopordo Carcin. Aver. 8,-c.
Fr. 1739.), Handel, Juncker, and Ross;
myrrh, by Nicolas (Hufeland N. Annalen, i.
p. 362.); fixed airs, by Beddoes, Percival
(Essays, ii. p. 73.), Ingenkousz, and Peyril-
he (De Cancro, p. 75.); digitalis, by Richter
(Chirurg. Bibl. b. iv. p. 591.); the hydro-sul-
phuret of ammonia, by Burns; petroleum, by
Rammazzini and Pierce; the rhododendron
chrysanthemum^ by Pallas; and aconitum, sar-
saparilla, guaiacum, the beccabunga, the phellan-
drium aquaticum, &c. by various writers. All
these have been prescribed both internally and
externally, with littie or no advantage, or with
very temporary benefit only.
36. g. Of the numerous external remedies re-
commended at various periods, the preparations
of arsenic and quicksilver; charcoal and carrot
poultices; the mineral acids, particularly the oxy-
muriatic and chloric acids; the chlorurets, and
many of the metallic salts; camphor, the balsams,
and the terebinthinate substances; ammoniucum,
galbanum.and myrrh; and the greater part of the
astringent, antiseptic, detergent, and stimulating
vegetable medicines, have obtained a greater de-
gree of reputation ; and, when some of them are
judiciously combined with one another, and with
narcotics, they are deserving of notice as discu-
tients in the early stage of the disease, and as pal-
liatives in its ulcerating state.
37. Frictions of the part were advised by Pow-
teau, and Young entertained sanguine expec-
tations of the result of pressure, — a practice which,
very recently, has received the support of Re ga-
mier, and several French physicians. M. Jou-
bert states, that he has found small local blood-
lettings, and the following pills, most serviceable
in the different stages of cancer. (Archives Gen.
vol. xvi. p. 282.)
No. 86. Tv Sapoins Medio. ^ iv. ; Gum. Ammoniac!
^ ij. ; Ext. Conii et Ext. Aconiti Nap. 5 jss. ; Massse Pilid.
Rufi 3 j' M. Contunde bene siuiu), et divide in Pilulas
gr. v.
He directs two of these to be taken night and
morning, increasing the dose by an additional one
daily, until twelve, fifteen, or even twenty, are
taken, morning and night. The rest of the treat-
ment consists in applying poultices of the recent
conium; using deobstruent and solvent beverages,
a mild diet and regimen, and wearing an issue or
seton in the arm or thigh. '1 his plan has likewise
been advised by Dr. Low assy, by whom it was
first practised.
38. h. Sir A. Cooper expresses himself very
strongly against low diet in this disease, — a practice
which had been much insisted on by ^Mr. Fi:ar»
son, Dr. Lambe, and Hufeland (Journ. der
Pract. Arzneik. b. i. p. 289.) The opinion of Sir
Astley is certainly in accordance with accurate
observation, and rational induction. This very emi-
nent surgeon states, that he has seen most benefit
j derived from Flu mmer's pill gi\en at- bed-lime,
CANCER — Treatment.
289
and stomachic tonics in the day, consisting chiefly
of the bitter infusions, with ammonia, and the sub-
carbonates of the alkalies. Some advantage was
also derived from a pill, consisting of half a grain
ol' stramonium, with two grains of camphor, given
twice or thrice a day.
39. Since the introduction of iodine into prac-
tice, the preparations of it have been tried in the
different stages of cancer by several physicians.
The results of the trials which have been made of
this substance are certainly such as ought to war-
rant the use of it in the early states of the disease.
The cases recorded by Dr. Wagner (Rev. Med.
Juin, 1823.), and by Mr. Hill, of Chester, are
much in favour of it. I have been consulted in
two cases occurring in females between thirty and
forty, for what was considered, by the attending
practitioners, scirrhus mamma, owing to the lan-
cinating and remitting pains, and the diseased
state of the nipple and axillary glands. The)' were
both put upon a course of iodine (F. 32S, 329.);
and cooiuin, with the sub-carbonates of potash,
was given internally; a light nutritious diet, and
strict attention to the state of the uterine functions,
were also observed. Perfect recovery has taken
place in both; but it appears doubtful whether or
not they were genuine cases of scirrhus, notwith-
standing the signs now alluded to were present.
They had, however, withstood other means of cure
for a long time. The treatment, in one of the cases,
was chiefly conducted by Mr. Faxon, according
to the above suggestions.
40. C. Conformably with the opinion stated
above (§ 26.), I conceive that the treatment of
this disease should be directed to the fulfilment of
the following intentions : — 1st, To support the
energies of life, by exciting the digestive functions,
and the abdominal secretions and excretions; 2d,
to soothe the morbid sensibility of the part, and
promote the absorption of morbid depositions in
its tissues, by means of anodynes combined with
deobstruents and discutients ; and, 3d, to impart
vigour to the frame by suitable medicine, diet, and
regimen. The remedies which are calculated to
fulfil the first indication, may be often conjoined
with those intended to accomplish the second and
third; and both internal and external means may
be simultaneously used, with those views. The
medicines already enumerated comprise nearly all
that have been found of any service in this dis-
tressing malady. But the advantage to be derived
from them will mainly depend upon their combi-
nation and exhibition appropriately to the circum-
stances of individual cases.
41. The preparations of iodine given in very
small and frequently repeated doses, with potass,
and conium, or opium, will be found amongst the
best remedies that can be used; inasmuch as, when
exhibited in this manner, they are both tonic and
deobstruent. They may also be used externally
in the form of ointment ; but one third of the
proportion of hydriodate to the ointment usually
employed should be prescribed, and friction with
it ought to be of much longer continuance than
commonly directed. Either stramonium, conium,
opium, belladonna, hvoscyamus, oraconitum, may
be given in various forms in the intervals between
the exhibition of the iodine ; and be combined
with tonic infusions or decoctions, with the fixed
or volatile alkalies, or with camphor in doses of
from two to six grains. They may also be tmd
25
in conjunction with the preparations of arsenic, or
of iron, or the chlorates of potash, soda, or lime,
and as external applications also, when the disease
has gone on to ulceration. In females, scirrho-
cancer is generally connected, at its commence-
ment, with disorder or the cessation of the men-
strual discharge. In such ca-ses, the preparations
of iron with ammonia, or the fixed alkalies, and
aloes, are sometimes of service. I have observed
most advantage in these cases from frequent and
full doses of conium, in the form of powder, given
with the sub-borate of soda.
42. Tonic infusions, or decoctions, with liquor
ammonias acetatis, or with the carbonates of the
alkalies, and extract of conium, or the tincture of
hyoscyamus; the oxymur. hydrarg. in the com-
pound tincture of cinchona, or compound decoc-
tion of sarsaparilla; or small doses of blue pill, or
hydrarg. cum creta, with camphor, and either of
the narcotic extracts; the preparations of sulphur,
and the sulphurels ; the phosphates of iron, or
this metal combined with ammonia, and conium;
the sulphates of quinine and zinc; and the balsams
and terebinthinates ; may severally be employed.
No. 87. R Decccti Cinchonas 5 j- 5 1-iq. Amnion. Acet.
3 ij. ; Liq. Amnion. TT) xx. ; Extr. Conii gr. vj. ; Tinct.
Capsici Annui TT) viij. M. Fiat Ilaustus, ter die sumeu-
dus.
No. 83. R Potassae Sulphured 3 jss. ; Pulv. Fol. Bella-
donna; ^) jss. i Saponis Castil. 3 j. 5 Gum. Amiooniaci 3 j.
Svrup. Simp. q. s. Simul contunde, et divide massam ia
Pilulas lx. quaruin capiat tres ad quatuor ter quotidie.
No. 89. R Infus. Anlhemidis § jss. ; Liq. Potassas
TT) x. ; Tinct. Ilyoscvami 3 ss- M- Fiat flaustus, ter die
capiendus.
No. 90. R Hydrarg. cum Creta gr. j. ; Camphorae rasas
gr. iij. 5 Extr. Aconiti (vel Belladonna?, vel Stramonii)
gr. ss. ad gr. j. ; Soda? Suh-carhon. exsic. gr. viij. ; Bali.
Peruvian, q. s. ut fiant Pilulaj iij. mane nocteque sumen-
da?.
No. 91. R Arseniei Albi gr. vj. — x. ; Opii Puri gr. xij.
— xx. ; Oxydi Zinci 3 ss. ■, Butvr. Recent. 5 j. ; Cera;
Flava; Liquet". 3 jss- j Longe trilurat. misceantur exac. tiss.
et f. Unguentum parti afieets applic. (Hahless, De
Arsen. Usu. in Med. NoHm. 1811.)
No. 92. R Extr. Conii mac, Balsam. Peruv., aa 5 j- >
Plumhi Acet. V3 j. ; Tinct. Belladonna; TT) xij. ; Tinct.
Opii Comp. (F. 729,) V) j. ; Ungueut. Cera; g j. M. Fiat
Unguentum.
No. 93. R Ferri Atnmoniati 5 jss. ; Extr. Conii, 3 j- >
Pulv. Capsici Annui 3 ss. ; Extr. Aconiti gr. iv. Camphora'
rasa; gr. xv. ; Extr. Allies purif. >") j. j Syrup. Simp. q. s.
M. Contunde bene simul, et divide in Pilulas xlviij. qual uin
capiat tres, ter, quaterve quotidit*.
No. 94. R Herba; Beccahungae contus. ^ ij. ; Pulr.
Capsici Annui 3 jss. ; Aqu* Ferventis O j. Macera bene
et cola. Dein adde Liq. colat. Solut. Arseniei 3 ij. (vel
Chlor. Calcis 3 jss0i Extr. Opii Aquos. 3 j- M. Fiat
Lotio, pro parte affecta.
No. 95. R Balsam. Canad. 3 jss. ; Oxyd. Zinci 3 ij. ,
(vel Sub-carb. Polassae exsic. 3j)i Pulv. Fcdii Conii }1 ij. ;
Pulv. Capsici }) jss. ; Pulv. Tragacanth. Comp. q. s. ut
fiat Massa Pilularis, quara divide in Pilulas xlviij. Capiat
ties ter die; et augeatur dosis ad quatuor quater q«u-
tidie.
43. D. Although the malady obviously has a
constitutional origin, yet the propriety of extirpat-
ing the affected part, as soon as the true scirrhous
character becomes manifest, may be conceded.
After this is accomplished, the constitutional vice
■may be more successfully combated, and the re-
appearance of the local disease more probably pre-
vented than at a later period. When, however, the
system exhibits any of the symptoms of the can-
cerous cachexia, whether the adjoining glands be
enlarged or not, nothing will be gained by an oper-
ation ; but some advantage may still accrue from
judicious and energetic medical treatment, par-
ticularly from tonics combined with anodynes,
alteratives, and deobstruents. Whilst medical
290
CATALEPSY — Path o lo g t.
measures have often obtained the credit they by no
means deserved, from the circumstance of local
diseases mistaken for scirrhus having been re-
moved by them; so I believe that surgical opera-
lions have sometimes acquired reputation from the
same cause.
44. During the treatment of this malady, atten-
tion must be especially directed to the secretions
and evacuations. The bowels ought to be kept
freely open, with deobstruent laxatives, combined
with" tonics and vegetable bitters. The diet should
be nutritious, and easy of digestion. Pork, in every
state, ought to be avoided, as well as other indi-
gestible kinds of meat. Change of air, and of scene,
with agreeable amusements, serve essentially in
assisting the influence of a judiciously devised
method of cure, and should, therefore, not be over-
looked by the practitioner; and several of the tonic
and deobstruent mineral waters are of use, particu-
larly those of Bath, Tunbridge, Buxton, Spa, &c.
BlBLIOG. AND REFER. — Le Dran, Mem. de l'Acad.
Rov. de Chirurg. t. vii. p. 223. — B. Peyrilhe,On Cancerous
Diseases, translated from the Latin, with Notes, kc.
Lond. 1777. — M. Akenside, On Cancer, in Transac. of
Coll. of Physic. Lond. vol. i. p. 45. — Johnson, Practical
Essay on Cancer, 8vo. Lond. 1810. — Himly, in HuftlumVs
Journ. der. Prakt. Heilk. 1309, par. xii. p. 126. — Home,
Observations on Cancer, &c. Lond. 1805. — Adams, On
Morbid Poisons, 2d edit. 1 807. — Howard, Pract. Obser-
vat. on Cancer, 8vo. Lond. 1811. — Fount?, Cases of Can-
cer and Cancerous Tendency, vol ii. Lond. 1816. — Rouztt,
Recherches et Observations sur le Cancer, 8vo. Paris,
1818. — Bayle et Cayol, in Diet, des Sciences Med. t. iii.
p. 555. — tVenzel, Ueber die Induration und das Geschwiir
an Indurirten Theilen, 8vo. Mainz, 1815. — Baumann,
Ueber den Krebs, kc. 8vo. Leips. 1817. — Hill, in Edin.
Med. and Surg. Journ. No. lxxxvii. p. 282. — Wardn.ji,
in Introduction to Dr. Bail/ie's Morbid Anatomy, vol. ii.
p. 36. — Scarpa, Sullo Scirro e sul Cancro Memorie, 4to.
1822. — Cruvcilhier, Essai sur l'Anat. Patholog. t. i.
p. 127. — I'elpeuti, in Revue Medicale, t. i. p. 217. 1825. —
Lambe, On the Effects of a peculiar Regimen in Cancer-
ous Complaints. Lond. 1815. — Carmichael, On the Effects
of the Preparations of Iron upon Cancers, kc. 2d. ed. 8vo.
Dub. 1809. — Abernethy, Surgical Wcrks, vol. ii. Lond.
1811. — Rodman, On Cancer of the Breast, 8vo. Lond.
1815. — C. Bell, On Carcinoma, in Trans, of Med.-Chirurg.
Society, vol. xii. p. 213. — A. Cooper, Lectures, in Lancet,
vol. ii. p. 559. — Breschet et Ferrus, in Diet, de Med. t. iv.
p. 131. — Ullmann, in Encyclopud. Worterb. der Med.
Wissen. b. vi. p. 559. — Recamier, Sur le Traitement du
Cancer, &c. t. i. Paris, 1826. — Begin, in Diet, de Med. et
Chirurg. Prat. t. iv. p. 425.
CARCINOMA. See Cancer.
CARDIALGIA. See Indigestion.
CARDITIS. See Heart, Inflammation of, &c.
CATALEPSY AND CATALEPTIC ECSTASY.
Classif. 2. Class, Nervous diseases; 1. Order,
Comatose Affections (Cullen). 4. Class,
Diseases of the Nervous Function; 4. Order,
Affecting the Sensorial Powers (Good).
II. Class, III. Order (Author, see Pre-
face).
1. Catalepsy and Ecstasy, although treated of
by some writers as distinct affections, generally
present very nearly the same pathological con-
ditions, as respects the presumed states of circu-
lation in the brain, of vital energy, and of nervous
influence ; manifest similar morbid relations and
complications, in their origin and progress; are so
far modified in their symptoms, as frequently to
pass insensibly into each otner; and therefore re-
quire, according to such manifestations, a treat-
ment in all respects the same. For these reasons
I shall consider them, in this article, as varieties
of the same species of disease ; and, if nothing
more be gained by thus connecting them, repetition
will be, at least, avoided.
1. Catalepsy — Trance (from xaTa/.rrpte,
the action of seizing, and that from y.ara-
/.uiizuioi. I seize). Syn.' KuTu).tafig, Greek.
Catalepsia, Catalepsis, Caiochus, Prehensio,
Congelatio, Auct. Lat. Canes Ecstasis, Ca-
ms Catalepsia, Good. Entonia Catalepsis,
Young. Catalepsie, Fr. Die Starrsucht,
Katalepsis, Ger. Catalepia, Ital. Trance.
2. Defin". A sudden deprivation of sense, intel-
ligence, and voluntary motion, the patient retain-
ing the same position, during the paroxysm, in
which he ivas at the moment of attack, or in which
he may be placed during its continuance; the
pulse and respiration being but little affected.
3. This disease is very rare; so much so, that
its existence has been doubted by many writers,
who consider it to have been feigned. Its occa-
sional occurrence is, however, well ascertained.
I have seen one case of it in my own practice,
and been consulted by letter respecting a second.
I recollect, also, an undoubted example of it in
an hospital, the practice of which I attended when
a student. It presents no precise or undeviating
train of symptoms, but varies in many particulars;
the phenomena noticed in the definition being
those most uniformly present. This varying char-
acter of the disease, according to the description
given of it by authors, is owing to two circum-
stances;— 1st, to the modified state which it
actually assumes, from the circumstances con-
nected with its origin; and, 2dly, to certain of its
phenomena having been mote particularly noticed
by some authors than by others, who have either
mentioned them incidentally, or entirely overlook-
ed them.
4. Symptoms. — This is an intermittent and
apyrexial disease, occurring in paroxysms of vari-
able duration ; and generally after very irregular
"intervals. The seizure is occasionally announced
by premonitory symptoms, — by headach, mutabi-
lity of temper, yawning, tinnitus aurium, vertigo,
palpitations, lassitude, pain or slight spasm of the
limbs or neck, confusion of mind, &c. ; but it is
commonly sudden, — the patient retaining the
same expression of the countenance, and posture
of the body, as at the moment of attack. The
eyes are fixed, are open or shut, the pupils usually
dilated, but contractile from a strong light; and,
from their unvarying expression, and the un-
changed attitude, the body has the appearance
of a statue. Any position, in which the head,
trunk, or limbs are placed, is retained without
deviation; the passive contractility of both the
flexor and extensor muscles being such as to
admit of a change as well as retention of the
position during the paroxysm. The evacuations
are either suspended during the fit, or passed
involuntarily.
5. After a very indefinite duration — sometimes
of only a few minutes, at others of several or
even many hours, but rarely of days — the pa-
tient is restored to consciousness. In a remarka-
ble case, however, detailed by Dr. Burrows, the
fit lasted many days. Restoration is usually in-
stantaneous, accompanied with sighing, and fol-
lowed by pain or confusion in the head, and a
sense of fatigue and lassitude. The patient has no
recollection of what has passed during the fit : and
the same ideas, and, according to some, even the
same sentences, which had been suspended by the
seizure, have been pursued>,the moment of recovery
CATALEPTIC ECSTASY — Pathology.
291
6. The countenance, during the paroxysm, is
sometimes little changed ; at other times, it is
(>aler than usual; hut it is more commonly slight-
v suffused, and the pulsations of the carotids
more forcible than natural. The respiration is
variable, sometimes it is embarrassed: the tem-
perature of the surface is also unequal; being
generally depressed in the extremities and in-
creased in the head, evincing an irregular distri-
bution of the circulation. The pulse is occa-
sionally very slow: Sauvagks found it only 50;
but it is more commonly quick and small. The
senses are so entirely abolished, that the patient
may he pinched, without feeling it; and he can-
not hear the loudest noises. The state of the
muscles during the attack varies somewhat in
different cases. They are often slightly rigid, but
not to the extent of preventing the easy change
of position of the limbs; and sometimes the po-
sition so permanently retained is one, which no
person in health could so long preserve. M.
Georget states, that the muscles often present
a degree of tetanic rigidity; but this is only some-
times the case, particularly when the disease is
more nearly allied to Ecstasy. In some cases, it
would seem as if a partial state of volition exist-
ed, of which the patient either had no conscious-
ness, or a very imperfect consciousness at the
time, and consequently, no recollection of the act
subsequently, as in some states of sleep.
7. In the more complete seizures, sense, intel-
ligence, voluntary motion, and consciousness, are
entirely abolished; but, in some instances, the
abolition is only partial; the patient being con-
scious, but incapable of moving or speaking.
This imperfect form of the disease has very gen-
erally received the appellation of catochus from
nosologists; and numerous instances of it are on
record. A very marked case, and nearly ap-
proaching to fully formed catalepsy, is recorded in
the Edinburgh Medical Commentaries, by Dr.
Fitzpatrick; and slighter grades of it have
been met with as a subordinate symptom of
chronic nervous diseases, particularly of the severe
and obstinate forms of hysteria. In a case, how-
ever, of well marked catochus, in a female, de-
tailed by Dr. Lubbock, no hysterical symptoms
existed; and, instead of unusual susceptibility of
the system having been observed, in this and other
cases which he had met with, more than common
torpor was apparent. M. Petetin and others,
who believed in animal magnetism, conceive that
sensation, instead of being lost for the time, is con-
centrated towards the epigastric region; and that
the intelligence, so far from being altogether
abolished, is exalted to a degree to amount almost
to prophecy. But these opinions can only be
applicable to ecstasy.
II. Cataleptic Ecstasy. Ecstasis, Ecstasy
(from exOTariig, from i-inn^u). Syn. Ex-
tase, Fr. Entzuckung, Begeisterung, Ger.
Estasi, Ital. Ecstatic Trance.
8. Defin. Suspension of consciousness of
external objects, and of voluntary motion, arising
from, and attended by, a high degree of mental
excitement and abstracted contemplation, the
muscles continuing more or less rigidly contract-
ed, or only partially relaxed.
9. Under the term ecstasy, Dr. Good has
described a variety of catalepsy, but little dif-
ferent from the usual appearance of that form of
seizure, instead of the particular modification of
disease to which the name ecstasy has usually
been applied. This variety of cataleptic disorder
is generally induced by mental excitement and
sustained contemplation of some particular sub-
ject, most generally of religious topics, and of
those exciting the affections and passions. The
patient suddenly seems mentally struck, or car-
ried away from all external objects; either stand-
ing or sitting in a most excited and impassioned
position, with the eyes fixed and open; and some-
times uttering either the most enthusiastic and
fervid expressions, or the most earnest denuncia-
tions and warnings, or the most absurd exclama-
tions, with the feeling or belief of their reality;
and total abstraction from, or unconsciousness of,
all surrounding objects or persons.
10. This affection is variously modified. In
some cases it very nearly approaches to pure ca-
talepsy; in others, to a sort of maniacal excite-
ment. Dr. Chisholm records an instance of
this latter state in a young female, in whom it
alternated with mania; and I was consulted by
a practitioner in the country, respecting a most
marked case occurring in a religious young lady,
where it was evidently connected with, if not
consisting of, an exalted form of hysteria. During
the attack, she sung and composed long doggerel
strains. Many of the cases which have lately
made so much noise in this metropolis, under the
idea of inspiration with " unknown tongues," evi-
dently belong to this affection; at least, such of
them as have not been feigned. The effects pro-
duced by the practisers of animal magnetism,
upon nervous persons, sometimes appear allied to
this affection. Many of the Italian improvvisatori
are possessed of this faculty only whilst they are
in a state of ecstatic trance, similar to this disease.
And few of them enjoy good health, or consider
their faculty otherwise than a morbid one.
11. The Terminations of Cataleptic
and Ecstatic Seizures are generally either
in health, or in disease of the cerebral functions.
They may pass into mania, epilepsy, or confirm-
ed insanity. Dr. Burrows's case, already al-
luded to, was complicated with mania, following
excited and ungratified passions, and interruption
of the menses. Recovery, however, took place,
and the patient afterwards bore children. Dr.
Gooch met with a case which supervened on,
and was followed by, melancholia. J. Frank
treated a case of catalepsy, that terminated in
mania, of which the patient at last recovered;
and Behrends details the history of a case com-
plicated with mania. Pinel records a case of
catalepsy which terminated in apoplexy. Ros-
tan states, that he has observed a case in which
inflammation of the lungs was associated with it.
In many instances, these affections terminate, as
they commence, in most severe hysteria ; with
which a very large proportion of them are more
or less intimately allied.
12. But little is known of their relation to
morbid states of the brain or viscera. Holier,
however, informs us, that he found the vessels of
the brain and cerebellum distended with black
blood, and slight extravasation in a case which
terminated fatally. Lieutaud and Ab Heers
make mention of fibrinous concretions formed in
the longitudinal sinus, with disease of the Jungs
and liver. According to the state of the counte-
292
CATALEPSY — Treatment.
nance, temperature of the head, and action of
the carotid arteries, during the lit, it may he in—
1 erred that active congestion, or an efflux of blood,
far beyond what obtains in health, takes place to
the brain, and is instrumental in the production of
the disease.
13. Prognosis. — These affections do not ap-
pear to be attended with much danger. The
fully formed cataleptic seizure is, however, a seri-
ous disease. The cases already adduced in illus-
tration of its termination are sufficient to indicate
this. Fatal cases are, however, noticed by Ho-
lier, Dodonceus, and the authors just quoted.
Aetius, De la Tour, Fahr, and Sauvages,
state that they have seen it disappear after copi-
ous epistaxis, and return of the menses.
14. Causes of Cataleptic Seizures. —
A. The predisposing causes are, whatever di-
minishes vital power, and increases the suscep-
tibility of the nervous system, particularly the
depressing passions, violent and continued sorrow,
great anxiety, unrequited affection, intense and
sustained mental applications, religious contem-
plations, exhaustion from repeated miscarriages or
severe confinements, and excessive venereal indul-
gences and manustuprution. The hysterical; hypo-
chondriacal, and melancholic temperaments, are
evidently most disposed to these attacks. They
occur at all ages, from six or seven years till old
age; but they are very rare before puberty; and
are much more frequent in females than in males.
15. B. These affections are most commonly ex-
cited by some violent mental impression ; by cer-
tain of the above predisposing causes, when acting
intensely, particularly religious enthusiasm; great
mental application, and the passion of love; frights,
terror, or uncommon dread; the irritation of worms
in the prima via ; suppression of the menses, of
eruptions and accustomed discharges; injuries of
the head (Stark); concealed mental emotions,
and ungratified passions; and disturbance of the
uterine functions. Renard {Huf eland's Journ.
die Pr. Heilk. June, 1S15.) relates a case which
was occasioned by disease of the ovaria. Spren-
gel states, that these seizures are induced by
onanism. J. Frank remarks, " nunquam cata-
lepsin in Judaeisobservavi, ac onanise vitium rarius
inter eos, quam alias aptid gentes inveni." (Prtas,
Med. Univ. Pracip. v. ii. p. 487.) 1 believe that
many cases in females are chiefly exalted or more
severe states of hysterical affection; and more or
less connected with disorder of the nerves and cir-
culation in the uterus and ovaria.
16. Diagnosis and Prognosis. — The prac-
titioner must not overlook the fact of all those
affections being frequently feigned, particularly
by females, even by those in good circumstances,
and when there can be no end to serve by the
imposture further than to create interest in their
behalf. Although cataleptic and ecstatic seizures
pass insensibly into each other, and are in their
nature obviously very intimately related, yet their
more extreme and distinct forms are very differ-
ent. In the former affection, the patient resem-
bles a statue, is entirely deprived of voluntary
motion, and is perfectly mute: in the latter, the
countenance is animated and earnest; the muscles
are more or less rigid; the patient talks, exclaims,
or even sings with the utmost ardour; and the
character of the whole frame is that of the most
abstracted and intense contemplative excitement;
consciousness of all other objects and ideas, ex-
cepting of the particular subject by which the
mind is excited, being abolished: but the consci-
ousness is often of a morbid or imaginative kind;
the patient conceiving, as in the instances adduced
by Tissot, that he has seen wonderful visions,
and heard singular revelations. Ecstasy ma}' be
confounded with somnambulism and reverie. The
excited, and, as it were, inspired appearance of
the patient, in the former aflection, is sufficient to
distinguish it from the more passive character of
the latter, in both of which he resembles a person
half asleep, or sleep-walking. The statue-like
appearance and muteness of the cataleptic are
alone sufficient to distinguish this disease from
these latter affections. (See § 4 — 6.).
17. Catalepsy may also be mistaken for as-
phyxia, syncope, apoplexy, and even for death
itself. The total suspension, however, of re-
spiration and circulation, the deep colour of the
lips and countenance, in asphyxia; the flexi-
bility of the limbs, great paleness of the face, and
the scarcely perceptible performance of the re-
spiratory and circulating functions, in syncope;
and the congestion of the head and face, the
stertorous breathing, relaxed and flexible limbs,
and the attendant paralysis, in apoplexy; are suffi-
cient of themselves to distinguish it from any of
the modifications of the affection now under con-
sideration. It is possible, also, that a cataleptic
patient may be considered as being dead. Ihere
are many instances on record, where persons in
a state of trance have narrowly escaped being
buried alive; and there is even reason to suppose
that, in countries where burial usually takes place
much sooner after dissolution than in this, such
a circumstance has actually occurred. But this
could never have occurred, unless the respiration
and pulse hud been suppressed, and the counte-
nance pale. The stethoscope may now possibly
prevent such an occurrence from taking place, by
detecting the feeble action of the heart, which
can never be altogether extinct in catalepsy. The
states of the sphincters, and of the cornea, and
the temperature of the trunk of the body, will
further serve to prevent so distressing a mistake
from ever occurring, even independently of due
reservation of the body from inhumation, till in-
dubitable proofs of death show themselves. As
to discovery of feigned seizures of these affections,
the general characters of the case, and the prac-
titioner's own acumen, must be the chief guides.
18. Treatment. — When we consider that
evidence of determination, or of active congestion,
of blood in the head, lias generally been furnished
in these affections, the propriety of vascular deple-
tion will not be disputed. If the signs of general
or local plethora be very manifest, and if the
disease have any relation to suppression of the
menses, cupping between the shoulders, the ap-
plication of a number of leeches to the nape of
the neck and behind the ears, stimulating pedi-
luvia, and bleeding from the feet, should be em-
ployed. If the temperature of the head, and the
action of the carotids be increased, the affusion
of cold tvater on the head, or the use of cold or
evaporating lotions in this quarter, whilst the low-
er extremities are plunged in warm water, will be
of service. In addition to these, purgatives should
be given by the month, and repeated; a constant,
but moderate action, being Thereby exerted upon
CATARRH.
293
the bowels ; and antispasmodic or turpentine
QQemata should be administered from time to
time. (See F. 130. 13,3. 160. 152.). The aloe-
tic purgatives (F. 450 — 455. 470. 518.), are par-
ticularly eligible, when the affection is connected
with irregularity of the menstrual evacuation.
Diedif.r advises active hydragogue cathartics.
19. The above means are equally applicable
to the paroxysm, and the interval, or suppression
of accustomed evacuations, in cases characterised
by plethora, or local determination of blood. If
resorted to in the fit, they may be conjoined with
various antispasmodics, as valerian, music, ether,
assaftrtida, camphor, ammonia, &c, and volatile
stimuli may be occasionally held to the nostrils,
when the face is pale, and signs of determination
of blood to the head are wanting.
20. The utmost attention should be directed,
during the intervals, to the state of the uterine
organs. If signs of congestion or of irritation are
detected in this quarter, cupping on the loins, the
application of leeches to the groins and tops of the
thighs, and the internal use of the boracic acid,
or of the sub-borate of soda, combined with re-
frigerants and anodynes, should be resorted to.
The frequent association of these complaints with
hysteria indicates the propriety of having recourse
to a nearly similar treatment to that recommend-
ed in it, and to the same appropriation of medi-
cinal means. Behrends attaches considerable
importance to the state of the stomach and prima
via in cataleptic seizures. There can be no doubt
of the functions of these organs being often im-
peded or disordered, and of the propriety of res-
toring them to a healthy state. This can be done
only by a judicious combination of Ionic and
aperient, or of deobstruent medicines.
21. When these affections have arisen, as they
not infrequently do, from depressing or exhaust-
ing causes, the judicious combination of tonics
with gentle aperients and antispasmodics, will be
of much service. The shower-bath, salt water
bathing, change of air, tonic and deobstruent min-
eral waters, regular exercise, early rising, and
mental amusement, will be most advantageous in
such cases. Several of the causes of the disease
are both of an exhausting nature, as respects the
constitutional energies, and of an exciting kind,
in regard of the cerebral organs, particularly some
of those which induce the ecstatic form of seizure
(§ 8 — 10.). In these, it will be necessary to di-
minish the local determination to the brain, which
is generally present, by the means indicated above
(§ 18.), whilst we soothe the nervous system,
and restore the digestive functions and the ener-
gies of the frame. To accomplish these ends, we
must resort to a combination or alteration of
tonics with anodynes, antispasmodics, and ape-
rients (F. 453. 572.), keeping at the same time
the head cool, the secretions and evacuations free,
the mind amused and disengaged, the feet warm,
and the blood as regularly distributed throughout
the body as possible.
22. \Vhen the disease is complicated with
mania, melancholia, or epilepsy, similar means to
those already stated may be employed, appro-
priately to the state of vascular excitement and
vital powers, and to the symptoms more imme-
diately connected with the brain and the uterine
organs. In several cases of these complications,
full and frequent doses of calomel will be of ser-
25*
vice, and, under careful supervision, it may be
judicious to exhibit, in conjunction with anodyne,
nervine, or antispasmodic remedies, the milder
preparations of mercury, until the mouth is slight-
ly affected. In all cases where the above means
fail of producing the expected effect, and parti-
cularly in these complications, issues, or setons,
perpetual blisters, or the tartarised antimonial
ointment, or moxas, should be directed to the
nape of the neck, the occiput, or behind the ears,
and perseveringly continued. In most instances,
whether simple or complicated, after the affection
of the mouth by mercurials, or the long continu-
ed use of setons, &c, the more tonic and restor-
ative means advised above should be prescribed.
Amongst the various antispasmodic medicines
recommended by authors on these affections, I
may notice the different antispasmodic gums, by
.Stark (Klin. Instit. p. 172.) ; the ammoniated
copper, by Theussisk (Samml. Auserl. Abh.
fui' Pract. Aerzte, b. xvii. p. 279.); electricity,
by Ledra and Sigaud la Fond (De VElect.
Med. p. 396.) ; the cautery to the occiput, by
Blankard (Collect. Med. Phys. cent. v. No.
18.) ; and cinchona combined with valerian. The
different preparations of iron, and various anti-
spasmodics, have been recommended by Dr.
Lubbock, and exhibited by him in a case where,
however, they appeared of little service, most ad-
vantage having been derived from travelling, pure
air, and agreeable mental occupations. (Edinb.
Med, and Surg. Journ. vol. i. p. 61.). During
the whole course of treatment, the strictest refer-
ence ought to be had to the nature of the predis-
posing and exciting causes, the habits and prac-
tices of the patient, and to his diet, and physical
and moral regimen.
Biblioo. and Refer. — Srhcnlc, De Catalepsi. Jense,
1671. — F. Htffinann, De Affectu Catalept. raris. Francf.
1692. — Boerhaave, Aphorismi, fee. § 1036. — Dionis. Diss.
sur la Mort. subite et la Catalepsie. Paris, 1718. — G. W.
JVede-1, Diss, de Catalepsi Affect, raris. Jen. 1711. — Roe-
der, Diss. Raro Affect. Catalepsi. Erf. 1721. — Peynell,
in Philos. Trans. No. 437. — Delins, Diatribe de Cata-
lepsi. Ed. Secun. Erl. 1754. — L. E. Hir.ichel, Gedan-
ken von der Starrsucht oder Catalepsie. Berl. 1769. —
Hnme, Principia Medicine, ed. Amst. 1775, p 232. — Gun-
drumm, Disser. de Catalepsi. Helms. 1776. — Schilling,
Diss. iEgr. ex Amore Catalep. factum exhibens. Geiss.
1776. — llrmmer, De Differ. Extas. et Catalep. Geiss.
1776.— Sauvages, Nosol Method, t. ii. p. 418. — Fitzpa-
trirlc, Edin. Med. Comment, vol. x. p. 242. — Tis.iot, Traite
des Ncrfs et de leurs Malad. fee. cfa. 21. — G. L. Fabri,
Tract. Pathol, de Catalepsi. Hals, 1786. — //'. Gerson,
Diss, de Calepsi. Giitt. 1797. — Ossius, De Catalepsi.
Math. 1799. — C. A. I/linger, Dc Catalepsi. Francf. 1800.
— IV. F. Dreysig, Handworterbuck der Medic. Kinder,
b. iv. abth. 2. p. 360. — Pctelin, Elect. Animale nrouvee
par le Decouv. des Phenom. Phvsiq. et Mor. de la Cata-
lepsie, ,V- Paris, 1808. — A'. Sprrvgel, Handbuch der
Pathol, b. iii. p. 225. — Dufour, in Journ. de Med. t. Ixx.
p. 418. —Savery, in Journ. dc Med. Contin. Dec. 1811.
p. 419. — Gilibrrt, in Actcs de la Societ. de Montp. Ann.
xiii. No. vi. — Fi/nn et Lenormand , in Revue Medicale, t.
iii. p. 52. 1825. — Handtwick, Diss, de Ecslasi. Host. 1755.
— i'.hn; in llcdleri Biblioth. Med. par. ii. p. 131. — Bang,
in Art. Reg. Socict. Med. Ilavn. vol. i. p. 101. — Reil,
Fieberlelue, b. iv. p. 572. — Zzainger, Theatrum Vita> Hu-
mana-, p. 223. — S'tuvnges, Nosol. Meth. I. iii. p. 422., et 1.
iv. p. 397. — J. Frank, Praxeos Med. Universa Pra-cepta,
t. ii. p. 475. — Robert, in Journ. de Med. Contin. Dec.
1811, p. 415. — Sarlandiire, Histoire d'un Catalcptintie,
&C. Paris, 1816. — /). A. G. Richter, Die Specielle
Therapie, fee. bd. viii. p. 465. — Bouillaud, in Diet, de
Med. et Chir. Pratiques,!, v. p. 15.
CATARRH. — Simple Catarrh. Stn. Ca-
tarrhus (from y.crtttphtui, defluo). Gravedo,
Coryza, Bronchos, Catarrheuma, Fluxio,
Rluuma, Capiplenium, Auct. V'ar. Catarrhua
294
CATARRH— Causes.
simplex, Richter. Phlegmhymenitis ( from
tpXtyutt, mucus, and vfitr, a membrane), Hil-
denbrand. Catarrhe, Rhume, Fluxion, Ft.
Fin Fluss, Schnupfen, Kutarrh, Ger. Cutarro,
Reuma, Ital. A Defluxion, a Cold.
Classif. 1. Class, Fevers; Order, Flux-
es (Cullen). 3. Class, Sanguineous Func-
tion; 2. Order, Inflammations (Good). II.
Class, I. Order (Author, see Preface).
1. Defin. Sneezing, watery discharge from
the nostrils; lachrymose state of the eyes; slight
gravutive headach, chillness, evening fever , some-
times accompanied with sore throat, hoarseness,
and cough.
Path. Defin. Specific irritation of the mu-
cous surface of the nostrils, extending to the
frontal sinuses and eyes, in one direction ; to
the posterior nares, fauces, and throat, in an-
other; and occasionally also to the pharynx,
asophagus, glottis, and trachea, thus terminating
in catarrlial bronchitis.
2. Although the most common of all diseases,
there are few which are less understood, or have
called forth a greater diversity of opinion, than
catarrh. This uncertainty is chiefly owing to its
varying characters, arising from the limitation or
extension of its seat, the temperament and habit
of body of the patient, the causes which occasion
it, and the severity of the attack. If the aflection
be not extended much bevond the Schneiderian
membrane, it very generally receives the name
of coryza, or catarrhal coryza ; if it be seated in
the frontal sinuses it is called gravedo, or catar-
rhal cephalalgia ; if in both these situations, a
cold in the head ; if the fauces be its principal
seat, catarrhal cynanche, or catarrhal sore throat;
if the glottis and pharynx, catarrhal cough and
hoarseness ; if it advance to the trachea and
iHonchi, catarrhal bronchitis; and if the eyes be
primarily affected, catarrhal ophthalmia. It may
Uius be limited to any one of those situations,
or be extended to two, or more, or even all of
them, according to the predisposition of the parts
and of the person affected. It may even pro-
ceed further, as to the air-passages on the one
hand, or to the oesophagus and digestive organs
on the other, after having subsided in, or disap-
peared from, its primary seat; and it may even be
coexistent in several, or even all of these situations.
3. If we consider the origin and phenomena
of catarrhal affections, we shall observe many
characters warranting an analogy between them
and rheumatism on the one side, and erysipelas
on the other. Catarrh is a disorder proper to
mucous membranes, and is not limited to the
parts of this tissue above specified. The same
causes which occasion it in them, will sometimes,
although much less frequently, excite it in other
parts of this system, according to morbid predis-
position of the organs. Rheumatism is an affec-
tion of the fibrous, sero-fibrous, and aponeurotic
structures, and generally proceeds from the same
or very similar causes to those which produce
catarrh; they are both also often present at the
siiue time, and in the same person, and the epi-
demic prevalence of both is not uncommon.
Erysipelas is an affection of the skin , also often
depending upon similar causes to those which
produce catarrh and rheumatism, particularly
those connected with the states of the atmosphere;
and all of thetn are benefited more or less bv a
nearly similar treatment. Neither of these dis-
eases is the same as true inflammation, although
presenting more or less of the inflammatory cha-
racters, but also some which are proper to each.
On this account, therefore, should they be view-
ed, even when approaching the nearest to inflam-
mation, as essentially specific diseases; possessing,
however, certain symptoms in common with one
another, and with inflammation; the same causes
acting on a certain number of individuals, pro-
ducing catarrh in many, rheumatism in some,
erysipelas in a few, and true inflammation hi
others, according to the diathesis, habit of body,
state of the abdominal functions, previous disor-
der, &c. of the affected.
4. I. Causes. — A. The predisposing causes
of catarrh are referrible chiefly to original con-
formation and diathesis, and to previous disorder,
particularly as respects the state of the digestive
and assimilating organs. It most frequently af-
fects persons of a phlegmatic temperament, relax-
ed habit of body, and delicate constitution, or
who are weakened by any cause, particularly bv
morbidly increased secretions and discharges; also
those with long necks and narrow chests, or who
indulge in warm apartments and beds, who rise
late, and take little exercise in the open air. It
is very common among the inhabitants of cold,
moist, and changeable climates, more particular-
ly during spring and autumn, and in variable or
wet seasons; and in persons whose digestive or-
gans are deranged, the functions of the liver tor-
pid, and whose biliary organs and alimentary
canal are loaded by morbid or accumulated secre-
tions.
5. B. The exciting causes of catarrh are most
commonlv cold and moisture, or other states of
the air, which either are or are not perceptible to
the senses, but which impede or check the insen-
sible cutaneous perspiration, and change the func-
tions of those parts of the mucous surfaces most
obnoxious to their first impression. That there is
something in the air, often producing catarrh, be-
yond what is perceived by our senses, is shown
by the very general or even epidemic prevalence
of the affection during states of the weather and
of the air, in which nothing peculiar can be
observed. Its great frequency, particularly in
certain localities and seasons, has induced some
authors, amongst whom Dr. jMacculloch is
pre-eminent, to impute it to a diluted or generally
diffused malaria proceeding from the usual sour-
ces of this active agent of disease.
6. Change of locality, whilst it will often re-
move a cold, will also frequently occasion it,
especially in some constitutions; and a current of
air, particularly if it come directly on the face, is
a very common cause. The occurrence of ca-
tarrh on travelling and visiting places at a dis-
tance has been attributed to malaria; and this
mav very possibly be the case in many instances.
Whenever I have gone any distance into Essex,
I have returned with catarrh. It is very com-
monly believed by unprofessional persons, that
the disease is infectious; from the circumstance
of its commencing in one member of a family,
and attacking others successively. This spread
of the ailment, however, may be in a great
measure owing to the diffusion of the same
cause in the atmosphere, whether it be a much
diluted or weak local malaria, or a more widely
CATARRH — Progress and Terminations.
295
spi-rading epidemic influence. Still I believe
that there arc some grounds for the popular be-
lief. Although these causes will explain much
of what is imputed to infection; still, it may,
either of itself occasion the disease, or, when
superadded to them, induce an attack in those
whom the states of the air, without such aid,
might have spared. When catarrh is occasioned
by local or generally diffused influences, it may
not only thereby assume an infectious character,
but really possess it; thus countenancing the opin-
ion of Dr. Cullen, that the epidemic prevalence
of the disease only is infectious; yet, still, 1 ques-
tion if this limitation be just. There can be no
doubt, however, that when it arises from epidem-
ic, malarial, or infectious sources, it is usually
febrile and severe, and very prone to extend
along the air-passages on the one hand, and to
the digestive mucous surface on the other, par-
ticularly the former; while catarrh, arising from
the more common causes of cold and moisture
merely, in any one of the many ways in which
these causes are applied to, and affect either the
whole or parts only of the frame, is more com-
monly seated in the cephalic mucous surfaces, as-
suming the form of cold in the head, coryza, or
sore throat, and quickly subsiding. It should not
be overlooked, also, that sudden change from a
low to a high temperature, or from a very dry to
a very moist air; and even the being more than
commonly overheated, without any very apparent
chill, or exposure to cold in any form subsequent-
ly, will off en produce catarrh. This is especial-
ly the case, if the exposure to warmth be sudden,
after an impression of cold of some continuance,
as the coming into an overheated apartment out
of a cold and moist atmosphere, — the instantane-
ous transition from a raw air of about 32J to a
dry air of upwards of 70J.
7. II. Symptoms. — Owing to the circumstan-
ces already alluded to (§ 2.), catarrh manifests
itself in various forms; but most commonly in
the following manner : — A. Its slighter states.
At a period generally varying from a day or two,
to six or seven, but occasionally after even a
shorter or longer time, from exposure to the cause,
this affection commences with a sense of chilli-
ness or coldness, lassitude, and heaviness of the
head, followed by dryness, fulness or stuffing of
the nasal passages, frequent sneezing, a dull pain
and sense of weight in the forehead, and stiffness,
or rather uneasiness, in the eyes. To these is
more or less quickly added a distillation of a wa-
tery fluid from the nose and eyes, with slight
redness and tumefaction of the mucous surfaces
of these parts. Occasionally the above symp-
toms appear nearly simultaneously. The deflux-
ion is generally somewhat acrid and saline, pro-
ducing slight excoriation of the parts over which
it passes. These phenomena constitute the gra-
vedt) of Cei.sus, and the coryza or dejluxiov.
of various authors. Thev may be the only ail-
ment, and not proceed further, or they may have
Others rapidly superadded to them, depending
upon greater constitutional disturbance, and the
extension of the affection to a larger surface.
In the former case, the general lassitude and
chilliness ushering in the complaint are often so
slight as to be overlooked ; but, in the latter
case, and in the severer states of the disease
about to be noticed, they are commonly more
marked from the commencement and amount
even to slight shiverings, followed by white
tongue, acceleration of pulse, and increase of
heat in the evening. The posterior nares and
fauces, as well as the nose and eyes, are affected;
and the patient complains of a sense of rough-
ness, or soreness of the throat; loss of the sense
of smell; sometimes of dulness of hearing, with
soreness or pain extending along the Eustachian
tube to the ear, with slight redness of the fauces
and mouth, hoarseness, frequent tickling cough
and efforts to excrete a mucous fluid abundantly
secreted from the posterior nares, fauces, pha-
rynx, and trachea; and sometimes with a loss
or suppression of voice, from slight cedematous
fulness about the glottis. To the foregoing are
very commonly added, pains resembling those
of rheumatism in various parts of the body,
particularly about the neck, head, and limbs,
loss of appetite, costive bowels, and slight
thirst.
S. B. Its severe forms. — The above symp-
toms constitute the usual form of simple catarrh,
which frequently subsides in from three, to seven
or eight days; the fluid secreted becoming grad-
ually less copious, .more opaque and coloured,
and, at last, thick, small in quantity, and yellow-
ish white, or yellowish green; all disorder quick-
ly disappearing. But in very many other instan-
ces, as the coryza and watering of the eyes sub-
side, straitness, oppression, and uneasiness in the
chest, supervene; with fits of coughing, and all
the symptoms described under the catarrhal form
of Bronchitis. In other cases, the symptoms
indicate, from the beginning, a more severe af-
fection, and a more evident constitutional disturb-
ance, approaching more nearly to a state of in-
flammatory irritation of the mucous membrane of
the cephalic passages, than the preceding form.
In this case, the coryza and watering of the eyes
are attended by much soreness and heat of the
eyes, nostrils, fauces, and throat; by frequent
sneezing; and by the secretion of a very copious,
watery, and colourless fluid, excoriating the parts
over which it passes. The fauces are red; the
tonsils somewhat inflamed and enlarged; and
there is a short, dry, tickling cough. The fever,
which, in the slighter state of disease, was scarce-
ly noticed, is much more evident in this, particu-
larly towards evening; and is ushered in by chills,
or shiverings, the chills often continuing through-
out, and preceding the evening febrile exacerba-
tions; catarrhal fever usually thus assuming a re-
mittent type. The pains felt in different parts of
the bodv, and the general lassitude, cough, anor-
exia, sluggishness of the bowels, and thirst, are
also greater in this, than in the preceding state of
the affection.
9. Throughout the disorder, the patient is un-
usually susceptible of the impression of cold, even
although the skin be warmer than natural. He
is also inordinately disposed to experience an ac-
cession of, or to contract a fresh cold, upon the
slightest exposure to its causes, or even to the
least depression of temperature. Owing to this
circumstance, catarrhs are often very much pro-
longed, and either assume a chronic form, or in-
duce chronic bronchitis, and other serious affec-
tions of the air-passages and lungs.
10. C. Progress and terminations. — This
form of catarrh either disappears, as in the slight-
296
CATARRH — Complications or.
er states of the disorder, with a diminished and
thickened secretion, less frequent and less severe
fits of coughing, and subsidence of fever, in from
four, to seven or nine days ; or it affects, in a
much shorter period, — sometimes almost from
its commencement, — the pharynx, trachea, and
large bronchi, producing slight or severe bron-
chitis; or it terminates in this disease, or in pneu-
monia, or even in pleuritis. But most commonly,
under proper management, it is attended merely
by a moderate catarrhal affection of the trachea
and bronchi ; with fits of coughing, increased
mucous expectoration, &c, constituting catarrhal
bronchitis. It also sometimes extends down the
oesophagus, and affects slightly the stomach, in-
ducing numerous dyspeptic symptoms; and, in
persons with an irritable state of the digestive
tube, occasionally passing off at last with mucous
or serous diarrhoea.
11. III. Prognosis. — In general, catarrh is
a very slight ailment, and attended with no danger
as respects itself. But, in aged persons, in those
disposed to pectoral diseases, particularly those
who may have tubercles already' formed in the
lungs, who have had haemoptysis, or who are
asthmatic, or have experienced attacks of bron-
chitis, pneumonia, or pleuritis, catarrhal affections
require strict attention, as they very often quickly
produce, or terminate in, these maladies. In
many persons, also, they are very prone to be-
come chronic, either in the form of a chronic co-
ryza, with continued irritation, and slight redness
of the posterior naresand fauces, and an abundant
muco-puriform discharge; or in some one of the
states of chronic bronchitis. In the aged, and in
those of a phlegmatic temperament, or lax habit
of body, catarrh often passes into a chronic bron-
chial flux, when it has been neglected, or renew-
ed by incautious exposures during the treatment.
Children of a lymphatic and flaccid habit of body
are very liable to catarrh in the form of coryza;
and in them it very frequently assumes a chronic
form: the thick mucopurulent secretion filling up
the nares, and, in infants, preventing them from
taking the breast, and rendering them irritable,
each attempt at sucking disordering the pulmonary
and cerebral circulation in such a manner as even
to occasion convulsions. In children also, the
coryza, when allowed to become chronic, some-
times degenerates into ozana, with ulceration.
12. IV. Complications. — Catarrh very
commonly ushers in the febrile exanthemata, par-
ticularly measles ; and even accompanies them
through their course, especially in the form of
bronchitis. It is also very liable to appear dur-
ing convalescence from them. Its connection
with rheumatism has already been noticed (§3.),
both disorders evidently springing from the same
causes. Continued fevers, as well as some epi-
demic visitations of fever, are not infrequently
complicated with catarrhal affections. The as-
sociation of catarrh with biliary and gastric de-
rangements is very common, sometimes in con-
sequence' of the disposition to be affected by its
causes during biliary disturbance, and occasional-
ly owing to the circumstance of simultaneous dis-
order of the digestive, cephalic, and respiratory
mucous surfaces, having arisen from the impres-
sion of the same exciting causes. These com-
plications have especially characterised the various
occurrences of epidemic catarrh, which have
been observed. (See art. Influenza.)
13. V. The Nature of Catarrh is deserv-
ing of some notice. Many pathologists, particu-
larly those of the modern Parisian school, — the
followers of Laen nec and Broussais, — con-
sider it as ordinary inflammation of the cephalic
mucous membranes, or parts of this tissue which
it usually affects. Other pathologists, more espe-
cially Richter and Hildenbrand, view it,
with stricter propriety, as an inflammation of a
specific kind. I believe, although it very often
terminates in true inflammation when it extends
to the bronchial tubes, that it chiefly consists of a
specific irritation of that portion of the mucous
surface primarily affected by it, nearly allied to
inflammation, and soon followed by, or accom-
panied with, great increase of the secreting func-
tions of the part; or, in other words, that it is not
pure inflammation, but an irritation of a specific
or peculiar kind, attended by slightly increased
vascularity, afflux of the circulating fluids, and
augmented secretion. Since the time that Van
He l mont ridiculed, in his Catarrhi Delir amenta,
the opinions then entertained respecting catarrh,
enquiries into its nature have been more rational,
although, up to the present time, ideas have still
continued very vague as to the extent of surface
affected by it, many even of modern writers com-
prising under catarrh, not only bronchitis, but
even all affection of mucous surfaces, attended
with a copious serous or sero-mucous discharge.
14. One of the most interesting questions con-
nected with this subject, and one which has been
agitated by J. P. Frank and others, is, whether
the defluxion is a consequence of the suppression
of the cutaneous perspiration, arising out of the
irritation which the secretion retained in the cir-
culation produces upon the cephalic and pulmonic
mucous surfaces; or of the specific irritation and
morbid impression of those parts by the exciting
causes of the disease. The former opinion was
very generally received by the followers of the
humoral pathology ; and the latter by Hoff-
mann, and subsequently by Cullen, Pinel,
and other disciples of his school. Pinel consid-
ered the febrile phenomena merely as symptom-
atic of the inflamed mucous membrane, discarding
the plausible opinion advanced by Botai., that
whatever of inflammation exists is caused by the
acrimony of the catarrhal discharge, and that the
local ailment is consecutive of the constitutional
disturbance, — a doctrine which is in strict ac-
cordance with the description of the disease given
by Richter, and with the more usual succes-
sion of its phenomena. In some cases, however,
it is very difficult to determine the priority of
the general disturbance, the. local ailment being
equally early. Upon the whole, I believe it is
not proved that the constitutional affection is the
consequence of the local, although the former is
generally increased in proportion to the severity
of the latter; nor does it appear that the de-
fluxion is caused by the suppression of the cuta-
neous perspiration, even granting that suppression
is actually produced, — -a position by no means
established. I would thence infer that the causes
of catarrh affect primarily the organic nerves
supplying the surface principally disordered, and,
through them, the system generally ; and that,
CATARRH — Treatment.
297
owing to this change, tlio secreting functions and
circulating actions of the part primarily or spe-
cifically impressed, arc altered, and tilt: disease
fully developed; its chief modifications arising out
of t lii- decree to which the constitutional actions
are disturbed, of the extent of surface affected,
and of the grade of irritation produced in the
capillaries of the part.
15. VI. Tr E A t m e nt. — The treatment varies
much according to the symptoms and periods of
the disease. Immediately upon the approach of
catarrh, before febrile exacerbation has appeared,
anil whilst ailment is limited to the cephalic mu-
cous surfaces, very opposite means to those re-
quired when fever is present, or when the affection
has extended to the trachea, and threatens to pro-
duce bronchitis, are generally most serviceable.
Under the former circumstances, a judicious ex-
hibition of stimulants of any kind, but especially
stimulating diaphoretics, will either cut short the
disorder, or render it much shorter and more mild;
whilst, in the latter state, particularly when any
pectoral symptoms have appeared, considerable
risk will be incurred in some constitutions, al-
though either little or none in others, of inducing
inflammatory action by the same measures.
16. Early in the disease, therefore, and while
a copious defluxion has not come on, the patient
may inhale through the nostrils the vapour of
warm water, or of any emollient and anodyne
decoction or infusion: if the ailment is no more
than a coryza, or cold in the head, febrile action
not having appeared, he may take, upon going
to bed, an active stimulating draught, consisting
chiefly of ammonia, camphor, spirit. a?ther. ni-
trici, &c, with or without a narcotic. Either of
the following will be used with advantage as long
as febrile action, or any acute affection of the
bronchi, has not appeared : —
No. 9<!. R Spirit. .Ether. Nit. 5 j.— t iij. ; Tinct. Cam-
phor* Comp. ~, j. — o ij. ; Mucilag. Acaci<e '■, ij. ; Spirit.
Anisi ~, j. — ' ij ; Liq. Amnion. Acet. ', ij. ; Mist. Cam-
phors '-, j. ; Svrup. Tolutan. ~D j. M. Fiat Ilaustus, hora
■omni Bumendus.
No. 97. \{ Camphorae rasae, gr. iij. — vj. ; Amnion. Sub-
carbon, gr. vj. — x. •, Pulv. Ipecac, gr. j. ; Extr. Ilyoscyami
gr. vj. j Oooaerv. Jlos. q. s. ut fiat Bolus, h. s. s.
17. The above draught will often arrest the dis-
ease, when given sufficiently early. In some cases
I have tlirected the bolus to be taken with it,
either the hvoscyamus or the tinct. camph. co.
being omitted. On the following morning, a sto-
machic aperient may be taken; but nothing more
is necessarv, not even diluents, as, at this period,
they will have little further effect than to increase
the defluxion. When the pulse becomes acceler-
ated, and somewhat fuller or harder than natural,
with other signs of febrile action; or when the
throat is more or, less affected, and particularly
if there be irritation about the glottis and trachea;
a different practice is required. Diluents will
now be of service, particularly in conjunction
with emollients, diaphoretics, &c. Any of the
medicines of this description in the Appendix
(F. 238. 244.), or those denominated pectoral (P.
389. 4 26.), will be of service; or the following may
be used. Richtkr states, that the first of these has
generally been employed by him early in catarrh.
No. 9K. H Calomel gr. j. ; Kxtr. rjyoscyarol gr. ij. j
Gum Ararii' I'ulv., Sacchari Albi, fin gr. xv. IVtisci ei
liat Pulvis. Dispcns. ta es quatuor. Suniat aeger tertin quaqufl
hora uniiui.
No. 99. |! Mueilag. Acacia? ~ j. ; Mist. Camphors ft
Mut. Atnvgilal. Dulc. iij 5 ss' i Liquor. Amnion. Acet.
~ iij. ; Tinct. Camphorw Co., Spir. iEthcr. Nit., aa ?■> 89. ",
Syrup. Tolutan. ', ... ,\1. V iat Hailltus, quaita vel quinti
quriqiic hoiri oapiendus,
18. \\ In vex we deem it requisite to act
moderately on the bowels, either in the course or
at the decline of the complaint, a full dose of the
flour of sulphur, either with, or without cream of
tartar, will be found to act most beneficially, both
on the catarrh and on the abdominal functions.
When febrile action becomes more fully developed,
or if the disease assumes an inflammatory charac-
ter, with headach, flushed countenance, or hard
cough, a suitable quantity, either of the liquor
antimon. tartariz., or, of the vinum ipecacuanha:,
may be added to the above draught; and either
of the following given at bed-time : —
No. 100. |{ I'ulv. Ipecacuanha? gr. ij. ; Hydrarg. Sub-
mur. gr. iij. ; Pulv. Opii Puri gr. j. ; Mucilag. Acacia; q. s.
ut fiaut Pilula; ij.
No. 101. K Pulv. Jacob! Veri gr. iij. — v.; Hydrarg.
Suhniur. gr. iij. ; Opii Puri gr. j. (vel Extr. Ilyoscyami gr.
v.) ; Syrup q. s. M. Fiaut Pilula? ij.
19. When ailment begins to subside, or when
it seems likely to degenerate into a chronic state,
with more or less affection of the bronchi, the
treatment recommended in Catarrhal bronchitis,
or in the slighter chronic states of the disease,
should be prescribed. (See Bronchitis, § b'9.)
Uufeland recommends a decoction of the un-
toasted coffee-berries, or the carduus benedictus,
in those cases. Joerdens advises the oleum cam-
phoratum (F. 449.) on sugar; Lf.ntin, the oleum
terebinthinse rubbed on the loins; and Ivortum,
camphor, with sal ammoniac. The decoction of
Iceland moss, with ipecacuanha, or spiritus aather.
nit. and syrup of poppies, may also be used, or
either of the following : —
No. 102. Zinci Oxydi gr. j. (vel Sulphatis gr. ss.); Pulv.
Ipecacuan. gr. ss. ; fixtract Ilyoscyami (vel Uonii) gr. iij.;
Extr. Glycyrrh. gr. ij. Fiaut Pilula; ij. ter quaterve in die
sumendae.
No. 103. R Extr. Papaveris Albi gr. iij. ; Mucilag. Aca-
cia; ~, j. ; Tinct. Camphors Comp. ' ss. ; Spirit. Anisi ^ j. ;
Decocti Althaea; et Aq. Sambuci aa, ", ss. ; Spirit. iEther.
Nit. TT) xx.; Svrup. Tolutan. 5 j. M. Fiat Ilaustus, ter
quaterve quotidie capiendus.
20. When catarrh is connected with biliary
disorder, or with accumulated sordes in the prima
via, an ipecacuanha or antimonial emetic at the
commencement of the treatment will often be of
much service ; especially when followed by a
dose of calomel and an aperient draught, or sto-
machic purgative, in order to evacuate whatever
morbid secretions or faecal matters may have been
collected. If it be complicated with rheumatism,
calomel, combined with antimony and opium, and
subsequently with camphor, ipecacuanha, and opi-
um, will be found of service ; biliary collections,
&c. being carried oil' by the exhibition, every day
or alternate davs, of a stomachic purgative. If
catarrh be accompanied with symptoms of debi-
lity, or with those of a nervous character, forming
what some German pathologists have termed
nervous catarrh, the liquor ammonko acetatis,
with larger doses of camphor than under the pre-
ceding circumstances, or with the spirit, amnion,
aroin. or succinati, or the spirit, alliens sulphur.
comp., and any of the anodynes 'in common use,
;ne appropriate medicines. When the disease be-
come- chronic, change of air is most beneficial.
I luring the treatment, the patient should avoid ex-
posures to atmospheric vicissitudes, and partakeon-
ly of light bland diet, observing the injunctions laid
down for the management of convalescence from
bronchitis. (?ee Bronchitis and I.nkluknza.)
298
CELLULAR TISSUE — Alterations of.
Biblioo. AND REFER. — Cehus, De Medicina, iv. 2.
p. 375. — Bot al. Comment, de Catarrho. Lugd. 1565, 160.
— Schneider, De Catarrhis, Iibri vi. 4to. Witeb. 1660.—
Ro[fink, De Catarrho Narium. Jen. 1690. ; et De Catarrho
ad Xares, ad Fauces, et Pulmones. Jenae, 1672. — Juncker,
De Congestionibus, vulgo Catarrhis et Rheumatismis.
Halae, 1748. — Chandler, Treatise on the Disease called a
Cold, Svo. Lond. 1761. —Stoll, Rat. Medendi, t. iii. p. 39.,
t. iv. p. 223. — Wallich, De Frequenti Catarrhorum e
Primis Viis Origine. Goet. 1777. — J. P. Frank, De Cu-
rand. Morbis, lib. v. pars i. p. 108. — Kelson, On the Nature
and Cure of Colds, 8vo. Lond. 1797. — Cul/en, First Lines
of the Pract . of Med. vol. ii. p. 83. 4th ed. — ffaartmann,
De .Stiolog. Catarrhi, Abo. 1802. — Kortum, in Hufrland
und Himhj, Journ. der Pract. Heilk. July, 1810, p. 48.—
Hufdand, N. Annalen, b. i. p. 173. — Lentin, BeytrSge,
ii. obser. 16. — Joerdens, Huftland's Journal d. Pr. Arzn.
b. vi. p. 429. — Pair, Med. Diet. vol. i. p. 369. — Richter,
Therapie Specielle, b. ii. p. 84. — Hildenhrund, Institu-
tiones Practico-Medicae, t. iii. p. 459. — Duges, Sur l'Etat
Catarrhal. Rev. Med. t. iii. p. 210. 1825.— Macculloch, On
the Production and Propagation of Malaria, and the Dis-
eases occasioned by it. Svo. Lond. 1827.
CELLULAR TISSUE. Syn. Tela cellulosa,
Corpus cribrosum, Tela mucosa, Auct. Var.
Tissu Cellulaire, Fr. Tissu Muqueux, Bordeu.
Corps Cribleux, Fouquet. Reticular Membrane,
W. Hunter. Filamentous Tissue. Cellulo-fila-
mentous Substance. Its Diseases.
Alterations of the. Classif. Spe-
cial Pathology. — Morbid Structures.
1. A. The quantity of the cellular tissue varies
greatly in different constitutions, a large proportion
of the soft solids consisting of this structure, par-
ticularly in persons of a lax fibre and rounded
fleshy form. It is relatively more abundant in
the female than in the male ; in the young than
in the aged; in the sanguine, phlegmatic, or lym-
phatic temperaments, than in the melancholic ;
and in those who are fair, than in the dark com-
plexed and swarthy. It may be diminished, in
parts, from pressure ; or throughout the body,
from disease, or inanition. Long continued and
laborious exertions will also apparently lessen it;
or at least diminish its bulk, by causing the ab-
sorption of the serous and fatty matters deposited
in its areola? or interstices. It is remarkably in-
creased bv full and rich living, and by indolence;
but its bulk is then evidently, in a great measure,
owing to the general fulness of its minute vessels,
and to the greater proportion of fluid contained
in its interstices. Partial increase of this tissue
is also observed, but chiefly in consequence of
disease. It forms, in such cases, the basis of
various morbid growths, particularly encysted,
scrofulous, sarcomatous, and scirrhous tumours.
2. B. The consistence of the cellular tissue also
varies greatly. In some persons it is unusually lax
and extensible; in others, it is uncommonly dense
and tenacious. The slighter changes of consistence
are the result of original conformation, and of
age. It is usually more lax in females than
males, in the phlegmatic and lymphatic temper-
aments, than in the melancholic and bilious ;
and in very young persons, than in those of
mature or advanced age. The state of vital
energy also influences its consistence; for as the
powers of life are reduced by disease, &c. its cohe-
sion is proportionately lessened, and it becomes
more lax and inelastic. Changes of consistence
occurring in parts are chiefly the consequences of
inflammatory action. Continued pressure has the
effect of condensing it, and changing it from a
nearly semifluid state, into a fibrous, lamellatod,
und firm structure.
3. C. Inflammation of this tissue gives rise to
the most varied and important changes, according
to the vital energies of the frame, the state of
constitution, and habit of body, the nature of the
exciting causes, and the intensity of the disease.
In a previously healthy state of the system, and
when the exciting cause is not of a septic or poi-
sonous nature, the inflammation is usually of the
phlogistic or phlegmonous character, and its ex-
tension is limited by the formation of coagulable
lymph around the centre of the part inflamed;
and which, becoming condensed with the cellular
tissue exterior to it, forms a cyst for the enclosure
of the purulent matter which is usually formed
within the part, when the inflammation has pro-
ceeded to a certain height. (See Abscess, § 5.)
4. When the inflammation arises from septic
or poisonous animal secretions, or from the more
common causes of irritation, or of local injury
acting on an unhealthy habit of body, or during
unwholesome or epidemic states of the air, it as-
sumes a spreading or diffusive character. The
disease, however, may be spreading, without being
primarily diffusive ; for it sometimes commences in
a point or circumscribed spot, as in phlegmonous
inflammation ; and from the influence of certain
causes, hereafter to be noticed, coagulable lymph
is not formed so as to limit its extent, as in that form
of the disease, and it consequently spreads more or
less rapidly ; the part soon losing its vitality, and the
secretion from the affected vessels infiltrating and
contaminating the portions adjoining it, until ex-
tensive destruction and sphacelation of this tissue
takes place. The inflammation may, on the other
hand, owing to nearly the same causes, attack, al-
most coetaneously, a considerable extent of struc-
ture, and terminate either in the same way, or in a
manner nearly resembling it. Spreading inflam-
mation of the cellular tissue is generally the con-
sequence of external exciting causes, particularly
punctures, abrasions, wounds, fractures, &c. acting
upon a predisposed system, and more commonly
gives rise to a foul serous or sanious secretion, and
terminates in sphacelation or gangrene; whilst dif-
fusive inflammation is more usually produced by
internal causes, or such as affect the nervous or
constitutional powers previously to the develope-
ment of the disease in the cellular tissue; the secre-
tion which is formed in the part approaching more
nearly than that of the foregoing to a puriform
matter, and extending in various directions in the
course of this structure, under the integuments, &c
winch it but little affects. The former is often con-
nected with hospital gangrene, or is nearly allied
to it, as well as to various forms of foul spreading
ulceration; the latter is frequently an attendant
upon erysipelas, without, however, constituting
any of the states of that disease; and upon the in-
oculation of animal poisons, as in the dissection of
bodies recently dead of diseases.iii wliich the blood
and soft solids are more or less vitiated. (See
CellularTissue— Diffusive Inflammation of.)
5. Cellular tissue is also often the seat of
chronic inflammation, generally in circumscribed
parts, giving rise to cold or chronic abscess (see
Abscess, § 19.); or to certain manifestations of
scrofulous disease. In this state of inflammatory
action, gelatinous or albuminous fluids are com-
monly effused into the interstices of a greater or
less extent of this tissue ; imparting to it a stcollen
or hardened appearance; as in rheumatism, gout,
imperfectly cured erysipelas, pelagra, eleplianti-
CELLULAR TISSUE — Diffuse Inflammation of.
299
asis, and probably that peculiar affection denomi-
nated the induration of the cellular tissue of new-
born infants. Otto comprises also phlegmasia
dolens under the class of lesions of this tissue,
which arises from chronic inflammation; but we
have not sufficient evidence of this origin. In-
deed, facts, as far as they have been ascertained
regarding it, very conclusively show, that other
Structures besides this are affected at a very early
period of the progress of this disease.
6. D. Infiltrations, or effusions of fluids from
the circulating vessels, frequently take place in this
tissue, and constitute the prominent phenomena of
various diseases. Hamorrhagc sometimes occurs
in it, either from external injuries, or from internal
causes affecting the vitality of the system and the
States of the capillaries and circulating fluids.
When it originates in the latter source, the effused
blood is usually infiltrated into the interstices of
the structure in circumscribed spots, forming ec-
chvmoses, and sugillations, as in scurvy and pur-
pura hamiorrhagica, &c. When the haemorrhage
is extensive, it is commonly owing to the rupture
of an aneurismal vessel or varix. The infiltration
of serous fluids is very common, either in circum-
scribed parts {adema), or more or less generally,
although in different degrees, in the greater part
or the whole of the body (anasarca). This pre-
ternatural increase of the serosity usually moisten-
ing the cellular tissue is owing to various causes,
explained in the article Dropsy ; and cTiiefly
to increased exhalation, either from augmented
determination of the circulation, or deficient tone
of the exhalants, or both, — to impeded absorption,
either from obstructed circulation in the veins or
inactivity of the absorbents, — and to oppletion
of the vascular system by the serous or watery
Earts of the blood, from obstructed elimination
y the kidneys or by the respiratory and digestive
mucous surfaces, and by the skin. A general
state of very slight oedema, or an unusual fulness,
softness, and flaccidity of the cellular tissue, — a ]
condition obviously depending upon its laxity or !
deficient cohesion, conjoined with the presence j
of a greater proportion of watery fluid than in |
the healthy state, — not infrequently also is ob-
served, particularly in phlegmatic and lymphatic
constitutions. This has usually been termed leu-
cophlegmasia ; and although it may not amount '
to actual disease, yet it undoubtedly forms the
first stage of several slowly formed maladies, and ;
is usually attended with that state of the frame
described in the article Cachexy. It is of im-
portance to attend to the chief pathological rela-
tions of this state of the cellular tissue, as they
furnish useful indications respecting the nature
and treatment of various diseases with which it
is often connected. It commonly proceeds from
an originally weak conformation, subsequently
heightened by diminished vital power of the sys-
tem in general, and defective cohesion of this
tissue in particular.
7. The urinary secretion sometimes escapes
into the cellular structure, which it violently in-
flames ; the part thus infiltrated being usually
affected by the spreading form of the disease, and
the constitution thereby suffering most severely,
as in other cases of this state of inflammation.
This tissue is sometimes also infiltrated by aeriform
fluids, constituting the emphysema or pneumatosis
of authors. This species of infiltration arises either
from the escape of air into the cellular substance,
owing to laceration of some part of the respiratory
mucous membrane; or from a morbid secretion
by the vessels in certain advanced stages of dis-
ease, as in the last period of some forms of in-
flammation. (See art. Emphysema.)
8. E. The cellular tissue is also very frequently
the seat of a great variety of morbid growths,
and formations of a specific and malignant kind.
Amongst these, the most important are simple
serous cysts, hydatids, tubercles, melanosis, earthy
and bony concretions, the vascular sarcoma of
Abernethy, &c. These adventitious produc-
tions very often commence in some part or other
of this tissue, even when they are found in other
structures; the matrix, or medium of connection
furnished by it to other textures and organs, being
most frequently their point of origin. Certain
parasitic animals, especially the larvae of the
oestrus, filarice, and cysticerci, are also occasion-
ally met with in the cellular membrane. Changes
of colour are not unusual, most commonly in con-
sequence of biliary obstruction, giving rise to jaun-
dice; and of certain malignant fevers, when it is
either yellowish or yellowish green, and deficient
in its vital cohesion.
Cellular Tissue — Diffusive Inflam-
mation of the. Classif. III. Class,
I. Order (Author).
9. Defin. — Severe constitutional disturbance,
either preceding or following intense pain and
diffuse swelling of some part of the cellular tissue,
with rapid pulse and depressed vital poioer.
10. The parts of the cellular tissue chiefly
affected, according to Mr. Hunter and Dr.
Craigie, are those in which the adipose sub-
stance is most abundant. In respect, however,
of its seat and nature, this important malady has
been much misunderstood, owing to the circum-
stance of its most commonly occurring as a com-
plication with diseases of those structures, whose
anatomical connection with this tissue is extremely
intimate. Dr. Duncan, to whom we are in-
debted for the most comprehensive account of it
which has hitherto appeared, has erred in consid-
ering other maladies, thus contingently related to
it, as forming varieties of it, rather than as being
occasional complications with it. It is true, that,
while diffusive inflammation of the cellular struc-
ture arises primarily, constituting the only or prin-
cipal complaint, it is also associated (generally in
a secondary form, or in consequence of the exten-
sion, of inflammation from immediately adjoining
tissues) with inflammations of absorbing vessels
and glands, with phlebitis, with inflammation of
the fasciae, and most commonly with erysipelas;
these generally proceeding from the same causes,
and from similar states of constitution and vital
energy of the patient, as occasion it; and one or
other of these diseases often appearing simultane-
ously with it. But, when thus associated, it may
constitute either the least, or the most remarkable
part of the malady; and, therefore, in such cases
at least, can only be viewed as a more or less
important part of a complicated disease.
11. I. Causes. — A. The predisposing causes,
as far as they are ascertained, are epidemic states
of the atmosphere; impure conditions of the air
originating in local sources, particularly the foul
air of crowded or imperfectly ventilated hospitals
and apartments; morbid accumulations of bile in
300
CELLULAR TISSUE — Inflammation of— Symptoms.
the g;ill bladder and ducts, and of sordes, &c. in
the prima via; lowered vital power, from what-
ever cause; the use of unwholesome food, a ca-
chectic habit of body, and deranged state of the
digestive functions, or of the secretions.
B. The exciting causes are chiefly local injuries
and sprains, especially punctures and abrasions ;
venesection and the ligature of veins; the inocu-
lation of various animal poisons, generally of a
septic tendency; acrid substances, or vegetable or
animal matters in a state of disease or decomjwsi-
tion, applied to the cellular tissue; and even the
simple contact of morbid secretions and fluids with
any part of the body. The numerous instances
which occurred a few years since in Plymouth
Dock, and described by Dr. Butter and Mr.
Tritk, were chiefly referrible to epidemic or
endemic states of the air; were generally excited
by local injury ; and were complicated with
ervsipelas.
"12. II. Symptoms. — A. The local symptoms
are variously modified, according to the causes by
which the disease is produced, a. In some cases
it proceeds with very severe lesion of the part to
which the cause is applied, as when the fluids and
secretions of a diseased animal come in contact
with the skin, and give rise to the disease called
" pustule maligne^ by the French, or malignant
anthrax. In this case the morbid matter produces
a vesicle, from its effects on the rete mucosum,
followed by a tubercle, arising from the extension
of the inflammation to the true skin, whence it
penetrates to the subjacent cellular tissue. Its
progress then is very rapid and alarming. A
considerable swelling now extends to some dis-
tance, presenting a peculiar character. The sur-
face of the skin is shining, and the swelling is
elastic, diffused, and resisting, with a throbbing
pain and sense of heat, followed by a feeling of
torpor, tightness, and weight of the part. This
morbid state extends in all directions; and, upon
examination, excites a sensation between the soft-
ness of oedema and the elasticity of emphysema,
to which the terms boggy, or doughy, have been
applied. The central parts generally soon be-
come entirely deprived of life, and the mortifica-
tion glides below the skin, and destroys the cellu-
lar tissue all around ; the constitution being most
seriously affected. A nearly similar state of the
part primarily injured not infrequently follows the
application of various acrid matters, animal or
vegetable, directly to the cellular tissue itself.
Punctures, also, which penetrate as far as this
tissue, or mere abrasions of the cuticle, may also
occasion it; the chief difference being in respect
of the extent to which the skin is affected. In
some of such cases, particularly when punctures
are the cause, either with or without the applica-
tion of morbid matter, the skin is very slightly
diseased, although the cellular tissue is very ex-
tensively destroyed; whereas, in other instances,
especially when the cuticle is abraded, or when
acrid matter is applied externally to the skin, this
structure is very manifestly inflamed at the same
time, and the malady presents the characters of
erysipelas, complicated with this affection of the
cellular membrane.
13. b. When the disease arises from punctures,
mechanical injuries, chemical irritants, and some-
times from wounds received in dissection, the
constitutional disease is, as in the foregoing in-
stances (§ 12.), preceded by the local affection.
The mischief commences in the seat of injury,
and extends from thence to the trunk of the body,
and sometimes also in an opposite direction, with-
out leuving any interval apparently sound. The
progress of this variety diriers greatly in different
cases ; being in some confined to the limb, or
part of the limb, to which the cause is applied,
and in others proceeding rapidly to the trunk,
and terminating fatally. In a few of the in-
stances following vena-section, the puncture heals
as usual, and either remains permanently united,
or opens again, and gives vent to some purulent
matter; but more commonly union does not take
place; the lips of the incision remaining slightly
swollen, red, and everted. Some ichorous or
puriform discharge appears, and disease extends
continuously from the wound to the shoulder or
breast.
14. c. In the most dangerous form of the ma-
lady, as that consequent upon the inoculation of
a virus or morbid matter, a vesicle or pustule
forms in the part to which the poison is applied,
with very remarkable constitutional disturbance,
followed by severe diffusive inflammation of
some part of the cellular texture, generally on the
same side with that on which inoculation of the
disease took place, but at a distance from it, and
not continuously with the primary pustule. In
such cases, the manner in which the malady is
propagated from the local injury,— which is most
commonly in the fingers, — to the seat of the
diffusive inflammation, which is usually in some
part of the trunk, has not been satisfactorily
shown. It has been supposed to pass along the
absorbents, and, arriving at the axillary glands,
; to excite inflammation in them, extending to
the surrounding cellular tissue ; others have
thought that the process takes place along the
veins; but the accuracy of either of those views
has not been demonstrated by dissection, both
these sets of vessels having been found free from
disease in cases of this description. The history
of this most dangerous malady, and the nature of
the cause which excites it, render it more proba-
ble that the morbid impression is made upon the
organic nerves of the part, and that the frame is
soon generally affected, owing to the anatomical
and functional relations of this system of nerves;
the intimate connection of which with the blood-
vessels disposing the consecutive diffusive in-
flammation to appear on the same side with that
on which the morbid impression was first made.
The primary pustule is usually of very little ex-
tent or severity, often heals before the consecu-
tive inflammation takes place, and is evidently
the local effect of the virus upon the capillaries
of the part to which it was applied. But it is
quite insufficient to account. for the rapid and
violent constitutional disturbance which follows,
and which can only be explained by referring it
to the change produced by the morbid matter in
the organic system of nerves primarily, and con-
secutively in the vascular system, and in the blood
itself.
15. The chief and not infrequent illustration
of this form of the disease is furnished us in the
cases which follow punctures received on open-
ing recent subjects. In the course of ten or
twelve hours from the time of sustaining the in-
jury in the finger, ornomntil after five or seven
CELLULAR TISSUE — Inflammation of —Terminations.
301
days, the patient complains of rigors, remarkable
debilitv and Frequency of pulse, with sickness at
stomach', retchings, &e. A pustule appears in
the part, but not always ; and generally no con-
nection can be traced between it, even when it
is formed, and the diffusive inflammation which
takes place during the progress of the constitu-
tional affection. In some cases, a few red lines
may he traced, or swelling of the surrounding
part is observed ; hut neither advances any dis-
tance, the parts above being perfectly sound. In
the course of the violent fever induced by the
inoculation in the hand, the consecutive inflam-
mation usually appears in the axilla, and extends
towards the sternum, along the neck, down to
the loins or haunch, or even to the thigh of the
same side. In some instances, it terminates at
the mesial line ; in others, it passes continuously
to the other side. It occasionally is translated
from one side or part to the other, by a kind of
metastasis, as in gout or erysipelas.
16. The inflammation of the cellular tissue of
the trunk, whether arising from a continuous
extension of the disease from the arm, or part
originally affected, as in certain states of the dis-
ease (§ 12, 13.), or in the course of the constitu-
tional commotion (§ 14.) excited by the inocula-
tion of a morbid virus, always possesses peculiar
characteristics : it is diffuse or extensive, without
the smallest tendency to point ; being flatly ele-
vated above the sound parts, usually by a raised
or defined margin. It is smooth and equal, with-
out central hardness, and with all the characters
already noticed (§ 12.). In general, no cords,
which can be supposed to be diseased lymphatics,
veins, or arteries, can be traced under the surface,
and the glands are either very slightly or not at
all enlarged. The diffused swelling commonly
furnishes an obscure sense of fluctuation; but, fre-
quently, when punctures have been made into it,
little or no discharge has been procured.
17. The pain of the swollen part is most acute
in every instance, whether the swelling be in an
extremity, or extend along it to the trunk, or
commence in the trunk itself; and it is quite in-
dependent of whatever affection of the skin may
accompany the malady. In some cases, the in-
teguments present not the least redness, although
the cellular tissue has extensively suppurated, or
even sphacelated; but the skin is commonly more
or less affected, although in a secondary manner,
in consequence of the extension of disease from
the cellular tissue to it, and generally subsequent-
ly to the manifestation of acute pain. In the ad-
vanced stages, the skin has often a reddish or
pink coloured blush, and occasionally a mottled
or livid hue. In some cases, at a still further
advanced period, solitary vesicles form over the
diseased cellular tissue, and contain a serous, or
sero-sanguineous, or ichorous fluid. The tem-
perature of the part is sometimes much below
natural.
18. B. The febrile commotion, whether ap-
pearing consecutively of the diffuse inflammation,
directly produced in the part primarily injured,
or previously to the affection of the trunk, is of a
typhoid or adynamic type, and is accompanied
with the most marked disorder of the nervous
system, with anxious collapsed countenance, and
frequency of pulse ; more particularly when ex-
cited by the inoculation of a morbid matter, as
26
by wounds from dissecting recent subjects, and
when preceding the disease of the cellular tissue
of the trunk. The fever sometimes commences
insidiously, but more frequently in a very evident
or tumultuous manner. The pulse soon becomes
very quick, sharp, broad, soft, or compressible.
The patient lies in the supine posture, with de-
pressed shoulders, and without turning to either
side. Delirium is common, but it is generally
intermittent ; and profound coma Is rare. The
respiration always is quick, laborious, and pain-
ful, partly owing to the inff animation of the cel-
lular tissue of the side of the thorax, and its ex-
tension to the costal pleura. As the disease ad-
vances, the peculiar cadaverous fetor emitted by
the patient, the yellowish or lurid hue of the sur-
face, the offensive and sometimes coloured sweat,
which, in rare instances, proves critical, and the
tendency to ulceration in the parts pressed by the
weight of the body, show that the blood, the se-
cretions, mid the soft solids, are more or less con-
taminated. Towards a fatal close, the raving
delirium is often accompanied with muttering,
and starting of the tendons ; and alternated with
stupor ; the breathing becoming panting, labo-
rious, or interrupted.
19. The Terminations of the disease vary
with the exciting cause, the state of the patient's
constitution, and the part primarily affected.
When it arises from mechanical causes, as after
veneesection, simple puncture, &c, it may termi-
nate with spreading suppuration, which may or
may not be attended by sloughing of the cellular
structure : and this result may occur both in cases
which end fatally and in those that recover ; a
partial regeneration of this tissue taking place in
some of the latter. In the milder cases, the in-
flammatory action changes its character, and
shows a tendency to stop ; the disease terminat-
ing in phlegmonic suppuration and granulation.
If the cellular substance adjoining a serous mem-
brane become affected, this latter participates,
and the inflammation spreads rapidly over it,
generally producing an effusion of sanguineous
serum ; but sometimes, also, adhesion of the op-
posite surfaces. Occasionally the adjoining peri-
osteum becomes diseased, and even the cartilages
and bones denuded. A fatal termination occurs
either rapidly from the intensity of the disease,
or more slowly from some one of its sequela; :
and usually takes place, in the first instance, in
from four to fourteen days ; in the second, not
till after two or more weeks, or even longer ;
but the common period is from the sixth to the
tenth day.
20. III. Appearances on Dissection. —
Dr. Duncan has given a very minute and ac-
curate account of the successive changes that take
place in the diseased structure. As the malady
often attacks progressively various parts, it is
sometimes found after death, in all its stages, in
the same subject. In the part last affected,
which is frequently the space between the last
ribs and the os ilium, the cellular substance is
merely cedematous, with increased vascularity ;
the infiltrated fluid being either limpid or tinged
with red, and readily flowing from the divided
tissue. In a more advanced stage, the effused
matter is less fluid, often higher coloured, but not
yet puriform. The diseased structure is next
found gorged with a white semifluid matter,
302
CELLULAR TISSUE — Inflammation of — Diagnosis.
which greatly augments its thickness, separating
the particles of fat at a distance from each other,
but does not flow from the incision. In a subse-
quent stage, this matter is opaque, whitish, or
reddish, or greenish, but is now so fluid that it
flows from the incision. It is still, however, con-
tained in the cells of the tissue ; and it is only in
the last stage, and after the texture of the part is
entirely broken down, that this puriform matter
is met with in collections, mixed with portions of
the sloughy tissue. At this last stage the matter
is not circumscribed by any cyst, or defined cavi-
ty, but is gradually lost in the adjoining cellular
substance, without any line of demarcation. (See
art Abscess, § 15.)
21. The cellular tissue itself is usually gray or
ash coloured. It is detached extensively from
the textures it connects, or adheres to them and
the skin in sloughy shreds ; and long sinuous
cavities are found between the tendons or muscles.
The muscular structures adjoining are generally
more or less diseased, the inflammation extending
to their interfibrous cellular tissue ; which, how-
ever, does not appear to be alone affected, the
muscular fibres having their colour altered, and
being more easily torn than in health. As respects
the blood-vessels, the number of visible red ar-
teries is increased, and the veins are enlarged, and
turgid with black blood. Mr. J. Hunter states
that he found, " in all violent inflammations of
the cellular membrane, whether spontaneous or
the consequence of accident, that the coats of the
larger veins passing through the inflamed parts
became also considerably inflamed; and that their
inner surfaces take on the adhesive, suppurative,
and ulcerative inflammations ; for in such inflam-
mations, I have found in many places of the veins
adhesion, in others matter, and in others ulcera-
tion." (Trans, of Soc. for Improvement of
Med. Knowledge, 8vo. Lond. 1793. p. 18.)
22. The lymphatic vessels have not been suf-
ficiently examined. The axillary glands have,
however, been observed somewhat enlarged, and
embedded in the diseased cellular tissue. Dr.
Duncan states, that, although a tender and
swelled axillary gland has been frequently men-
tioned as one of the first symptoms observed, he
has never found them so much changed as at all
to support the idea that their affection was the
primary cause of the alteration of the surround-
ing parts. The state of the fascia has been very
generally overlooked in dissections of fatal cases
of this malady, as well, indeed, as that of the
blood-vessels and lymphatics ; but the fasciae,
tendinous expansions, sheaths of tendons, &c.
are not always unchanged, although they appear
not to have suffered in some instances. The skin
is often severely affected, but not essentially or
primarily, in the idiopathic form of diffused in-
flammation of the cellular texture.
23. IV. Diagnosis and Complications. —
a. Diffuse inflammation is readily distinguished
from phlegmonous inflammation of the cellular
tissue, by the circumscribed hardness of the latter,
by the elevation of the tumour, and its pointing
and becoming soft in the centre ; and especially
by the phlogistic character of the attendant fever,
which will also indicate the nature of the disease,
when phlegmonous inflammation is seated be-
neath fascia;. In the less severe cases of the dif-
fuse disease, particularly when it is principally
seated in those parts to which the exciting cause
has been directly applied, and when it has been
judiciously treated in the early stages, a disposi-
tion to pass into the phlegmonous state, by the
formation of coagulable lymph, and the limitation
thereby put to its extension, are very generally
observed. Indeed, this change of character con-
stitutes the favourable termination of the disease ;
although it may also occur as a complication in
unfavourable or even fatal cases, especially when
veins or fascia; are also affected.
24. b. Diffuse inflammation of the cellular
tissue is often consequent upon erysipelas, or
complicated with it, particularly the erysipelas
phlegmonodes; the difference between them con-
sisting in the circumstance of this tissue being
primarily and mainly affected in the former ; and
consecutively of the inflammation of the skin, in
the latter.
25. c. Inflamed veins may be distinguished
from this disease, when they can be felt stretch-
ing like cords in the direction of the swelling,
and when the pain and tenderness on pressure
are chiefly limited to the same line. There is
usually, also, little or no affection of the skin,
even secondarily, and the disease is generally
more confined to a limb ; fulness of the pectoral,
cervical, and lateral muscles and surface being
commonly wanting. (See Veins — Inflamma-
tion of.) When the tumefaction is very great, it
is extremely difficult to determine respecting the
affection or non-affection of the veins : the con-
secutive inflammation of these vessels, however,
and its complication with this disease, is very
common, as Mr. Hunter has so accurately stat-
ed, and more recent researches have confirmed.
26. d. The diagnosis between this malady and
inflamed lymphatics is also extremely difficult,
owing chiefly to the same cause, namely, to the
oedema and congestion of the surrounding and
distal cellular tissue consequent upon the obstruc-
tion of these vessels in the inflamed state. The
existence of superficial red streaks, not connected
with veins, running along an extremity from the
part where the exciting cause is supposed to
have been applied, and swelling of the lymphatic
glands to which they lead, are the only proofs
we usually possess of the lymphatics being dis-
eased ; and the absence of their appearance is
the chief evidence of their being unaffected.
But, as in cases of inflamed veins, diffuse in-
flammation of the cellular substance very gen-
erally follows inflammation of the absorbents, as
satisfactorily shown by Abernetht, James,
Duncan, and Breschet. The difficulty of
diagnosis, however, in a great proportion of
cases, excepting at their commencement, must
be evidently owing to the very sufficient reason
of their co-existence.
27. e. The same circumstance also explains
the difficulty sometimes found of distinguishing
the disease from inflammation of the fascia; for in
the majority of instances, the affection commences
in the cellular tissue, and extends to the fascia,
this latter, structure being very rarely inflamed
primarily, unless after it has experienced some ex-
ternal injury. Even when the fascia is primarily
inflamed, it will not be possible, on some occa-
sions, to form an accurate diagnosis, as disease
commonly extends theuce to the cellular tissue
on each side of it. W*hen the fascia is affected,
CELLULAR TISSUE — Inflammation of — Pathological Inferences. 303
■ither primarily or consecutively, contraction of
the limb is generally occasioned: but this is in-
Bufficienl evidence of inflammation of the fascia,
as inflammation ami distension of the parts in-
cloaed by it will produce this effect. When the
disease commences in the cellular tissue, and ex-
tends to that portion enclosed by fascia, or to this
structure itself, the skin is often unaltered even in
colour. In a most severe case, attended by Mr.
PaRKJEB and myself, the whole leg and thigh,
to far above the hip, were affected, and the limb
contracted, and yet the skin was natural. The
inflammation may, however, originate in the
skin, extend to the subjacent cellular tissue, thence
to the fascia, and, ultimately, to the cellular tis-
sue beneath it; forming an important variety of
erysipelas, well described by Mr. Copland
lb rcHisoN, and constituting the triple compli-
cation of diffuse inflammation of the cellular sub-
atance with that of the skin on the one side, and
willi that of the fascia on the other, the first being
most extensively and destructively diseased. The
local and constitutional suffering in such cases
chiefly arise from the pressure made by the fascia
upon the inflamed and tumid cellular tissue under-
neath it.
28. /. Whilst it is important to distinguish be-
tween injury or inflammation of a nerve, and this
malady, it must not be overlooked that the one is
often associated with the other; priority of affec-
tion in respect of either being the chief object of
diagnosis. When, after a puncture or other local
cause, very acute pain is complained of, particu-
larly in the situation and the course of a nerve,
with severe or obstinate symptoms of great ner-
vous irritation, convulsions, &c. accompanying it,
we may conclude that the disorder has originated
in a nerve; and, if to those symptoms are added
the diffuse, boggy swelling, &c. already described
(§ 12.), we may likewise infer that dilluse in-
flammation has subsequently attacked the cellular
tissue.
29. g. I have met with some instances of dif-
fuse inflammation of the cellular tissue as a com-
plication and termination of several severe or fatal
states of disease in the puerperal slate, both with
and without affection of the skin; but only in the
wards of a lying-in hospital. They have appear-
ed hi two forms: 1st, In the advanced progress
of asthenic inflammation of the uterus, attended
with an excoriating and foetid discharge, which
has first irritated the skin about the nates, — the
cellular tissue underneath becoming diffusely in-
flamed to a great extent, and destroyed; and, 2d,
After cases of inflammation of the uterine veins,
evidently in consequence of the vitiation of the
circulating fluid. Dr. Otto, Dr. Duncan, and
Dr. Craioie, refer phlegmasia dolens to diffuse
inflammation of the cellular substance. But, I
think, on insufficient evidence. If this tissue be
really inflamed in that disease, other structures
participate; and it certainly is not the part first
affected. In the cases which I have seen exam-
ined after death, — only three in all, — the nerves
and veins were the parts to which the symptoms
of disorder were first referred; the veins being
obstructed in all the cases. (See Phlegmasia
Dolens.)
30. h. The cellular tissue of the side of the
neck and throat is sometimes diffusely inflamed,
apparently from an extension of disease, in an-
gina maligna, and worst form of scarlet fever, the
patient sinking from it rapidly. 1 have, however,
met with one case of this description, where re-
covery ultimately took place. This disease also
rarely occurs near the anus, or about the buttock
and perinirum, in the course of fevers, dysentery,
&c. But it is more disposed, on these occasions,
to limit itself, and to terminate in suppurating ab-
scesses. When it occurs in aged persons, from
the escape of urine into this tissue, it generally
extends rapidly and terminates fatally; and a
nearly similar result follows its appearance after
important surgical operations, as after lithotomy,
amputations, and the ligatures of veins and arte-
ries for aneurismal dilatations of them.
31. V. Pathological Inferences. —
a. Conformably with recently accumulated facts
connected with diffusive inflammation of the cel-
lular tissue, it may be concluded that it presents
various morbid associations and grades of intensity,
as well as distinct relations to the attendant con-
stitutional disturbance, according to the diversified
causes which occasion it: — 1st, That depressed
vital power, or a previously disordered state of
the chylopoietic viscera, or general cachexy, is
often requisite to its occurrence : 2d, That abra-
sions, the irritation of acrid secretions or decom-
posed animal or vegetable matter, simple punc-
tures, injuries received during the dissection of
subjects in a state of incipient decay, and the con-
tact of morbid fluids, most commonly produce the
disease primarily in the part in which the injury
is sustained, the mischief spreading continuously
from thence; although occasionally appearing af-
terwards in other parts, without any continuous
connection, when the circulation has become con-
taminated by the primary affection : 3d, That,
when originating and spreading as now stated,
sometimes the skin, at other times the veins, occa-
sionally the lymphatics, on some occasions the
thecae or fascia?, and more rarely the voluntary
nerves, or any two or more of these, participate
more or less in the disease : 4th, There appear to
be other causes, wliich, acting in the manner of
specific poisons, produce comparatively but little
effect on the part to which they are directly ap-
plied; but which affect the system universally,
chiefly by depressing and otherwise changing the
organic, nervous, and circulating functions, the
alteration of the cellular tissue appearing subse-
quently: 5th, That the local affection in this form
of disease, which may be denominated consecu-
tive diffusive inflammation of the cellular tissue,
is often of very small extent compared with the
severity of the constitutional disturbance; and,
very frequently, appearances of contamination of
the frame present themselves before the cellular
tissue is affected, and even then the affection may
be trilling, or even not recognisable (see Poisons
— Animal.): 6th, That the malady originating in
the inoculation of a poison or virus, particularly
dining the examination of recently dead bodies,
cannot be ascribed to inflammation of veins, or
of lymphatics, or of nerves, or of fasciae, or even
of the cellular tissue itself; and that, although this
last most frequently exhibits morbid appearances,
yet are these appearances obviously contingent
upon general disease of the frame, interesting in a
special manner its various vital manifestations.
(See Author, in Load. Med. Repos. vol. xx. p.
24. 1S23.)
304
CELLULAR TISSUE — Inflammation of — Treatment.
32. b. As respects the association of the local
and constitutional affection, all the eases of this
disease maybe divided into two classes: — 1st,
Those in which the constitutional disturbance is
mainly owing to the primary local lesion, or its
extension, whether it be inflammation of the cel-
lular tissue alone, or of this tissue associated with
inflammation either of veins, lymphatics, thecee,
aponeuroses, or of the skin; the relation subsist-
ing between the intensity of the primary local af-
fection, and the constitutional disorder, being
more or less apparent and co-ordinate (§ 12, 13.) :
2d, Those in which the local lesion is obviously
the least important change that has been induced,
either directly by the exciting cause, or consecu-
tively by the constitutional affection; and, even
when it becomes the most serious, is manifestly
the result of the constitutional affection (§ 14.),
and disproportioned to it. Thus the local and
the general symptoms are presented to us in a
different order in these two forms of the disease.
In the first, also, the febrile action is more in-
flammatory than in the second, but still partaking
of the irritative character, as has been very justly
insisted upon by Mr. Travers. In the second,
it is more asthenic; the nervous system is much
more disordered; the anxiety, distress, and men-
tal and physical depression, are greater than in
the first; and all the organic functions more
gravely affected; the blood, the secretions, and
soft solids, becoming at last very evidently alter-
ed.* (See Blood, § 139. et seq.)
33. VI. Prognosis. — The danger of this dis-
ease is much less when it is accompanied with
inflammatory, than with adynamic or highly irri-
tative fever, and morbidly excited sensibility. In
general, the rapid extension of the disease from
the arm to the trunk; great tumefaction of the
region of the pectoral muscles; the first appear-
ance of the inflammation in this situation, or in
any part of the trunk, from causes which first
occasioned serious constitutional disturbance; re-
markable frequency of pulse following rigors,
with anxious collapsed countenance, ferrety eyes,
delirium, difficult respiration, depression of mind,
the accession of fresh rigors, extreme debility,
and stupor; are all indications of great danger.
The nature of the cause, also, should influence
the prognosis. When it proceeds from the liga-
ture of a vein, venisection, and particularly from
wounds in dissecting recent subjects, the danger
is great. There is, however, less risk when the
disease arises in the part to which the cause has
been applied, and when the skin becomes much
affected with a disposition of , the inflammation to
* It may be stated at this place, that the disease which
has been observed to follow inoculation of an animal poison
during the examination of recent subjects is obviously dis-
tinct from diffuse inflammation of the cellular tissue, al-
though this local affection, or some modification of it, often
takes place in the advanced stage of that disease, which has
accordingly been referred to in this article as one of the
chief causes of the lesion now under consideration. The
subject is, however, considered more fully in the article on
POISONS. In justice to myself, I should state, that I pub-
lished, in the London Medical Repository for Juhj, 1823, p.
24 — 27., some remarks on the nature of the maladv infected
by inoculation from recent subjects, and the operation of ani-
mal poisons on the economy; and I request the favour of the
reader who is interested in these important subjects to refer to
these remarks, and to the conclusions, to which Mr. Travers
has come, in his work on Constitutional Irritation, p. 413.
Lond. 1826.
limit itself, and form healthy pus, than when it
appears consecutively of a pustule merely in the
part inoculated, and of fever with extreme de-
pression.
32. VII. Treatment. — A. Prophylaxis. Pre-
cautions are absolutely requisite when punctures
are received in post mortem examinations, or
when the cuticle about the nails and hands of the
examiner is abraded. Some constitutions are
more liable to be inoculated in this way than
others, particularly persons who are out of health
at the time, or whose vital energies are depressed.
Wearing gloves during a morbid dissection may
be of use in such circumstances. Dr. Duncan
suggests the anointing of the hands with cam-
phorated oil, or with simple axunge, before
handling the viscera. Abrasions about the fin-
gers should be protected by adhesive plaster. If,
notwithstanding, punctures are received, or if an
abraded or punctured part come in contact with
any of the fluids or soft solids of a recently dead
body, with animal or vegetable matter in a state
of decomposition, with acrid or morbid secretions,
suction or perfect ablution of the part ought in-
stantly to be performed; a pledget of lint, wet
with either a strong solution, or the oil, of cam-
phor (F. 449.), or with turpentine, applied to it,
and the application covered so as to prevent its
quick evaporation. On the several occasions of
the employment of these means, in the persons
both of myself and of my medical friends, no dis-
turbance has accrued from these accidents. Two
partial exceptions, however, have occurred, but
in such a way as to confirm the propriety of this
practice, and illustrate the nature of one form of
the disease. The punctures, in these two cases,
were received when examining the bodies of fe-
males who had, but a few hours previously, died
of malignant puerperal fever; and the application
was not resorted to until after leaving the apart-
ment where the inspection was made. In one
of those cases, — that of a pupil, — camphor was
used; in the other, — that of my friend, Mr.
Churchill, — ammonia was employed. Both
these gentlemen experienced, within twenty-four
hours afterwards, considerable general disturb-
ance, with sickness at the stomach, and nervous
depression and debility. Al] disorder, however,
disappeared in a day or two after the exhibition
of warm diaphoretics and stimulants; but in
neither case was the least irritation observed in
the part punctured. The morbid impression was
evidently made upon the organic nervous sys-
tem, as evinced by disorder of the functions more
immediately dependent on it; but was not so in-
tense, relatively to the state of predisposition, as
to occasion further disease. As to the use of
ligatures, &c, 1 must refer the .reader to what I
have stated respecting them in the article on Ani-
mal Poisons.
35. B. Curative treatment. — a. It will be evi-
dent, from the history of diffusive inflammation
of the cellular tissue, that local means are chiefly
applicable to certain of its states and complica-
tions. When the primary local affection is at-
tended by much pain, both cold anil warm ap-
plications have been recommended by different
writers. The choice, however, between them, may
be determined by the sensations of the patient :
but warm fomentations, unremittingly employed,
appear to me the safest, particularly when inilam-
CELLULAR TISSUE — Inflammation or — Treatment.
305
mation is externally apparent. When the local
affection B limited chierly to the part to which
the Cause was applied, or its vicinity, the detrac-
tion of blood from it by leeches or scarifications,
and incisions through the integuments, ought not
to be neglected. The latter of these two modes
of local evacuation, as first recommended by Mr.
Copland Hutchison, is evidently the most
beneficial, not merely by procuring a more decid-
ed and rapid discharge, but also by giving an ex-
ternal outlet to the matter which otherwise would
infiltrate the cellular tissue, and extend the mis-
chief. Even in cases of great vital depression,
and when the cellular tissue is consecutively dis-
eased, incisions should not be neglected ; they
being compatible equally with an energetic, tonic,
or stimulating treatment, as with its opposite: and
they are not the less necessary in the early stages
than at later periods, and when fluid is diffused
through the cellular structure. When the part
affected is deeply seated, they should be deep and
large, so as fully to reach it ; their number being
proportionately diminished. But the great object
is to make a free passage for whatever fluid mat-
ter may have formed, or that will form subse-
quently. This practice has received the appro-
bation of Dr. Duncan, and the best recent wri-
ters on this disease; and its propriety has satisfac-
torily been shown in those cases which have fallen
under my own observation.
34. b. The general means of cure are usually
directed with the intention of subduing the local
affection, and more especially the state of high
nervous sensibility and vascular irritability which
exists, whether this state be consequent upon the
primary lesion produced by the exciting cause,
or whether it be the immediate effect of that
cause, ami the antecedent of any affection of the
cellular tissue, as in cases of inoculation by mor-
bid matters or animal poisons. But, although
this intention is generally kept in view, very dif-
ferent, and even opposite, measures have been
recommended for fulfilling it. It is evident that
the same measures are not suitable to all states
and periods of the disease ; and possibly to this
cause may be imputed the great diversity of
means which have been advised, and the partial
success attributed to very opposite methods.
Much also is owing, more generally than has
been admitted, to the constitutional powers of
the patient. A number of practitioners and wri-
ters advocate general blood-letting, and trust
chiefly to it for the fulfilment of the above inten-
tions, without adverting to the fact, that the mor-
bid states forming the essential characters of the
disease are, in their severest and most deadly
forms, independent pf sthenic action, and cannot
be either limited or subdued by venisection, al-
though it may be required to a moderate extent ;
particularly when the local affection arises prima-
rily and directly from the exciting cause, impli-
cates any of the parts which I have noticed as
being involved in its complicated forms, and is
chiefly antecedent of the grave constitutional dis-
turbance characterising the advanced stag's of
disease. But even in such cases, the depletion
should be practised early, and confined chierly to
young, plethoric, or robust persons ; the local
evacuation consequent upon free incisions being
sufficient in most cases. In other respects, the
treatment in this form of the disease may be sim-
26 *
ilar to that recommended in inflammation of the
veins ; for the principle acted upon by Mr. John
Hunter in respect of that malady, and which is
founded in accurate observation, is equally appli-
cable to this — namely, to impart energy to the
system, so as to enable the vessels to form coagu-
lable lymph, by which the extension of the mor-
bid action may be limited, and a diffusive or
spreading inflammation may be converted into
the phlegmonous state. This practice is still
more imperatively required in the other form of
the disease, or that in which the affection of the
cellular tissue is consecutive of a constitutional
disturbance, excited by a morbid virus or animal
poison.
35. The frequent inefficacy of depletions and
the antiphlogistic treatment, and even their in-
jurious effects, as shown by the rapid sinking
consequent upon them, are fully demonstrated by
the history, given by Dr. Butter, of the disease
which occurred in Plymouth Dock, and by the
cases after wounds in dissection recorded by va-
rious writers. The instances of recovery after
this practice cannot be brought as evidence of its
efficacy ; inasmuch as the stuallness of their num-
ber ; the tonic treatment, which, in several of
them, followed vascular depletions; and constitu-
tional energy ; may be adduced to disprove it.
After studying the cases which have been pub-
lished by Dr. Duncan, Dr. Colles, Mr. Tra-
vers, Dr. Dease, Dr. Butter, &c, and re-
flecting on my own limited experience, I would
strenuously recommend the following measures,
in addition to those already advised : — As to the
question of blood-letting, that is already disposed
of ; but I may further add respecting it, that,
however great the severity of the pain, or the
sensorial excitement; or however frequent, open,
sharp, or bounding the pulse ; these symptoms
should be arguments against, rather tlKin in fa-
vour of venisection. But if the pulse be not re-
markably frequent, or if it be firm and constricted,
then this operation ought to be performed. Yet
I should expect little or no advantage from this
practice, in those cases of the disease which pro-
ceed from the inoculation of putrid or morbid
animal matters or poisons, whatever the charac-
ter of the pulse may be. It is, however, seldom
such as can warrant depletion in these cases ;
being generally of the former description, and
rarely of the latter. The object which we should
propose to accomplish, next to that already stated,
is to rouse and support the energies of life, and
thus to oppose to the extension of the disease an
augmented vital resistance. This can be done
only by a stimulating and tonic treatment, and by
the expulsion from the frame of such impurities
and morbid matters as may tend to impede the
natural functions, and depress their energies. The
means which we should employ with these views,
if judiciously selected, will be more efficacious
than any other for the fulfilment of the intention
proposed above (§ 34.). The agents which I
have found most successful in attaining them, are
large doses of camphor, with opium, sometimes
also with calomel, and the occasional exhibition
of spirits of turpentine, either alone or with castor
oil. and of one of the enemata (F. 148, 149.)
contained in the Appendix. The plan I have fol-
lowed in several cases of this disease, mostly of a
more or less complicated nature, which I have
306
CELLULAR TISSUE — Induration of.
treated, has been to give the following bolus, or
the pills first prescribed; and a few hours after-
wards the draught, which, in three or four hours,
should be followed by an enema (F. 151.): —
No. 104. R Camphor* ras* gr. x. — xv. ; Hydrarg. Sub-
mur. gr.x.-xx.; Opii Puri gr. jss.-ij.; Pulv. Capsici
gr. iv. ; Conserv. Rosar. q. s. ut fiat Bolus, statim sumendus,
et horas post tres vel quatuor repetendus.
No. 105. R Camphor* ras* gr. v.j.-xn.; Amnion
Carbon, gr. xv. ; Hvdrarg. Submur. gr xx ; Pulv. Capaici
Aonui gr". viii. Opii Puri gr. iij. ; Muc.lag. Acacwq.s.
ut Bant Pilul. xij., quarum capiat b.nas omn, ho, a vel
'n"o'°'iOB. R Olei Terebinthin* ^sS.— ^j. (vel etiam
Olei Rictoi 5ss.)i Olei Cajeput* V\ vj. ; Lact.s Recentis
5 ij. Fiat Haustus.
36 If a free evacuation of the bowels be pro-
cured, the bolus and draught should not be re-
peated more than once; if the evacuation be scan-
ty, they may be given a third time, having pro-
longed the period between the second and third
doses; in the intervals between which, as well as
subsequently, the following pills and draughts
may be taken : —
No. 107. R Camphor* ras* gr. iij. — v. ; Amnion. Car-
bon, gr. iv. ; Pulv. Capsici gr. j. ; Mucilag. Acacia- q. s ftt.
Fiant Pilul* ij., secunda, tenia, vel quarla quaque hora
auinend*, cum Haustu sequente.
\o 108. II Mist. Camphor* §].; Liq. Ammon. Acet.
*iss. : Spirit. iEther. Sulphurici Comp. 3j. i Jmct. Cap-
sici Annul TTJ x. ; Syrup. Aurantii ".ss M. Fiat Haustus,
cum Pil. supra prescript* capiendus : vel.
No. 109. R Infus. Cinchona: U • ^"\- Amnion. Acet.
7ii. : Spirit. Amnion. Arom. 5*>. ; Tinct. Capsici "| XI • ',
Olei Ca.eput* 1TJ vj. M. Fiat Haustus, ut supra sumendus.
37. In the slighter cases, less active means will
be found sufficient; but when the disease assumes
a serious form, and particularly if the constitu-
tional symptoms manifest themselves before the
affection of the cellular tissue has commenced or
made any sensible progress, the above or similarly
active remedies must be energetically prescribed.
38. During the course of the more adynamic
states of the malady, after alvine evacuations
have been procured, I have seen the best effects
follow the liberal use of wine, and large doses of
bark with the aromatic spices. If the tongue and
mouth be parched, the pills or bolus, and the tur-
pentine draught, prescribed above, should precede
the exhibition of the wine, bark, or sulphate ot
quinine. The irritability of the stomach and de-
lirium, often accompanying the advanced stage of
the worst states of the disease, being more readily
allayed by powerful stimuli, as camphor, capsi-
eum, ammonia, ether, spirits of turpentine, ca]e-
put and other essential oils, wine, bark, sulphate ;
of quinine, brisk bottled ale and stout, very small j
doses of opium, brandy, &c, than by medicines
of any other description, it will be necessary to |
administer these, in forms of combination suited
to the circumstances of the case ; chiefly with
the view of rousing and supporting the energies
of life, changing the state of morbid action, and
thereby preventing the extension of the local
mischief, and the tendency to contamination of
the fluids and solids of the frame. The regimen
during the treatment should be in accordance
with these intentions, and the patient should be
allowed what he may crave for ; as desire in
Bach cases for articles of food, or for particular
beverages, is the instinctive expression of the
wants of the economy.
BlBLIOG. AND REFER.— Morrmd, Hist, de PAraoVmie
Rov. des Sciences, An. 1766.- J. Hunter, Med. and Philos.
Comment, vol. ii. p 430. Svo ed. 1775. ; and Trans of Soc.
for Improvement of Med. Knowledge. Lond. 17 JJ. WXl-
ton and Wills, Ibid. vol. iii. pp. 360 367. - C. Smyth,
Med. Communications, kc. vol. II. p. 190. Lond. 1790.—
Voiles On Wounds received in Dissection, Dub. Hosp. Re-
ports, vol. iii. p. 200. ; et Ibid. vol. iv. p. 240 -Dense, «n
fedin. Med. and Surg. Journ. July, 1826,— JTuemcffl, in
[hid. Julv, 1825.— Duncan, Trans, ot" Med. and Cnirure.
Soc. of fedin. vol. i. p. 470. - Hirissi, in Journ de Me_d.
kc t xii. p. 417. Paris. 1806. — Home, Philos. Trans, for
1810 p 75. —James, On the Nature and Treatment of In-
flam. &c. 8vo. Lond. 1821. — A. C. Hutchison, Trans, of
Med. andChirurg. Soc. vol. v. p. 280. - Trovers, On .Con-
stitutional Irritation, 2d ed. 8vo. Lond. 1827.; in Lond.
Med. and Phvs. Journ. Feb. 1823, p. 176. — Burlo-J,, in
Ibid. Aug. 1823, p. 177. — Rust's Magazin fur die Oesam-
mte Heilk. b. xiv. p. 100.—-fVansborou?h, in Lond. Med.
Repos. Mav, 1823, p. 353. — Author, Ibid. vol. xx p 24.
-Wo, in Med. and Phvs. Journ. Ap. 1825, and Feb.
1827 — Velson, in Ibid. Aug. 1823. — Thomson, in Ibid.
\p. 1325. — Forbes, in Ibid. July, 1826. — Earle, in Ibid.
Jan. 1827. — Butter, On Irritative Fever, &c. 8vo. 1825.
— Craigie, Gen. and Path. Anatomy, Svo. p. 34.
Cellular Tissue — Induration of.
Syn. (Edematie concrete, Billard. ScUreme,
Chaussier. Squirrho-Sarque, Beaumes. Skin-
bound.
Classif. III. Class, I. Order (Author).
1. Defin. A wax-like consistence of the
skin and sub-cutaneous cellular tissue, commenc-
ing in the hands, face, and lower extremities —
the parts most remote from the centre of the cir-
culation; often extending to the trunk, the parts
being cold, often pale, yellowish, or rose-colour-
ed, frequently mottled, or livid, with u-eak pulse
and respiration, terminating in congestion of
the lungs and asphyxy.
2. This affection was first 'described, in 1/IS,
by J. A. Uzembezh's, physician to the hospital
atUlm, and afterwards more fully investigated
by Doublet, Andry, Auvity, Hulme, Den-
man, and Underwood, as well as by several
contemporary writers. It is very prevalent and
fatal in some of the lying-in and foundling hospit-
als on the Continent/but is comparatively rare in
this country, especially during recent times. Its
nature and seat have been much discussed by
foreign medical writers; and even at present, va-
rious" points connected with its pathology are not
fully established. It is, however, evident that
the" disease assumes various forms, and exhibits
different morbid relations, which may be referred
to the two following varieties.
Var. i. (Edematous Hardening of the Cellular
Tissue; ScUreme ademateux, Chaussier
and Dugf.s.
3. In this form of the disease, the sub-cuta-
neous cellular tissue is infiltrated with a yellowish
coao-ulable albuminous serum; the limbs of the
infant are more or less tumefied as well as hard,
are somewhat rigid, and the skin assumes a vio-
let tint owing to the pulmonary congestion ac-
companying it; with weak oppressed respiration,
and feeble irregular pulse. • In some cases it
commences with simple oedema, particularly when
it arises from exposure to cold. If the cold have
acted upon the greater part or whole of the sur-
face of the body, the affection is sometimes more
or less universal, but usually most remarkable in
the limbs. It rarely attacks the abdomen, chest,
and neck. The parts diseased are cold, tumid,
discoloured, insensible, hard, and receiving and
preserving the impression of the ringer when very
firmly applied. During the progress ot the affec-
tion, the crv becomes very weak and peculiar,
dyspnoea increases; the thorax is dull on per-
cussion ; and the impulsCof the heart, and the
respiratory murmur, are found weak on ausculta-
CELLULAR TISSUE — Induration of— Causes.
307
tion. De^tli often follows in from four to eight fluence of cold upon new-born infants, and gen-
days, without any convulsion, hut generally pre- erally occurs from the second to the fourteenth
cederf by a letfiargic somnolency; and spasmodic day from birth. Imperfect or anwholesome
attacks resembling slight trismus, and opisthotonos nourishment, and the influence of a vitiated at-
sometimes occur in the advanced stage. The in- mosphere, particularly the air of crowded hospit-
dorated parts occasionally assume an erysipelatous ids, upon the imperfectly developed respiratory
appearance, and, in rare instances, pass into spha- functions, are, in my opinion, amongst its most
celation. In favourable cases, or after an early energetic causes. It is very apt to occur in pre-
and judicious treatment, the affection subsides; the maturely born infants, in those of a feeble con-
hardness, and afterwards the oedema, disappearing stitution, and who are deprived of the mother's
in the course of two or three weeks. M. Gar- or nurse's milk. M. Palletta remarks, that
DIEN states, that he observed suppuration of the out of sixty-five cases, forty were prematurely
affected part to occur in one case only. born. M. Ratier states, that its dependence
Var. ii. Induration affecting chiefly the Adipose upon atmospheric cold is shown by the greater
Tissue; Sclereme concret, Chaussier, number of cases at the Hospice des Enfans
Duces; Skin-bound, of English authors. Trouves, when winter sets in. But as a free
4. This variety generally depends upon the ventilation, and dissipation of the foul air of an
sudden impression of severe cold ; is compara- hospital ward, are in some measure prevented
lively rare, and is chiefly met with in lying-in and during cold weather, the prevalence of the dis-
fbnndling hospitals. The cheeks, limbs, fori- ease at this season may be equally owing to this
arms, thighs, hack, abdomen, chest, and neck, circumstance. M. Billard has shown that the
successively, or two or more of them simultane- number of cases in the warm months is usually
ously, assume a remarkable hardness, which not much less than in the cold, in the above-
yields not to the pressure of the finger. The named hospital. Dr. Bigeschi, however, states
temperature and sensibility of the surface are a fact, in his report of the Lying-in Hospital at
much depressed; and with difficulty raised. The Florence, which shows the great influence of cold
skin is pale or yellowish, and wax-like; some- in causing this affection. He observed the disease
times livid or mottled. Trismus and opisthotonos very prevalent during the winter season, especially
are more common in this, than in the precwffng if rigorous; and he consequently ordered the in-
vaiiety. There is little or no tumefaction or fant to be kept in the mother's bed, as warm as
oedema; the skin being fixed and immoveable possible; and from that time no case of it occurred,
upon the subjacent parts. In some instances, the M. Souville has met with the disease frequently
extremities and back are somewhat emaciated, in the northern departments of France, and also
dry, and even rigid, particularly in the advanced attributes it chiefly to cold, the influence of which
stage; and the cheeks find temples are collapsed, is likewise admitted by Palletta. It some-
At the commencement, the appetite and digestion times, also, occurs in the course of the bowel
are often not much affected; but during the pro- complaints incidental to infants, particularly when
gress, and towards the close of the disease, the improperly nourished; and it is frequently com-
bowels become more or less disordered. Dr. plicated with the jaundice of this epoch. M. Bil-
Denman and Dr. Underwood seldom met
with it but accompanied with some bowel com-
plaint. The infant soon becomes too feeble to
draw the breast ; it utters a peculiar moaning
noise, or feeble whining cry; and has the ap-
lard states that, in seventy-seven cases with
cedematous induration, thirty were jaundiced.
7. B. Appearances in fatal cases. — In the first
or most common variety, the cellular tissue is
found loaded by a thick albuminous serum, which
pearance, even early in the complaint, of dying; coagulates by heat, and which, according to M.
and, at last, sinks apparently asphvxied. In Leger and M. Billard, partly escapes upon
favourable cases, the skin and extremities lose dividing it. Dr. Palletta, however, states that,
their hardness and rigidity, and the infant re- upon division, it remains firm and concrete, the
covers gradually, if pulmonic inflammation does infiltrated matter not escaping. In the second or
not come on, and carry it oft*. Inflammation of more rare form of the affection, the cellular and
the indurated parts seldom or never appears in adipose tissues are hard, concrete, and frequently
the course of this variety. of a deep yellow colour. The adipose tissue often
5. Pathology. — M. Gardien states, that he presents a number of small dark yellow grains
has sometimes remarked a slight increase of heat dispersed through it. The lymphatic glands, as
precede the insensibility, coldness, and hardness well as the mesenteric glands, are enlarged ; and
of the parts affected ; but without any general slight serous or sero-albuminous deposition into
febrile symptoms. The only indications of dis- the cellular tissue is observed throughout the
order he has observed to usher in either variety, body, with sanguineous or sero-sanguineous iiifil-
are difficulty of respiration, and a peculiar feeble- tration of parts of it; and etl'usion into the shut
ness of the pulse and of the voice. Somnolency cavities. The vessels of the brain are usually
or lethargy is very usual during the course of the congested. The cavities of the heart are loaded
disease, and, as M. Doublet observes; increases with blood; the foramen ovale is sometimes more
towards a fatal termination. The affection, par- open than it should be; the pericardium contains,
ticularly the latter variety, is rarely congenital, some sanguineous serum ; the lungs are often
M. DuparCO.ue has detailed two cases in which congested or hepatised ; and the larynx and
tin? infant upon delivery was so hard and rigid as epiglottis cedematous. The liver is frequently
to resemble a mummy, the vessels of the umbili- large and congested ; the gall-bladder and he-
cal cord being diseased. patio ducts full of bile; and the gastro-iotestinaJ
6. A. I'auses. — The different states of fins mucous surf ice more or less inflamed. The most
di-rasr have been attributed to a syphilitic taint, constant morbid appearances are the engorgement
It is, however, most commonly owing to the in- of the venous system; the dark or black state of
303
CELLULAR TISSUE — Induration of — Treatment.
the blood; the accumulation of a thick, deep-
coloured, viscid, or coagulated fluid in the adi-
pose and cellular tissues, imparting to them a
condensed or firm appearance; and the conges-
tion of the thoracic viscera : but these latter are
commonly not otherwise diseased.
8. C. Proximate Cause. — The first variety of
this affection may be considered as a form of
oedema; the peculiarity resulting chiefly from the
thick, coagulable nature of the effused fluid, and
the deficient developement of animal heat in parts
far removed from the centre of the circulation ; in
consequence of which the adipose matter either
is secreted in a morbid state, or cannot be pre-
served in its natural semifluidity. The second or
more rare form of the affection is chiefly to be
attributed to this change of the adipose substance,
which, owing to defective vital manifestation in
the part, and the depressed grade of animal
warmth, assumes the condition which it usually
presents soon after death. M. Denis supposes
that the disease is connected with the gastro- i
intestinal irritation so frequently found upon dis-
section. Dr. Holme and, more recently, Dr.
Pall etta viewed it as consecutive of, and oc-
casioned by, the congestion of the lungs and the
difficulty of the pulmonary circulation ; whilst
M. Baron, physician to the Parisian Hospital,
in which from two to three hundred cases occur
every year, considers that the internal congestion
takes place subsequently to the appearance of
the disease. I believe that this is the more cor-
rect view; for M. Billard found unusual con-
gestion or hepatisation of the lungs in less than
one half the cases he examined. There can be
no doubt, however, that as the affection of the
cellular tissue proceeds, and as the circulation in
. this tissue and in the extremities is more and
more retarded, congestion of the internal viscera
comes on; but not always in the same organ;
the encephalon, cavities of the heart, liver, and
spleen, also experiencing this change; sometimes
with serous or sero-sanguineous effusion into the
adjoining shut cavities. The frequent complica-
tion of the disease with jaundice would seem to
indicate that the biliary organs are more or less
affected ; and such may be the case in respect
of their functions: but M. Billard found, in
ninety cases, twenty only of organic lesion of
the liver, the icteric appearance being evidently
dependent upon the morbid state of the serum
of the blood, and the deficient vital endowment
of the cutaneous capillaries. M. Breschet had
found the foramen ovale more than commonly
open in many cases, and inferred that the affec-
tion was caused by this circumstance. M. Bil-
lard states, that his numerous examinations do
not countenance this inference, but admits that
they are often coincident changes. This writer,
who has paid much attention to the subject, con-
cludes, that general debility, congenital plethora
of the vascular system, congestion of venous blood
in the tissues, and unusual dryness of the skin
previous to the exfoliation of the epidermis, are
its chief predisposing causes ; and that vascular
plenitude, an engorged state of the cellular and
adipose tissues, and the influence of external
agents interrupting cutaneous transpiration, are
its more immediate causes; the coldness of the
extremities and affected parts resulting from the
slowness of the circulation and the depression of
the vital powers.
9. Diagnosis and Prognosis. — A. This
affection is obviously more or less intimately
related to cedema on the one hand; and, in some
instances, to erysipelas on the other : — to the
former, by the effusion of fluid in the cellular
tissue; but differing from it chiefly in the persist-
ent, firm, wax-like, and coagulated state of the
infiltrated part, and in the reddish yellow, livid,
or mottled appearance of the skin; — to the lat-
ter, by its frequently dark red, or livid colour;
but differing still more widely from it, in the prin-
cipal affection of the cellular tissue, in the re-
markable coldness of the part, languor of the cir-
culation, and general absence of any change in
the skin itself. And it is distinguishable from both,
by the peculiar cry of the infant ; the weak,
moaning, and sibilant respiration, the dvspnosa,
the feeble irregular action of the heart; the leipo-
thymia and lethargy, and the frequent complication
with trismus and tetanic spasm; as well as with
the peculiar jaundice of infants. It may be also
mistaken for erythema nodosum; but the knotted
sensation, upon passing the fingers over the skin,
furnished by this affection, is sufficient, of itself, to
distinguish it from the smooth, cold, and diffused
hardness of the present disease.
10. B. The Prognosis should be alwavs re-
served or cautious. A large proportion of those
attacked die, particularly in hospitals, even under
the most judicious management ; sometimes, in
two, three, or four days, in the most severe cases,
and in prematurely born children that have been
exposed, soon after birth, to cold. But, generally,
the disease does not terminate either way in less
than from six or eight days to twenty or thirty.
It may even be more prolonged; and when re-
covery is advancing, inflammation of the lungs
or digestive canal, or effusion on the brain, may
occur, and either cut off the patient, or put his life,
in the utmost jeopardy.
11. Treatment. — The intentions of cure
will vary with the particular form of the disease.
In the first, or oedematous variety, in which vas-
cular plethora is generally present, depletion is
often of service; particularly if the circulation in
the extremities and affected part be at the same
time excited by means of frictions with warm stim-
ulating liniments. MAI. Baron and Billard
prefer frictions to the use of the vapour bath, re-
commended by MM. Duges, Peligot, and
others. In the second variety, in which there is
less oedema, and greater induration, and, according
to several recent writers, a coagulated state of both
the adipose substance and the fluid effused into the
cellular tissue, blood-letting may not be admissible.
MM. Chambon, Palletta, and Gardien,
however, consider that, in this variety also, de-
pletion should be practised, in order to relieve the
cerebral congestion attending it; and therefore re-
commend two small leeches to be applied behind
the ears. In this practice I have generally con-
curred, but have adopted it with much caution in
prematurely born or weakly infants ; directing,
also, for all the states of the disease, calomel or
hydrarg. cum creta, with soda, and small doses of
ammonia; the compound decoction of sarsaparilla
with liquor potassas the warm bath, followed by
repeated frictions of the^surface with stimulating
CHEST — External Examination of, in Disease.
309
liniments: and the nourishment Nature intended
lor the infant. Although a very common and fatal
disease in [Vance, it is seldom observed in this
country; and even at the Infirmary for Children,
cuses of it have very rarely presented themselves.
I have not met with an instance of it in the
Queen's Lying-in Hospital.
12. After the above means have been perse-
vered in for a time, a few drops of spirits of tur-
pentine and sweet spirits of nitre may be given
occasionally in sugared dill-water; and the infant
enveloped in very soft flannel or wash-leather,
which ought to be covered over with oiled silk,
in order, to prevent the dissipation of the animal
heat. Dr. Palletta states that he treated, with
uncommon success, the very numerous cases that
occurred in the Lying-in Hospital at Milan, with
half a grain of the kermea mineral (F. 637.) giv-
en three or four times a day, and warm bran or
warm dour applied to the parts affected. Andry
and Gardie.n advise the use of blisters; — the
former to the affected parts; the latter to the nape
of the neck, with the view of preventing the oc-
currence of cerebral congestion; — but I have had
no experience of their use in this disease; and
consider them less efficacious than frictions with
stimulating liniments, several formulae for which
are given in the Appendix. During treatment, a
pure warm air, and the natural food of the infant,
furnished by a healthy nurse, will be found ex-
tremely conducive to recovery.
Bibliog. and Refer. — U:e.mbezius, in Ephem. Nat.
Curios, cap. ix. oh. 30. p. 62. 1718.— Doublet, in Journ. de
Med. Avr. 1735, p. 447. — Batumi's, Fondemens de la Sci-
ence Method. i!< < Maladies, t. i. p. 314. — Underzoool, On
the Diseases of Children, 8'h edit. 8vo. p. 256. — Qurditn,
Traile Comp. d'Accouchemens et des Malad. des Filles, des
Fem. et des Enfans, t. iv. p. 91. Paris, lS2S.—P«/lettci, in
Archives Gen. de Medccine, t. v. p. 105., et Ibid. t. ix. p. 276.
— Levrr, in Ibid. t. vii. p. 16. — Duparcque, Nouv. Biblio-
theq. lied. Sept. 1823, p. 333.— Rutier, Archives Gener.
de M.'decine, t. xvii. p. 42. — Billurd, in Ibid. t. xiii. p. 204.,
et Traite des Maladies des Enfans, &.c. 8vo. Paris, 1828, p.
169.— Duges, Manuel d'Obstetrique, kc. Paris, 1 830, p. 437.
CEPHALITIS. See Brain, Inflammation of.
CHEST. Sv.\. Thorax, Fr. Der Brustkasten,
Ger. Torace, Ital. The Thorax.
External Examination of, in the
course of Disease. — Classif. Gen-
eral Pathology — Semeiology.
1. Regions of the Chest. — It is necessary to
divide the chest into different regions, in order to
give precision to our diagnostic researches. This
is done by drawing horizontal and vertical lines
from certain conspicuous parts of the body. The
first horizontal or transverse line extends anterior-
ly from the humoral extremities of each clavicle,
across the junction of the clavicles with the upper
part of the sternum, posteriorly passing over the
last cervical vertebra1; the second, around the
middle of the chest, anteriorly passing over the
nipples, and posteriorly passing between the spine
of the scapulae and their inferior margins; the
third passes around the lowest part of the chest,
from the zyphoid cartilage, and over the hypo-
chondria. The first vertical line extends from
the upper to the lower extremity of the sternum;
the second and third, from each acromial ex-
tremity of the clavicles to the external rami of
the pubes; the fourth and fifth, from each poste-
rior margin of the axilla' to the crests of the ilia;
the sixth and seventh, from the clavicular trans-
verse line along the posterior border of each
scapula, or a little exterior to it, to the middle
horizontal line; and the eighth, along the spinous
processes of the dorsal and cervical processes.
To these lines may be added one drawn on each
side, from the last cervical vertebra, around the
lower part of the neck, and sloping downwards
to the upper part of the sternum. Thus the chest
will be divided into sixteen regions, viz. two su-
perior, or humoral regions; four anteriw, — the
subclavian and submammary; four lateral, — the
axillary and subaxillary; and six posterior, — the
scapular, subscapular, and interscapular.
2. The viscera lodged beneath each of the
different regions of the chest, and the nature of
its parietes, are too well known to require any
notice. I therefore proceed to point out the va-
rious methods which are employed to investigate
the diseases of the thoracic organs. These con-
sist of inspection, mensuration and manual exam-
ination, percussion, succussion, and auscultation.
3. A. Inspection. — It is important for the
physician to take into consideration the form and
size of the chest, in estimating the causes, nature,
and tendencies of disease. Vigour of constitution
is generally incompatible with a small or ill form-
ed thorax; this conformation not only disposing
to various affections of the viscera contained in
this cavity, but also aggravating their severity.
Every change from the due proportions of the
chest ought to be considered of importance. This
cavity is generally artificially modified in its form
in females. Its capacity is reduced in a trans-
verse direction, by the lateral compression to
which it is subjected; and, owing to the same
cause, the superior abdominal viscera are pushed
upwards, and it is thereby further diminished in a
vertical direction. Put the compression thus ex-
ercised not only reduces the absolute capacity of
the chest, but it also prevents the elevation of the
ribs, and the descent of the diaphragm during
respiration, rendering each inspiration of small
amount, and insufficient for the developement and
wants of the frame. It moreover presses the
lower ribs downwards and inwards upon the more
important viscera contained in the abdomen; pre-
vents the ascent of the contents of the caecum;
and favours lateral curvature of the spine, which,
in its turn, tends remarkably to diminish the ca-
pacity of the chest.
4. During inspection of the thorax, there are
other circumstances, besides its form and size,
which should fix attention. The actions of its
parietes, the equality of the motions of each side,
and their connection with the movements of the
abdomen, are of the utmost importance. In
pleuritis, the motions of the ribs of the affected
side are greatly impeded; and if both sides be
affected, the costal parietes are but little moved
during respiration, this function being chiefly per-
formed by the diaphragm and abdominal muscles.
On the other hand, when the diaphragm, or
either of its serous surfaces, are inflamed, or
when intense inflammation affects any of the su-
perior abdominal viscera, respiration is chiefly
performed by the costal parietes. In the first
case the respiration is said to be abdominal, in
the second thoracic.
5. It is chiefly by actual inspection of the
chest that we can ascertain the existence of
oedema of iW surface: the distance between the
ribs, the prominence of the spaces between each,
310
CHEST — Deformities of the.
the existence or non-existence of partial contrac-
tions, and bulgings or prominences of its walls, —
are all important facts in our diagnosis of diseases
seated in this cavity. Thus, in phthisis, when
the pulmonary tissue is tuberculated, shrunk, or
contracted, &c, a falling in of the ribs, particu-
larly of the subclavian region of one or both sides,
is observed; whilst in asthma and emphysema of
the lungs, the ribs are full and expanded. This
state, however, of the ribs may exist only on one
side; as in cases of pleurisy of one side, termi-
nating in effusion, in empyema, and in pneumo-
thorax, we often observe the affected side ex-
panded, and the intercostal spaces prominent,
whilst the other is natural. In other instances of
organic disease, one side may be uncommonly
contracted; as after cures of old, or chronic, or
circumscribed pleurisy, in partial or general de-
struction of one lung, and in lateral curvature of
the spine. In many of these, the opposite or
sound side is fully developed, owing to a slight
hypertrophy of the sound lung; in cases of curva-
ture, one side is always prominent in proportion
to the depression of the other. The prominence
of the sternum, and lateral depression of the ribs,
which is so common in children; and the falling
in of the sternum, and prominence of the ribs;
are ascertained by inspection.
6. B. Manual examination and mensuration. —
It is of importance to ascertain the existence of
tenderness on pressure in various parts of the
chest, particularly when the patient complains of
pain, or dilHcult respiration. This can only be
done by manual examination. Extreme sensi-
bility of the external surface indicates either irri-
tation of the membranes of the spine, or rheuma-
tism ailecting the parietes of the chest. When
pressure in the intercostal spaces is required to
develope the pain, disease is usually seated in the
pleura, or parts beneath it, or in the pericardium.
It is seldom, however, that we can occasion pain
by pressing between the ribs in cases of organic
disease of the substance of the lungs, or even of
the pulmonic pleura, unless this latter has formed
adhesions to the costal pleura. During manual
examination, attention should be paid to the ex-
istence, the kind, and the extent of moisture on
the surface of the chest; to its temperature,
which is generally more or less increased in in-
flammations; and to the palpitations or impulse
of the heart. It is evident that the existence of
oedema or emphysema of the surface of the chest
is chiefly to be ascertained by manual examination
of it.
7. Mensuration of the chest may be sometimes
required, in order to ascertain either the degree
of prominence of one side, or of the contraction
of the other. In both cases a piece of tape is
used; the measurement being made from the
spinous processes of the vertebra; to the central
line of the sternum, and from the top of the
shoulder to the lowest rib. The admeasurement
should be taken during a full inspiration and ex-
piration, and the progressive increase or decrease
noted. It will often happen that no difference
between either side exists during a state of tran-
quil respiration; and yet, upon forced respiration,
the difference is very manifest.
8. Mr. Abernf.th y proposed, many years ago,
— and the proposition has been recently revived on
the Continent, — to ascertain the capacity of the
lungs, by measuring the quantity of air they are
capable of containing, as an indication of the ex-
tent of disease by which they are affected. The
recommendation was rational, and deserving of
greater attention in several affections of this organ
than it has received, particularly when the evi-
dence furnished by the measure is duly estimated
in conjunction with other signs. The method
simply consists of the patient taking as deep an
inspiration as he is able, and then expiring through
a tube, one end of which is passed under a glass
jar, containing, and inverted over, water. The
quantity of water displaced is the measure of the
capacity of the lungs. A person, full grown and
in health, usually displaces from six to eight pints.
If the amount be much less than this, it may be
inferred that the lungs are obstructed by disease
of their substance, or by tumours, effusions of
fluid in the pleura, or other causes pressing upon
them externally. Although muscular debility, or
spasm, may diminish the quantity of air inspired,
yet there can be no doubt that the method is cal-
culated to furnish very useful information.
9. Some years since, it was proposed by a
physician on the Continent, to test the capacity
and soundness of the lungs by causing the patient
to take as full an inspiration as possible, and to
count from one upwards, in a deliberate manner,
during the following expiration, and whilst ex-
piring as slowly as he can. The number that
will be reached, either during the expiration or
whilst the breath is retained, or before a new in-
spiration is entered upon, will be an index of the
soundness of this organ. Dr. Lyons, who has
more recently recommended a modification of this
method, advises that the period should be noted
by the seconds hand of a watch. He states that
a healthy individual will not continue counting
above thirty-five seconds; and that, in confirmed
phthisis, the period never exceeds eight, and sel-
dom six seconds. I have practised this method
during the last five years, and have seldom found
a healthy person who could proceed beyond thir-
ty-five seconds, and scarcely one who could go
beyond forty; but I have met several cases of
pulmonary consumption, where, up to a very ad-
vanced stage of the disease, twelve, fifteen, and,
in one case, twenty seconds were reached; and
even in the last stage, eight or ten seconds are
not uncommon; although the number mentioned
by Dr. Lyons is much more frequent.
Percussion, succussion, and auscultation of the
chest are comprised in the articles Auscultation
and Percussion.
Bibliog. and Refer. — Autnbrugger, in Journ. de
Medecine, t. xxxii. p. 84. — Double, in Journ. Gener. de
Mill. t. xxix. p. 241. — Luennec, De l'Auscultation Mediate,
C nil'. n.._ L I 1> — lOOC iLMMnflii DUmaIiuiimI
&c. 2d edit. 8vo. t. i. Par. 1826. — Abrrnethy, Physiological
Essays, part ii. p. 157. — Lyons, .Edin. Med. Journ. vol.
wviii. p. 453. — Dupuytren, Archives Gen. de Med. t. \\i.
p. 556. — Piori-y, Precede Operatoire, kc. dans l'Exploration
des Organes, Svo. Paris, 1831.
Deformities of the Chest. — Classif.
I. Class, HI. Order (Author).
1. 1. Lateral Depression of the Chest.
Depression of the lateral parietes of the chest had
escaped the attention of authors, although of very
frequent occurrence, until M. Dupuytren wrote
a memoir on the subject (Repertoire Gt'n. d% An-
atomic, $c. t. v. p. 1 10.) A few scattered remarks
on the subject may be Jbund in the writings of
Van Swieten, J. L. Petit, Levacher, and
CHEST — Deformities of the.
311
others, who have attributed it to rickets and other
affections, and have evidently been unacquainted
with it9 nature, causes, effects, and method of
treatment. Not a week passes without eases of
this contraction being presented at the Infirmary
for Children ; and although sometimes a con-
genital deformity, it lias appeared to me very fre-
quently to be greatly increased, if not altogether
occasioned, subsequently to birth, by the very
common practice among nurses of lifting the child
by pressing the palms of the hand on the sides of
the chest, immediately under the arm-pits. This
deformity consists of a greater or less depression
of both sides of the thorax, with a proportionate
protuberance of the sternum and abdomen for-
wards, and of the vertebral column backwards.
2. It is most commonly found in infants born
of debilitated, lymphatic, scrofulous, and rickety
parents. — particularly those inhabiting low, cold,
and moist situations, or who live in small ill-ven-
tilated apartments, — and amongst children who
are badly clothed and nourished. In many cases
the deformity does not consist of merely a level
depression of the lateral parietes ; but the ribs
are actually bent inwards, the sternum and spine
forming a curve outwards. In some, the lower
or upper parts of the sternum are the most promi-
nent. This extreme grade of depression is sel-
dom or ever met with at the moment of birth ;
M. Dupuytren thinks differently. My expe-
rience leads me to state that it generally conies
on gradually after birth, owing to deficient infla-
tion and developement of the lungs, arising from
the weakness of the muscles of inspiration, and
flexibility of the ribs at the time of birth. In
cases of this description, the vital energy of the
lungs is insufficient for their healthy actions, and
the respiratory mechanism is unable to accom-
plish their full expansion, or to sustain the con-
tinued pressure of the atmosphere, before which
the soft and imperfectly formed thoracic parietes
gradually yield. The manner in which nurses
frequently lift infants, as already stated, tends fur-
ther to increase the mischief, particularly in those
who are originally weak and ill-nourished. The
effects of this coarctation of the thorax upon the
functions, and ultimately on the structure, of the
lungs and heart, soon become very evident. We
usually find the pulse quick, and the breathing op-
pressed ; with a weak voice, occasional anxiety,
and incapability of speaking or reading for any
time, or of uttering many words without frequent
pauses. In the newly-born infant, there is great
difficulty of suckling, from its inability to raise the
ribs with sufficient power to perforin this process.
It is seized with suffocation when at the mother's
breast, which it often quits with fits of crying.
As it advances in age, the disorder of respiration
and circulation is still more remarkable, particu-
larly upon ascending acclivities. The pulse be-
comes quick, irregular, or intermittent ; and is
accelerated upon the slightest cause, whether
physical or mental.
3. In children whose chest is thus compressed,
the tonsils generally, or rather constantly, be-
come tumid, — so much so, as frequently to in-
crease the disorder of the respiratory actions ;
and all the structures and organs of the body
are impaired both in function and in develope-
ment. owing to the derangement which the de-
pression occasions to respiration and circulation.
Tn many cases which have come before me,
rapid emaciation, great debility, defective assimi-
lation and sanguifaction, an atrophied and flaccid
state of the muscles, softening of the bones, fre-
quently asthenic or chronic bronchitis, and swell-
ing of the glands, have followed the deformity,
and terminated the life of the patient.
4. Organic lesions. — In these cases the ap-
pearances observed on dissection are such as the
original and consecutive ailments lead us to ex-
pect. These consist in retarded developement of
the skeleton ; want of union between the bones
composing the cranium; enlargement of the heads
of the long bones, sometimes with softening and
flexures of their bodies. Dentition is also retard-
ed ; and, if it have proceeded, the crowns of the
teeth are eroded. The voluntary muscles are
atrophied, soft, pale, and exhibiting a fish-like
structure. The lungs are compressed towards
the vertebral column, and present a correspond-
ing depression to that of the lateral parietes of the
chest, with the marks of the ribs indented in their
posterior and lateral surfaces. This organ is often
studded with tubercles of various sizes ; portions
of it are frequently often inflamed or hepatised ;
and, in some cases, attended with bronchitis, the
bronchi are more or less loaded with mucus, or
muco-purulent matter. The substance of the
heart is commonly pale and flaccid ; and, in
young infants, the foramen ovale is sometimes
widely open; and in older children, but imperfect-
ly closed. The mucous follicles of the intestinal
canal are often tumefied, but rarely ulcerated, ex-
cepting when a chronic diarrhoea has attended
the latter stages of the thoracic compression. The
mesenteric glands are also occasionally much en-
larged.
5. II. Depression of the Sternum, with
lateral prominence of the ribs. — This deformity
is the reverse of the former : the sternum is press-
ed inwards, either at its middle or lower part, or
along its whole extent ; the ribs are very much
bent, and prominent laterally ; the chest being
broad, but compressed anteriorly, the shoulders
high, and the spine either straight or but little al-
tered from its natural form. This change has also
been much overlooked by authors. Mr. Coul-
son, however, has lately noticed it in an instruc-
tive article on deformities of the chest. It is by
no means uncommon both in young and grown
up subjects, although not so frequent as the lateral
depression. In cases of depression of the sternum,
the lungs and heart are compressed anteriorly;
their functions much altered, and ultimately their
structures. This deformity is very seldom con-
genital, being the consequence of weakness, or of
a scrofulous or tubercular diathesis. I have met
with two instances of it out of six members of one
family who died of consumption soon after puber-
ty. It is in some cases antecedent of any appar-
ent disease of the lungs ; in other instances, it is
consecutive of pulmonary disease ; and in others,
of external pressure and stooping occupations.
b. It is not uncommon to find, females with the
chest of a cylindrical or oval form, instead of being
a truncated cone ; entirely in consequence of the
inordinate pressure to which its lower part has
been long subjected from tight lacing of the stays.
In some of these cases, the sternum, particularl-
its lower part, is pressed inwards. The etlec
however, of this habit, and of the deform/
312
CHICKEN-POX.
which it occasions, have been alluded to in anoth-
er part. (See Chest — Examination of the , §3.)
7. Treatment. — A. The cure of the lateral
depression of the chest is by no means so hopeless
as it may appear, particularly if* it be attempted
at an early period, and before serious organic
mischief has been produced. Invigorating medi-
cines and nourishing diet are requisite, particularly
in conjunction with various external and mechan-
ical means.
8. a. The external treatment which I have
found the most successful, consists of warm or
tepid salt water bathing in infants ; and in direct-
ing the mother to make pressure very frequently
through the day upon the protuberant spine and
sternum, by placing one hand on the former and
the other on the latter. But this pressure must
be so managed as to be made only at the mo-
ment of expiration, and entirely suspended during
the moment of inspiration, so that no impediment
may be in the way of the free dilatation of the
parietes of the chest. The practitioner should
take cure to instruct the mother in the manner
of employing the pressure upon the sternum and
spine, with the view of throwing outwards the
depressed lateral walls of the chest. The more
frequently this pressure can be employed, the
better ; and its benefits will be considerably pro-
moted by applying the following liniment, night
and morning, along the spine, or even upon both
the sternum arid spine. I have employed this
and similar liniments, in these situations, with
the greatest advantage, in this and several other
diseases connected with debility, particularly in
young subjects.
No. 110. R Linimenti Coniphorae Comp., Linim. Sapo-
nis Comp., aa % j. ; Olei. Terebinthina; X, vj. , Benzioni
t ij.: Styracis Balsami ~, jss.: Olei Cajeputs, Olei Liuionis,
5a 3 ss- M- e' fiat Liniinentum.
9. In public practice, I have usually substituted
for the above, either equal parts of the compound
camphor and turpentine liniments ; or these, with
the addition of the soap liniment, or their equal
quantities of olive oil and turpentine, with a little
soft soap. In conjunction with these means, the
artificial salt water bath, with a very large pro-
portion of salt, at a temperature suited to the
peculiarities of the case, will be found extremely
serviceable. As soon as children affected by
this depression of the walls of the chest can be
brought to employ the muscles of the upper part
of the body in a determinate manner, this mode
of treatment should also be employed. Perhaps
the best mode of overcoming the depression, by
developing muscular action and power, is to
cause the child to raise weights, by means of
ropes and pulleys placed at a considerable height
over its head ; so that, by taking hold of the rope
with both hands raised above the head, and pull-
ing it downwards, the muscles may be brought
into action , and the parietes of the chest thereby
dilated. But moderate and duly regulated exercise,
particularly of the muscles of the arm and trunk
of the body, accompanied with invigorating medi-
cines and regimen, will be productive of benefit.
10. b. Internal treatment should always be
conjoined with the means stated above. The
digestive functions generally require regulation,
and tonic or permanent excitement. After hav-
ing evacuated morbid secretions and fascal ac-
cumulations from the bowels, by means of the
usual purgatives, of which rhubarb, or senna com-
bined with a tonic bitter, is among the most suit-
able, Brandish's alkaline solution, or the solution
of potash, or other preparations of this substance,
may be given, either in some gruel or mutton
broth, or in a tonic infusion, or combined with
the preparations of iron. The following powders
may also be taken once, twice, or thrice daily : —
No. 111. ]{ Ferri Sulphatis exsic. gr. ij. — vj.; Potassae
Sulphatis er. xij. — w.; Pulv. Cascarillae 5j. — ,jss. Mi=ce
bene, et divide in Cartulas xij. apquales, quarum capiat
mum bis terve quolidie.
No. 112. R Potass* Sub-carbon, gr. j. — iv.; Ferri Sub-
carbon, gr. iij. ; Pulv. Rhei gr. iv. — ix. : Pulv. Cascarilla
(vel Calumbajt gr. v. — xij. IVfisce. Fiat Pulvi,.
No. 113. K Ferri Tartarizati gr. iij. — xvj. ; Pulv. Ca-
Jumba; gr. vj. — xij. ; Pulv. Ziugib. gr. ij. M. Fiat Pulvis.
11. Instead of these, the tincture of ammo-
niated iron ; mixtures containing sulphate of
quinine ; or the tincture of iodine, in doses of
one to three drops, twice or thrice daily, may be
employed advantageously. In every other re-
spect the treatment is the same as that recom-
mended for Rickets. But whatever mode of
cure be adopted, change of air, or at least a
wholesome pure air, with regular exercise, is
requisite to its success. In this deformity, the
various exercises resorted to with the view of
imparting strength and agility to the frame, will
be useful, if judiciously directed.
12. B. The treatment of the other deformities
of the chest must be conducted very nearly on the
same principles ; the pressure, in cases where.it
may be proper to have recourse to it, being made
in an opposite direction to that recommended
above, when the anterior parietes are depressed.
But this deformity is very seldom met with so
early in life as to admit of any expectation of
advantage from the use of pressure. The other
means, as long as the pathological states of the
thoracic viscera do not contra-indicate them, are
the most applicable.
Bibliog. and REFER. — Dupuytren, in Repertoire Gk-
nerale il'Anatomie et Pathologie, Ace. I. v. p. 128. — Coul-
son, in London Medical Gazette, vol. iv. p. 69.
CHICKEN-POX. Syn. Varicella, Crystalli, Va-
riola Spuria, Variola Lymphatica, Variola
Volatica, Auct. Var. Variola Pusilla, He-
berden. Exanthema Varicella, Parr. Syno-
cltus Varicella, Young. Emphlysis Varicella,
Good. Verole Volante, Fr. Die Undchten
Kindspocken, Ger. Ravaglione, Ital. IVater-
jags, IVater-pox.
Classif. 1. Class, 3. Order (Cullen). 3.
Class, 3. Oder (Good). III. Class, DI.
Order (Author).
1. Defin. An eruption over the body, of semi-
transparent glabrous vesicles, with red margins,
accompanying a slight attack offerer, seldom
passing into suppuration ; but, on the third day,
bursting at their tips, concreting into small puck-
ered scabs, and leaving no cicatrices.
2. Under the name chicken-pox, or varicella,
have generally been comprised certain eruptions,
which closely agree in many features with each
other, and which in some respects resemble small-
pox. It is from this latter circumstance that they
claim a very particular notice, as they are gene-
rally of so slight a nature as to require but little
medical treatment. They were formerly very
generally confounded with small-pox ; but the
difference between them was remarked as early
as the beginning of the sixteenth century by Vi-
dus Vidius and Ingrassias. Sen.vert and
CHICKEN-POX — Description of.
313
Rivf.ri, professors at Wirtemherg and Montpel-
lii r at tin- commencement of tlio seventeenth
century, and Dibvib broeck, statu that the
distinction was well known in Germany, France,
and Italy, i" the vulgar, who had a separate ap-
pellation for this eruption. Morton was the
lirst in this country to mark the difference, and to
describe this disease tinder the name "chicken-
pox." by which it appears to have heen common-
ly Known before he wrote. Since then it lias
been noticed by Fuller, and accurately defined
as a distinct disease by Heberden. Ife, how-
ever, continued to designate it by the term vari-
ola pusiila ; wliilst his contemporaries, Vogel,
Burskeius, and Sauvages, also applied to it
the generic term variola, with the specific desig-
nation of volatica, spuria, and lymphatica. But,
as Dr. B \ t E -\i a n has remarked, this circumstance
cannot be considered evidence of their consider-
ing it as genericajly the same with small-pox.
The entirely distinct nature of chicken-pox was
very generally believed in, since Dr. Heberden
pointed out the difference between it and the
small-pox, until recently questioned by Dr. John
Thomson, by whom the opinion of the earlier
physicians, that they are merely varieties of the
same disease, has been revived. This learned
physician, and M. Bkrard, urge in favour of
this opinion the circumstance of variola and vari-
cella appearing from the same exciting causes,
whether those affected have been vaccinated or
not ; and affirm, that persons exposed to the in-
fection of chicken-pox have caught small-pox,
and that the former appears only in those whose
constitutions have been modified by the influence
of either small-pox or cow-pox. On this subject
MM. Schedel and Cazenave remark, that in
those epidemics which they have had opportuni-
ties of noticing in Paris, the several eruptions
might be classed under three heads: 1st, Variola
properly so called; 2dly, The malady termed va-
riloide, or variola modified ; 3dly, An eruption
purely vesicular, offering every appearance of
varicella. The same cause, namely, variolous
infection, seemed to develope these several erup-
tions, which were observed in the same quarters,
in the same streets, in the same houses. When
the disease made its appearance among a numer-
ous family, some had small-pox, some modified
small-pox, and others chicken-pox. One circum-
stance was striking to every one, namely, the
mildness of the disease in those persons who had
beer, vaccinated, and in the majority of those
who had already had variola.
3. These facts certainly favour the opinion of
Dr. Thomson ; but, as the above writers have
stated, many cogent arguments have been urged
against it, especially by Abercrombie, Bryce,
Luders, &c. : — 1st, It is very difficult to deter-
mine, during a small-pox epidemic, whether the
occurrence of that disease among individuals com-
ing in contact with persons infected with chicken-
pox is rather the result of this communication,
than of the variolous infection which at that mo-
ment developes the malady on all sides : 2d,
Vesicular varicella, properly so called, is not
transmitted by inoculation, and never produces
variola : 3d, Those persons who consider chick-
en-pox as contagious, have confounded it with
modified small-pox : -4th, Varicella appears in
persons who have not been vaccinated, and who
27
havc never had the variola ; consequently, in
such cases, it cannot be regarded as a variola
modified by the prior existence, either of this dis-
ease or of vaccination : 5th, Vaccination practis-
ed shortly after the disappearance of varicella pur-
sues its course in the most regular manner, which
inner happens when vaccination follows variola:
O'th, The progress of varicella is uniformly the
same, whether it occurs before or after vaccina-
tion, or after variola : 7th, Variola sometimes
reigns epidemically, without being accompanied
by varicella ; and, on the other hand, the latter
may become epidemic without being attended by
the former. In fact, the characters of the erup-
tion, and the symptoms of varicella, differ essen-
tially from those of variola.
4. I. Description. — A. Of the eruption.
Under the name chicken-pox are included differ-
ent varieties of eruption, generally characterised
by very slight and brief antecedent fever, con-
sisting of vesicles or very imperfect pustules which
maturate and decline in three, four, or five days,
occurring chiefly during infancy and childhood,
but also at adult age, and occasionally prevailing
epidemically. The generic term, chicken-pox,
comprises three species, or rather varieties, which
have been distinguished from each other for very
many years in different parts of this country, by
the popular names of chicken-pox, swine-pox,
and hives. These Willan and Bateman dis-
tinguished, according to the form of their vesicles,
into, 1st, Varicella Lentiformis ; 2d, V. Coni-
formis ; and, 3d, V. Globularis. Dr. Good
has adopted these names and distinctions, but has
added a fourth, the V. Corymbosa, the cluster-
ing or confluent chicken-pox; which, if consider-
ed at all as a distinct variety, is not of frequent
occurrence; but has occasionally been observed
by Bateman, Ring, and myself.
Var. i. Lenticular Chicken-pox, Vari-
cella Lentiformis ; V. Lymphatica, Plenck.
5. This variety appears, on the first day of
eruption, in the form of small red protuberances,
of an irregularly circular, or rather tending to an
oblong figure, with a nearly flat and shining surface,
in the centre of which a transparent vesicle is very
soon formed. On the second day of the eruption
the vesicle is filled with a whitish lymph, and is
about the tenth of an inch in diameter. On the
third day the lymph is straw-coloured ; and, on
the fourth, the vesicles which have not been bro-
ken subside, and are puckered at their margins.
Few of them are entire on the fifth day ; but the
orifices of several which have broken are closed
or adhere, so as to confine a little opaque lymph
within the puckered margins : on the sixth day,
small brown scabs appear in place of the vesicles;
and become yellowish on the seventh and eighth
days, gradually drying from the circumference to
the centre. On the ninth and tenth days they
fill off, and leave for a time red marks "on the
skin, without depression. The disease may, how-
ever, be longer than now stated, owing to fresh
vesicles appearing during two or three successive
days, and going through the same stages as the
first. The eruption is usually distinct, is general
over the body, and comes out first on the back
and breast. The vesicles, even when they sup-
purate, leave no cicatrices. The pustules of small-
pox break out first on the face, neck, and bre.ist,
and always leave depressions.
314
CHICKEN-POX — Diagnosis.
Var. ii. Conoidal Chicken-pox, Varicella
Coniformis ; Varicella Verrucosa, Plenck ;
Variola Lymphatica, Sauvages; Pemphigus
Variotodes, Frank ; Verolette, Fr. ; Rava-
glio, Ital. ; Sioine-pox.
6. The vesicles of this variety arise suddenly,
have a somewhat hard and inflamed base, and
are on the first day acuminated, containing a
transparent lymph. On the second day they are
a little more turgid, their bases more inflamed,
and the lymph in many of them is of a light
straw-colour. On the third day the vesicles are
shrivelled, and those which are broken have their
lymph concreted into slight gummy scabs. Such
of them as remain entire, and have their bases
much inflamed, contain, on this day, a whitish
puriform fluid; every vesicle of this kind leaving,
after scabbing, a durable cicatrix. On the fourth
day, thin dark brown scabs are seen intermixed
with others, which are rounded, yellowish, and
semi-transparent. These scabs gradually dry,
separate, and fall off in four or five days.
7. A fresh eruption of vesicles usually takes
place on the second or third day, and has a simi-
lar course to the preceding; the whole duration
of the eruptive stage being thus six days in this
variety of varicella. In some instances minute
red tubercles appear, and subside without forming
vesicles. The scales last formed are generally
not separated till the eleventh or twelfth day. In
some cases, when the febrile symptoms have
been severe, slight ulceration takes place in the
vesicles from which the scabs have fallen off, leav-
ing depressions or cicatrices, but only in parts sub-
jected to pressure.
Var. hi. Globular Chickkn-pox, Varicella
Globularis ; Hives.
8. The vesicles of this variety are large and
globular, but their base is not quite circular. -
They are surrounded by inflammation, and con-
tain a transparent lymph, which is slightly turbid,
and resembles milk whey, on the second day of
the eruption. On the third day they subside,
become shrivelled as in the former varieties, and
appear yellowish from the admixture of a small
quantity of puriform matter with the lymph; some
of them remaining in the same state till the fol-
lowing morning; but before the conclusion of the
fourth day, the cuticle separates, and thin dark
scabs cover the basis of the vesicles. The scabs
dry, and fall off in four or five days afterwards.
9. B. Of the constitutional affection. — All
these varieties of chicken-pox may attack the
same individual at different epochs, and offer the
same symptoms, whether before or after small-
pox or vaccination. They are frequently associa-
ted with the epidemic prevalence of small-pox.
They appear principally in the early months of
the year, and the spring; seize chiefly young per-
sons, and adults sometimes; and each of them,
with few exceptions, affects a person only once in
their lives. Varicella is preceded, for twenty-four
or forty-eight hours, by chills, depression, anor-
exia, costiveness, and thirst, with heat of skin,
flushed countenance, accelerated pulse, tendency
to perspiration, and other febrile symptoms.
Sometimes there is nausea, or even vomiting,
with pain at the epigastrium and through the
limbs. In some cases, the fever is so very slight
as to be overlooked ; and, in infants, is often indi-
cated only by heat of skin and fretfulness. The
eruption usually commences on the back and
breast ; appearing next on the face, neck, and
scalp ; and lastly on the extremities. It is some-
times preceded, for a few hours, by a general
erythematous rash ; and the vesicles are usually
most abundant in the conoidal form ; they being
sometimes coherent, or seated close together, but
seldom confluent. When thus coherent or clus-
tering, they form the fourth variety of Dr. Good
(§ 4.). Owing to the itching which accompanies
them, children often break the vesicles by scratch-
ing; whence proceeds an increased inflammation,
forming a yellowish pus, more or less consistent.
This happens particularly on the face. The crusts
which replace these pustules remain much longer,
and leave small cicatrices. As the vesicles ap-
pear successively during two or three days, we
may perceive the eruption exhibiting its sever-
al stages at the same period, in the same indi-
vidual.
10. II. Diagnosis. — The vesicle full of ser-
um on the top of the pock, on the first day of the
eruption, — the early abrasion of many of the
vesicles, — their irregular and oblong form, — the
shrivelled state of those that remain entire on the
third and fourth day, and the radiating furrows of
others which have had their ruptured apices clos-
ed by a slight incrustation, — the general appear-
ance of the small scabs on the fifth day, at which
time the small-pox pustules are not at the height
of their suppuration, — sufficiently distinguish
chicken-pox from small-pox. Dr. Willan has
pointed out the characteristic circumstance, that
variolous pustules are, on the first and second day,
small, hard, globular, red, and painful ; impart-
ing the sensation, when the finger is passed over
them, similar to that which one might conceive
would be excited by the pressure of small round
seeds under the cuticle. In varicella, almost ev-
ery vesicle has, on the first day, a hard inflamed
margin ; but the sensation communicated to the
finger is like that from a round seed flattened by
pressure. As the pustules of small-pox, more-
over, become gradually developed, they contain
a white thick matter ; the formation of which
precedes suppuration, as shown by Dr. Ash bur-
ner. When the globular vesicles or hives ap-
pear, as is sometimes the case, intermixed with
the lenticular or conoidal eruption, they afford a
ready distinction from the small-pox, to the pus-
tules of which they bear little resemblance.
11. It is not, however, so easy to distinguish
varicella from modified small-pox. The symp-
toms precursory of the latter are usually intense,
which is never the case with the former. In mod-
ified variola, the eruption is pustulent, and the
pustules are small, circular, and generally depress-
ed in the centre. After the scaly crusts drop off,
tubercles are frequently seen, which disappear
but slowly. In varicella, the vesicles, which
are at first transparent, contain a fluid which be-
comes sero-purulent ; and they are never followed
by tubercles, as in modified variola. To this I
must add, that varicella is not infectious; whereas
modified variola may be transmitted by iuocula-
tion, and may even, in some cases, occasion a
very severe attack of true small-pox.
12. III. The Treatment of varicella is very
simple : the patient should remain in bed, in a
temperate atmosphere; ought to be placed on low
diet, and abstain from animal food for a few da\ ?;
CHLOROSIS — Causes.
315
should have the bowels duly regulated, and pax-
take freely of lukewarm diluents.
Biblioo. ano Refer. — Fichu Flditu, De Chrvs allis.
—In^rassias, De Tumor. Print. Nat. I. i. c. l. — Sennertus,
Med. PrmcL I. it. cap, 12. — Rivcrhis, Prax. Med. cap. ii. —
Diemeroroeck, De Variolis et Morbis, cap. ii. — Morton,
Pyrotolocia, A:c. p. 38. — Fuller, Kxautheinatologia, p. 161.
17J0. Hrberrien, in Trans, of the Coll. of I'hvs. vol. i. art.
x \ i i. ; et comment de Morbis, cap. 96. — t'ogef, De Cognos-
cend. etCur. Horn. Morb. §128. 1772.— Burserius, Inst.
.Mid. t. ii. cap. 9. §305. — Sauvages, class iii. gen. ii. sp. 1.
— Wilton, On Eruptive Fevers, 4tb edit. p. 321. — Ring,
Med. and I'hvs. Journ. vol. xiv. p. 111. — Thomson, On
Varioloid Diseases, 8vo. — Rayer, Traite de Maladies de la
Pcau, Rvo. t. i. p. $40.—Cazenaoe et Schedtl, Abrege Prati-
que de .Mai. de la Peau, 8vo. p. til.
CHLOROSIS. Der. and Syn. From /Xaqbg,
paleness, yellowish green. Pallidus Morbus;
Fadus 1'irginum Color; Pallor Virginum ;
Morbus Virgineus; Faidi Colores; Icterus al-
Otu ; Icteritia alba ; Cachexia Virginum vel
Muliebrum ; Febris Amatoria ; Chlorosma,
4*c. Aurt. Var. Chlorose; Pales Couleurs, Fr.
Die Bleichsucht, Ger. Green Sickness, Eng.
Classif. 2. Class, Nervous Diseases ; 2.
Order, From Defect of Vital Energy
(Cullcn). 5. Class, Diseases of the Sexu-
al Functions ; 2. Order, Affecting the Or-
gasm (Good). I. Class, II. Order
(Author, in Preface).
1. Defin. Pale yellowish green complexion,
languor, debility ; depraved appetite, with oc-
casional nausea or sickness, and disorder of the
sexual secretions; generally occurring about pu-
berty, or soon afterwards.
2. Chlorosis has been very generally consider-
ed as a variety merely of amenorrhoea, particular-
ly by Cullen, Pinel, and Frank, although
they have classed it as a distinct disease. As to
its occurrence independently of retained or sup-
pressed menstruation, there can be no doubt,
although it is frequently connected with such dis-
order. It Ls also similarly related to dyspepsia,
and to anaemia ; Dr. Young classing it with the
former disease. Sauvages includes, as a va-
riety of chlorosis, the cases of ancemia which oc-
cur in infants and children, denominating them the
chlorosis infantum. But, although several such
cases are met with in practice, they seldom pre-
sent the yellowish green tinge of this disease,
being usually of a white or exsanguineous pale-
;i'--, unless when complicated with jaundice,
which is but rarely remarked. They are entirely
referable, in respect of their pathological relations
and terminations, to anaemia (see Blood — De-
ficiency of); and are sometimes, owing to the
exhaustion attendant upon their last stages, mis-
taken for hydrocephalus. S v D E H h A M considered
chlorosis as a variety merely of hysteria, connect-
ed with a cacochymia, — its frequent complication
with that disease being evidently the source of
this fallacy; and, lastly, Van Swieten viewed
it as a form of cachexy. These opinions serve
to show the propriety of considering it as a dis-
tinct disease, but more or less intimately related
to those complaints, owing to the circumstance
of them all originating in a nearly similar state
of vital energy, particularly as manifested in the
organic nervous system ; specific differences be-
tween them consisting in the particular viscus or
part more especially allected, and the grade and
mode of such affection.
3. Dr. Good divides chlorosis into two species,
the atonic and entonic ; but this is an unnecessary
refinement, no phenomena which warrant such a
distinction presenting themselves in practice. In-
deed, the entonic only consists of a state rela-
tively of less deficiency of vital power than the
atonic, and is, in many cases, merely the first
stage of the disease ; particularly when it occurs
in tolerably strong females, and whilst the torpid
function litis not as yet extended much further
than the sexual organs, in which it originated,
the digestive, assimilating, and vascular organs
not having sustained much disorder. Dr. Gooch
has likewise made mention of an acute chlorosis,
occurring chiefly in married women. But the
state of disease thus designated by this physician,
is simply that chronic disorder, often attended
with slight irritative fever, following large losses
of blood, which are not readily supplied by the di-
gestive and assimilating functions; and is in all re-
spects a state of anaemia. (See Blood, §34. etseq.)
4. I. Causes. A. Predisposing causes.
Chlorosis is most frequent in girls about the age
of puberty ; either previously to the appearance
of the menses, or when they are retained, or
occur irregularly, or with difficulty. But married
women, particularly widows and those who have
not borne children, are not exempt. It is even
met with in males, although rarely, about the
period of puberty ; as remarked by Hamilton,
Blane, Desormeaux, Roche, and myself in
two or three cases. When observed in this sex,
it is apparently connected with protracted evolu-
tion of the sexual organs ; and one or two of the
young females of the same family are sometimes
also affected. The lymphatic and melancholic
temperaments ; feeble and delicate constitutions ;
residence in cold, moist, and miasma! localities
and climates ; insufficient, unwholesome, innu-
tritious, and watery vegetable food ; inattention
to the digestive functions, particularly those of
the bowels ; the abuse of diluents, of acid weak
wines, or of spirituous liquors, early in life ; too
great indulgence in warm bathing ; prolonged
sleep ; tight lacing at an early age ; and what-
ever debilitates and relaxes the system ; predis-
pose to this disease. The most frequent causes in
this country are sedentary occupations in crowd-
ed and ill-ventilated manufactories and towns,
especially those employments which require a
stooping position, and are prosecuted by females
at a very early age, or before the frame is de-
veloped.
5. B. The more common exciting causes, are
longings after objects of desire ; depressing pas-
sions and affections, especially unrequited love,
or unfortunate or imprudent attachments ; long
\ entertained feelings of sadness or anxiety, par-
ticularly when caused by removal from friends,
and the scenes of recent happiness and affection.
According to MM. Desormeaux and Roche,
privation of the physical gratification of love is
a very frequent cause. Retention, difficult and
imperfect occurrence of the menses, have very
generally been enumerated amongst its causes ;
but the uterine disorder is rather a coincident ef-
fect of the same pathological state that produces
chlorosis (§ 12.). Suppression of the menses,
excessive menstruation, and manustupration, are
sometimes concerned in its appearance; the latter
acting chiefly by debilitating the frame generally,
by exhausting the energy of the sexual organs,
316
CHLOROSIS— Diagnosis— Prognosis.
and thereby assisting the operation of other caus-
es, particularly when the functions of the stomach
and bowels are torpid, or otherwise disordered.
The influence of constipation, and focal collec-
tions in the caecum and colon, in occasioning the
disease, cannot be questioned, although somewhat
exclusively insisted upon by Dr. Hamilton, in
opposition to the opinion of Dr. Cullen, who re-
ferred it chiefly to an inactive state of the ovaria.
It seems, however, quite as evident that the tor-
por of the digestive organs, especially of the low-
er bowels, and the inactivity of the uterine organs,
depend upon the state of the organic system of
nerves, which supply not only those viscera, but
also those concerned in assimilation and circula-
tion,— all those functions presenting more or less
disorder in the course of the disease.
6. II. History and Symptoms. — Chlorosis
presents two stages ; the incipient, and the fully
developed or confirmed. It also manifests various
morbid associations or complications. A. The
incipient stage commences insidiously, and almost
insensibly. The patient is at first languid, listless,
weak ; loses her complexion ; has no disposition
to amusement, if it require mental or physical
exertion ; is often without appetite, or craves for
particular, and sometimes unwholesome, kinds of
food; the bowels are costive; bodily exertion soon
occasions shortness of breath, and fatigue ; the
breath is offensive ; the tongue is white or pasty;
sleep is disturbed or unrefreshing, and oppressive
in the morning ; she often complains of intermit-
tent headach, pain of the left side, and palpita-
tions, which are induced by the slightest cause ;
the pulse is quick, weak, and small ; and the
catamenia are either retained, or are scanty, and
of a pale colour : all these symptoms gradually
increase, and the countenance becomes more
and more pale, and assumes a greenish yellow
tint.
7. B. The fully developed disease presents its
characteristic complexion — the pale greenish yel-
low of an etiolated plant. The lips, gums, in-
sides of the cheeks, are pale; the eyelids are livid,
sometimes edematous, particularly in the morn-
ing ; the conjunctivae are remarkably white ; the
sott solids flaccid ; the extremities cold ; and the
ankles edematous. The tongue is usually pale,
soft, flabby, and indented at the edges by the
teeth ; sometimes it is smooth, glossy, and fissur-
ed. The appetite is more and more capricioua
and morbid ; sometimes with pica, or a desire for
pickles and acids ; and nausea and vomiting, es-
pecially in the morning, and cardialgia or gastro-
dynia after meals, not infrequently occur. If the
menses have already appeared, they become gra-
dually more dilficult, and scanty ; are attended
with syncope or pain ; are of short continuance,
pale, or watery ; recur at longer periods, and at
last disappear. The patient is often sad ; enter-
tains depressing and sinister ideas ; prefers soli-
tude, and is capricious. In the more advanced
or inveterate cases, the finger nails are brittle,
dry, and split or break oft"; the hair is weals, falls
out, is lank, dry, and splits at its extremities.
The abdomen is often tense, distended, and slight-
ly painful. A constant pain is complained of un-
der the left breast, sometimes with a slight cough;
the constipation alternates with diarrhoea ; some
degree of emaciation takes place ; the cedema ex-
tends, or assumes the form of anasarca or ascites ;
various irregular states of hysteria occasionally
appear during the course of the disease; and some
one or two symptoms become prominent, occa-
sionally deceiving both the patient and medical
attendant by their severity. Thus the headach,
pain of the side, palpitations, cough, &c. occa-
sionally lead to the apprehension of inflammatory
states of the brain, or of the pleura, of disease of
the heart, or of phthisis.
8. C. Terminations and complications. — When
the disease becomes inveterate from neglect, in-
efficient treatment, or the continued operation of
its causes, &c, it often assumes diversified forms,
owing to morbid associations. The continued dis-
order and debility of the digestive organs, and the
consequent insufficient supply of healthy chvle to
the blood, as well as the imperfect sanguifaction
of what is supplied to it, sooner or later gives rise
to anaemia, which, in its slighter grades, owing to
the causes hereafter to be noticed (§ 12.), even
accompanies the early stage of chlorosis. In fe-
males who have been married, or in those who,
previously to the appearance of the disease, had
the uterine functions and discharges regularly and
fully established : hysteria, in some one or more
of its numerous states, is commonly observed.
Chlorosis is sometimes also complicated with
swellings of the glands, or with chronic cutaneous
eruptions, or with hsematemesis and malaena ;
and occasionally terminates in dropsy of either
the thoracic or abdominal cavities. Mania and
delirium rarely ensue in the course of its advanc-
ed stages and inveterate forms.
9. III. Diagnosis. — Chlorosis is most inti-
mately related, in its symptoms, and the nature
of the changes which constitute it, to anaemia.
Indeed, the advanced stage of the former is often
identical with the latter; the chief differences con-
• sisting in the pale, greenish, or greenish yellow
tint of the countenance, the torpor or disorder
of the uterine functions, and affection of the
stomach in chlorosis. It also often resembles,
other chronic diseases, particularly those seated
in the stomach, and tuberculous affections ; but
not so closely as to be mistaken for them.
Neither the nervous headach, nor the hysterical
pains, particularly those complained of in the
left side and under the left breast, nor the palpita-
tions of the heart, can with due attention be con-
founded with inflammation or organic change in
these situations : yet I have seen these mistakes
made, and nearly fatal consequences ensue. —
the practitioner having been deceived by the fre-
quency of the pulse in such cases. In this, as
well as in other diseases, much advantage will
accrue from recollecting that the most acute pain
is generally owing to a pathological state the re-
verse of inflammatory ; and that the most fre-
quent pulse is very far from. indicating a necessity
for blood-letting, which, if practised in such cases,
will increase the morbid sensibility and the vas-
cular irritability, even when it does not hasten a
fatal termination.
10. IV. Prognosis. — Chlorosis is always
chronic; is generally cured, particularly in its sim-
ple form ; but sometimes also terminates fatally,
owing to the associated lesion of various functions
and organs. Recovery may be confidently ex-
pected, when it is incipient or uncomplicated,
and none of the internal viscera betray marked
disease ; especially if it toave not continued longer
CHLOROSIS — Pathology — Treatment.
317
than two or three months, and the menses have
do) appeared. If it occur in married women,
sterility is often the consequence ; or, it" children
are borne, they are generally feeble and unheal-
thy. Chlorosis should be viewed in a serious
li^ht. if it have been of long duration; if the cat-
ainenia, after having appeared, are gradually sup-
pressed; more particularly if the signs of anaemia
to a considerable degree be present; if emacia-
tion be rapid, with quick respiration and cough;
if the oedema of the extremities extend; if symp-
toms of effusion of serum into the cavities super-
vene; if hainatemesis or malaena occur; and if it
h:i\e resisted, in its earlv stage, a judicious treat-
ment. In the advanced progress of the disease,
especially when it is complicated, death some-
times takes place unexpectedly, but seldom with-
out evidence of excessive depression of the organ-
ic nervous influence, and of great deficiency of
the circulating fluid. (See Blood, § 42. et seq.)
11. V. Pathology. — A. Morbid appear-
ances. The adipose substance is sometimes not
much diminished ; but the rest of the soft solids
is flaccid and pale, from a deficiency of the red
blood. Effusion of serous fluid is commonly met
with in the large cavities, particularly those of the
pleura, pericardium, and peritoneum, and occa-
sionally also in the ventricles of the brain. The
lungs are frequently osdematous, or studded with
tubercles; the liver is often enlarged, and some-
times pale or tuberculated ; the stomach small,
pale, and contracted ; the mesenteric glands
slightly enlarged ; the ovaria and uterus, in some
instances, are imperfectly developed, or contain
small tumours ; the cavities of the heart are oc-
casionally somewhat enlarged, and their parietes
are generally flaccid and pale, or slightly atro-
phied; the blood is commonly pale, aqueous, and
deficient in coagula, — those which are found in
the large veins and auricles of the heart being
of a very light colour, and small. These are the
most common lesions ; but others are sometimes
noticed, both in the organs now mentioned, and
iu different parts, as in the spleen, pancreas, gall-
bladder, kidneys, &c. In some cases but little
change beyond the exsanguineous state of the va-
rious structures are observed, as in those recorded
by LlF.UTAUD.
12. B. Nature of the disease. — It has been
considered by many writers, and amongst others
by Wk.df.l, Korte, Cullen, Desormeaux,
and Roche, that chlorosis is chiefly dependent
upon debility or torpor of the nervous influence
developing and actuating the ovaria and uterus.
Hoffmann, Dab. win, and Saunders connect
it more immediately with obstructed function of
the liver. Hamilton refers it chiefly to torpor
of, with accumulated sordes in, the digestive or-
gans, particularly the lower bowel-; and An oral,
to the deficient and morbid state of the blood. If
we reflect upon the character of the associated
phenomena constituting the disease, in relation to
their causes on the one hand, and to their conse-
quences and terminations on the other, we must
necessarily arrive at the inference, that all the
organic functions — those of digestion, assimila-
tion, sanguifaction, nutrition, and generation, —
are inade |uately performed ; and, as the organ.s
devoted to these offices are intimately connected
one with the other, and actuated by the organic
nervous system, that consequents the vital ener-
27*
gy of this system is insufficient for the purposes it
is destined h> perform. ' We know that the evo-
lution of the sexual organs is owing to the state
of vital power; and that, by a reciprocal influence,
the activity of those organs increases all the other
functions of the frame. Therefore, as we com-
monly observe this disease at the period of puber-
ty, and associated with imperfectly developed or
performed function of the sexual organs, we must
necessarily infer, that the defective energy of the
organic nervous system delays or arrests their de-
velopement, and weakens their functions ; the
whole frame being thereby deprived of the stimu-
lus they impart to it. Consequently, if the causes
continue to operate, or if this system experience
no salutary or natural excitement, all the organic
functions languish more and more ; the chyle is
imperfectly prepared ; and sanguifaction and as-
similation are inadequately performed ; all the
phenomena of an advanced state of the disease
being the result.
13. VI. Treatment. — A. In its first stage,
this affection is generally soon removed, 1st, by
a due attention to the causes, — particularly the
mental or moral causes, — and by removing or
counteracting them as far as possible; 2d, by eva-
cuating all morbid and accumulated sordes from
the alimentary mucous surfaces, and regulating
the alvine secretions and excretions; and, 3d, by
imparting vigour to the digestive and organic
functions, and exciting at the same time the tor-
pid or imperfect actions and secretions of the ute-
rus. It will generally be necessary to ascertain
the causes of the affection, or to direct the atten-
tion of the friends of the patient to their nature,
tendencies, and the best means of counteracting
them. The medical treatment may be commenc-
ed with a moderate dose of calomel or blue pill,
and a few grains of powdered ginger, given at
bed-time ; and the following morning the secre-
tions should be more fully promoted and evacua-
ted by a dose of castor oil, or of the compound
decoction of aloes. After the bowels have been
freely evacuated, the following pills, or Form.
No. 877. should be taken daily, either during or
after dinner : —
No. 115. R Aloes Socot., Ferri Sulphatis, aa gr. ij. ,
Gum. Maslich. gr. j.; Pulv. Capsici gr. ij. ; Syrup. Simp.
vel Olci Carvoph. q. s. jVI. Fiant Pilula; duae.
During the use of these, it will generally be re-
quisite to promote the functions of the liver, and
excite the bowels, by the occasional repetition of
the calomel and ginger at bed-time, and the pur-
gative draught the following morning. In some
cases, the operation of the medicine may be very
advantageously promoted by an enema. In many
instances, nothing beyond what is now recom-
mended will be necessary ; but, in addition, a
course of chalybeate mineral waters may be di-
rected ; and, tinder every circumstance, exercise
in the open air, particularly on horseback, change
of air to the sea coast, a light nutritious diet, and
warm clothing, especially of the lower extremi-
ties, should be recommended. Flannel drawers
will be found of service in winter.
14. B. In its second stage, or in the more ob-
stinate cases, or when the affection is attended
with difficult or scanty menstruation, the tinct.
ferri ammoniati, or the tinctura guaiaei ammo-
uiati, and the phosphate of iron, are preferable to
the sulphate of iron, — the compound aloetic de-
318
CHOLERA — History and Symptoms.
coction being the most suitable aperient. When
pains of the head, or of the left side, or other
symptoms of hysteria, or palpitations, are com-
plained of, these medicines will be advantageous-
ly associated with camphor and hyoscyamus.
When the torpor of the uterine system is evident,
conium will, however, be preferable in such cases
to hyoscyamus, and may be given either with
these medicines, or with any of the ammoniated
spirits. In a few obstinate cases of the disease, I
have prescribed, with marked advantage, small
doses of the extract of nux vomica, and the
strychnine, as in Formula? 542. 565. and 907.
15. If the disease still persist, if the ankles
swell, or if dropsical symptoms come on, and the
menstrual evacuations continue suppressed, ad-
vantage will sometimes accrue from rubbing the
loins assiduously every night with either of the
liniments, Form. No. 296. and 311., and acting
gently on the bowels by means of the following
pills : —
No. 116. R Pilul. Aloes cum Mvrrha ~ j. -, Saponin
Castil. -^ss.; Olei Crotonis Tiglii TT| iij. Contunde bone
Bimul, et divide in Pilulas xxiv., quarum omni node capiat
unam, binas, vel tres.
16. In the course of practice, I have seen three
cases of the disease complicated with swelling of
the parotid and submaxillary glands. In order
to remove these tumours, I prescribed iodine in-
ternally, in small and frequent doses, giving also
at bed-time the aloes and myrrh pill. In these
instances, the menses gradually came on, and all
disorder vanished. I have on other occasions
observed a very marked emmenagogue, as well
as tonic effect, produced by the preparations of
iodine; and from these effects, as well as from
their efficacy in the above cases, I consider them
calculated to prove of use in certain states of ob-
stinate chlorosis. On some occasions, particular-
ly when chronic eruptions appear in the course
of the disease, sulphur will be found the best
aperient, and the following pills will be produc-
tive of benefit; but, in addition to those already
particularised, several recipes will be found in the
Appendix suited to the different forms and com-
plications of this affection, as well as of other de-
rangements of the uterine functions.
No. 117. R Soda? Sub-horacis 9 ij. ; Sulphur. Pra>cip.
5j.: Mucilag. Acacia; q. s. Fiant Pilule xxiv., quarum
capiat ties ter quotidie. (See also F. 519.)
No. 118. R Sub-horacis T) ij. ; Pulv. Capsici Annui
J)j.; Pilul. Aloes cum Mvrrha 5 j. ; Olei Sabinae q. s.
M. Fiant Pilulae xxx., quarum capiat binas ter die.
No. 119. R Ferri Sub-carbon. 3 j- ; Sulphur Depur.
J j. ; Mvrrha» Aloes Soc, Fellis Taur. Insp., aajss. Con-
tunde bene simul, et divide in Pil. gr. iv., quarum sumat
binas vel tres bis terve in die. (Recommended by RlCHTEH.)
17. Electricity and galvanism have been ad-
vised by Renaud and Sicaud la Fond for
this disease; and the ammoniated copper, by Bi-
anchi. The preparations of iron have very pro-
{ierly been directed, in conjunction with the alka-
ies and myrrh, by Willan, with stimulants and
bitters, by Schjeffer, with assafcetida, by
Hirschel, and with cinchona and rhubarb, by
Ranoe. Marriage has been suggested as a rem-
edy for chlorosis, by Wedel, Le Blanc,
Korte, and several others. Cold bathing has
been recommended by Brandis, and condemn-
ed by Darwin; and purgatives have been chief-
ly depended upon by Hamilton. The use of
mineral waters is certainly of much service in
chlorotic cases. Those of Driburg, Pyrmont,
Spa, Carlsbad, &c. on the Continent, have been
much praised by Brandis, Marcard, and
Krf.ssig ; and the chalybeate springs in this
country, by most practitioners. But equal advan-
tage will sometimes accrue, in the inveterate forms
of the disease, from the sulphureous and saline
waters, in addition to a judicious course of medi-
cine; and from the Bath and Buxton warm springs,
used in the form of baths. The warm hip-bath, some
salt and a little mustard having been added to the
water, is also beneficial. (See Menstruation.)
BlBLIOG. AND REFER. — Hippocrates, De Morb. Mill,
sect. v. p. 125. — Baltonius, De Morb. Mul. Opera, vol. ir.
pp. 66. 129. — Le Blanc, Ergo Venus Amantium Ictero.
Paris, 1616. ±- Hiiffinann, De Genuina Chlorosis Indole, v.
Opera, Supp. ii. part ii. p. 389. — Wedel, De Chlorosi seu
tcedis Virginium Coloribus. Jena?, 1681.; et De Venere
Medica et Morbosa, p. 23. — Korte, De Pallore Virginum,
Venerem indicante. Hal. 1759. — Ranoe, in Acta Reg. Soc,
Med. Haun. vol. iv. p. 111. — Richter, Die Specielle Ther-
apie, &c. b. iii. p. 752. — Darn-in. Zoonomia, vol. iii. p. 157.
8vo. ed. — Brandis, Ueber die Wirkung der Eisenmittd
und, &c. p. 113. — Schcejfer, in Hufeland's Journ. der
Pract. Arznevk. b. vi. p. 267. — Bianchi, in Brerit, Com-
ment. Med. dec. i. t. ii. n. 2. — Cullen, Works b_v Thomson,
vol. ii. pp. 293.384. — Hamilton, Observ. on Purgative
Med. he ch. iv. — Gagnion, Sur la Puberte de la Ferame,
et sur le Chlorosis. Paris, 1809. — Frank, Efemeridi Fisicc-
Medici, 1805. —Horn, Archiv fur Pract. Med. b. v. st. I.
p. 90. — Desormeaux, Diction, de Med. t. t. p. 166. —
Roche, Diet, de Med. et. Chir. Prat. t. v. p. 230.
CHOLERA. Syn. Cholera Morbus, Passio Cho-
lerica, Diarrhcea Cholerica, Auct. Lat. Cho-
liree, Cholerragie , Trousse-galant, Fr. Die
Gallenruhr , Brechruhr, Ger. Diarrhaa Cho-
lera, Young.
Classif. 2. Class, Nervous Diseases ; 3.
Order, Spasmodic Affections (Cullen).
1. Class, Diseases of the Digestive Func-
tions; 1. Order, Affecting the Alimentary
Canal (Good). II. Class, III. Order
(Author, in Preface).
1. Defin. Griping pains, followed by vomit-
ing and purging, very rare'y with flatulent eiiic-
tations and dejections, and always with spasms
of the extremities, particularly the inferior, and
anxiety.
2. I. History and Symptoms. — The term
Cholera has been in use since the time of Hip-
pocrates, who admitted two species of the dis-
ease, — one humid, the other dry, — /olioa t'yo»~,
Xohioa i»;g«. According to Celsus, it is derived
from /oXil} and 5*01, signifying literally bile-flux.
Trallian, however, derives it from /o?.us and
Qtw, intestinal flux. Galen, adopting the dis-
tinction established by Hippocrates, attributed
the humid cholera to the presence of acrid hu-
mours generated by the corruption of the food ;
and the dry cholera, to an acrid flatus. With
very slight modifications, this doctrine was re-
ceived by Fernel, Baillou, Sydenham, F.
Hoffmann, Bianchi. Sauvages, and Vo-
ce l, the difference chiefly consisting in the part
they ascribed to the bile, and to the state of this
secretion, in the production of the disease. Cul-
len directed attention, more accurately than his
predecessors, to its nervous and spasmodic char-
acters. Pinf.l was, however, the first who made
any considerable innovation on the opinion of the
Ancients as to its nature. He classed it as a species
of the genus of fevers, to which he applied the term
of 3Iiningo-gastric. M. Gf.offrov (Diet, des
Scien. Mt'd. t. v.) subsequently attributi d to it an
inflammatory character; and MM. Broussais and
(iiiAvii:i; afterwards contended that it consists
CHOLERA — History and Symptoms.
319
of inflammation of the mucous surface of the di-
gestive tube commencing with nervous symptoms.
;{. This diversity of opinions will be fully ac-
coonted lor in the sequel ; but I may ;it present
remark, that they may be in many respects re-
conciled, inasmuch as the particular form of dis-
order, for which each exclusively contends, fre-
quently exists as a part of the morbid condition
constituting the disease. After having paid con-
siderable attention to the literature of cholera, and
had much experience of all its forms — of two of
them in my own person — I consider that it ad-
mits of division into the following distinct va-
rieties: — 1st, The Cholera Biliosa, or bilious !
cholera ; 2d, Cholera Flatulenta, flatulent chol- '
era ; 3d, Cholera Spasmodica, the spasmodic
cholera, or Mart de Chien. As I believe the
disease which has appeared in recent times, and
has received numerous appellations, among which [
that of epidemic cholera has been most common-
ly used, to be a different malady from the other !
fonn> of cholera, I have treated of it in a distinct ■
article. (See Pestilence.)
L Cholera Biliosa, Bilious Cholera;
geliqa vyQtft Gr. ; Cholera Humida, Lat. ;
Cholerragie, Fr. ; Die Galltnruhr, Ger.
4. Defin. Copious and frequent vomiting and I
purging, at first of the alimentary and facal
matters, ivith a redundancy of bile, and spasms
of the legs and thiglis.
5. Causes, States, $-c. — This is the most com-
mon variety, and presents itself sporadically, en-
demically, and in an epidemic form. When it
appears sporadically, it is often slight, and of
short duration ; but is also sometimes extremely
severe, according to the state of the patient, and
nature of the exciting causes. In this form, it is
not infrequently met with during summer and
autumn, and but very rarely in spring. It gener-
ally attacks persons whose bowels and secreting
viscera have either been, for some time previous-
ly, in an inactive state, or become loaded by an
accumulation of retained, and thereby altered se-
cretions, particularly bile ; and arises from ex-
posure to the sun*s rays, or to a high degree of
temperature, and afterwards to cold, or cold com-
bined with moisture, particularly when applied to
the extremities ; from sudden atmospheric vicissi-
tudes, particularly cold easterly or northerly winds
after hot weather ; from cold miasmal night air, and
dews, after a warm sun ; cold drinks when the
body is overheated, and the incautious use of ices;
from cold, indigestible, or unripe fruits, particu-
larly melons, cucumbers, pine-apples, and poison-
ous or irritating ingesta of any kind ; the excessive
use of spirituous or malt liquors, and ingurgita-
tion ; from large doses of cathartic or emetic
drugs (Henry, Diss, de Choi. Morbo. Hal.
1740.); fright, particularly from thunder (Phil.
Trans. 16b7.) ; and from whatever occasions a
sudden depression of the vital energies of the
frame, and irruption of accumulated bile into the
duodenum.
6. The intimate relation existing between this
species of cholera, and the colica cibaria or sur-
feit, in respect of their causes, and several of their
symptoms, did not escape the notice of Syden-
b I m. I >r. ( ioon has also remarked the similarity.
But the distinctions are nevertheless sufficiently
marked, and more numerous than those writers
have assigned. The spasms of the extremities in
the latter ; the retraction of the testes, the copious
vomitings and alvino evacuations, with redun-
dancy of bile, particularly after the vomiting and
purging have continued for some time, and the
more acute character of the disease, are sufficient
to mark the wide difference between them.
7. In the endemic form, cholera is seldom pre-
sented to the observation of practitioners in north-
ern countries. To certain districts in some south-
erly climates, particularly between the tropics,
bilious cholera may be said, from the frequency
of its occurrence, to be strictly endemic, although
in a less marked degree than certain forms of
fever, or dysentery, or even hepatitis. Accord-
ing to my own observation, and that of several
friends whose range of experience has been great,
bilious cholera is very prevalent in situations which
are subject to emanations from decayed vegetable
matter, or putrid matter of any description ; par-
ticularly from swamps, moist grounds, the banks
of rivers, lakes, or canals, &c, and from foul
drains or cesspools, during warm seasons, or
wide and rapid changes of temperature ; or when
the thermometer rises high during the day, and
sinks low towards the night and morning.
8. Bilious cholera assumes the epidemic form,
sometimes in warm climates, and not infrequent-
ly also in temperate countries. In the Litter, this
form of the disease manifests itself only in the
months of July, August, and September, — the
number of cases increasing from June to Septem-
ber, when they are usually most numerous, and
diminishing rapidly in October. The epidemic
bilious cholera is generally most remarkable dur-
ing very warm summers and autumns, occurring
after a very rainy winter and spring, or after a
succession of wet seasons ; and when the days
have been warm, bright, and sunny, and the
nights comparatively cold or chilly, with heavy
dews. Owing to this state of season, the atmos-
phere is humid, and loaded with the miasms of
decayed vegetable and animal matter ; and, ow-
ing to this cause, together with the high range of
temperature, the bile is secreted in greater abun-
dance than usual, and is more liable to become
acrid or otherwise altered (see Liver — Dis-
ordered Function of the) ; and the cool nights,
particularly if the air be much loaded with ex-
halations set free from the soil by the rays of a
scorching sun, tend to check the cutaneous ex-
halations, and determine the chief current of cir-
culation and secretion to the abdominal viscera.
The use of fruit, which is usually abundant at
these seasons, also augments the frequency of the
disease, by promoting the operation of the other
causes. It increases the acidity of the prima via,
as contended for by Bertrand and Linnaeus,
renders the contents of the bowels, and the se-
cretions poured into them, of a more irritating
quality to the nerves of the stomach and intestinal
canal, and thereby often promotes the irruption
of acrid bile, which had been long pent up in the
gall-bladder and hepatic ducts, and which is a
great cause of irritation when it is suddenly pour-
ed into the duodenum.
!». During states of temperature and of season
which favour the extrication of exhalations from
the soil, the epidemic visitations of this variety, of
cholera arc more severe. In many cases, occur-
ring al these periods, the disease can scarcely be
imputed to the state of the biliary secretion mere-
320
CHOLERA — Duration and Prognosis.
lv. but rather to the internal congestions occasion-
ed by its exciting causes, giving rise to spasmodic
contractions of the alimentary canal, to vomiting
and purging, and to spasms of the voluntary
muscles, &c. ; the bile accumulated in the gall-
bladder and hepatic ducts being let loose and
thrown into the intestines only subsequently to
the seizure, and owing to the vomitings and
purgings which usher it in. In some cases, in-
deed, this irruption of bile is prevented from
taking place, until an advanced stage, by spasm
of the common duct, extended to it from the
duodenum, as more commonly occurs in the
third variety of the disorder. When the various
causes now referred to combine to produce the
disease, particularly in persons of a nervous and
irritable temperament, and who have neglected,
for a considerable time before, the state of the
bowels, and secretions poured into them, it can-
not be a matter of surprise, that its symptoms as-
sume the severe form described by Sydenham.
10. Symptoms. — Bilious cholera, in whatever
state it occurs, differs chiefly in its degree of se-
verity. It is chiefly characterised by anxiety,
and by painful and violent gripings, evidently
proceeding from spasmodic contractions of the
alimentary canal, taking the duodenum for their
point of departure, and occasioning the continued
or frequently repeated rejection of their contents
by vomiting and purging. Owing to the ana-
tomical connection of the great sympathetic or
ganglial system with the voluntary nerves and
other parts of the frame, the spasms extend to
the abdominal muscles, and muscles of the lower
extremities, — the testes being forcibly retracted
to the abdominal ring, — and are accompanied
with great pain. The tongue is dry or clammy ;
thirst is very urgent, and the urine scanty and
high coloured. The pulse is at first full and fre-
quent ; but, as the disease continues, it becomes
smaller, weaker, and more rapid. At more ad-
vanced periods, the spasms sometimes extend to
the arms and hands. The symptoms often con-
tinue with little variation for some hours ; but,
when the attack is severe, seldom without the pa-
tient's strength being greatly reduced ; the coun-
tenance at last becoming anxious and collapsed ;
the breathing frequent, interrupted, and laborious,
and sometimes with singultus ; the pulse feeble,
irregular, and intermittent ; and the extremities
cold or clammy, with leipothymia or fainting.
1 1. Duration and Prognosis. — The cholera of
temperate climates is seldom fatal, unless when it
is more than usually prevalent, after very rainy
and hot seasons. But, when neglected or im-
properly treated, especially at such times, a fatal
issue may occur, but very rarely in less time
than twenty-four hours. In milder cases, it may
extend to two or three days, and then terminate
either favourably or unfavourably, most com-
monly the former ; the vomiting, purging, and
spasms subsiding, and entirely ceasing, the pulse
becoming slower and fuller, and the countenance
resuming its former expression. An unfavourable
issue is indicated by a continuance of the purging
and vomiting, particularly after substances are
taken into the stomach, a hurried, gasping re-
spiration ; great frequency, feebleness, irregular-
ity, and intermissions of the pulse ; collapse and
paleness of the countenance ; coldness and pulse-
lessness of the extremities, with anxiety, and fre-
quent fuintings, &c. Tn general, however, even
when left to itself, the disease operates its own
cure in the course of some hours ; or it continues
for one, two, or in milder cases for even three
days, and ceases by degrees ; the morbid secre-
tions which excited the attack having been evacu-
ated, and the irritation they occasioned having
subsided. Although nature may accomplish this
without aid, yet the assistance of art is generally
required to ensure its attainment. The febrile
symptoms attending the early stage of the dis-
ease, unless in some instances of its epidemic
prevalence, are merely the consequence of the
pain, spasms, vomitings, and general commotion
of the nervous system, and usually subside im-
mediately these disorders are allayed.
ii. Cholera Flatulenta, Flatulent Chol-
era; -/(y'/Arta \voa, Gr. ; Ch. Sicca, Lat.
12. D efin. Vomiting and purging rare, some-
times retellings; gripings and spasms of the ab-
dominal muscles, with great and oppressive flatu-
lence, temporarily relieved by eructations, and
dejections of flatus.
13. This variety was formed by Hippocrates,
continued by Sydenham, and, after having been
discontinued by the majority of' modern writers,
who, if they at all remarked it, considered
it rather as a form of colic than of cholera, was
again distinguished as a species of this latter dis-
ease by Dr. Good. It is very rarely met with in
practice ; and generally holds an intermediate
rank between flatulent colic and cholera, some-
times approaching more nearly to the former.
In none of the very few cases of this description
which have come before me (not exceeding two
or three), have I observed a natural secretion of
bile ; but, on the contrary, the liver has evinced
signs of great torpor, and the whole digestive
organs have been manifestly enfeebled, long pro-
tracted dyspepsia and hypochondriasis having ex-
isted previous to the attack.
14. This form of the disease is chiefly charac-
terised by spasms of the alimentary canal, ap-
parently excited by acrid, rancid, and indigestible
substances ; and by an irritating gas, either se-
creted from the digestive mucous surface, or gen-
erated from the decomposition of the imperfectlv
digested food. (See articles Colic and Flatu-
lency.) The painful and flatulent griping is ac-
companied with severe spasm of the abdominal
muscles, anxiety, occasional retchings, flatulent
irritations, and calls to stool, with slight tenesmus,
and very scanty, offensive, pale coloured, and
watery evacuations, with flatus. Considerable
depression of the powers of life, acceleration of
pulse, pale, anxious countenance, coldness of the
extremities, and sometimes alarming sinking, su-
pervene, when the disease has been neglected.
15. Causes. — This rare form of cholera chiefly
appears in the debilitated, and those of a melan-
cholic temperament ; and is generally excited by
a surfeit, by cold drinks when the body is over-
heated, by the use of cold or unripe fruits, par-
ticularly melons, water-melons, cucumbers, un-
ripe plums, mushrooms, and animal poisons, es-
pecially the rank parts of bacon, or tongues, sau-
sages, &c. when kept too long, or insufficiently
cured ; also by unhealthy or stale fish, and by
cold or moisture after having been exposed for
some time previously to a high range of tempera-
ture. The author was jery recently the subject
CI IOLER A — Spasmodic.
321
of an attack as described above, from having par-
taken of tongue kept too long after having been
imperfectly cured In this case the affection was
much more nearly allied to cholera than to colic ;
and this be is the'hetter enabled to state, from the
circumstance of having been the subject of the
other varieties of the former disease at different
periods of his life.
iii. Cholera Spasmodica, Spasmodic Cho-
lera; Mort de Chieu, Fr.
16. Defin. I romiting and purging of watery
matters, toithout any appearance of bile ; spasms
violent, and extending generally through the
frame ; speedily folio tied by sinking of the pow-
ers of lit')'.
17. This variety of cholera may be said to be
endemic in some intertropical countries, particu-
lar! v in the eastern hemisphere, where it has oc-
casionally assumed also an epidemic form, nearly
approaching the remarkably fatal pestilential cho-
lera, which appeared in Bengal in 1817, and
which has subsequently spread over all Asia, Eu-
rope, and part of Africa. (See Pestilence.)
It has been very imperfectly noticed by Bontius,
Curtis, Paisley, Sonnerat, and Girdle-
stone; but its nature and treatment were very im-
perfectly known, until Dr. Johnson described
its symptoms, and pointed out a more successful
method of cure than had previously been employ-
ed. Several of the cases of cholera, which Syden-
ham has described as epidemic in 1669, seem to
have been of the variety now under consideration.
is. Causes, symptoms, $c. — This form of
cholera proceeds from exposure to cold, or to a
cold, raw, and moist atmosphere, or to the night
air loaded with terrestrial emanations after the
prevalence of warm weather, or exposure to a
hot sun; or, in a word, it generally results from
a more intense grade of the same causes, particu-
larly the exhalations from the soil, that produce
the bilious cholera. It commonly commences
with chilliness, sometimes amounting to a rigor or
shiver ; soon followed by gripings, and frequent
purging of a watery, slimy, or sero-mucous matter,
which is sometimes thrown oft' with great force.
To these succeed nausea and retchings, with the
ejection of a watery fluid ; anxiety at the epigas-
trium ; spasms of a violent, painful, and tonic
character, attacking the muscles of the abdomen,
thighs, le^s, thorax, and, lastly, the arms and
hands; a small, quick, and contracted pulse; great
thirst, and immediate rejection of whatever is tak-
en into the stomach. As the disease proceeds,
the pulse becomes weaker and smaller; the spasms
more general ; the purging constant and painful,
generally with tenesmus ; the vomitings are re-
newed, upon the ingestion of substances into the
stomach; and the powers of life rapidly fail. Dur-
ing this time, the fluids evacuated from the stom-
ach and bowels present no appearance of bile, al-
though occasionally bile is seen in the evacuations
to a small extent. In the course of a few hours,
the features shrink, the hands and feet become
cold and clammy, the exacerbation of the r-]>;isuis
force out a cold clammy sweat on the face and
breast; the pulse is extremely small and weak, or
nearly disappears; — in a case which came before
me in Africa, in 1816, the pulse could scarcely be
felt font hours from the attack; — the spasms as-
sume more of the clonic character; and the con^
tents of the stomach are now, in the more dan-
gerous cases, sometimes thrown off, without any
effort or retching. Commonly, during all this
time, feecal matters, and the biliary secretions are
retained, apparently owing to the extension of the
spasm from the duodenum to the common biliary
duet, and to Bpastic constrictions of parts of the
colon ; the epigastrium and hypochondria being
sore, tense, and tumid. When the disease is
treated with decision, the vomitings cease ; free
evacuations, with a discharge of bile, take place;
and the patient soon recovers. But if neglected,
or improperly managed, the powers of life fail
very rapidly; the eyes sink, and are surrounded
with a livid circle; the countenance assumes a re-
markably anxious cast, or is pale, wan, and shrunk ;
and the spasms extend to the very fingers. The
breathing now becomes extremely laborious; the
patient is restless; and at last is carried oft', some-
times in the space of ten or twelve hours.
19. Such is the progress of spasmodic cholera,
as it was observed by the writer in the years 1816
and 1817, in an intertropical climate, and as he
then experienced it in his own person. About
the same time other cases of a milder form oc-
curred, and presented the characters described as
constituting the bilious variety of the disease,
with which the writer had also been formerly
attacked in this country, in the end of September,
1815, — a season of unusual warmth, — when
he was attended by his friend Mr. Qukjde.
There can be no doubt that the first and third
varieties of cholera chiefly differ in degree, and in
the circumstance of the latter arising, in most
cases, from the operation of causes of a more in-
tense grade than those which induce the former.
But as additional phenomena are developed in
the latter variety, and other symptoms assume a
different or modified character, and especially as
a distinct method of cure is requisite to its remov-
al, the propriety of distinguishing it as a separate
form of the disease is manifest.
20. II. Diagnosis. — This disease can be mis-
taken only for the pestilential cholera, or for poi-
soning by acrid substances. The diagnosis be-
tween this and the pestilential malady is fully
pointed out in that article. It is often difficult to
distinguish between the different varieties of true
cholera (the pestilential disease which has been
very generally viewed as a form of cholera being,
in my opinion, very different in all its relations
from this), and the disorder occasioned by irritat-
ing poisons. Dr. Christison, in his very able
work on Poisons (p. 93.), has assigned the more
rapid termination of poisoning, in fatal cases, as
a ground of distinction. But he supposes that
dentil from cholera occurs at a later period than
it usually does : and, hence, this source of diag-
nosis cannot be much relied upon. Death from
irritating poisons usually takes place within thirty-
six hours, and sometimes within twelve hours;
being seldom delayed beyond sixty hours ; but
the fatal i>sue in cholera is very rare, he consid-
ers, in less than three days. I believe, however.
that, although death from the common cholera
of this climate is rare, it more frequently Occurs
from twenty-four hours to eight and forty, than
,it a later period. Greater dependence is to be
placed upon the appearance of the matters vom-
ited, which are more frequently sanguinolent
after irritating poisons than in cholera. But the
chief diagnostic sign is the sense of heat, acridity,
322
CHOLERA — Causes — Treatment.
or burning in the throat, descending in the course
of the oesophagus to the stomach, which is so
much complained of in poisoning, and precede*
•the vomiting. In cholera, when a similar sens-
ation is felt, it is usually confined to the region of
the stomach, and is consequent upon the vomit-
ing.
21. The diagnosis between cholera and other
diseases which resemble it the nearest is easy.
It is distinguished from colic, by the frequency of
the vomiting and purging, the spasms of the mus-
cles of the extremities, and the greater accelera-
tion of pulse ; — from diarrhoea, by the vomiting
and the spasms; and by the quickness of the pulse
in the latter stage of cholera; — from dysentery,
by the tenesmus, bloody stools, absence of the
spasms of the extremities, and of the vomiting ;
or the occasional presence merely of this last
symptom in that disease; — from ileus, by the ap-
pearance of the matters vomited, and the obstruc-
tion of the bowels constituting that malady; —
and from painters' colic, by the absence, or oc-
casional occurrence only, of vomiting ; by the
constipation, the paralytic signs, &c. charac-
terising that disorder; and by the history of the
case.
22. III. Causes and Pathological
States. — The remote causes have been already
noticed in connection with the symptoms and
forms of the disease they occasion. A. As to
the morbid appearances, they may be staled as
generally being very slight in rapidly fatal cases,
and consisting merely of irritation of the mucous
surface of the duodenum, stomach, and small in-
testines; but without any change of structure. If
death takes place at a more or less remote period,
injection of the capillaries, with congestion, some-
times with ecchymosis, and enlargement of the
mucous follicles, is observed more or less exten-
sively— either in streaks or patches — in the
inner surface of the digestive tube. In fatal cases
of the third variety of the disease, the liver has
been found congested, the gall bladder and he-
patic ducts filled with dark coloured inspissated
bile, and the common ducts sometimes constrict-
ed or obstructed.
23. B. The pathological state constituting the
disease, seems to consist of irritation of the mu-
cous surface of the digestive tube, commencing
in the duodenum, and extending in each direction
— to the stomach, small intestines, and along the
common duct, to the gall-bladder and liver, —
with increased action of the muscular coats of
these viscera, and determination of the circulating
fluid to them. This irritation or morbid excite-
ment, owing to the connections of the organic
nerves supplying these parts, is propagated to the
spinal nerves, by which the muscles of the abdo-
men and extremities are affected bv painful and
violent contractions ; and it is chiefly owing
to the exhaustion of the vital manifestations of
the organic system of nerves, and to the frequent
and profuse discharges, that a fatal issue takes
place : the circulating organs, which are actuated
by this system, being, in consequence, incapable
any longer of performing their functions.
24. A question may arise as to whether the
disease commences with the irritation of the mu-
cous surface of the duodenum and adjoining por-
tions of the digestive tube, or with determination
of the circulation to the liver and adjoining vis-
cera, and an irruption of bile, which has become
more than usually irritating, owing to its reten-
tion in the biliary apparatus, or to its formation
from redundant or noxious materials accumulated
in the circulating fluid (see Blood, § 119. and
120.), during high ranges of temperature, and
moist miasmal states of the air. It is not very
material which of these phenomena is the first to
occur : probably either may precede the other ;
and even, in some cases, that both may be near-
ly coetaneous. It is, however, most "likely that
the procession of morbid phenomena described
above (§ 22.) obtains in the great majority of
cases.
25. C. The different states of cholera may ter-
minate differently from either of the wavs already
noticed (§ 10. 14. 18.): in may pass into inflam-
mation of the stomach or of the intestines, or of
both; it may also lapse into dysentery, or into a
regular attack of gastric, bilious, remittent, or in-
termittent fever. The supervention of some of
these diseases upon, or their association with,
cholera, has been long since noticed bv Morton
and Torti ; and, more recentlv, bv Jackson,
J. P. Frank, and Schmidtmann; and must be
familiar to experienced practitioners, particularly
in warm, moist, or miasmal climates. In many
such instances, this mode of termination is to be
imputed to the nature of the exciting causes, the
constitution of the patient, and sometimes also to
the premature arrest of the evacuations bv opium,
and the neglect, subsequently, of procuring the
discharge of morbid secretions by purgatives, &c.
26. IV. Treatment. — Demulcents, diluents,
and weak broths or soups, have been very gener-
ally given at the commencement of a choleric at-
tack, particularly of its first or common form,
since the time they were recommended by Sy-
denham. In slight cases, and at its beginning
merely, this is as judicious treatment as can be
adopted. But in the more severe seizures, and
particularly if a delay of two or three hours has
taken place in applying for or procuring medical
aid, much more decided means should be resort-
ed to. In such cases, it is no longer necessary to
promote the evacuation of the offending matters,
which have generally by this time been expelled.
It is preferable, therefore, in these, and, indeed,
under most circumstances — 1st, To allay the
irritable state of the stomach, the spasms, and
other urgent symptoms of the disease; 2d, To
remove, bv appropriate means, as blue pill, dilu-
uents, mucilaginous fluids, and deobstruent aperi-
ents and enemata, whatever morbid secretions
may be retained or re-accumulated; 3d, To pre-
vent the occurrence of inflammation of the diges-
tive mucous surface, by sheathing the surface of
the bowels from the irritating action of the mor-
bid and accumulated secretions during their dis-
charge; 4th, To support the powers of life when
they appear to sink ; and, 5th, To restore and
promote the functions of the various emuncto-
ries.
27. A. Opium, generally in the form of pill, is
the medicine most to be depended on for the ac-
complishment of the first intention, especially in
mild cases of the first variety. From one to three
grains of it may be taken at once; but. in more
severe attacks, and in the second and third varie-
ties, it is preferable at first to combine it with
from ten to twenty grains of calomel, which, in
CHOLERA — Tr e atm f nt.
323
a large dose, is one of the most quickly effica-
c a means we possess of diminishing vascular
irritation of the internal surface of the stomach
and small intestines. When a large dose of these
remedies ban been given, a repetition may nol
even he required ; but, in the severe states of the
disease, it will be necessary to repeat it once or
even twice, after an interval of from three to six
hoars, or even longer, according to the urgency
of the case. If the attack require the exhibition
nt" two or three such doses of calomel, little ap-
prehension of its affecting the mouth should he
entertained, as such a state of disease admits not
el' the retention of the whole of it ; and, when it
is necessary thus to repeat it, the biliary organs
will derive benefit from it [f the first doses of
opium and calomel be not retained, they should
be immediately repeated. In plethoric or robust
subjects, when the pulse is fully developed, and
the spasms severe, especially in the third variety
of the disorder, a full or moderate bleeding may
be directed ; but it should be performed early,
and restricted to young or robust subjects. This
practice was employed by Dr. J. Johnson in
India ; and subsequently adopted by numerous
other practitioners, as well as by myself. 1 should,
however, state, that 1 have prescribed it only for
Europeans who had recently arrived in a warm
climate ; hut natives, or acclimated Europeans,
require a different treatment (§ 80, 31, and 32.).
In slighter cases opium, if not too early exhibited,
will lie sufficient to cure the disease ; and the in-
s must be few, in which its use, in some
form or other, can be dispensed with. Its supe-
riority to other medicines in cholera has been ad-
mitted by Linn £08 (Morbi Naut. India. Ups.
1768.), Thomann (Annalen «<Z1800.), Young
(On Opium, S,-c. p. 30'.), Q,uarin (Animadver-
siones l'rarl. pp. 204 — 207.), and by most recent
writers. Reide (View of Dis. of the Army,
p. 63.) advises it to be given in copious draughts
of tepid diluents ; Percival (Essays, vol. ii.
p. 405.), in enemata ; and Sydenham (Opera,
p. 177. ed. Lug. Bat.), after diluents and demul-
cents had been freely given, and the offending
matters removed. When, however, vomiting
and purging have existed some time, more par-
ticularlv in severe cases, opium ought to be im-
mediately exhibited ; but in order to secure the
effect of it, or of calomel combined with it, the
patient should now refrain from diluents, in order
that the rejection of the medicines may not be
risked by them ; and should merely rinse his
mouth frequently with some cooling beverage,
swallowing only minute portions of it, at short in-
tervals. Sydenham has very justly remarked,
— and the importance of the observation has been
acknowledged by Frank and Schmidtma.vn,
— that when opium is given too early, much dis-
order of the bowels and abdominal organs, with
more or less fever, continues afterwards to be
complained of; evidently owing to the arrest of a
salutary effort, and the retention of morbid secre-
tions. But the second intention of cure (§ 26.),
and the combination of calomel with the opium,
have for their objects to prevent this result in cases
where all the morbid secretions may not have been
expelled before the opium has been administered.
28. It Is not unusual to find, upon being called
to a case of the disease, that aperients had been
freely exhibited with the \ iew of promoting the
evacuation of the offending secretions. But this is
a hazardous practice, ami is often, as Sydenham
h is remarked respecting it adding fuel to the fire:
its propriety at a later period, when the vomiting
and spasms have disappeared, will be admitted.
2,'t. If the spasms, pain at the epigastrium, and
internal heat, be severe, very warm fomentations,
or the hot bath at about 100J or 102J, are of
much service if used early in the attack. But
neither these, nor blisters, nor sinapisms, are so
instantly and perfectly remedial as the turpentine
fomentation applied over the abdomen. (See Art.
CAECUM, §32.). Several authors have recom-
mended the use of cold or iced fluids, with a view
of allaying the heat complained of in the stomach.
They deserve notice chiefly from being recom-
mended by Aretjecs (Curat. Acut. Morb. 1. ii.
ch. iv.), C/elius Aurkltanus (p. 258.), Lien-
ard (Ergo Cholera Morbo Erigidus Polus.
Paris, 1626.), Hoffman (De Cholera, obs. v.
Opp. iii. p. 173.), Cleghorn (Diseases of
Minorca, p. 222.), Penada (Osservazioni, fyc,
IVeigel Hal. Bibl. b. iv. st. 1. p. 134.), and Pan-
zani (Beschr. der Krank. von Istrien, fyc).
Bartholinus (De Usu Nivis Med. p. 141.) ad-
vises the application of ice over the epigastrium ;
and Birnstiel, cold vinegar to the same region.
The nitric acid drink has been much employed in
India in cases of cholera. A favourable account
of it in this disease was published by Sir J. Mac-
grigor, in' Duncan's Annals for 1802. And
Mr. Hope has recently recommended it conjoined
with opium, in the cholera of temperate climates.
30. When the severity or duration of the more
urgent symptoms has occasioned feebleness of
pulse, with cold skin, and other symptoms of ex-
haustion, restorative means are requisite. Am-
monia, camphor, the tethers, brandy, Cayenne
pepper, the various aromatics and spices, are
now the most serviceable medicines, and should
be given frequently, and in moderate doses,
variously combined, and generally with small
quantities of opium. Although at an earlier
stage it was necessary to prescribe opium in a
large dose, yet at this period very small quan-
tities only ought to be given, particularly if ex-
lubited frequently. Any of the following will be
now of advantage : —
No. 120. R Aq. Anethi % j. ; Magnes. Carbon. 9 j. ;
Spirit. Ammon. Arom. TT| xxvj.; I'ulv. Capsici gr. iij.-;
Tmct. OpiiComp. (F. 729.) Tl| x.; Confect. Aropi. gr. vij.
M. Fiat Haustus, secundis horis capiendus.
No. 121. R An. IMenth. Viriil. 3 x. ; Ammon. Carbon,
gr. v. ; Magnes. Calcinat. 3 »• i Tinct. Capsici An. TT) xij. ;
Spirit. Pimento ^j.: Tinct. Opii. Comp. IT) xij., Olei Cin-
nam. IT] j. M. Fiat Ilaustus.
No. 122. R Infus. Caryoph. 3 x.; Magn. Calcin. £) j.;
Tinct. Cardamom. Comp. 3 j- > Tinct. Opii Camphor.
(F. 728.) 3j.; Syrup. Zingiberis 3 j. M. Fiat Haustus.
31. In this stage of the disease, the application
of sinapisms or blisters to the epigastrium, a3
directed by Celsus (I. iv. ch. xi.), Morelli
(Nuovo Giornale di Milano, 1792.), and Aas-
kow (Acta Iieg^ Soc. Med. Haun. i. p. 154.) ;
of stimulating and irritating frictions of the sur-
face, as advised by Aretjeus (Cur. Acut. Morb.
I. ii. ch. iv.), Cadmus Aurelianus (p. 257.),
and Alexander Trali.es (1. v. ch. vi.), and
of warm analeptic and aromatic epithems and
embrocations, as prescribed hv Morton and
(riuARiN (Animad. Pract. p. 206.), may be re-
sorted to. In the third variety of cholera. —
which differs from the first chiefly as to se\ erity
324
CHOLERA — Treatment.
and the more prolonged obstruction to the flow
of bile in its early stages, or throughout its course
in fatal cases ; — in addition to the means already
stated (§ 30.), the external measures now men-
tioned may be employed ; but they are much less
efficacious than the embrocation noticed above
(§ 29.). One of our principal objects in this state
of the disease is to procure a discharge of bile
into the intestines. Large doses of calomel, with
opium and camphor, are the internal remedies
most to be depended upon for the attaining of this
end. But, if the energies of the frame begin to
sink before it be obtained, it will be necessary to
have recourse to diffusive stimulants in order to
counteract the depression : at this period the calo-
mel either may be left off, if a sufficient quantity
has been taken, or may be combined with full
doses of ammonia or camphor ; the stimulants
already prescribed (§ 30.), or warm brandy and
water, being also given at short intervals, or in
larger quantities. The second variety requires
the measures now stated, with the addition of
purgative and emollient enemata. If the flatulence
be urgent, F. 135. 150. will be productive of im-
mediate relief.
32. The natives of warm climates, or Euro-
peans acclimated in them, require from the be-
ginning, that the calomel should be combined as
now advised ; and that aromatics, antispasmodics,
and anodynes, be given early in the disease. The
large quantities of hot spices usually employed by
these classes of persons, as well as the nature of
the attack resulting from the constitution, natural
and acquired, of those affected, render it necessary
to prescibe aromatics and hot spices, especially
Cayenne pepper, in large proportions, in con-
junction with opium, camphor, &c. and to have
recourse to the external means already noticed,
almost from the commencement of the attack-
Afterwards when urgent disorder has subsided,
calomel, or blue pill, with aromatics, followed
by warm stomachic aperients, and by purgative
and antispasmodic enemata, will be required.
33. B. Having relieved the more urgent symp-
toms, whether of violent irritation or of conse-
quent exhaustion, and having allowed some time
to elapse in order that the viscera may recover
their functions, it will be necessary to promote
the discharge of the secretions which may have
accumulated during the calm which had been
procured, particularly when the inordinate action
is followed by complete torpor of the bowels. In
cases where calomel had been freely exhibited,
mild stomachic aperients will be all that is neces-
sary ; but they should be given with caution, and
at a time when there appears no risk of re-ex-
citing the choleric attack, which may be readily
done by the too early exhibition of purgatives.
It will therefore, at first, be better to trust chiefly
to enemata ; to prescribe the mildest aperients
only, and when they are absolutely required ;
and to administer chiefly mucilaginous fluids, &c.
If calomel have not been previously given, a
moderate dose, either of it or blue pill, at bed-
time, will be even now necessary ; and the latter
may be repeated every third night, an aperient
draught, or a dose of castor oil, being taken
on the mornings following, for some time sub-
sequently, until the alvine functions assume a
healthy state. But if the stomach still remain
irritable, it will be preferable to prescribe merely
a blue pill, or the hydr. cum creta, at bed-time,
and employ enemata.
34. C. If, during the progress of disease, or
when the urgent symptoms have somewhat sub-
sided, the pulse continues frequent, sharp, or
constricted, with tenderness at the epigastrium,
a furred tongue, great thirst, nausea, and retch-
ings upon substances being swallowed, and gen-
eral uneasiness, we should conclude that inflam-
mation of the stomach and upper part of the
intestinal tube has come on. In this case, from
twelve to twenty-four leeches should be placed
upon the epigastrium, and afterwards a succes-
sion of warm poultices, the last of which should
be followed by the terebinthinate fomentation
already noticed. In some cases, it will be ne-
cessary, from the severity of this consecutive dis-
ease, and the patient's habit of body, to bleed
from the arm, previously to applying leeches.
In cases where the fomentation is not employed,
sinapisms or blisters may be directed, but not
until depletion has been carried as far as may be
considered either necessary or judicious; and small
doses either of hydrarg. cum creta, with magnesia
or sub-carbon, of soda, may be given every four
or five hours ; or of nitrate of potash, and almond
emulsion, or any other demulcent substance, with
the frequent use of enemata. The termination
of cholera in gastric, bilious, remittent and inter-
mittent fever, or in dysentery, and the circum-
stances to which I have imputed this occurrence
(§ 18. 25.) ought not to be. overlooked, but should
influence our practice both at the commencement
and during the course of the attack. When it
has passed into these diseases, it must necessarily
be treated according to the new form it has as-
sumed.
35. An attack of cholera soon occasions great
exhaustion ; and sometimes so great sinking, that
even fatal syncope has occurred from allowing
the patient to remain too long on the night-chair,
or suddenly to assume the erect posture. In
severe cases, thcpatient must be kept in a hori-
zontal position ; and besides the medical treat-
ment already prescribed in this state of the dis-
ease, mild demulcent soups, beef tea, chicken
broth, jellies, and sago or arrow-root, with wine,
may be given him. In cases of this description,
the exhibition of aperients by the mouth must not
be ventured on during convalescence, at least not
for several days ; and even then with circum-
spection, and in conjunction with stimulants or
tonics. We must endeavour to regulate the se-
cretions by gentle alteratives, and to procure
their discharge by enemata. During convales-
cence from cholera, strict attention should be
paid to the state of .the digestive functions. The
patient ought to abstain from all irritating and in-
digestible kinds of food, and heating liquors, and
from overloading the stomach. Change of air,
gentle travelling, and moderate exercise, are ex-
tremely conducive to perfect recovery.
Bibliog. and Refer. — Hippocrates. Epid. v. 1144.
1159. — Pietre, Ergo Cholera? Morbo conrenit Venawotio.
Paris, 1624. — Bontius, Med. Indor. cap. 6. — Ballonius, Op-
era, vol. i. n. 55. 57. vol. iii. n. 65. — Reidlin, Lin. Med. p.
273. 1695.— Morton, Pvretologia, sive de Morb. Acut. &x.
pp. 35—40. 133. 4lo. 1696. 6enev. edit. — Bianehi, Hist.
Hepatica, p. 117. — Hoffmann, De Cholera, Opp. vol. iii. p.
174. — Torti, Therap. Special, ad Febres Period. Perni-
ciosas, &c. 1. iv. c. i. p. 250. 4to. Franc. 1756. — Heberden,
Trans, of Coll. of Phys. Lond. vol. Si. p. 153.— Porter, Ed.
Med. Essays, vol. iii. p. S57. — Stoll, Rat. Med. part iii.
CHOLERIC LEVER OF INFANTS — Symptoms.
325
p. f,.(. _ /.;..,. j. On thr Pi«. of Hot Climates, if. p. 248.—
. V, arks, .-!. by Thornton, 1827, v..l. i. p. 301., and
vol. ii. p. 476. — Dick, in Medical Comment, vol. \. [>. 12.
•i, (in l'.l.iilc Piicases, vol. ii. p. 27. 8vo. Loml.
1820. ./. /'. Frank, De Ourand. Homin. Morb. lib. r. pari
ii. „. ; . in,- Specielle Therapie, b. iv. p. 157.
y. ,;, .1 iseaaea of Intertrop. Climates, p. 270. 4ili
a\. CMsho/m. On Dis. of Tropical Countries, &c. p. 85.
Svo. Lond. 1822. — Sehmidtmann, Summa Observat. Med.
vol. ill. p. 405. Hit. 1826.— Hope, in lidin. Med. and Surg.
Journ. vol ixvi. p. 41.
Cholkric Fkvfr of Txfants. Cholera
of Children, Cholera Infantum, Rush and
Dewees. — Classif. III. Class, I. Order
(Author).
1. Dkfin. Vomiting and purging, with fever
grncrally of a remittent type, irregular spasmodic
convulsions, and rapid emaciation, attacking in-
fants and children.
2. I. History, &c. — This disease attacks
children during the summer and autumnal months,
and sometimes as early as April and May. It oc-
curs at any period, from the age of two or three
- to that of several years. After this age,
the same causes which produce it occasion, ac-
cording to their combinations and the state of pre-
disposition of the patient, either fever of some
kind, or cholera, or inflammation of the stomach
and bowels.
3. A. Causes. — Tt is often independent of any
disorder from dentition, as shown by the age at
which it frequently occurs, and the seasons to
which it is almost entirely limited. That it is not
always caused by acid, acrid, or stale fruit, and
indigestible substances, has heen proved bv ex-
amination of the history of numerous cases; al-
though, doubtless, this cause, as well as dentition,
will contribute to its occurrence. It is certainly
not owing to worms, as fat as my own observa-
tion may be depended upon; besides, it is often
met with at an age anterior to that at which worms
form in the intestinal canal; and, in fatal cases,
worms are not more frequently expelled from the
bowels than in mauy other diseases, as remarked
by Dr. Rush. But it is evidently owing to the
influence of high ranges of atmospheric tempera-
ture acting upon malarious localities, and upon
close, low, thickly inhabited, and imperfectly
cleansed and ventilated streets, closes, and lanes,
•1 by the above causes, particularly by pre-
mature weaning, want of the mother's milk, errors
in diet and clothing, &c That it originates
chiefly in an atmosphere loaded with putrid or
mephitic effluvia is shown by its occurrence
among children thus circumstanced; by its fre-
quency during the seasons already specified in
temperate climates, particularly in localities which
possess the materials or sources of such exhala-
tions; bv the periods of its prevalence among
children in warm climates, and in America; and
by its appearance at the same time with the cho-
lera of adults, and with remittent and intermittent
fevers. This origin is further shown by the cir-
cumstance of its being generally accompanied with
fever, frequently of a remittent type. In some
mtv unhealthy climates within the tropics, the
children born of European parents seldom reach
two or three years without having an attack; and,
in some places, scarcely one will survive this aire,
if allowed to remain in them, — this disease cutting
them oft before they reach a year or two, and
often when they are only two or three weeks old.
According to Dr. Dewees, it is one of the most
28
fatal diseases of children in the large towns of the
United States; and it is certainly not an infrequent
malady of the same class of" patients in this me-
tropolis.
4. B. Symptoms.— The choleric fever of infanta
sometimes begins with diarrhoea.; but more com-
monly with violent vomiting and purging which
are soon followed by fever. The matters vomited
are usually yellowish or greenish yellow; and the
dejections are slimy, watery, sometimes offensive,
with a soar or putrid odour, and tinged with blood.
The natural faeces are generally retained, although
small lumps are occasionally passed. In some
cases, at an advanced stage, they consist nearly
altogether* of water, or of substances recently
taken. The muscles are irregularly and spas-
modically convulsed or contracted; the child is
much pained, is restless, and throws the head
backwards and forwards, the lower limbs being
forcibly drawn upwards. Thirst is intense and
unquenchable, cold fluids being eagerly desired.
The pulse is small, quick, and feeble. Determi-
nation to the brain is soon sympathetically ex-
cited, as evinced by increased temperature of the
head, and a tendency to stupor. The extremities
are commonly colder than usual; and the abdo-
men is hot. All the febrile symptoms are exacer-
bated in the evening, and occasionally attended
by delirium during the night. The eyes are lan-
guid and hollow, are half-closed during sleep; the
countenance soon becomes contracted and col-
lapsed, and the cutaneous surface insensible. In
the most acute cases, death may occur in twenty-
four hours; but the disease is most frequently of
considerable duration, presenting occasional re-
missions. Its violence is much lessened by cool
dry states of the air, and increased by a close
moist atmosphere. In some cases the vomitings
soon abate, and it seems to pass into dysentery,
or chronic diarrhoea, either with or without tenes-
mus, tormina, and occasionally with prolapsus
ani. It often runs on several weeks with tempo-
rary exacerbations and remissions; occasioning
remarkable emaciation, and, lastly, flatulent dis-
tension of the abdomen, and aphthae on the tongue ,
lips, &c.
5. C. The Prognosis will depend upon the
effect of the remedies employed, particularly on
the state of the discharges. If these become
more abundant, of a darker colour, and more
bilious; and if the irritability of the stomach, the
cerebral disturbance, and the fever, subside; we
may expect d. favourable issue. Un the contrary,
increase of restlessness, of the spasms or convul-
sive movements, and of the cerebral symptoms,
rapid emaciation, small thready pulse, cold damp
surface, watery pink-coloured stools, constant
puking, and especially flatulent distension of the
abdomen, and the appearance of aphtha-' about the
mouth, continued stupor, with the eyes half open,
and occasional convulsions, are very unfavoura-
ble signs. A favourable issue should not be ex-
pected with any confidence until healthy bile ap-
pears in the stools, and the evacuations assume a
natural character.
6. D. In fatal cases, the digestive mucous
membrane is commonly found more or less in-
flamed, thickened, softened, its submucous surface
infiltrated, and rarely ulcerated or excoriated.
'I lie mucous follicles, especially those of the small
and large intestines, are enlarged or ulcerated; the
326
CHOLERIC FEVER OF INFANTS — Treatmekt.
mesenteric glands are often enlarged; the liver
is sometimes darker, and generally much larger,
than natural; the gall-bladder is occasionally tilled
with bile; and the spleen is manifestly congested.
In a few instances, the intestines have been found
more remarkably inflamed, and adherent by
means of exudations of lymph on their peritoneal
surfaces. In the more protracted cases, effusions
of serum are found within the cranium; but, in
recent cases, the brain presents little or no morbid
appearances beyond slight congestion.
7. E. Its nature. — The symptoms, and the
appearances after death, clearly show that this
disease consists of inflammatory irritation, often
rapidly passing into inflammation of the greater
part of the mucous surface of the stomach, and of
the small and large intestines; frequently accom-
panied with depressed vital energy of the frame,
congestion of the liver, and a morbid state of the
abdominal secretions, and occasioning sympa-
thetic disorder either of the functions or of the
substance of the brain and its membranes.
8. II. Treatment. — At the commencement
of the disease, demulcents may be administered.
Dr. Rush recommends an ipecacuanha emetic;
but Dr. Dewees disapproves of emetics, — an
opinion which is agreeable to my experience. I
have usually first had recourse, in the slighter
cases, either to hydrarg. cum creta or calomel, in
frequent doses, and combined with magnesia or
soda; or to nitrate of potash with the sub-carbon-
ate of soda, in demulcents; and to the application
of leeches on the epigastrium, whenever tender-
ness of this region could be detected. After a few
of these powders have been taken, a dose of calo-
mel, sometimes with a grain of James"s powder,
has been given at bed-time, and castor oil the fol-
lowing morning : at the same time, oleaginous
glysters have been administered, and, as the
symptoms abated, those of an emollient kind em-
ployed. If the patient be not very young, a few
drops of tinct. opii, or a little syrup of poppies,
may generally be added to the injection. The
warm bath, or the semicupium, should never be
omitted in the treatment of this disease, the sur-
face being well rubbed with a coarse towel upon
coming out of the bath, and the child afterwards
placed in warm blankets. These means, if early
resorted to, will generally succeed in the less se-
vere cases occurring in temperate climates. But,
in the more intense states of the malady, medi-
cines given by tlie mouth will not be retained;
and such a dose of opium as will not be rejected,
may be injurious. In these, it will be preferable
to commence with the application of leeches to
the epigastrium; and to endeavour to procure
more healthy evacuations, and a discharge of bile
downwards, by repeated injections, consisting of
a solution of common salt (about two or three
tea-spoonfuls) in warm water. The frequency of
the stools ought not to prevent the administration
of the injection ; which will generally relieve the
vomiting and other symptoms as soon as bilious
or faecal evacuations are procured.
9. When the disease appears to be brought on
by improper ingesta, the vomiting may be pro-
moted by diluents. But the object should be to
quiet the stomach as soon as possible. For this
purpose Dr. Dewees recommends, for very
young children, as well as for those who are older,
a tea-spoonful of strong coffee, without sugar or
milk, every fifteen minutes. Of this treatment I
have had no experience. In cases where the
more bulky medicines are not retained, the plan
of giving minute doses of calomel, adopted by Dr.
Dewees, may be followed. He directs a quar-
ter of a grain of calomel intimately mixed with
half a grain or a grain of sugar, to be placed dry,
every hour, upon the child's tongue, until the
stools become more copious, less frequent, and of
a dark green colour. When this change is effect-
ed, the powders are to be given less frequently.
After the bowels have been well evacuated, he
prescribes an injection in the evening, with a few
drops of laudanum, according to the age of the
child; and if the disorder is not much abated, he
recommences with the calomel powders as above,
on the following morning, repeating the injection
at night. I have never tried this practice, having
found the means recommended in the preceding
paragraph (§ 8.), with those about to be noticed,
generally successful.
10. In the more acute cases, especially when
fever is early developed, and much heat of the
abdomen or of the head is complained of, the dis-
ease should be viewed as being entirely dependent
upon inflammation of the mucous surface of the
digestive tube, and affecting the brain sympa-
thetically. In these, leeches must be placed upon
the epigastrium, or behind the ears; if applied to
the former situation, a succession of warm poul-
tices should follow them, a full dose of calomel,
intimately mixed with a little sugar, be exhibited,
and, soon afterwards, an oleaginous injection
(olive oil or castor oil, or both, in gruel, strained
mutton broth, or any other demulcent vehicle)
thrown up. If these measures fail of producing
the advantage expected, the back, loins, or insides
of the thighs, should be rubbed twice or thrice
daily with either of the liiiiments F. 296. 300.
311., particularly upon coming out of the warm-
bath, or semicupium, which ought to be employed
once or twice daily, and rendered more efficient
by adding salt or mustard, or both, to it. The
application of blisters for two, three, or four
hours, and re-application of them for an equally
short time in another place, may be subsequently-
had recourse to, when the preceding measures do
not answer the purpose for which they were di-
rected. In the more severe cases, particularly
when the motions are bloody, a mucilaginous
draught, with castor oil and two or three drops
of laudanum, may be given; and, if it be not re-
tained, an enema, consisting of the same ingre-
dients, may be administered, or any of the ene-
mata contained in the Appendix suited to the
circumstances of the case, and proportioned to
the age of the patient.
11. In the advanced stage of the disease, espe-
cially when it passes into a dysenteric state, and
when the exhaustion is great, and the stools are
offensive, small doses of the chlorate of lime, or of
potash, in an aromatic water, or in mucilaginous
draughts or injections, will be very serviceable.
In this chronic period, when the disorder lapses
into the form of diarrhoea, proceeding from chro-
nic inflammation of the intestinal mucous surface,
the following powders may be given alternately
with the chlorates, or either before or after they
have been tried : —
No. 123. R Hydrarg. cum Creta jr. j. ; Magn. CMe
gr. iij. 5 Gum. Acacia; et ^Sacch. Allii, ;ia gr. v.; Tinct.
CHOREA — Symptoms.
327
Opii Oomp. TPj — ij. Fiat Pulvis, quovis in vehiculo idonco
iiweodus. hit tei v,- hi die.
No, 134. It Sod* Sub-carhon. gr. iv. ; Pulv. Acacia-
jr. \i|. ; \,|ii.r Cinnam. ", rj.j Syrup. Papayeria 3 »9- M.
Fi.it II. in. In-.
12. It will often be of the utmost service, even
at this advanced stage, to give a full dose of
calomel, and, if there still be fever, a grain of
James's powder, at bed-time; from half a drachm
to a drachm of the spirits of turpentine occasion-
ally, with an equal quantity of castor oil being
taken on the following morning in some aromatic
water, or in milk : or, from live to twenty-five
drops of the spirits may be prescribed three or
four times daily in any suitable vehicle. During
this period of the complaint, small quantities of
rhubarb, magnesia, and ginger; lime-water with
milk, the preparations of columba with soda,
those of catechu with chalk, the hydrarg. cum
creta with Dover's powder, the decoction of
pomegranate bark, or small doses of the sulphates
of iron and of potash, may severally be employed
according to circumstances. If pain be still com-
plained of, small doses of the compound tincture
of opium, or of Dover's powder, or of syrup of
poppies, become absolutely necessary. In this
chronic state of the disease, the sub-borate of
soda given internally, either alone, or with an
equal quantity of supertartrate of potash, has
proved extremely useful in my practice at the
Childrens' Infirmary; either of the liniments, No.
296. 300. 311., being rubbed daily over the ab-
domen, and a flannel roller afterwards placed
around it. In this stage of disorder, Dr. Chap-
man recommends the following : —
No. 12.5. It Ferri Sulphatis cr. ij. ; Acidi Sulphur, gtt. x.;
Sacchar. Albi 3 j. ; Aq. Fontan. 5 j. M. Capiat 5 j. ter
qu.ilerve quotidie.
13. The febrile nature of the disease, and its
evident connection with inflammation of the mu-
cous surface of the stomach and bowels ought
not to be overlooked. In its early stage, there-
fore, cooling febrifuge medicine and beverages
may be allowed the child, in order to assuage the
thirst. With this view the liquor amnion, acet.
with nitre, and spirit, aether, nit., may be given,
with aq. foeniculi, at short intervals ; and, in the
more advanced stage, when the irritability of the
Stomach has subsided, small doses of the sulphate
of quinine, either in syrup or in compound infu-
sion of roses; or the infusion of cinchona, with a
few drops of liquor potassa;, or of the sub-car-
bonate, may be directed. When the stomach
will retain it, this infusion, with liquor amnion,
acet., very small quantities of nitrate of potash,
and the spirit, a-ther. nit., has proved beneficial.
14. Regimenal and Prophylactic Treatment. —
a. When the disease occurs, as is most commonly
the case, in infants under a twelvemonth, the
diet should consist, at the commencement of the
attack, exclusively of the mother's milk, or when
it has been recently weaned, a healthy wet-nurse
should be procured. If, however, the child will
not take the breast, small quantities of diluted
sweetened milk may be given, or thin rico or
barley-water, with some gum added to it. Be-
sides these, soda water, marsh-mallow tea, and
the water poured off an infusion of toasted oatmeal,
or oat-cakes, may be also tried. In the latter
stages of the complaint, the usual farinaceous
aliments may be allowed. Dr. Rush attributes
much importance to the moderate use of salted
.provisions at this period, and of port wine; and I
have had occasion to know, that both of these are
often extremely beneficial when properly restrict-
ed. 1 believe that the want of a sufficient quan-
tity of salt in the food of children, in climates
and states of the air requiring this condiment, is
often concerned in the causation of the disease.
For no malady is change ofair more necessary than
for this. The child should be removed from the
crowded town to the open country; an elevated,
dry, but not bleak, situation being selected. Re-
moval to the sea-side is also very beneficial; or,
when a more complete change cannot be enjoyed,
a close, low situation may be exchanged, even for
a time, for one that is more open and elevated.
15. 6. The prophylactic measures may be
briefly stated to consist of allowing the infant a
healthy breast of milk till it is a year old; of
wearing flannel next the skin, and keeping the
lower extremities warm; of regulating the diet,
and avoiding excess in fruit, and the use of unripe,
over-ripe, or stale fruit; and of attending to the
state of the gums during the period of dentition.
BlBLIOO. AND REFER. — Rush, Medical Inquiries and
Observations, p. 131. 2d ed. — Valentin, in Journ. Gen. de
Medecine, vol. xxix. p. 459. — Dewees, On the Physical and
Med. Management of Children, &c. Lond. ed. 8vo. p. 443.
1826. — Parrish, On the Prophylactic Treatment of Cholera
Infantum, &c, North Amer. Med. and Phvs. Journ. July,
1826. — Billurd, Traite des Maladies des Enfans Nouvcau-
nts et a la Mamelle, fee. 8vo. Paris, 1828, p. 414.
CHOREA. Syn. Chorea Sancti Viti (from
Xonla a dance with singing) ; Saltus Viti,
Chorea Sti. Modesti, Choreomania, Ballismus,
Orcheslromania, Epilepsia Saltatoria, Auct.
Var. Choree, Fr. Der St. Veitstanz, Ger.
Classif. 2. Class, Nervous Diseases ;
3. Order, Spasmodic Disorders (Cullen).
4. Class, Nervous Affections; 3. Order,
Affecting the Muscles (Good). II. Class,
III. Order (Author, in Preface).
1. Defin. Tremulous, irregular, involuntary ,
and ludicrous motions of the muscles of voluntary
motion, more marked on one side than the other,
without pain, occurring in both sexes, more fre-
quently in the female, and chiefly between eight
and fifteen years of age.
2. This disease was formerly called the Dance
of St. Guy by the French, and of St. Weit' by
the Germans, from the circumstance of it being
so prevalent in Swabia, and other parts of Ger-
many, during the fifteenth and sixteenth cen-
turies, that patients crowded to a chapel near
Ulm, dedicated to this saint, who had, by the aid
of the priests, obtained great celebrity in its cure.
It appears to have been known to the ancients;
for the Scelotyrbe of Galen very nearly resem-
bles it. The earliest writers, since the revival of
letters, who noticed this affection are, Plater,
Horstius, and Sennert, under the name of
Chorea Sti. Viti. In 1560, Bairo, physician to
the Duke of Savoy, mentioned it under the name
of " Indispositio Saltuosa Membrorum." But
Sydenham was the first author who accurately
described it.
3. I. History, &c. A. Symptoms. — The pa-
thognomonic characters of chorea .consist in dis-
ordered movements of parts actuated by the vol-
untary order of nerves; the functions of volition
and of muscular action being deranged analogously
to the manifestations of the mind in mental aliena-
tion. The disordered movements vary very con-
siderably, in respect of the number of parts affect-
ed, and of the intensity of the affection : hence it
328
CHOREA— History of, &c.
may be partial or general, slight or severe. It is
more frequently partial than general, and is very
often confined to the muscles of one side of the
body. The description by Sydenham has been
copied with little alteration by many authors; and,
although extremely accurate in respect of some
states of the disease, it by no means embraces all
the varieties : that by Dr. Hamilton is, upon the
whole, the best, particularly as respects its fully
developed form.
4. This affection is often preceded by more
or less marked disorder of the organic functions :
the appetite is variable, the digestion imperfect,
the bowels costive, the abdomen tumid, and the
vis-acity and physical activity diminished. To
these are frequently added timidity, fretfulness,
desire of solitude, sighing, palpitations, concealed
mental affection, &c. These symptoms of disor-
dered health are followed by slight, .irregular, and
involuntary twitchings of the muscles, particular-
ly those of the face. These motions increase,
assume the form of irregular clonic and continued
convulsions, and are often attended by increased
hardness, or tumefaction, of the lower regions of
the abdomen, and constipation. Owing to the ir-
regular convulsive motions of the face, jaw, head,
and neck, of the trunk and extremities, and from
the circumstance of these motions taking place at
different times, the patient has a jumping, starting,
or palsied walk, and cannot perform the usual
occupations of the extremities with the steadiness
and regularity of health. The characteristic mo-
tions vary in degree ; but they are always present
during the continuance of the disease, excepting
while the patient is asleep, when, in most in-
stances, they altogether cease.
5. Different muscles are sometimes successive-
ly affected ; but those first convulsed still continue
so until the termination of the disease. When the
affection is fully formed, articulation is impeded,
but seldom completely suspended. Deglutition is
often difficult ; the eyes lose their lustre and ex-
pression; the countenance becomes pale, languid,
vacant, and, in the severest and most protracted
cases, conveys the idea of imbecility, or even of
fatuity. In the course of disorder, the muscles
seem much more soft and flaccid than natural,
and emaciation takes place : vertigo and headach
are often complained of. The pulse is a little ac-
celerated; the bowels are always constipated, and
the urine is usually pale and copious. The tongue
and gums are pale ; the former being occasional-
ly protruded, irregularly and spasmodically. In
some of the severest cases the mouth is variously
twisted, and a drivelling of saliva takes place from
it : the eyes are distorted, or rolled in various di-
rections, and the sight is occasionally defective.
The disposition and temper are unstable or irrita-
ble ; the mind is often harassed by various con- !
cealed mental impressions and ideas ; and the
emotions or desires are variously excited, without
any sufficient or apparent cause. In some cases,
deglutition is much impeded, and fluids are for-
cibly thrown up from the pharynx in attempts at
swallowing them. Bernt and Frank state, [
that the urine and faeces are occasionally passed
involuntarily during the height of an attack ; but !
this rarely occurs in simple chorea. There is
seldom any pain complained of, and, although
the movements cease during sleep, yet the rest '
is often disturbed.
6. Such is the state of the fully formed disease ;
but it presents endless varieties, sometimes in-
sensibly lapsing into hysteria, in other cases ap-
proaching to paralysis ; row scarcely to be dis-
tinguished from convulsions ; in one instance re-
sembling tarantulism, and in another being close-
ly allied to paralysis tremens. In some cases,
the muscles of the face and neck are more affect-
ed than those of other parts ; whilst in others,
those either of the upper or of the lower extremi-
ties, or of one limb only, are most convulsed.
7. B. Duration, complications, and termina-
tions.— a. The duration of this affection under
treatment is various — from two or three weeks to
several months : the most common duration being
from one to two months. The shortest period
of treatment, in the cases which have occurred to
me, was eleven days. Relapses are, however,
not infrequent. I have seen the affection to re-
turn thrice in the same patient, b. Chorea is very
frequently associated with other disorders : in fe-
males with chlorosis, retention or suppression of
the menses, anaemia, hysteria ; and, in males,
with rheumatism, with paralysis, disease of the
head, and dropsical effusions in the serous cavities.
c. It also not infrequeniiy terminates in these,
and in convulsions, epilepsy, anosmia, dropsy,
palsy, hydrocephalus, and complete idiotcy. A
return, however, to health is its most common
issue. In a case related by Dr. Elliotson, it
terminated in apoplexy ; and Dr. Brown refers
to three instances in his- practice, where it ter-
minated in violent convulsions, with cerebral
symptoms, coma, and death.
8. Its complication with rheumatism, rheu-
matic pericarditis, and disease of the membranes
of the spine, was first demonstrated by the writer,
in a case, the post mortem inspection of which is
detailed in the fifteenth volume of the London
Medical Repository ; the connection having been
subsequently confirmed by Dr. Prichard and
by Dr. Roeser, who have met with similar
cases. The association of chorea with hysteria is
very frequent about the period of puberty : and
when the former occurs, after this term. Indeed,
the majority of cases exhibiting choreal symptoms
at or subsequently to the epoch of pubertv in the
female, partake more or less of the hysterical
character — in many instances to the extent of
appearing as a modified form of hysteria, rather
than as chorea : and, upon strict inquiry, some
irregularity is generally detected in die accession
or subsequent occurrences of the catamenia.
Females who are attacked by, or have been sub-
ject to, chorea anterior to the period of puberty,
occasionally experience at this age retention or
postponement of the catamenial discharge ; or,
if this secretion at all appears, it is scanty and at
irregular intervals. Both the chorea and disorder
of the catamenia evidently depend upon a similar
condition of the vital manifestations of the organic
nervous system, and chylopoietic viscera. The
following procession of morbid phenomena is not
uncommon : chorea with defective action of the
digestive, assimilating, and secreting functions,
and torpor of the liver ; at a subsequent term,
protracted catamenia, or scanty and irregular ap-
pearance of the secretion, occasionally with va-
rious hysterical affections, seldom amounting to a
complete fit of the hysteria : and. lastly, when the
catamenia become established, the hvstericai af-
CHOREA — Diagnosis and Prognosis.
329
fection is sometimes more fully pronounced; and,
with the regular establishment of the uterine func-
tions, the chorea disappears. Dr. White re-
lates the case of a lady, aged 42, who appears to
have been the subject of chorea of an irregular or
rather doubtful character, and liable to attacks of
hysteria. In this case, which has been too readi-
ly admitted by Dr. Goon as one of chorea, the
menstrual discharge is reported to have heeu re-
gular ; but it is probable that in this, as many
other instances of diseases occurring in females, a
more strict inquiry would have detected some de-
rangement in the uterine functions.
9. C. The appearances found on dissection of
fatal cases are rather referrible to the complica-
tions than to the disease itself. In general, the
body is somewhat emaciated, and the muscles soft,
flaccid and pale. The stomach, bowels, and as-
sociated viscera present only contingent lesions :
they are, however, often flaccid and pale, some-
times with a slight effusion of serum in the peri-
toneal cavity. In a few instances, signs of irrita-
tion of the uterus have been observed. Dr. Haw-
kins, found, in a case he examined, besides in-
creased vascularity of the uterus, earthy concre-
tions in the pancreas, omentum, and mesentery,
with tubercles in the lungs. In the fatal eases
recorded by Dr. Prichard, Dr. Rokser, and
myself, adhesions of the opposite surface of the
pericardium, with effusion of serum in it, and
slight effusion into the pleura, were observed. In
a case which occurred in my practice, the surface
of the heart was covered in parts with coagulable
lymph; its cavities were mnch enlarged, and their
walls thin, pale, and flabby, resembling the mus-
cles of white-fleshed animals. M. Desperriere
met with effusion of serum into the pericardium.
Soemmering states, that he detected the results
of inflammatory action in the membranes of the
brain; and several authors have made mention of
small ossitic deposits in the arachnoid of the dura
mater. Dr. Brown, in the only one, of the three
cases which terminated with convulsions and
coma, that he had the opportunity of examining,
found congestion of the vessels of the brain, with
slight serous effusion between the membranes, and
in the ventricles, and a calcareous concretion of a
cubic form, and the size of half an inch, in each
side, in the medullary substance of the left hemi-
sphere,— the convulsive movements having been
chiefly on the left side of the body. Dr. Coxe
found the vessels of the brain congested, and
twelve ounces of serum in its ventricles : Dr.
Wii.lan, also, in two instances, observed sever-
al ounces of serum in the ventricles of the brain.
Dr. Patterson describes appearances of the
membranes, consisting of vascular congestion with
effusion of serum, and states, that a patient cured
of the disease very soon died of hydrocephalus.
M. Serres found, in one instance, a fatty tu-
mour resting on the tubercula quadrigemina ; in
another, appearances of increased vascularity,
with sanguineous effusion; and in two others, in-
flammation of this part of the brain. He further
•tates, that, in experiments on living animals, he
remarked injury of these parts to produce phe-
nomena resembling chorea ; but be at the same
time admits that he has sometimes met with cases
of chorea, in which no diseased appearances in
the brain could be detected after death. In a
case which occurred to me in 1819, complicated
28*
or rather alternating with rheumatism, with me-
tastasis of this disease to the heart, and subse-
quently to the membranes of the spinal cord, in-
flammatory appearances, with coagnlabfe lymph,
and an effusion of turbid serum, were found
through nearly the whole extent of these mem-
branes, the patient having died in a state of uni-
versal paralysis. Changes in the spinal mem-
branes similar to those described by me were ob-
served in the four very interesting cases detailed
by Dr. Prichard : in these latter, also, more or
less congestion of the vessels, with effusion of
serum between the membranes, and in the ven-
tricles of the brain, was remarked. Dr. Ai.ip-
randi has also detailed a case, in which morbid
appearances similar to those described by myself
and Dr. Prichard were found in the spinal
canal.
10. II. Diagnosis and Prognosis. — a. This
disease, in its ordinary states, may be distinguish-
ed from other affections of a similar kind by the
permanency, the clonic, and the partly voluntary
nature of the movements, and their cessation dur-
ing sleep. In convulsions, the movements, how-
ever irregular, and in other respects resembling
chorea, are not continued, are not even partially
under the influence of the will, and are of the
most violent or tonic kind. The disease to which
the name chorea was originally given approached
nearer this latter description, but presented no
uniform character, — various nervous disorders,
very different from each other in many of their
essential symptoms and pathological states, as the
nervous affections resulting from the bites of the
tarantula or other insects, irregular forms of hys-
teria, and convulsion, receiving this appellation;
and, even at present, many irregular forms of
convulsion, particularly those of a clonic kind,
are often confounded with chorea. The only
other disorder for which it may be mistaken is
paralysis tremens, which occurs at a later period
of life than chorea, is generally more limited to a
single limb or part of the body, the movements
being more of a tremulous than of a spasmodic
kind, and to a much less extent; and not partak-
ing of the starting, jumping, twitching, and ludi-
crous character possessed by those of chorea.
11. b. The Prognosis in the simple or uncom-
plicated state of chorea is generally favourable.
But when it comes on after attacks of rheuma-
tism, or in conjunction with this disease ; if it
follow the disappearance of the acute or chronic
exanthemata and eruptions, or arises from injuries
of the head, or from manustupration; if it be as-
sociated with epileptic convulsions, or with more
or less complete paralysis of some limb or part;
and if signs of ansemia, chlorosis, dropsical effu-
sion, affection of the functions of the brain, or
idiotcy, manifest themselves, an unfavourable, or
at least a cautious, opinion of the result should be
offered. It would seem that the disease is more
severe or more frequently complicated in large
cities, or in some places, than in others, for the
very different results of practice cannot otherwise
be well explained. Dr. Parr states, that in
about sixty cases, in which the treatment very
generally employed by other physicians was re-
sorted to, all recovered, and only two had relaps-
es. I have met with three or four fatal cases;
Dr. Prichard has recorded four; Dr. Brown
refers to three in his practice ; and I have occa-
WO
CHOREA — Causes— Nature of.
sicm to know that a similar issue is not rave in
cases occurring both in London and in Paris.
12. III. Causes. — A. Predisposing causes.
Chorea is much more frequent in the female than
in the male sex. According to the experience of
Heberden, Thilenius, J. Frank, Rejeves,
Mansoh, Elliotson, and myself, three of the
former to one of the latter are affected by it. The
most common period of life is from seven years
to fifteen — from second dentition to puberty; but
no age is entirely exempt from it. M. Bout-
eille met with it in a lady of SO, complicated
with hemiplegia; Dr. Powell and Dr. Maton,
in females of 70 ; Dr. Crampton, in a female
upwards of 40. I have seen it in a man upwards
of 50; and cases sometimes occur as early as five
or six years. The nervous temperament, and
great sensibility of the nervous system; hereditary
disposition; constitutional debility from whatever
cause, either from original conformation, or from
bad or deficient nourishment in early infancy,
particularly an insufficient supply from the mother
or nurse's breast, or total deprivation of this nu-
triment; effeminate education, and premature ex-
ercise of the mental powers; precocious excite-
ment of the desires and affections; debility of the
digestive and assimilative viscera; neglected state
of the bowels, leading to accumulations of de-
ranged secretions in the prima via; torpid func-
tion of the liver, and other secreting and assimil-
ating organs ; cold and moist climates ; confine-
ment or sedentary occupations in low, unhealthy,
or crowded places; low or innutritions diet, espe-
cially vegetable food; impure miasmal air; want
of personal cleanliness ; and the ricketty, scrof-
ulous, and rheumatic diathesis ; constitute the
chief predisposing causes of the disease.
13. B. Exciting causes. — These are not often
readily ascertained. The most common are the"
irritation of worms or of morbid matters accu-
mulated in the bowels (Stole, Bai.dinger,
Wendt), and fright. Dr. Reeves and Mr.
Bedingfield state, that the great majority of
cases which they treated was attributed to fright;
and a nearly similar statement is made by Stoll
and Ecker. Injuries affecting some part of the
nervous system especially, as (alls upon the head
and back (Geash, Frank); the improper em-
ployment of lead, mercury, &c. (De Ha en);
suppressed eruptions, discharges, &c. (Thilen-
ius, Darwin, and Wendt), particularly tinea
capitis, itch, herpes, perspiration of the feet, &c. ;
metastasis, or extension of rheumatism to the
membranes of the spinal cord (Pi.ouco.uet,
Copland, Prichard, &c.) ; previous disease,
especially the eruptive fevers, epilepsy, hysteria,
and mental disorder (Sallaba); second denti-
tion ; suppressed discharges ; anxiety, the dread
of impending occurrences, concealed mental im-
pressions and moral emotions, and the influence
of imagination (Darwin, Haygarth), parti-
cularly morbidly exercised imagination in con-
nection with sexual desire ; frequently excited
jealousy and envy; masturbation, and retained,
or difficult, or suppressed menstruation, particular-
ly if occasioned by this practice (Richter, &c),
and cold long endured, — are all occasionally ex-
citing causes of the disease.
14. IV. Nature of the Disease. — Opin-
ions as to the pathological state originating chorea
have been' extremely various. Sydenham con-
sidered it as a species of convulsion, occasioned
by a humour affecting the nerves. Salvages,
(Ym. in, and many others, ascribed it to general
debility, attended by unusual mobility of the sys-
tem ; and several writers, among whom I may
notice Bouteille, Clutterbuck, Serres,
Lisfranc, Sic, to inflammatory action of some
part of the cerebro-spinal axis; thus viewing it as
intimately related to paralysis. Dr. Hamilton
attributed it to disordered functions of the bowels,
affecting the musoular actions sympathetically ;
and a very large number of writers, to debility
deranging principally the nervous and muscular
systems ; the torpid states of the organic func-
tions being a related or associated manifestation
of disorder.
15. A. The exact seat, as well as nature, of the
disease can be inferred with accuracy only from
attentive observation of the causes in relation to
the states of the system at its commencement, of
the phenomena in its course, and of the structur-
al changes existing in cases which have terminat-
ed fatally. The writer was the first who demon-
strated, by post mortem research, inflammatory
appearances of the membranes of the spinal cord ;
but he cannot on that account infer that the dis-
ease is owing to that cause. Indeed, in the case
in which he observed it, the affection of these
membranes was recognised, during the life of the
patient, as a contingent lesion arising from metas-
tasis of the rheumatism with which it was associ-
ated. M. Serres, having found disease of the
corpora quadrigemina in four cases, considers
these bodies as the seat of chorea, and thinks the
results of his experiments, and of those of MM.
Flourens and Rolando, on the functions of
this part of the brain, countenance this opinion.
Other pathologists, particularly MM. Bocil-
laud and Magendie, conceive that it is seated
in the cerebellum, because the functions which
they ascribe to this organ are chiefly affected —
the disease, in their opinion, consisting of disorder
of the actions of this part. If we reflect, that a
number of disorders, more or less resembling each
other, have been considered as chorea; that these,
as well as chorea itself, are often complicated
with, or run into, other affections of an organic
or inflammatory kind; and that it is never fatal
excepting in consequence of its consecutive and as-
sociated changes, especially those affecting the
brain and spinal cord ; the diversity of lesion ob-
served after death, and of opinions derived from
this source chiefly as to its seat, will not appear
surprising.
Iti. I think that chorea, in its simple state,
occurs most commonly in persons whose vital
powers are depressed, the whole circle of vital
organs performing their functions imperfectly, and
thereby occasioning increased susceptibility of the
nervous system. This state constitutes the apti-
tude to be affected by the exciting causes of this
disorder; whether those acting directly upon the
brain, through the medium either of the mind it-
self or of the senses, as terror, fright, mental im-
pressions, moral emotions, &c. ; or those which
influence indirectly the cerebro-spinal nervous
system, by irritating or otherwise disordering the
organic nerves, as worms, morbid matters in the
prima via. The susceptibility ot' the fame having
been induced, either class of causes nay occasion
| the malady, — the former, by changing the coudi-
CHOREA AND RELATED AFFECTIONS — History of.
331
tion of those parte about the base of the braio
which direct or influence the functions of the spi-
nal cord, ami, through it, of the voluntary mus-
c],.Si — the latter, by disordering the functions of
gallic nervous system, and thereby affecting,
through the medium of the branches communica-
ting wiih the ganglia placed on the roots of the
spinal nerves, the nerves of voluntary motion:
occasioning the irregular muscular movements
uting the disease, in the same manner that
irritation of the visceral nerves produces the au-
tomatic movements of the foetus in utero. In
such cases, the disorder of the organic nerves
may be extended, by means of the sympathetic,
to the spinal nerves either of one side only, or of
both, as well as to the nerves and parts about the
base of the brain, disease being also subsequently
induced in those parts of the brain or spinal cord
in which they originate. According to this view,
will readily he explained the frequent connection
of chorea with hysteria and uterine disorder, as
the patient advances through the period of puberty
and adolescence, as well as the disappearance of
the disease after the developement of the sexual
organs, and the healthy establishment of the ute-
rine functions — events intimately related with,
and necessary to, the clue manifestation of vital
energy throughout the frame.
17. In other words, therefore, the proximate
cause of chorea, in its simple and true form,
Be sms to consist of debility, with some degree of
irritation of the organic or ganglia! c!a.-.s of nerves,
extended more or less to those of volition, and
occasioning morbid susceptibility of the nervous
svstem generally, with diminished power, in-
creased mobility, and irregular actions of the
muscular svstem, particularly of those muscles
supplied with the nerves principally affected.
Whilst this appears to be the pathological state
of the majority of cases of chorea, yet instances
not infrequently occur in which disorder evidently
commences in the spinal cord or its membranes,
disturbing the functions of the nerves issuing from
the affected put. In many cases, the lesion of
the cord and of its membranes is occasioned by
irritation propagated to the roots of the voluntary
nerves; but in those which are connected with
rheumatism, as well as in some otherwise related
and produced, the mischief evidently originates
ia the membranes of the cord itself. When,
however, the disease commences in the organic
nervous svstem, affecting the voluntary nerves
only secondarily, pain is not complained of upon
examining the spinal column; but when it is seat-
ed in the cord or its membrane-:, pain or uneasi-
ness is felt in this situation, and the disordered
motions are more or le~s limited to particular
parts. When the original cause of mischief is
seated in the brain, or when tin- cephalic organs
become consecutively diseased, the affection par-
takes more of the characters of true convulsion,
either with or without hysterical symptoms, but
most commonly with such phenomena.
18. V. Of nervous Disorders resem-
bling Chorea. — Whilst true chorea, according
to the application of the term in recent times,
seems to originate in the organic nerves, and to
disturb the functions not only of the voluntary
nerves, as explained above, bat also of those parts
of the cerebrospinal axis in which they originate;
the affections I am about to notice, most com-
monly depend upon a disordered state either of the
mind, or of some of the parts within the cranium,
and are often attended by more or less affection
of the generative and digestive organs. The dis-
ease to which the name Chorea Sti. \'i!i was first
applied, very nearly resembled that produced by
the bite of the tarantula, as it is described by
Bagi.ivi and Sauvagi s; and. if tlu> description
of the former disorder furnished by SSchenck,
Paracelsus, and Felix Plater had not been
confirmed by the more accurate observation of
modern practitioners, it might have been viewed
as greatly exaggerated, if not entirely feigned, a.
The chorea of the writers of the sixteenth century
appears to have consisted of inordinate muscular
exertions and movements in regulated measures,
proceeding from an irresistible mental impulse,
excited by the influence of music or imitation on
the mind. IIorstius states, that it sometimes
recurred annually at the same period; and that
the sound of music often increased it to a state of
frenzy, those affected continuing dancing for an
incredibly long period, in a most excited manner.
It appears to have consisted chiefly of a sort of
lascivious dance, kept up an uncommon length of
time, until the impulse to excessive muscular mo-
tion was subdued by exhaustion, and has not in-
appropriately been called Morbus Saltatorius and
Epilepsia Saltatoria by later writers, b. Ac-
cording to the account given by Baglivi and
Sauvages of the effects of the bite of the taran-
tula, the patient is seized, a few hours after the
injury, with difficulty of breathing, anxiety, and
sadness. The violent symptoms of the first days
are succeeded by a peculiar melancholy, which
continues until, by dancing or singing, it is at last
entirely removed. Persons thus affected frequent
churchyards and solitarv places, lay themselves
out as if they were dead, evince the utmost de-
spair, howl and sigh, assume various indecent
attitudes, run about, or roll themselves on the
ground, and are either pleased with or dislike
particular colours. Shortly after being stung,
they fill down, deprived of sense and motion,
either breathing with difficulty and sighing heavi-
ly, or lying as if quite dead. Upon the sound of
music they begin to -move their fingers, hands,
feet, and successively all the parts of the body,
sighing, dancing, and assuming a thousand fan-
tastic gestures. They continue these motions for
several hours, until they are exhausted, and cov-
ered by perspiration; but they return again, after
some repose, to this violent exercise, which is
kept up for ten or twelve hours each day, during
four or five, but seldom so long as six days. This
affection has received various names from Con-
tinental writers, amongst the chief of which are
tarantismus, tarantulismus, Choreomania, Me-
lancholia saltans, C/iorea Sti. Johaunis, Chorea
Sti. Valentini, and Dtnnonomania.
1!). According to the above account of both
affections — the original rliorea of the Germans,
and the taranHsmus of SauVages — there ap-
pears to he but little difference between the latter,
at it.s advanced or second stage, and the former.
It is very difficult to believe that the whole, or at
least the greater part, of the phenomena in both
these affections was not feigned. It is, however,
admitted, that the poison of the tarantula spider
i- M n- ! successfully counteracted by the exciting
influence of music on the mind, and the profuse
332
CHOREA AND RELATED AFFECTIONS — Treatment of.
perspirations produced by continued dancing. A
writer in the New York Medical Repository de-
tails an instance of a convulsive disorder occasion-
ed by the bite of a spider, and cured by music.
Mr. Kinder Wood has recorded a case, which
originated in disordered menstrual function, with
cerebral symptoms and painful affections of the
nerves of the face, that resembled in every re-
spect the malady to which the German physicians
gave the name of chorea.
20. The disorder, also, which has usually been
called the "Leaping Ague" in Scotland, seems
to be very closely allied to the original chorea.
It is described very nearly as follows by a writer
in the Edinburgh Medical and Surgical Jour-
nal : — Those affected first complain of a pain ill
the head or lower part of the back, to which suc-
ceed convulsive fits, or fits of dancing, at certain
periods. During the paroxysm, they distort their
bodies in various ways, and leap about in a sur-
prising manner. Sometimes they run with great
velocity even in dangerous places, and when con-
fined, climb or leap from the floors of the cot-
tages to the rafters, or swing by, or whirl around,
one of them. They often dance or leap about
with greater agility, vigour, and exactness than
they are capable of exerting at other periods ;
the affection apparently consisting chiefly of a
morbid and irresistible propensity to dance, tum-
ble, and run about in a fantastic manner. Cases
of this form of disorder have been detailed by
Tulpius, Penada, Reil, Bruckmann,
Westphal, Crichton, Piedagnel, Lau-
rent, and others. In M. Piedagnel's case
there was a propensity to run forwards, until the
patient, a man, dropped down exhausted. On
examining the brain after death, tubercles were
found pressing on the anterior part of the hemi-
sphere. A similar instance occurred in the father
of a medical friend, and terminated in paralysis.
The subject of M. Laurent's case was propel-
led backwards with considerable velocity.
21. Dr. Watt has given the history of a dis-
order which he has called chorea, or periodical
jactitation, in a girl of ten years, that was preceded
by excruciating headach and vomiting. To this
affection of the head succeeded the propensity to
turn around in one direction on her feet with
great velocity, like a spinning top. This pro-
pensity subsided after having continued above a
month, but was followed by an exasperated 're-
aim of the headach, and loss of power over the
muscles of the neck. She was afterwards seized
by a different kind of motion, occurring in fits,
which lasted daily, from two or three, to six or
seven hours ; this consisted in placing herself
across the bed, and rolling rapidly round on her
sides from one end of it to the other. When laid
in the shallow part of a river she rolled around,
although at the point of being drowned. The
affusion of cold water did not stop the rotations,
which were about sixty in a minute. In a little
more than a month these movements were re-
placed by others of a different kind. She now
laid herself on her back, and, drawing her head
and heels towards each other, raised her trunk,
afterwards falling with some force on her back by
straightening her body. These motions were re-
peated ten or twelve times in a minute, were con-
tinued for about five weeks, and were then fol-
lowed by the propensity of standing upon her
head. Having raised her feet perpendicularly
upwards, she fell down as if dead, but instantly
placed herself on her head as before, again fell,
and continued to repeat these movements for fif-
teen hours a day, and as rapidly as twelve or fif-
teen times a minute. The affection had resisted
emetics, cathartics, local depletion, blistering,
setons, &c, but disappeared after a spontaneous
diarrhoea. Dr. Watt refers to two similar cases
which had come to his knowledge ; and another
instance has been adduced by the writer, under
the designation of " Inquirer " of an instructive
article on the subject, in the third volume of
the Edinburgh Medical Journal. Mr. Hunter
has also given the particulars of an instance of
rotatory affection resembling chorea, in the
twenty-third volume of the same work.
22. Dr. Robertson has described a peculiar
form of convulsion, in many respects like chorea,
which spread at one time (1800) as an epidemic
amongst a sect of religious enthusiasts in the
states of Tennessee and Kentucky, evidently
from the influence of imagination and irritation
on morbidly excited minds. The seizure was
violent, and distinctly convulsive at the com-
mencement, but it usually passed from this state
into one more chronic, and more nearly approach-
ing chorea. Persons thus affected are described
by Dr. Robertson as being continually inter-
rupted in their conversation by the irregular con-
tractions of the muscles, and as having no com-
mand over these contractions by any effort of
volition ; lying down in bed does not prevent
them, but they always cease during sleep. Re-
missions and exacerbations are common, but occur
without regularity. During the remission, a pa-
roxysm is often excited by the sight of an affected
person, but more frequently by shaking hands
with him. The sensations of the patient during
the fit are said to be agreeable, and are expressed
by the enthusiastic by laughing, shouting, dancing,
&c, followed by fatigue, and a sense of general
soreness. The affection at last becomes slighter
by degrees, and finally disappears. Cases of sim-
ilar nervous disorders, and apparently interme-
diate between chorea and convulsions, and often
partaking of many of the features of hysteria, as
well as the affection called Malleatio, have been
detailed by Tulpius, Horstius, JYIorgagni,
Wichmann, Majendie, and others above re-
ferred to (§20.). It is difficult to believe, how-
ever, upoii perusing the particulars of the fore-
going cases, that they are altogether the actual
phenomena of disease. It is very probable that the
morbid affection of mind, — the disordered state of
the desires, or of the mental impressions, — exalts
the derangement of the nervous system to that
singular pitch, of which these cases are rare ex-
amples. (See arts. Convulsions, & Hysteria.)
23. VI. Treatment. — A. Conspectus of the
treatment. Purgatives have been recommended
in chorea by Sydenham, Whytt, Hamilton,
t'HEYNE.and others. Sydenham, however, did
not confide the cure of this affection to them en-
tirely, for he also directed occasional depletion,
with tonics in the days intervening between the
exhibition of the purgatives, and narcotics at bed-
time. Emmenagogues, particularly aloes, myrrh,
assafcetida, hellebore, savine, castor, the melissa
officinalis, spiritus ammonia succinatus, saffron,
borax, &c. have been \ery properly prescribed
CHOREA AND RELATED AFFECTIONS — Treatment of.
3.33
by RlCHTER, ScHMIDTM \NN, and Several OtllCr
German writers, particularly when the disease
ooonre sboul iln- period of puberty, and is con-
nected with hysteria, or disorder of the menstrual
discharge. Anthtkithitica are the chief medicines
ad\ bed by Ho felan i> and Thilenius. Wait
and S \i . i. \it v viewed the disorder as possessing
an inflammatory oharacter, and therefore directed
foe it the antiphlogistic regimen. Tonics have
found supporters in Dover, Werlhof, Ma-
BOB, Eckstein, Hii.dxbra.ND, Elliotson,
and many other writers. Hut they do not agree
in the kind of tonic which should he employed :
thus, HlLDEBRAND prefers the sulphuric and
viineral acids; Werlhof and Mahon, the
cinchona hark; GRIFFITH prescribes the bark,
with the carbonate of potash. Eckstein,
Wendt, and Ei.i.iotson recommend the pre-
paration of iron, in preference to other tonics.
The fixed alkalies ' have been noticed favourably
by Wendelstatt; and the mineral springs at
Ems by Bruckmann. Sir Geo. Baker, Na-
(. EL, and .Michaklis prescribed the flowers of
the cardaminc pratensis; the latter in doses of a
drachm every six hours. The leaves of the Seville
orange tree, in the form of powder, decoction, or
infusion, were much praised by De Haen, Wes-
terhoef, Werlhoff, and Engelhard.
The arnica montana received the commendation
of Theussink; and the chenopodium ambroisio-
ides, that of Plenck and of Eckf.r.
24. Narcotics and sedatives have also been
prescribed in this affection. The inspissated juice
of the root of the belladonna was employed in
doses of one sixth of a grain, with apparent ad-
vantage, by Stold, Lentin, andKETTERLiNG.
Stole, however, directed at the same time fric-
tion with a liniment composed of the spiritus ser-
pilli, essentia castorei, and camphor, to which I
am inclined chiefly to attribute the benefit derh ed.
M. All am an i) has likewise prescribed belladon-
na with advantage. Stramonium was used by
Sidren; digitalis by Uwins and some others;
and opium by Swainston. The prussic acid
has lately received the commendation of Mr. Stu-
art. He employed it in two cases, after purga-
tives had been exhibited in large doses, with de-
cided advantage. The prussiates of iron or of
zinc are also productive of benefit.
2o. Antispasmodic remedies have been resort-
ed to by several physicians. Camphor has ob-
tained a well-deserved notice from Werlhoff,
Mahon, Wilson, and others. The cuprum am-
moniatum has been prescribed by Dr. Walker,
after alvine evacuations, and found beneficial in
where bark and other tonics have failed.
Will in, I'm ins. I)i i. ari\ i , and'l'n eussink
ha\ e also spoken of it favourably ; and M e kk car-
ried it so far as to produce an emetic effect. Val-
erian has been recommended by Bouteille,
Bernt, Murray, Guersent, &c. After the
bowels have been evacuated, it is in many cases
an excellent remedy, either given by the mouth,
or administered as an enema. The oxyde of zinc
has received a very extensive trial in this affection
from Hart, Bcbseri, Thilenius, Schraud,
Wright, Hufeland, and Kerst. Stoll,
however, states that no benefit is derived from it,
although pushed to a great length. I have seen
much more advantage produced from the sulphate
than from the oxide of zinc. Although the oxide
may be given without advantage, and irritate the
stomach, the addition of a full dose (gr. ij.) of the
cuprum ammoniatuiii in combination with the
zinc will be borne without inconvenience. This
fact, which was ti:st noticed by Dr. Odier, of
Geneva, in a letter to Dr. Duncan, may be ta-
ken advantage of in the treatment of chorea; for
I am not aware that it has as yet been acted upon
in respect of this disease. The nitrate of silver
has jikewise been fully employed, and certainly
with benefit if purgatives have been premised.
France, Uwins, and Crampton have found
it successful in extremely obstinate cases.
26. Arsenic, in the form of Fowler's solution,
has also been directed with advantage in severe
cases of chorea, especially after free alvine eva-
cuations have been procured, by Mr. Martin,
Dr. Salter, and Dr. Gregory. Iodine has
been given by Dr. Manson, Dr. Gibney, Dr.
Peltz, and myself; and, when judiciously pre-
scribed, particularly when the disease appears
about puberty, and is connected with obstructed
menstruation, is often of great service. In cases
of this kind, a blister applied over the sacrojn, as
recommended by Dr. Chisholm and Mr. Swan,
and found beneficial by them, has been produc-
tive of marked advantage in my practice. The
propriety of scarifying deeply the gums, when the
affection occurs about the period of second denti-
tion, has been very properly insisted upon by Dr.
Gregory and Dr. Monro.
27. The cold bath has been much used by M.
Dupu ytren in chorea, and sea bathing has been
recommended by Hufeland and Himly; but
the shoioer bath, or the simple affusion of cold
ivater on the head whilst the patient is seated, is
preferable at first, in my opinion. If the shower
bath be directed in cases of females, the patient
should stand, whilst receiving the bath, in a pan
of warm water. Dr. Ferrari prescribed with
benefit a solution of tartarized antimony internal-
ly, and ice along the vertebral column, followed
by immersion daily in a cold bath, and by purga-
tives, bitter tonics, and hyoscyamus. Setons, is-
sues, and moxas in the neck, or over the vertebrae
of the back, have also been employed by several
practitioners. Dr. Aliprandi, however, relates
a case where issues and moxas proved of no ser-
vice. Drs. Physick and Young have made
use of the black snakeroot, the cimicifuga race-
mosa, and experienced decided advantage from it.
This substance seems to act more rapidly than
others in the cure of the disease, and without any
sensible action on the secreting functions. It is
given in doses of from ten grains to a drachm.
The animal oil of Dippel has been found of ser-
vice by Werlhof; the cajepvt oil by Rams-
p e B ; and the cod and tusk-liver oil, and spirits
of turpentine by the author, who first prescribed
them in this disease. Electricity has been sug-
gested by De Haen, Fothergill, Schaef-
FER, &c. ; and galvanism by several writers.
Large doses of musk were directed by Dr. Ma-
ton and Dr. Powell, after free alvine discharg-
es had been procured.
28. Respecting the propriety of blood-letting
in chorea, much contradictory evidence has been
furnished. Sydenham prescribed it as a subsi-
diary remedy ; Dr. Cui.lkn states that it was
sometimes useful, at other times injurious ; Dr.
Watt obtained, he informs us, decided advan-.
334
CHOREA AND RELATED AFFECTIONS — Treatment of.
tage from the practice; Dr. Armstrong found
it very hurtful ; and Dr. Clutterbuck trusted
to it almost entirely, repeating it several times af-
ter intervals of a few days. M. Bouteille view-
ed the disease as either congestive or inflammato-
ry, and commenced the treatment with blood-let-
ting, which he generally repeated, and with pur-
gatives. M. Serres, having observed vascular
turgescence about the corpora quadrigemina in
four fatal cases, has recommended leeches and
counter-irritants to be applied to the upper part
of the spinal column; and M. Lisfranc, also,
has directed blood-letting and leeches to the nape
of the neck. Dr. Hunter and Dr. Harrower
have depended upon purgatives and the inunction
of the tartar emetic ointment on the scalp and
along the spinal column. Aromatic liniments to
the spine were directed by Chrestien; the tur-
pentine and camphor embrocation to the same sit-
uation, by the author; and tartar emetic plasters
by Dr. Johnson, who also advised a grain of the
nitrate of silver, with two grains of pilul. hydrarg.
and five of the extr. colocynth. comp. as a purga-
tive. §It may further be added, that Ecker justly
insists upon the superiority of sulphur as a purga-
tive in this disease. The application of blisters to
the spine has been recommended ; but, in two cases
in which I have had recourse to this practice I
thought the effect was injurious rather than bene-
ficial.
29. B. Treatment recommended by the author.
— A careful consideration of the nature of the
disease will readily suggest a rational treatment.
The first indication is to remove morbid secre-
tions and fa?cal accumulations, the usual cause of
irritation of the organic nerves. The second, to
subdue vascular irritation or erythism of the ves-
sels of the spinal cord or brain, when the symp-
toms indicate its existence. The third, to rouse -
the energy of the organic nervous system, and
the vital actions of the assimilating and secreting
organs, and to impart energy to the frame, a. A
judicious employment of purgative remedies, va-
ried according to the peculiarities of the case, and
the states of the patient's system, is indispensable
to the fulfilment of the first intention. When the
disease appears previously to approaching puber-
ty, it is not very material what kind of purgatives
are first prescribed : but it should be recollected,
in the treatment of this disease, perhaps, more
than in many others, that a judicious combination
of purgatives, with tonic, or stimulating, or anti-
spasmodic remedies will more rapidly restore the
patient than confiding in purgatives merely. In-
deed, we are enabled, by such combinations, part-
ly to accomplish two indications of cure at the
same time; and frequently we secure a more de-
cided operation on the bowels and secreting vis-
cera by the combined means. It will very gen-
erally be necessary to commence with the exhi-
bition of a full dose of calomel, either alone or
with other purgatives, or followed by them five or
six hours afterwards : but the doses of calomel
ought not to be frequently repeated in this disease ;
nor, in my opinion, will it be found serviceable to
continue purgatives long, without either exhibiting
them with a bitter tonic or antispasmodic remedy, or
with both, or alternating them with these remedies.
When purgatives are thus prescribed, they may be
continued longer, not only without producing any
detriment, but generally with decided advantage.
Cases will not infrequently occur, in which little
or no benefit can be remarked until they have
been given almost unremittingly for a long period
— the evacuations being at first nearly natural,
but afterwards betraying disorder, and proving
that the repeated exhibition of purgatives was re-
quisite to unload the biliary ducts and gall-blad-
der, and remove faecal matters retained in the
cells of the colon. For this purpose, I have gen-
erally preferred the compound infusions of gen-
tian and senna, in equal proportions, with some
antispasmodic and a corrigent. This combina-
tion seldom acts frequently, but usually copiously.
The oil of turpentine, either followed, soon after
its exhibition, by some other purgative, if it does
not act upon the bowels, or combined with it, is
extremely beneficial; and, whenever the evacua-
tions are offensive, or of a morbid appearance,
especially if the case be complicated with worms,
ought never to be neglected. In such cases, a
single dose of calomel at bed-time, followed, in
the morning, with the turpentine, combined with
castor oil (in the proportion of three parts of the
former to two of the latter), and floating on the
surface of milk, or some aromatic water, is most
decided. In this affection especially, the medical
attendant should examine carefully the state of
the evacuations, and be guided, in a great mea-
sure, by their appearance, as to the repetition and
selection of purgative medicines. The benefit
derived from this class of remedies in chorea was
sufficiently demonstrated ■ by Drs. Hamilton
and Parr, and, although questioned by several
practitioners of the present day, cannot be denied.
Instances of their failure have been chiefly owing
to the neglect of combining them in the manner
insisted upon above, or of exhibiting tonics, stim-
ulants, or antispasmodics, in the intervals between
their operation. The good effect of treatment, as
well as the operation of purgatives, will be much
enhanced by rubbing either of the liniments F.
296. 311. on the loins or abdomen, once or twice
daily, and by allowing a light nutritious diet,
chiefly of animal food.
30. b. Contemporaneously with the fulfilment
of the first indication, the secorid should receive
due attention. In many cases, the means used to
accomplish the former will be sufficient to remove
existing irritation about the roots of the voluntary
nerves ; but when we have marked evidence of
irritation of these parts, or of determination of
blood to any part of the cerebro-spinal axis or
investing membranes, either in the state of the
pulsation of the carotids, increased temperature
of the head, coldness of the extremities, tender-
ness or pain from the occiput along the spinal
column, particularly when pressing between the
vertebrae on each side of the spinous processes,
the application of leeches behind the ears or along
the spine, and repeating them according to cir-
cumstances, or cupping in that situation, will be
requisite, and not incompatible with the use of
tonic and antispasmodic medicines, in cases pre-
senting symptoms indicating the propriety of re-
sorting to them. After leeches, the cold affusion
on the head or on the spine, night and morning,
or the shower bath; rubefacient liniments to the
latter situation, or the tartar emetic ointment or
plaster; warm woollen clothing on the lower ex-
tremities, and attention to the mental emotions;
constitute important parts of the treatment.
CHOREA AND RELATED AFFECTIONS — Treatment of.
335
31. An accurate idea of the remote causes of
th.' disease, as well as of their probable operation
and continued effect, should lead not only to their
removal as far as possible, hut also to a treatment
modified accordingly. The mental impressions
and moral emotions are often more or less affected,
particularly in those irregular forms of disorder,
which have very generally been confounded with
chorea. This circumstance should not escape the
attention of the physician, as it points to the em-
ployment of moral management in aid of medical
measures. As the mental affection, when it exists,
has generally an intimate relation to the remote
causes of the disease, the importance of ascertain-
ing the existence of the former, as well as the
nature of the latter, as a basis of an appropriate
treatment, must be manifest.
32. c. Having removed accumulations of mor-
bid matters, and subdued irritation existing about
the origin of the voluntary nerves, or in parts of
the cerebro-spinal axis, or enveloping membranes,
and having excited the actions of the secreting and
assimilating organs by the means stated above,
the third intention of cure is to be now entered
upon in a more decided manner, by the exhibition
of tonics combined with antispasmodics, and by
due attention to the state of the bowels, and func-
tions of the secreting viscera and surfaces. The
combination or alteration of bitter tonics with
aperients and antispasmodics will often be neces-
sary during this stage of the treatment ; or an oc-
casional dose of a brisk purgative, or of calomel,
will be exhibited with advantage during the em-
ployment of tonics. Even when the bowels are
so active as apparently to render this interference
unnecessary, a dose of the pilula bydrargyri, given
once or t\vice a week, either with or without the
pilula aloes cum mvrrha, will be found serviceable.
As to the choice of tonics, no immutable rule can
be laid down. The state of the pulse, and of the
secreting organs, should be the chief guide in the
selection of them. Attention to the mode of com-
bining them is also of much importance. Bark,
in any form, will be beneficial when judiciously
prescribed. The following powder will be found
serviceable, and may be taken in some aromatic
water ; the doses of the ingredients being varied
according to the age of the patient, and the state
of the bowels : —
No. 126. R Pulv. Cinchona gr. xij.; Pulv. Rhei jr. viij.;
Sodae Sub-carb. gr. x. ; I'ulv. Cspsici Annui gr. ij. Misce.
If the decoction be preferred, it will be found
most beneficial when given with liquor ammonia?
aoetatis, and a little of the spiritus n onise aro-
maticus. 'I he sulphate of quinine is an excellent
medicine, especially when the patient is old enough
to take it in the form of pill, when it may be
most advantageously combined wtth aloes, as in
F. 572 — 577., or with camphor and aloes as fol-
low-;. In this state of combination a decided ac-
tion will be exerted on the bowels : —
No. 127. R P amphora' rasa>, Quininaj .S nlphnl i«, aa '.) j.;
Extr. Aloes Purif. >..; Exlr. (icntian.i- fv.-l I'ilnl. Haitian.
Pomp.) 3 j.: Syrup. Simp. q. 9. M. Fiant I'ilula- IXXvj.,
quaruin capiat binas bis quotidie1.
33. In this stage of treatment much advantage
will often be obtained from valerian, combined
with other antispasmodics and tonics, or with the
alkalies (F. 269. 368.); from the preparations of
iron, as recommended in the article on Chloro-
sis, (§ 13.), or in F. 521. 523. ; and from the
sulphate of zinc (F. 582—587), or the arsenical
solution (F. 3<>4.). As chorea is sometimes com-
plicated with disease about the heart, or the roots
of the voluntary nerves, or the membranes of the
brain or spinal cord, of an inflammatory nature,
care should be taken not to exhibit this last active
substance, or even the preparations of iron, or of
bark, until the symptoms of these complications
have been removed by local depletions, cold af-
fusions, or the shower-bath, and counter-irritation.
A similar precaution is still more requisite in re-
spect of the employment of strychnine, or the nux
vomica (see F. 443. 541, 542. 565. 907.), which
I have found of much service in the advanced
course of treatment of the simple fonu of chorea,
or when it has been associated with rheumatism
of the joints or extremities, with chlorosis, hysteria,
or amenorrhcea ; in which complicated states of
the disease 1 have likewise found the tincture of
iodine, and hydriodate, or ioduretted hydriodate
of potash of great service (F. 234. 722.). The
formula:' for the above medicines given in the Ap-
pendix, or the following, may be adopted : —
No. 128. R Olei Valeriana; Tt) xij.; tere cum Saccli.
Purificati 5 ajss- i (um »dde Infra. Valeriana; 5 vijss ; Liq.
Arsenicalis TT) xv. ail xxx. Misce. Capiat cochlearia duo
larga ter quotidie.
No. 129. R Pulv. Calumba; gr. x. ; Pulv. Valerians
gr. xij. — ?)j. -, Carb n. Ferri Pra?p. gr. x. ; Pulv. Cionam.
gr. vj. M. Fiat Pulvis, vol Electuarmm molle cum Syrup.
Zingib. q. s., bis terve quotidie sumatur.
No. 130. R Carbon Ferri Pra'p. ^ss.; Pulv. Snpertart.
Potassas ~, vj.; Confection. Senna;, Syrup Zingiberis, aa ^J*s.
Misce. Fiat Electuamm, cujus capiat Cochleare unuin mini-
mum mane nocteque.
No. 131. |! Carbon. Ferri; Snlph. Praecip. 5a 7, ij. ;
Potassa- Snpertart. Pulver. SJ v.; Confectionis Senna; et
Syrup. Zingiberis aa \ jss. Misce. Fiat Elecluarium. Su-
matur Coch. iiimm minimum mane nocteque.
No. 132. R Sub-boratis Soda>, Supertart. Potassap, aa in
Pulv. 5'ij-i Carbon. Ferri ~ ij.; Confectionis Senna; J ij.;
Syrup. Zingiberis q. s. ut fiat Elertuarium molle, cujus
Cochleare unum minimum mane nocteque sumatur.
34. During the use of these medicines, the tar-
tarized antimonial ointment or plaster may be ap-
plied to the spine ; and when the tonics are not
combined with aperients, the former may be ex-
hibited in the course of the day, and the latter at
bed-time, as they may be required. The nitrate
of silver may also be tried in doses of half a grain,
or a grain, combined with aloes, or the aloes and
myrrh pill.
35. C. The treatment of the complicated and
irregular states of this disease must necessarily
be modified according to the diversified form it
assumes. The association of the disease with
rheumatism has been observed by me on several
occasions, and, in nearly all, there has been a
marked disposition of the rheumatic affection to
recede from the joints or extremities, and attack
the internal libro-serous membranes, as those of
the cerebro-spinal axis and the pericardium. This
unfavourable result has generally been promoted
by a too lowering treatment ; but prevented by
tonic and stimulating medicines, with due atten-
tion to the alvine evacuations. In cases, therefore,
complicated with rheumatism, chlorosis, anemia,
or retention of the menses, the purgatives selected
should be of a warm and stomachic kind, or com-
bined with cordial and stimulating substances ;
the ammoniated tincture of guaiucum, camphor,
serpentaria, and similar medicines, being also em-
ployed. In these states of disease, the internal
use of the cod or tusk-liver oil will he found most
beneficial. Having observed instances in which
336
CLIMACTERIC DECAY — Symptoms.
the suppression of the rheumatic affection of the
joints by the use of embrocations and liniments
was rapidlv succeeded by the appearance of in-
ternal disease, the application of such remedies to
the external seat of the rheumatic disorder should
not be resorted to.
36. In the irregular forms of chorea, particu-
larly those which present more or less of an hy-
steric character, the functions of the uterus, and
the circulation of the brain or spinal cord, or both,
are often disordered. In these it will be requisite
not only to evacuate the bowels freely, but also
to allay uterine irritation, where it seems to
exist, by leeches applied to the tops of the thighs,
or cupping o*ver the sacrum, and to promote the
monthly evacuation, when scanty or retained, by
purgatives and emmenagogues. In many cases
of this description, the application of a number of
leeches to the occiput, neck, and behind the ears,
the cold affusion on the head, or the shower-bath,
with warm clothing on the lower part of the
body, and due regulation of the moral emotions,
will materially aid the treatment. The more the
attack assumes the characters of tonic convulsion,
the more requisite will it in general be to have re-
course to local depletions, especially if the affec-
tion occur after puberty, and be connected with
interrupted menstruation.
37. During convalescence, and even in the ad-
vanced course of treatment, change of air, agree-
able amusement, exercise in the open air, the uss
of chalybeate or aperient mineral waters, and a
light nutritious diet, commencing with warm salt
water bathing during the treatment, and con-
cluding with cold salt water bathing in advanced
convalescence, followed by smart frictions of the
surface of the body upon coming out of the bath,
will materially promote and confirm recovery, as
well as prevent a return of the disease.
Bidlioo. and Refer. — Willis, De Morhis Convulsivis,
cap. vii. p. 21. — Tu/piw, I. i. cap. 1G, n.—Horsli'us, Epist.
Med. s. vii.; Opera, 4lo. 2d vcd. p. 129. — Sydenham, Opera,
p. 160.— Wedel, De Chorea Sti. Viti. Jens, 1682.— Felix
Plater, Observ. 1. i. 130. — Ramspek, Diss. Riga Remedior.
Prastaritiss. &c. Bns. 1745, p. 35.— Schwartz, De Taraiitismo
et Clioreo Sti. Viti, ice. Vien. 1766. — Fothergill, in Philos.
Trans, for 1799, part \.—De Haen, Rat. Med. part i. p. 142.,
part iii. cap. vi. p. 221. — Burserins, Institut. vol. iii. p. 242.
— Penada, Saggio d'Osservazioni, n. 9. — Merle, Museum
der Heilkunde, b. iv. p. I98.-^S>/<, Rat. Med. pars iii. p.
405., et pars iv. p. 469. — Wendt, Nachriclil von dem Krank-
eninstitut zu Erlang. 1723.— BnMingiw, N. Mas;, b. ix. p.
185. — Ecker, in Pinefs Nosog. Pliilos. t. ii. p. 94. — Geath,
Phil. Trans, vol. liii. 1763.— De Haen, Rat. Med. par. iii.
n. 202. — Sidren, Dissert. Morb. Casus, Sp. &c. Upsal. 1785.
—Sallaba, De Morh. Variol. Posth. Vien. 1789.— Plouc-
quet, Ohscr. Med. Tubing. 1787.— White, Edin. .Med. Com-
ment, vol. iv. p. 326. — Hart, in Ihid. vol. i. p. 76.— Odier,
in Ibid. vol. iii. p. 191.— Walker, in Ihid. vol. x. p. 238.—
Armstrong, in Ihid. vol. ix. p. 317. — Thilenius, Medic, mid
Chir. Benierk. fcc. p. 115. — Werlhof, Ohs. de Feb. sect. ii.
§ 4. — Swainston, Thoughts, Phvs. and Pract. ,tc. York,
1796.— Robertson, On Chorea Sti. Viti, 8vo. Phtitad. 1805.
— Hamilton, On Purgative Medicines, ch. vi. — Plenk, De
Morbis Infantum. Vien. 1 807. — Richter, Die Specielle Thc-
rapie, b. vii. p. 757. — Hufeland, in his Journ. der Tract.
Heilk. b. i. p. 152., et June, 1811, p. 83., Mav, 1K12, p. 12.
—Hildenbrand, in Ihid. h. xxiv. st. i. p. 147.— Wendelstatt,
in Ibid. p. 149. — Eckstein, in Horn's Archiv. Jcc. h. iii. p.
241.— Briickmunn, in Ibid. Jan. 1811, p. 9., et 1S12. p. 168.;
et Journ. de Med. t. lxxiv. p. 136.— Wright, Mem. of Med.
Sue. of Lond. vol. iii. Ap. n. 24. — Leniin, Med. Bemer-
kung. &c. 180O. p. 76.— Engethur I, Mm. der Heilk. b. iv.
p. 123. — Westphal, Pathologia Daemoniaca, p. l. — Wich-
mann, Ideen zur Diagnostic, b. i. p. 1-34. 144. — Mahon,
Journ. de.Med. t. Iviii. t. 553.— Allamtm I, Journ. deMid.
Cent. t. xviii. 6^ 203.— Frank, Acta Instil. Clin. Vilnens,
t. iii. p. 51. — Theussink, Beobacht. der K. K. Josephs-
Academie, b. i. n. 5. — Ketterling, [ie Chorea Sti. Viti. E f.
1803. — Sehaeffer, Kinderkrankh. p. 393.— Reil, Rieberl-
ehre, b. iv. p. 626.— Martin, Trans, of ."Med. ?,;.i I I .
Soc. vol. iv. p. 45. — Kinder Wood, in Ibid. t. vii. p. 237. —
Wutt, in Ibid. vol. v. p. 1. — Salter, in Ibid. vol. x. p. 218.
— Gregory, Ibid. vol. xi. p. 299. — Willan, Reports on the
Diseases of London, p. 245. ; and Med. and Phvs. Journ.
vol. vii. — Coxe, Med. and Phys. Journ. vol. xiii. p. 405.,
and vol. xviii. p. 221. — Paterson, in Ibid. vol. xiii. p. 119.,
vol. xv. p. 127., and vol. xviii. p. 234. — Pell:, Ibid. vol. lix.
p. 454. — Kerst, De Zinco ejuscpie Usu praecipue in Chorea.
Jen. 1812. — Muton, in Lond. Med. Repos. vol. v. p. 148. —
Bedingjicld, Compend. of Med. Practice, Lond. 1816, p.
52. — Copland, in Lond. Medical Repository, tc. vol. xv.
p. 23. — Pilchard, in Ihid. vol. xxi. p. 1. — Rotser, in Hufe-
land's Journ. der Pract. Heilk. Nov. 1828. — Sei-res, Lancet,
vol. xiii. p. 133. — Aliprandi, in Giornale Analit. di Med.
Milano, Guigno, 1828.— Ferrari, in Ibid. Nov. 1828.— Gib-
ney, Med. Gazette, vol. i. p. 54. — Armstrong, his Lectures
on Medicine, Lancet, vol. viii. p. 70. — Clutterbuck, Lec-
tures on Med. Ibid. vol. xii. p. 421. — Piedagnel, in Magen-
die's Physiology, translated by Milligan, 3d. edit. p. 189.—
Laurent, in Ibid. p. 191. — Boutcille, Traite de la Choree,
tc. Paris, 1810. — Powell, Trans, of College of Phvs. vol. v.
p. 358. — Maton, in Ibid. vol. v. p. 188.— Crampt'on, Trans,
of the Assoc, of Phvs. of Dublin, vol. iv. p. 111.— Griffith,
Philad. Med. Mus. l'806.— Reeves, in Edin. Med. and Surg.
Journ. vol. viii. p. 314. — Hunter, in Ihid. vol. xxiii. p. 261.
—Jeffreys, Ibid. p. 273.— Stuart, in Ibid. vol. xxviii. p. 271.
— L'-.eins, in Ibid. vol. viii. p. 408. — Swan, in Ibid. vol. xxii.
p. 94. — Crichton, in Ihid. vol. xxxi. p. 300. — Manson, Re-
searches on the Elfects of Iodine, 4cc. p. 230. — Elliotson,
Trans, of Med. and Chimrg. Soc. vol. xiii. p. 252.; and Med.
Gazette, vol. vii. p. C52. — Chishohn, On Diseases of Trop.
Climates, Rvo. 1322, p. 97. — Lisfranc, Archives G> ner. de
Med. Sept. 1S27. — Harrower, in Glasgow Med. Journ. vol.
ii. p. 212. — Young, in the American Journ. of Med. Sciences,
vol. ix. p. 310. — Brown, Mcdico-Chirurgical Review, he.
vol. xv. p. S26. — Johnson, in Ibid. vol. xv. p. 431. — Serres,
Revue Medicale, 1S27. t. iii. p. 513.
CLIMACTERIC DECAY. — Climacteric Dis-
ease.
Classif. 3. Class. 4. Order (Good). I.
Class. V. Order (Author).
1. Dkfin. General decline of the vital powers,
at the age of senescence, without any evident cause.
2. The ancients believed that very important
changes took place in the economy at certain
periods ; the first being the seventh year, and the
subsequent epochs answering to the numbers re-
sulting from the muliplieation of three, seven, and
nine, into each other : as the twenty-first, the
forty-ninth, the sixty-third, and the eighty-first
years. The two last were called grand climac-
terics, as the life of man was supposed to have
reached its allotted term. The doctrine of cli-
macteric periods has been traced to Pythago-
ras, who derived it from the Egyptians ; and,
although its truth has been denied by many emi-
nent physicians, it has been believed in by others.
The changes which take place at these epochs
are of two opposite kinds ; that of renovation,
and that of decay. It is the latter of these which
will here be considered.
3. Symptoms. — This disease has been very
minutely described by Sir H. Halford. It
usually conies on insensibly. The patient first
complains of fatigue upon slight exertion; his ap-
petite becomes impaired ; his nights are disturbed
or sleepless, and his mornings unrefreshed. The
tongue is somewhat while ; the pulse a little accel-
erated ; the face extenuated, occasionally slightly
bloated ; the body emaciated, and the ankles and
legs disposed to swell. The urine is not deficient,
but the bowels are sluggish, and pains, with ver-
tigo, are occasionally felt shooting through his
head and various parts of the body, but are not
possessed of the rheumatic character. As the
vital exhaustion proceeds, the stomach loses all
its powers ; the emaciation is greater : the lower
limbs are more oedematous ; restlessness through
the day and sleeplessness through the night in-
crease, and all the vital manifestations, mental
CLIMACTERIC DECAY — Causes —Treatment.
337
and physical, are gradually extinguished. Such
is the usual progress of the simple form of the
disease, or rather gradual decay of the vital en-
ergies, — a decay which is not peculiar to, but
which may occur at any time intermediate be-
tween, the grand climacteric periods. This sim-
ple form of decay is, however, less frequently ob-
served than its complication with other affections.
Persons who, together with the anxieties, griefs,
and distresses of life, have been subject to disease
of some particular organ, as of the lungs, liver,
brain, heart, &C, who are of a gouty, rheumatic,
or calculous diathesis, generally experience at
these epochs an aggravation of such diseases,
which assume a more dangerous character from
the vital decay which is thus attendant upon
them. Indeed, in most cases, these accidents,
moral and physical, constitute the exciting causes
or occasions of the appearance of climacteric
disease, as wrell as complicate and aggravate its
progress.
4. Causes. — This disease is more common to
meu than women, probably owing to the more
tumultuous and exhausting life passed by them —
to their greater exposure, during the preceding
terms of existence, to the numerous causes of
mental and corporeal exhaustion incidental to the
states of modern societv and civilisation. It is not
infrequently occasioned by the mental depression
arising out of pecuniary Losses ami disappoint-
ments, and the death of old and attached friends
and relatives. Thus, we sometimes observe it
proceed rapidly to a fatal issue, or combated with
great difficulty, after the loss of the partner of the
principal part of the patient's existence. It may
also be caused by a marriage contracted late in
life, or by unusual intemperance, or some acci-
dental shock or commotion of the frame.
."). As to its nature, climacteric decay is ob-
viously the concatenated phenomena arising from
that exhaustion of the vital energies which takes
place at a more or less advanced age, in conse-
quence of the cares, turmoils, and. physical exer-
tions, attendant on the existing states of society,
particularly in the middle classes of life ; the
exhaustion manifesting itself especially in these
functions which are most intimately related to,
and concerned in, the perpetuation of the vital
endowment of the fame, and which are actuated
by the organic system of nerves. As this decay
of the vital energies — this breaking up of the con-
stitution, as u is ;omii!:)ii:\ r died — is necess iniy
experienced by the whole frame, it is obvious,
that it may not only be hastened by whatever is
either mentally or corporeally injurious, as well
as by specific forms of disease, but that it will be
more or less remarkably evinced in those organs
which have especially suffered during attacks of
previous illness : hence the complicated states in
which senile decay is usually observed, and the
rapid progress and unfavourable issue of maladies
appearing about the climacteric periods.
tj. Treatment. — The simple form of this
- ■ requires tonic and cordial medicines, with
generous diet, a dry wholesome atmosphere,
change of air, the occasional use of the tonic and
deobatruent mineral waters ; agreeable occupa-
tions and amusements; and, above, all, the conso-
lations arising out of the recollection of a well-
spent life, and confidence' of the future. During
the course of treatment, particularly of the com-
29
plicated states of the affection, the digestive, se-
creting, and excreting functions require to be as-
sisted, by means of the warm, bitter, and cordial
aperients (F. 86. 214. 206. 572.); and if internal
congestions, or suh-inllammatory disorders, mani-
fest themselves, evacuations should not be prac-
tised without combining or alternating them with
restoratives and tonics. The best aperients are,
in such circumstances, rhubarb or aloes combined
with gentian, quinine, guaiacum, or myrrh, or with
the carbonates of the alkalies and the balsams.
But, on all occasions, even of acute disease occur-
ring at the climacteric epochs, it should be recol-
lected, that the vital energies soon feel the shock,
not only of the malady, but also of a too active or
lowering treatment ; and that, even when such
practice is most required, we should endeavour to
support the powers of life by means the best cal-
culated to fulfil this object, without increasing the
morbid action, and to meet the first indications of
depression or exhaustion by suitable cordials and
tonics. The utmost attention should also be paid
to the previous habits and indulgences of the pa-
tient ; and if the discontinuance of them is likely
to sink the constitutional energies still lower, they
ought not to he relinquished. Various instances
have occurred, showing the ill effects of want of
attention to the above caution, during the course
of my practice.
7. A gentleman had been for some years at-
tended by the writer. At the age of eighty-one
years, during a severe winter, he suffered much
from bronchitis, accompanied with great sinking
of the vital energies, liis habits were social, and
he lived highly. He recovered, however, by
means of warm diaphoretics, and tonic cordial
aperients, with a due regard to his accustomed
indulgences, and to the precept of Hoffmann,
" ne. subilo muta assueta, quia assuetudo est altera
naturaJ" The following year he had a similar
attack, at his seat in the country. A nearly op-
posite treatment to that which was adopted by
the writer in his previous illness was directed by
his medical attendants on this occasion, and in a
few days he expired when seated on the night-
stool, (see Hoffmann's treatise " Dc Siiu erecto
in Morbis pericu/osis valde noxio,'") about half an
hour after the physician had left him, and given a
favourable opinion of the result to his friends.
8. General had served nearly all his life
in the East Indies, and was upwards of eighty,
but of a robust constitution, liis ailments, when
he was seen by me, could not be referred to any
particular organ, and were attributed at the time
to senile decay : the liver performed its functions.
Nothing beyond the regulation and promotion of
the digestive and excreting functions was attempt-
ed ; and he was allowed a light and nutritious
diet, with change of air, the use of the Bath wa-
ter, &c. Under this plan he improved greatly,
and was able to travel with ease from one part
of the country to the other, and, when in town,
to dine daily at the Oriental Club. The lust oc-
casion but one on which I saw him, he came to
my house, to inform me that his relatives were
not satisfied with the progress he had made, and
had repeatedly urged him lo change his physician.
1 accordingly retired ; but, a few days afterwards,
was requested to see him. He was then sinking
fist, evidently from the effects of a lowering treat-
ment and of profuse evacuations upon a decayed
3.38
CLIMATE — Physical Relations of.
frame. Speedy dissolution could not be averted ;
1 therefore declined all interference. He died not
many hours afterwards.
Bibi.ioq. and Refer. — Codronelii, De Annis C'imar-
(ericis Comment. 8vo. lion. 1620. — Brendetius, Monument.
Fragilitatis Humana; mementancae Anni Climacteric!, 4to.
Alst. 1653.— Putin, Ergo al) Annis Climactericis nil metu-
endura, 4lo. Paris, 1657.— De Filisro, De Fato Annisque
Fatalibus tarn Hominibus quam Regnis, 4lo. Franc. 1665.—
Salmatiw, De Annis Climactericis el Antiq. Astrolog. Dia-
tribe, 8vo. Leyd. 1678. — Zie.gra, De Annis Cliuiac. Vita;
Humana;, 4to. Viteb. 1682. — Hoffmann, Annor. Climacl.
Medica et Rationalis Explicalio, Operum vol. v. p. 89., et
vol. vi. p. 105. — Hilscher, De Vano iEtatis Humana; Anni
C3 Climact. magni vutgd dicti Timore, 4to. Paris, 1743.—
(Inner, De Annis Climacl. 4to. Jena-, 1792.— Ha/ford, in
Trans, of the College of Phvs. of Lond. vol. iv. p. 316.—
Rtnauldin. Diet, des Sciences Medicates, t. v. p. 360. —
Good, Studv of Medicine, edit, by Cooper, vol. iji. p. 226.
3d edit. — Pinfl. in Archives Gtner. de Med. t. ii. p. 7. —
Fowart, in Ibid. t. v. p. 393.
CLIMATE. Syn. (From y.Xlua, a region).—
Climat, Fr. Das Clima, Ger. Clima, Ital.
Classif. General Pathology. — JEti-
ology and Therapeutics.
1. Climate, in its rigorous acceptation, means
only a district placed between certain equatorial
and meridional circles ; hut it possesses a much
wider signification in medicine, and is more com-
monly applied to the conditions of the soil, sur-
face, elevation, and position of a country, in con-
nection with the general states of the atmosphere,
influencing the health of the human species, and
of the higher races of the animal kingdom : —
" L'ensemble de toutes les circonstances naturelles
et physiques, au milieu desquelles nous vivons
dans chaque lieu." — Cabanis.
2. I regret that my limits will not admit of en-
tering fully upon the consideration of the physical
conditions which combine in forming the climate
of a country, and not only modify the constitution
of men, giving rise to a great part of the most
acute diseases to which lie is liable, but also assist
in removing others of a dangerous tendency. It
is obvious, that a knowledge of the elements out
of which disease arises, and which may be taken
advantage of, and even artificially combined, for
its removal, must be of essential advantage in the
healing art. Indeed, the importance of the sub-
ject has been admitted since the time of Hippo-
crates, whose treatise tiiq'i aiotov i SaTvn y.al
•to&tov will be read, even at the present day, with
the greatest advantage. I shall, therefore, draw
a mere sketch of the subject, and indicate the
sources whence more detailed information may
be obtained.
3. I. The Physical Relations of Cli-
mat f. — The climate of a district or of a country
essentially depends, 1st, upon its position, in re-
spect of distance from the equator ; 2d, upon its
elevation above the level of the sea, and its prox-
imity to the shores of the ocean, or the beds of
large rivers, &c. ; 3d, upon the geological and
mineralogical formations constituting the basis of
its soil ; 4th, upon the nature of the soil itself, its
cultivation, and the vegetable productions by
which it is covered ; and, 5th, upon the prevail-
ing winds or currents of air. Under these heads
are comprised a number of subordinate phenome-
na, giving^ rise to important modifications in the
climate of a district. In the brief account, about
to be given of the subject, the temperature and
humidify of a place will be first considered, and
afterwards those circumstances which relate more
immediately to the nature of its locality.
4. A. Of the temperature and humidity of
climates, and their effects. — The temperature of
a place influences not only the organization, but
also the diseases, of the inhabitants ; and, as it
varies with the latitude, physical conditions of a
district, state of cultivation, &c, it is evident that
the physicians of the northern countries of Eu-
rope have to treat different constitutions and states
of disease, from those which come before prac-
titioners in more southerly regions. The effects
of temperature upon the human frame vary re-
markably, owing to numerous concurrent circum-
stances, and the extent, rapidity, and frequency
of its changes. The mean annual beat, the ex-
treme range of temperature, not only during par-
ticular seasons, but also in each month ; the usual
mean of such month, and daily variation ; have
altogether a manifest influence upon the human
frame. Geographers have divided the globe, in
relation to its temperature, into arbitrary divisions,
well known as the torrid, the two temperate, and
the two frigid zones ; but the climate of the coun-
tries placed within these divisions are so greatly
modified by other circumstances than by distance
from the equator, especially by elevation above
the level of the sea, by distance from the ocean,
want of cultivation, &c, that many places within
the temperate zones, and even in those parts of
them which are the nearest the meridian, ex-
perience, particularly at one period of the year,
remarkably low ranges of temperature ; whilst
others, much further removed from the equator,
are subjected, during summer especially, to as
great heat as places within the tropics. In coun-
tries or districts near the ocean, or large lakes
and rivers, and particularly in islands or places
partially surrounded or indented by the sea, the
extremes of heat are moderated, but the air is
moist, and the changes of season are uncertain
and variable ; whilst in those situate far inland,
and removed from lakes or the beds of large
rivers, the range of atmospheric temperature is
very great, particularly in latitudes above 40°
north, or in places considerably elevated above
the level of the sea ; and the air is remarkably
dry. Even in countries within the tropics remote
from the ocean, or having high ranges of moun-
tains placed between them and it, that may attract
and condense into clouds and rain the moisture
carried by the sea winds over the land, the dry-
ness of the atmosphere is very great, and, where
the currents of air have passed over extensive
tracts of arid country, is even extreme. This is
well shown by the Harmattan winds, which,
having blown over the dry countries of central
Africa, visit its western coast, and change the
extreme humidity of that part, during their con-
tinuance, to a state of remarkable drvness. In
the more inland districts, therefore, of large con-
tinents or islands, placed without the torrid zone,
the depression of the thermometer during their
winter months, and elevation of it in summer, are
greater than is indicated by their distance from
the equator, and the air is much drier than in
places otherwise circumstanced. In these latter,
particularly insular situations, &c, the climate is
more equable but much more humid. In the
former the seasons are regular, the change con-
stant and rapid ; in the latter they are variable,
irregular, their accession slow, and attended by
storms and hurricanes.
CLIMATE — Physical Relations of.
339
5. The intensity of the solar beams, and con-
sequently of light, in warm countries, is very in-
fluential in modifying not only the vegetable and
annual creation which inhabit them, but also
many of the physical phenomena which con-
tribute to tbe constitution of their climates. It
would seem as if the solar beams were decom-
posed hv the soil and its products, and, whilst
furnishing heat and light to objects upon the sur-
face of the earth, served to supply or to replace
the locomotive electricity, which is constantly cir-
culating through, and actuating, not only the crust
of the globe, but also the vegetable and animal
creations which cover it ; passing thence, at last,
into the atmosphere. Observation has clearly
shown that electrical phenomena are most ener-
getic, and of most frequent occurrence, in coun-
tries and is seasons in which the solar influence
is the greatest ; and that, while dryness of the
atmosphere causes its accumulation in objects
placed on the surface of the globe, a moist state
of the air favours its passage thence, and its ex-
cessive increase in the clouds, giving rise to va-
rious meteorological phenomena. In a dry at-
mosphere, particularly in inland districts, thunder
and lightning, — the more violent electrical changes
occurring in this fluid, — do not take place ; whilst
vegetables and animals, as well as other bodies,
placed on the earth's surface, are more than
usually charged with electricity ; whereas, in a
warm and moist atmosphere, especially in mari-
time or insular situations within the tropics, these
phenomena are very frequent, and the electricity
is rapidly carried oh? from the earth.
6. It is evident that the annual quantity of rain
in a particular district is very intimately connected
with the nature of the climate ; depending as it
does upon the sources and amount of evaporation,
and the prevailing winds. In the middle countries
of Europe, the annual quantity of rain usually
ranges from 12 to IS inches. In the south-east
side of this island, and in the vicinity of London,
it commonly varies from 20 to 25 inches ; whilst
it is nearly double this amount in the western
parts of Great Britain and Ireland ; the greatest
quantity falling in July, when the mean monthly
temperature is highest, and the smallest quantity
in February and March. As we advance towards
the equator, the annual quantity of rain increases,
chiefly in maritime countries, and parts in which
ranges of high hills or mountains skirt the sea-
coast, and varies from 80 to 120 inches. But the
number of dry days is increased, particularly in
districts situate inland ; the greatly augmented
quantity of rain falling at a particular season, and
in a much shorter space of time than in colder
regions. In cold or temperate maritime places,
on the other hand, the rain descends in slighter
showers, and much more frequently, although in
much less quantity ; leaving fewer dry, and oc-
casioning more foggy and drizzling days, than in
warm or inland countries.
7. B. Besides the foregoing, there are other
circumstances which concur in forming the climate
of a place. The chief of these are, the nature
of the locality, the soil, the abundance and exu-
berance of the vegetable creation, the state of
cultivation, the prevailing winds, &c. In the
consideration of the locality, elevation above the
level of the ocean, proximity to its shores, the
vicinity of large rivers or lakes, the condition of
the surface, its elevation into hills or mountains,
or depression into valleys or ravines, and the 9tate
of vegetation and cultivation, are the chief fea-
tures that require notice. Places inland, which
are elevated high above the sea, or the banks of
large livers or lakes, have their mean temperature
diminished, in proportion to the elevation, much
below those which, although equally far removed
from the equator, are situate near the level of the
ocean, or the bottoms of valleys ; and the in-
habitants thus breathing a drier, purer, and cooler
atmosphere than in these latter localities, are
more athletic, less subject to febrile diseases of a
malignant or severe character, and reach more
advanced ages. The influence of elevation above
the level of the sea, and other circumstances of
locality, upon the health of man, is chiefly shown
in warm climates, and the more southerly of
temperate countries. In the north of Italy, and
in various districts in the south of Europe situate
on the sea-coast, near the banks of lakes and
rivers, and in low or narrow valleys, where a
deep, moist, and rich soil abounds with organic
substances in a state of decay, the air is humid,
loaded with effluvia ; is much more stagnant and
dense ; and, although the heat is moderated, as
respects the extremes of its 'range, much within
the limits to which it advances in elevated and
inland parts, yet is it more oppressive, the at-
mosphere frequently being sultry and relaxing.
Hence it is, that in these low situations the hu-
man frame is imperfectly or weakly constituted ;
a small proportion of the children born are rear-
ed ; visceral and glandular diseases abound ; and
the mean duration of human existence is much
shorter than in adjoining districts, which are
either more highly elevated, or removed from
the sources of contamination ; and, from these
districts, the diminution of the population of the
former, continually occurring, is chiefly supplied.
The East and West Indies, and the coasts of
South and North America, furnish numerous illus-
trations of the influence of locality upon the cli-
mate, and thereby upon the constitution and health
of the human race. So very different is the cli-
mate of Vera Cruz, and places in the vicinity,
from other parts in the same latitude, but situated
some hundred feet above the level of the sea,
that the comparatively robust and healthy inhabi-
tants of the latter are more subject to the endemic
fevers of the former localities, when they visit
them, than the natives ; a continued residence
having impaired the susceptibility of the inhabi-
tants of the former places.
8. In the consideration of the soil, the geologi-
cal and mineral relations of the place can scarce-
ly be overlooked. In general, the older forma-
tions of rocks, and those of a homogeneous and
compact nature, support a finer, a more deep,
and more absorbent soil than the sandstone rocks
and others, the debris of which form a coarse
and gravelly substratum, through which the rain
percolates and flows ofl', it not being retained in
the surface to be evaporated, carrying with it into
the air a portion of decayed vegetable and animal
matter, as in the case of clayey, deep, absorbent
soils, that yield by evaporation nearly all the rain
which falls upon them. Whilst deep, rich, and
moist soils, particularly near the banks or em-
bouchures of rivers, on the shores of lakes, on
the sea-coast, and near its level, or in low con-
340
CLIMATE — Physical Relations of.
fined valleys, or at the basis of mountains, es-
pecially in countries within 40° of the equator,
are very productive of malaria ; dry, sandy, or
gravelly soils, somewhat elevated above or re-
moved from the mouths and banks of rivers, and
covering level, gently undulating, or moderately
hilly places, are most salubrious. In northern
and temperate regions, maritime places are equal-
ly healthy with inland districts, or even more sa-
lubrious, unless the latter be considerably ele-
vated, possess a dry, well-cultivated soil, and be
without marsh lands in their vicinity. But in
warm climates, and even in many temperate
countries, during warm seasons, places on or near
the sea-coast are more productive of insalubrious
exhalations than inland districts, owing not mere-
ly to their being more nearly on a level with the
sea, and subjected to a denser and more moist
atmosphere, but chiefly to the circumstance of
the soil in such localities being more deep, rich,
and absorbent ; more liable to inundations from
heavy rains or swollen rivers, and from the sea
itself ; more fertilised by the decay of vegetable
and animal bodies ; and hence more productive
of the elements of unwholesome exhalations,
when their extrication is favoured by a hot sun,
and their retention and accumulation in the air
are promoted by its more constant and greater
humidity. Ravines, deep valleys, marsh grounds,
the banks of rivers liable to exposure after inun-
dations, the banks of lakes or canals similarly
circumstanced ; a soil profusely covered by suc-
culent plants and other vegetable productions,
and not reclaimed by cultivation, or but recently
cultivated ; grounds and soils exposed to the ac-
tion of the sun, after having been long covered
by an exuberant vegetation ; the cultivation of
rice, or other vegetable productions, which re-
quire occasional inundations or profuse irrigation;
the partial admission of sea-water, or its percola-
tion through the natural embankments thrown up
by the waves in low swampy parts of a coast ;
and the accumulation of dead vegetable or ani-
mal matter, of ordure, &c, in ditches, sewers, or
drains, &c. ; are the principal sources of those
vapours and gaseous emanations which, being
extricated by heat, and dissolved in the moisture
of the air, act unfavourably upon the human con-
stitution, and originate several of the most fatal
diseases to which it is liable.
9. C. The cultivation of a country has also a
marked influence upon the state of its climate.
A district covered by a rank and exuberant vege-
tation— by extensive forests — is cold and moist,
if situate beyond the tropics, its temperature and
humidity being many degrees lower than that
which a state of high cultivation would produce.
A country similarly circumstanced within the
tropics is also cooler and more moist than if it
were cultivated ; but the air is remarkably close
and oppressive ; and teems, as well as the soil,
with the lower grades of animal creation, to the
generation and nourishment of which its abun-
dant wild vegetation chiefly contributes. Whilst
the wooded and uncultivated districts of high
latitudes occasion coldness and humidity of the
atmosphere, abound in miasms from decayed
vegetable matter, and produce the diseases usual-
ly proceeding from these causes, especially in-
termitteuts, catarrhs, rheumatism, pulmonary af-
fections, &.c, places covered by an exuberant
vegetation within the tropics, particularly those
near the sea-coast, and upon its level, abound
with the effluvia arising not only from vegetable
matter constantly in a state of decay, but also
from animal exuvire, and the dead of mvriads of
insects and reptiles which infest these localities,
and occasion malignant and remittent fevers,
dysentery, and diseases of the abdominal viscera.
10. Although cultivation renders a climate
warmer, drier, and more salutary, especially
in temperate countries, yet for many years after
the soil is cleared from its more bulky vegetable
productions, and when it is first exposed to the
action of the sun, especially in low latitudes, its
endemic diseases often become more severe than
even previously, and not infrequently assume an
epidemic or pestilential form. The medical his-
tory of the West India islands and adjoining
coast of America, as well as of the United States,
furnishes numerous proofs of this position. The
surface of the earth, previously in a great meas-
ure protected from the action of the sun*s rays
by the thick and exuberant vegetation that cover-
ed it, and the temperature lowered by a freer
evaporation and transpiration from the leaves,
yielded a less noxious effluvium than when en-
tirely exposed to the sun's rays, and to the free
action of air heated many degrees higher by the
exposure. In its unreclaimed state, the noxious
exhalations proceed chiefly from the decayed
vegetable matter covering the soil, a great por-
tion of which seldom rises above or extends be-
yond the higher foliage of trees ; in its cleared
state, the emanations are the product of the earth
itself, and result from its richer constituents, and
those elements of animal and vegetable matter
with which a deep absorbent soil abounds, par-
ticularly in warm countries. The exhalations
from the former source are more constantly and
uniformly generated ; but, from the latter, thev
are only occasionally formed, and require a
concurrence of circumstances, especially a high
range of temperature, a situation but little ele-
vated above the sea, the vicinity of the sea-coast,
and probably a certain degree of humidity of the
air, and peculiar state of its electricity, for their
generation.
11. D. Prevailing uincks have much influ-
ence upon a climate. In Great Britain, and
most countries forming the north-west of Europe,
northerly and easterly winds are frequent during
March, April, and .May, owing to the current
established to replace the warmer air, as it rises
from the surface of the Atlantic and more south-
erly countries, now warmed by the sun as it
passes to the northward of the equator. These
winds are generally dry and cold, precipitating
the moisture in fogs, and occasioning catarrhal,
bronchial, pulmonary, and rheumatic affections,
and, under certain circumstances, agues. During
summer and autumn, southerly and westerly
winds are most prevalent, and the air is more
moist, owing to the temperature of the inland
countries of Europe being now greater than the
surface of the Atlantic ; and to the air, loaded
with exhalations from the ocean, rushing to re-
place the strata which are constantly rising from
the heated surface of these countries, and deposit-
ing the moisture in the form of showers, &C. as
it passes over the land ; the hills, mountains, and
places in their vicinity, which first attract the
CLIMATE — Physical Relations of.
341
clouds formed by the exhaled moisture, experienc-
ing tlu- greatest fall of rain. During November and
December, northerly and easterly winds are again
frequent, and the fall of rain is much increased.
As the atmosphere receives or dissolves a portion
of those fluid or gaseous substances with which it
comes in contact, it is obvious that currents of air
passing over the sources of the insalubrious exha-
lations enumerated above (§ 8.), will be more or
less fraught with them. On the Other hand, the
air readily imparts a portion of those foreign sub-
stances dissolved in it, when brought in contact
with bodies differently circumstanced. Hence it
follows that prevailing winds, whether in north-
ern, temperate, or warm countries, will have con-
siderable influence on the climate, particularly in
these last, for there the winds are generally most
regular and constant, especially at certain sea-
sons : places experiencing the sea breezes, and the
winds which have passed over a dry and well cul-
tivated country, being favourably circumstanced;
but those exposed to currents of air from the
sources of disease already referred to, being not
much more fortunately placed than if they were
immediately surrounded by insalubrious localities.
In the case of towns, villages, or dwellings, thus
situate, ill effects may be partly guarded against
by planting double or treble rows of tall trees in
such a manner as to intercept the noxious exha-
lations in their passage from the places in which
they are generated. In this way the ancients
protected their villas and towns from malaria;
and it has been shown in modern times, that the
foliage of trees attracts and absorbs these exha-
lations as they circulate through it, particularly
at the season when they are most abundantly ex-
tricated from the soil.
12. Maritime places, in warm climates, and
the more southerly of temperate countries, whilst
they experience in the day-time, during the great-
er part, of the year, regular sea breezes arising
from the current of air replacing that which has
been rarefied by the heated surface of the earth,
are also subjected to land winds during the nights,
owing to the less rapid evaporation and greater
heat of the surface of the ocean at this time, the
rapid radiation of heat from the soil soon reduc-
ing the temperature of its surface below that of
the ocean in the same latitude. These winds are
often fraught with effluvia, which, having been
exhaled during the heat of the day into the upper
regions of the atmosphere, are at night precipi-
tated to its lower stratum, and are very produc-
tive of disease in those exposed to them. The
currents of air that during the heat of the day
passed from the ocean more or less loaded with
i>ture, return to it in the night, charged not
only with humidity, but also with terrestrial ema-
nations; thus rendering places situate in the vi-
cinity of the sea, and nearly upon the same level,
more insalubrious than the elevated districts in-
land. Numerous places in the Cast and West
Indies, South America, and Africa, furnish illus-
trations of this principle, as well as various dis-
tricts in North America, and in the south of
Kurope, particularly those on the shores of the
Mediterranean.
13. General view of the subject. — From the
foregoing, therefore, it will be seen that the word
climate, embraces not only the temperature of a
country, and the phenomena which depend upon
29*
the distribution of heat, but all the modifications
of the atmosphere by which our organs are sen-
sibly affected, particularly states of humidity, va-
riations ot barometric pressure, changes of electric
tension, the admixture of gaseous emanations or
substances dissolved in the atmospheric moisture,
clearness and serenity, and tranquillity as respects
both horizontal and vertical currents. All these
exert a powerful influence, not only upon the
developement and health of the vegetable and
animal structures, but also upon the sensations,
the intellectual endowments, and the moral emo-
tions of mankind, in the different regions and
zones of the world. Comparatively few of these
atmospheric changes can be ascertained other-
wise than by a long series of attentive observa-
tions; and these have been made only at a few
parts of the earth's surface; and hence, as re-
marked by an able writer, though we know with
some precision the general circumstances which
modify the distribution of heat, we are still im-
perfectly informed as to the influence of local
causes of deviation from the mean state that would
be attained if the surface of the earth were per-
fectly regular, and its power of absorbing and
emitting heat and light were every where the
same. Europe and Asia are contrasted with each
other in respect of many of the circumstances
which affect their climate. In a general view,
Europe may be regarded as being almost a pen-
insula, broken, moreover, and intersected by
numerous arms of the ocean and inland seas.
Owing to the causes already alluded to (§ 11.),
the predominating winds are from the west, and
these, for the whole of the western portion of this
quarter of the globe, are sea winds softened by
passing over a mass of water, the temperature of
the surface of which, even in the month of Janu-
ary, under the mean parallels of 45 or 50 degrees,
does not fall below 48-1 and 52° of Fahrenheit.
Europe has also the advantage of being placed to
the north of immense tracts of tropical land,
which, by its diurnal radiation, produces effects
very different from an equal superficies of ocean.
Masses of heated air are constantly rising from
the arid surface to the higher regions of the at-
mosphere, and are impelled towards the colder
countries of the north. On. the northern side of
this quarter, circumstances are unfavourable to
the accumulation of extreme cold; for a very
small portion of land is placed beyond the polar
circle, and the whole northern extremity is se-
parated from the polar ice by an open sea, the
temperature of which is very much higher than
that of a continental country in the same latitude.
The comparatively high temperature of the sea
on the north of Europe is chiefly to be ascribed
to the direction of the great oceanic valley which
separates Kurope from America, and the existence
of the gulf stream; the intertropical Atlantic wa-
ters flowing from the Gulf of Mexico into the po-
lar seas.
14. The circumstances which thus contribute
to render the climate of Europe mild, do not exist
in respect of Asia, or even of America. Their
northern boundaries extend to the winter limit
of the polar ice. The north winds, unobstructed
by any chain of mountains, blow with unmiti-
gated fury over icy plains extending northward
to the pole, and eastward to the point of maxi-
mum cold, which, according to Humboldt,
342
CLIMATE — Its Influence on Man.
and. others, seems to be situate near the meridian
of Behring's Straits. The refrigerating effects of
these winds are not counterbalanced by burning
deserts on the southern side of these continents;
or, as respects Asia, by any great extent of land
placed below the equator; consequently the Asi-
atic countries situate in the temperate zone, more
especially, are not warmed by ascending cur-
rents of heated air, such as those which arise
from the deserts of Africa, and are so beneficial
to Europe. The position of the great mountain
chains of Asia, and the elevation of the country,
also contribute to diminish the temperature, they
presenting a barrier to the warm winds from the
equatorial regions. Elevated plains and groups
of lofty mountains accumulate and preserve the
snow till late in the summer, and give rise to de-
scending currents of air, which cool the circumja-
cent countries. Asia, moreover, in the whole
extent of Europe, has no sea on its western side;
consequently the west, or predominating winds,
are, for the greater part of this quarter, land
winds; and their severity is increased by the
great enlargement of the land towards the north.
These circumstances occasion remarkable differ-
ences in the climates of Asia and the western
countries of Europe. The eastern part of the lat-
ter, however, nearly assimilates with the western
districts of the former; and, with the whole of it,
to the nortli of the 35th degree of latitude, has a
climate in which the temperatures of summer and
winter are widely different from the mean tempe-
rature of the year. At Moscow (lat. 55J 45'),
where the mean temperature of the year is only
40° Fah., the mean temperature of the hottest
month is 70£°; while at Paris (lat. 483 50'), 7°
farther south, where the mean temperature of the
year amounts to 51°, that of the hottest month is
only about 654°. In no part of the world, not
even in Italy or Madeira, do finer grapes come to
maturity than at Astiakan, on the borders of the
Caspian; and yet at the same place, or even still
farther south, under the latitude of Avignon and
Rimini, the thermometer falls in winter to 18J
and 22° below the freezing point. ( hi the west-
ern coast of France, in the latitude of 48J, the
mean temperature of the year is the same as at
Pekin, the latitude of which is only 40°; while
the temperature of the winter months is 14^u
higher in the former.
15. The mean temperature under the equator
is not precisely determined; but Humboldt
thinks it does not exceed 80° of Fahrenheit. The
greatest Simmer heats are found in countries
contiguous to the tropics. On the Red Sea, for
instance, and in Arabia, the thermometer is often
seen to rise to 1 1 0° at mid-day, and to remain at
94^ during the night. A few degrees within the
tropics, the sun at midsummer continues for a
considerable time to pass daily very near the ze-
nith; and the day, increasing with the latitude,
is longer than under the equator; so that the
amount of nocturnal radiation is diminished.
Among the local causes which contribute to give
an excessive temperature to the Arabian penin-
sula and the north of Africa, the sandy surface
almost deprived of vegetation, the constant dry-
ness of the air. the direction of the winds, and
the quantity of heat radiated from earthy particles
carried about in the atmosphere, are the most
prominent.
16. II. Influence of Climate on the
Human Constitution. — From what has been
already adduced, the action of climate on the
human frame must be admitted to be extremely
complex; the ultimate result arising chiefly from
the combined operation of heat, light, electricity,
atmospheric pressure, the various emanations
arising from the soil, and the productions, vege-
table and animal, constituting the food of man.
The human species is, in many respects, moral as
well as physical, moulded by the climate and soil
which he inhabits; and, by this pliability of his
functions, under the influence of atmospheric and
other vicissitudes, is the only animal that is truly
cosmopolite. In considering the influence of cli-
mate on man, it will be advantageous to view it,
first, with reference to extensive communities and
races of the species; secondly, as respects the na-
ture of the food which different climates provide
for the uses of man, and its co-operation with the
climate in modifying the human frame, and coun-
teracting the effects of rigorous seasons, and the
unfavourable influences to which it is exposed in
arctic and tropical regions; and, thirdly, as regards
the changes produced in individual constitutions
after migrating from one climate to another.
Neither the limits nor the scope of this work will
permit me to consider these subjects in all their
relations; I must, therefore, confine myself to
such topics as have an evident and important
bearing upon practical medicine: — in respect either
of the causation and nature of disease, or of ra-
tional methods of cure.
17. i. Climate in relation to the Va-
rieties of the Species and their pre-
vailing Diseases. — Although man is more
readily assimilated with particular climates than
any other animal, yet thus faculty is not equally
possessed by all the varieties of the species and
the natives of every latitude. It is more particu-
larly manifested by the inhabitants of temperate
climates; probably owing to their greater vital
energy, and to their habitual exposure to alternate
extremes of temperature and of season. The na-
tives of polar regions on the one hand, and of
tropical countries on the other, possess it in a much
less remarkable degree; and not only are they
speedily cut off by removal from the one climate
to the other, but they often sutler greatly from a
residence in temperate countries. !t should not,
however, be overlooked, that man. like many of
the individuals below him in the scale of creation,
often derives advantage from a change of locality;
provided that the change is not made to opposite
climates, but to districts of equal or greater salu-
brity.
18. It has long been a matter of dispute whe-
ther the differences, intellectual and physical,
presented by the various races of man, -have arisen
from the continued, slow, and imperceptible ope-
ration of climate; or have been originally in press-
ed upon the species. The evidence and arguments
connected with this subject fall not within my
province. Eat it is of importance to the practical
physician to note what those peculiarities are,
that characterise the different races of man; and,
whether they he the result of elimatorial influ-
ence or of original conformation, to consider them
in connection with the climates to which we
find them more particularly appropriated in our
survey of man in his distribution over the globe.
CLIMATE — Its Influence on Man.
343
However cursorv this survey may be, there ore
certain facts of the utmost practical importance
to ever* one who entertains philosophic, ideas
in medicine, which should not be overlooked ;
namely, that the slow and continued operation of
apartteolar climate actually changes the human
frame in many respects to that state which its in-
digenous inhabitants present ; and that the con-
stitution, thus assimilated, is necessarily the best
suited to the external influences to which it is ex-
posed, and the food furnisned by the soil of which
it is the native. There are, however, certain
characteristics, especially those which distinguish
the .Ethiopian and .Mongolian varieties, that a
succession vC ages has not been sufficient to im-
part to different races which had migrated to the
climates they inhabit ; and which must, there-
fore, be imputed to original conformation.
19. A. The effects of great cold, and of the
privation ofsolw light, during nearly two-thirds
of the year, upon the human frame, are observa-
ble in the stunted growth and the weak muscular
power of the Samoi'ed, the Ostiaks, the Esqui-
maux, the Greenlander, and the Laplander, com-
pared with the inhabitant of temperate climates.
In the arctic regions, the human body, like many
of the lower animals, and the productions of the
vegetable kingdom, rarely reaches that state of
developement it presents in temperate countries :
the features and stature retain an appearance of
boyhood or youth, almost until marks of age ap-
pear ; the complexion is grayish ; the head Hat,
the face broad, the eyes far apart, and the whole
figure squat and unattractive. Eemale pubes-
cence, however, according to the accounts given
by Linn .eos, Humboldt, Lyon, Parry, and
m: v \ klin, as indicated by the accession of the
catamenia, is not delayed beyond the period usual
in temperate countries — most probably owing to
thi' premature excitement of the generative organs
in th.! unrestrained intercourse of the sexes, that
takes place at an early age. To this cause, also,
is to be imputed the circumstance of their females
being less prolific than those of temperate climes;
whilst, in these races, the instinctive feelings
which tend to the preservation of the individual
and of the species are sufficiently strong, the in-
tellectual endowments and moral sentiments are
remarkably torpid. The benumbing influence of
cold, and of the privation of solar light, is also
manifested in the functions of the nervous and
sanguiferous systems. Diseases generally assume
among them an asthenic form ; fevers being of a
low tvpe, and sthenic, inflammations of rare oc-
currence. As long as the natives of arctic regions
remain in their own countries, they are exposed
to but few causes of disease besides cold, the
scarcity of provisions, occasional excessive reple-
tion, and various contagions. 'I he soil being al-
most constantly frozen, even during summer, at
the depth of a very few feet, deleteriens emana-
tions seldom or never issue from it: hut infectious
maladies, when once introduced, become ex-
tremely destructive, and several of them often
very prevalent, owing to their low, small, and
unventilated dwellings, and their want of personal
and domestic cleanliness. When, however, they
migrate to more temperate and southerly regions,
they are very liable to febrile and sub-inflamma-
tory diseases, arising from increased temperature,
the vicissitudes of season, and other novel c
to which they become exposed: whilst their mala-
dies seldom require, their constitutional powera
can but ill tolerate, a lowering treatment, or large
sanguineous depletions.
20. B. Although extreme and continued de-
pression of temperature produces the above ef-
feels, more moderate cold, particularly when
alternating with a temperate summer heat, pro-
motes the developement of both the body and
mind. Countries situate between 45J and 63° of
northern latitude are inhabited by the most robust
and enduring of our species, in respect to both
physical and intellectual powers. It may be
stated in general of the northern temperate zone,
that the inhabitants of its more southerly coun-
tries have made the earliest advances in civilisa-
tion, and that those of its middle and more north-
erly climates have carried the useful arts and
sciences to the highest perfection. Within the
range of this zone, man presents the greatest di-
versity of temperament, of constitution, and men-
tal endowment. Muscular frames, plethoric hab-
its of body, and the sanguine temperament, pre-
dominate among the natives of the more norther-
ly of temperate climates, particularly as regards
Europe and its western countries. Affections of
the chest and respiratory organs, inflammations,
fevers complicated with inflammations of the
lungs or of the brain, and rheumatism, are the
most prevalent diseases. Epidemics assume most
frequently amongst them a phlogistic character :
and vascular depletions are more required, and
better borne, in the treatment of their maladies.
Climates which are the most variable, as to both
the commencement and the course of the differ-
ent seasons, are, notwithstanding the many dis-
advantages imputed to them, the most favourable
to the advancement of the various bodily and
mental powers. The rapid and frequent vicissi-
tudes of weather preclude, as respects the com-
munity generally, the regular adoption of means
to guard the body against their operation : con-
sequently the frame becomes habituated to their
operation, and thereby fortified against the in-
jurious impressions which would be otherwise
made by them. That countries thus circum-
stanced are benefited rather than injured by this
state of weather and season, is shown by the
robust frames, the mental activity, and the lon-
gevity of their inhabitants. The physical and
moral history of the British Isles, Denmark,
Sweden, and the more continental districts of
western Europe, demonstrate this fact. In the
eastern countries of this quarter of the globe, as
well as in ( ei.tral Asia and in North America,
the seasons being much more regular in their ad-
vent and in their course, measures are more
regularly and uniformly adopted to moderate the
extremes of temperature and the vicissitudes of
weather ; and these have, in many instances, the
effect of enervating the frame, of promoting the
extension or prevalence of disease, and of thereby
diminishing the mean duration of human life. Of*
this description is the use of excessively warm
clothing, and of stoves, which overheat the air of
the apartments, without renewing it so rapidly as
is often requisite to the wants of the economy.
Hence, whist the external atmosphere is cold,
dry, and invigorating to the healthy frame in a
state of activity, the air in-doors is close, warm,
and depressing ; the frequent alternation from
344
CLIMATE — Its Influence on Man.
the one to the other, or the constant residence in
the latter, being injurious even to those in health,
and causing diseases of the thoracic and abdomin-
al viscera.
21. While the natives of northerly inland
countries suffer more especially from the extremes
of temperature and of season, and the circum-
stances which arise out of them, they are less
exposed to emanations, arising chiefly from the
decomposition of vegetable and animal matter —
to those endemic sources of disease that produce
so much suffering and mortality in low or level
districts, and in more southerly climates, where
the atmosphere is moist and warm. The inhabi-
tants of temperate countries considerably elevated
above the level of the sea, and of mountainous
places, are generally of a spare, firm, and mus-
cular habit of body, and strongly formed; chiefly
owing to their active and industrious modes of
life, and the pure and light state of the air they
breathe. The irritable, sanguine, and nervous
temperaments, and quick, irritable, and generous
dispositions ; predominate among them. Inflam-
matory, ha:morrhagic, and spasmodic diseases,
particularly haemoptysis, bronchitis, consumption,
asthma, inflammations of the lungs and- pleura,
rheumatism, and disorders of the circulatory or-
gans, are most common. Their females are more
virtuous and prolific, and the mean duration of
human life longer, than amongst the natives of
lower districts and warmer climates.
22. C. There are certain peculiarities in the
natives of temperate countries, particularly of
European countries, that must strike the patholo-
gist as intimately connected with the nature and
treatment of their diseases. These are chiefly the
complexion of the skin, the large developement
of the respiratory, biliary, nervous, and circulat-
ing organs, compared with those of the natives of
intertropical countries. The skin of the dark
races is not only different in colour, but is also
considerbly modified in texture, so as to enable
it to perform a greater extent of function than the
more delicately formed skin of the white variety
of the species. The thick and dark rete mucos-
um of the former is evidently more suited to the
warm, moist, and miasmal climates of the tropics,
than that with which the latter variety is pro-
vided. The skin of the negro is a much more
active organ of depuration than that of the white.
It not merely exhales a larger proportion of
aqueous fluid and carbonic acid from the blood,
but it also elaborates a more unctuous secretion,
which, by its abundance and sensible properties,
evidently possesses a very considerable influence
in counteracting the heating effects of the sun's
rays upon the body, and in carrying off the super-
abundant caloric. Whilst the active functions,
aided by the colour, of the skin, thus tend to
diminish the heat of the body, and to prevent its
excessive increase by the temperature of the cli-
mate, those materials that require removal from
the blood are eliminated by this surface, which,
in the negro especially, performs excreting func-
tions very evidently in aid of those of respiration
and of biliary secretion. In the white variety of
the species, on the other hand, the functions of
the lungs and liver are much more active than in
the darker races, changes to a greater extent
being performed by respiration in the former than
in the latter, as I have proved by experiment.
The liver is also larger, and its secretions more
copious in the European than in the negro or
Mongol.
23. In the inhabitants of northern climates,
and elevated or cold countries, the functions of
the lungs and kidneys are extremely prominent,
and those of the skin and liver much less so ,
eliminating or depurating actions on the blood
being performed chiefly by the former organs.
But, in the natives of intertropical climates, the
skin assumes, as shown abose (§ 22.), a more
extensive function, and, by its activity, compen-
sates for the diminished operation of the lungs,
liver, and kidneys, generally observed among
them, aided, no doubt, by the secretions from the
intestinal mucous surface. In temperate coun-
tries, the various emunctories of the frame pre-
sent a degree of activity in strict keeping with
this general connection of climate with the de-
velopement and activity of these functions. In
the warmer districts of temperate climates, and
especially in those which are subjected to a dense,
moist, and miasmal atmosphere, the changes pro-
duced by respiration are diminished, and those
effected by the cutaneous and intestinal mucous
surfaces are increased. If the natives of such
districts belong to the white variety of the species,
their cutaneous surface not being constituted so
as to enable it to perform the compensating action
for which the skin of the darker races is destined,
a different organ performs this office, and the liver
assumes an increased action, combining and eli-
minating several of the effete constituents or
elements as they accumulate in the circulation,
and thereby giving rise to an increased and modi-
fied biliary secretion.
24. D. If we compare the organization and
functions of the negro (and I may add, of the
Mongol) with those of the European, the follow-
ing general results will appear, and, together with
what has been now advanced, will serve as the
source of very important pathological and thera-
peutical inductions : — The circulating organs, the
lungs, the liver, the middle and anterior lobes
and convolutions of the brain, the muscles, and
the bones, excepting those of the head and face,
are very evidently smaller, and their functions
less prominent, in the former than in the latter
variety ; whilst, on the other hand, the skin and
its functions are much more developed. With
the activity of function, conjoined with frequent
exposure to the action of numerous excitants,
the disposition to, and occurrence of, disorder
increase ; and, accordingly, diseases of the lungs
and circulating organs, of the liver, and of the
nervous system, predominate in the white races
of man ; and chronic affections of the skin, and
those acute maladies which chiefly attack this
surface and the intestinal mucous membrane, in
the dark varieties of the species. Amongst the
latter, fevers are not common ; and when they
occur, they are usually slight, terminate speedily,
seldom assume an inflammatory or continued
type, often pass off* with critical discharges from
the skin or bowels, and not infrequently lapse
into a state of low or chronic dysentery. The
exanthematous diseases generally assume in them
a severe and asthenic form, and rapidlv spread
by infection. Verminous disorders are very com-
mon in them ; but affections of the brain and
its membranes, and of^the teeth, are extremely
CLIMATE — In relation to the Food of Man.
345
rare; the omnia] contents seldom suffering ma-
terially in tli" comae of febrile attacks. The
remarkable thickness of the bones of the head,
in nearly all these races, protect the membranes
and brain from the causes of disorder to which
they are liable; ant) the continued exposure of
the head to the action of the sun and air, tin? ab-
sence cf mental culture, and their modes of life,
by no means dispose these parts to disease. In-
flammations, particularly those of a sthenic cha-
racter, are very rare; and, if vascular excitement
attend the early stage of these maladies, it soon
exhausts itself and passes into the opposite ex-
treme. Disorders, which consist chiefly of mor-
bidly increased discharges, from deficient tone of
the extreme vessels, and those of a spasmodic
form, are not uncommon.
25. E. The organization of the dark races of
man, chiefly as respects the state of vascular ac-
tion and tone, the developement of the viscera
already referred to (§ 22 — 24.), their food, modes
of life, excessive addiction to venereal indulgence,
the continued influence of a moist and miasmal
atmosphere, and the characteristic features that
their diseases consequently assume, generally
preclude the employment of large vascular de-
pletions. During the progress of febrile and ex-
anthematous maladies, critical evacuations from
the skin and intestinal mucous surface frequently
occur, the latter of which are very apt to assume
a colliquative or chronic state, and, if not ju-
diciously controlled, to carry off the patient.
Hence the propriety of employing free evacu-
ations of the prima via, with warm diaphoretics,
at the commencement of their diseases, and of
supporting the energies of life in the advanced
Stages. The circumstances now referred to as
modifying the constitution and diseases of the
dark races of our species, should never he over-
looked when devising plans for treating them.
Nor should the fact be neglected, that worms,
especially lumhrici, in the intestinal canal, are
very frequently connected with the origin of
many maladies o{ remote but related organs. Af-
fections of the stomach, diarrhoea, colicky pains,
leucorrhoea, various spasmodic and convulsive
disorders, chronic dysentery, &c. very often arise
from this cause; and, no more than the cause itself,
will ever be permanently removed, in these races
especially, by evacuations alone, but bv com-
bining them with stimulants, tonics, and anti-
septics. Although both the habits and modes of
living of the dark races, and the constitution of
their digestive organs, require the occasional use
of active purgatives, in order to remove the sa-
burra and colluvies which so rapidly collect on
the intestinal mucous surface, yet those medicines
should generally be combined or alternated with
substances which exert a cordial and tonic influ-
ence, as their vital energies soon sink under fre-
quent evacuations when deprived of an accustom-
ed or requisite stimulus. (See Art. Disease.)
26. ii. <)e tiii: Food OF .Man in UKi.AiiuN
to Climate and tiii: Constitution of tiii;
V kBiETiss or thk Species. — The intimate
relation which subsists between the food of man,
and the nature of the soil and climate which he
inhabits, and the combined operation of both
upon his constitution and the character of his
diseases, have seldom been considered in a
manner deserving of the subject. Man, although
in some measure independent of the nature of
the sod or climate in which be lives, is yet, hi
several points of view, the creature of both.
His manifestations, both moral and physical, are
moulded by both influences, like the animals
which are below him in the scale of creation,
although generally in a much less degree. It
is the soil that furnishes him food, and the
air which he respires derives much of what is
noxious to his frame from that source. When-
ever, therefore, the natural history and discuses
of man come under consideration, they should
be viewed in relation to those productions of
the soil on which he subsists — with which, in
many respects, he may be considered as a fellow
product, but holding a superior station, and by
which are often caused many of his ailments.
As it is beyond the scope of this work to enter
fully into the very interesting considerations
which this subject involves, I can only point to
its more general connections; and I do this more
with a view of directing the attention of others
to the subject, than of satisfying my own wishes
as to its discussion.
27. As the physical and intellectual powers of
man enable him to occupy the whole surface of
the globe, it follows that he cannot be restricted
to any particular kind of food — in other words,
he must be naturally omnivorous, as a consequence
of his ubiquity. If the wastes of Lapland, the
shores of the icy sea, the frozen coasts of Green-
land, and the deserts of Terra del Fuego, were
destined by nature for the habitations of man, then
is he not an herbivorous animal ; nor is even a
mixed diet necessary for his support. It would
be impossible to procure vegetable productions
where the earth's surface is almost constantly
either frozen or covered with snowr. The con-
tinual use of animal food is as natural and whole-
some to the Esquimaux, as a mixed diet is to an
Englishman. The Russians who winter on Nova
Zembla, according to Dr. Aiken, imitate the
Samoieds, and eat raw flesh and drink the blood
of the rein-deer, in order to preserve their health
in these arctic regions. The Greenlander de-
vours, with good iippetite, the raw flesh of the
whale, or the half frozen and half putrid flesh of
seals; and drinks the blood of these latter ani-
mals, or regales on dry fish and whale oil.
29. Within the tropics, man is subjected to
the continued operation of a high temperature,
which excites the nervous functions and vascular
action, notwithstanding the provision with which
nature has furnished bis integuments in order to
moderate the animal heat. This provision, as
we have seen, consists chiefly of the dark colour
of the rate mucosum, which speedily gives off the
superfluous heat of the body, and of the great
activity of the perspiratory functions (§ 22.). In-
tertropical countries, particularly such as are low
or swampy, while they abound with the produc-
tions of the vegetable kingdoms, and with nu-
merous swarms of insects and reptiles, maintain
very few of those gregarious animals which serve
as food ; and thus, we perceive that their inha-
bitants, unless in elevated and cool situations, as
in Abyssinia, .Mexico, &c, are obliged, by the
scarcity of these animals, to subsist on vegetable
productions, and to adopt a system of religion,
which, while it tends to prevent the entire de-
struction of the more useful species, is sufficient
346
CLIMATE — In relation to the Food of Man.
to restrain their numbers within their appropriate
means of subsistence, and without encroaching
on or impairing the supply of food with which
the vegetable creation furnishes man. Hence, in
many places of intertropical Africa, the lower
animals, whose numbers are few, are occasionally
made sacred by the priests for a time; and in
other places of this continent animal food is very
rarely enjoyed. In Hindostan, the natives are
almost debarred from the use of flesh meat; and
the cow is made sacred, evidently to prevent the
destruction of a species, whose milk furnishes
man with one of the chief articles of diet.
29. But nature provides a more suitable ali-
ment to the inhabitants of those climates. The
date, the palm tree, the cocoa-nut, the sago tree,
the plantain, the sugar-cane, and the banana ;
the yam, cassava, ground-pea, and other roots ;
a great variety of refreshing fruits ; and, more
particularly, the very abundant production of
nutritious grains, especially the Indian corn and
rice, richly supply the natives of these climates
with wholesome food. The general and neces-
sary adoption of a vegetable diet within the
tropics, from the exuberance of the vegetable
creation, and the comparative scarcity of those
gregarious animals chiefly destined for the use
of man in cold and temperate regions, is neces-
sary to the existence of the human species in the
higher ranges of temperature, and in the more
unhealthy districts in hot climates. The adop-
tion of animal diet exclusively, or of too large a
proportion of it, disposes the human frame, when
exposed to the influence of tropical heat, to those
diseases which arise from endemic causes, —
viz. the decay of vegetable and animal matters,
the exhalations of marshy and absorbent soils,
and other emanations accumulated in moist and
close situations; and to those which affect the
alimentary canal and other abdominal viscera.
Various epidemic diseases also often produce their
greatest havoc, and assume pestilential characters,
amongst those, who, to the predisposition occa-
sioned by a high range of temperature, have
superadded that arising from a too full animal
diet. It appears to be a salutary law of nature,
that, in those climates, where animal food would
be detrimental to the human race, there the ani-
mals usually destined for the purpose are few in
number, and stunted in growth. The localities,
indeed, which are the most destructive to man,
are also the most inimical to these animals, which,
if they were chosen as the chief article of food,
would both dispose to disease and increase its fa-
tality. Thus it appears, that the distribution of
the classes of animals over the surface of the globe
is so apportioned, and certain of their orders and
genera so restricted to particular latitudes and
climes, as to be subservient to the wants of man,
without becoming hurtful, or endangering his ex-
istence in countries in many respects unfavourable
to his bodily and mental developement.
30. While the vegetable diet, which the hottest
and most unhealthy climates furnish, is the least
liable to excite the nervous system, or to over-
load the circulating and secreting organs, or to
irritate and inflame the excreting viscera, it
serves to promote endurance, and, with the hot
spices which grow spontaneously in the same
localities, to counteract the contaminating changes
produced in the body by the vegeto-animul
effluvia to which it is frequently exposed. In
both Indies, and in intertropical Africa, the in-
habitants of low and moist situations live almost
exclusively on rice and maize ; with these they
consume, as a condiment, a very large quantity
of the hottest spices, the stimulating and tonic
qualities of which preserve them from the effects
of the diminished temperature and terrestrial
emanations during, and after, the rainy seasons
and monsoons, and in some measure from in-
testinal worms and other parasitic animals. To
these spices, even the feathered creation, and
the lower animals, occasionally resort, especially
during the unhealthy seasons. Were the inha-
bitants to live chiefly on animal food, and use the
strong fermented liquors made in colder climates,
the nervous and vascular systems would be inor-
dinately excited, irritability being thereby soon
exhausted ; and they would be as much disposed
to, and affected by, disease, as unseasoned Euro-
peans, who, partly owing to these causes, so soon
become its victims, after having removed to
low, moist, and hot situations between the tropics.
Nature adapts her productions in every climate
to the necessities of man ; and appropriates
them to his real, but not his imagined wants,
— to his state of constitution, as modified by the
operation of soil, air, and temperature ; and no-
where is this provision more manifest than in
warm countries. There, if the causes of disease
be most energetic, as they most indisputably are,
she has chiefly restricted- them to those which
proceed directly from the soil and the climate,
while she has confined those arising from the
nature and the abuse of food within narrow
limits ; as there man is destined, by the circum-
stances already alluded to, to live chiefly* on a
vegetable diet, and is liable only to occasional
deficiency of its supply. But even the inflictions
which nature thus imposes on the inhabitants of
these climates are accompanied by abundant
means of preventing their invasion, or arresting
their progress. The most unhealthy situations
not only abound with suitable means of sub-
sistence, but also present spontaneously the most
efficacious prophylactic and curative agents for
the diseases that are endemic in them. Thus
rice, the banana, the plantain, the juice of the
cocoa-nut and of the palm, the oil of the palm-
nut, kc, are the most wholesome articles of food
in the districts wherein they are most abundant
The low grounds on which these are produced
abound with deleterious miasms ; ;ind the stag-
nant water, which there often serves for the
necessities of life, contains the ova of insects and
animalculse. While the former occasion agues
and remittents, the latter gives rise to diseases
of the digestive canal, and to the generation of
worms; and both causes- combine to produce
fevers, diarrhoea, dysentery, cholera, visceral ob-
struction, &.c. In the above localities grow the
different species of the capsicum, — the principal
condiments employed by the natives; and these
are also the chief prophylactics and remedies for
their constitutions, against the diseases now alluded
to. By the side of the palms and the cocoa-nut
grow the different species of the tamarind and the
croton, which are, respectively, the mildest and
most cooling aperient, and the most active ca-
thartic. Thus nature provides an antidote to the
bane which is imposed ou the inhabitants of
CLIMATE — Effects of Change of, on Man.
347
unhealthy warm climates, anil, by adopting the
indications she presents, they are enabled to exisl
without suti'ering much more from disease than
the Datives M' temperate countries, or having the
allotted span of human existence much abridged.
It is in no small measure owing to his persisting
in the diet, beverages, clothing, and modes of
living, suited to a cold or temperate climate, and
to which he bad become accustomed, that the Eu-
ropean is liable to disease when he has removed
to a hot country. When travelling in the most
unhealthy parts of intertropical Africa, in 1817,
1 met with an Englishman, who had lived there
between thirty and forty years, and was then in
the enjoyment of health. The circumstance was
singular ; and, in answer to my enquiries as to
his habits, he informed me, that soon after his
removal to that pestilential climate his health had
continued to sutler, when, after trying various
methods without benefit, he had pursued as close-
ly as possible the modes of life of the natives,
adopting both their diet and beverages, and from
that time he had experienced no serious illness.
31. In countries approaching the poles, where
the continued low temperature, and the want of
solar light during two-thirds of the year, tend to
diminish nervous and vascular energy and tone,
and to lower the whole circle of vital actions,
nature has furnished man with those articles of
food which are the best calculated to nourish, to
stimulate, and impart vitality to the frame, and
thus to enable it to bear up against the rigour of
the seasons, and the injurious influence of the
climate. Without such food, the inhabitants of
arctic regions would fall a prey to diseases of
debility, and the higher latitudes would soon be-
come entirely depopulated. In these, as well
as in northerly and elevated parts of temperate
countries, nature spontaneously provides man
with those substances which are the most ener-
getic, both as preventives and as remedies of
those diseases which arise from the influence of
climate. The various species of pine abound in
the coldest regions, and furnish, in numerous
forms, the most efficacious internal and external
medicines, and even the most wholesome bever-
ages in these maladies. Hemorrhagic diseases,
low fevers, asthenic inflammations, scorbutic and
cachectic affections, the extreme effects of cold
upon the extremities, &c, are most successfully
prevented or treated by the judicious use of tere-
binthinate preparations. This observation is also
applicable to the arnica montana, and other al-
pine plants.
32. The temperate zone, whilst it furnishes in
its wide range the greatest diversity of climate —
in some localities that of the tropics, in others that
of arctic regions — provides man with the greatest
abundance of animal and vegetable food : thus
enabling him to combine both, or to adopt more
or less of either, according to the nature of the
08, of the climate, and the particular circum-
stances in which he may be placed. Nature is
always provident: she takes sufficient care that
each particular district or country shall have with-
in itself, or be capable of producing by requisite
labour, those articles of food which are most ap-
propriate to the climate, and thereby tin; most
wholesome to its inhabitants. When commerce
or manufactures increase the population of a dis-
trict beyond the means of sustenance derivable
1 from the soil, and lower animals, in the vicinity,
the food which is obtained from a similar climate
is generally the most wholesome. Various dis-
orders originate from the introduction, from re-
mote countries, of unsuitable articles of luxury
into diet ; and not a few arise from the improper
mode of preparing food, which would otherwise
be wholesome. Thus, the hot spices and the
high-seasoned dishes, which, during the tropical
rains, would be beneficial to the natives of those
climates, who live chiefly on vegetable diet, fre-
quently are productive of disease amongst those
who partake too freely of animal food, or the
high-feeding inhabitants of commercial cities.
The adoption, also, of highly seasoned dishes,
with an undue quantity of flesh meat, — undue,
because exceeding the wants of the economy, and
the circumstances of the climate, — and the use
of spirituous and fermented liquors, are fertile
sources of disease, particularly fevers and affec-
tions of the abdominal viscera, among Europeans
residing in warm places or during warm seasons.
33. From these and other considerations the
following corollaries may be drawn : — That the
climate of a country should, in a great measure,
guide man in his selection of food ; those produc-
tions which are most abundant around him being
most appropriate to the circumstances in which
he is placed : and that the nature of his food thus
conspires with the climate to modify his constitu-
tion, whilst it serves to counteract the rigours of
season, and the unwholesome influences to which
he is constantly exposed in very hot as well as in
very cold countries.
34. ih. Of the Effects produced on the
Human Constitution by Change from one
Climate to another of a very differ-
ent or opposite Description. — By refer-
ring to what has been already advanced respect-
ing the physical relations of climate, and the cir-
cumstances more immediately connected with cold
and warm countries respectively, and by connect-
ing these with the peculiarities characterising the
races of man inhabiting both, we shall readily
perceive that a most important revolution will
take place in the animal frame from the change,
in whichever direction it may be made ; and that
such revolution will be great in propoi^ion to the
suddenness and greatness of the change ; it being
in either case attended with more or less febrile
commotion or other diseased action.
35. 1st. Of change from a cold or temperate
to a warm climate. — A. Keeping in view the
following characteristics of a cold and temperate
climate — viz. its low temperature, the alternations
of season, the pureness of the atmosphere, the
more nutritious, invigorating, and stimulating na-
ture of the food, and the effects of warm clothing
— and connecting these with the vascular pletho-
ra, the active functions of the brain, lungs, liver,
and Kidneys of its inhabitants, the disturbances
which will result when they are subjected to a,
continued high range of temperature, and to an
atmosphere loaded with moisture, and frequently
with vegeto-animal effluvia, may be anticipated.
It is now full v ascertained that the effects of a
high range of temperature, and of moist miasma]
air, on the European constitution, are, a diminu-
tion of the changes effected by respiration on the
blood, an increase of the secreting and excreting
functions of the liver and skin, and a decrease of
348
CLIMATE — Effects of Change of, on Man.
the urinary .excretion. When, therefore, the ple-
thoric European migrates to an intertropical coun-
try, the functions of I lie lungs and the pulmo-
nary exhalation become diminished ; the requisite
changes are not effected on the blood, notwith-
standing the excitement of the nervous and vas-
cular systems by the increased temperature ; and
the already active and developed liver is irritated,
and has its functions augmented, by the increase
of those elements in the blood, that the lungs
and skin cannot remove from it. lience proceed
febrile attacks, particularly when excited by their
appropriate causes ; inordinate activity, with a re-
lative frequency of the diseases, of the liver ; the
secretion of acrid bile; and the disorders especial-
ly affecting the alimentary canal and excreting or-
gans. The general adoption of too rich and nour-
ishing food and beverages by those who remove
from cold to hot climates, tends greatly to increase
these evils, as already explained (§ 30.); and the
influence of high temperature and of a vertical sun
upon the European head is productive of disease
both of it and of the liver. To these effects, the
mental cultivation and activity of Europeans some-
what predispose them ; whilst their heads are not
so well guarded from external influences by the
constitution of its integuments and hair, and the
thickness of the cranial bones, as those of the
negro and Mongol varieties of our species.
36. The obvious indications resulting from these
facts are, that natives of cold countries migrating
to warm climates should, particularly if the change
has been made abruptly, live abstemiously, and
promote the functions of those organs which per-
form the most essential part in excreting effete
or injurious elements from the circulation. The
head should be kept cool, and protected from the
rays of the sun ; the surface of the trunk and
lower extremities ought to be preserved in a
freely perspirable state, so as to take off the load
of circulation, and derive from the excited liver.
In order to promote the secreting and depurating
functions generally, active exercise, short of fa-
tigue, should be taken, without exposure to the
causes of disease, particularly those which are
endemic. As the maladies which most frequent-
ly supervene on change from a cold to a warm
climate proceed neither from the increased tem-
perature alone, nor from greater moisture of the
air, but from these conjoined with malaria, and
not infrequently also with wide ranges of tem-
perature during the twenty-four hours, especially
in high and inland localities — with hot days, and
cold, raw, and dewy nights, and with a too full
and exciting diet and regimen, causing fevers,
dysentery, and diseases of the biliary organs —
care ought to be taken to avoid those causes, as
well as whatever may tend to assist their opera-
tion on the frame, and to protect the system
against the suddeii daily changes by warm cloth-
ing at night, &c.
37. B. The consideration of the effects pro-
duced by migration, durvig a state of disease,
from a cold to a warm and moist climate, is of
the utmost importance. Keeping in mind its in-
fluence upon the healthy frame — chiefly in ex-
citing the functions of the skin and liver, and di-
minishing those of the lungs — we are led to
prescribe it in the treatment of various diseases.
In hamoptysis, this change is obviously beneficial,
especially as a warm and moist atmosphere, by
this mode of operation, lessens the activity of
the pulmonic circulation and the disposition to
sanguineous exudation from the surfaces of the
bronchi. Bronchitis and tubercular phthisis are
also often benefited, and the progress of the latter
much delayed, by this state of atmosphere, es-
pecially when adopted early. Chronic rheuma-
tism is sometimes cured by this change, seeming-
ly owing to its influence in promoting the biliary
and cutaneous functions. Dropsies, particularly
anasarca and hydrothorax, have been, in a few
instances, removed by a change to a warm cli-
mate ; but whilst a moist state of the air is most
serviceable in pulmonary and hamiorrhagic dis-
eases, dry warmth seems more beneficial in drop-
sies, dyspeptic affections, and hypochondriasis,
evidently from its effects in augmenting the in-
sensible perspiration and the pulmonary exhala-
tion, and imparting tone to the capillary circula-
tion. Besides these, gout, in its early stages,
dysmenorrhaa, and scrofula m nearly all its
forms, are benefited by a change to a warm, or
even a mild and dry, atmosphere.
38. 2d. Of migration from a warm to a cold
or temperate climate. — This subject should be
viewed in relation, first, to the change as it affects
the dark races of man ; and, secondly, as it re-
spects those belonging to the Caucasian variety,
who have either been born or acclimated in warm
countries. — A. If change from a cold to a warm
climate is productive of disease and great mortal-
ity in the white constitution, the migration of the
dark races to a cold or temperate country is not
less fatal to them ; and whilst the change pro-
duces, in the former case, fevers, diseases of the
biliary organs, and of the alimentary canal, it
occasions, in the latter, tubercular phthisis, and
other tubercular affections, with diseases of the
-bronchi, &c. When the dark races, particularly
the negro, and those of the Mongol variety who
are natives of intertropical and low countries, mi-
grate to places subjected to a low range of tern-,
perature during a great part of the year, the de-
pressing influence of cold upon the nervous system
and vital actions of the lungs and skin, gives rise
not only to tubercular formations, but also to in-
creased secretion from the internal mucous sur-
faces, and they are, in the great majority of cases,
cut off", in a few months or years, by diseases of
the lungs, kidneys, and bowels. Those, however,
who change the climate progressively, or who are
born in countries of an intermediate temperature,
and who are provided with warm clothing and ani-
mal or nutritious diet, suffer much less than those
who migrate in a more direct manner, even al-
though possessed of these latter advantages. The
native African who removes immediately to Eu-
rope seldom lives over two winters in it; whilst the
negro who has been brought, to the West Indies,
and subsequently to the southern states of North
America, previously to his arrival in more northern
countries, and enjoys necessary food and clothing,
will often not suffer materially from the change.
39. B. Those who have been born of Euro-
pean parents, or been seasoned in w arm climate;*,
not infrequently sutler after removal to temperate
or cold countries. Even, although the change may
have become necessary from chronic affections
of the liver or bowels, yet may it for a while ag-
gravate or render more acute hepatic disorder,
or superadd to it disease «f the lungs ; and many
CLIMATE — As a Therapeutical Agent.
349
who have experienced only functional disorders
of the stomaeh or liver, or who acquired merely
a tendency to them during their residence within
the tropics, have heen attacked by active disease
Boon after their return to Europe. Others, also,
who have suffered more seriously, have had their
complaints aggravated alter a short residence in
England, although they were benefited during
their voyage home. 'This result of change to a
colder climate proceeds not, however, altogether
from the temperature or the .state of the seasons,
but in a great measure from the imprudence of
the patient. Frequently, however, a colder at-
mosphere is prejudicial for a time, by constricting
the vessels on the external surface, and determin-
ing an increased How of blood to the large internal
viscera, and thereby occasioning congestion and
obstruction of those organs which have been
weakened by previous disease or the influence
of climate. Another frequent consequence of
change from a warm to a cold country is a
diminution of all the secretions, particularly those
of the skin and liver: originating vascular pleth-
ora and visceral engorgement. In this state of
the vascular system, if the cutaneous or pulmo-
nary surface be subjected to cold, particularly
cold combined with moisture, after the circulation
has been determined to these parts by hot rooms
and crowded assemblies, or if reaction rapidly
follow the impression of cold, the great mass of
Mood is thrown upon the internal viscera, which,
if not relieved by a free secretion, become the
seat either of congestion or of inflammation.
Hence it is that hepatitis, or dysentery, so fre-
quently follows changes from a high to a low
tempe-ratnre. The remarkable liability to dis-
- of the respiratory organs, observed in those
who have returned to Europe after a long resi-
dence ui warm countries, is evidently owing, in
many instances, to pre-existing disorder of the
liver, which has extended thence to the lungs,
owing either to the increased action of this latter
organ upon removal to a colder climate, or to
imprudent exposures to cold, or to breathing a
very warm and close air immediately upon com-
ing out of a cold and dry atmosphere.
40. In order to counteract these effects of
change, warm clothing, particularly of the lower
extremities, with the use of flannel next the skin,
should be adopted; and exposures to cold and
moisture, and the night air be avoided. The
diet ought to he light, and of moderate quantity ;
the strong wines imported into this country ab-
stained from; and. above all, the functions of the
bowels and abdominal viscera carefully watched,
and promoted whenever they seem to flag. It
may he of importance to know the most suitable
period of the year to arrive in this country, after
the frame has become assimilated, by a long resi-
dence, to a warm climate. If an invalid return
in winter, the sudden transition from a warm to
a cold country may be detrimental; if early in
the spring, he is liable to feel the effects of a
variable season for some time. The least ob-
jectionable period extends from .May to Septem-
ber; and if the cold of the winter months be
found too severe in the more easterly counties, or
in the metropolis, the climate of Devonshire or
of Bath may be tried with as. great advantage as
that of most of the southern parts of continental
Europe. Old residents in a warm climate will i
30
experience much advantage from residing some
time in the more, southerly parts of Europe,
before passing to England or other countries of
the north, more particularly if they use a course
of the warm mineral waters of Yield, Carlsbad,
or Ems, in their way.
41. The children born of white parents resi-
dent in the more unhealthy countries within the
tropics, very generally die at an early age if they
be not removed to a colder climate. They com-
monly sink from the choleric form of fever
described in a separate article as incidental to
infants; or from diarrhoea, dysentery, or diseases
of the abdominal secreting viscera, often assum-
ing a remittent form. When, therefore, either
of these appears in this class of patients, removal
to a temperate climate should be advised when it
can be effected; taking care to guard them, by
warm clothing, &c, from vicissitudes of temper-
ature for a considerable time after the change,
and attending to the first indication of pulmonary
or tubercular disease, or disorder of the liver and
bowejs.
42. HI. Of the particular Localities
which are beneficial in disease, or of
Climate as a Therapeutical Agent. • —
In this part of the subject I shall consider, first,
the different parts of Great Britain which may
be suitable places of residence for invalids ;
secondly, those in the south of Europe and the
Mediterranean ; and, thirdly, those in the At-
lantic and West Indies.
43. i. Climate of certain places in England. —
The chief difficulty in this country is to find a
mild and sheltered climate for invalids from pul-
monary disease; and it is almost exclusively to
the south and south-west parts of the island, iu
the immediate vicinity of the sea, that we must
direct our enquiries. The general use of coal
fires in all the large towns in Great Britain, ow-
ing to the quantity of sulphur this mineral con-
tains, and of sulphuric acid fumes and fuliginous
matter generated, renders the air more irritating
to the lungs, and increases the risk of a winter
residence in these places, to all those who suffer
from, or are even liable to, diseases of the re-
spiratory organs. This, together with other con-
siderations— especially the results of observation
— renders it imperative on the medical attendant
to recommend removal to a more salubrious lo-
cality. The mild situations I shall notice are in
the south, the south-west, and the west of the
island.
44. A. The south coast is much milder and
more moist than the east and inland parts of the
island, during the months of November, Decem-
ber, January, February, and March ; but from
April till October the temperature of the latter
is greater. On this part of the coast, Undercliff,
in tbo Isle of Wight, Hastings, and Brighton,
have been recommended as winter residences
for invalids, a. Undercliff is the most sheltered
and mild of these places in winter, and its air
softer and more humid in summer than either.
b. Hastings is sheltered, during the winter and
spring months, from the north iind north-east
u inds; and, of the various places on this part of
the coast, ranks next to Undercliff as a residence
for invalids with pulmonary affections, c. Brigh-
ton is more exposed than the foregoing to the
north and north-east winds, and its air is drier,
350
CLIMATE — As a Therapeutical Agent.
and hence more bracing. It is therefore more
suit;iMe than they to the nervous, the simply de-
bilitated and relaxed, to the dyspeptic, to those
affected with chronic bronchitis and asthma at-
tended by greatly increased secretion. Dr.
Clark very properly suggests that invalids who
select the south coast as their winter residence,
should pass the autumn at Brighton, and the win-
ter at Hastings; the climate of the former being
mild to the end of December.
45. B. The southwest coast of the island is
very mild in several situations during the winter,
and has, therefore, been very generally recom-
mended in diseases of the respiratory organs. Dr.
Clark estimates the temperature of its more
sheltered localities as being 5° higher than that of
London, during the winter months; and the tem-
perature of the south coast as only 2° higher. But
I conceive that there are, at least, 6° and 3°, re-
spectively, of difference between these and Lon-
don and its vicinity. Besides, it is not only the
range of temperature that should be considered,
but its greater equality, and less rapid vicissitudes,
and the increased humidity, and more soothing
influence of the air. — a. The places on the const
of Devonshire most in repute as residences for the
consumptive, are Torquay, Dmvlish, Sidmouth,
Exmouth, and Salcombe. Of these, Torquay is
the best ; and, according to the reports of Dr.
Clark, Dr. Foote, and of my friend Dr. W.
Hutchihson, who has resided in it, superior to
all other places in our island in pulmonary cases.
46. 6. Penzance is the principal place in Corn-
wall recommended for invalids. Its peninsular
situation, and south-west position, give it a re-
markably soft, humid, and mild atmosphere; and
the equality of its temperature, not only through-
out the year, but also during the day and night,
renders its climate in many respects superior to-
that of most places in the south of Europe, and
brings it next to Madeira. Ihe quantity of rain
that falls annually at Penzance is nearly double
that which falls in London; the number of rainy
days is much greater ; and the temperature of
the air at night at least 7° higher during the
winter months. This mildness, equality, and
humidity of climate, is, however, somewhat im-
paired by its exposed situation, and its liability to
high winds.
47. Both the Land's End and the coast of
Devonshire, owing to the predominating charac-
ter of softness, humidity, and equality of climate,
exert, along with a soothing, an evidently relax-
ing effect. Hence this coast is best suited to the
irritable and inflammatory states of disorders of
the respiratory organs, and such as are charac-
terised by irritation, but little expectoration, and
dryness of skin. In cases attended with a copi-
ous expectoration, great relaxation of the mucous
surfaces and soft solids, and in nervous debili-
tated persons, this climate will prove injurious.
Even in those cases where it is evidently indi-
cated, and actually proves of service, removal
will be necessary to a somewhat drier air during
the summer ; and this should not be deferred
longer than June, or undertaken before April or
May ; the patient generally deriving much be-
nefit by returning the succeeding winter. The
observations now made upon the climate of the
south-west coast apply to that of Jersey and
Guernsey, to which islands invalids sometimes
repair, and occasionally with advantage. South-
west winds generally prevail in them during au-
tumn and winter, and cold north-east winds often
continue long in the spring. The summer climate
of these isles is excellent. Of the two, that of
Jersey is preferable.
48. C. The West of England. — The mean
temperature of this part of the island is a little
lower than the southern coast, but in March and
April it rises somewhat above it. Bath and
Bristol are about 3J warmer than London during
the months of November and December ; but
this difference is reduced more than one half
during January, February, and March. In this
part of the country, the vale of Bristol is the
most sheltered and mildest. The climate during
the winter is rendered more mild by the vicinity
of the ocean, whilst the groups of surrounding
mountains attract the clouds and diminish the fall
of rain below the current to which its western po-
sition would otherwise subject it. Bristol Hot-
wells, and the lower parts of Clifton, are the
most sheltered spots, and the best suited to con-
sumptive patients ; whilst other invalids will find
most advantage in the more elevated situations
which the latter presents. In general, the climate
of this place is perhaps the mildest and driest in
the west of England ; and, therefore, one of the
best winter residences for invalids. It is drier and
more bracing than that of the south-west coast,
and therefore not so well suited to consumptive
cases, and to those affected by irritative action in
the respiratory passages and bronchi. For these,
the more soft and humid air of Torquay and
Penzance is preferable; but, with the return of
summer, the consumptive invalid will relinquish
the latter for the former with benefit. Clifton
and Bath are certainly preferable places of resi-
dence to the south-west coast, in cases of pro-
tracted dyspepsia, gout, and scrofula, particularly
the last occurring in )Oung persons, and relaxed
habits. In these affections, the waters of Bristol
Hot-well will, with regular exercise on horseback
or on foot, prove extremely beneficial.
49. The more inland districts of this part of
England furnish various places which are salutary
to invalids during the summer. Malvern, and
the surrounding country, with the Malvern wa-
ters, are very serviceable in scrofulous and dys-
peptic cases; and, for the consumptive and other
invalids, various places in Wales, as Abergaven-
ny, Aberystuith, Tenby, Barmouth, &c. will be
visited during the season with advantage. Where
a course of goat's whey may be considered of
advantage, a summer residence in Wales will be
preferred. There are various other places which,
besides their mineral waters, furnish excellent
summer residences for the invalid. Buxton, Mat-
lock, Leamington, Cheltenham, Tunbridge Wells,
&c, independently of the use of their respective
mineral waters, prove excellent places of resi-
dence for those who are debilitated or exhausted,
whose mucous surfaces are relaxed, or whose di-
gestive, secreting, and assimilating functions are
imperfectly performed, and any of the abdominal
viscera congested or obstructed. In these latter
circumstances of disease, especially, the appro-
priate use of the waters of those places, assisted
by regular horseback or walking exercise, by-
suitable medical treatment, and by ment.d re-
laxation and amusement, will often prove of
CLIMATE — As a Therapeutical Agent.
351
great service. In prescribing the mineral waters
of anv of ihOM pi. ices, due reference should be
had tii the nature of the climate ; and, on the
oilier hand, when directing change of climate,
some attention should be paid to the waters
which the place may afford ; as the appropriate
use of t lie one, whilst the patient is experiencing
the influence of the other, will materially pro-
mote the end in view.
50. In a very great proportion of cases, where
the state of the patient admits of change of local-
ity, much advantage will accrue from passing
the autumn on the south coast of the island, as at
Brighton, Hastings, or Underdid", after having
passed the summer at the foregoing watering
places. In general, when the digestive and gen-
erative organs are disordered, frequent change of
air, and travelling by easy and short journeys,
with gentle exercise, particularly ou horseback,
agreeable amusement, and regular habits, will
prove of marked advantage, and greatly aid
medical treatment.
51. ii. Of the Climate of certain parts in
France. A. The West and South-west of
France furnishes several places, the climate of
which possesses the softness and humidity which
are requisite in pulmonary diseases. The mean
annual temperature of the south-west of France
is stated by Dr. J. Clark to be 4" higher than
that of the south-west of England ; and the cli-
mate of both generaly agree or disagree with the
same diseases. — a. That of the south coast of
Britaay is mild during the winter, and temperate
in summer, the mean temperature of this pro-
vince being about oti.t"". Its climate is soft and
relaxing ; and it is hence suited to dry bronchial
irritations, to haemoptysis, and tubercular cases.
Laehnec found it very favourable to consump-
tive patients, and states that the proportion of
such in this part of France is very small. In
scaly eruptions on the skin, dysmenorrhcea, and
in irritable habits of body, this climate will be
often of service.
52. b. Pou, situated at the base of the Pyre-
nees, from the account of it given by Dr. Clark
and Dr. Play fair, appears to be the best place
in the south-west of France for invalids ; and yet,
in no respects is it superior to the south-west of
England in consumptive cases. Its air is still and
mild in winter and spring ; the chief advantage
it offers being the great mildness of its spring.
Dr. Clark gives the following comparison : —
Its mean annual temperature is 4^° higher than
that of London, and about 3J higher than that of
Penzance ; it is about SP lower than that of .Mar-
seilles, Nice, and Rome ; and 10s lower than
that of .Madeira. In winter, it is 2' warmer than
London, 3J colder than Penzance, tiJ colder than
Nice and Rome, and 1SJ colder than Madeira.
Hut in the spring, Pau is t>J warmer than Lon-
don, and .V warmer than Penzance ; only 2 l,
colder than Marseilles and Rome, and 7 colder
than Madeira. The range of temperature between
the warmest and coldest months at Pan is 32P;
this at Ixindon, and likewise at Rome, is 26 ;
at Penzance it is only 18-", and at Madeira I 1 .
The daily range of temperature at Pau is 7 \ ; at
Penzance it is 61 ; at Nice, Sy, and at Rome,
IK Pau is drier and warmer than the south
part of England in the spring, and northerly winds
are less injurious. One of its chief advantages
is Hs vicinity to the watering -places among the
higher Pyrenees, which are often beneficial places
of summer residence to those who have passed
the winter and spring at Pau.
53. B. The South-east of France. — The cli-
mate of the tract of- country extending along the
shores of the Mediterranean, from Narbonne and
Montpellier to the Vrar, is warmer and drier, but
more exciting, than that of the south-west. It is
subject to sudden vicissitudes of temperature, and
to cold winds, especially the north-west, or Mis-
tral. It is decidedly prejudicial to consumptive
patients, especially when the disease has made
some progress, and to irritative affections of the
stomach, trachea, or larynx ; and is service-
able chiefly in diseases of debility and relaxa-
tion unattended by inflammatory or hemorrhagic
action.
54. Dr. Clark ranks the principal places on
the coast of Provence in the following order, as
residences for invalids : — Hyeres, Toulon, Mar-
seilles, Montpellier, Aix, Nismes, Avignon. — a.
Hyeres possesses the mildest climate on this part
of the coast, being sheltered from the north winds
by a range of hills ; and its inhabitants being
comparatively exempt from pulmonary affections.
b. At Marseilles the climate is dry, variable, and
subject to cold irritating winds. It is therefore
injurious to consumptive patients ; and is one of
the places in France where pulmonary diseases
are most prevalent. Invalids requiring a dry air,
and capable of bearing cold winds, may be bene-
fited by residing here for some time. c. Mont-
pellier has obtained a reputation for salubrity to
which it has no claims. According to MM. Four-
nier and Murat, more than a third of the deaths
that occur in the hospital of this city are from
pulmonary consumption. The prevalence in this
part of the country of northerly winds during
winter and spring, both accounts for the fre-
quency of pulmonary diseases, and points out its
unfitness as a residence for patients thus affected.
d. Aix is still more exposed than Montpellier to
the Mistral and north winds, and pulmonary com-
plaints are very prevalent among its inhabitants.
55. C. Nice, although situate on the same line
of coast as Provence, enjoys a much milder cli-
mate than any part of that province. It is pro-
tected by a lofty range of mountains from the
north winds ; and the daily range of temperature
is there less, than at almost any part of the south
of Europe. During winter the weather is settled,
and the atmosphere clear, the thermometer sel-
dom sinking to the freezing point, excepting at
night. At this season, however, as well as in the
spring, cold dry winds are not infrequent ; and
the climate is, upon the whole, dry and exciting.
Hence it is not favourable to pulmonary consump-
tion,— the very disease for which it was formerly
very improperly recommended. It is likewise
unfavourable to irritable or inflammatory states
of the larynx, trachea, and bronchi, attended
with scanty expectoration, or haemoptysis, Rut
chronic bronchitis, bronchonrhoeaj and humoral
asthma, are generally very much benefited by
the climate of Nice. It is also serviceable in all
Cases of debility, torpor, and relaxation of the
mucous surfaces ; in chronic rheumatism, gout,
external scrofula, dyspepsia, and hypochondriasis.
352
CLD1ATE — As a Therapeutical Agent.
56. iii. Of the Climate of Italy and Mediter-
ranean.— A. Genoa is not favourably noticed
by Dr. Clark as a residence for invalids; but
Dr. Johnson, on the authority of Dr. Mojon,
speaks of it in more favourable terms. It is best
suited to those affected by chronic bronchitis, and
dvspeptic and gouty complaints ; and to persons
of relaxed and phlegmatic habits of body. Pisa,
Rome, and Naples are the other places in Italy
most frequented by invalids. The climate of
Pisa nearly resembles that of Rome, the latter
being somewhat warmer and drier in winter.
Dr. Clark considers the climate of Rome as
one of the best in Italy for consumption, un-
attended by ha?moptysis. For those, however,
who cannot take exercise in the open air, and
must confine themselves to sheltered situations,
the Lung' Amo in Fisa is the best place of resi-
dence to be found in Italy. The climate of
Naples is considered by this writer, as well as by
M. Lasnyer, more exciting than that of the
two foregoing places ; and it is more subject to
high winds. The diseases which a residence in
either of these three cities will benefit, are those
above enumerated. Persons who remain in Italy
during the summer, will find Lucca, Sienna, and
the vicinity of Naples, the coolest situations.
57. D. There are various other places on the
shores and islands of the Mediterranean, the cli-
mates of which are suitable to invalids ; but we
possess little or no accurate information respect-
ing them. Malaga in the south of Spain, Cag-
liari in Sardinia, and some parts on the coast of
Sicily, afford a mild winter climate, but the diffi-
culty of reaching them, and of obtaining in them
many necessary comforts and conveniences, al-
most precludes invalids from the northern parts
of Europe from visiting them. Malta is not
open to these objections ; but, according to Dr.
Hennen, the quantity of dust raised from its
arid soil, and suspended in the air, during dry
weather, renders it an unsuitable climate for con-
sumptive patients. A considerable number, also,
of the inhabitants die of pulmonary diseases. In
his work on the medical topography of the islands
of the Mediterranean, Dr. Hennen states a fact,
which is perfectly in accordance with my obser-
vation in warm climates, although doubted by
Dr. Clark, viz. that those of the Ionian Islands,
winch are decidedly most malarious and remark-
able for remittents, have had fewest pulmonary
affections amongst the British troops. In re-
spect of the health of the troops stationed in these
Islands, this writer states, that, from an average
of seven years, phthisis has borne a proportion to
other complaints of 1 to 1984, only. At Malta,
on an average of eight years, consumption has
occurred in the proportion to other maladies of 1
to 931. Including all pulmonic complaints what-
ever, the proportion to others, as regards the
Ionian Isles, has been 1 to 20| ; and, as respects
.Malta, 1 to 14. Taking into calculation the
whole Mediterranean islands, the proportion of
pulmonic, to other diseases, has been 1 to 17^ in
the British army.
58. iv. Climate of the Northern Atlantic. —
Under this head the climates of Lisbon, Cadiz,
Madeira, the Canaries, the Azores, Bermudas,
and the Bahamas, may be arranged ; all of winch
have been recommended to persons requiring a soft
and equable climate, during the winter and spring. |
59. A. Madeira is, of all these places, indis-
putably the best, as respects both the climate,
and the comforts and conveniences within the
reach of the invalid. The frequency and ex-
cellency, also, of the means of convevance to
and from the island are no small recommenda-
tions. From the minute account furnished of the
climate of this island, by Drs. Gourlay, Hein-
EKF.it, and Renton, after a long residence in it,
and from the effects I have observed in several
persons who had resorted to it as a winter's resi-
dence, it may be justly concluded, that it is su-
perior to any part of the south of Europe for con-
sumptive cases. Its central ridge of mountains
gives it, in summer, a cool land wind ; and the
north trade winds, at this season, render it tem-
perate and salubrious. During winter and spring,
Funchal, and parts near the sea-shore, are the
best places of residence; and, during summer, the
more elevated situations in the interior are cool
and agreeable. The mean annual temperature of
Madeira is about 6" higher than the south-east of
France and Italy ; and the heat throughout the
year is much more equably distributed. The
winter of the former is 12J warmer than that of
the latter, and the summer 5° cooler. At -Ma-
deira the extreme annual range is only 143,
whilst it is double this amount at Pisa, Rome,
and Naples. In respect also of the progression
and steadiness of its temperature, it excels those
places. Rain falls at Madeira on 73 days of
the year, and at Rome on J 17 days, and chiefly
during the autumn in the former. The air is
also more soft than at Rome.
60. B. The Canaries possess the next best cli-
mate to Madeira. The mean annual temperature,
however, of Santa Cruz, the capital of the former,
is 71"; whilst that of Funchal, the capital of the
Jatter, is only 65J. The summer temperature of
Santa Cruz is 7- warmer than that of Funchal,
and the winter temperature 5" warmer. Flence
the mean annual range of temperature is greater
in the Canaries than in Madeira; which possesses,
in other respects, advantages sufficient to recom-
mend it in preference to the former in pulmonary
diseases.
61. C. The Western Islands, or Azores, enjoy
a climate nearly approaching to that of Madeira.
They are, however, more subject to high raw
winds, particularly those from the north and
north-west, which are often very cold and harsh;
and the temperature of winter is lower, and that
of summer higher than in Madeira. The air is
also more humid. From a very short visit I made
to Madeira and the Azores, — to the former in the
spring, and to the latter in winter, — I should con-
clude the Azores to be much inferior to Madeira
as a residence for invalids, chiefly because of the
absence of many necessary comforts and con-
veniences, of their stormy winters, and the infre-
quency and ineligibility of the opportunities of
transport between them and this country. The
climate of the Bermudas and Bahamas presents
no advantages sufficient to obtain for them a
preference to those already noticed. They are
liable to storms, and to harsh northerly winds in
winter, from the American coast, whilst their
summers are very hot.
62. v. Climate of the H'est Itidies. — The mean
annual temperature of the West Indies, at the level
of the sea, is 79°, 80-, and 81°; and during the
CLIMATE — As a Therapeutical Agent.
353
winter months, in some places, about 3J, and in
oth.-rs only I lower. The extreme annual range
■ 80 , and the mean daily range about t> . This
continued high temperature exhausts the energies
of in\ aluls ; and the clearness of the slues, and
great power of the sun, present suitable exercise
m the open air. A visit to the West Indies of a
few months' (Juration, made either to some of the
most healthy islands, or passed chiefly aboard
ship, will, however, prove of service in several
chronic alfections, particularly those referred to
above (§37.), excepting consumption in its more
advanced Stages. 1'ersons much disposed to this
disease, either hereditarily or by the conformation
of the chest, &c, or who are threatened by its
early stages, will find a removal to the West In-
dies one of the prophylactic measures most to be
depended upon. When residing some time in an
extremely malarious place within the tropics, 1
observed that the most healthy persons in it were
those who were constitutionally disposed to pul-
monary disease. But 1 believe, that the observa-
tion often made, is perfectly correct, that removal
to an intertropical country, when phthisis is far
advanced, will only accelerate its progress. It
may also be stated, that severe and protracted
catarrhs are very common upon entering between
the tropics. In gout, chronic rheumatism, scro-
fula, and calculous affections, a residence in the
West Indies is often productive of advantage.
63. vii. Of residence on the sea shore and
voyaging. — There are certain topics connected
with change of climate often discussed during the
course of practice, viz. whether are inland situa-
tions, or places on the sea-shore, whose climates
are physically alike, most serviceable in pulmo-
nary diseases ? and whether or not sea-voyages
possess any advantage over a land resilience in
these complaints, a. In respect of the first ques-
tion, it may be stated, that places on the sea-shore
are generally more humid than those inland, and
oftener, on this account, preferable in the dry and
the hemorrhagic pulmonary affections ; whilst a
situation somewhat iuland, or not removed above
a few miles from the coast, seems somewhat more
serviceable in those cases of consumption which
are otherwise characterised. But the question has
not been satisfactorily determined, and, indeed, is
not easy of solution.
64. h. With reference to the second question,
it may be stated more confidently, that sea-voy-
aging, in a suitable climate, is preferable to land
residence in the early stages of phthisis, and par-
ticularly when it is attended by haemoptysis. This
advantage is evidently to be attributed to the in-
fluence of the ship's motion on the sanguineous
and nervous systems. This opinion was argued
for by Dr. Gregory, in his excellent thesis, Be
Morbis Cceli Mutatione Medendis, and has been
generally admitted. Cruising in a warm or even
temperate latitude, particularly in tlio Atlantic, is
preferable to voyaging, because of its longer dura-
tion. Whilst the sun is north of the equator, the
climate between the 3Uth and 50th degree of lati-
tude ; and while the sun is south of the equator,
that from the 20th to the 35th or 40th degree of
north latitude, wiH be found the most salutary.
During winter, voyages between Madeira and the
Weal Indies ; and, in summer, between Madeira
and this country, in the vessels constantly trading
between England and the W est Indies, and winch
30*
generally touch at Madeira, might be undertaken
with advantage. These vessels furnish tolerable
accommodations, which may be easily improved
or adapted to the state of the invalid.
65. A. When the winter has been passed in
any of the wanner situations noticed above, at-
tention ought to be paid to the time of returning
to this country. This should not be earlier than
the first, or later than the last week in June.
If the invalid have passed the winter in the
south of France or in Italy, these places may be
left early in .May, and he may travel cautiously
through Switzerland, avoiding exposure to the
evening and morning air. During the journey,
warm clothing should be resorted to as soon
as the temperature falls so low as to become
sensibly cold; and a free circulation in the skin
and extremities ought to be carefully preserved.
66. B. With respect to the diseases which are
benefited by change of climate, it is unnecessary
to add any thing at this place, as the climates
which seem most serviceable are noticed wdien
discussing the treatment of those diseases in which
most advantage is derived from removal to par-
ticular climates. The affections for which this
treatment may be employed, are scrofula, tuber-
cular disease of the lungs, hemorrhage from the
lungs, &c., chronic bronchitis, asthma, chronic
rheumatism, dyspeptic and hypochondriacal af-
fections, urinary calculi, and various cachectic
and hydropic affections. (See the treatment of
these complaints in their respective articles.)
Biblioq. and Refer. — Hippocrates, Jltiil AIqwv,
VOaTOJV, ll/Ttmv, Vander Linden's edit. 8vo. vol.i. p. 827.
—Cruger, De Zonis et Climatibus, 4to. WiUeb. 1660.— Wer-
ttr, lie Morbis Climatum, 4to. Duisburgi, 1704. — Burgar,
De Methodo Medendi pro Climat. Diversitate varie inslitu-
enda, 4to. Lu^d. Balav. 1724. — Hartmunn, Diss, de Climate,
ejusque Notitta Medico adniod. oecessaria, 4to. Regio, 172!'.
— t'. Hoffmann, De Medendi Methodo varia pro Cliuiatis
Diversitate. Halfp, 1734.; et in part i. vol. ii. Supp. ejusdem
operura. lien. ed. 1753. — Kr&ger. De Diversitate Corpor-
um Morb. et Curationurn secundum Ketones Europa?, 4to.
Halae, 1744.— G. G. Richter, De Insofatione, Opusc. t i.
Goet. 17 7. — De Buchner, De Difl'erentiis Naturarum re-
spectu Climatiim, 4to. Hala>, 1746. — A'. A. Lorry, Sur
I'Usisje des Alimens, Sec. vol. ii. Paris, 1757.; Journal de
Physique, vol. i. p. 430. Paiis, 1773.; et Ibid. vol. iii. p. 243.
Paris, 1774. — A. ffilson, Observat. relative to the Influence
of Climate on Vegetable and Animal Bodies, Lond. 1780. —
J. J. P/enck, Bromatologia, s. Doct. de Esculentis et Potu-
lenlis, ,Vc. Vindob. \lM.—J.L.S-hurer, De Atmosphera
Electrica. Argent. 1786. — Dar/uc, Hist. Naturelle de la Pro-
vence. Avign. 1782, t. i. p. 15. — Schneider, De Eflficacia
Ventoruin, Duisb. 1790. — J. C. Ehrrmiuer, De Lucis in
Corp. Hum. Vivum ellicncia. Gflt. 1797.— E. Horn, lie Lucis
in Corp. Hum. Viv. prater Visum eu"ic. Goet. 1797. — Ca-
banis, Rapports du Physique et Moral de 1'Homme. Paris,
1802. p. 235. — Gvurlay, On the Climate and Dis. of Ma-
deira, J:r. 1311. — ftlurut, Topograph. Med. de la Ville du
Montpelier, 8vo. 1810, p. 149.— C. K. Weiss, Diss. Ciiraalol.
Medica [nitia listens. Lips. 1813.— L. Cerutti, Collect.de
Tillui ii in Organism. Hum. Actione. Lips. 1814. — J. En-
nemoser, l>< ftlontium inlliou in VaJetudinum Ilomin. Vita-
Genus et Morbus. Ber. 1816.— J. Knirsch, Synopsis de Cli-
mat. Med. Vind. ItlS.—Sigavd, Travaux de la Soc. de
Mi M. de Marseille, 1818, p. 14.-^7. Cop/and, The Medical
Topography •■! the West Coast of Africa, in Quarterly Journ.
of I ign lied. vol. ii. p. l.; Appendix to Ricktrand'*
Physiology, p. 582. 627.; and in Griffith's Trans, of Cvvier's
Regne Animate, vol. i. p. 130. — rtrey, in Uirt. des Scien.
Med. t. v. p. 330. — Forbes, On the Climate of Penzance and
the Land's End 8vo. 1821.— Holland, On the Duration and
Distribution of Rain 4cc. 8vo, Lvme, .1828. — Nuumnnv,
AIL-. Seniiotik. Ber. 1826, p. 125. et teq.—Hennen, Skelcb-
e 01 th" Med. Topography of the Mediterranean, itc. 8vo.
Lond. 1830, p. 221.— A. de Humboldt, Annates de Cbimie
el de Physique, t. \o. p. 22.; et Fragmens de Geologic et
de Climatologie Asiatiques, 2 mm. Paris, 1831, t. ii. Foreign
Quarterly Review. Julv, 1832. — Chuholm, On the Climate
of Bristol and Clifton, in Edin. Med. and Sur:;. Journ. vol.
xiii. p. 265., and vol. xvii. p. 164. — B. Gaspard, Journ. de
354
COLD — General Effects of.
Physiol. I. vii. p. 227.— Fodcrd, Hist. Nat, Medicale, &.c.
biix Alpea Maritime*, &c. Strasb. 1823. — Rostan, Diet de
M4d£ciue, l. v. y. 361. — Hcineben, On the Climate and
Med. Topog. of Madeira, Med. Renos. In Copland, vol. xxii.
1 S2 1, p. l. — ,/. Johnson, Influence of Tropical Climates cm
Europ. Oonstitut. 8vo. 4ih ed. 1827.; ;nul Change of Air, or
the Pursuit of Health, thruugh France, Switz.,and Italy, Sec.
8vo. 1831. p. 2S5. et sen. — Annesley anil Author, Researches
on the Dis. of India and Tropical Countries, Sic. 4lo. 1828
and 1829. vol. i. p. 661., and vol. ii. p. 6. — Lasnyer, Sur des
Climats d'ltalie, kc. dans les A if. de Poitrine, be., in Souv.
Biblioth. Med. Juil. 1829.—./. Clark, The Influence of Cli-
mate in Chronic Diseases of the Chest and Digestive Organs,
<tc. 8vo. 2d ed. 1830.
COLD. — (Classif. Pathology. JEtiology
and Therapeutics.)
1. Cold is merely a relative term, expressing
a sensation produced by the abstraction of heat
by any substance of a lower temperature than
that of the body or part which feels ; conse-
quently this sensation is not always occasioned
by the same degree of temperature. Nature has
recourse to various means for abstracting animal
heat from the body, under circumstances requiring
it ; and for preventing the dissipation of it, under
other circumstances ; and the instincts and reason
of the animal creation are often evinced in further-
ing these objects. The dark skin of certain va-
rieties of our species, and the thin hairy covering
of many of the lower animals inhabiting hot coun-
tries ; the fair well-clothed skins, and the thick
coverings of wool or fur with which those of cold
climates are provided ; and the construction of
the dwellings, &c. in different and opposite cli-
mates ; are all provisions intended to accelerate,
under certain circumstances, and to delay, the
dissipation of animal heat under others.
2. The functions of the living economy can be
performed within a certain range of temperature
only, for any considerable time. Above or below
this range, they will more or less rapidly cease,
according to the extent to which the change may
be carried in either direction, and the rapidity
with which it is effected. Whilst the abstraction
of heat is produced more rapidly than it is sup-
plied, either in a part or in the whole body, de-
pression of the vitality takes place co-ordinately
with the rapidity of the loss of temperature ; but,
on the other hand, when the abstraction of heat
is altogether prevented by living in a medium of
equal or greater temperature, excessive vascular
excitement, rapidly exhausting the sensible and
irritable properties of the tissues, and thereby
terminating human existence, is the consequence.
The heat of the human body seldom varies, in
health, above 100° or below 96J of Fahrenheit's
thermometer ; and although man mav live in a
lower temperature than the zero of this scale,
when suitably fed and clothed, owing to the
activity of the respiratory and heating functions,
yet, in consequence of the nature of these func-
tions, he cannot exist for any considerable time
in a mean range of temperature above that of
his own body. In no part of the globe is the
mean annual range of atmospheric heat within
twelve degrees so great as that of the living
frame.
3. i. Physiological and Pathological
Effects of Cold. — A. A general view of its
effects. In considering, therefore, the effects of
cold upon the body, due reference should be had
to the state of the respiratory and heating func-
tions, which are essentially vital, and active in
proportion to the greatness of the constitutional
powers. The abstraction of caloric, or cold,
when carried far, first depresses, and afterwards
annihilates, the vital actions of a part, by de-
priving it of that principle which is necessary to
preserve the various tissues composing it in a
suitable state for reciprocity of action, and which
observation shows to be necessary to the healthy
performance of the sensiferous and circulating
functions especially. When heat is abstracted to
a greater extent than it is supplied, sensibility is
diminished or numbed ; and circulation, as re-
spects both rapidity and size of the current in the
vessels, is lessened. This effect may be produc-
ed in a part or extremity to the extent of anni-
hilating these functions in it, whilst in the internal
viscera they either remain entire, or are but little
changed. When this is the case, the part affect-
ed will permanently lose its vitality, if these func-
tions be not soon restored by frictions, and a very
gradual admission of heat. A part thus atiected
by cold is said to be frost-bit, — an accident to
which the more exposed parts of the body are
liable in very depressed states of temperature.
Even friction only may occasion too quick a
change of temperature, if it be not made with
some substance, as snow, which may prevent the
loo sudden increase of heat, and the risk of im-
moderate reaction. When the vital energies are
weak, a less degree of cold will depress them
than when they are energetic ; and, upon its re-
moval, vascular reaction will be less apparent, or
even not at all supervene.' If cold be not great,
or too long applied, relatively to the vital ener-
gies, increased action, as evinced by a glowinc
sensation, follows its impression. When, on the
other hand, it is excessive, either in degree or
continuance, the depression of vital power, es-
pecially the manifestations of this power in the
nervous and circulating organs, is co-ordinate, the
living animal sinking into a state of torpidity from
which it is with great difficulty roused. Thus
cold, momentarily or briefly applied, when the
constitutional powers are not very much impaired,
proves, if not excessive, an excellent invigorating
or tonic agent, owing to the reaction which fol-
lows ; but when acting energetically, or for too
long a time relatively to the state of those powers,
it will produce one of two effects, according to
the circumstances attending it, or following its
application : either it will depress the vita] actions
beyond the power of recovery, the system sinking
into a comatose state, or struggling between tins
state and partial or irregular reaction ; or it will
be followed bv increased or even uncontrollable
vascular action, soon exhausting the vital mani-
festations of the vessels and the irritability of the
frame, or of the part principally exposed, and
occasioning dissolution of the blood. While the
continued action of that degree of cold, which
may be endured for a short time, very often pro-
duces the former result ; the momentary exposure
to excessive cold, or the injudicious application of
heat in an inappropriate or too rapid a manner,
after the more moderate but prolonged action of
this agent, is usually followed by the latter. In-
flammations are not infrequently induced in
this manner in the organs to which cold has been
directly applied, as in the case of inflammation o{
the lungs coming on after passing into a warm
apartment immediately from a cold atmosphere.
hi other cases, the impression of cold when pro-
COLD — Its particular Effects.
355
lonir.-il. although moderate, may, by diminishing
\ ital action in the parts on which it acts, so deter-
mine and increase it in distant or even opposite
parts or surfaces, as to give rise to inordinate se-
cretion or vascular action in the latter. Such
1 lt-iiiLi the more general effects of cold upon the
system, it will be advantageous to examine its
mode of operation more closely, in order that we
mav be enabled to form accurate ideas as to its
influence in the causation and removal of disease.
4. B. Particular effects of cold. — a. The
primary effects of the abstraction of heat from a
part, to the extenl of producing a decided sensa-
tion of cold, appear to be exerted upon the ner-
vous system, whose sensibility and vital manifes-
tations it lowers, and, when excessive, entirely
annihilates. These effects are obvious in both
the organic and voluntary classes of nerves; and
are at first attended by an alteration of their sen-
sil>i!it\ of a slightly painful kind, often followed by
loss of their functions. Thus, cold will occasion-
ally give rise to local paralysis. When an in-
tensely cold substance is applied to a living tissue,
the rapid abstraction and passage of its caloric
through the living surface intervening between
them, cause similar effects to those following the
rapid communication of caloric by a heated body,
and thereby momentarily excite the nerves and
vital turgescence of the intervening parts. Thus,
intense cold will produce vesication, inflammation,
&c. of the skin.
5. b. The action of cold, when slowly or mo-
derately applied, in diminishing vital turgescence,
the hulk of the tissues, and the activity of the cir-
culation, seems coeval with the effects produced
by it on the nerves. By this action the small ar-
teries, veins, and secerning pores are constricted,
and the communicating canals between the ex-
treme arteries and radicles of the veins are ren-
dered smaller and less pervious. Hence, when
cold is applied to the surfaces of the body, the
circulation there and in the vicinity is diminished,
and the blood is driven thence, and accumulates
in the large veins of the internal viscera. Owing
partly to this operation, and partly to the sedative
effects of cold upon the nervous sj stem, the whole
Circulation becomes weakened, and congestion of
the large vessels and internal erectile tissues takes
place. If the impression of cold is only for a short
period, the vital energy not being at the time ma-
terially deficient, the heart and large vessels are
enabled to react upon the load that oppresses
them, and an increase of the circulating functions
ensues. But when the impression of cold con-
tinues, circulation becomes less and less active,
with at first slight or inefficient efforts at recovery,
and at last ceases entirely.
(>. c. Muscular parts are very sensibly affect-
ed by cold, in consequence of its effects upon the
nerves supplying them, and of the diminution of
the circulation in them. Nervous energy, there-
fore, being depressed, and the circulation weak
and insufficient, muscular contractions also be-
come weak and tremulous; and the muscles sub-
sequently stiff, or altogether rigid, frequently with
cramps or spasms intervening between these
states. A share of these extreme effects is,
doubtless, owing to the vascular congestion pro- I
daced on the cerebrospinal axis, and on the
origin of the nerves supp ying the muscles. The
crumps often occurring after plunging into cold '
water, or while swimming, are illustrations of the
effeel on th oscular system of moderate cold
suddenly applied to the surface, and of its action
thereon, through the medium of the nervous and
vascular syst s. After the power to make
muscular exertion ceases, in consequence of the
continuance or increase of cold, remarkable still-
ness and rigidity of the voluntary muscles super-
vene, sometimes extending to the respiratory
muscles, and producing asphyxy. In many cases,
where cold acts intensely or suddenly upon the
surface of the body, rigidity takes place with re-
markable celerity, as stated by CiuiNTUs Cur-
ri us, and MM. Parat, Martin, and Beau pre,
to have occurred in the expedition of Alexan-
der, and the retreat of Napoleon from Mos-
cow. Trismus and tetanus have followed, in
some cases, a moderate decrease of temperature,
and difficult articulation is not an uncommon ef-
fect of this cause.
7. d. The influence of cold upon the respira-
tory and calorific functions is very manifest.
When atmospheric cold is moderate, and suf-
ficient exercise is taken in it, and the cutaneous
surface and extremities are sufficiently clothed,
then respiration is energetic, the changes pro-
duced on the blood are complete, and animal
heat is freely generated, and is sufficient to sup-
ply the continued loss of it from the surface of
the lungs. But when cold depresses the nervous
power, owing either to its excess, or to the cir-
cumstance of its acting simultaneously upon both
the cutaneous and pulmonary surfaces, or to the
circulation being unaided by muscular exertion,
then respiration becomes laborious, quick, and
painful; and the production of animal heat is in-
suiticient to preserve the fluids and soft solids in a
suitable state for reciprocal action, rigidity, fol-
lowed by congelation, first of the extremities, and
subsequently of more central parts, taking place.
As long as the nervous energy and the circulation
are unimpaired, animal heat is freely developed;
but it becomes co-ordinately depressed with the
failure of these, and returns in a proportionate de-
gree with their restoration. When cold has acted
for a considerable time upon the frame, animal
heat is either restored with difficulty, or it con-
tinues to vacillate and sink with the nervous and
circulating functions until death supervenes. It is
chiefly during the period which elapses between
the exposure to cold, and restoration from its ef-
fects, that diseased action commences, or is de-
veloped. Too long continuance in a cold bath,
wet clothes, and numerous other means of refrig-
erating the body, will produce a loss of tempera-
ture that may never he recovered. Dr. Currie
found that a man with a temperature of 98", three
hours after cold bathing and exposure to a north
wind, bad not recovered his natural heat, although
warm stimuli, frictions, &c. had been employed.
During such states id' protracted restoration, vari-
ous morbid states are apt to originate and to give
rise to a train of diseased actions, varying in al-
most every case with the constitution, tempera-
ment, predisposition, and habit of'body of the in-
dividual. Even after reaction has taken place,
some particular organ or part may suffer especially
owing to these predisposing circumstances; and
inflammation, with effusion, disorganization, &c.
may be the result.
8. e. The effects of cold upon the brain and the
356
COLD — Pathological Effects of.
organs of sense and voluntary motion, are similar
to those already described. Hearing, sight, touch,
&c. become imperfect, the functions of mind im-
paired, and insensibility, somnolency, delirium,
and convulsions supervene. The somnolency, and
indifference to the consequences of indulging it,
when long exposed to cold, have been well known
since the accounts given of the cases of Dr. So-
landf-r and Sir J. Banks, in Terra del FuegO,
of Maupf.rtuis in Tornea, and of Captain
Parry's associates in the north-west expedition.
But the fullest description of its effects upon the
senses and cerebro-spinal centres is given by
Beaupre. The same degree of cold, according
to the state of the system and the extent to which
the surface is protected, will cause either delirium
of a quiet comatose kind, or raving madness, or
convulsions, passing into tetanic rigidity. Great
insensibility and somnolency will also often steal
upon their victim, without any other mental dis-
turbance; and occasionally they will be preceded
by tremors, delirium, and convulsions.
9. /. Cold produces very decided effects upon
secreting organs and surfaces. When it acts
directly upon either of these structures, it dimin-
ishes or entirely suspends their functions, owing
both to its sedative action on the nerves and cir-
culation, and to its constricting influence upon the
canals and pores of the part, it thereby lessening
vascular turgescence and vital manifestation.
Cold air or cold fluids acting upon the external
surface interrupt the functions of the skin, par-
ticularly if the cold be combined with moisture.
A similar effect is produced upon the pulmonary
mucous surface, only if the cold' be intense, and
if it be at the same time humid. As long as the
cutaneous surface is protected, and the vital ener-
gy of the frame is unsubdued, the exhalation of
vapour from the lungs, and the other changes in
the blood that take place in this organ, are not
materially interrupted until the temperature of the
air falls much lower than can be endured by the
external surface. When, however, the air is
very humid as well as cold, the aqueous exhala-
tion from this organ also is much lessened. The
remarkable tolerance of cold by the lungs during
exercise and a protected state of the external sur-
face, is evidently owing, 1st, to the circumstance
of the quantity of air received at each inspiration
being a part only of the whole air contained by
them; and, 2d, to the changes in the capacity of
the circulating and respired fluids for caloric,
by which the respiratory actions are attended.
Whilst the nervous and circulating functions are
unimpaired by cold, diminution of the cutaneous
and pulmonary exhalations is compensated for,
and injurious plethora of the vascular system
prevented, by a proportionate increase of the se-
cretions from the kidneys and intestinal mucous
surface. Owing to this activity of the internal
secretions, and centralisation of vital energy, the
appetite is also increased — sometimes rendered
even ravenous — digestion is accelerated, and the
stomach enabled to dispose of substances which
would otherwise be rejected from it. When cold
acts upon the frame for some time, and is great
relatively to the condition of the digestive organs
or vital power, a nearly paralytic state of the
nerves of the alimentary canal may ensue, giving
rise to interrupted secretion, to flatulent dilation
of large portions of it, either with or without
spastic constriction of other parts, and to painful
and anxious suppression of all its functions.
10. C. Of the effects of cold in various states
of the system. — a. It has already been stated that
the injurious effects of cold are great in proportion
to the depression of vital power at the time of its
action. When the surface of the bodv is warm,
or even overheated, but not perspiring, when
vascular action is energetic, or the nervous power
excited, cold is well and safely borne; but when
the body is perspiring freely, and at the same
time exhausted, or the depressing mental passions
are in operation, it produces a much more in-
tense and rapid effect, not only by obstructing
the cutaneous perspiration, but also by occasion-
ing either interruption of the internal .secretions,
followed by febrile action, or a morbidly in-
creased flow of some one or more of these secre-
tions, according to the state of the body at the
time. The experiments, however, of Fordyce,
Blagden, and Dobson, and the practice of the
Russians, show that the free perspiration produced
by heated air and the vapour bath, as long as the
excitement of the nervous and vascular systems
occasioned by these continues, may be checked
with impunity, and even give rise to a salutary re-
action.
11. b. Exposure to cold and wet, in cases of
shipwreck, &c, particularly in winter, is produc-
tive of bad effects, great_ in proportion to the
rapidity with which evaporation of the moisture
from the surface of the body takes place. As the
temperature of the sea, in winter, is always high-
er than that of the air, and is not lowered, as that
of the air is, by evaporation from the wet clothes
of the person thus exposed, so has it been ob-
served on numerous occasions, and particularly
in the instance recorded by Dr. Currie, that
persons who have remained almost wholly im-
mersed in sea-water have always lived longer,
than those who were exposed to the refrigerating
action either of the wind only, or of the wind as-
sisted by evaporation from the wet surface and
clothes. Protracted immersion, also, is not so
injurious in salt as in fresh water. This is chiefly
owing to the higher temperature of the former
than of the latter, and partly, perhaps, to the
stimulating effects of the salts dissolved in sea-
water on the skin. In cases of shipwreck it is
not unusual to find, that those who had taken
spirituous liquors to excess during ti>e period of
their peril are the first to fall victims to the effects
of cold. This, most probably, is owing to the
exhaustion consequent upon the excitement pro-
duced by spirits; to the fluxion and centralisa-
tion of vital power in the parts on which the
stimulus directly acts; and chiefly to the circum-
stance that such excesses cooperate with cold in
producing congestion of the vessels within the
cranium, and apoplectic lethargy.
12. c. During states of morbidly excited vas-
cular action, unattended by free excretion, or a
perspiratory state of the skin, the external or in-
ternal application of cold is beneficial, by lower-
ing the nervous and vascular excitement to that
state which is requisite to a due performance of
the secreting and excreting functions. Eut in or-
der that this effect should be obtained, it will gen-
erally be necessary to continue the application of
COLD — Pathological Effects of.
357
cold for some time, or frequently to repeat it after
short intervals, as reaction usually follows a brief
use of it ; hut as soon as tin: disposition of the
morbidly increased action to recur no longer is
evinced, a prolonged application of cold may he
injurious hy depressing the vital energy so low,
that recovery cither of the part on which it di-
rectly acted, or of the system generally, may be
a mailer of dilficulty. In many of sm-h cases,
rigors will follow the too protracted or intense
operation of this agent, and be the means of
bringing about reaction, which, however, may
assume irregular or excessive states, or produce a
new or modified train of symptoms.
13. d. During the exhaustion following muscu-
lar exertion in hot weather, and while the surface
is freely perspiring, cold in any way is most in-
tensely and rapidly injurious, particularly when it
is applied to the stomach. The ingestion of a
large quantity of a cold fluid in this state has
been speedily followed by death. This extreme
effect has not been satisfactorily explained. That
inflammation may he so quickly induced cannot
be admitted. It seems more probable that the
sudden impression of the cold Huid upon the
nerves of the stomach, together with the rapid
distension of the organ, paralyses the system of
nerves which supplies the digestive organs, and
which is evidently that part of animal organiza-
tion on which the vital manifestations through-
out the frame more immediately depend. Even
when cold, owing either to the less bulk of the
cooling body, or to the state of the stomach and
system at the time, is not quickly or intensely in-
jurious, still it may be productive of injury by fa-
vouring the developement of inflammatory action
in the stomach or liver, or by interrupting the se-
creting actions of these and adjoining viscera.
14. D. Changes observed in cases of death by
cold. — Quelmalz found the vessels of the brain
turgid with blood, and the large veins and arteries
filled by polvpous concretions ; and he refers the
sopor preceding death to congestion of blood in
the cerebral vessels, and effusion of serum in the
ventricles of the brain. Rosf. n also observed the
vessels within the cranium engorged with blood.
Cappki. states that he found the blood and fluids
accumulated chiefly in the pectoral and abdominal
viscera. Dr. Kkllie detected, in two cases
examined by him, the same appearances as were
remarked by Q.UELMALZ, I&osen, and Cap-
pel ; and noticed, in addition, a bloodless state
of the scalp, engorgement of the sinuses, integrity
of the substance of the brain, remarkable redness
of the small intestines from turgescence of the
blood-vessels, and absence of tympanitic disten-
sion.
15, E. Of cold, or undue abstraction of ani-
mal heat, as a cause of disease. — < lold is either a
predisposing or an exciting cause of a very great
number of diseases, particularly among the poor,
ar.d during the winter and spring seasons, as
J. P. Frank and Sir G. Blank have demon-
strated. The injurious effects of this agent on
intuits and children are great in proportion to the
earliness of the age at which they are exposed to
it. I believe that more than one half of the
deaths, and two-thirds of the diseases, that occur
among the children of the poor, are more or less
caused by it. ("old will produce modified and
even opposite effects, according to its intensity
and duration. It has already been shown, that,
during the integrity of vital power, a brief or
moderate impression of cold is an indirect stimu-
lant, and an excellent tonic remedy ; whilst a
very intense or prolonged action of this agent is a
direct deprivement of the vital energies, even al-
though the rapid abstraction of much cold may
inflame and disorganize the parts through which
it is caused to pass. Hence it must be obvious
that cold will be either a predisposing or an ex-
citing cause of disease, according to the intensity,
duration, and manner of its operation, to the con-
stitution of the person on which it acts, and to
the other causes and influences which cooperate
with it. The same circumstances will also ex-
plain the great diversity of its effects, and its op-
eration in determining the characters and compli-
cations of numerous maladies, even after their
career has commenced.
lb'. After what has been advanced respecting
the physiological and pathological action of cold,
I need not add any further observations on the
manner in which it operates in the causation of
particular diseases. It will be sufficient to enu-
merate those which it most frequently produces,
either by its unaided operation, or in conjunction
with a pre-existing disposition or disorder, and
with other morbid influences. Fevers, inflam-
mations of the individual viscera, dropsies of the
shut cavities and anasarca ; catarrhal and bron-
chitic affections, haemorrhages ; diarrhoea, dysen-
tery, and diabetes ; rheumatism and gout ; apo-
plexy and paralysis ; tetanus, and other spas-
modic and convulsive maladies ; the obstruction
of secreting and excreting functions — of the bile,
of the urine, of the catamenia, and of the intes-
tinal excretions ; scrofulous, scorbutic, and chlo-
rotic complaints, hardening of the cellular tissue
and oedema, chilblains, and congestions and ob-
structions of glandular and secreting parts, are
among the most common consequences of this
agent. Fevers occasioned by cold alone are
generally ephemeral, or of short duration, when
no particular organ or function is already in fault;
and the reaction — generally ushered in by rigors
— is of a salutary tendency when kept within due
bounds : but cold favours directly and indirectly
the spread of typhoid infection ; and its action on
the frame during the progress of all continued
and exantheinatous fevers is very often injurious,
unless judiciously regulated and employed, and is
productive of many of the dangerous complica-
tions which frequently arise in their course, as
well as of the local affections that appear during
or after convalescence from them. Such is more
remarkably the case in respect of the exanthema-
tous fevers. Dropsical and hemorrhagic effu-
sions, although obviously depending, in many
cases, on pre-existing organic change, yet often,
even in these instances, have been determined
by this agent. The greater prevalence also of
dropsies, particularly after the exanthemata, in
cold than in warm climates ; and the paucity of
pulmonary, hemorrhagic, and diabetic complaints
in hot countries, ought not to be overlooked.
The frequency of dysenteric, tetanic, and spas-
modic affections in warm climates is no argument
against their production by cold, inasmuch as
they there arise chiefly from a relatively great
depression of temperature The influence of cold
in occasioning apoplexy and paralysis, particular-
358
COLD — Prevention and Treatment of its ill Effects.
ly in aged persons, has been long admitted and
satisfactorily proved by Wepfer, Zacutus,
CCLLEN, FoTHERGILL, MaRCARD, PeNADA,
Walther, Thilenius, Weber, and others;
and scrofula is almost entirely a disease of cold
and moist countries.
17. F. Circumstances of ten favouring or deter-
mining the injurious action of cold. — a. Weak-
ness of constitution favours the injurious action of
cold upon the frame. Infants, convalescents from
disease, and aged persons, are more injuriously
affected by cold than those in whom the nervous,
circulating, and respiratory functions are fully
developed and unexhausted, and who are thereby
enabled to generate vital heat to supply the loss
of it going forward on all the exposed surfaces.
b. Exhaustion by excesses is one of the most
common predisposing states to the injurious oper-
ation of cold. The violent or fatal effects of a
cold bath at a moment of exhaustion by muscular
labour have been well known, at least since the
time of Alexander the Great, who nearly
perished from this imprudence. The exhaustion
consequent upon venereal excesses renders the
system remarkably sensible of depressions of
temperature, as well as disposes it, in an uncom-
mon degree, to the ill erlects usually resulting
therefrom. The same remark applies to the de-
pression consequent upon the excitement of spirit-
uous liquors. The habitual indulgence in warm
apartments, and sleeping in close chambers, with
too great a quantity of clothes on the bed, are very
injurious, especially to females, c. The internal
determination of the fluids accompanying cer-
tain diseases, as chronic bronchitis and diarrhoea,
chronic inflammations of the viscera, cachectic af-
fections, &.c, and even that attendant upon a full
meal, or the occasional or repeated indulgence in
exciting beverages, or the operation of cathartic
medicines, favour the injurious operation of cold
upon the frame, particularly in delicate constitu-
tions.
18. ii. Treatment of the ill Effects
of Cold. — A. Means of prevention and coun-
teraction, a. Vascular and mental excitement,
and physical and moral courage, are among the
most powerful aids to the resistance of cold. To
these should be added, when within reach, warm
woollen or fur clothing ; exercise ; warm dilu-
ents, as tea, coffee, chocolate ; gently stimulating
cordials and tonics, and warm nutritious diet. All
vinous and spirituous excitants are injurious when
used against intense or prolonged cold, as they
occasion internal fluxion and exhaustion. If re-
sorted to at all, they should only betaken in small
proportions, and in large quantities of hot diluents.
This opinion is founded on repeated observation,
and agrees with that advanced by Dr. Clendin-
WING, who has paid much attention to this sub-
ject. According to the experience and practice
of northern nations, and of those in warm coun-
tries who use either no clothing, or but little, the
anointing of the cutaneous surface with oleaginous
substances tends greatly to retard the refrigeration
of the body.
19. b. When cold has produced incipient ill
effects in the frame, indicated by horripilation,
trembling, rigors, &c, a warm bed; hot diluents;
stimulating diaphoretics, especially large doses of
the spiritus alher. nitricus (from 3 j- to r> iij. for
a dose), either alone, or with the nitrate of potash
and camphor ; the repeated exhibition of ammo-
nia, camphor, and opium — the last in small quan-
tities ; the warm or vapour bath, followed by
friction of the surface ; warm spices and cordials,
are among the most certain means of restoration.
It should be kept in recollection, that the sooner
we succeed in counteracting the directly sedative
effects of cold, the less violent will be the conse-
quent reaction, and the less injury will ultimately
result to the economy. As soon as reaction be-
gins to appear, the treatment should be modified;
and the means used to determine to the skin should
be of a less stimulating kind ; as the preparations
of antimony and ipecacuanha ; nitre, with cam-
phor, and either of these substances ; Dover's or
James's powders, &c. &c. Whenever cold has
caused shiverings or rigors, with pains in the head,
back, and limbs, free reaction not having yet
supervened, we may be satisfied that this state of
system is associated with interrupted secretion
and excretion ; and that a quick restoration of
these functions should be attempted. Therefore,
if there be no symptom to forbid it, an en.etic,
followed by warm diluents, and the warm bath,
and these by a cathartic medicine, should be pre-
scribed, in order to restore a salutary reaction,
and the suppressed secreting and excreting func-
tions. In cases presenting the extreme effects of
either very intense or prolonged cold, the means
of restoration should be very gentle at first, and
very gradually increased, as the chief danger to
be feared proceeds from' excessive reaction — ex-
cessive as respects the depressed state of vital
power upon which it supervenes — and the rapidi-
ty with which inordinate action exhausts the re-
maining irritability and vitality of the frame. The
means found most successful in restoring a frost-
bit limb, viz. a very gradual increase of tempera-
ture and cautious admission of stimuli, are requir-
ed in such circumstances.
20. JS. The injurious effects from cold fluids
taken into the stomach, when the body is per-
spiring and exhausted, require instant aid. These
effects somewhat resemble those proceeding from
an injury sustained upon the epigastric region ;
and consist of quick, laborious, or gasping re-
spiration, remarkable weakness and irregularity
of the pulse, great collapse and pallor of the
countenance and surface, rapid loss of the animal
heat, vertigo, with dimness of vision, loss of
hearing, &c, and general torpor, followed by
coma and death — the one rapidly succeeding the
other. In such cases, warm diluents, with ammo-
nia, camphor, and opium ; cordial diaphoretics,
frictions of the limbs and surface generally with
stimulating embrocations ; hot fomentations, sina-
pisms, and cataplasms of Cayenne pepper to the
epigastrium, and especially animal warmth ap-
plied to the surface, particularly the anterior sur-
face of the trunk, are the chief means of recovery.
The remedy much employed in foreign countries
in cases of external injury on the epigastrium is
obviously appropriate in such cases, viz. the ap-
plication to this region of one of the lower ani-
mals the instant that it is killed and opened, and
before it is skinned, or has lost any of its warmth.
21. hi. Of the remfdial Operation of
Cold. — It does not come within the scope of this
work to enter fully into the therapeutical applica-
tion of cold ; but I will very succinctly notice the
subject at this place. A*. As respects the efftci we
COLD — Therapeutical Operation of.
359
wish to procure from it, cold is employed, 1st,
in a alight degree, or for a short period; in order
to produce its indirectly tonic influence ; 2d, iu a
greater amount relatively to the state of the sys-
tem, i" procure its directly sedative operation,
without inducing in any considerable degree its
consecutive or indirect effect ; and, 3d, to obtain
its astringent or constrictive influence on circu-
lating canals and vessels. B. As to the mode of
usjna ii i" order to produce* either of these effects,
much importance ought to he attached. It may
be directed, 1st, to a part or the whole of the
txternal surface — a. by sponging with, or the
employment of a douche, or the allusion of a
continuous stream of, cold water locally, or using
a cooling lotion ; b. by alfusing over all the body
some cold or tepid fluid, or by sponging the sur-
face generally with it; c. by immersion in a cold
or tepid bath : 2d, to the internal surfaces — a. by
respiring a cool or eVen cold air; b. by the inges-
tion of cold liquids; and, c. by the injection of cold
or tepid fluids into excreting canals or passages.
22. It is obvious, from what has been ad-
vanced, that the mode of using cold will determine
its therapeutic effects, not absolutely however, but
only relatively to the state of the system at the
time, and the nature and stage of the complaint
in which it is prescribed. Thus, cold air, the
cold allusion, shower bath, douche, and plunge
bath, will produce either an astringent, or a tonic,
or a sedative operation, according to the length
of time either of them is employed without re-
miasion ; a brief or momentary use of either,
whether directed to a part only, or to the whole,
of the surface, being followed by its indirect or
tonic action ; and a prolonged use, by a more or
less permanent sedative effect. In the treatment
of diseases of debility, or states of depression, we
require the former operation, and, suiting the mode
of applying the remedy to the nature of the af-
fection, resort to it momentarily, and repeat it
frequently. In maladies attended with excite-
ment, interrupted secretion, &c, we desire the
latter effect, and prolong the application till we
arc satisfied as to the extent to which we have
obtained it. In congestion and hemorrhages we
Wish to obtain the astringent or constrictive ope-
ration of cold, and therefore resort to it in a sud-
den or impulsive manner, as in affusion, douche,
or aspersion ; and as this particular effect of cold
appears to be connected, and to commence, with
it> sedative action, and to terminate with, or to
be overcome by, the consecutive reaction, ac-
cording as it may supervene, so are we guided in
determining the degree and duration of the cold
to be employed, in order to astringe congested or
bleeding parts. In the appropriation of each of
ihe modes of using this remedy, by which very
opposite effects are thus to be obtained, the prac-
titioner is guided by considerations arising out of
its operation upon the various systems and organs
of the body, by its etfects directly exerted on the
seat of its application, and by ii> sympathetic
action upon parts remote from thence, and upon
internal viscera. It is, therefore, obvious that
much advantage in practice will accrue from our
entertaining correct ideas as to its action upon
internal organs, when applied to a part or the
whole of the external surface. I have already
stated, that cold — whether cold air or cold water —
constrict; the whole cutaneous surface, and de-
termines the flow of blood into the large trunks
from the smaller canals and vessels (5 5.); and
that when directed for a short time, moderate re-
action is usually brought about bv this internal
determination of the Circulating fluid, and conse-
quent excitation of the centres of nervous and
circulating functions. This mode of operation,
must never be overlooked when employing cold
as a remedy. The only question connected with
it is, whether this constriction of the vessels near
the external surface is limited to it, or extends
sympathetically to internal parts. It is obvious,
that, when the circulating fluid is propelled from
one part, it. must be determined to some other ;
hut, whether does it accumulate in the large ves-
sels, or retire both to them and to other surfaces ?
Pathological facts clearly show that the latter is
most commonly the case. Giannini has, how-
ever, argued that the fluids are not driven upon
the centre, but that constriction also takes place
in internal viscera. That such an effect arises
from the sudden and momentary shock produced
by cold on the surface, and contributes to bring
about the consecutive increased action, may be
admitted, especially if it be employed locally, or
in the vicinity of a congested or relaxed part; but
when its action is of any considerable duration,
or is directed to an extensive surface, the internal
viscera must necessarily experience a proportion-
ate increase of the circulating fluid. Thus, the
brief affusion of a stream of cold water on the
head, in cases of congestion of the encephalon,
will tend to constrict the congested vessels, and
remove the morbid condition, whilst a more
general or prolonged application of cold will ac-
tually produce the very state, which this local
use of it, in a sudden and momentary manner, is
so efficient in removing.
23. In many cases, as in the excitement of
fevers and acute inflammations, when the skin is
hot and dry, we employ either local or general
cold, with the simple view of abstracting a portion
of the increased heat, which, owing to inordinate
vascular action, and to the interruption of the
perspiring and cooling function, becomes a mor-
bid stimulus, and thus perpetuates the cause that
originates it. It is obvious that cold, when judi-
ciously employed in such cases, will even favour
transpiration, and will lower excitement to that
state which is compatible with a return of the
secreting functions ; but so much pathological
knowledge and experienced discrimination are
required to the advantageous or even safe em-
ployment of it, that no surprise can exist as to the
disuse into which the practice has fallen. When
the stage of excitement of continued and cxanthe-
matous fevers has been either imperfectly devel-
oped, or is about subsiding into collapse ; when
internal viscera are weakened and congested, and
the skin is about regaining its interrupted func-
tion, the employment of cold in any way is at-
tended by great risk, more especially when ap-
plied to the surface generally.
24. The good effects of cold applied to the
head, in those diseases accompanied' with an ex-
cited circulation in it, have induced various au-
thors to recommend a similar practice in acute
inflammations of the thoracic and abdominal
a. There can be no doubt that the strictly
local application of cold, as near as possible to>
the organ affected, can be attended with bo dan-
360
COLIC — Its Pathology.
ger, particularly when the inflammation is acute,
and chiefly attacks serous surfaces; and it may be
in some instances productive of benefit ; but we
are still in want of faithfully observed facts to
illustrate the eflects of this treatment in a satis-
factory manner. In hemorrhagic affections, a
judicious use of cold is often of great service — as
the cold affusion or aspersion, the shower-bath,
and cold sponging, in epistaxis and haemoptysis ;
iced fluids taken into the stomach in havmate-
mesis; enemata, and injections per vaginam, of
cold liquids, in haemorrhage from the bowels,
Menorrhagia, and flooding after delivery. Dr.
Drake, of New York, has recently recommend-
ed very cold air to be respired in inflammations
of the respiratory organs; but, from the admitted
influence of cold air in increasing the activity of
the respiratory functions,- and, consequently, the
phlogistic disposition of the circulation, it appears
to me a practice of doubtful efficacy.
BlBLlOG. and REFER. — i. Pathological Operation of
Cold, ff.—Q. Curtius, De Gestis Alexand. Mas;. 1. vii.
cap. S.—Ruii/e, History of Cold, 4to. Lond. 1683.— ii'cdel,
De Frigore Morbifero. Jena;, 1695. — Klqeckhof, De Fri-
gidis Nervorum Svstematis inimicis. Lugd. Bat. 1736. —
Quelmalz, Prog, quo Frigoris Acrioris in Corpore effectus
expedit, &c, in Hulleri Disp. Med. vol. vi. 1758. — Cappel,
Observ. Anat. dec. i. p. 2. — Gmelin, Voy. en Siberie, t. i.
p. 381. — Gladbach, De Morbis a Vestitu insulHcienle, kc.
Franc. 1762. — Rosen, Anat. p. 142. — Leonhard, De Frig.
Atmosph. Effect, in Corpus Hunianum. Lips. 1771. —
Halier, Physiol 1. xii. § 12. — Cullen, De Frigore et ejusque
Vi et Effectibus in Corpus Hunianum. Edin. 1780. — Carrie,
in Edin. Med. Comment, vol. xviii. n. 37. p. 237.— He-
berden, in Philos. Trans. 1795 and 1796.— P /so, De Med.
Brazil. 1. i. — Parat et Martin, Actes de la Soc. de Saute
de Lyon, t. i. p. 300. — Rush, Med. Inquiries, No. 9. — K.
Humboldt, Versuche uber die Gereizte Nerven-und Mus-
kelfaser, b. ii. p. 224. et 238.— Giannini, in Maries N.
Journ. der Med. Lileratur. b. x. St. 1. p. 54. — Rozierc, Sur
la veritable Mode d'Action du Froid, kc. Journ. G£n. de
Med. t. xx. p. 435.— Art. Froid, ill Diet, de Scien. Mtd.
t. xvii. p. 41. — Kellie, On Death from Cold, Trans, of
Medico-C'hirurg. Society of Edinb. vol i. p. 84. — Clendin-
ning, On Cold as a Cause of Disease, &.c, Lond. Med. and
Physical Journ. for June, July, and Sept. 1832.
il. Therapeutical Action of Cold. — Bartholinus, De Usu
Nivis Medico, cap. 15. § 31. — De Porras, Animadver-
siones de Nivis in Potu Usu, 8vo. 1621.— Vallisne. H, Del'
Uso e dell' Abuso delle Bevande e Bagnature Cable o
Fredde, 4to. Modena, 1725.— F. Hoffmann, De Potus
frigidi Saluhritate. Halae, 1729.— Rirhter, De Salutari
Fngoris in Medicina Usu. Goet. 1740. — Rluhme, Morbo-
rum Curationes per FrigllS. Goet. 1773. — Linnaus, in
Amcenitat. Acad. vol. vii. No. 136.— Frank, Interp. Clinic,
vol. i. p. 437. et seq. — Klett, De Epithematum frigidorum
Vi atque Usu, kc. Erl. 1794.— Bom, De Cal. et Frig. Usu
Med. Host. 1 804.— Hufeland, Bibliothek der "Pract.
Hcilk. xii. h. iii. st. p.' 3. — Jfeher, Hani's Arcbiv. fiir
Pract. Med. b. vi. p. 237. — J. Currie, Med. Reports on the
Effects of Water, Cold and Warm, as a Remedy in Fever.
8vo. Liverp. 1797. — Drake, On the Respiration of Cold
Air in Pulmonary Diseases, Amer. Journ. of Med. Sciences,
vol. ii. p. 229.'— J. Copland, On the Affusion of Cold
Water in the Treatment of Diseases, and of its Mode of
Operation, in Lond. Medical Gazette, vol. x. p. 39. and 78.
COLIC. — Der. and Syn. from xw.ot, Colon.
Kialixuv ulytjfta, Gr. Colica, Passio Colica,
Dolor Colicus, Enteralgia, Colicodynia, Tor-
mina, Auct. Var. Colique, Fr. Das Buuchgrim-
men, die Kolik, Germ. Dolori Colici, Ital.
Belly- Ach, Eng.
Classif. 1. Class, Nervous Diseases ; 3.
Order, Spasmodic Affections (Cullen).
1. Class, Diseases of Digestion; 1. Order,
Affecting the Alimentary Canal (Good). I.
Class, I. Order (Author, in Preface).
1. Dt'.riN. Severe griping pains in the bow-
els, with costiveness, and often with vomiting.
2. Colic was formerly considered as seated
chiefly, if not entirely, in the colon ; but many
writers of the last three centuries have applied the
term to acute pains of the bowels, attended by
costiveness, and unaccompanied by fever, arising
either from a primary affection of them, or from
disease of some other viscus in their immediate
vicinity, with which they are connected, and
often sympathetically affected, through the me-
dium of the ganglial nerves.
3. The first mention made of the disease, by
the denomination Colicus Dolor, is to be found in
Celsus and Pliny; and, according to Sennert
and Tronchin, the same name was used by
Thf.mison and Philon, physicians of the Au-
gustine age, when, as Sprengel justly supposes,
colic must, from the manners of that period, have
been a common complaint. But, although the
term colic appears not to have been in use, it
cannot be supposed that such affections were
before unknown. It is more probable that they
were included under the general appellation of
abdominal pains, in use from the time of Hippo-
crates. The greater number of modem writers
have divided the disease into certain species or
varieties, according to the presumed nature of its
exciting causes and pathological states. S.uva-
ges presents us, accordingly, with no less than
22 varieties. Dr. Cullen arranges the idiopa-
thic states of the colic into, 1st, The Spasmodic,
either with stercoraceous vomiting, or with in-
flammation superadded; 2d, The Colic ofPoitoui
3d, Colic from continued constipation; 4th, From
acrid matters in the bowels ; 5th, From retention
of the meconium; 6th, From stricture of the bow-
els; and, 7th, From the obstruction occasioned by
calculous formations. Dr. Good adopts a nearly
similar division to the foregoing, preserving the
1st, 2d, 3d, and 6th varieties; and substituting
for the others, Colic from Surfeit, and Colic from
the generation of Flatulence — C. Cibaria and C.
Flululenta. M. Pariset gives the following va-
rieties : — the flatulent ; the stercoraceous : the
bilious; the inflammatory ; the hemorrhoidal;
the menstrual ; the spasmodic ; the metastatic ;
from calculous and other hard bodies; the ver-
minous ; from organic changes in the bowels ;
and from lead. M. Chomel divides the disease
into nearly the same varieties, and adds to them
that arising from acerb or acid fruits, and fer-
mented liquors, or Colique Vt'gt'tale. The only
additional arrangement of the forms of colic,
which deserves being noticed, has been given by
Schmidtmann, as follows : — A. Inflammatory
colic ; B. Sanguineous or plethoric colic ; C.
From substances passing through or lodged in the
bowels; D. From the metastasis or repression of
other diseases; E. Flatulent colic; and F. nervous
colic. Each of these comprises several varieties,
according to the exciting and proximate causes.
4. Colic, according to the extended accept-
ation of the word, arises from so many causes,
and presents so many morbid ralations, that a
satisfactory arrangement of its different states*
is by no means an easy matter. I shall, how-
ever, attempt to group into distinct species those
forms of the disease which resemble each other
most nearly, or which arise from intimately re-
lated causes, noticing the peculiarities or modi-
fications presented by the principal varieties.
Those forms of colic which chiefly, NT more
immediately, depend upon a morbid sSate of the
COLIC — Its Pathology.
361
intestinal canal will conic first under considera-
tion; and next, those which an- symptomatic of,
or complicated with, other diseases, to treating
of the former, those states which are the most
simple, and apparently consist of functional dis-
turbance of the bowels, will be first noticed, and
subsequently those which proceed from more
complicated or organic causes. As I agree with
Burskki, Cli-i.kn, Good, Abercrombie,
Monro, and others, that ileus is often either an
aggravated state, or advanced stage, of colic, or a
consequence of organic or other causes affecting
the calibre or canal of some part of the small or
large intestines, I shall treat of it at this place, and
after the more simple or lass dangerous forms of
colic have been discussed.
5. I. Colic chiefly and primarily,
from functional disorders of the
Bowels.
i. Simple Colic. ■ Syn. Colica Convulsiva,
Bo net; C. Spasmodica, Hoffmann; C. Fla-
tulenta, Good, &c. ; C. Nerveuse, Chomel;
C. Nervosa, etC. Spasmodica, Sehmidtmann.
Classif. I. Class, I. Order (Author).
Defi.v. Acute pain in the bowels, with occa-
sional partial remissions, flatulent distension, or
spasmodic contractions, or both, at the same time,
relieved by pressure and the expulsion of flatus.
G. There appear to be three morbid conditions
of the intestinal canal, which more or less exist in
the simplest as well as in the most severe and
complicated forms of colic, and which evidently
depend upon depressed vital power of the diges-
tive canal: 1st, Morbidly increased sensibility
and irritability of some part or the whole of the
bowels; 2d, Irregular distension and spasmodic
constriction of ditlerent parts of their canal; and,
3d, more or less copious generation of flatus in
their tract, occasioning great distension and irre-
gular reaction of the muscular tunics — the second
morbid condition adduced. According as either
of these states predominates above the others, the
attack assumes a nervous, a spasmodic, or a flat-
ulent character; and it has thus acquired these
specilic appellations from different authors.
7. A. The nervous form of the complaint oc-
curs most commonly in females, and in persons
of a nervous and irritable temperament, passing a
sedentary or indolent life, and of a costive habit
of body; sometimes without any evident cause,
but often after inattention to the state of the
bowels, exposure to cold, or some mental emo-
tion or excitement. The attack is usually sud-
den, and the pain is felt in one or more places in
the abdomen, but shifts its place frequently, and
is exacerbated at irregular intervals. The face
Is pab*. and anxious; the abdomen is irregularly
contracted, and pressure of it often affords slight
relief. During the severity of the pains, a cold
perspiration is forced out on the surface, and
leipothvmia, or sinking, is frequently complained
of. The bowels are constipated, and borhorygmi
are constant. The duration of the attack is usu-
ally short — from one to several hours; and it
generally terminates favourably ; but repeated
returns of the affection are very common, upon
errors of diet, and from mental inquietude.
8. B. The mine flatulent form of colic presents
greater distension of the abdomen, the expulsion
of flatus giving ease. The distension and pain
are often traced along the course of the colon,
31
and are most complained of in the situation of
the sigmoid flexure and crjecum. The quantity
of flatus generated is often very great, and it evi-
dently proceeds chiefly from irritation of the mu-
cous surface of the bowels, giving rise to the
separation of a gaseous fluid from the blood by
the vessels of this surface; the matters retained
in the prima via being insufficient to furnish, by
their decomposition, — granting that they undergo
this change, — so great a quantity of flatus as is
generally voided. Owing to the irritation produc-
ed by the llatus, the bowels are inordinately dis-
tended in one part, and irregularly constricted in
another; the part which was contracted, losin*
its tone, and becoming, after a time, greatly dis-
tended, and the distended portion experiencing at
intervals, irregular spasmodic constrictions. Thus
the retained flatus is propelled from one part to
the other, occasioning griping, shifting pains, and
rumbling noises, or borhorygmi, of the abdomen.
The bowels are always constipated; and when
evacuations are procured, they chiefly consist of
hard lumps, and are accompanied with the escapo
of much flatus ; the secreting functions of the
bowels being evidently impeded. This modifica-
tion of the complaint, as well as the preceding,
is frequent in hysterical females, and persons of
indolent habits, living much on vegetable diet,
whose intestinal and biliary secretions are scanty,
acrid, or otherwise vitiated; and their digestive
functions weakened by indulgences.
9. C. The more spasmodic form of colic is in
many cases merely a somewhat aggravated state
of the preceding; the extremely painful spasmod-
ic constriction predominating above the flatulent
distension, and extending more or less to the ab-
dominal muscles, giving rise to severe and irregu-
lar contractions, often with retraction, of the
abdominal parietes. Whilst the two preceding
varieties are very seldom attended by sickness or
vomiting, unless in the severest states, this variety
is frequently accompanied with this symptom;
and, in its worst forms, vomiting, upon taking
substances into the stomach, is very general.
Constipation is also very obstinate; injudicious
attempts at relieving it often increasing the vom-
iting, and converting simple colic into either en-
teritis or simple ileus. This form of colic often
attacks those of spare habits of body, of the hy-
pochondriacal and bilious temperaments, who live
chiefly on coarse vegetable food, and are addicted
to fermented or spirituous liquors.
10. ii. Colic from the injurious Nature or
Quantity of the Ingesta. — C. Accidentalis,
Willis and Cullen; C. Vegitale, Chomel ; C.
Ciliaria, Good.
Defi.v. Severe twisting, griping pains in the
abdomen, with vomiting, and rigid contractions
of the abdominal parietes, followed, in some
eases, by griping alvine evacuations, and loose-
ness.
11. A. This species of colic presents various
modifications, according to the nature of the of-
fending cause; and it has been accordingly dif-
ferently described and named. Its' states vary
greatly in severity, according to the nature of the
ingesta occasioning it, whether those of a solid or
fluid kind. It may be here remarked, that the
colic of 1'oitou, or colica Pictonum (which name
has been very generally confounded with colica
piclorum, or painters1 colic), and the form of the.
362
COLIC, BILIOUS — History, &c. of.
disease endemic in some other countries, although
in many respects the same as lead or painters'
colic, are evidently partly occasioned by the
crude wines, new spirits, and the acerb and acid
nature of the liquors in common use, as well as
by lead, which is sometimes dissolved in them.
(See Lead Colic, §26.) ClTESios, Piso, Car-
dan, Sennert, Wepfer, and many recent
authors, have imputed the endemic of Poitou,
Madrid, and other places, entirely to the nature
of the ingesta, into many of which mineral sub-
stances could in no way enter. The evidence
furnished hy their writings, and in the treatises of
Grashuis and Tronchin, and my own expe-
rience, favour the opinion that acid and acerb
liquors are often concerned in the production of
colic, without the aid of lead; to which, however,
the most severe cases, and those accompanied
with paralysis, are attributable, as shown by Sir
G. Baker. Dr. Batejias doubts the power of
these ingesta, independently of their impregnation
with lead, to produce tlie disease. His opinion
is, nevertheless, opposed by the fact, that a large
proportion of the cases of colic which occur in
districts where acid and spirituous liquors are
much used, is not attended by the paralytic and
other symptoms characteristic of lead colic, and
that many of them run on to dysentery. Whether
or not the colic stated by K.empekk to prevail
in Japan, owing to the use of fermented beverages
prepared from rice, depended on the presence
of lead, cannot be ascertained. I had means of
knowing that the colic so prevalent among the
natives of Africa is clearly owing to the excessive
use, particularly when over-heated, fatigued, or
covered by perspiration, of the acid beverages
prepared from the juice of the palm and other
trees, and in the making of which no sort of metal
utensil, or of glazed pottery, is at all employed.
Linnjeus imputes the prevalence of the com-
plaint among the Laplanders to the use of stag-
nant water, containing small worms, &c. In
various parts of the noitli of Europe, where but-
ter-milk whey, and vegetable infusions, are fer-
mented into very acid liquors, and used for com-
mon drink, most severe attacks of coke follow
their ingestion in a cold state, particularly when
the body is perspiring. Dr. Chishoi.m attrib-
uted the prevalence of colic in Devonshire to the
abuse of cider in summer and autumn, by the la-
bourers, when busily engaged in the hay and com
harvest — the cold acerb cider inducing a spas-
modic state of the bowels in persons overheated
by laborious exertion.
12. B. Various articles of food will occasionally
disagree from some peculiar idiosyncracy, the
articles themselves not being injurious. Such is
sometimes the case, when a person, who has been
living sparingly, indulges in a too full meal, or
partakes of a substance to which the stomach, the
functions of which are perlmps weak, is unaccus-
tomed. Pork, cooked very soon after being
killed, particularly if used as an article of diet in
warm climates, is very apt to produce attacks of
colic, followed by griping evacuations from the
bowels. A similar effect often is induced by
blown or tainted meat, mildewed wheat or rye,
and by cold, acerb, indigestible, or unwholesome
fruits, as cucumber, melon, &c. The injudicious
use of cold griping purgatives, as senna, &c, will
often, if not properly combined with other medi-
cines, occasion this state of colic in hypochondrial,
bilious, or phlegmatic habits.
13. Most severe effects often follow the inges-
tion of poisonous fish, muscles, lobsters, mush-
rooms, &c, and of the minute fungi sometimes
formed on smoked meat and sausages, or on
cheese. But the colic which is produced in these
cases is the least dangerous part of the mischief;
the affection of the nervous and vascular systems
being often of still greater importance. Instead,
therefore, of considering the effects of these sub-
stances as varieties of colic, as Dr. Good has
done, I have viewed the disorder of the stomach
and bowels as a part only of the circle of morbid
actions they occasion, and have therefore treated
of them in the article Poisons.
14. The presence of arsenic in wines, or the
fumes of this metal; preparations of antimony,
copper, or zinc; and the accidental solution of
these, or conversion of them into a salt by sub-
stances about to be received into the stomach; are
often productive of disorder, of which colic is one
of the most prominent features, generally attended
by vomiting, and sometimes followed by loose-
ness, or by tenesmus and dysenteric symptoms.
Lead colic is very often occasioned by the inges-
tion of the metal in some state or other by the
mouth, and should therefore be treated of at this
place, but the peculiarities of this variety require
for it a separate consideration. Many substances
occasion, when taken in hurtful quantities, effects
of which colic is among the most prominent; but
which, as they present certain diversities, are de-
scribed in a separate article. (See Poisons.)
15. C. Infants, especially from birth to the
termination of teething, and occasionally older
childrep, are very liable to this form of colic.
The state of the mother's milk, arising from the
want of health, or manner of living, the irritation
connected with dentition, too early feeding, too
much or inappropriate food, acidity of the prima
via resulting therefrom, and want of attention to
the bowels, are the most common causes of this
complaint among infants. In children it is often
produced by acerb or unripe fruit, and by cold.
In very young subjects it is characterised by more
or less flatulence, screaming, tossing of the arms,
and forcible drawing up of the lower extremities
upon the abdomen, with vomiting, costive bowels,
and greenish, offensive, and acid evacuations;
followed by looseness; or free evacuations at-
tended by tormina.
16. iii. Colic from a morbid State of the Se-
cretions poured into the Bowels, and Re-
tention of the Excretions. — Colica Atra-
biliaris, Meyserey; C. Biliosa, Hoffmann;
C. Stercorea, Ettmuller, Sauvages, and Cul-
len; C. Pituitosa, Sennert, Fernel, &c. : ('.
Stercorale, et C. Biliease, Pariset; C. Con-
stipata, Good; C. Biliosa. et C. Stercoracea,
Schmidtmann: Hepatic Ileus. Musgrave; Co-
lica Madridensis, et C. Hispanienxis, Auct
Var. Dry Belly-Ache.
Defin. Severe griping pain, with pon~aceotis
or bilious vomitings, constipation, or scanty
evacuations, and often with hiccup, tension of
the abdomen, and restlessness, the motions pro-
cured presenting various morbid appearances.
17. This species of colic has been differently
described, and named as above, according to the
views entertained respecting its nature. We
COLIC, BILIOUS — History, &c. of.
363
have Been that \\\c first variety of the disease con-
sists of various morbid states, chiefly characterised
by deficient function and altered sensibility of the
bowels, &&; and thai the second variety is prin-
cipally occasioned by (he nature and quantity of
the tngesta. The variety which I next have to
consider comprises certain tonus of disorder aris-
ing mainly from the morbid condition of the se-
cretions and faecal matters contained in the bowels,
hut aided by other causes; and it may be divided
into, a. The colic of infants, caused by retained
meconium ; b. colic arising from accumulated
fecal matters in the bowels ; and, c. From the
irritation of morbid secretions poured into the
intestines from the liver, &c.
18. A. The colic which is owing to the reten-
tion of the meconium (C Meconialis, Sauvacks
and GOOD,) in new-born infants, is chiefly met
with in those who have either not been sufficiently
early put to the mother's breast ; or who have
been suckled by a nurse, or brought up by hand.
The milk which is tirst secreted, possesses pur-
gative qualities, intended by Nature to promote
the expulsion of the secretions, which had accu-
mulated in the prima via during the latter period
of foetal life; and when the infant enjoys not this
requisite kind both of nourishment and medicine,
the meconium is retained, becomes viscid, acid,
and irritating to the bowels, occasioning costive-
Dees, distention, screaming, drawing up of the
lower extremities, sickness, &c.
l!). B. It is evident that the retention in the
caecum and cells of the colon, of those excre-
mentitious matters which require to be thrown
off from the bowels, will be productive of more
or less disorder, Such retention usually occurs
very early, and in advanced life ; in those who
pass an indolent existence, or are engaged in
sedentary occupations; in persons whose howels
are torpid from debility or exhausted sensibility ;
in females who are pregnant, or who are of an
advanced age; and in men who have old hernia?.
It is often preceded by indigestion, cardialgia,
constipation of the bowels, and fulness about the
i. the sigmoid flexure, and occasionally the
whole coarse of the colon. In many cases, large
accumulations in the Cecum or Colon (see
these articles), may be detected by manual ex-
amination. Sickness and vomiting, however, sel-
dom come on until abdominal griping pain has
been for some time complained of, and the stom-
ach has been irritated by acrid purgatives. Later
in the complaint, the abdomen becomes tense,
tumid, and painful on pressure; the pulse accele-
rated; and the tongue, which was from the com-
mencement loaded at the root, more foul or furred.
This form of the disease is very apt to terminate
in dysentery, enteritis, or ileus.
20. C. The form of colic which occurs, and
even prevails, in some of the West India Islands,
has often been confounded with lead colic, from
the supposition that the new rum drunk in these
Islands contains lead in solution. Mr. Q,uif.r,
Dr. Chishomi, and Dr. Thomson, who resided
long in the West Indies, state that this disease is
not so common as formerly in these islands, owing
to tin; improvement in morals, and the use of
wanner clothing; and that nothing is more erro-
neous than attributing it to the poison of lead.
These physicians refer it to the intemperate, use
of spirits, and to alternations of heat and cold.
Mr.QuiER and Dr.Muso.RAVE, who have given
a very detailed account of this complaint, as they
observed it in Jamaica and Antigua, where it is
of frequent occurrence, slate positively that lead
is not concerned in its production. From the his-
tory they have given of this endemic colic of the
West |ndies ; and from the descriptions of the
colic, which is perhaps the most common disease
in Madrid and several provinces of Spain, fur-
nished by MM. Pascal and Makijiiam), who
treated many hundred cases of it in the French
army that occupied Spain during the peninsular
war, and in I8J4 — all which accounts are now
before me; I conclude that the colic of Spain and
that of the West Indies depend upon the same
causes — evidently of an endemic kind; are char-
acterised by similar symptoms ; run the same
course, evince similar lesions, and are cured by
the same treatment. Indeed, I have seldom met
descriptions of any disease so much alike as those
furnished by Dr. Mi;sG rave and hy M. Mar-
quanu, who himself had the complaint, the
causes and treatment of which he has so ably in-
vestigated. After examining the causes to which
writers, particularly Hoffmann and Thiery,
and others copying them, have imputed this af-
fection, viz. to lead and metallic substances dis-
solved by acid wines, &c, M. Marquand states
those to which the natives attribute it ; namely,
the use of vegetable acids and unripe indigestible
fruits ; large draughts of wine and water, and of
much milk; and insufficient clothing on the trunk
of the body and abdominal regions. But these
causes, he remarks, are in operation in many
places of Spain and Portugal where colic is rare,
and therefore some endemic cause not yet dis-
covered must be in operation. M. Larrey im-
putes it to atmospheric vicissitudes and acid
beverages, and designates it " Colique bilieuse
rheumatismale," MM. Aulagnier, Libron,
and Jacob, who have had extensive experience
of this disease in Spain, concur with M. Mar-
quand in denying the influence of lead in pro-
ducing it ; and think that its causes are not yet
fully ascertained. The negative information fur-
nished by these writers, the character of the
symptoms, and particularly the appearance of the
evacuations, would lead me to infer that, in both
the colic of Spain and the colic of the Wast Indies,
endemic causes, — especially those which proceed
from the soil, and produce intermittent and remit-
tent fevers, — impede the functions of the liver and
intestinal surface, and occasion an accumulation
in the hepatic ducts, gall-bladder, and prima via,
of acrid or otherwise morbid secretions, which,
owing to their irritation, or to concurrent or de-
termining causes, give rise to a series of painful
and diseased actions, and imperfect or abortive
attempts at their evacuation. The symptoms re-
ferrible to the liver — its congestion — the signs of
irritation about the duodenum, the vitiated dark
appearance of the stools, and the relief obtained
from free alvine evacuations, are proofs of this
position.
21. Symptoms. — The patient1 generally experi-
ences premonitory symptoms before the accession
of the attack. These consist of dull and pressing
pains in the whole, course of the colon, but par
rjcularly in its arch; loss of appetite ; irritability
of temper, and difficulty in evacuating the bowels,
which, however, are not costive. The patient
J64
COLIC FROM LEAD— History, &c. of.
has often several evacuations in the course of the
day, but in small quantity, and with much fla-
tus ; and he experiences less distress in bed than
when he is up. The tongue is moist, and loaded
only at the root; and there is much thirst. These
symptoms usually continue two or three days ;
about the third, the patient has no longer any de-
sire to go to stool, and evacuates no more flatus;
but the pain becomes more severe, and more
fixed and constant at the epigastrium, with a
twisting pain at the umbilicus : the countenance
is pale, and expressive of pain and anxiety ; the
pulse is slow, small, regular, and constricted, but
not febrile; the skin is dry, but not hot; and the
urine is scanty, but not otherwise unnatural. The
patient often sits with his arms crossed over, and
pressed upon, the abdomen, and the trunk bent
forwards. If he be in bed, the thighs are pressed
up upon the belly. Along with these symptoms,
and generally soon after the accession of consti-
pation, porraceous or bilious vomitings come on,
commonly in small quantities, mixed with glairy
matters, or those last taken into the stomach, and
accompanied with hiccup. There is no sleep,
but a continued restlessness : the pain is now
nearly constant, and most severe, particularly
about the epigastrium and umbilicus, and is not
ameliorated by any position. As the malady pro-
ceeds, the thirst increases ; and the fluids taken
generally aggravate the hiccup, and are soon
thrown off. The eyes are sometimes slightly
yellow, and the whole surface rather sallow.
The patient is distressed by the continued severity
of the pain, the hiccup, and the want of sleep;
wandering and delirium comes on, sometimes
with deafness, epileptic convulsions, and rarely
with fajculent vomiting ; these latter symptoms
generally portending a fatal result.
22. This disease, left to itself, usually runs its
course in eight or ten days, and rarely extends
beyond the fifteenth. Pain or uneasiness in the
right hypochondrium is often felt some time before
the attack, and occasionally not until the advanced
progress of it. In some cases, the pain and vom-
iting cease, upon the free spontaneous excretion
of flatus, with dark, hard motions : but occasion-
ally they return after a short time, and black
atrabilious matter is thrown off the stomach.
The discharge from the bowels is generally very
morbid, offensive, and of a dark, blackish, or
deep green colour. In other cases, where the
patient has been neglected or improperly treated,
chronic debility, with marasmus, and, more rare-
ly, paralysis, supervenes, and usually terminates
fatally. The abdomen is seldom much retracted,
excepting about the umbilicus ; but, at the last
or fatal stage of the disease, it is much dis-
tended. The bowels usually resist the action of
the most powerful purgatives at its advanced
period, and injections are thrown up or retained
with difficulty.
23. Prognosis. — a. A favourable issue is in-
dicated by free evacuations, followed by amelior-
ation of the abdominal pain and vomiting, by
the circumstance of the pulse remaining below
100 beats in the minute, and the non-superven-
tion or subsidence of hiccup, b. — An unfavour-
able result is preceded by more or less tender-
ness, tension, and tumefaction of the abdomen;
by a pulse above 100 ; by obstinate constipation,
and immediate return of the injections ; by the
severity and continuance of singultus ; by dry-
ness of the tongue, and increased restlessness and
tossing.
24. Dissection has thrown little light on the
nature of the disease. M. Marquand, whose
experience was extensive, considers that what-
ever change of structure is observed, is merely
a contingent circumstance, or accidental com-
plication. M. Pascal states, as the result of
the examinations he made of six fatal cases, that
little or no lesion was observed in any part of the
alimentary canal, excepting slight redness of the
mucous surface of the duodenum : the gall-blad-
der was loaded with thick bile ; but the other
viscera were natural. He further states, that he
found the sympathetic ganglia injected. A pe-
rusal, however, of his description of the appear-
ances presented by them, impresses me with the
belief that what he considered to be unusual
vascularity, was not more than they always pre-
sent in the healthy state.
25. iv. Colic from the Poison of Lead. —
Syn. Colica Saturnina, C. Pictorum, C.
Pictonum, Auct. Var. C. Rhachialgia
(rQa/iuXyia, Spine-Ach), Astruc, Good ;
C. du Poitou, C. de Plomb, C. Metallique,
Rachialgie Metallique, Auct. Gall. Blei-
colik, Trocken Colick, Germ. Devonshire
Colic, Painters'1 Colic, Lead Colic, |*c.
Defin. Dull remitting pain, becoming con-
stant and violent, extending to the back and upper
and lower extremities ; vomiting, obstinate con-
stipation, often followed by paralysis.
26. I have already noticed the fact of this
disease being often confounded both with the
form of colic produced by acid and acerb in-
gesta (§ 11.), and with that depending upon a
. morbid state of the secretions poured into the in-
testinal canal (§ 20.). Lead colic chiefly attacks
house-painters and plumbers, workers in the
different preparations of lead, glaziers of earthen-,
ware, miners, ornamental and water-painters,
gilders, and rarely chemists and printers. It is
very probable that the colic so prevalent in
Devonshire, Poitou, and, according to Tronchin
and Wanstroostwyck, in Haarlem and Am-
sterdam, arises in some instances from a portion
of lead contained in acid beverages, and pos-
sibly from the Water used for domestic purposes;
but that the endemic colic of the West Indies
and Spain is occasioned by lead, as many sup-
pose, has been disproved, as we have seen, by
the more accurate observations of modern en-
quirers, especially directed to this point. Lead
colic arises not only from the introduction of
the mineral into the system along with the in-
gesta. but also from its oxides being allowed to
remain in contact with the surface of the body;
as in the case of workers in lead, as shown by
Lentin, Brambilla, Sir G. Baker, and Dr.
Reynolds ; and from the volatilised fumes of
lead floating in the air, in recently painted apart-
ments, as observed by Percival, Henckel,
Gardanne, Badeley, and Goon. It is ex-
tremely probable that lead produces a more in-
jurious action upon some constitutions than upon
others; and that its oxides and sub-salts are more in-
jurious than its super-acetate. The most quickly,
and sometimes the most powerfully, injurious
operation of lead is when* its oxide is mixed prin-
cipally with turpentine, for the purposes of house-
COLIC FROM LEAD — Historv, &c. of.
365
painting. This spirit carries along with it, daring
its volatilisation, a portion of the oxide, and thus
poisons the respired air. thereby aflectina the re-
spiratory nerves and even the blood itself. Soon
after Sir il. Hakik's investigation of the effects
of lead, and of the substances which either contain-
ed, or might by possibility contain it, was made
{>ublic, every tiling which came in contact with
ead in anv form was viewed with suspicion.
Dr. I'i ki ivvi. first demonstrated the folly of
these apprehensions ; and although the water
which supplies a million and a half of persons in
this metropolis passes through leaden pipes, and is
long retained in leaden cisterns, which are often
allowed to become foul, yet, I believe, that no
case of lead colic occurs from this cause, except-
ing in those who are affected by lead in a different
and manifest manner. Dr. Batkman never met
with a case in London which could not be traced
to this source; and 1 certainly never did, notwith-
standing the readiness with which the effects of
lead are produced in some persons. Although
lead is thus the efficient cause of the complaint,
it is not always the only cause. Thus, the acid
beverages or spirits in which the food is taken
may determine its effects ; or an attack may be
induced, in a person imbued with the lead poison,
by improper ingesta, spirituous liquors, exposure
to cold, and by sulphureous waters, or sulphureted
medicines, and cold griping purgatives. Cases
have been recorded by Dr. Wall and Sir G.
B&KER, where the external medical use of the
preparations of lead occasioned the disease, but
such are of rare occurrence.
27. Symptoms. — Lead colic usually commences
with obscure pain of the abdomen, which be-
comes, at tirst, at intervals, so severe, that the
patient screams, tosses himself about, and vainly
seeks a posture that will lessen his sufferings.
Some lie for a while on the abdomen, and others
press upon or rub this part with the hand. The
pain is generally greatest at the pit of the stomach,
and as the disease proceeds, extends to the back,
upwards to the arms, and downwards to the loins,
thighs, and legs. A twisting pain is also general-
ly felt about the navel, which is at first drawn
inwards ; and cutting pains shoot at times with
great violence to both hypochondria and iliac
fosse, and through the abdominal muscles. The
voluntary muscles often become so sore that they
cannot bear the slightest pressure ; and the pain
frequently alternates between the stomach and
bowels and the external muscles. Sickness and
constipation are early symptoms, — the matter
thrown off the stomach consisting of a slimy fluid,
either with or without acrid deranged bile, which
is continually being secreted, accumulates, irri-
tates, and is evacuated. To these are generally
added bitter eructations, hiccup, severe headach,
pains of the wrists, hands, ancles, soles of the feet,
&c. ; and frequently of the shoulders and neck.
Til'-'' Bymptems are aggravated during the night,
depriving the patient of a moment's repose. The
pulse is not, at tirst, affected — sometimes in no
measure throughout the disease ; in many cases
it is below the usual standard, and in others
quicker and weaker, more rarely fuller or strong-
er. The tongue is pale, moist, and soft, without
erection of the papillae. The skin is commonly
soft and moist ; it is rarely hot. The urine is
various, but more frequently copious than othor-
31*
wise. Costivenees continues as the disease ad-
vances ; sometimes a griping disposition to stool
occurs : and if anj feces are passed, they are
scybalous, hard, resemble sheep's dung, and are
mixed with a dirty watery fluid containing a dark
slime, and occasionally a" little blood. .M. MeR-
at analysed the matters evacuated, but could not
detect any lead in them. The abdomen is insen-
sible to pressure ; in some instances rigid arid
knotted ; but in the latter stage often distended
and slightly painful, chiefly from the distension
of the bowels, and affection of the muscles, in
the cases which have occurred in my practice,
distension of the abdomen was as frequent as re-
traction, owing evidently to inflation and fecal
engorgement of the colon, the course of which
could be distinctly traced under the abdominal
parietes. M. Andral has also met with a simi-
lar state of this cavity. In some cases I have
remarked considerable retraction around the um-
bilicus, while all the rest of the abdomen in the
course of the colon was greatly distended. Dr.
Munro states that the sphincters of the bladder
and rectum are sometimes so contracted that the
urine and feces cannot be voided. I have ob-
served this chiefly as respects the sphincter ani —
a clyster pipe being with difficulty introduced.
If the complaint be not soon ameliorated, the
pains of the back, loins, and limbs become more
violent, and are attended by extreme weakness,
tremulousness. and even partial or complete pa-
ralysis, particularly of the extensor muscles. In
some cases, dyspnoea, palpitations, and a short dry
cough, are complained of, seemingly owing to the
pressure of the inflated colon upon the diaphragm;
and occasionally epilepsy, coma, or even apo-
plexy, supervenes.
28. Duration, Complications, and Prognosis.
— A. The duration of the attack varies from two
or three to twenty-five days. M. Ranque found
that, out of 1 47 cases, 1 29 recovered between the
second and the thirteenth day of treatment, and
the remainder before the twenty-sixth day. But
relapses, or rather returns, of the complaint are
most common. I have met with instances of a
ninth and tenth attack ; and more numerous seiz-
ures have occurred in the practice of others. In
more unfavourable cases, the disease continues
for weeks, or even months, with occasional inter-
missions; but such may be viewed as a succession
of attacks, and occur chiefly in drunken workers
in lead — addiction to spirits aggravating and re-
producing the ell'ects of lead on the system.
29. B. This disease is sometimes complicated
with epilepsy ; more frequently with palsy, in
which it often terminates ; and rarely with in-
flammation of some one of the abdominal viscera,
and with mania or delirium.
30. C. The prognosis is favourable when the
symptoms are mild, or are ameliorated by treat-
ment ; but it should be given with caution and
reservation when the attack is very severe, is
attended by hiccup, by obstinate and continued
vomiting, by tremulousness, and by distension of
tin- abdomen. It should be unfavourable, if com-
plications (§ 29.) appear in its course ; or if deaf-
ness, blindness, focal vomiting, and symptoms of
ileus, supervene.
3!. Appearances observed on dissection. —
Lead colic is most commonly fatal from the com-
plications that occur in its course. In its simple
366
COLIC AND ILEUS — Pathology of.
state it seldom terminates in death. The exami-
nations made by Senac, Astruc, and Bor-
dieu, furnish nothing satisfactory. Stoll ob-
served the gall-bladder loaded with dark bile :
Sir G. Baker describes the bowels as being per-
fectly natural throughout, and the muscles pale
and wasted. De Haen states, that he found
contractions of the colon and caecum in all the
cases he opened. M. Me rat examined seven
cases, which he says presented the same appear-
ances as those described by De Haen ; whilst
M. Andral details six cases, in all of which no
such contractions were observed, nor any other
morbid change of the alimentary canal. M. Louis,
also, found no alteration in the bowels. Most of
those who die of this disease are carried orT in
epileptic convulsions, or have had paralytic symp-
toms. The state of the cerebro-spinal axis is
hence deserving of examination. M. Andral,
however, states, that he detected no lesion of the
brain, nor of the spinal cord, nor of the voluntary
nerves. A case I had an opportunity of exam-
ining confirms the observations of Sir G. Baker
and Andral.*
32. II. Colic arising most frequently
from Change of Structure or re-
lative Position of the Bowels. —
Classif. IV. Class, I. Order (Author),
i. Colic from Mechanical Obstruction of the
Canal of the Bowel. — Syn. C. Calculosa et
C. Schirrhosa, Bonet, Chomel, Lamotte ;
C. Constricta, Good.
Defin. Costive, flatulent state of the bowels,
attended by passing colicky pains, relieved by
liquid, difficult motions, and often accompanied
by a sensation of constriction ; tumour or diffi-
culty in a particular part of the abdomen.
33. Considerable mechanical difficulty is often
experienced for some time before a severe attack
of colic or ileus takes place. A patient, whom I
have long attended for slight colic pains, and
irregular state of the bowels, without full or satis-
factory evacuations, states, that a sensation of
soreness in the situation of the arch, and of diffi-
cult passage to the left flexure of the colon, with
painful distension about the caecum and right side,
are often felt shortly before an evacuation. Dr.
Monro remarks that stricture of the bowels in
its early stage occasions costiveness, alternating
with diarrhoea and colic pains. If the obstruction
be low in the bowels, solid faeces are either not
* Mr. Byam and myself recently examined the body ol'a
painter, who died at the age of 78. He had been a verv
strongman, and in constant employment all his life up to a
few days before his death. He died of hamiatemesis, from
disease of a branch of the coronary arterv of the stomach.
The substance of the heart was soft and flabby. The small
and large intestines were sound; the liver was' studded with
collections ol a pultaceoua semilluid matter, of a grayish-
white colour, contained in very thin cvsls, from the size' of a
hazel nut to a walnut, the portions of liver surrounding them
being softened and of a dark red colour. The top of the an-
terior mediastinum, and space behind the top of the sternum,
contained an immense mass, nearly the size of the closed
hand, of enlarged glands, of a cheesy consistence and ap-
pearance ; and a similar change of the absorbent glands ex-
isted behiud the arch of the aorta, the superior cava, Sic. ex-
tending in the form of a long cushion down the vertebrae into
the abdomen. The small arch of the stomach, the pylorus,
and commencement of the duodenum, were remarkably
thickened, from the deposition of adventitious matter, the
thickened mass nearly approaching the characters of scirrhus.
The coats of the arteries of the stomach were diseased, and
contained atheromatous matter.
passed, or they are of small quantity and slender
calibre. These strictures are most commonly
met with in the colon ; and their situation, in
some cases, may be inferred from the sensations
of the patient, and the symptoms observed in ex-
amining the abdomen : they are fully described in
the article on Morbid Structures of the Diges-
tive Canal. (See also articles Cecum and In-
testines.) When colic is owing to the pres-
ence of concretions, stones of fruit, &c. in the
bowels, distinct hardness, or even tumour, is
sometimes felt ; but, in many instances, no such
change can be detected, although the patient
generally refers to some part of the abdomen as
presenting a fixed pain, or obstacle to the func-
tions of the intestines. (See art. Concretions
— Intestinal.) In all cases of colic pains arising
from the above pathological states, great distension
and tenderness of the abdomen often speedily
come on, partly owing to inordinate dilatation of
that portion of the canal above the obstruction.
Sickness also at stomach, and vomitings, gen-
erally precede or follow these symptoms, with
restlessness and distress ; and the complaint soon
assumes all the characters of ileus, unless the re-
tained matters pass the obstacle, or the obstruct-
ing body itself be propelled downwards and evac-
uated, as is often the case in respect of biliary and
other concretions. 'When colic proceeds from in-
cipient mechanical obstacles in the intestinal canal,
the symptoms are less violent ; but thev are of
frequent recurrence, until -the obstruction is re-
moved, or they increase so as to produce inflam-
mation of the bowels or ileus.
34. ii. Colic, with complete Obstruction of the
Bowels, and Stercoraceous Vomiting, Ileus,
Volvulus — Syn. ED.ioc (from ti/.iu, I con-
stringe), Hipp. ElXldv (from ttXita, volvo, I
roll about — hence, volvulus), Aretaeus. Xo-yo-
daifio$ (from ^oqSij, a cord, and u.ttc, I kill),
Galen, Jlforbus tenui Intestini, Celsus. Acu-
tum Tormentum, Ccel. Aurel. Iliaca Paxsio,
I/iacus Morbus, Chordapsus, Miserere, Do-
lor Ileus Spasmodicus, Auct. Var. Volvulus,
Baillou. Ileus Varus, Sydenham. Ileus Spas-
modicus, Sauvages. Colica Ileus, Good. Pas-
sion lliaque, Fr. Darmgicht, Ger. Volvolo-
passione Iliaca, Ital. Iliac Passion, Eng.
Defin. Violent griping pain, obstinate coiisti-
pation, with retraction of the navel, and spasms
of the abdominal muscles, tension, tenderness and
distension of the abdomen ultimately supervening,
and generally with stercoraceous vomitings.
'So. Galen, and after him, Van Swietes,
viewed ileus as merely a form of inflammation
of the bowels. Others, particularl v Sauvages,
Barthez, Cullen, Pinel, and Alibert,
ascribed to it chiefly a nervous or spasmodic
character. Many writers, of the last century
have divided it into idiopathic and symptomatic :
whilst M. Kaige Delorme, and others, have
disputed its idiopathic nature, and particularly its
nervous origin, and have considered it, as it,
doubtless, most frequently is, a consequence of
mechanical obstruction, inflammation, or some
pre-existing disease. There can, however, be no
doubt, although many of the cases observed may
have been merely severe instances of colic, in
which the proper symptoms of ileus had not
come on, that it sometimes occurs as a simple
COLIC AND ILEUS — History, &c. of.
367
and idiopathic disease, as Barth SB, Maxwell,
ami l>r. Abkrcrombii have demonstrated; and
that dissections of fetal cases sometimes present
do morbid change sufficient to explain the symp-
toms or to account for the result. In the cases
recorded l>v Barth i /. and Maxwell feculent
vomiting, and the discharge by the mouth of
matter thrown into the colon, are described to
have occurred, and yet recovery took place. In
many instances, perhaps the majority, ileus su-
pervenes on one or other of the forms of colic
already described ; or, in other words, certain
pathological states commence with symptoms,
which, in the tout ensemble, constitute some one
of the forms of colic described, and terminate in
fully developed ileus. Such terminations are most
common in the second, third, and fourth varieties
of colic. But in rare instances, ileus comes on
suddenly, with the most violent abdominal pain
and vomiting, the 'patient tossing about in the ut-
most agony, the other symptoms of the disease
rapidly appearing, and most frequently terminat-
ing fatally.*
36. History. — Ileus is either preceded by con-
stipation and colicky pains, or it is a more intense
form of colic from the commencement, the symp-
toms ditVering only in degree. Early in the dis-
ease, constipation; twisting and violent pain about
the umbilicus, sometimes not aggravated by, but
even alleviated by pressure ; constant retchings ;
absence of fever, and a pulse not exceeding, or
even below, the natural standard, are the usual
signs. If relief be not soon procured, the ab-
domen enlarges, and becomes tense, tender,
and tympanitic ; the countenance is anxious and
collapsed ; feculent matters are ejected by the
mouth ; the pulse becomes frequent, small, and
constricted, the thirst urgent ; and violent tor-
mina, with ineffectual attempts at evacuation of
the bowels, hiccup, failure of the mental energies
and \ it.il powers, with cold, clammy, and par-
tial sweats, cold extremities, cold, sunk features,
leipothvmia, and sinkings, supervene. In many
cases, inflammatory Bymptoms appear early in
the coarse of the malady, and pass rapidly into
those indicating the commencement of gangrene.
The state of the tongue is different in different
cases, and stages of the complaint It is occa-
sionally not materially changed. Often the dis-
ease is referrible at its commencement to no par-
ticular region of the abdomen ; but as frequently
the patient refers his sufferings to a particular
part, — sometimes to the ileo-cascal region, occa-
* Professor , of Berlin, during his visit lo London,
was attacked the day after dining with a party of scientific
men, when tie sat with li is hack to a large tire. I was called
to him, and found him in tin: utmost agony, with a pulse of
natural frequency, his abdomen tense, tympanitic, and sub-
setjuentlv tender to the touch. What he vomited at first
consisted of half digested substances ; subsequently it was
mixed with natters which had apparently roine from the
upper part of the small intestines. Calomel and opium were
administered, and oleaginous encmata repeatedly thrown up,
A flexible Imuiie was introduced it h whole length, and large
glytters were injected without difficulty ; but the latter were
returned soon after without any effect, The abdomen in-
creased in site: mental distress and debility became ex-
treme; the matters rejected by the mouth were more ob-
nnu-lv feculent; hiccup and leipothvmia appeared, and he
died in two days. Au examination was not permitted. The
character, of the atiack so-i.-e-.tecl the idea of a paralysed
*tate of the bowels, sritb inverted action of theii uppei portion,
gradually extending downwards. The ..ri-in of the suffer-
ings was not referred to any particular part of the abdomen,
nor had any obstruction been previously complained of.
sionally to the situation of the sigmoid flexure of
the colon ; in some cases, in the course of the
right or transverse colon ; in others, above or
about the umbilicus, or low in the iliac and pubic
regions. In till such cases, we nitty suspect me-
chanical obstruction arising from some one or
other of the following causes, which have been
repeatedly discovered on dissection : —
37. Changes observed in fatal cases. — 1. Great
distension, as if from paralysis of the muscular
coat of ;i large portion of the small intestines,
without inflammation or any other change. 2.
Dilatation, with a cord-like contraction, in either
the small intestines, or in the large ; more fre-
quently the latter. 3. Dilatation, with inflamma-
tion, lividity, and exudation of lymph on the
serous suffice. 4. This latter state, conjoined
with gangrene, and either with or without exuda-
tion, occurring in the small or large intestines ;
more frequently in the former. 5. These changes
combined with contractions, — occasionally only
one, often more, the intervening parts being dilat-
ed,— in some part of the bowels. 6. Unnatural
convolutions, twists, loops, or knots, in some part
of the small intestines. 7. Various convolutions,
or duplicatures, or twistings in the large bowel,
with an appearance of elongation owing to re-
laxation or paralysis of the longitudinal bands of
muscular fibres. 8. These latter, conjoined with
recent or old cellular adhesions of the opposing
serous surfaces of the duplicated portions. 9. One
or more introsusceptions ; the introsuscepted por-
tion being either in a downward or upward direc-
tion, sometimes uninliamed, as in infants and chil-
dren; frequently inflamed, adherent by lymph, or
gangrenous, particularly in adults ; and occurring
in any part of the intestinal tube. 10. Old adhe-
sions of one part of the small or huge intestines
to another, or to the parietes of the abdomen, or
to the omentum, or some other viscus, without
obstruction of the canal. 11. Similar adhesions
occurring in reduced or old hernia?, or in hernia?
for which an operation had been performed and
the bowel returned. 12. Filamentous or cellular
bands confining or encircling a portion of intes-
tine, sometimes after reduction of hernia, occa-
sionally in a large and irreducible hernia, and even
where no hernia had existed (Garihshork,
Mokeau, Moscati, Walther, Abercrom-
bie, myself, and others.) 13. Adhesions of the
appendix of the caecum to some part, after pass-
ing over or around, and strangulating a portion
of intestine. (See art. CjE cum.) 14. Strangula-
tion of a portion of one side of the intestine in the
femoral arch, without producing any tumour, and
without obliterating, or even sensibly diminishing
the canal of the bowel.* 15. Various states and
forms of internal strangulation, often produced by
old adhesions formed between opposing portions
of the serous surface, more commonly low in, or
about the middle of the abdomen, — by portions
of omentum, — by rents in the omentum, through
which a portion of intestine had passed, and by
various adhesions, obstructions, and changes iu
the position of parts of the bowels. 16. Stran-
gulation iu the mesentery, owing to partial adhe-
sions (Swammf.rdam). 17. Various states of
contraction in the small and large intestines from
* This occurred in a female servant of the author, who
was siczed with ileus, without any antecedent disorder.
368
COLIC AND ILEUS — History, &c. of.
organic changes in their coats, more particularly
about the cacum, sigmoid flexure of the colon and
rectum, as scirrhus, fungus, soft cancer, &c. (De
Haen, Khan, Hodges, Thomann, How-
ship, Auh.ESI.ey, Abkrcrombik, Travers,
&c.). 1^. Internal polypous or malignant excres-
cences, or external diverticula (Portal, Clo-
quet, Copland, Hutchison, &c). 19. Ob-
structions of the canal of some part by biliary and
intestinal concretions, stones of fruit, bones, in-
durated faxes, and balls of worms. 20. The
pressure of encysted or other tumours, abscesses,
&c. in the pancreas, kidneys, omentum, uterus,
ovaria,* or between these latter and the rectum.
21. And lastly, The circumstance of ileus being
produced by hernia?, both of the more common
kinds, and of those that are uncommon, as hernia
of the ischiadic notch, diaphragmatic hernia, &c,
should not be overlooked. Of these, and even of
other internal changes productive of ileus, nu-
merous instances are to be found in the works to
which I have referred at the end of this article, at
the places pointed out. (See also articles Cecum,
Colon, Constipation, Digestive Canal,
Intestines, &c.)
38. Of Volvulus, or Ileus arising from intus-
susception.— a. The invagination of one or more
portions of intestine is not infrequently met with
in post mortem examinations; and on some occa-
sions its existence may be known during the life
of the patient. The number of intus-suscepted
portions may vary from one to ten ; the greater
number being most frequently met with in chil-
dren, amongst whom invagination is also most
common. In this class of patients it is frequently
unconnected with any marks of inflammation ;
and, from the healthy appearance of the part thus
affected, and the facility with which the invagina-
ted portion is replaced, it seems probable that in-
tus-susception has taken place, either very shortly
before, or at the period of death. In the majori-
ty of instances it is an accidental consequence of
pre-existing disease, most frequently of the intes-
tinal canal, arising from an irregular action of the
muscular tunics, occasioned by irritation of the
mucous surface. Thus worms have been found
in or near the invaginated part : and in adults it is
generally observed in connection with inflamma-
tory action of some one of the intestinal surfaces;
and as a consequence of dysentery and chronic
diarrhoea, particularly the dysentery of warm cli-
mates ; a considerable number of the dissections
which Mr. Annesley made in this disease in the
East Indies presenting one or more invaginations,
commonly in the small intestines. I have also
not infrequently found it in fatal cases of inflam-
mation of the brain, or its membranes, in children.
Although generally a fatal occurrence, intus-sus-
ception is not necessarily such. 1 believe that it
sometimes occurs in infants, without being pro-
duced or followed by inflammation ; gives rise to
symptoms of ileus, or merely to slight colic ; and,
either with or without the aid of medicine, some-
* A lady, to whom I was called, had inflammation of the
uterus, and an abscess formed between the upper part of the
vagiaa and rectum, pressing upon the latter so as to prevent
the evacuation of the bowels and injection of glvstcrs. Colic,
followed by ileus, took place. During an attempt to throw
up as enema, by passing a male catheter up the rectum, the
abscess burst into the rectum, and a large quantity of pure
pus, followed by copious feculent motions, cauie away, when
all the dangerous symptoms disappeared.
times is restored to its natural position. In adults,
however, even when it occurs without pre-existing
inflammation, it almost always causes the most
acute inflammatory action, often terminating in
the accretion of parts, or in gangrene, chiefly
owing to the strangulation of the invaginated part.
Many cases, however, terminate fatally before
sphacelation takes place ; whilst in others, gan-
grene occurs during life, and the invaginated part
passes off by stool ; union of the opposing ex-
tremities of intestine formed by the separation of
the dead invaginated part, and the ultimate re-
covery of the patient sometimes being the result.
39. One of the most common causes of inva-
gination of the intestines is the inappropriate use
of drastic purgatives. In all the cases of inva-
gination observed after death from dysentery, that
I have perused, purgatives had been tmsparingly
and unnecessarily exhibited. M. J. Cloqiit
has published a case, wherein a female died of
enteritis consequent upon invagination of about
fourteen inches of the ileum, occasioned by a
polypous excrescence arising from the mucous
surface, and which, having been pushed onwards
by the peristaltic action of the intestine, had drag-
ged the part to which it was attached along with
it. Costiveness is often a prelude to this change,
hardened faeces, &c, producing local irritation.
Intus-susceptions are most frequently downwards,
and but rarely upwards. Dr. Monro thinks that
an inverted .action of the bowels is requisite to
the production of the latter. They are most
common at the termination of the ileum in the
caput caecum. The quantity of intestine that
passes within the other varies from one to thirty
inches, or even more. In an infant, to the ex-
amination of which I accompanied Mr. Alcock,
nearly the latter extent, including the ileum,
caecum, and ascending colon, was invaginated.
In some rare instances, the ileum, caecum, as-
cending and transverse colon, passes into the sig-
moid flexure, or even as low as the rectum ; or
the caecum and colon only (Whatkly, Monro,
&c). I have met with two or three such cases
in infants and children. In rarer instances, a
portion of the colon and ileum has passed out at
the anus.
40. Diagnosis. — Is it possible to distinguish
volvulus or ileus owing to intus-susception. from
colic or ileus arising from other pathological
states? I think that symptoms may present
themselves, which will, in some instances, lead
the observing practitioner to infer the existence
of invagination. The sudden invasion of the
symptoms of severe colic or ileus after a violent
straining at stool ; and, subsequently, the con-
stant desire to go to stool, attempts at evacuation
being accompanied with violent tormina and te-
nesmus, and either unattended by evacuation, or
followed by the discharge of a little bloody mu-
cus, and these by symptoms of enteritis ; are
amongst the most constant concomitants of inva-
gination. In some instances, also, the sudden oc-
currence of an elongated tumour, in addition to
these symptoms, and before abdominal distension
comes on, will further guide the opinion ; particu-
larly if the invagination be extensive, and seated
in the caecum or course of the colon. Much will,
however, depend upon the precision and tact with
which an examination of the abdomen is made.
In all such cases, the rectum should be examined
COLIC — Sympathetic and Complicated Forms of.
369
the finger; and the extort to which enemata may
be thrown Op Observed as BO additional means of
information; for whenever the intus-susception is
in the colon, as much fluid cannot be thrown up
as in health. Hiccup and a small irregular pulse
characterise the advanced disease, and indicate
the existence of inflammatory action in the in-
vaginated bowel. When a portion of intestine is
discharged by stool (as is rarely the case, the
patient even recovering and enjoying health after-
wards), there can be no doubt of the nature of the
malady. Dr. Mc>nro mentions an instance of
double intus-susception, or intus-susception of the
invaginated part, communicated to him by Mr.
A. Burrs. I once met with such an occurrence
in a child a few months old.
4). III. Of the Sympathetic and Com-
plicated Forms of Colic ; or, Colic
owing to morbid States of associated
Viscera. — Colic, in one or other of the forms
already described, but most commonly in its lirst
or simple state (§ 5. et seq.) is not infrequently
caused by some other disease. Many of the au-
thors of the last two centuries, and several con-
temporary Continental writers, have treated of
colic when thus originating or associated as essen-
tial forms of the complaint. Although obviously
only a symptom, or, at most, a part, of an im-
portant and often extensive disease, it is not the
less deserving of notice when thus associated. It
cannot be a matter of surprise, when we consider
the relations subsisting between the different ab-
dominal viscera, by means of the ganglial system
of nerves distributed to them and influencing their
functions, that disease of one of these will often
change the sensibility and functions of the ali-
mentary canal, with which it is more or less
intimately connected in respect both of organi-
zation and function. As it is useful to be aware
of the various morbid associations of colic, I shall
notice such as are most commonly met with in
practice, with reference to the authorities who have
considered them as distinct forms of the disease.
42. A. Sennert, Kindler, Walter,
Detharding, Bonk, Tissot, Sauvages,
anil Schmidtmann, have noticed an inflamma-
tory colic; which, however, in no respect differs
from inflammation of the bowels either in an
acute, sub-acute, or chronic form. Colic often
rapidly passes into enteritis, and occasionally into
dysentery ; and, chiefly from this circumstance,
together with the more phlogistic nature of the
attack, and the abdominal tenderness, Cdllen
and Good also have distinguished a variety of
the disease by the term inflammatory. In many
cases, also, of chronic, sub-acute, or septic pe-
ritonitis, the muscular tunics of the intestines are
paralysed, and their canal distended by flatus ;
the colicky symptoms predominating over and
masking the inflammatory action. Hence chronic
peritonitis has been often confounded with colic,
as I demonstrated in a memoir on that disease
published many years ago ; but, in such cases,
the colic is merely a symptom.
43. B. Hoffmann and Schmidtmann have
distinguished a species of colic, by the term pleth-
orica or sanguinea, comprising under it the
varieties arising — a. from pregnancy : b. from
diflicult or suppressed menstruation (the CoHea
Memlrualis of various writers) ; c. from sup-
pression of the lochia ; d. from congestion or
inflammation of the uterus (C. Uterina, Auct.
var.); and e. from hemorrhoids (C. hamor-
rhoidalis of Alberti, Hoffmann, Nk.kf.l,
R.AN06, and \l\\ f.) That colic is often asso-
ciated with these affections, or is occasioned by
them, there can be no doubt ; but it is unneces-
sary to dignify these varied states of disorder, by
arranging them as distinct forms of this disease.
It is sufficient to notice them, so as to inform the
inexperienced practitioner as to their occasional
occurrence, and the importance of attending to the
connection in practice , more particularly as they
require a modified treatment for their removal.
44. C. Colic also frequently is an attendant
upon acute, sub-acute, and chronic diseases of
the liver, gall-bladder , and ducts; and, more es-
pecially, upon the passage of gall-stones through
the common duct. In such cases, the colic is
not infrequently associated with jaundice. This
connection of the complaint has been fully illus-
trated by Baillou, Vogel, Lieutaud, Pro-
chaska, Soemmerring, Wandeler, Wit-
ting, Conradi, &c. and should not be over-
looked. (See art. Concretions — Biliary.) In
such cases, the fixed pain in the right epigastrium
and hypochondrium, extending to the back, and
right shoulder-blade or shoulder, in addition to
the abdominal colicky pains, vomiting, and cos-
tiveness, with or without jaundice, will assist the
diagnosis. Some authors have likewise noticed
the connection between colic and disease of the
pancreas. That the latter will sometimes occasion
the former cannot be doubted : but the difficulty
of ascertaining the connection during life is great;
more particularly as functional disorder of the
duodenum, so generally present in almost all
cases of colic, is readily mistaken for disease of
the pancreas. (See arts. Duodenum, and Pan-
creas.)
45. D. The occasional dependence of colicky
affections upon inflammation or other morbid
states of the kidney, and upon the irritation of
calculi in this organ, its pelvis, or ureter, has
been long known. Such complications have oc-
curred to every practitioner, and have been par-
ticularly noticed by Horstius, Martius, Piso,
Freytag, and Cruchet: they are most fre-
quently met with in goutv and dyspeptic subjects,
and persons advanced in life.
4(>. E. a. The frequent and obvious connection
of colicky affections with worms, particularly in
children and young persons, requires no further
remark than that, although the former is merely
a symptom of the latter, both obviously originate
in debility of the digestive functions, b. The
occurrence of colic in the gouty and rheumatic
diathesis, during the more erratic and irregular
forms of these affections, and after the disappear-
ance or retrocession of them from an external
part, has been so often observed, that many
systematic writers have particularised a Colica
Arthritica (Hoffmann, Musgrave, Stoll,
H.vNii, Brandis, Reich, Schmidtm ann, &c.)i
and a C Rheumatica (Haller, Stoll, Eyer-
el, Lentin, l!\.soe, Thorn, &c). c. The
frequent appearance, also, of this affection in
hysterical females, or associated with hysteria, is
well known, and chiefly deserving of notice as
respects the treatment : the intimate connection
of both disorders with morbid sensibility of the
organic nerves, and increased mobility of muscular
370
COLIC AND ILEUS — Remarks on their Pathology.
parts influenced by them, and the not infrequent
dependence of them both ou congestion of the
uterine organs, are too obvious to require illus-
tration, d. Flatulent colic is often consequent
upon, and complicated with, asthma and bron-
chorrhcea ; owing to the impeded function of
respiration in these diseases, and the discharge
of gaseous fluids from the blood by the digestive
mucous surface ; and, when it occurs in such
cases, it aggravates the original complaint, e.
The only other complication of colic, which may
be mentioned, is its occurrence with, or even
after the disappearance of, eruptive complaints ,
and in connection with scorbutic and chronic
affections of the skin. This association has
been noticed by Haller, Sigaud la Fond,
Schmidtmann, and others; and has been term-
ed by some writers, Colica Metastatica. It is
probable that, in such cases, a sub-acute or chronic
inflammation of some part of the intestines takes
place consecutively of the primary affection, the
colic being merely a symptom of the inflamma-
tory state. But we should recollect that, in all
affections of the skin, the digestive mucous sur-
face is more or less irritated or otherwise affected,
and the allied functions disordered; and that an
increase of such disorders may both change the
state of the cutaneous eruption, and give rise to
severe colic.
47. General Remarks on the Pathol-
ogy of Colic and Ileus. — A. The remote
causes of colic. Many of these have been par-
ticularised when describing the different forms of
the disease; a few only require to be enumerated.
The more common of these are cold applied to
the abdomen, loins, or feet; exposing the back to
the strong heat of a fire; acrid, cold, indigestible
esculents; cold fluids taken when the body is
overheated; solid bodies accidentally or otherwise
taken, that admit not of solution or change by the
juices in the prima via ; irritating or poisonous sub-
stances, and the injudicious use of acrid or drastic
purgatives, particularly hellebore, scammony, and
colocynth : the violent passions and emotions of
the mind, as terror, anger, &c. (See § 12. et cet.)
48. B. Remarks as to diagnosis and prognosis.
■ — An important point connected with the nature
of the disease, and one which Dr. Abercrombie
appears to have fully made out, is the fact of its
sometimes being fatal with no other morbid ap-
pearance than great and uniform distension of
the bowels, a. There can be no doubt that this
state will of itself— without any inflammatory
action — give rise to tenderness and tension of the
abdomen, and thus simulate inflammation, with
which, however, it is very often accompanied ;
and into which sudden distension of the bowels
is very apt to terminate. 6. Although ileus is
generally the result of obstruction of the canal of
the bowels, it is not necessarily so : for in fatal
cases of both Madrid and lead colic, as well as
in several of ileus itself recorded by Dr. Aber-
crombie and other authors already referred to,
no obstruction was found on dissection. The cases
recorded by Barthkz and Maxwell also show
the propriety of not losing sight of this fact in the
treatment of the disease, c. Sudden cessation of
pain, and sinking of the vital energies, are not
necessarily evidence of the accession of gangrene;
for they have occurred in fatal cases of colic and
ileus, where no inflammatory action and no gan-
grene were detected; and, in some few instances,
recovery has followed; and, on the other hand,
as Dr. Abercrombie has remarked, extensive
gangrene has been observed in cases where the
pain was violent to the last. These facts con-
firm an opinion which I had given many years
since, that the symptoms often referred to internal
gangrene do not prove its accession, but the ex-
haustion of vital power, and of the sensibility of
the organic nervous system ; and that a great
proportion of the instances of sphacelation found
upon dissection did not exist previous to dissolu-
tion, but accompanied or followed the fatal issue.
d. The pulse is often a most fallacious guide in
every form of colic and ileus; fatal cases some-
times occur, in which the pulse, till within a
few hours of dissolution, does not rise above the
natural frequency; and in some cases in which
there is no inflammatory action, the pulse is
frequent throughout, c. Although faeculent evac-
uations are amongst the most favorable indications
in the disease, they are not to be implicitly relied
upon; for, when the disease is in the small in-
testines, much faeculent matter may have ac-
cumulated in the ca?cum and colon, which may
be brought away by injections without the af-
fected part being benefited. The subsidence of
the more urgent symptoms after the discharge
of fseculent motions is the only sure ground of
a favourable prognosis, f. Though the organic
changes I have enumerated (§ 37.), often pro-
duce colic or ileus, they do not necessarily do so;
for gradual exhaustion of the organic functions,
and of life itself, without colic, may be the result.
They may also exist for a long time without
sensibly interrupting the functions of the bowels,
until some concurrent or determining cause occurs,
and suddenly developes the disease in its worst
forms, g. The existence of spasm in some part
of the intestines, so much insisted upon by writers
as the cause of various states of simple, Madrid.,
and lead colic, as well as of volvulus, is evidently
of less frequent occurrence than is supposed.
Although I would by no means disallow its ex-
istence, and cannot admit, with Dr. Aber-
crombie, that the cord-like constriction of a
portion of intestines frequently observed is its
natural state, as in the case of the urinary bladder,
yet it must be admitted that several symptoms,
which have usually been referred to spasm, are
actually owing to flatulent dilatation. Spasmodic
constriction, however, evidently exists; for, in-
dependently of the occasional detection, after
death, of a more constricted state of a part of
a bowel than can be considered natural, we
cannot explain various phenomena connected
with colic and volvulus without its aid. Besides,
its existence is supported by analogical evidence;
for it is a principle in the human economy, that
all membranous, and, d fortiori, all muscular,
canals contract spasmodically or inordinately
upon irritation of their internal surfaces, h. In
lead colic, the last or more dangerous symp-
toms, whether of the complete form of ileus
or not, are certainly more unequivocallv at-
tended with inordinate distension, particularly of
the colon, than with constriction, even although
the sphincter ani may be at the time spasmodi-
cally contracted. «. From the foregoing facts,
the reader may infer that the diagnosis between
colic and inflammation cannot be stated with
COLIC — Treatment of its Simple States.
371
precision, as there is no one symptom that can be
relied upon, — Tor inflammation with its conse-
quences may exist, and yel the abdomen may not
be painful on pressure. But it is from the man-
ner oi their association, and, still more, upon
numerous minute circumstances, — some not ad-
mitting of satisfactory description, others of only
casual occurrence,— and upon the age, employ-
ment, constitution, and habits of the patient, us
well as from the operation of remedies, that we
are to form our inferences both as to the diagno-
sis, and as to the result.
49. Treatment ok the different Spe-
cies and Varieties of Colic. — I. Of the
Colic DEPENDING chiefly on functional
lhsoRUK.K. As soon as a practitioner sees a pa-
tient in colic, his first object is to ascertain whether
or not there be strangulated or incarcerated hernia,
or either tension, tumefaction, or retraction, of the
abdomen, 01 circumscribed tumour or hardness in
any part of it, or in its immediate vicinity. By
the knowledge thus acquired, as well as by the
information he may derive as to the cause and
history of the complaint, lie will be much assisted
in devising an appropriate mode of cure.
60. i. Treatment of the simple forms of colic.
(§ 5.). — We have seen that these states of colic
chielly depend upon debility, or deficient vital
enemy of the alimentary canal, giving rise to
altered sensibility of the organic nerves supplying
it, to imperfect or irregular action of its muscular
coat, and to interrupted or morbid secretion from
i's mucous surface and associated viscera. These
states of disorder are to be removed, 1st, by
anodynes combined with stimulants and cordials,
which will generally calm the more urgent s\ mp-
toms; 2d, by purgatives and enetnata directed so
as to excite the secretions, and evacuate retained
excretions; and, 3d, by gentle tonics and cordials,
in order to remove debility and promote the di-
gestive actions; all the causes likely to reproduce
the disease being carefully avoided.
51. A. Such stimulants as are most anti-
spasmodic, and carminative in their action, judi-
ciously combined with anodynes, and assisted in
their operation by frictions of the abdomen with
suitable sedative liniments, or by fomentations,
may be first employed. Formula'. 178. 1ST. 211.
377. S35. in the Appendix, or the following, will
generally remove the painful symptoms : —
No. 133. 1! Aa. Menth. Virid. " x. ; Spirit. Pimento;
-;.. Ani-i) t j. ; Tinct. Hvoscyami -, sa.; Confect.
Opii zr. \. M. Kin Hamtus itatim sumendua. Or,
_V> 134, R Aq. Piinentae ~ \. ; Tinct. Camphor. Comp.
" j-. ; Spirit. Mvrysiicae, Spir. C.irui, aa ", St.; Confect.
Aromat, trr. x. Fiat H.iusius statin) capiendus, el pro re
nata repetendus.
50. 135. R Camphors" rasae ", j. : terc rum 01. Amyg-
dal. 5 --., el adde 01. Lioi % j. ; Tinct. Opii 5 ij ; 01.
Rosmarini 5 "• M- F'1' Linimenhun, cum quo ulinalur
abdomen a«idue urgenle flalii aut dolore.
If the simple colic evince nervous or hysterical
characters, the preparations of valerian, the spirit.
amnion, foetid., kc may be given or added to the
above, [f these afford not immediate relief, it will
be more judicious to have recourse to laxative,
oleaginous, and antispasmodic enemata, than to
persist in their exhibition. Any of the formulae
in the Appendix suitable to the circumstances of
the case may be directed; or the warm balsams,
betida, the terebinthinates, the oil or extract
of rue, and infusion of valerian, may be employed
in this manner, along with the oleum oliva?, or
oleum lini, or any demulcent decoction. When
the complaint assumes the flatulent form, tho
warm spices, or their oils, triturated with magne-
sia or sugar, may be prescribed, or added to the
above formula'.
52. B. Having relieved the more urgent symp-
toms in this wav, — an indication the more requi-
site in the spasmodic state (§9.) of simple colic,
and often requiring a freer use of the narcotics
and .antispasmodics than is specified above, — it
will be necessary to act upon the bowels by pur-
gatives given by the mouth. In most cases, a
full dose of calomel, or of blue pill, is least likely
to offend the stomach, whilst it is the most bene-
ficial in its operation upon the suspended secre-
tions: it will be advantageously followed in a few
hours by a dose of castor oil, with a few drops of
tinct. opii. or tinct. hyoscyami; or by the decoc-
tuni aloes comp. with the subcarbonate of soda,
the tinct. of hyoscyamus and compound tincture
of cardamoms, either of which may be repeated,
if necessary, and its operation promoted by the
enemata already particularised.
53. C. Having evacuated the bowels, the next
object is to restore the energy of the digestive
organs, and to promote the abdominal secretions.
This may be done by a course of mineral waters.
as the Harrogate, the Tunbridge, the Bath, the
chalybeate Cheltenham waters, or the artificial
waters of Pyrmont, Carlsbad, Ems, &c, and by a
judicious combination of gentle tonics with laxa-
tives and the-alkaline carbonates, according to the
peculiarities of the case; the blue pill, or Plom-
mer's pill, with soap, being also occasionally
given at bed-time. Sydenham recommended
the Peruvian balsam, to restore the digestive func-
tions, and prevent a return of the disorder; and
certainly there are few substances better suited
for the purpose than it, when judiciously exhibited,
or combined with other medicines.
54. If we find the foregoing means fail of af-
fording verv marked relief, we should suspect
either some degree of latent inflammatory action
or a disposition of the complaint to pass into this
state; and unfortunately inflammation of the bowels
may proceed to a dangerous extent, without either
the state of the skin, or of the pulse — without
any febrile symptom — indicating its existence.
This topic should not be overlooked by the young
practitioner. Morgagni, Rivkrius, Simson,
1)f. Haen, Bursf.ri, Schmidtma.nn, and
Abercrombie, have demonstrated — and my
experience has frequently confirmed their observa-
tions— not only that enteritis will often assume,
during the greater part of its progress, all the
symptoms of simple colic, but that the complaint
may run its course;, until the sudden cessation of
the painful symptoms, without any evident cause,
furnishes the first evidence both of pre-existing
inflammation and of incipient gangrene. On this
and other accounts, therefore, we should endea-
vour, in all the states of this variety of colic, to
ascertain the existence or non-existence of in-
flammatory action, or even vascular erithism in
some part of the alimentary canal. If this dis-
order exist, the tongue will generally be red at
its point or sides, and furred or loaded in the
middle; the urine will he small in quantity, or
high colored: cardialgia will s times be corn-
plained of; and if tenderness on pressure be felt,
372
COLIC — Treatment of Bilious, &c.
it will cither be independent of any marked dis-
tension of the abdomen, or it will be attended
with tension and fulness, anxiety, a dark or dusky
appearance about the eyes and mouth, and with
thirst. Under these circumstances especially,
and in the more severe attacks, particularly in
the spasmodic, occurring in persons previously
in health, blood-letting should not be omitted;
and even in doubtful cases, blood may be taken
either from the arm, or from the abdomen by
cupping or leeches, followed by fomentations
and poultices, — if there be tumefaction, by the
warm turpentine fomentation and injection.
Heating carminatives and antispasmodics will
be injurious in all such cases, whether vomiting
be present or not; and too active endeavours to
procure alvine evacuations by means of purga-
tives given by the mouth may increase the dis-
order. I have derived more advantage in these
cases from small and repeated doses of the sub-
carbonate of soda, or the sub-borate of soda, with
nitre, in camphor mixture or some aromatic water
— from the use of enemata and gentle frictions of
the surface of the abdomen with a rubefacient lini-
ment (F. 311. 313.) — than from purgatives. In a
few cases I have given the hydrocyanic acid, either
in full doses of the oleum ricini, or in the oleum
amygdal. dulcis. When judiciously prescribed,
this" powerful sedative has a most beneficial effect
in restoring the digestive functions after the attack-
is removed. The hydrargyrum cum creta, or the
blue pill, with taraxacum, hyoscyamus, or extract
of hop, may also be given after the action of the
bowels is restored.
55. ii. Treatment of colic from injurious in-
gesta, fyc. (§ 10.) — a. The state of disorder
proceeding from cold acid beverages will gene-
rally be soon removed by antacids, combined with
narcotics, as ammonia, soda, magnesia, &c. given
with opium, or hyoscyamus, and with cordials or
carminatives (F. 179. 347, 348.); enemata and
frictions of the abdomen, as already recommended
(§ 51.) may be also employed, according to the
circumstances of the case. 6. When the affec-
tion is occasioned by cold, acerb, or indigestible
fruit or food, it will generally be necessary to
commence the treatment by an active warm
emetic; and afterwards cordials, cardiacs, and
enemata (§ 51, 52.), may be prescribed, c. If
the complaint be produced by fish, Cayenne pep-
per is an almost unfailing antidote, d. If it be
occasioned by smoked or tainted meat, or other
esculents that have disagreed with the digestive
organs, emetics, and afterwards cordials, warm
aromatics, and stimulating clysters, with frictions
of the abdomen, are among the most successful
means, e. Colic sometimes is a consequence of
indigestion, and of acidity or sordes in the digestive
tube, often occasioned by too much or indigestible
food; it then requires a combination of antacids
with aperients or purgatives, as the compound de-
coction of aloes, or the compound infusions of
gentian and senna, with soda and ammonia. Af-
ter the urgent symptoms are removed, the digest-
ive functions should be strengthened and promot-
ed by gentle tonics and deobstruent laxatives (F.
214. 218. 362. 872.). Richtkr recommends
for this purpose equal parts of assafcetida and the
fel tauri inspiamtum, especially in the form of
the complaint, proceeding from acidity.
56. The colic of infants has been stated to
proceed chiefly from acidity of the prima via
occasioned by the quality or quantity of the in-
gesta (§ 15.). The sub-carbonates "of the alka-
lies, magnesia, and the preparations of chalk or
lime, with carminatives and cordials, are there-
fore required. (See F. 616, 633.) A combi-
nation of magnesia with the oxide of zinc is pre-
scribed by Richter. Magnesia, soda, or am-
monia, in the aqua fceniculi dulcis or aq. anisi,
and afterwards a dose of fresh castor oil ; the
semicupium, and, if it be requisite, an emollient
or oleaginous enema, to which a little extractum
rutae, olei anisi, or tincture of assafcetida, has been
added, will generally remove all disorder. If,
however, these do not soon give relief, the enema
should be repeated, and the abdomen rubbed with
an antispasmodic liniment (§ 51, R 135.). If
the complaint occur about the period of dentition,
the gums ought to be examined, and scarified, if
any fulness or redness be remarked in them. If
these means fail, those recommended in the sec-
tion on volvulus (§ 77. et seq.) must be put in
practice.
57. iii. Treatment of colic from morbid secre-
tion, fyc. — A. The colic occurring in new-born
infants, from retention of the meconium, is gene-
rally soon removed by a dose of castor oil; and,
if it fail, by an oleaginous clyster, or by one con-
taining a tea-spoonful of honey and another of
common salt, assisted by the semicupium, and the
means stated above (§ 56.). B. Colic from ac-
cumulation of f cecal matters,' (§ 19.), or from
constipation of the bowels, obviously requires
purgatives and oleaginous or saponaceous injec-
tions. Stoll prescribed emetics in this form of
the complaint, and was followed in the practice
by Sims and Hosack ; Rivf.rius gave rhu-
barb and the turpentines ; and Baglivi and
Sydenham advised cathartics and anodynes in
oleaginous emulsions. The preparations of sul-
phur, in doses sufficient to act on the bowels,
have been praised by Agricola and Rave; and
frictions and bandages of the abdomen have been
recommended by many eminent writers. In this
form of the disease, more advantage will be ob-
tained from the repeated exhibition of medicines
of a simply relaxing operation (see F. 82. 96.
430.), assisted by large oleaginous and sapona-
ceous injections in the manner recommended by
Dr. .Maxwell (see § 77.), than by cathartics,
which may irritate or inflame the upper parts of
the digestive canal, before they can reach or
affect the parts where obstruction exists. Spirits
of" turpentine, with olive or castor oil, when per-
fectly diffused and suspended in a suitable ve-
hicle, are extremely efficacious in this state of
disorder. An ounce of the spirits, with two or
three of either of these oils, in about sixteen or
twenty-four ounces of a mucilaginous decoction,
should be slowly but steadily thrown up by
means of the enema apparatus, the pipe of
which may be provided with a guard, to prevent
the regurgitation of the fluid. In order to facili-
tate the passage of this enema along the colon,
the patient may be placed in bed, with the pelvis
considerably elevated, and friction of the abdo-
men may be employed during and after the in-
jection of it. If there be no nausea, the following
may be taken, and repeated in six or eight hours,
if it be requisite : —
No. 136. ]\ Fotassa? Supertart. in pulv. 5 j55- — 3 'j.
COLIC FROM LEAD — Treatment of.
373
Majnc*. Oalcinat ", »«. ! Contact. Scam el Syrup. Zingi-
I ii- .1.1 J ij. . Old Ani«i TT) iij. JVI . Fiat Kir. murium.
[f nausea be complained of, a full dose of calomel
only may be exhibited ; and. after a few hours,
the above electuary given, and the injection re-
peated; or the treatment recommended in the
article Cohstipa mob may be adopted. If ten-
fornftfffl and tension of the abdomen, with hard,
constricted, oppressed, or quick pulse, be present,
inflammation should he suspected, particularly if
vomiting also exist. In this case blood-letting
must he practised, and the disease treated in all
respects as stated in the articles on Inflammation
of the Intestines and Peritoneum:
5S. C. The West Indian and Madrid colics
(§ 20.). — a. Dr. Mi1 so rave, whose experience
of Weal India colic has hern extensive, recom-
mends ten or fifteen grains of calomel to be
exhibited immediately, and afterwards live grains
combined with a cathartic. He likewise advises
a dOse of ;i purgative mixture to be given in the
intervals, if the stomach will retain it. The in-
tentions ibis physician proposes are to evacuate
the bowels, and to affect the system with mer-
cury. As soon as the mouth becomes affected,
the calomel should be omitted, and alvine dis-
charges promoted. When the spasmodic action
of the bowels is severe, and signs of vascular ex-
citement appear, blood-letting ought to be prac-
tised ; this evacuation tending both to relax the
bowels, and to promote the absorption of the calo-
mel. In addition to these means, the warm bath,
and terebinthinate eoemata, should be employed.
5.'). b. The Madrid colic (§ 20.).— M. Mar-
q i a n n states that an emetic given at the very
commencement of the attack is sometimes of use,
by evacuating retained bile ; but that it may be
prejudicial, particularly if exhibited in an ad-
vanced period of the complaint. He recom-
mend-:, as the safest and most successful practice,
1st, to calm existing irritation by opiates; and,
2d, to restore alvine evacuations. He prescribes
a grain of opium every three hours till relief is
obtained, which is usually the case after the third
or fourth dose. I le afterwards exhibits purgatives,
and promotes their operation by glysters, which
generally bring away copious blackish and offen-
sive stools. The Spanish physicians have com-
nioiilv recourse to the oleum ricini as a purgative
in this complaint, but M. Ma.ro.cand prefers
scammony and jalap, as being, in bis judgment,
more certain and quick in their operation. This
treatment is the same as that long since recom-
mended by .Mr. Q.UIER, in the dry belly-ache of
the West Indies.
60. iv. Treatment of lead colic (§ 25.). — In
this variety of the complaint, as well as in those
forms which have received the denomination of
Madrid, West Indian, or hepatic colic, the hepatic
ducts and gall-bladder tire obviously obstructed
or loaded by morbid bile ; the irritation caused
by which most probably occasions spasm of the
common duct, duodenum, and pints in the vi-
cinity, in the early stages of the disease. Very
different, and even opposite, modes of treatment
have been recommended in lead colic, a. Blood-
letting has been directed by Calhette, \--
TRUC, ChRISTISON, and GREGORY ; whilst
other writer-, as Dubois and DueRESN] . licv
considered it either unnecessary or injurious. I
have prescribed it in some cases with manifest
32
advantage, the state of vascular action evidently
indicating the propriety of resorting to it J but, in
others that I have seen, it obviously would have
been injurious. When the fice is flushed, the
skin hot, and the pulse full or accelerated, it is
both safe and requisite. l>. The use of opium has
the support of the ablest writers on the disease —
of Grashuis, Riedlin, Stoll, Schlegel,
Reynolds, Baker, Adair, Eyerel, War-
ren, Wolff, De Haen, and Gendron; but
they are not agreed as to the period of exhibiting
it. Sir G. Baker commenced with purgatives,
whilst De Haen, Darwin, Warren, and
Bateman began with opium, and gave purga-
tives afterwards. Dr. Pemberton advised a
combination of both — of laudanum with castor
oil. It appears to me preferable to combine
the first dose or two of opium with calomel, as
recommended by Burger, particularly if the
functions of the liver be obviously affected, as
they often are, and if the stomach be irritable, as
it generally is in the advanced state of the disease.
But the dose of calomel should be large (from 10
to 20 grains), and not repeated oftener than once
or twice. This combination will frequently of
itself open the bowels; but whether it does so or
not, purgatives ought to be exhibited, and their
operation promoted.
61. c. As to the propriety of having recourse
to this class of medicines, there is no difference
of opinion, however much sentiments may vary
as to the choice which should be made of them.
Grashuis, Mosf.lv, Fischer, Friese, and
Odier, prefer the oleum ricini. Burger ad-
vises it to be given with manna; Eyerel, after
blood-letting, with emollients and opium ; and
Tissot in clysters. Several writers prefer the
combination of anti-spasmodics and sedatives with
purgatives, on the supposition that the obstruction
of the bowels attendant on the disease arises
from spasm in some part of them. But, as Dr.
Cheyne and Dr. Abercrombie have justly
contended, it is quite as much owing to distension,
from a paralytic state of the muscular coat, that
the obstruction occurs, as to spasmodic constric-
tion. According to this view, little benefit can
result, as respects the operation of cathartics,
from combining them with antispasmodic ano-
dynes, unless with such as may stimulate the
intestinal canal ; and, in fact, such seems to be
the result of observation. Some writers, con-
ceiving that lead colic may arise from the presence
of the acetate or the oxide of lead in the prima
via, have recommended the sulphate of magnesia
with the view of forming an insoluble sulphate of
lead. The experiments and views of Orfila,
Good, and Dr. Paris, seem to favour the em-
ployment of this sulphate as well as the sulphate
of alumina, exhibited with an excess of acid, or
in the compound infusion of roses ; and certainly
unequivocal benefit results from the practice. But
whether that benefit arises from reducing the lead
to an insoluble salt, or from the operation of the
sulphates in exciting the action of the partially
paralysed muscular coat of the bowels, and there-
by enabling them to expel retained matters of a
morbid or noxious description, cannot readily be
determined. We have no evidence of the exist*
ence of lead in the prima via to an extent that
admits of detection, nor has the formation of a
sulphate of lead been demonstrated. I am there-
374
COLIC FROM LEAD — Treatment of.
fore inclined to adopt the other mode of explain-
ing the operation of these salts. I have found
the croton oil an excellent purgative in this
disease, particularly when it is added to either
castor oil or the oil of turpentine, or to both. I
have in one or two cases caused the croton oil to
be rubbed over the abdomen in this species of
colic, with the hopes that it might act upon the
bowels; but I did not obtain this effect. The
quick irritation of the skin, however, that it pro-
duced, evidently proved salutary. Sulphur and
its preparations, as well as sulphureous waters,
have been prescribed by Luzuriaga in the
Madrid colic, in which they are obviously bene-
ficial; and subsequent writers, particularly Gar-
nett and Hahnemann, proceeding on the
erroneous opinion that the Madrid colic is identi-
cal with lead colic, have recommended them also
in the latter; but, bsOrfila has expressly stated,
they are most dangerous remedies in true lead
colic. A case demonstrative of this fact occurred
in my practice many years ago, and was pub-
lished in the London Medical Repository for
October 1822. The deleterious effects are there
ascribed to the absorption of su'phur, which was
taken by the patient, contrary to my advice, in
order to counteract the habitually costive state of
his bowels.
G2. d. The sulphate of alumina has been
given by some modern physicians, with the view
already stated (§ 61.) ; but with many its exhi-
bition has been altogether empirical. Grashu-
is, Quarin, Adair, Fischer, Schlegel,
Lindt, Percival, Michaelis, Gebel, and
Sommek favour the use of it, either alone or with
mucilaginous and narcotic medicines. I believe
that its efficacy is much enhanced by giving it with
camphor, opium, and demulcents. Schmidt-
ma nn details a case, in which the exhibition of
two or three doses of alum produced a most coJ
pious operation on the bowels, after the most
active purgatives had been given by the mouth
and per unum without any effect. When re-
siding on the Continent in ISIS and 1819, I saw
many cases treated by this substance, given in
doses of from a scruple to two drachms in gum-
water, or with camphor and opium. M. Kape-
I.er, in his hospital, into which many cases of
the disease are admitted, employed scarcely any
other medicine than alum dissolved in mucilaginous
decoctions, assisting its action by oleaginous clys-
ters. The worst cases, — those with paralysis,
loss of sight and hearing, violent cephalalgia, tre-
mors of the muscles and limbs, &c. were restored
jna much shorter time by. this than by any other
treatment, and with much less disposition to re-
lapse, or to pass into a paralytic state. I have
employed alum with uniform success in several
cases, and combined it with camphor, Cayenne
pepper, and occasionally with opium ; and have
always found that, when given in sufficient quan-
tity,— from two to four or five drachms in the
twenty-four hours, and assisted by oleaginous
clysters, — it will open the bowels more certain-
ly than any other medicine. M. Gendrin has
recently given alum in fifty-eight cases of this
disease, aU of which recovered in from three to
five days. He has also found that a drachm, or
a drachm and a half, of sulphuric acid in the
twenty-four hours, taken in three or four pints of
water, is equally prompt and efficacious. The
sulphate of zinc was recommended by Dr.
Mosely, seemingly from considering its opera-
tion analogous to that of alum; and the sulphate
of copper was mentioned by Harrison.
63. e. Mercury has been very generally pre-
scribed in this complaint, particularly by Clark,
Hunter, Warren, Biss, Burger, Clut-
terbuck, and others; but with very different
views. Some have given it simply as a cholo-
gogue purgative ; and others with the intention of
preventing the accession of paralytic svmptoms ;
although it is by no means obvious how it can
have this latter effect, since these symptoms sel-
dom originate in structural change in any part of
the cerebro-spinal axis, when they occur during
or after lead colic. Those who have prescribed
the preparations of mercury with this latter view,
as Clark, Warren, and Biss, have pushed it
to the production of salivation ; but, although I
admit that salivation will speedily alleviate the
abdominal symptoms, yet I am of opinion that it
will rather favour than prevent the accession of
paralysis, the more especially as I have observed
this affection to follow, notwithstanding the sali-
vation which had been produced with the hopes
of preventing it.
64. /. Besides the foregoing means, various
others have been recommended by writers on the
disease. Dr. Roberts has detailed two cases
in which the nitrate of silver was internally ex-
hibited with apparent benefit. Tobacco in vari-
ous forms has also been prescribed. Bartho-
lin us was the first to employ this plant in the
treatment of Colic, by directing its smoke to be
thrown up the rectum — one of the safest and most
beneficial modes of using tobacco internally. Dr.
Graves has derived much benefit from com-
presses, moistened with a strong decoction of it,
applied over the abdomen; and from croton oil
internally, assisted by clysters. Emetics have
been recommended by some writers; but they
are required only after lead has been taken in
poisonous doses, or at the commencement of the
attack, when the biliary organs are loaded by
vitiated bile. They, however, form a principal
part of the treatment usually adopted in the Pa-
risian hospitals. Cold and warm baths have both
been mentioned by writers as being sometimes
of service; but I consider the former attended
by some risk, and the latter seldom required,
although occasionally palliating the more painful
symptoms. The propriety of having recourse
to external irritation in this disease has been
admitted by many of the writers already referred
to, and blisters and various other means of a
similar kind have been adopted. In several cases
I have, however, found more advantage from
one of the liniments above recommended; or, if
an irritating effect was desired in a short time, I
have obtained it from either increasing the more
irritating ingredients contained in these liniments,
or applving a cloth moistened with one of them
closely to the abdomen. The hot turpentine
fomentation, or a few drops of croton oil rubbed
on the surface of the belly, will have a similar
effect ; but the former of these, accompanied
with suitable internal medicine, is the most rapidly
efficacious.
65. g. The great number of cases of this dis-
ease admitted into the Jiospitals " La CharM"
at Paris, and " Hotel Dim " at Orleans, naturally
COLIC FROM LEAD — Trkat
attracts attention to the plans of cure which are
then adopted ; but at neither of them is the treat-
ment bo simple or so quickly beneficial as that
adopted by M. Katklkk, and already stated.
At La Charity the treatment consists chiefly of
emetics, purgatives, sudorifics, and opiates; and
at several of the French hospitals large local de-
pletions are also employed. Lint the whole plan
v>( cure is generally complex and distressing to
the patient M. Ranq.ue, of the " Hbtel-Dieu"
at Orleans, states, that of about 150 cases he
treated, he did not lose one. He commences
with the semicupium ; and afterwards applies on
the abdomen and loins a large plaster, consisting
chiefly of diachylon, couium plaster, camphor,
and tartarised antimony. This is allowed to re-
main until pustules come out, and the pained
parts are rubbed with a liniment, the active in-
gredient in which is the extract of belladonna dis-
solved in sulphuric ether. He next administers,
once or twice daily, an enema with four ounces
of olive or almond oil, and twenty drops of the
Siberia] tincture of belladonna in the linseed de-
coction ; and prescribes, when the sufferings are se-
vere, small doses of the same tincture to be taken
at the same time in a demulcent mixture. This
treatment is persisted in for three or four days ;
and if considerable relief has not been obtained at
the end of this time, castor oil is given in small
and repeated doses, the anodyne liniment is as-
siduously employed, and the plaster on the loins
and abdomen is renewed, with an increased quan-
tity of camphor and tartarised antimony. Although
this plan of cure appears to be very successful,
yet relapses are very frequent after it.
66. h. The treatment adopted by the Author
in lead colic is directed with the views, 1st, of
relieving the sufferings of the patient ; 2d, of
evacuating the retained secretions, which are
always remarkably morbid, and apparently the
cause of the phenomena constituting the fully de-
veloped disease ; and, 3d, of imparting energy to
the weakened nerves, and parts that they supply.
In fulfilling these intentions, the practitioner is
often placed in a practical dilemma, from the cir-
cnmsl nice of the medicine, which is most to be
depended upon in relieving some of the most
urgent symptoms, and enabling the liver to throw
off the load of morbid secretions which oppress it,
having the effect, in some constitutions especially,
of increasing the exhaustion of nervous power,
and the tremors and paralysis attendant on the
worst forms of the complaint. Calomel, in a
large dose, either alone or with opium, has an ex-
cellent effect in allaying the distressing irritability
of stomach, and carrying the biliary and other
morbid secretions downwards : but if it be re-
peated in such quantity oftener than once, or if
free evacuations be not procured soon after its
administration, it is apt to atlect the mouth, and
to prolong the period of convalescence. I have,
therefore, endeavoured to procure from it a
soothing effect on the stomach, along with its
chologogue operation, guarding against its second-
ary action on the system ; and have prescribed
from ten to twenty grains in a bolus, with about
ten grains of camphor, and sometimes with two
of opium. This will generally allay the retchings,
and enable the stomach to retain the medicine
next to be given. About three or liuir hours after
the above lias been taken, a draught, consisting
MKNT OF. 575
of half an ounce each of castor oil and oil of tur-
pentine, with one or two drops of cruton oil, on
the surface of aqua pimentSB, is administered, and
its operation on the bowels promoted by a clyster
composed of about four ounces of olive oil, or
two of castor oil, one of turpentine, half an ounce
of sulphate of 7nagnesia, and from ten to twenty
ounces of the decoction of linseed, or of marsh-
mallows. This enema should be steadily thrown
up by the improved apparatus. Whilst this treat-
ment is proceeding, a liniment may be assiduous-
ly rubbed on the abdomen, and on the limbs, if
much pain be felt in them ; or a piece of flannel
charged with one of these liniments (F. 2!)7. 307.,
&c.) may be closely applied over the belly. If
these means procure evacuations, recovery will
soon follow ; but if the draught he thrown off the
stomach, or the injection be returned without
effect, they should nevertheless be repeated. If
the abdomen be much distended, and painful on
pressure, the hot turpentine fomentation ought to
be applied, as long as the patient can endure it,
instead of the liniment. These measures will sel-
dom fail of procuring most copious evacuations,
which should be promoted by sulphate of mag-
nesia, and spiritus sether. sulph. comp. in the com-
pound infusion of roses ; and by oleaginous clys-
ters with camphor or assafcetida, and oil of linseed.
After two or three doses of sulphate of magnesia
have been given, the following draught may be
exhibited, and repeated frequently ; the action of
the bowels being promoted by the enema.
No. 137. R Caruphora; rasa; cr. iij — vj.; tere cum Mn-
cilag. Acacia; J ss., et Aq. Pimentae §j. ; Sulph. Alumiii.
pulver. 3S5-i Spirit. Anisi 5 j-i Syrup. Croci 33S- Miser.
Fia< Hauatus, quarts vel quinta quaque hoia sumeudus,
prius agitata phiala.
No. 138. R Terebinth. Venet. vel Conimun. *vj. — ^j-i
Tinct. Assafcetida; ^ss. (vel. 01 Anisi 5j.)i Olei Oliva; 3iij.j
tere cum Vitel. Ovi, et adde Decocti Malva; g xvj., in quo
prius soluta erat sulphatis Magnesias 539. — 5 j., et fiat Enema,
67. i. The treatment of convalescence from lead
colic is of much importance, particularly when at-
tended with tremors, epilepsy, severe cephalalgia,
or paralysis. At first the alum and camphor should
be given for two or three days; and the action of
the bowels promoted by oleaginous enemata ; the
loins and abdomen being rubbed, night and morn-
ing, with one of the liniments already recom-
mended. As there is a great tendency of the dis-
ease to return, particularly when the patient fol-
lows the occupation which occasioned it, the
strictest attention should always be paid to the
state of the bowels, and the sulphates of mag-
nesia and alumina, with compound infusion of
roses, and some aromatic spirit, be taken fre-
quently ; and, upon the first indication of obstruc-
tion, recourse should be had to oleaginous clysters.
68. k. In oriler to remove the sequela of the dis-
ease, particularly the paralysis, the patient should
be allowed a generous diet, with exercise in the
open air ; and strychnine, or the extract of nux
vomica, with the aloes and myrrh pill, or F. 541,
565. may be taken twice or thrice daily. The
palsy arising from tho poison of lead is much
benefited by this active medicine, as well as by
frictions with stimulating substances, by electrici-
ty, and the use of splints along the fore-arm and
hand, as recommended by Dr. Pkmbkkton,
The Bath waters are very serviceable in pro-
moling perfect recovery, and preventing a re-
lapse : with these views, the balsams, particularly
376
COLIC AND ILEUS — Tre atm est of.
the Canadian and Peruvian, may also be taken,
with the sulphates of alumina and quinine, or
with tonic extracts, camphor, &c. ; and, under
every circumstance, the digestive organs should
be strengthened and the action of the bowels pro-
moted by tonics combined with aperients and
antispasmodics. I have obtained marked advan-
tage from strychnine thus combined, as well as
from several of the gum resins, as ammoniacum,
myrrh, assafcetida, and galbanum, particularly
when, besides the reduced nervous and muscular
power, the digestive functions still continued to
suffer. (For the prophylactic treatment of this
disease, see the article Arts akd Employ-
ments, § 17 — 30.)
69. II. Treatment of Colic caused
CHIEFLY KY CHANGE OF STRUCTURE OR
Position. — i. Of colic from constriction of the
bowels. This state of disease will not be bene-
fited by purgatives or carminatives ; but a judi-
cious choice and combination of aperients will
often be of service. In all cases of this descrip-
tion, due examination per anum should be in-
stituted ; and as stricture frequently occurs at the
upper part of the rectum and lower part of the
sigmoid flexure of the colon, a very long flexible
bougie should be carefully introduced, as recom-
mended by Dr. Willan. When we have reason
to suspect the existence of stricture in any part of
the colon, the use of mucilaginous, saponaceous,
or oleaginous enemata should be long persisted
in ; but the patient ought to be very careful not
to employ any oil that is not perfectly sweet. At
the same time, the action of the bowels may be
promoted by an electuary composed of equal
parts of the supertartrate of potash and sub-borate
of soda, with confection of senna and common
treacle, or either the inspissated juice of the sam-
bucus, or simple syrup. I have seen advantage
derived from a plaster, consisting of the cinplas-
trum picis comp., the emplast. ammoniaci cum
hydra rgyro, and either the extract, belladonna; or
the extr. conii, kept long applied over the abdo-
men. When the stricture appears to be low in
the colon, and yet beyond the reach of a bougie,
suppositories, with either of these extracts and
the lead plaster, will be productive of some re-
lief; and when it can be reached by a bougie,
the occasional introduction of one will often per-
manently remedy the disease.
70. Most of the cases of this complaint that I
have seen, have occurred in persons who had
long been in the habit of having recourse to purga-
tives, consisting chiefly of calomel and colocynth,
or the compound extract of the latter — substances
which have a remarkable effect in irritating the
internal surface of the colon and rectum, and con-
stricting their muscular tunics. It is obvious that
a frequent repetition of these medicines, unless
their effects be counteracted by emollient clysters,
will at last give rise to inflammatory thickening
of theparietes of the bowel, and constriction of its
canal. In most of these cases, also, there exists
inflammatory action of the internal surface of the
constricted part, and of its vicinity. Hence the
advantage usually derived from a cooling regi-
men, a spare or farinaceous diet, and cooling
gentle laxatives, assisted by soothing aud de-
mulcent clysters, as the following : —
No. 139. K Semin. Fceuicu) dulc, Semin. Anisi, aa con-
tus. J ss. ; Fol. Malva: et Flor. Anthem, aa 5vJ-i Aqua
0 jss. Coque ad 0 j. ; dein expnme, et adde liq. expresso
Olei 01ivae,vel 01. Lini, " iij. Potassa; Tartar, et Sub-bcratis
Soda? aa Jj. — 3 'j- Misce et fiat Enema, pro re nata inji-
ciendum.
No. 140. R Extr. JIvnscyami "^ij. Camphor* rasa; zr. vj.
— x. Sods Sub-carbon, ve] Sub-horatis ' jss. — ~, ijss.; Potas-
sa; Nitratis "ss.; lere cum Mutilag. Acacia- " vj., et adde
Decoct. Papaveris 5 x. — x,\. Misce et fiat Enema.
No. 141. R 'Exth 'Belladonna; gr. iij. — vj.; tere cum De
coct. Cvclonia" (vel Decoct. Allh;-.a>, vel Dec. Hordei Comp.)
Jxij. — xvj.; et adde Potassa- Sub-carbon, 3j.; Potassae Ni-
tratis '£)j. Misce pro Enemale.
71. ii. Treatment of Ileus. — The importance
of ascertaining, previously to the adoption of a plan
of treatment in this state of the disease, the exist-
ence of hernia, has been already noticed; but the
young practitioner should be aware that hernia
may exist without the patient being aware of it ;
and the real state of the case may be mistaken,
owing to the absence of any tumour, so very
small a portion of the side of the bowel being
strangulated as not even to obstruct its canal. I
have twice or thrice — once in one of my ser-
vants— met with such cases, in consultation with
eminent surgeons, where the exact state of parts
was inferred, and a successful treatment pursued.
There are certain forms of the disease which may
be briefly characterised, as they require a very
different treatment : — 1st, Great distension of the
abdomen, with diffuse, but not acute tenderness ;
obstinate costiveness ; retchings, particularly when
substances are taken into the stomach ; anxietv,
and general uneasiness ; 2d, The above symp-
toms, with fixed and severe pain, and great ten-
derness, felt in a defined part of the abdomen,
often about the region of the caecum : 3d, Violent
attacks of tormina, occurring in paroxysms, like
the strong impulse downwards from the action of
a drastic purge, — the action proceeding to a cer-
tain point — there stopping, and becoming invert-
ed,— followed by vomiting, which soon becomes
feculent (Abercrombie): and, 4th, Where the
symptoms of the third state are accompanied with
tenesmus, and the discharge of a small quantity of
bloody water or mucus, sometimes with indistinct
or elongated tumour, and the other signs already
described (§ 40.) as indicating invagination of
the bowels.
72. In the first of these the bowels are evident-
ly distended and inactive ; — in the second, they
are probably in a similar state, owing to obstruc-
tion, stricture, or strangulation, with inflamma-
tion, most frequently in the vicinity of the caecum
and its appendix ; — in the third, there are more
evident signs of stricture or strangulation ; but this
may also be an advanced stage of the second ; —
and in the fourth, the symptoms are more strictly
referrible to invagination ; although this may also
exist in the third of these states.
73. A. It is evident that the first of these states
will very frequently be much benefited bv pur-
gatives, particularly by a large dose of calomel
(from 10 to 20 grains), which will, either alone
or with camphor and hyoscyamus, allay the mor-
bid action of the stomach, and move the bowels,
particularly if it be assisted by the hot tuipentine
fomentation or epithem (§54.), and by enemata
(§ 57. 6b'. 70.). In cases where a full dose of
calomel only has been given, a dose of castor oil,
with ten or fifteen drops of laudanum, may follow
it in one or two hours ; and an injection with
three times the quantity jof the same medicines
may afterwards be thrown up. In some instances
COLIC AND ILEUS — Treatment of.
377
equal quantities of castor ofl and turpentine may
be given soon after the calomel. After the irrita-
bility of the stomach has subsided, the anion of
the bowels may be promoted by small doses,
frequently repeated, of the purified extract of
aloes, with hyoscyamus, and a small quantity of
extract oi' gentian, which will promote its action.
Ttallkski states that be lias found recently ex-
pressed Hnteed oil, in the dose of a large spoon-
ful, with a few drops of the oil oi' aniseed, given
every hour or two hours, extremely beneficial.
If the tirst dose of calomel neither opens the
bowels nor allays the anion of the stomach, it
may be combined with from one and a half to
three grains ^i' pure- opium. This will, in most
instances, settle tin; stomach and open the bow-
els, particularly if it be soon followed by the fo-
mentation and enema already advised.
74. B. The tendency of colic to lapse into a
latent or obscure state of inflammation has already
been noticed (§ 54.); and this tendency is the
greater, the more nearly the disease approaches
to ileus from its commencement. As colic in
every form is more especially an affection of the
muscular coats of the bowel, and as inflamma-
tion, when it supervenes, as it so frequently does,
upon colic, seems to attack this part especially,
and to terminate then more rapidly in gangrene
than when it originates in either the mucous or
peritoneal coats, so it becomes necessary to have
a prompt recourse to blood-letting, particularly
when rigors have occurred, and the pulse is op-
1 or constricted, and the habit of body
plethoric or muscular. In such cases, blood-
letting should be full and decided, and, if neces-
sary, repeated; but it ought not to be trusted to
alone, or even mainly; for if carried too far, or
employed too largely, or even at all in some cases
anil states of constitution, or too late in the disease,
it may hasten a fatal termination. It is beneficial
chiefly in the second and third states of the mal-
ady, especially when resorted to early, and fol-
lowed by local depletion, by calomel and opium,
the warm turpentine fomentation on the abdomen,
and subsequently by clysters (F. 144. 146, 147.).
I believe, however, that in many cases, particu-
larly those commencing as flatulent colic, blood-
letting carried to the utmost extent will not of it-
self prevent either gangrene from taking place, or
feculent vomiting from coming on. For in these,
and in ihu first state above specified, the muscular
and other coats seem to lose their vitality, with-
out almost any other mark of pre-existing inflam-
mation, that I could observe in some cases on
dissection, than change of colour. And yet,
when duly employed, particularly early in the
other states of the disease, blood-letting will
often give decided and immediate relief, and be
quickly followed by free evacuations and speedy
recovery.
To. C. Opiates and other anodynes are most
important remedies in nearly all the states of the
disease, but especially in tin; second and third
particularised. The propriety of premising gen-
eral or local blood-letting, or both, when it is
clearly indicated, and the advantages of combin-
ing opium or hyoscyamus, at first with a large
d ise of calomel, or camphor, or both, have been
adverted to. These remedies will often of them-
selves produce free evacuations; but in the states
of ileus now mentioned, purgatives given bv the
32*
mouth, unless of the mildest Kind, or combined
as above (§ 52.), and exhibited subsequently
to the above remedies, are seldom of service.
Appropriate enemata, however, should not be
omitted.
76. D. The tobacco injection is one of the
most generally adopted remedies in this disease,
and one which has received the warm sanction
of Dr. Ab BKCROMBtX. This able physician re-
commends it with judicious caution, and directs
at lirst only fifteen grains of the tobacco to be in-
fused for ten minutes in six ounces of boiling
water; the quantity to be increased to twenty
grains, and repeated after an hour, if no efi'ect be
produced. I believe that, when thus employed,
early in the disease, and in persons previously of
sound vital power, this will often be of service, or
at least not detrimental. Cut I have seen several
cases wherein this powerful substance, even when
no more than half a drachm had been infused for
fifteen minutes in a pint of water, produced the
most distressing effects; and in one case, where
it was given in opposition to my opinion, which
was in favour of a terebinthinate injection, death
followed its administration before three minutes
had expired, — evidently from its sedative opera-
tion in an advanced state of disease. I have seen
many cases in which it had been administered,
and, unless under the circumstances in which I
have stated it to be admissible, or when stimuli
are given at the same time by the mouth, I be-
lieve that it favours a fatal termination, by ex-
hausting the vital power of the alimentary canal,
and disposing inflammatory action to terminate in
gangrene. The introduction of tobacco smoke
into the large bowels appears a much safer and
more efficacious practice, and to be appropriate
to a greater number of the many morbid states
of which ileus is an effect.
77. E. Various other kinds of injection have
been recommended; and some of them are more
deserving of confidence in the treatment of ileus
than almost any other remedy. I have already
mentioned several (5 66. 70.), and referred to
others in the Appendix (F. 140, 141. 150.), on
which very considerable reliance may be placed.
Dr. M \ x we r.i. has found large injections of warm
linseed oil — from two to four pints — steadily and
slowly thrown up, regurgitation being prevented
by pressing the guard of the pipe against the anus,
remarkably successful, after feculent vomiting
bad come on, and the usual means had failed.
He recommends, in such cases, the patient to be
placed on the right side, with the pelvis elevated
above the rest of the body, the premature return
of the inj iction being prevented by firmly press-
ing a ball of linen against the anus. He directs
this clyster to be repealed every three or four
hours, until relief is obtained; and, when much
exhaustion is present, with the addition of lauda-
num. This physician likewise advises, in cases
where the existence of intus-susception is suspect-
ed, the inflation of the intestines by air, and ad-
duce, cases in which it was followed by copious
evacuations; hut it seems doubtful whether or not
invagination existed in any of them. This prac-
tice, lirst recommended bv Hippocrates, after-
wards insisted on by Ai.kx \ni>fr ofTRALLES,
Zacutus Lusitanus, and Riv erius, and men-
tioned by Sag a r, and some other systematic wri-
ters, is certainly deserving of trial where we have
ST3
COLIC AND ILEUS — Treatment of.
reason to suspect invagination or internal strangu-
lation. In most cases, however, inflation with to-
bacco smoke appears preferable; but, as Quarin
remarks, it should be frequently repeated, and its
effects carefully watched. Although the infusion
of tobacco has been chosen for injection by Vicat,
Fowler, Campet, Conradi, Hufeland,
and Abercrombie, yet I agree with Syden-
ham, 1)e Hakn, Sagar, Quarin, and many
others, in considering the smoke superior to the
infusion; the former being adopted by some mere-
ly on account of the greater facility of conveying
it into the bowels, and without reference to the
very different operation of these two modes of
employing this powerful medicine. But in cases
where inflation by air or tobacco smoke is adopt-
ed, purgative injections should speedily follow, as
directed by Hippocrates, if evacuations have
not taken place; for the smoke may even pass out
by the mouth, and yet copious motions may not
otherwise be procured. Besides these means,
yeast has been administered as an injection in
warm small beer, with the intention of evolving
its fixed air in the bowels, and thereby extricating
any unnatural convolution or slight invagination
that may have been formed. Sulphuric, (ether
has likewise been thrown into the large bowels,
with the expectation that its fumes would operate
in a similar manner. Antimonial wine, and the
powder or infusion of ipecacuanha have been
prescribed in enemata, witfi the view of relaxing
spasm, in cases where it is presumed to be the
chief cause of obstruction; whilst the infusion of
poppies and of chamomile flowers, various ano-
dyne, saponaceous, laxative, and oleaginous injec-
tions (§ 57. 66.), have also been directed with
the yiews already stated.
78. F. Baths, fyc. — Tepid or tuarm baths are
sometimes useful -adjuvants in the early stages
of the disease, and are generally recommended.
Cold fluids taken into the stomach, and thrown in-
to the large bowels, in considerable quantities, and
cold epithems constantly applied on the abdomen,
have been prescribed by Bureau,* Maret, Ra-
noe, Steidele, Darwin, Conradi, Bald-
ing er, Smith, and Abercrombie. The dash-
ing of cold water over the lower extremities and
abdomen of the patient, whilst he is kept in a
standing posture, has likewise been directed by
several physicians; but this practice, although oc-
casionally of service, seems less successful than
the judicious application of cold to the surface of
the abdomen itself. When this cavity is distend-
ed, tense, painful on pressure, particularly in a
circumscribed portion, with increased temperature
of its surface, the cold douche, or the application
of cloths moistened with vinegar and water, will
often prove of advantage. Dr. Brandis, of
Copenhagen, states that he has employed iced
drinks, and cloths wetted with iced water to the
abdomen, in ten cases with success; and that in
some instances the practice requires to be perse-
vered in for a long time, and assisted by antispas-
modic and laxative enemata, and by opiates with
stimulants and tonics taken internally.
79. G. When signs of depression of the vital
*.Mr. Bureau recommends th" use, and gives n plale de-
icfiptive, of a simple hydraulic apparatus for injections, (he
same in all respects as one lately introduced into this coun-
try from France, under (he name of clysmaduct, hut which
is iuited only to the injection of water.
energy manifest themselves in the advanced stage
of the disease, stimulants are required, and, if
judiciously selected and combined, their exhibition
will sometimes be rapidly followed by amend-
ment. Wherever the lowering measures already
noticed are followed by increase of the symptoms,
particularly vomiting and restlessness, or by sink-
ing of the nervous power or of animal heat on the
surface of the trunk, antispasmodic stimulants and
tonics should be conjoined, according to circum-
stances, with certain of the measures described
above. Purgative tinctures are soj^ietimes of ser-
vice in this state, particularly the tinctures of aloes,
with liquor potassa?, and tinct. hyoscyami; and the
tincture of senna, with spirit, ammon. succinati
and spirit, anisi, in large or often repeated doses.
Notwithstanding constant or even faeculent vom-
iting in this stage, advantage will sometimes be
derived from a full dose of unrectified oil of tur-
pentine (from - iv. — x.), taken on the surface of
aqua pimenta?, to which either spirit, anisi, tinct.
cardamom, co., or tinct. capsici, has been added.
I have seen the vomiting cease, and the disten-
sion of the abdomen rapidly subside, immediately
after this draught, which should be repeated if
the former has been thrown oft'. A full dose of
common oil of turpentine, taken by the mouth,
has a singular effect in constricting, and, as it
were, drawing the small intestines close to the
root of the mesentery; so that, in cases where I
have given it, and in which hernia had chanced
to exist, the hernial sac has become quite empty
soon after its exhibition. May not the advantage
obtained by it occasionally arise from the disen-
tanglement of a constricted or imprisoned portion
of intestine by this mode of operation, as well as
from its influence in restoring the action of the
paralysed and dilated coats of the bowel in other
cases? In many states of inflammatory action,
particularly those attended with exhausted tone
of the capillaries and depressed vital power, it is
one of the most active means we possess of pre-
venting gangrene or effusion, and of restoring the
natural action of the vessels.
80. H. In some cases, after depletions have
been carried far, or in nervous and irritable
habits, the inverted action of the stomach and
upper part of the alimentary canal appears to
continue in consequence of the vital exhaustion
and irritability of parts; but, if these states were
put a stop to for awhile, and the powers of life
supported, the natural action of the bowels —
respecting the immediate restoration of which
the patient is often injuriously harassed — would
generally at last return. Under such circumstan-
ces, pills consisting of the oxide of bismuth, cam-
phor, and opium, frequently repeated; or of the
first of these, and extract of bop, or of henbane, or
the hydrocyanic acid, in the recent oleum amyg-
dal. dulcis, or oleum oliva1, in moderate but rath-
er frequent doses, and occasionally with an aro-
matic spirit or distilled water; will often prove
of service, particularly when aided by the ex-
ternal means about to be recommended. When
thus exhibited, the prussic acid has a restorative
eflect; and it is still further beneficial when as-
sociated with suitable stimulants, as camphor,
aether, &c. In a few instances I have inferred,
from the situation of the pain, and other symp-
toms, that the disorder originated in the duodenum,
or jejunum; and in these especially, the oxide of
COLIC AND ILEUS — Treatment of, from Intus-susception.
379
bismuth and the prussic acid have been of con-
riderable benefit The tmnumiattd tincture of
guedaam, with paregorie e/ixtr, in full doses,
and given in milk, or in the recent oil of almonds
or of olives, or in linseed oil, has also occasion-
ally proved of advantage. The acetate of mor-
phine U sometimes of service in allaying the dis-
tress, anxiety, and irritability of the stomach and
diaphragm ;' but it should be prescribed in an
aromatic spirit, and in a dose which will secure
its anodyne effect without sinking the vital ener-
gies. [ have used the following with marked
advantage, repeating the dose every two hours
until an effect was produced : —
No. 1:2. R Acetatia Morphines c;r. iv. ; .Spirit. Myris-
ticas el Spirt. Pimentse mi .5 j.; Spirit. Camphorse et
Tinct BeDzoini Oomp. f\a -, ss. Solve. Capiat", j. ail 3 ij.
in Saccharum, vol Syrupum, vel Olea supra incmorata.
81. /. The ingestion of crude mercury, or of
globules of lead, to the extent of one or two
pounds, has been recommended in ileus by seve-
ral authors, particularly in that state of the malady
which presents the symptoms indicating invagi-
nation of a portion of intestine. Sydenham,
Schenck, Be lloste, Pa Re, Panzan 1, Hoff-
mann, Saga r,Q,uarix, Ne Vinson, Darwin,
Abercrombie, and many others, have noticed
this practice; some of them, as Sydenham and
Quarin, in doubtful terms — others more favour-
ably. M. Holland has detailed the history of
a case, wherein, other means having failed, he
gave about 10 ounces of crude mercury, which,
after a short time, occasioned a sensation of change
in the position of some part within the abdomen,
instantly followed by relief. Similar instances
have been recorded by Dr. Uwins and Dr. Bel-
li ci. I have never tried this metal; but, many
vcars ago, I saw a patient — a female between
twenty and thirty, — relieved from all the charac-
teristic symptoms of this state of the disease by
the ingestion of about two pounds of common shot,
which also has been recommended in volvulus, by
many of the best medical writers of the three last
centuries, and by some of them in preference to
quicksilver. Large blood-lettings, the tepid bath,
and various other means (§ 54. 77.), should gen-
erally precede the ingestion of lead or quicksilver.
82. K. Various external means besides those
already noticed, have been recommended in ileus.
SAGAK* states, that he was cured of volvulus, by
having the abdomen, at the commencement of
the attack, kneaded like dough, with oiled hands,
— a plan instituted evidently with the view of
disentangling a displaced portion of bowel. Ar-
et^eus, and Paul of JEc, in a, directed cupping
on the abdomen. Cel-i rs advised dry cupping
on both the loins and abdomen ; but little advan-
tage can be expected from this latter measure,
unless it be performed by one capacious vessel,
as is, I believe, occasionally done in some north-
ern continental countries. Quarin states, that
in an extreme case, all other means having failed,
and the pulse being small and irregular, the ex-
tremities cold, the countenance sunk, with hiccup,
&c, he had recourse to dry cupping, using for the
purpose porcelain bowls. Relief soon followed,
* "Olim Cririi incidi in nunc morbum (yolvulum) ct;o ;
Hun^iru^ Sartor accUui me rettituit intra trei hora< methodo
■eqnenti: imporitum me lupioum prato, inuoclisve oleo
olivarum mnnibui mis depsabal proul pistorei paslam ptrii*
subtiliter incipient successive semper foitius totum abdomen
mourn." (p. S20.)
and the bowels were copiously evacuated, their
action having been assisted by enemata of infusion
of chamomile flowers and tartarised soda.
83. L. Dr. Abercrombie expresses himself
in favour of large blisters on the abdomen ; but
much more certain and immediate reliel — often
within ten minutes after its application— is derived
from the hot spirit of turpentine fomentation,
placed over the whole abdomen. Where there
is little or no tenderness of this cavity, I have,
however, preferred inunction of its surface with
one of the liniments above directed (§ 51.) ;
keeping subsequently a cold turpentine epithem
applied. Forkes, Wii.mik, and Baldinger
also advocate the use of blisters on the abdomen;
but Meier prefers placing them on thejnsides
of the thighs. The recommendation of Syden-
ham, to keep a young dog constantly applied to
the abdomen, will appear to many a singular
remedy; but the views with which he prescribed
it are by no means devoid of reason.
84. M. Numerous writers antecedent to the
time of Quarin, and subsequently, have recom-
mended an incision to be made through the
parietes of the abdomen, and the internally stran-
gulated, or the invaginated, portion of bowel
extricated through it. Nuck has recorded a case
where this operation was performed with success.
Van Swieten objects to it, the uncertainty of
the existence of volvulus or internal strangulation.
But, in several cases of invagination which I have
seen, and in a great many 1 have perused —
almost all those, the history of which has been
fully detailed— the symptoms described (§ 40.)
as characterising this state were present, par-
ticularly the tormina, followed by desire of
evacuation, and tenesmus, with the discharge of
a little bloody mucus or water; the oblong tu-
mour, in a part of the abdomen, admitting of
being recognised at some period of the disease;
have been superadded to the other symptoms of
ileus, and pointed out its precise nature. In two
cases I felt inclined to have had the operation
performed ; and, indeed, suggested it. The di-
agnosis was found correct on examination after
death. A case is given by Dr. Fuschius, in
Hufeland's Journal for February, 1825, al-
most identical with one of these, and characterised
by the above diagnostic symptoms, in which he
resorted to this operation over the place to which
the patient referred the sensation of obstruction,
and where an obscure oblong tumour, in the
situation of the ascending colon, was detected.
An invagination of the colon was removed, and
the patient perfectly recovered. The reader need
not be inf >rmed that ileus very commonly pro-
ceeds from strangulated hernia, and sometimes
persists from adhesions, &c. after the displaced
bowel has been returned. The propriety of hav-
ing an early recourse to the operation after we
fail in returning the protruded intestine is here
very obvious.
s.">. A'. During, and subsequent to, conva-
lescence from ileus, the patient should wear flannel
next the skin, and promote the functions of the
Stomach and bowels by vegetable bitters com-
bined with gentle aperients, and the sub-carbon-
ates of the alkalies. The bulky and flatulent
vegetables Wight to be avoided, and the extremi-
ties and surface of the abdomen and loins kept
equably warm. The utmost attention should be
380
COLIC — Treatment of its Sympathetic States.
paid to diet ; all indigestible substances, and acid
or acerb beverages, carefully avoided.
86. III. Treatment of Symptomatic or
Complicated Colic — A. The means of cure
in most cases of this description should be directed
to the diseased viscus, by which the functions
of the alimentary canal are affected, a. Those
colicky symptoms which are produced by irri-
tation, or the passage of gall-stones through the
common bile-duct, and by the obstruction occa-
sioned by concretions in the intestines, will gene-
rally be relieved by nearly the same treatment as
that recommended in this article ; but whatever
difference should exist, is detailed in the article on
Concretions, b. The colic which is symp-
tomatic of worms in the intestines requires, if the
attack be severe, the internal and external means
already recommended to allay the urgent symp-
toms; but after this is accomplished, the remedies
resorted to for the cure of verminous disorders
should be employed. (See art. Worms.)
87. B. The occurrence of colic from affections
of the kidneys, particularly from calculi in their
pelvis or ureters, should not be overlooked by the
practitioner; nor should he forget that it is some-
times consequent upon aneurism of the abdominal
aorta, and of tumours formed in the mesentery,
or in the omentum, a. In the first of these pa-
thological states, much relief will be a Horded by
the alkaline sub-carbonates, with opiates or se-
datives, and followed by oleaginous purgatives
and enemata, in addition to whatever depletory
or other measures the circumstances of the case
will point out. The use of liniments with cam-
phor, soap, and opium, rubbed on the abdomen
and loins, will also give much relief. 6. In colic
depending upon the latter organic changes, little
beyond palliating the urgent symptoms by the
remedies now mentioned, can be expected.
88. C. Flatulent colic, generally of a pro-
longed description, and often not easily removed,
at least in a permanent manner, sometimes occurs
in the course of asthma and bronchorrhaa, owing
apparently to the interrupted functions of the
mucous surface of the lungs ; the evolution of
gaseous fluids, from the blood being impeded on
this surface, but supervening vicariously oil that
of the alimentary canal. In such cases, after the
bowels have been freely evacuated, carminatives
combined with ipecacuanha and hyoseyamus ;
the infusion of valerian, with prussic acid, and
spirit, amsi; powders of magnesia, oxide of bis-
muth or of zinc, and ipecacuanha; sulphate of
zinc, with myrrh, camphor, and opium or hyos-
cyamus; and camphor mixture, with extract of
belladonna, spiritus astheris sulphur, comp. and
spirit, menthse; are among the means which will
afford the greatest relief.
89. D. There are few more common compli-
cations than hysteria and colic; but the treatment
varies not materially from that now stated, a.
In such cases, the functions of the uterus require
strict attention; for morbid sensibility, and even
vascular excitement, both of this viscus and of
the ovaria, are often present. The treatment too
commonly adopted in this state of complication,
although it may give immediate but temporary
relief, not infrequently perpetuates the patholo-
gical state, of which both hysteria and colic are
merely symptoms. Instead of employing medi-
cines which excite both the digestive mucous
surface and the generative organs, in these cases,
cooling and soothing remedies are much more
appropriate to them, such as those above enu-
merated (§ 87.) ; local depletions, nitrate of
potash, sub-carbonate of soda, extract of hop,
cooling aperients, vegetable tonics, exercise in
the open air, &c. B. When the complaint is
symptomatic of difficult menstruation (§ 43.),
general or local blood-letting may be resorted to
in the plethoric subject : burin the weak or hys-
terical, camphor, ammonia, soda, kc. with hyos-
cyamus; or the acetate of morphine or laudanum
given in some aromatic spirit, the ammoniated
tincture of guaiacum in linseed tea, the prepara-
tions of rue and of juniper, and the treatment de-
tailed in the article on the Disorders of Men-
struation, will generally give speedy relief.
c. Colicky pains sometimes occur during preg-
nancy : in such cases, cooling aperients, with
antispasmodics and opiates or other anodynes,
and preceded by sanguineous depletion, if con-
gestion or plethora exist, will remove all disorder.
d. Severe attacks of colic are not uncommon
upon suppression of the menses or of the lochia.
If a tendency to inflammatory action manifests
itself, and especially if the patient be plethoric or
robust, general or local depletion should be prac-
tised ; a dose of a mixture composed of a decoction
of the radix rubia?, tincture and syrup of saffron,
and as much borax as it will dissolve, should be
given every two hours; the "volatile liniment with
camphor and opium ought to be rubbed on the
abdomen ; and, afterwards, a fomentation with
the decoction of poppy-heads, &c. applied to the
same situation. Schmidtmann advises a cata-
plasm, consisting of marshmallows, henbane,
bruised linseed, and poppy-heads, to be placed
■warm on the abdomen; and the steam of hot
water to be conveyed to the pudenda, e. If colic
proceed from congestion, or inflammatory irri-
tation of the uterus or ovaria, local depletions ;
diaphoretics, and refrigerants, combined with se-
datives ; aperients, with cooling emollient ene-
mata, and low diet, are the most appropriate
remedies.
90. E. Colicky complaints are not infrequently
referrible to congestion and irregular vascular
action in the liver, pancreas, or spleen; or, if
not arising from such disorders, are associated
with them, owing to deficient energv of the or-
ganic nervous system; and, consequently, to im-
perfect performance of the abdominal functions
generally, a. In cases of this kind, local deple-
tions, followed by purgaiives, exerting a chola-
gogue and deobstruent action, external irritation,
and, subsequently, by vegetable tonics, laxatives,
regular exercise, and a course^ of the Leamington,
Harrogate, Buxton, or Cheltenham, mineral wa-
ters, or the artificial waters of Carlsbad, Spa,
Kiiis, &c, according to the circumstances of the
case, will generally remove all disorder. Im-
peded circulation through the portal system, is
more or less concerned in the causation of colic
pains in these cases; the return of blood through
the mesenteric and hemorrhoidal veins deranging
the contractile actions of the intestines, and giving
rise, in many cases, particularly those in which
this pathological state obtains, to the additional
association of hemorrhoidal affections, which, if
neglected, may tern inateln anal fistula\ b. It is
not uncommon to find a severe attack of colic
COLIC — Treatment of its Sympathetic Statks.
381
usher in hamorrhoidal discharges : the impeded
circulation through the porta] vessels, and the
consequent fits of colic, being both relieved by
the coneeentiye hemorrhage from the hemor-
rhoidal veins and mucous surface of the rectum.
In almost all such cases, in addition to the con-
gestion and associated disorder of the assistant
chylopoietic viscera, there are more or less vas-
cular plethora, impeded secretion generally, and
deficient energj of the organic nervous ssstem, —
a complicated state of disorder evidently requiring
local depletions from the region of the liver, or,
as Continental practitioners very reasonably pre-
fer, from the vicinity of the anus, with the reme-
dies above stated, and assisted by regular exer-
cise, gentle tonics, aperients, and a regulated diet
and regimen. From this it will not appear singu-
lar that very dangerous attacks of colic, or even
of ileus, will sometimes occur after the operation
for hemorrhoids or anal fistula?, or other morhid
states of the rectum, when performed, as they
sometimes are, without previous medical treat-
ment of a kind appropriate to the state of internal
disease, c. The complication of colic witli either
acute or chronic jaundice is evidently referrihle,
either to the passage of gall-stones (§ 86.), or to
the pathological state of the liver now noticed,
or to inflammatory action in the duodenum or
biliary ducts, or, lastly, to congestion of bile in
the hepatic ducts, or in the gall-hladder. When
Bymptoms of local plethora or congestion can be
detected, cupping, and the rest of the treatment
now directed, will be serviceable. (See Jaun-
dice— Treatment of.)
91. F. When the colic arises from atonic, mis-
placed, or erratic gout, large doses of the sub-
carbonates of the alkalies, or magnesia, with
camphor or ammonia, are required, followed by
blood-letting, if the pulse, habit of body, and
strength of the patient admit of it ; by calomel,
with camphor and hyoscyamus, or opium, at
bed-time ; by active cathartics, conjoined with
stimulants and restoratives, as long as the alvine
. evacuations indicate the propriety of their ex-
hibition ; by purgative and antispasmodic injec-
tions, and by rubefacients and sinapisms to the
lower extremities. After morbid secretions and
retained feces are evacuated, colchicum may
then be given with ammonia, or with camphor
and magnesia. Bat arthritic colic occurs most
frequently in aged persons, or in those with ex-
hausted constitutions, in whom, instead of evacu-
ations, beyond the expulsion of morbid secretions,
active stimulants, — as large doses of camphor
and ammonia, or of guaiacum and ammonia, —
with warm spices, Cayenne pepper, and some-
times combined with opium or aconitum, and
assisted by sinapisms, are indispensably requisite.
92. G. If colic supervene on the disappearance
or suppression of rheumatism from the joints or
aponeurosis, or the repulsion of chronic eruptions,
local depletions, followed hv camphorated lini-
ments and fomentations; warm turpentine epi-
thems applied on the abdomen ; calomel, with
antimoniaJ preparations, or with ipecacuanha and
opium ; warm vapour and fumigating baths ; the
sub-carbonates of the alkalies, sulphur, the com-
pound decoction of sarsaparilla, or the decoction
of dulcamara ; blisters, tartarised antimonial pla-
ters or ointments, saponaceous and oleaginous ene-
mata ; and sinapisms to the extremities or parts
primarily affected ; constitute the chief means of
cure, 'i he frequency, and, in two of the forms
of the disease especially, the danger, of the com-
plaint now discussed have induced me to he more
circumstantial in the account of its pathology and
treatment than may appear requisite to many :
but I am convinced that the experienced prac-
titioner will not be of the number ; hut will find
cause to regret, with myself, upon reviewing his
knowledge, that his information on the suhjeet is
not. greater than his means of observation have
yet afforded him, or my labours can possibly
assist him in obtaining.
BibliOO. and REFER. — A. Common Forms of Colic.
— Pliny, Hist. Nat. 1. xxvi. cap. i. — Celsus, De Medicina,
I. iv. sect. 13, 14. — Alexander Pra/Uanus. I. iii. ch. 44 —
Baillou, Consult, v 1. i. p. 5.— Schenck, 1. iii. pp. 173. 179.
and 274. — IVi/lis, Opera Omnia, d Anim. Brut., par. ii.
rap. 15. p. 202. — Bonet, Sepulchretum, iVc. I. iii. sect. xiv.
cbser. 1. 5.; et Merctlrius Compitalitius, p. 115. et siq. —
Riverivs, Observ. cent. i. oh. 12, 13. 59, &c; cent. ii. oh. 12.
38, &lc. | cent. iii. oh. 22. 48.— Rolfnk; De Dolor,- Colico.
Jense, 1660. — Alberti, De Colica Hemorrhoidal] Ilalae,
1718. — Hoffmann, De Intestinorum Dolorihus, Opera, vol.
ii. p. 294.; et Consult, cent. ii. n. 16. — Huxham, in Philos.
Tra.is. No. 422.— Harris, De Moih. Inf. p. Sl.—Ka-mpfer,
AiDCen. Kxot. p. 588. — Juncker, De Morhis Colic.am conse-
quentibus, 4to. Hala>, 1749. — Agricola, Comment, in Pop-
pium, De Sulphure, p. 416. 462. — Sauvages, Nosologic
Melhodique, &.c. t. ii. p. 510. — isto/l, Ratio Med. par. ii. p.
135. 138., par. iii. p. 65. — Rosen, De Dolor. Spasiico-flatu-
h mis Prim. Viar. 8vo. Lond. 1771. — Burseri, Institut. .Med.
Pract. vol. iv. ed. Lips. p. 358. et seq. — Bang, in Act. Reg.
Soc. Med. Hann. vol. i. p. 285. et seq., et vol. iii. p. 115. et
141. et seq. — Ranoe, in Ibid. p. 349., et vol. iv. p. 113.—
Kbnig, De Remed. Indigenis.— Tode, Biblioth. i. 3. 148.—
Tournuy, Ergo Colico liolori Opium, 4to. Nanceii, 1784. —
Bandry, Sur la Colique Nervo-gastrique. Paris, 1805. —
Eberle, De Colica Infantum. Arq. 1784. — Barker, in N. Y.
Med. Repository, vol. v. No. iii. art. 3. — Conrudi, in Hufe-
Inuil's .Icuirn. der Pract. Arznevk. vi. b. p. 414. — Rave, in
Ibid. vii. b. p. 168. — Fromm, De Oleo Riciui, ejusque in
variis Col. Spec, efieclu pra-stant., 4to. 1806. — Mkhailis, in
Lioder's Journ. fur die Chirurg. iii. b. p. 633. — Thomann,
Annalen ad 1800, p. 271. — Oilier, in Journ. de Med. t. xlix.
p. 337. — Hosuck, in Lond. Med. Repository, vol. xviii. p. 77.
— Chomel, Dirt, de Medecine, vol. v. p. 448. — Schmidtmann,
Summa Observat. Medicar. vol. iv. p. 373. et seq.
B. West Indian and Madrid Colic — Hernandez,
Tratlato del Dolor Colico, 4to. Madriti, 1750.— Hunter, On
Diseases of Jamaica, k.c. — Lind, On the Diseases of Hot
Climates, p. 254. — Lsuuriaga, Dissertacion Medica sobre el
Colico de Madrid. Mad. 1796. — Chisho/m, On the Diseases
of Hot Climates, &c. 8vo. Lond. 1822, p. 92.— Larrey,
Mem. de Chirurg. Milit. I. iii. — Aulugnier, Recherches sur
la Colique de Madrid. Paris, 1811. — Libron, in Collect, des
Theses souten. a I'Ecole de Med. de Paris. 1809, No. 82.—
Jacob, Ibid. 1815, No. 86. — Thomson, Edin. Med. and
Surg. Journ. Nov. 1818, p. 614. — Musgrave, in Lond. ."Med.
Repository, hv Copland, Nov. 1825. — Pascal) in Journ. des
Progres des Scien. Med. t. ii. p. 240. — Marquaml, in Journ.
Complement des Scien. .Med. t. xxiii. p. 97. — Qui'er, Ac-
count of the Bilious Colic, or Dry Belly-ache, 8vo. London,
177:'. (extremely valuable).
C. LEAD COLIC— fieW/m, Lin. Med. 1695, p. 162.— Cal-
mette, Riverius Reoovatus, vol. i. Lyon. 1704. —fan Swieten,
Comment, vol. iii. p. 317. — Tronchin, De Colica Pictonum,
Bvo. Geneva;, 1757. — Grashvis, De Colica Pictorium, Amst.
1755. — /Jt Hun, tte Colica Pictonum, llag.i, 1745. — War-
rt i, in Med. Trans, ol Col. of l'hvs. of Lond. vol. ii. No. 7.
—Eyerel, Svlloge, obs. iv.— Astrvc, m Halter, Collect. Diss.
I. iii. .No. 84.— Utoll, Rat. -Med. ii. p. 270., iv. p. 7.5.,
ii. p. 333., vii. p. 307. et seq.—O. Baker, Medical Tracts
republished by his Son, 8vo. 1818, p. 1. and 420.— Dubois,
AnColicis figulis Venesection? (neq.j Paris, 1757. —Dufres-
,.,. I.. mi Dlicis figulis Veneesectio. Paris, 1777. — llar-
On the Cun ol lie Dry Belly-ache. Load. 1786. —
A lair, in Edin. Med. Comment, vol! \. p. -'.;.;.; et .Mi m. of
M..I. Soc. ol Lond. vol. ii. p. 236.— Merat, Sur la Colique
Mn, Hi. p..-. Paris, 1804.— Lentin, Beytrage, p. 336.; et Mc-
■ •. p. ii.;.; ei iii Blumenhach, Med. Biblioth. ii.
p. 149. — Hahnemann, in Ibid. iii. b. p. 546 — Ranque, in
Journ. lb- Progres des Scien. Med. i. ii. p. -' 12.— il'.dff, in
. Ephemer. Von Berlin, i. b. 2 -t. p. <:3. — Quarin,
Animadveisiones, p. 187. — Lindt, De Aluminis Virtnte Be-
it. 1784.— Hardy, OflheColii ol Poilou and Devon-
shire. 8vo. Lond. 1779.— Gnmttt, in Mem. of Me, I. Soc. of
Lond. vol. v. p. 123. — Percival, in Edin. .Med. Comment.
382
COLON — Torpid States of, &c.
vol. ii. p. 239. — Alcoclc, The Endemic Colic of Devonshire
not caused hv a Solution of Lead iu the Cyder; with Remarks
on Dr. Baker's Essay. Plymouth, 1769.— Fischer, Bemerk-
ungen tilnr London, Sic. p. 173. — Burger, in Hani's N. Ar-
chiv. ii. h. p. 342.— Gendron, in Recueil Periodique de la
Soc. do Sante & Paris, No. 5., et t. ii. p. 338. — Cheyne, in
Edin. Med. and Surg. Journ. vo'. iv. p. 314. — Sommer, in
HufelatuVs Journ. der Pracl. Arzneyk. vii. b. p. 83. — Mich-
tOtis, in Ibid. xii. 4 st. p. 31.— Gcbel, in Hufeland's Journ.
der Heilk. i. b. p. 195., et xvii. b. 3 st. p. 108. — Bateman.
Art. Colic in Rres's Cyclopaedia. — Roberts, in Transac. of
Lond. Coll. of Pbys. vol. v. p. 45.— Re mbe, ton, On the Ab-
dom. Viscera, &c. p. 150. — Andral, Clinique Medicate, t. iv.
Paris, lS27.—Paruet, in Diet, des Sciences Med. t. vi. p. 9.
— Oijiln, Toxicologic Generate, i. p. 637. — Friesc, in Ar-
chiv. der Pract. Heilk. fur Schlesien, iv. b. 1st. n. 6. — An-
dral, in Revue Med. t. ii. 1824, p. 203. — Kape/er, Archives
Gener. de Medicine, t. xviii. p. 370. — Graves, Dublin Hos-
pital Reports, vol. iv. p. 45. — Gregory, Practice of Phys. 3d
edit. p. 524. — Christison, On Poisons, p. 493. — Copland, in
Lund. Med. and Surg. Journ. vol. i. p. 147.; and in Loud.
Med. Repository, vol. xviii. p. 322. — Fournier, in Journ.
Hebdomad, de Med., t. vii. Paris, 1830. — Gendrin, Transac.
Medicales, Jan. 1832.— Uwins, Med. and Phys. Journ., v.
xxx. p. 441.
D. Ileus and Volvulus. — Hippocrates, HtQt vsoon;
iii., Opera, p. 491.; ZZioi Turrlrm , Op. p. 52. — Scribonius
Largies, De Compos. Med. ch. 28. — Aretaus, Curat. Acut.
1. ii. c. 5. — Paulas JEgineta, 1. iii. c. 44. — Bartholinus,
Epist. iii. p. 284.; Historia Anatora. cent. v. hist. 23,; et De
Usu Nivis Medico, p. 145. — Sydenham, Opera, p. 267. — Zn-
cidus Lusitanus, Pract. Admirab. 1. ii. obser. 29. — Bonet,
Sepulcliretum, 1. iii. sect. 14. obs. 7. 24., et I. iv. sect. 1. ob.
23.— Morgagni, Epist. xxxiv. No. 11, 12. 13.— Vicat, De-
lect. Oliservat. Pract. App. p. 31. — Hoffmann, De Passione
Iliaca, Opera, Supp. ii. n. 2. — Sugar, Systema Moriborum,
&.C p. 321. Vien. 1757.— Quarin, De Cur. Feb. et Inflam.
p. 384. Vien. 1781. — Monro, primus, Observ. en Intus-sus-
ceptio, in Edin. Med. and Phys. Essays, vol. ii. art. 27.; Ibid,
vol. iii. p. 387. — Simson, in Ibid. vol. v. par. ii. p. 664. — De
Huen, Rat. Med. par. i. p. 113., par. viii. c. 5., par. ix. c. 5.,
and par. xi. c. 3. — Monro, tertius, Morbid Anat. of the Gul-
let, Stomach, and Intestines, 8vo. 2d edit. p. bd.—Whalely,
in Philos. Trans, vol. lxxvi. — Fowler, Med. Reports of To-
bacco. Lond. 1785. — Barthez, Ohservat. sur les Coliqueslli-
aques essentiellement Nerveuses, in Mem. de la Sociele Med.
d'Emulation, t. iii. p. 401. — Darwin, Zoonomia, vol. ii. p.
533. — Ludxuig, De Causis Obstruct. Alvins, p. 32. — How-
ship, in Med. and Surg. Journ. vol. viii. p .129. — Hufeland,
in Journ. der Pract. Arzneyk. ii. b. p. 309. ; et in Journ. der
Pract. Heilk. Nov. 1809, p. 133.— Schaffer, in Ihid. Dec.
1810, p. 30. — Conradi, in Hufelandh Journ. der Pract.
Arzneyk. vi. b. p. 495. — Forbes, in Edin. Med. Comment.
vol. ix. p. 266. — Scott, in Ibid. vol. v. p. 183. — Nevinson,
On Crude Mercury in Obstructions of the Bowels, London,
1788. — Baillie, Series of Engravings, Case. iv. tab. i. — Sims,
Observations on Epidemic Disorders, kc. p. 27. — Gadolla,
De Vomita Intestinor. sive Volvulo. Vien. 1771. — Hurt-
mann, De Ileo Cognoscendo et Curand. 1780. — Gallesky,
Vom Miserere, etc. p. 70. — Sa/gues, in Journ. de Medecine;
1. xxxvi. p. 515. — Wolff, in Hufeland's Journ. der Pract.
Heilk. xvii. b. p. 189. — Bureau, in Mem. of Med. Soc. of
Lond. vol. ii. p. 227.— Baldinger, N. Magazin, viii. b. p. 77.
— Vogel, Methode den Ileus, <Sic. — Loder's Journ. fiir Chir-
urg. i. b. p. 541. — Monfalcon, in Diet, des Sciences Med.
t. xxiii. p. 511. — Raige Delorme, in Diet, de Medecine,
vol. xxi. p. 402. — Richter, Die Specielle Tbcrapie, iv. b.
p. 171 — 226. — Rayer, Archives Gem'-i. de Med. t. v. p. 68.
— Lebidois, Ihid. t. xiii. p. 230. — Louis, Ihid. t. xiv. p. 185.
—Regnault, Journ. Univers. des Scien. Med. t. iv. — Mor-
tier, Journ. Complement, des Scien. Med. I. iii. — Faget,
Journ. Geni r. de .Med. t. xi. — Dance, Sur les Invaginations
des Intestins, in Repert. Gener. d'Anatom. et Patbolbg. &c.
t. i. p. 441. — Smith, in Edin. Med. and Surg. Journ. vol. ix,
p. 2ZT.—Maru-clI, in Ibid. vol. xxi. p. 12.—Rolland, Ar-
chives Gem'-r. de .Medecine, t. v. p. 220. — Fuschius, in Ihid.
t. ix. p. 116.— M. Buct, in Ihid. p. 230.— Belluci, in Ibid,
t. xviii. p. 296. — Blizard, in Trans, of Med.-Chirurg. Soc.
vol. i. No. 14. — Baud, in Journ. Gen. de Med. t. xxiv. p.
20.— Brandts, in Nouv. Journ. de Med. t. v. p. 89.— Willan,
Miscellaneous Works, by Smith, Lond. 1820, p. 285. — Alirr-
crombie, On Diseases of the Abdominal Viscera, tc. Edin.
1828, p. 104.
Those who wish to he acquainted more fully with the opin-
ions of the writers of the fifteenth, sixteenth, and seventeenth
centuries, as to Ileus and Colic, will lind them detailed at
considerable length in BONET'8 Polyulthes, &.c. fol. vol. i.
p. 500. et sen. ; in his Mercurius, fol. p. 115. ; and in M.v.v-
cet's BibHotneca Medico Practica, ltd. vol. i. p. 575. Al-
though I have not availed myself of these collections in anv
way, owing to my circumscribed limits, and desire to give
more precise information of a later dale, and more iu accord-
ance with my experience, than that which they furnish, yet
will thev be found to contain much of what has been con-
sidered of much more modern date, and, wheT sifted from
the refuse, of no mean value.
The Bibliography of these disease*, in Ploucquet's
Med. Digesta, is brought down to the commencement of this
century; hut many of the references are inaccurate: that by
VoUNO is very scanty, and not select. The list appended to
the art. Ileus, in the great French Dictionary, is entirely a
catalogue of Theses on the subject, of no value ; instead of
consisting, as it ought, of references to the experience of the
best practical writers.
COLON. — Syn. ICmXor. Der Grimmdarm, Ger.
Hie Large Bowel.
1. The colon is very often the seat of disease,
the rest of the alimentary canal being but slightly
affected. In some complaints, as constipation,
colic, and dysentery, it is the part principally dis-
ordered ; and in others, as indigestion, diarrhcea,
ileus, peritonitis, &c, it participates in the disease
with the rest of the digestive organs. The inves-
tigation, therefore, of these maladies necessarily
includes the consideration of the chief morbid
states of this viscus. But there are other derange-
ments which require a brief notice at this place,
and which do not belong to these diseases, or to
those changes of structure that are common to it
and the rest of the alimentary canal, and which
will be considered in the article on the Pathology
of the Digestive Canal.
Torpor or Atony of the Colon, and its
Consequences. — Classif. — I. Class,
I. Order {Author).
2. Defin. General debility, with indigestion;
slow or irregular state of the bowels; distension,
borborygmi, or stridulous noises, in the course
of the colon; frequently pain or uneasiness, some-
times with tumours in some part of this viscus.
3. i. Its Pathology. — Atony and distension
of the colon may be variously associated with
Dther disorders. They obtain more or less in all
cases of constipation and colic which depend not
upon inflammation, or upon diminution or con-
striction of the canal of the intestines ; and they
are also often complicated with torpor of the liver,
and deficient secretion from the internal surface
of the colon. Distension is usually occasioned by
flatus or focal matters ; and it may produce little
or no inconvenience, beyond constipation, until
it reaches a great extent ; but it frequently sives
rise to flatulent and stercoraceous colic, and even
to ileus. The gases found in the colon are azote,
carbonic acid gas, and carburetted hydrogen, in
varying proportions ; and, when they accumulate
largely, they always produce borborygmi or an
unpleasant or painful sense of distension, and con-
stipation or colic. A. Flatulent distension of the
colon (see Flatulence) is commonly depend-
ent upon want of vital tone of the digestive organs
generally, and of this viscus particularly. In irri-
tation or inflammation of the bowels, flatus is
also generated in great quantity ; but it is usually
expelled quickly, especially when they are un-
obstructed, owing to reaction of their muscular
coats. Much doubt exists as to the source
whence this flatus proceeds. The circumstance
of its rapid reproduction after its evacuation,
when the bowels contain no substances which
could give rise to it, and various physiological
considerations, lead me to infer that it is in great
measure exhaled from the digestive mucous sur-
face ; the gases consisting chiefly of those which
pass into, or are fonnedlw, the blood ; and, in
health, are afterwards given out from it, on the
COLON — ToRroR of.
383
mucous surface of the lungs. Persons who often
expel the flatus from the lower bowels, where it
evidently is destined to perform useful purposes
in the economy, are most subject to an atonic
state of the colon, ami to a continued as well as
an increased generation of the intestinal gases;
and. when circumstances prevent the accustomed
frequency of their discharge, are most liable to ex-
perience the effects of their accumulation. Atonic
distension of the colon by flatus is also a common
attendant upon congestion of some one or more of
the abdominal viscera, and even upon general vas-
cular plethora, particularly when it oppresses the
circulating energies. It also often accompanies
hysteria: and, owing to the increased sensibility of
the organic nerves, as well as to the morbid irrita-
bility and irregular action of the muscular fibres of
tin- bowels, gives rise to various painful sensations
in their course, and to anomalous states of disorder.
4. B. When an atonic aid flatulent state of
the colon is associated with morbii irritability
of the muscular coat, painful sensations in some
part of the course of this viscus are frequently
complained of, particularly by females ; are by
them often referred to its left arch and descending
portion; and are attended by loud croaking or
stridulous noises, especially upon full respiration
and mental emotion. The bowels are usually
constipated, and attempts at evacuation are ac-
companied with slight tenesmus, the stools being
discoloured, hard, slimy, or in lumps. The ab-
domen is tumid ; and tenderness, often shifting
its place, and varying in degree or duration, is
sometimes felt. The whole digestive organs
necessarily participate in this state of disorder,
and perform their functions imperfectly. The
nervous system of organic life acquires increased
sensibility ; the cerebro-spinal system becomes
morbidly susceptible of impressions, particularly
in females; the countenance is pale, slightly dis-
coloured, and often covered by an oily moist-
ure ; the tongue is loaded, flabby, sometimes
large, presenting fissures on its surface, and the
impressions of the teeth on its edges; the pulse is
weak and soft; and a sense of distension and op-
pression follows a full meal. This state of dis-
order is very frequent in young females, who take
not sufficient exercise ; and, when neglected, is
often the forerunner of more serious ailments,
both of the bowels and of the generative organs.
5. C. Deficient vital energy of the colon also
gives rise to relaxation or irregular action of its
coats, to constipation, and to collections of faecal
matters, generally with more or less flatulence.
Fcccal accumulation/! to a great amount is most
commonly met with in aged females, or persons
far advanced in life, who have injured the tone
of the bowel by the frequent use of cathartics,
and have passed a sedentary and luxurious ex-
istence. They also occur, but to a much less
extent, in children and young persons, especially
females from the ninth to the eighteenth year of
age, and even upwards. Sometimes they occa-
sion large tumours, particularly in the caecum
and sigmoid flexure, hut occasionally also in the
transverse arch and other parts of tin? colon.
When distension proceeds from retained faecal
matters, in addition to the local >L'ms observed on
careful examination and percussion of the abdo-
men in the course of this how-el, numerous symp-
tomatic ailments are complained of. These vary
but little from those described above (§ 4.), and
in the article treating of accumulations in the
GjECUM (§ 11.). The countenance and skin are
generally foul, unhealthy, and devoid of .anima-
tion ; the perspiration i's thick, clammy, foetid,
and oleaginous; the breath very offensive -, the
tongue loaded or furred; the lips and gums are
pale; muscular energy is much diminished; the
appetite imperfect or capricious ; digestion dilli-
cult ; headach or vertigo is often present ; the ab-
domen is tumid, doughy, and inelastic. ; the urine
is loaded; the bowels are either constipated or ir-
regular, or, if daily evacuations take place, the mo-
tions are slimy, very dark or otherwise discoloured,
scanty, and offensive; and the pulse soft, weak,
often slow, but afterwards accelerated. In many
cases, pains in the loins, abdomen, and limbs, are
complained of, with mental inactivity, general las-
situde, oedema of the lower extremities, flabby in-
elastic state of the soft solids, leipothymia, or faint-
ing, upon quickly assuming the erect posture, and
occasional fits of sinking, especially in females.
6. Although torpor of the colon is most fre-
quently followed by fiecal accumulations and
distension, yet these are neither constant nor
necessary results of this state, at least to any
very manifest extent; for sordes and fiscal col-
lections may be very injurious to the mucous
surface, without, proving so from their bulk or
mechanical effects only. Indeed, they are often
noxious from their acrimony, without occasion-
ing remarkable distension, or any degree of ob-
struction, particularly when the vital energies are
depressed. Their presence, therefore, should be
inferred rather from various remote symptoms,
than from those which are referrible to the colon
itself. But, whenever disorder of remote organs
leads us to suspect torpor of this bowel, the
practitioner should make an accurate examination
of all the abdominal regions, commencing with
that of the caxum, following the course of the
colon, between the ilium and right ribs, below
the epigastrium, and under both hypochondria,
to the left side and iliac fossa, and to the hypo-
gastrium. If a sensation of doughy fulness be
felt by the examiner, in any part of its course,
the internal surface of the bowel is probably lined
with sordes and accumulated secretions, which
its vital energy has not been sufficient to throw
off. If hardness be felt, with more or less tu-
mour, feeal collections are most -likely formed.
Hut the evidence furnished by this examination
should not satisfy us: we should enquire after the
symptoms stated above, particularly the find or
clammy tongue, foetor of the breath, unnatural
state of the countenance and cutaneous surface,
and the offensive and morbid evacuations usually
attendant upon this ailment. A belief is too
generally entertained, that fecal matters and
sordes will not accumulate in the colon, unless
the patient has been constipated. But they may-
collect in its cells, the more central part of the
canal allowing daily evacuations; and they may
even remain there for a considerable period, pro-
ducing much irritation, and even a relaxed state
of the bowels; thereby misleading the judgment
I of the practitioner as to the pathological state
constituting the disorder. I low, therefore, is he
to form an accurate opinion? By a careful ex-
amination of the abdomen in the course of the
colon, of the urine, of the stools, and of all the
384
COLON— Torpor of.
organic and animal functions, and by ascertaining
the presence of the symptoms enumerated above
(§ 4, 5.)- In many cases, when the morbid
collections have become acrimonious, an irritative
diarrhoea continues for some time, or recurs at
intervals, before the morbid matters are fully
thrown off, owing to spasmodic constrictions of
parts of the bowel. On these occasions the stools
are watery or fluid, and are apparently composed
of discoloured faces, broken down and mixed
in a liquid; at other times they are dark green,
muddy, putrid, &c. ; very frequently they are
slimy, containing lumps of hardened feces, very
offensive, and of a dark green or brownish black
hue; and their evacuation is preceded by griping,
tenesmus, or a scalding sensation at the anus.
7. D. Imperfect action of the colon is evident-
ly dependent upon deficient vital energy of the
frame, owing either to original conformation, or
to various causes of exhaustion, acting chiefly on
the digestive canal and associated viscera, with
more or less torpor of the biliary functions. When
allowed to continue, it perpetuates and augments
the morbid condition in which itself originated ;
drawing other organs within the sphere of disease,
particularly those of mental manifestation, and of
generative function, in the female. In young per-
sons it often occasions, or is complicated vrith, cur-
vatures of the spine, chorea, chlorosis, retention or
suppression of the menses, nervous tremors and
convulsions, &c, and when the distension of the
colon is great, dyspnoea or shortness of breathing,
palpitations of the heart, &c; these affections ap-
pearing oftener, perhaps, along with it, as asso-
ciated effects of depressed vital power, than as con-
sequences of this particular lesion of function.
8. E. The more remote causes of torpor and
distension of the colon are, confinement in close
and crowded apartments during the greater part
of the day, and sleeping in chambers similarly
circumstanced ; constrained and sedentary posi-
tions, in which the abdominal muscles remain
nearly inactive; premature and excessive cultiva-
tion of the mental, to the neglect of the physi-
cal, powers, — the discipline of modern boarding
schools; the inappropriate combination and use
of purgative medicines ; indolent and luxurious
habits; occupations which prevent bodily activity,
and particularly those performed by the assistance
of machinery, .and in hot foul air stagnant in
crowded manufactories ; pre-existing debility of
the stomach and digestive canal, or of the frame
generally; paraplegia or hemiplegia; disease of
the spinal column, its membranes, or cord ;
neglect of the first intimation to alvine evacua-
tions; venereal excesses; the disgusting habit of
expelling the flatus from the bowels ; and by
whatever weakens, either directly or indirectly,
the vital manifestations of the alimentary canal,
or disorders the general health.
9. Local and constitutional effects produced
by torpor of the colon. — A. Owing to the course
and connections of the colon, to the remote causes
above enumerated, and to the depression of di-
gestive and vital energy they occasion, the matters
discharged into this bowel from the small intes-
tines, and the secretions from its own internal
surface, are liable to be retained for a long time.
Faecal accumulations and obstruction have been
now shown necessarily to follow such retention.
It may be next requisite to point out certain of
the most important and frequent consequences of
these states : — a. One of the most immediate is
the retention of the mucous secretion within the
follicular glands, as well as in the ducts leading
from them; causing distension, and subsequently
inflammation and ulceration of them. b. The
retention of focal matters in the colon is often
followed by absorption of much that otherwise
would have been excrementitious, both into the
general current of the circulation, and, at first, at
least, into the blood which flows into the portal
veins, where it often excites and irritates the
liver, and either is partially removed by this
viscus, giving rise to increased or vitiated biliary
secretion, or contaminates the whole circulating
and secreted fluids, c. The bile also may, par-
ticularly in warm countries, and in persons in
whom it is habitually secreted in excessive quan-
tity, be rapidly conveyed along the small intestines
with the chyme, and yet be retained too long in
the caecum and colon, whence it may be absorb-
ed, with a portion of excrementitious matters,
into the circulation, and give a lurid or unhealthy
aspect to the countenance, and occasion various
constitutional ailments, characterised chiefly by
lassitude, debility, irregular action of the bowels,
loaded urine, and a foul tongue, d. Faecal ac-
cumulations, when allowed to remain too long in
the colon, and thereby to give rise to gaseous and
noxious formations, not only impede many of its
functions, but also favour changes in the vascular
action and structure of its coats, particularly of
its mucous, sub-mucous, and muscular tunics, —
the first and second becoming irritated, inflamed,
or even ulcerated ; the third over distended, and
thereby deprived of its power of salutary reaction.
«. Among the most common consequences, also,
of torpor and fecal infarction of the colon, are
haemorrhage from it and the rectum, and hemor-
rhoidal tumours, arising immediately from the
foregoing changes, and from interrupted circula-
tion through the haemorrhoidal veins.
10. B. The effects of over-distension of the
colon upon the other abdominal viscera, owing
to the extensive connections subsisting between
them and this bowel, may be readily inferred.
a. The distended caecum and sigmoid flexure
of the colon press injuriously upon the femoral
nerves and blood-vessels, the ureters, and the
internal iliac veins; producing numbness, cramps,
pains, and, owing to the impeded return of blood,
more or less oedema, of the lower extremities.
The ascending and descending portions of the
colon press upon the kidneys and adjoining
vessels, occasioning disorder of the urinary se-
cretion, with a sense of weight, or dull aching
pain in the loins. Distension of the right and
left flexures, and transverse arch, deranges the
functions of the biliary organs, the duodenum,
stomach, and spleen, b. If the colon be dis-
tended to the utmost, not only are all these con-
secutive disorders much increased, but the de-
scent of the diaphragm is also much impeded,
and the actions of the heart and lungs materially
affected ; occasioning palpitations, intermissions,
and irregularity of the pulse, dyspnoea, and a
short and rapid respiration. Owing to this effect
upon the circulating and respiratory organs, the
return of the blood from the head is retarded,
various nervous ailments, and headach, are oc-
casioned ; and determination of blood to, and
COLON — To r p o it of — Treat u b n t.
38.5
ations and effusions of serum on, the brain
and in i nbranes, supervene as the more remote
effects, c FaBcal or flatulent accumulations in
the colon affect, in a very evidenl manner, (he
functions of the small intestines and stomach, or
increase disorder in tin-si' viscera, when it pre-
viously exists, — a circumstance of frequent oc-
currence, the function of digestion being equally
impeded with that of defecation, and owing to
the same primary pathological state, namely,
imperfect manifestation of vital power through-
out the organic nervous system. I tenee the in-
digestion, the acrid and tlatulent eructations, and
the imperfect chylifaction and nutrition, so fre-
quently associated with torpid function of the
large bowels. d. In children and young per-
sons, the mucous BOrdes, morbid secretions, and
excrementitious matters, that collect as a conse-
quence of this state, become not only a nidus for
worms — remarkably favouring their generation;
but also a cause of irritation to the mucous sur-
face, to the absorbing vessels, and to the mesen-
teric glands, owing to their partial absorption,
either alone, or with whatever chyle may be form-
ed. That diseases of the intestinal mucous sur-
face, and that obstruction and enlargement of
these glands, with tile consequent marasmus, &c,
often arise from the morbid impression and irrita-
tion caused by these retained excretions, an exten-
sive experience in the diseases of children has
fully convinced me ; and that dysentery and
diarrhoea, among this class of patients, as well
as in adults, frequently proceed from this cause,
more especially in warm and unhealthy climates,
will be acknowledged by every experienced prac-
titioner, e. Even many of the diseases that affect
the skin, and chronic ulcers of the lower extremi-
ties, arise from the absorption from the large
bowels of excrementitious matters, that irritate
and inflame, in the course of their elimination
from the blood by the cutaneous function, the
delicate vascular tissue subjacent to the cuticle.
This is particularly the case in warm countries
and seasons, in which the quantity of these mat-
ters always passing out of the circulation by the
skin is much greater than is usually supposed.
Wh itever opinion may be formed as to the origin
of BUCh affections, there can hi.' no doubt that the
treatment based upon this doctrine is the most
successful in removing them. /". Among other
consequences of fecal accumulations in the
colon, elongations and displacements of this
bowel may he ranked; and, when these changes
take place, thej increase the disorder which occa-
sioned them. It. has often been remarked, par-
ticularly by Esquikoi., lli\/.i:, and others, that
displacement of the colon is one of the most
common morbid appearances found in the bodies
of hypochondriacal and melancholic persona
Torpor or atony of this viscus favouring feral
accumulations in it, is an important characteristic
of these affections, and is manifestly connected
with the causation of displacement of the large
bowel. (See art. Htpochondri ists, &c.)
11. ii. TREATMENT. — The indications of cure
in cases of torpid function of the colon, consist —
1st, of evacuating whatever fiecal or acrimonious
matters may have collected in it : and, 2d, of
restoring the energy of the digestive organs, and
directing such regimen as maj prevent a return of
this disorder. A. Many practitioners, di
33
by the reports of the patient, or misled by the
appearances of the stools procured by the first
purgatives prescribed, stop fir short of the point
to which these medicines should he carried. It
is not sufficient to order two or three doses of
purgatives, or even of active cathartics; hut they
ought to he repeated, or continued so as to
secure their full elfect, and be combined with
such other medicines as will promote their opera-
tion without weakening the parts which they
Stimulate, and will prevent the patient from being
debilitated by them. In all affections of the
colon, purgatives that procure full, bulky, and not
frequent or watery evacuations, should be select-
ed. The preparations of aloes (F. 181. 454.),
those of senna combined with gentian (F. 266.
430.), castor oil, rhubarb and magnesia, precipi-
tated sulphur (F. 45. S2. 96.), the compound
jalap powder, &c. (F. 635, 636. 652.) operate
in this manner; and, particularly when we wish
to promote the secretions from the intestinal sur-
face, may he exhibited after a dose of calomel or
blue pill taken at bed-time ; or the compound
extract of colocynth, or the aloes and myrrh pill,
or jalap, may be combined with one of these
mercurial preparations, and the extract of hvos-
cyamus (see F. 462. 471. 881.). When it is
necessary to continue the exhibition of purgatives,
they should be either alternated with tonics, or
combined with vegetable bitters, which will both
promote their action, and increase the strength
of the patient (see F. 562. 572.). When the
motions are morbid, great advantage will be de-
rived front resorting to the use of clysmata, as
recommended in the article Colic (§ 57. (i6.
77.). If fecal collections to a great extent have
formed, they are indispensable remedies ; and
if symptoms of obstruction, or of irritation, or
chronic inflammation, are manifest, they should
be assisted by the external means there advised
(§ 66. 83.). Under every circumstance, the ex-
hibition of purgatives by the mouth, and of ene-
mata, should be persisted in until the stools
assume a natural appearance. (See also the
Treatment of diseases of the Cecum, and of
Constipation).
12. In cases where retained matters in the
colon have occasioned irritation, such clysters as
will promote the full evacuation of its contents,
and at the same time allay irritation, ought to be
resorted to from time to time. These will relax
irregular constrictions of the bowel, promote the
operation of purgatives given by the mouth, dis-
solve hardened feces, and loosen the adhesion of
tenacious secretions lodged in its cells. In cases
of this description, the soap injection, with, or
without, the addition of castor or olive oil, the
compound decoction of barley with common
salt, or the soda tartari/.atu ; the infusum. lini,
with the sub borate, or the sub-carbonate of soda
and assafcetida; the decoction of marsh-mallows,
with the infusion of camomile flowers and linseed
oil; and the turpentines triturated with white of
egg or mucilage ; will have a most beneficial
e feet, particularly when assisted by appropriate
laxatives taken by the mouth. When the irri-
tation of the bowel appears to he accompanied
by spasmodic constriction, the aperients should
be combined with either camphor, ammonia, ipe-
cacuanha, hyoseyamus, the compound galbanum
pill, Sec. ( F. 463. sjo.), according to existing cir-
386
COLON — Unnatural Positions of.
cumstances. In cases of this kind, much debility
is often present, and the functions of the stomach
require the aid of light nutritious food and gentle
tonics; the purgatives being exhibited either at
bed-time, or early in the morning, so as not to
disorder the functions of the stomach. Such
eccoprotic or alterative laxatives as are slow in
their operation (F. 503. 892.) should be taken at
night, and purgatives or cathartics that are quick
in their action early in the morning, so that they
may not interfere either with necessary food or
with requisite avocations.
13. When the focal accumulations cannot be
removed by the above means, others of a more
powerful nature, as the elaterium or croton oil,
assisted by colocynth or terebinthinate injections;
and the purgatives advised in the move obstinate
cases of colic audcotistipatinn, assisted by shocks
of electricity and galvanism passed through the
abdomen ; should be resorted to. When the
bowels are acted upon with great difficulty, the
stools being very black and offensive, we may
generally infer that not only is the colon torpid, but
the follicles are loaded or obstructed, and their
secretion morbid. In these cases, galvanism, as
shown in an instructive case by Mr. Clarkson,
promises to be of much service. In several in-
stances, when the pulse has been weak, and the
skin cool, I have added the extract of nux vomica
to the purgative with much advantage, and com-
bined a portion of this active substance with the
liniment (F. 306.) which has been rubbed on the
abdomen.
14. B. In order to prevent the re-accumulation
of morbid matters in the colon, and give tone to
the digestive organs generally, the patient should
daily attend to the first intimations of evacuation,
and promote the functions of digestion and de-
falcation, by resorting, whenever they flag, to
aperients or laxatives, combined with tonics.
Blue pill, with the aloes or myrrh pill, or F. 470.,
may be occasionally taken at night, and the tonic
and aperient medicine (F. 26b.) the following
morning. The diet and regimen should be care-
fully regulated, and exercise betaken in the open
air, either on foot or horseback. After health
has been in a great measure restored, chalybeate
mineral waters, and the artificial waters of Ems
and Pyrmont, will be productive of much benefit;
but frequently it will be more advantageous to
commerce with the Harrogate or Leamington
waters, or with the artificial waters of Seidschutz,
Eger, or Carlsbad, and have recourse subsequent-
ly to the chalybeates of Cheltenham or Tun-
bridge. In many cases, the warm or tepid salt
water douche over the abdomen, sea-bathing,
frictions of the surface of the body, and of the
belly especially, night and morning, with either a
hard towel or brush, will prove of much service.
15. II. Unnatural Positions of the Co-
lon, &c. — This viscus is not infrequently found
misplaced, and forming singular flexures, in those
who have sutl'ered from constipation, focal reten-
tion, dysentery, hypochondriasis, or melancholia.
But there are no constant symptoms by which
such changes can be inferred with much certainty
during the life of the patient. M. Esquirol
found, out of 16S dissections of melancholic
patients, the colon displaced in 33. This change
had previously been remarked by Morgagni
(Z>e Scd. et Caus. Morb. epist. iv. art. 16. et
seq.), Haller (Elem. Physiol. 1. xxiv. sec. 13.
et. seq.), Soemm erring (De Corp. Hum. Fab-
rica, t. iv. p. 313.), and Wells, but unconnect-
ed with mental disorder. In many cases, the
bowel is not only displaced, but is also elongated,
without being divided, as in its natural state, into
cells by partial partitions, and the tonic action of
its longitudinal bands. These changes seem to be
favored by relaxation of the mesocolon, and by
complete atony of those bands. An elongated
and displaced state of the colon is common in
cases of old hernia; and in these is often con-
nected with a stretched appearance of the mesen-
tery, but without any organic change of the
coats of the bowel : but sometimes the unnatural
flexure or duplicature is adherent at its opposite
sides, forming a large loop, particularly when it
has been consecutive of acute or inflammatory
dysentery. Displacement may take place in any
part of the bowel, but it is most common in the
transverse arch and sigmoid flexure; the former
part hanging down towards the pubis, generally
in an unadhering, but occasionally in an adher-
ing, loop; and the latter part crossing over to
the right side of the abdomen, or passing behind
the pubis. Duplicatures of the colon may also
form at the right or left parts of its arch; the op-
posite peritoneal surfaces being more frequently,
in such cases, adherent to a considerable extent
by coagulable lymph. Several plates are given
by Mr. Annesley illustrative of this change;
which is not infrequently observed in fatal cases of
chronic dysentery, particularly in warm climates.
That these unnatural flexures are also often caus-
ed by fecal collections, and by obstructions to
the fecal discharges situated either in the rectum
or in the sigmoid flexure of the colon, appears
very probable; but they may also arise from a
naturally elongated formation of the bowel.
That, when once produced, they favour such
collections, with their consequences, particularly
severe dyspeptic and hypochondriacal ailments,
dysentery, severe colic, or even ileus, and great
distension or inflammation of the colon or small
intestines, cannot be doubted; but that they will
occasion insanity or melancholy, as Esquirol
and Hinze suppose, seems not to be made out.
Dr. Yelloly states that Mr. Lawrence and
Mr. Dalrymple, who have examined many
bodies of insane persons, have very seldom ob-
served in them any deviation from the natural
course of the colon.
16. As we have no certain or even probable
means of ascertaining the existence of the?e
changes during life, it is unnecessary to offer any
remarks on their treatment. But this is a matter
of but little importance, as the disorders which
they produce are in all respects the same as those
already noticed; and even if their nature were
recognised, they can be remedied or alleviated
only by the means described above, particularly
by laxative and solvent enemata; and by what-
ever will, whether taken by the mouth, or injected
per anum, preserve a fluid state of the stools, or
reduce them to a softened condition, and promote
the healthy secretions and regular functions of
the large bowels, and of the digestive organs in
general. (See F. 82. J)8. 144.) — (See art. Di-
gestive Canal, for the organic lesions of the
colon; and arts. DiaSkho: a, Dysentert, and
Intestines, for its other diseases.)
COMA AND LETHARGY.
387
BlBLIOO. axi> Refer. — Severinut, Da Recond. Absr.
Nat I. iv. cap. 35. (Greatly distended, fyc.) — Adolphi, De
Intestino Cell., mull. Morbor. Nido, be. Lipsisc, 1718. —
Voter; De Situ Natur, al Prtatematurali [nteat. Ooli. Wi-
tch. 1737.— Fischer, Da Morbis IntesL Coli.&c. Erf. 1728.
— Efamiergvr, Observat. Clinic. Jens, 175-1, p. 10. (Great
distention.) — Stoerck, Annus Med. t. i. p. 126., et t. ii. p.
Flatulent and fiscal distension, and laceration of the
longitwiinat tnn.fc.) — Leusinirk, lie Morbis a Situ Intes-
lin. Crassor. pendentibus. Goet. 17.56. — fan Royen, Dc
Intest Crania, multorum Mori). Causa et Sedc. Lugd. Bat.
it, j, Bvo, — White, Cases in Surgery, p. 13. — Hamilton,
On the Utility of Purgative Medicines, 8th ed. 8vo. 1826. —
Abernethy, On the Constitutional thi^inof Local Diseases,
8vo. — AVA, Patholog. Intest. Coli. Erlang 1802. — Wells,
in Transac. of Society for promoting Med. and Chirurg.
Knowledge, voL iii. p. 158. — Stjutrol, in Diction, des Sci-
ences Med. (. xxxii. p. 172.; et Journ. Gcner. de Med.
Fran, et Etrang. Mai el Juin, 1818. — Geoghegan, Transac.
of the College of Physicians of Dublin, vol. i. p. 194. (Great
distension of the colon.) — Stoker, in Ibid. vol. ii. p. 6.
Rupture from distension, without ulceration.) — Hints,
Archives Giner. de Med. t. iii. p. 125. (Displacement of
colon.) — Yello/y, in Edin. Med. and Surg. Journ. vol. xvi.
p. 476. (Displacement of colon.) — C/arkson, in Ibid. p. 475.
— Annesicn and Author, Researches on the Diseases of In-
dia, &.C., vol. ii. p. 50. et seq.
COMA. — Stn. and Deriv. Kwua, Profound
Sleep (from Kto, I lie down). Cants, Sauva-
ges, Good. Cataphora, J. Frank. Lethargie,
Assoupissement, Fr. die Schlafsucht, Schlaf-
fieber, Ger. Sopore, Somnolenza, Ital.
Classik. 2. Class, Nervous Diseases; and
1. Order of this Class (Cullen). 4. Class,
4. Order (Good). IV. Class, III. Or-
der (Author, in Preface).
1. Df.fin. Preternatural sleep, with physical
torpitude, and suppression of the mental powers.
2. I. Varieties and Symptoms. — There
are various modifications of coma, each of which
have received different appellations, as Lethargus,
Cataphora, Agrypnia, Cams, &c. ; these names
being also used generically by some authors, but
more frequently specifically, as I shall apply them
on this occasion. They are all most commonly
symptomatic of pre-existing disease; but they are
also occasionally primary affections. I shall,
therefore, after describing very succinctly each
variety of coma, and its more constant symptoms,
notice it first as a primary affection, and next as
an important phenomenon in other acute diseases,
particularly of their severe forms or advanced sta-
ges: afterwards the different pathological states
causing this affection, the signs which distinguish
them, and, lastly, the means best adapted to re-
lieve them, will be briefly stated.
3. i. Coma VlGIL — Agrypnia, Kwua aynv-
nwvdt: (Hippocrates), Typhomania, Sopor
cum Agrypnia — is characterised by a constant
disposition to sleep, without falling into quiet,
sound, or natural sleep; by low muttering deliri-
um, or unconnected talk; unnatural action of the
hands and lingers, sometimes also of the feet;
pale sunk countenance; a natural or but slightly
increased temperature of the head; by the patient
opening the eyes and staring about upon the
slightest disturbance, or starting up as if frighten-
ed by strange sights, and again attempting to lie
down; and sometimes by difficulty of speech and
of swallowing liquids.
4. ii. Lethargy — Lethargus* (from Xi-6n,
* I have, conformably with the received acceptation of
lethargy in this country, made it the slightest form of soporose
coma; although the ancients, our countryman Willis who
has written Bbly on this affection, the greater number of wri.
ters of the sixteenth and seventeenth centuries, and many
modern German authors, have defined it nearly as follows:—-
"profound sopor, or preternatural sleep, with fever ami de-
Lethe, et aoyoe, celer), Veternus, Lot. — is cha-
racterised by slight but constant somnolency, or
mental and corporeal torpor, evidently depending
upon a morbid condition of the brain; when ad-
dressed, the patient answers forgetfully, and after-
wards sinks into the same state as before. This
is a slighter grade of the following varieties, and
may pass into them.
5. iii. Coma Somnalentum — Cataphora — is
characterised by sopor or profound sleep, without
the power of wakening spontaneously; the pa-
tient, when roused, slowly opening the eyelids,
and answering either rationally, forgetfully, or
incoherently, but immediately afterwards falling
into the same state of profound sopor; and fre-
quently by relaxation of the muscles of the lower
jaw, it thereby differing from apoplexy and carus.
6. iv. Coma profundum — Carus, Kufios — is
characterised by its more or less sudden inva-
sion; by the profound sopor, the eyes being shut
as in a deep sleep, and the patient being generally
deprived of motion and sensation. Sometimes,
however, upon being called to loudly, he opens
his eyes, but immediately shuts them, without
answering any question; and occasionally when
pinched he draws away the part, indicating re-
maining sensibility; the breathing is undisturbed
or irregular, sometimes laboured, but without
stertor : there is seldom much febrile heat, and
the evacuations are passed without consciousness.
7. A. Review of the chief symptoms. — a. The
pulse varies greatly in each of the above states of
coma. It is generally slow, full, and soft; but
it is also often small and quick in coma vigil, or
in any ot the varieties, when accompanying the
last stages of fever; and small, hard, and some-
times irregular, in the coma attendant upon in-
flammatory action of the brain or its membranes.
It is also frequently unequal, intermittent, and
generally slow, but sometimes also quick, in the
coma produced by injury of the brain, and by
hemorrhage or effusion of fluid within it. b. The
respiration is often natural, as in coma vigil;
sometimes accompanied by sighs, or laboured, as
in coma profundum; frequently slow, and very
seldom stertorous, unless in the coma of apo-
plexy, c. The pupils of the eyes are generally
more or less dilated, and sluggish in their mo-
tions, or altogether insensible to light; but they
are sometimes, in the most unfavourable cases,
much contracted, or one contracted and the other
dilated, d. The countenance, is usually tumid,
and without expression; sometimes pale or bloat-
ed, or red or injected; the eyes are prominent or
suffused, and the head somewhat warmer than
natural, or of the healthy temperature, the beat
of the carotids being full or strong : in the coma
consequent upon fever, and in coma vigil, the
features are commonly pale, sunk, and cool; the
action of the carotids being weak and soft in
some cases, and hard and oppressed in others,
e. The mental powers are commonly suppressed;
but upon being momentarily excited, they some-
times appear more or less disordered, particularly
in any of the states of coma supervening upon
fever, or inflammation of the brain or its mem-
branes; low delirium and febrile heat then being
also present. /. The surface of the body is often
natural, sometimes cold or clammy; but when
Urium " thus applying the term to the more profound state
of febrile coma.
388
COMA AND LETHARGY — Idiopathic
SYMPTOMATIC.
the affection is caused by fever or inflammation,
the temperature may he somewhat elevated,
and the dun dry. g. The extremities are fre-
quently natural at first, hut they are also often
cold or clammy, or become so. ft. The posi-
tion is commonly supine, without attempts at
motion, in profound coma; and, in the worst
cases, the patient slips down in bed. i. The
tongue is natural, or merely much loaded, in
some instances; hut in coma symptomatic of in-
flammation or fever, it is usually furred, dry, and
brown, hard, and constricted. k. The divine
excretions are either retained, or passed without
consciousness.
8. B. Duration and termination. — a. Any one
of the forms of coma may be sudden in its attack,
and terminate speedily in death; or it may come
on gradually, and he of short duration, sense
and voluntary motion as slowly returning. The
seizure may he repeated frequently, or it may be
periodic, particularly when attendant upon epi-
lepsy, or remittent fever of a bad form. When
its accession is slow, it often commences with
drowsiness or headach. b. Its duration is very
various; the lethargic and slighter varieties being
occasionally of long continuance — sometimes
lasting many weeks, and spontaneously passing
oft"; the more profound states of coma frequently
terminating fatally in a few hours, and seldom
continuing longer than a very few days. c. It
may terminate in either recovery or death, or in
some other disease with which it is more or less
closely related, as apoplexy, paralysis, insanity, or
melancholia, epilepsy, and epileptic or other forms
of convulsions with which it occasionally alternates ;
and in inflammation of the brain or its membranes.
9. C. Diagnostic remarks. — The states or
grades of disease described above may pass one
into the other, or into some other malady, wheth-
er they appear primarily or consecutively. They
are often very nearly allied to, or rather are less
degrees of, apoplexy; and apparently consist of
a somewhat similar condition of the organic, ner-
vous power and vascular action within the brain,
to that which obtains in a great proportion of the
attacks of that disease (§ 62. et seq.), particularly
those which do not immediately depend upon
hemorrhage, a. The close resemblance of many
cases of coma vigil to ecstasy, and of the other
states of coma to catalepsy, not only as to the
grouping of the sensible phenomena which re-
spectively constitute them, but also as to their pre-
sumed proximate causes, indicate that catd'lepsy
and cataleptic ecstasy are merely unusual modifi-
cations of the state of cerebral disease now under
consideration, b. The absence of stertor consti-
tutes the chief difference between the most pro-
found state of coma, cams, and apoplexy, c. The
fulness and strength of the pulse, particularly in
the carotids, and the natural or strong state of the
respiration, are sufficient to distinguish coma from
syncope, in which latter the action of the heart is
greatly diminished primarily, the functions of the
brain tailing consecutively. </. Coma differs from
a.sphyxfi in the circumstance of the respiratory
functions being first suppressed, and subsequently
the action of the heart in the latter; the conse-
quent coma arising from congestion of venous
blood in the brain, produced by the abolished re-
spiration, and obstructed circulation through the
lungs and cavities of the heart.
10. II. Of Primary or Idiopathic Coma.
— Either of the varieties described above may
occur as a primary affection arising from states of
the organic nervous power and circulation with-
in the brain, which will be noticed in the sequel
(§ 13.), and which are commonly produced by
the following agents: — Causes. — Ihe continued
or intense action of cold upon the nervous system
and circulation; the influence of narcotics, par-
ticularly in some constitutions; indulgence in
spirituous or intoxicating liquors, either carried
too far or continued too long; venereal excesses;
insolation; fatigue or prolonged watching; the in-
fluence of particular odours, condiments, or kinds
of food, in some temperaments; inanition or ex-
haustion of vital power, by whatever cause, es-
pecially in the aged of the male sex ; immoderate
evacuations or discharges; mepbitic or carbona-
ceous fumes or gases; sadness, anxiety, fright,
terror, anger, and other violent mental affections;
the inappropriate use of either warm or cold baths;
the exhaustion of vital or nervous power by ex-
cessive or long continued pain; concussions and
injuries of the brain ; erratic, atonic, or retrocedent
gout; pregnancy or child-bearing; and suppression
of the menses or lochia; are the causes which
produce, in a primary form, any of the states of
coma described above.
11. III. Symptomatic Coma. — Either of the
varieties of coma may supervene in the advanced
course, more rarely on the. invasion, of intermit-
tent, remittent, or continued fevers, particularly
typhus; of inflammations of the brain and its
membranes; and of insanity and melancholia.
Simple determinations of blood to, or congestion
of, the encephalon will frequently be sufficient to
induce the slighter states of coma; whilst its more
severe or profound conditions are common conse-
quences of effusions of blood or serum, and of
numerous organic changes occurring within the
head. (See Brain — Organic Lesions of its Mem-
branes and Substance, § 21 — 84.). It is one of
the most important symptoms that appear in the
course of erysipelas of the face or head, and of
exanthematous fevers; it may likewise supervene,
particularly coma vigil, in the advanced stages of
several acute maladies evincing exhaustion of the
vital energy of the brain and nervous system, and
in those in which the circulating fluid and secre-
tions become vitiated or contaminated. The co-
ma which is usually consecutive of epileptic or
convulsive attacks consists of the slighter varieties
denominated lethargic and somnolent, forming a
part or consequence of these diseases. Coma is
sometimes, also, a symptom of severe hysteria,
particularly in plethoric persons with interrupted
catamenial discharge; and, in rare instances, of
worms, but by no means so frequently as stated
by some writers. The occasional occurrence of
any of the varieties of coma from suppression or
retention of urine, from metastasis of gout and
rheumatism, from the suppression of accustomed
discharges, and more rarely from the retrocession
of eruptions, and the drying up of old ulcers,
should not be overlooked, particularly as such
morbid relations require a peculiar and appropri-
ate treatment.
12. IV. The Prognosis in most cases of coma
is unfavourable; for, although many will recover
— even the great majority — the slighter cases will
often present sudden changes. A much more
COMA AND LETHARGY — Pathology of.
389
favourable opinion may be entertained of coma I
when it is produced by narcotics and spirituous
liquors, than when it comes on in the course o\'
febrile or malignant diseases, particularly after
the absorption of morbid matters into the blood.
The occurrence of epistaxis, of swellings of the
parotids ; the accession of the catamenia, or the
hemorrhoids : a feculent diarrhoea ; copious gen-
eral perspiration ; abundant discharge of urine
depositing a sediment; erysipelas, eruptions, boils,
gout, or rheumatism, appearing in externa] parts,
particularly the lower extremities; and the re-
turn of sound natural sleep during a state of j
coma vigil, or typhomania; are very favourable —
indeed, critical symptoms. The persistence of
the affection; scanty secretion or retention of
urine; subsultus; spastic contractions of one or j
more limbs; loss of speech, and total insensibil-
ity; distortion of the eyes; vomiting or retching;!
a previous breaking up of the constitution; pre-
existing cachexy, and old age; bleeding from the
ear, when it has been caused by external injury,
as in concussion; constant supine posture, and j
slipping low down in the bed ; coldness of the
head, with sunk countenance, and cold clammy
surface ; loss of the faculty of deglutition, or re-
turn of matters put in the mouth; are very un- j
favourable signs.
13. V. Pathology. — A. Primary and symp-
tomatic coma may be resolved into the following
pathological states, either of which may exist
singly, or in conjunction with one another: — 1st,
Exhaustion of the organic nervous influence sup- i
plying the brain, or torpor or suppression of it, i
inducing a state which may be called paralytic —
a paralysis of all the cerebral functions : this con-
dition is produced chiefly by directly or indirect-
ly sedative causes, and by whatever depresses '■
or exhausts the vital energy generally, or the
nervous power in particular : it may be attended
by anaemia of the brain ; and then the coma will
be preceded by, or accompanied with, convul-
sions, or alternate with them ; but it is more j
frequently productive of some one of the states
about to be noticed, especially congestion, and
occasionally effusion within the head : it may go
on to dissolution, or it may be followed by re-
action and active congestion or acute inflainma- !
tion ; the comatose states sometimes observed
at the invasion of dangerous forms of fever, and
of certain apoplectic seizures, and the coma of ;
the early stage of concussion of the brain, being
of this description. 2d, Congestion of the capil-
laries, veins, or sinuses of the brain, is, perhaps,
the most common morbid condition that obtains
in coma, as respects the vascular system : but this
state can scarcely arise, unless the organic nervous
influence with which these vessels are supplied
has been exhausted or depressed, excepting in
those cases where the congestion proceeds from
obstructed return of blood by the sinuses, or by
the large veins coming from the head : in many
cases, therefore, the existence of this state pre-
suppose^ tliiit first described, at least to some ex-
tent; and whither thus originating, or proceeding
from impeded or obstructed return of blood, will
equally occasion pressure of the organic nervous
and cerebral tissues, and suppression of their
functions : congestion of the blood-vessels within
the bead may, moreover, be associated with some
other morbid states, as with contamination of the
33*
circulating fluid; as in the coma that occurs in the
advanced stage oftyphus, and when morbid se-
cretions are absorbed into the blood. 3d, Active
determination of blood to the bead will seldom
occasion more than lethargy or coma vigil, —
states which are frequently produced in this way in
the advanced stages of various acute diseases, and
sometimes by the use of anodynes, which, in some
constitutions, disorder the nervous functions and
excite the cerebral circulation. 4th, Inflammation
of the brain or membranes, owing to the tume-
faction consequent on it, &c, will often be ac-
companied with coma; and still more frequently
terminate in it, as shown in the article on that
disease : and, as we have seen that coma will
thus proceed from very different or even opposite
states of organic nervous power, and of vascular
action, it becomes a matter of the utmost practi-
cal importance to distinguish them with accuracy :
but not only may those pathological conditions
exist in different cases, they may obtain at differ-
ent stages of the same case : thus the coma of
concussion, in which the first of those conditions
exists, may successively pass into congestion and
inflammatory action, formisg the three stages
which Mr. Abernkthy has very accurately
pointed out in concussion of the brain ; coma,
accompanied with very different symptoms, and
modified in degree, being present throughout.
5th, The circulating fluid itself may be more or
less changed ; it either being of a darker colour,
and in a less decarbonised state, than in health ; or
having entirely lost the power of coagulating,
or presenting a coagulum of a weak or dissolved
texture. (See Blood, § 94.) In addition to
this state of the circulating fluid, congestion of
the cerebral vessels and increased action of the
heart may exist, as in the advanced stages of
malignant, exanthematous, and febrile diseases ;
these associated lesions may be also preceded by,
or coexistent with, depressed vital or organic
nervous energy of the encephalon. 6th, Effusion
of blood or serous fluid within the brain will
give rise to profound coma, generally as a conse-
quence of either the first, second, third, or fourth
preceding states, occurring either primarily, or in
the advanced progress of febrile diseases.
14. B. It must be evident, that a successful
treatment of coma, under the numerous circum-
stances and diversified forms in which it presents
itself in practice, must be based upon a recogni-
tion of the pathological states that occasion it.
But how are these states to be ascertained ? The
difficulty even of an approximation to this know-
ledge is doubtless great ; but the practical results,
to which the information leads, are of the utmost
importance, as respects both the issue, and the
reputation of the physician. I shall therefore
oiler a few remarks, with the view of facilitating
the investigation of this subject, and placing our
intentions of cure upon a rational basis, a. In
the first of the above pathological states, the
pulse is weak, soft, unequal, or intermitting ; the
pulsation of the carotids is smaller', weaker, and
softer than natural ; the breathing is soft, slow,
or laboured, but without stertor ; tl>e limbs and
muscles are relaxed, and deprived of sensibility ;
the surface is pale, cool, moist or clammy, par-
ticularly the extremities ; the head is cool, or at
least not above, frequently below, the natural
temperature ; the countenance is pale or suidi ;
390
COMA AND LETHARGY — Treatment of.
ihe eyes open, without suffusion, ;ind the pupils
dilated ; the tongue is soft, flabby, and broad,
unless in the last stages of fever, when it is covered
by ;i brown or dark fur ; and the skin is dry or
harsh. The feebleness and intermissions of the
pulse, the depression of animal heat, and the loss of
Sensibility and voluntary motion, are generally in
proportion to the exhaustion of vital power in the
brain, and therefore important guides in the treat-
ment of coma, b. The second pathological con-
dition, or that of congestion, will vary in different
cases, or even in different stages of the same case,
from the depressed state of vascular action and
animal heat, described above, to that now to be
noticed. The pulse is oppressed, or full, slow,
irregular, occasionally nearly natural, — in the
carotids somewhat fuller, stronger, or more labour-
in;:, than in health, or in other parts where it can
be felt ; the respiration is either natural or slow,
laborious or irregular ; the countenance is slightly
tumid, bloated, or livid; the eyes are somewhat
suffused and prominent, the pupils dilated and in-
sensible ; the temperature of the head is occa-
sionally natural, but more frequently slightly
increased, and the face and scalp moist ; the ap-
pearance of the tongue, as in the foregoing state,
varies according as the coma is a primary or con-
secutive state of disease ; the evacuations are
either retained or passed insensibly ; and sensi-
bility, voluntary motion, and menial manifest-
ation, are abolished in proportion to the extent
of depression of the organic nervous influence of
the bruin, and of vascular congestion. This state
may supervene on the former with more or less
rapidity, and terminate either in « return to
healthy action, or in the third and fourth states
referred to. c. The third and fourth patho-
logical states are different grades of vascular
action, often arising out of the preceding : that
consisting of active congestion or increased deter-
mination of blood through the cerebral vessels
may present nearly the same symptoms as those
characterising congestion, but in a much slighter
degree ; sensation and voluntary motion not being
quite abolished ; the coma being in its slighter
grades, — as lethargy and coma vigil, very rarely
coma somnalentum. The pulse and respiration
may not be materially affected, or it may be
merely accelerated ; the temperature, even of the
head, may also be natural, or but slightly in-
creased, that of the extremities being depressed;
the countenance may not be materially changed ;
in some cases it may be even sunk or depressed;
but the carotids generally beat more fully and
rtrongly than in health ; and the mental mani-
festations are not merely more or less suppressed,
hut sometimes also disordered. The state of in-
flammatory action, and its consequences, give rise
to phenomena of greater intensity than those now
noticed, and which have been very fully de-
scribed in another place. (See Brain, § ISO.)
(/. The fifth state which 1 have referred to, as
obtaining in some eases of coma, seldom occurs
alone, but is associated with one or two of the
preceding, particularly the first, second, or even
the third conditions. It' is characterised chiefly
by a lurid, foul, dirty, or cachectic appearance of
ihe surface ; a sunk or sallow countenance ; a
frequent, soft, small, or broad and open pulse : by
low delirium or typhomania ; starting of the ten-
dons, and {licking of the bed-clothes ; preceding
and associated febrile, exanthematous, or malig-
nant diseases ; and by fetor of the secretions and
excretions. In some cases, when this state has
come on rapidly, the tongue is merely broad,
flabby, marked by the teeth at the edges, and
covered by a creamy sordes ; but in the last
stage of acute diseases, it is deeply furred, or coat-
ed with a thick mucous sordes of a dark brown
colour, often extending to the gums, and even to
the lips. e. The sixth and last state, that of effu-
sion, may be consequent upon any of the preced-
ing, and be caused by one or more of them. If
the effusion be sanguineous, the attack is often
sudden ; the respiration is generally stertorous,
irregular, &c; and signs of local paralysis may
often be detected. (See Apoplexy.) 11' se-
rum be effused, the coma is as profound as that
caused by sanguineous effusion ; but slower in its
accession, and less frequently attended by sterto-
rous breathing, and local paralysis; it is also more
commonly preceded by signs of inflammation, ac-
tive determination, or congestion of blood, within
the head. (See Drops v oe the Encephalon. )
15. VI. Treatment. — The foregoing patho-
logical states will often insensibly lapse into one
another, as in concussion and inflammation of the
brain, giving rise to distinct stages of these dis-
eases, and requiring a different treatment for each ;
and, according as they may thus vary, so will
their symptoms be modified ; the .principal pheno-
mena connected with the cerebral functions, the
pulse, the respiration, the animal temperature,
the state of the head and carotids, &c. being the
practitioner's guides in the direction and com-
bination of his means of cure. These means
will now require no further notice than a bare
enumeration, as they are more fully discussed
in the articles on the diseases in which coma, in
one or other of its forms, most commonly pre-
sents itself.
1(5. A. Thefirst pathological state (§ 13, 14. a.)
requires stimulants and counter-irritants; but these
remedies must be exhibited with much caution ;
as an excessive or inappropriate use of them
might produce, even in the slighter cases of cere-
bral exhaustion, determination of blood to the
head, and convert congestion into inflammation, —
consequences which will frequently supervene, at
least in a slight degree, as in concussion, not-
withstanding the utmost care to avoid them.
The preparations of ammonia, musk, and cam-
phor, internally and externally employed ; eue-
mata, containing the same medicines, or the infu-
sion of valerian, castor, assafetida, or the tere-
bintbinates; wine and cordials, given frequently
and in small quantity; irritating or vesicating em-
brocations, cataplasms, sinapisms (Cei.sus, Are-
t.eus, Paui.us .Ecineta, to the head), and
plasters, as well as moxas, and the cautery (Za-
c u t u s Lu s it a n u s , R h o d i o s , and Se v e r i s u s )
applied to various parts, or even to the head itself;
blisters to the nape of the neck, behind the ears,
or to the head (Boxet, LanzaNI, Syden-
ham); volatile substances held to the nostrils or
applied to the temples; errhines (('.i:i.ii> AuRE-
liakus, &c); tirtication (Aretjeus, Sklii);
galvanism and electricity (Hufeland, &c); the
affusion of warm, tepid, or, in some, cold water
on the head ; active and stimulating emetics
(Riviere, Rigal, &cr); purgatives combined
with stimulants, antispasmodics, and tonics ;
COMA AND LETHARGY — Treatmkst
391
cathartic clysters, conjoined with similar sub-
Btaacea ; the use of coffee and green tea, pnr-
bcularlv when tliis state of disease has followed
the ingestion of sedative or narcotic poisons, and
after the stomach has been evacuated by emetics
and i he stomach pomp, and washed out by the
injection of warm water; are severally of use in
tins state of coma, and may be resorted to in va-
rious combinations, according to the circumstances
and severity of the case. All those measures are,
however, not equally applicable to every case
where this pathological state may he presumed to
exist ; but the judgment and experience of the
practitioner can alone enable him to employ them
in an appropriate manner; the shades of differ-
ence in particular cases requiring certain means,
or peculiar combinations of them, scarcely ad-
mitting id" description, at least within the limits to
which I am necessarily confined.
17. B. The second pathological state (§ 13,
14. /».), when closely verging, as it occasionally
does, upon the first, will require several of the
means enumerated with respect to it ; whilst,
when folly formed, and approaching that of active
determination or congestion, but few of them are
applicable. .Much, however, will manifestly de-
pend upon the habits and the constitution of the
patient; upon the nature and duration of the dis-
ease of which coma is an advanced phenomenon;
and upon the state of the pulse, the temperature
of the head, and the character of the countenance.
The first state is injured by blood-letting in any
form, it being even not an infrequent consequence
of inanition, or even of anosmia of the brain; but
this second state will generally be benefited by
depletion, and in proportion to its approximation
to the third and fourth states described above
(5 13, 14. c). The question chiefly is as to
what extent it may be carried, and the manner in
which it may be performed. In the majority of
cases, local depletions, by cupping between the
shoulders and nape of the neck, or by leeches
applied behind the ears or on the neck and occi-
put; bv simple scarifications by a lancet in the
last-named situation in some cases ; in Others
bleeding from the feet whilst they are placed in
warm water, and cold or tepid water is being
poured in a stream upon the head; and in certain
Distances the application of a number of leeches
on the inside tops of the thighs, or about the anus;
are the preferable modes of having recourse to
depletion in ibis state of disease; but the extent
lo which the evacuation should be carried must
entirely depend upon the symptoms and circum-
stances of the case, and the effects produced by
it. In addition to this important means, purga-
tives ought to be given by the mouth, and their
ac inn increased b\ cathartic ;l>sters, in which
either assafcetida, valerian, camphor, the terebin-
thinates. or other antispasmodics and stimulants,
mav be also exhibited. Counter-irritants and de-
rivatives should be applied, but at a distance from
the head; and, while a frequent operation of the
bowels is procured, the functions of the skin and
kidneys should be promoted bv diaphoretics and
diuretics, the extremities being kept warm, the
head cool, its hair cut off, and the shoulders highly
elevated. In many instances of this state, even
local depletion should be cautiously employed;
and in these, as well as in others, much advantage
will often accrue from having recourse to restor-
ative means. It is in this pathological condition
of coma, and in those about to lie noticed, that
oil of turpentine, in large doses, so as to act freely
on the bowels, has proved so beneficial in my
practice. This state very generally obtains in
coma from narcotics and spirituous liquors; and
is then, especially, very remarkably benefited by
the cold affusion on the head, and the prepara-
tions of ammonia.
IS. C. The third and fourth states (§ 13,
14. c.) require nearly the same treatment as the
second, but carried much further ; general and
local depletion, cold allusion on the head, or the
application of ice, or evaporating lotions ; tho
most active cathartics, clysters, and derivants or
counter-irritants, and the other measures, as fully
pointed out in the article on Inflammation of the
Brain (§ 174.). When these states have gone
on to effusion either of blood or of serum, — tho
sixth pathological condition adduced, — the treat-
ment recommended in Apoplexy and in Dropsy
of the Escf.phalon (see these articles) should
be employed.
19. D. The fifth pathological state obviously
requires stimulants, tonics, and antiseptics, par-
ticularly camphor in considerable doses; the chlo-
rides of soda, potash, &c. ; wine, with cordials,
spices, &c. ; bark, with camphor ; purgatives
conjoined with stimulants, so as to excite the
eliminating or depuratory functions ; cathartic,
tonic, and antiseptic clysters; calomel, combined
with camphor and ammonia, or musk; the tur-
pentines given by the mouth, and in enemata,
with capsicum and aromatics; external derivation
and counter-irritation; the various balsams, with
the chlorides, &c. ; quinine, with the aromatic
sulphuric acid; the preparations of cinchona or
cascarilla with soda, or with the muriatic acid,
or muriatic a:jther; Cayenne pepper internally, as
well as externally in camphorated embrocations,
&c. When coma is consequent upon the retro-
cession of gout, rheumatism, erysipelas, or cuta-
neous eruptions, the propriety of having recourse
to sinapisms, rubefacient pediluvia, and other
derivatives, in addition to such other means as
the symptoms of the case may suggest, must be
obvious. If it follow suppressed discharges, we
should endeavor to restore these, or produce one
supplemental of them. (See the treatment of
the diseases of which coma is most frequently au
important symptom.)
BlBLIOQ. AND ItKFER. — Hippocrates, TIt't't rm.'Ooii ,
iii. ii|i|i. p 488. — Galen, Lib. de Comate, cap. ii. t. vii. p.
195. — Cetnu, I. iii. cup. 20.— Aretaus, Cur. Arut. 1. i. c. 2.
— Paulut JEgintta, I. iii. cap. 9. ft 10. — Oribatittt, Svnop
I. viii. c. i. — Avicenna, Canon. I. iii. fen, i. tract iii. c. 7,
fcc— Zacutm Lutitamu, IV. Hi.t. I. vii. Ob*. 1. (The.
actual cautehf behind the ears.) — tthadhu, 1. i. obs. 3G.
i 7 Vu- cautery to the neck.) — Severimu, De EfScac. Med.
p. 213.— BaUoniui, Contult I. i. 45., I. iii. 32.— Willis, De
Anim. Brut. Path. cap. 3, 1. 5. — Riverius, Pi ax. Med. t. i.
cap. i. — Sydenham, Opera, ;.. 281, — Bonet, Sepulchretum,
I. i. sect. iii. obs. .5. 13. t(i. — Eutn, Be Oomate Somnalento.
Basil 1674c-- Heinz, De Aflectibui Soporosis. Argent. 1677.
—Morgagni, Epist. r. art. 13. 23. 29— 36.— Bellini, De
Morbis Capitis, p. 455.— Hoffmann, De Affect. Soporosis,
obs. 5. Opp iii. p. 216. — Boerhaave, De Morbis Nervorum,
p. 640.— i •«-•.' /.<•. .v, 1),- T\ pbomaaia. Francf. 17.tO.—
Kriigt ; De Somno, MorboBiin Matreel Filio. Helms. 17.51.
— // He ,Ohscrvat. Med. pract, Goet. 1750.— Sauvaret,
v. iii. class ri. — \.i\. 7.— /(rm?, in Acta Reg. Soc. Med.
II ■in. vol. iii. p. Wt*—Vogel, Beobachtungen, No. 9.—
Hinze, in Stark's Archiv. h. vi. p. 17::. — Bekrendt, in ll»fr.
landU Jouni, der Pr. Il.ilk. I>. xi. 2 st. p, 1. ; Ibid. b. xx.
Iili st. p. h. (flafvaninx recommended in.) — Rigal, in
Mc-.n. de Toulouse, 1788. — Portal, Conn d'Aoatomie Med.
392
CONCRETIONS, BILIARY — Pathology of.
t. i. p. 21. {An instance of coma from narrowing of the
carotid arteries.)— Se/ti, in Brugnatclli, Bibliotheca Kisica,
v. ii— Brewster, Ktlin. Philos. Trans, for 1817. (fdiopath.
coma from congestion.) — Cooke, Treatise on Nervous Dis-
eases, v. i. p. 372. (Idiopath. lethargy.)— J. Frank, Prax-
eos Med. Univ. pra-cepta, par. ii. vol. i. sect. i. p. 367. —
Bahn, in Kncyclopad. Worterhuch der Med. Wissenschaf-
ten, b. viii. p. 107.— (Boners Thesaurus Med. Scrip, t. i. p.
715., and his Mercurius, tc, p. 616.; also Mangtt's Bibli-
otheca Med. Script., art. Carol, and Ploucqueth Medicina
Di^esta, art. Coma, may be consulted bv the curious ; but
little information of importance will be obtained.)
CONCRETIONS, Biliary.— Syn. Calculi or
LapUli Cystici ; Calculi Fellei ; C. Biliares ;
C. Biliarii ; Cholelithi ; Hepatalgia Calcu-
losa; Var. Auct. Concrementa Biliaria, So-
emmering. Chololithus, Good. Calculs Bil-
iares, Fr. Die Gallenstein, Ger. Gall-stones.
Classif. 1. Class, Crrliaca; 2. Order,
Splanchnica, Gen. Hi. {Good). I. Class,
II. Order (Author).
1. Defin. Concretions formed in the bile-
passages, and occasioning in many instances
more or less disturbance, with paroxysms of pain
commonly referred to the right epigastrium and
hypocJiondrium, reaching to the back, fyc, with
increased suffering whilst passing into the ali-
mentary canal, and often giving i-ise to sickness or
vomiting, to jaundice, and severe attacks of colic.
2. Biliary concretions were first noticed by
Benevenius, Fallopius, Vesalius, Kent-
man n, and Fernelius, who were nearly con-
temporaries. They were afterwards more ac-
curately described by Glisson, Hoffmann,
Morgagni, Bianchi, Boerhaave, Van
Swieten, and particularly by Haller ; and
the more recent researches of Heberden, So-
EMMERRING, THOMSON, ThENARD, BoS-
tock, Merat, and Chevreul, have greatly
advanced our knowledge of their nature and pa-
thological relations. Notwithstanding the fre-
quency of these concretions, and the very serious
symptoms they occasion, but little attention has
been paid to them by practical writers since the
appearance of Soemmerring's Treatise; and
they have been nearly overlooked by the majority
of systematic writers. Haller remarks (what
every pathologist will acknowledge), that they
are infinitely more frequently found in post mor-
tem researches than calculi of the urinary pas-
sages ; and Heberden agrees with him in
admitting that, while urinary calculi are much
more common in the male, biliary concretions
are most frequent in the female sex — probably in
the proportion of one in the former, to four or
five in the latter.
3. I. Description. — Biliary concretions vary
remarkably as to form, size, number, and colour,
as well as composition, a. They may exist in any
number — from one to a thousand, or even more.
Morgagni, Walter, and B a illie, have found
the latter number ; and Soemmerring, with
many of the authors referred to at the end of the
article, have observed from fifty to several hun-
dreds, and even upwards, either in the gall-
bladder, or in the ramifications of the hepatic
ducts. When thus numerous, they are usually
very small — the size of pin-heads, or but little
larger — of a dark brown, green, or greenish yel-
low colour, sometimes almost filling the gall-
bladder, and occasionally slightly agglutinated by-
thick bile. More frequently, however, a small
number, or two, three, or four are detected, and
very often only one. When only two or three
are found, they sometimes are jointed into each
other, or have their opposite surfaces smooth or
flat. In rare instances they seem divided by a sep-
tum. 6. When one, two, or three only exist, they
are usually large, but they seldom reach the size
of a hen's egg, or are much larger than a walnut.
Dr. Saunders, however, has found one of the
bulk and figure of the gall-bladder, which it filled.
They are not infrequently as laige as a pigeon's
egg, or as a hazel nut; and are often found from
that size downwards, c. Their colour varies
through every shade of black, green, brown,
yellow, white, &c, that of the surface often dif-
fering from the centres and certain of their layers.
They are often beautifully mottled or marbled;
sometimes white and shining like spermaceti; at
other times dull like wax ; occasionally lamel-
lated; often crystallised or striated, either with
or without distinct centres, which are frequently
different in colour and composition from the por-
tions crystallised or collected around them. They
are also more or less opaque, or slightly translu-
cent, d. Their form varies from a round, oval,
or oblong — when they are solitary — to a cone,
a cube, pentagon, polygon, &c, when more nu-
merous. They are usually smooth, sometimes
polished, particularly the surfaces that have been
in contact with each other; more rarely rough or
glabrous, and occasionally they appear as broken
into fragments, e. Their consistence also varies
from what is barely sufficient to preserve their
form, to that which does not yield to the pressure
of the finger, and is divided by a knife with
difficulty. /. Their specific gravity is much more
frequently below, than above, that of water ;
consequently, they are commonly found swim-
ming on the surface of water when the evacu-
ations are mixed with it.
4. Situation and Composition. — Biliary con-
cretions have been found in every part of the
biliary passages : — 1st, In the radicles of the
hepatic ducts ; 2d, In the hepatic duct, and its
ramifications; 3d, In the cystic duct; 4th, In the
gall-bladder ; and, 5th, In the common duct.
They have been likewise found in every part of
the intestines, in their passage out of the body;
and, in rare instances, in the stomach, whence
they have been observed to have been ejected
by vomiting. These concretions are often the
result of obstruction to the course of the bile ;
and are then generally found to consist of an
admixture of inspissated bile with mucus. But
more frequently they are a consequence of an
alteration of this fluid from its healthy consti-
tution, as respects either the presence of ele-
ments foreign to it, or the superabundance of
those which are the least soluble, and which
are precipitated during the retention or accu-
mulation of bile in the ducts and gall-bladder;
the latter being most commonly the case. Of
this description are the concretions formed of
a crystallisable fatty matter described by Pool-
letier de la Salle and Fourcroy, under
the name of adipocire, afterwards by Makcet,
Bostock, &c, and named cholesterine by
Ch evreul. Some biliary calculi consist almost
entirely of this substance. " Others are formed of
mucus and the thickened yellow matter, or the
resin, of bile; and many art composed of choles-
terine, the yellow matter, and the resin. Instances
CONCRETIONS, BILIARY — Symptoms.
393
of Concretions different from these in composition
have been noticed by Marcet, Orfila, and
C\> ks rou,bu< they are very rare. The greater
part of these thai consist of cholesterine have
inspissated bile lor nuclei, which, having passed
•long the hepatic ducts into the gall-bladder,
form the centres around which the cholesterine
Crystallises. All these are soluble in warm
alcohol. Which deposits the solution in brilliant
crystallised plates when cold ; also in spirit of
turpentine, and in the Esthers, or in an admixture
of turpentine and aether, leaving more or less of
a residuum, according to the quantity ol" mucus
or animal matter they contain. They also form
a soapy solution in the caustic alkalies, melt at a
high temperature, are inflammable, and insoluble
in water.
5. The formation of biliary concretions in the
radicles of the bile-ducts has been disputed; but
M, Croveilhier has given a very tine illustra-
tion of this rare occurrence in his excellent pa-
thological work. When found in this situation,
they generally consist of very small grains, of
variable size and form, and of a dark green co-
lour, disseminated through the healthy structure
of the liver, and are formed chiefly of inspissated
bile. Biliary concretions are most commonly
found in the gall-bladder, and are usually the
consequence of the remora or accumulation of
bile; the absorption that takes place of its watery
parts during its retention probably occasioning
the precipitation or concretion of such of its more
solid ingredients as it can no longer hold in so-
lution or in suspension. SoEMZH krring, how-
ever, supposes that they form very rapidly, with-
out any absorption or inspissation of the retained
secretion; and this is probably more frequently
the case, particularly in respect of those consist-
ing chiefly of cholesterine, and when irritation of
the internal surface of the gall-bladder produces
a morbid secretion, which may combine with the
less soluble ingredients of bile, or dispose them
to crystallise, particularly when they are secreted
in larger quantity than natural, owing to a defect
of the assimilating functions, and consequent
accumulations of the elements of a morbid biliary
secretion in the blood.
6. II. Symptoms. — Calculi in the gall-blad-
der seldom give rise to any marked or definite
symptom unless they are very large, obstruct
the outlet of this receptacle, or excite inflamma-
tion of its mucous surface. Every experienced
practitioner must have met with cases in which
these concretions have been evacuated, and others
also in which the gall-bladder has been found,
after death, tilled with them, without any ailment
referable to this organ having been complained
of. The symptoms, therefore, usually stated to
proceed from concretions in the gall-bladder
should be viewed with limitations, inasmuch as
they are not necessarily consequent upon their
actual presence in it, and as they may proceed
from some other pathological states. But, whilst
we should view these symptoms with cauti we
ought not to reject them; for, although concre-
tions may form, and even pass mto the alimentary
canal, without creating much disturbance, or
giving rise to any symptom distinctive "f tlir
existing derangement, yet not infrequently their
presence, particularly their passage from the lm'I-
bladder into the intestines, occasions such a train
of morbid phenomena, as will often enable the
observing practitioner to form a correct diagnosis.
7. A. Of calculi in the gall-bladder. — Pa-
tients with biliary calculi often complain of a
sense of weight and oppression at the epigastrium,
and right hypochondrium, with cardialgia and
various dyspeptic symptoms, especially after a
meal, with constipation or slight irregularity of
the bowels, an occasional deficiency of bile in
the evacuations, and sallow or yellowish tint of
the countenance and skin. In some cases a dull
pain in the epigastrium, with a tympanitic fulness,
is felt (Stkack); and in lean persons, a distinct
tumour below the anterior margin of the right
ribs may occasionally be detected, particularly
when signs of obstructed excretion of bile have
previously existed, indicating its accumulation in
the gall-bladder. These may be all the symp-
toms, and often so slight as not particularly to
interest the patient; they may, even when most
evident, continue a longer or shorter time, until,
at last, the pain and uneasiness increase, — espe-
cially when the patient turns, or lies upon the left
side, uses exertion, rises quickly to the erect pos-
ture, takes a full inspiration, or soon after a meal,
— and extend to the right hypochondrium, to the
back or right shoulder-blade, sometimes to the
right breast, shoulder, arm, and side of the neck,
and even throughout the abdomen, particularly to
the right Hank and hip.
8. B. The symptoms indicating the passage of
concretions into the intestines may not differ
materially from the above, excepting in their se-
verity and duration ; and they often have little
rekat ion to the size of the calculus. When the
concretions still remain in the gall-bladder, they
occasion either little or no disturbance, or such as
has been now described, in a more or less con-
tinued form. But when they are passing along
the ducts, the symptoms are often very sudden
in their invasion, of much greater intensity, of
shorter duration, and generally recur in paroxysms.
The pain is then frequently very acute, is attended
by nausea, flatulence, or vomiting, by a bitter
i taste in the mouth, a?id or bitter eructations,
I irregularity of bowels, colic, or distension of the
abdomen," &c, and is followed by either a com-
I plete jaundice, or a slight yellow tint about the
eyes or lips, the cheeks being clear. This discol-
ouration commonly passes off soon after the par-
j oxysms ol" suffering, which often come on about
two hours after a full meal, and it either recurs
! along with, or follows closely upon, them; but it
IS not. nor, indeed, any of the symptoms enume-
rated, constantly observed, us Coe, .1. 1*. Frank,
and others, have demonstrated, and as every ex-
perienced practitioner must have remarked, even
when large concretions have found their way
into the bowels. The pulse is generally unaf-
fected, and there is no fever, unless in the more
violent seizures, or after their frequent recurrence
or long duration ; when, in addition to these
■• symptoms, loss of flesh and strength, a furred,
loaded, dark yellowish tongue, gr.eat restlessness,
anxiety, and tenderness at the epigastrium, and
right hypochondrium, are observed. 1 he inter-
vals between the attacks are extremely variable.
Sometimes toe paroxysms are periodic; and are
evidently owing, on these, as well as on other
Occasions, either to some change in the position of
i the concretions, or their passage into the intestines,
394
CONCRETIONS, BILIARY — Symptoms.
or to inflammation produced by them in the gall-
bladder and ducts. In many instances they are
most excruciating ; the patient is bent double,
rolls about in great agony and anxiety, or presses
upon the epigastrium, and complains of an acute
or lacerating pain in the region of the ducts and
duodenum, either with leipothyma or syncope; or
with retching, distension of the abdomen, and
severe colic. Females — who are most subject to
these seizures — sometimes experience more suf-
fering from them, than from parturition; and even
in them the pulse may not be affected. The
bowels are more frequently constipated than re-
laxed, and the motions are often devoid of bile,
although diarrhcea be present. The most acute
attacks may terminate as suddenly as they com-
menced, the patient soon recovering his strength
and functions, unless more calculi remain to be
passed. They are usually of short duration — not
exceeding a few hours; but they become longer
after their repetition, sometimes at last continuing
several days, with partial remissions. Occasion-
ally they are preceded by a sensation of some-
thing unusual, or alive, in the region of the
stomach, or in various parts of the abdomen; and
attended by dryness or slight pain of the throat,
thirst; inability to straighten the trunk, or to keep
it erect; by scanty, orange, or high coloured
urine, and slight strangury.
9. C. The affections and lesions sometimes caus-
ed by biliary concretions attach to themselves much
interest. In some cases, violent convulsive mo-
tions come on, from the pain and irritation they
occasion, cither with or without vertigo, headach,
and cerebral congestion. Mental depression, ob-
stinate dyspepsia, hypochondriasis, and melan-
cholia; also flatulent and colicky states of the
bowels, constipation, and diarrhoaa; are not only
frequent attendants upon, but also consequences
of, biliary concretions. The less common dis-
orders they occasion are, dyspnoea, syncope, slow
remittent states of fever, haemorrhoids, suppres-
sion of the catamenia, and apoplexy (Burseri).
The effects produced by them upon the gall-blad-
der and ducts are often most important; inflam-
mation, thickening of their coats, ulceration, great
dilatation of the ducts, adhesion of them, or of
the gall-bladder, to the duodenum, or of the latter
to the stomach, liver, or colon, or even to the
parietes of the abdomen, with ulceration, and
passage of the calculus into any of these parts of
the digestive canal, or through an external open-
ing at the right epigastrium, having been observed
by several eminent authorities. Colombus states,
that, upon the examination of the body of the
celebrated Ignatius Loyola, a biliary calculus
was found to have ulcerated its way through the
gall-bladder, into the trunk of the vena porta.
Cheseldf.n mentions acase in which two large
calculi made their way, by inflammation and ul-
ceration, through the abdominal parietes ; and
similar instances are recorded by Hoffmann and
Crell, in one of which about eighty small cal-
culi passed out through a sinuous ulceration
below the right ribs. Toi.f.t states a case in
which a biliary concretion of the size of a pigeon's
egg was discharged from an ulceration at the um-
bilicus; and Buettner saw thirty-eight calculi
discharged in the same situation. Schurig men-
tions an instance of two such concretions having
been taken from an abscess in the anterior ab-
dominal parietes, opened by Fabricius ; and
cases have been recorded by Block, Haller,
VVinckel, Dixon, Calloway, and Baffos,
of tumours having formed below the cartilages of
the right false ribs, followed by inflammation, ul-
ceration, and the discharge of biliary calculi of
various sizes. Soemmerring states, that he
has a preparation of a gall-bladder filled with
concretions, and having an ulcer at its fundus,
through which one of them had escaped. J. P.
Frank found, in the body of a woman who died
during the puerperal state, the gall-bladder rup-
tured, and containing calculi, to which he attri-
butes the rupture; and he met with another case
in which the calculi had occasioned abscess and
ruptureof this viscus. Mr. Brayne has detailed
an interesting case, in which adhesion of the gall-
bladder to the duodenum had occurred, and in the
centre of this adhesion an ulceration into the in-
testine had taken place, through which a very large
calculus had passed, and been discharged by stool,
a considerable period before the death of the pa-
tient; and similar instances are alluded to by Dr.
Saunders, as having been observed by Dr.
Cheston and Mr. Cline. It is not improbable,
that in some of the instances on record, in which
biliary concretions have been voided by vomiting,
adhesions of the gall-bladder to the stomach had
taken place, and the concretion had made itsway
by ulceration at the place of adhesion into this
viscus, from whence it had been ejected. A
reference to the cases recorded by Schurig,
Ortesch, and Biondi, in which biliary con-
cretions had been evacuated from the stomach, will
show that this is not an unreasonable inference.
10. Besides the usual appearances produced
by inflammatory action in the coats of the gall-
bladder, viz. adhesion to adjoining parts, thick-
ening, ulceration, &c, they have been found
almost or altogether destroyed by suppurative
ulceration. In a case detailed by Dr. Scott, .
they were half an inch in thickness; and Hal-
ler observed them destroyed by suppuration
and ulceration — the calculus that had caused the
inflammation lying in the midst of a disorganized
and puriform matter. Obturation of the ducts
has been often "found on dissection, the gall-
bladder being at the same time enormously dis-
tended by accumulated bile. In many cases, the
ducts have been found very much dilated after the
passage of large calculi through them. Such cases
have been recorded by Walter, Dietrich,
Richter, Thomas, Craigie, &c. Heister
found the common duct dilated so as to admit his
little finger. Morgagni states, that he has ob-
served the same duct so wide that its diameter was
nearly two fingers' breadth; andSoEMMERRiNG
has preserved, in his museum, several specimens
of great dilatation of this canal. Riysch and
Blumenbach have found biliary concretions in
the substance of the liver; and others that had
perforated the cvstic duct, and caused ulcerations
of both the liver and duodenum. Walter ob-
served the ramifications of the hepatic duct,
throughout nearly all the liver, enormously dilated,
and filled with bile and some thousand small cal-
culi; and Cruveilhier and myself have met
with very great distension of all the ramifications
of this duct, with thickening of its coats, and con-
cretions mixed with viscid bile throughout their
canals. It is obvious that concretions, either in
CONCRETIONS, BILIARY — Causes, &c.
395
the hepatic ducts or in the gall-bladder, will
sometimes give rise to very serious disease of llie
liver itself. " A torpid state of this viscns, BO fre-
quently observed ■ eeaneetion with tlieir forma-
tion. is rather tlieir cause than tlieir effect 1 lonce
obstruction of the liver, and its consequences,
particularly dropsy in some one of the shut cavi-
ties, or the cellular tissue, are of more frequent
occurrence than inflammation of this organ; but,
nevertheless, both acute hepatitis and abscess of
the liver have been sometimes met with, owing
10 biliary concretions.
11. J). When biliary concretions, particularly
those of a large size, have passed into the intesti-
nal canal, they often give rise to very severe and
even dangerous symptoms. Cases have been re-
ferred to in the article Cecum, in which I had
seen fatal results, consequent upon the passage of
biliary calculi into the appendix of the caecum,
they having produced inflammation, ulceration,
or gangrene of this process, and, consecutively,
fatal peritonitis : and, in the case recorded by
Civ aimer, where a biliary concretion had es-
caped by an ulceration in the right groin, it is
verv probable that it had passed out through the
caecum, by inducing inflammation and ulceration
of this part. The more common consequences,
however, are, thirst, constipation of the bowels,
colicky pains, sometimes tenderness on pressure
referred to a particular part of the abdomen, fol-
lowed by tenesmus, alvine evacuations, and the
passage of the calculus. When it is very large,
the symptoms will he the same as enumerated
with reference to Intestinal Concretions, or it
will produce severe colic or ileus. Instances
of fatal results, sometimes occurring very rapidly,
from biliary calculi, have been adduced by seve-
ral of the authors already named, as well as by
Bianchi and Kichtkr; those of a slower pro-
gress have presented, with various organic lesions
and dropsical effusions into the large cavities, —
consequences which have sometimes not appear-
ed until a remote period from the voiding of con-
cretions.
12. III. Causes. — Biliary concretions occur
much more frequently in the female than in the
male sex, and during the decline of life, than at
an early age. They are very rarely met with
much before the prime of life, and still more rare-
ly in children. Their generation is favoured by
the phlegmatic, bilious, and melancholic tempera-
ments; by the violent or depressing passions —
particularly anger, sadness, anxiety, Xcc. ; the use
of spirits; by sendentary occupations, rich and
full living; protracted sleep; by sitting with the
body bent forwards after meals (Hoffmann,
Van Bwieteh, Cos) ; by chronic dyspepsia and
costiveness; and by imperfect assimilation and
corpulency. Torpid or disordered function of the
liver and gall-bladder; inaction of the latter and
of its ducts; and a vitiated secretion of the bile
itself; are obviously connected with the produc-
tion of these concretions. Several writers have
supposed that they arise from a putrescent state
of the bile retained in the gall-bladder; but, as
Gold w i rz and So km m erring have shown, this
change, even granting it to occur, would rather
prevent than favour their production. Various
writers, as Leak e, suppose that they are formed
from the inspissation of the bile in the gall-blad-
der, from absorption of its watery parts : but this
cannot be the only or even a principal cause, as
we often find this secretion remarkably thickened
from long retention in this receptacle, without
such formations. The absorption can, therefore,
only favour the occurrence of other changes in
the bile, to which certain peculiarities in its^com-
position strongly dispose it. The verv small
concretions which occur in the ramifications of
the hepatic duct generally consist of inspissated
bile and mucus; and these, as they pass into the
trunk of this duct, or are carried into the gall-
bladder, may become the nuclei around which
the superabundant cholesterine in the bile collected
in the gall-bladder or in the ducts may crystallise;
the increased quantity of this fatty matter in the
bile being the chief pathological condition con-
nected with their formation. As far as my own
observation has extended, these concretions have
occurred in persons whose assimilating functions
have been imperfect. That the liver performs
an assimilating as well as a secreting oifice, has
been shown by me in another work (see Appen-
dix to Richerand's Physiology, p. 580.); and
when, either from torpid function of this organ,
or from imperfect action of the other assimilating
viscera, the chyle is not perfectly animalised,
fatty matter abounds in the circulation, and is
modified into cholesterine during its excretion by
the liver — that portion of it which the watery
parts of the bile cannot preserve in solution, crys-
tallising into biliary concretions upon the occur-
rence of the circumstances favouring this change.
The fact, that these concretions are most com-
monly met with in fat persons, in whom assimi-
lation is defective, and at that period of life when
it begins to flag, — imperfect assimilation causing
the superabundance of fatty matter in the circula-
tion, and its consequent deposition in the adipose
tissue — seems a strong proof in favour of this
opinion, which is further confirmed by the cir-
cumstance of my having observed the serum
whitish or milky on two occasions on which blood
was taken from persons with biliary calculi, — an
appearance now demonstrated to arise from the
superabundance of fatty matter in the serum (see
Blood, § 104.). I need not occupy my limits
with the various speculations, or opinions, enter-
tained by authors respecting the remote as well
as pathological causes of biliary concretions, par-
ticularly as the most of them have been found to
be erroneous. Those who are curious respecting
them, will find almost all of any consequence that
has li sen adduced on the subject, in the references
at the end of the article, and particularly in the
works of ( !o E and So i M H E RRINO.
13. [V. The l)i wiNosis and Prognosis can
only be inferred from the entire history and con-
tingent circumstances of the case; as there are no
symptoms, which, from their constant presence,
or relation to certain pathological conditions, will
of themselves enable the practitioner to form a
correct judgment as to the precise nature or re-
sult of the disease : and yet the experienced and
observing will very generally draw. tolerably cor-
n ( t conclusions as to both, from reasoning on the
prbcession, relation, or grouping, of the symptoms
present : and, although the disease is not fre-
quently fatal, he will often have reason to be
cautious in hazarding an opinion as to the ultimate
or remote result; especially as the same morbid
condition of the system that gives rise to these
396
CONCRETIONS . BILIARY — Treatment.
concretions, often occasions other dangerous mal-
adies, even although the concretions themselves
do not produce any fatal lesion, or even serious
disorder.
14. V. Treatment. — The measures required
in cases where the concretions are presumed to
be in the gall-bladder, are somewhat different
from those, which their passage along the ducts
usually demands. 1st. When the symptoms lead
us to suspect the presence of concretions in the
gall-bladder, the medicines recommended by So-
emm erring may he prescribed in various states
of combination. These consist of the sub-car-
bonates of the fixed alkalies, the muriate of am-
monia, the acetate of potass, the spiritus setheris
nitrici, the liquor potassae, Castile soap, the ex-
tracts or decoctions of taraxacum, herba sapo-
naria, the fimiaria, &c. It is obvious that deob-
struent aperients, and the above medicines, will
often have much influence in improving the
biliary secretion, and promoting its discharge into
the duodenum, particularly when the patient
takes regular exercise in the open air, and saline
mineral waters. The remedy of Dura no e,
consisting of three parts of the spiritus Athens
sulphur, comp., or the sulphuric aether, and two
of rectified spirits of turpentine, given in doses of
half a drachm to a drachm, has been much em-
ployed on the Continent; and, although it generally
occasions unpleasant eructations, and sometimes
increases the sickness, it has received the com-
mendations of SoEMMERRING and RlCHTER,
who advise it to be given after the exhibition of
emollient, resolvent, and aperient remedies; and
to be followed, particularly in cases where the
passage of the concretions along the ducts is sus-
pected, by the repeated use of gentle laxatives.
I have prescribed the remedy of Duranue in
somewhat larger doses, and combined with it the
tinct. of hyoscyamus, and certainly with marked
benefit. Numerous French and German writers
speak favourably of this medicine, while others
fear its effects in cases where inflammatory action
may exist. But my experience has proved that
it will not aggravate such action, and far less give
rise to it.
15. The deobstruent medicines that are most
to be depended upon in this state of disease, are,
the extract or decoction of taraxacum in large
doses, with the alkalies (F. 77. 391.), the sub-
carbonates, the acetates, or the sub-borates of the
alkalies; or with soap, amrnoniacum, blue pill,
small doses of villi antimonii tartarizati, and the
sethers (F. 397. 503—510. 837.). After these
have been exhibited for some time, Durande's
remedy may be taken on 'he surface of any fluid,
or mixed in the yolk of an egg. Active purga-
tives or cathartics are upon the whole less bene-
ficial than a frequent repetition of laxa'ivcs, or of
such purgatives as are gentle and emollient in their
operation; and even these, when exhibited earlv,
are generally less successful than when deferred
to a more advanced stage of the treatment. The
oleum ricini, in doses of about one or two drachms.
triturated with mucilage, or with the yolk of an
egg, and repeated every five or six hours until it
operates, manna, the oleum olivcc, the acetate of
potass, &c, and warm milk whey, are the most
appropriate laxatives. In many instances, a full
dose of calomel, or five grains of blue pill, may
precede their exhibition, as either of these often
proves beneficial, especially when combined with
a full dose of hyoscyamus, and about a grain of
camphor, and without any risk of those unpleas-
ant effects imputed to it, or rather dreaded from
it, by various Continental writers. The operation
of Ituativcs should be promoted by the exhibition
of oleaginous, saponaceous, and emollient clysters.
As to the use of emetics, opposite opinions have
been advanced. Hoffmann, Durasde. and
Frank very justly express themselves decidedly
against them; and, indeed, Bertin declares that
he has met with cases, in which they caused rup-
ture of the gall-bladder, its duct being obstructed
by a calculus.
16. 2d. Those cases in which the symptoms
indicate the passage of concretions into the bow-
els (§8.) require, in addition to the means above
enumerated, warm anodyne fomentations; the
belladonna plaster placed over the right hypo-
chotidrium; the exhibition either of this narcotic
internally, or of the acetate of morphine, opium,
or hyoscyamus; the remedy of Duranue, or
the combination of it with one or other of the
medicines now mentioned. In some cases, an
anodyne and discutient liniment (F. 297. 313.)
may be placed over a warm poultice, and applied
to the chief seat of pain. Local or general de-
pletion is seldom of much service either in this or
the preceding state of the disease, unless the ex-
istence of vascular plethora, or of tenderness of
the hypochondrium and epigastrium, the state of
the pulse, or habit of body, indicate it, when it
should not be omitted. If tumour and tenderness
of these regions, with other marks of inflammation
of the gall-bladder and ducts, manifest them-
selves, general and local blood-letting, followed
by poultices and fomentations, are requisite. In
. such cases, as well as in the more violent parox-
ysms of the malady, the treatment recommend-
ed by Bricheteau — of the success of which,
in some very obstinate and instructive cases, he.
has adduced very striking proofs — may be put in
practice. This consists of the application of a
bladder, containing pieces of ice, over the seat of
pain; of repeating it, as soon as the ice is dissolv-
ed, until relief is obtained; and of administering
subsequently mild laxatives and clysters until the
bowels are freely evacuated. Merat bad pre-
viously advised the injection of cold enemata:
and Duranue, of those which are tepid; but
the cases adduced by Bricheteau seem con-
clusive of the superior efficacy of the means he
has recommended. Petit has contended for
the propriety of making ;m early opening into
such tumours at their more prominent part, with
the view of evacuating the calculi, or the accu-
mulated bile, which the gall-bladder cannot expel
owing to occlusion of its duct. But the incerti-
tude of adhesions having been formed between its
fundus and the abdominal parietes, and of success
even although they have actually taken place,
must prevent every physician from directing the
performance of this operation. In the majority of
cases, the tumour will point outwardly, and either
open spontaneously, or arrive at that stage which
will warrant the artificial opening of it if the ad-
hesion have formed. Even in three such cases,
Morgagni found only one which healed up fa-
vourably; the other two long remaining in the
state of fistulous ulcerations. — "Ergo non. nisi
in adhesione vesicular fellea* ad intesumenta abdo-
CONCRETIONS — INTESTINAL.
397
minalia, tentenda exulccratio est, vel apertura ar-
tilirios.t." (SOEM HKBKINO.)
17. 3d. When the previoos ailments and the
existing symptoms indicate thai the concretions
have passed into the bowels, the use of gentle
laxatives, a* advised above, or the treatment di-
rected with raped n> Intestinal Concretions,
and Colio, is strictly appropriate. In some in-
stances, when the calculi are large, they w ill give
ri^e to much suffering referred to the csBCum, the
sigmoid flexure of the colon, and to the rectum ;
thej occasioning, in this last situation, constipation,
colic and urgent tenesmus. In these cases, the
rectum should he carefully examined, and me-
chanical as well as medical means used to facili-
tate the passage of the concretion.
18. 4th. After the patient his been relieved,
ami. indeed, during the continuance of the treat-
ment, the evacuations should he carefully exa-
mined, and mixed with water, with the view of
detecting the concretions, — this being of much
importance as respects not merely the diagnosis,
but also the treatment. If we have reason, either
from their presence in the motions, or from the
disappearance of ailment, to presume that they
have been evacuated, remedies ought to he pre-
scribed with the view of improving the digestive,
assimilating, and biliary functions. The use of
taraxacum with soda, ice. (F 76. 392.); of gentle
and deobstruent aperients ; of vegetable hitters,
with the alkaline preparations, and laxatives ;
regular exercise ; light digestible food, and ripe
Lruiis ; a moderate use of lean but fresh meat;
the strict avoidance of fatty substances and of
spirituous liquors, of mental disquietude, and of all
the exciting causes (§ 12.) ; should be enjoin-
ed, and the patient recommended change of air,
the Cheltenham or Leamington mineral waters,
and the artificial waters of Seidlitz, Scheidchutz,
Eger, Pyrinout, Spa. and Carlsbad, according as
they maj be respectively appropriate to the cir-
cumstances of particular cases.
Hini.ion. and REFER.— Fernelius, Patholoj. lib. vi.
cap. 5—10.—/,'/ iu», De Ah, In i. fflorb. Causia, c. 9-1. —
JCentmann, apud Gesner, lie Omni Ker. Fossil, lienere ; et
apml >•■'■■ - ii -ri. Anatom. I. iii. sect. 2. olis. 30.36. —
/ ttalnu, Examen ObservaL Faltopianarum, p. 124. — Co-
lumbus, He He Anatom. I. \\. p. In. — Schurig, Litholojia,
-/:. Stahl, De < 'alnil. Generation*;. Halse, 1699.—
Korb. episL i. art. 45—49., ep.
ii. art. 77. 79. 443.— fitoncAt, Hisloria Hepatis, t. i. p. 175.—
. Dilucidatio Valvul. cap. iv. ohs. 2-1.; et Observ.
Anatum. obi. "7. tii:. 69. — Glisson, Anatom. llepatis, cap. 8.
. De Cab uli in Vesic Pel lea General. 4to. Witteb.
vnZ.—Hoffm a .. Medii ina Ration. Svst. ••[ Museum, &c.
p. 95. et 9b'. , et Ephem. Nat. Curios, dec. i i. — lioerhnnve,
■i. ad Institul. Path. § 790 — I'an Swieten. Conine n-
taria, 4tc. § 950. — Ore, - h Diarium, p. 283.— Chi
Anatomv, p. 1<I6. — Sabatier, De Variis Calcul. Biliar. Spec.
1 1 -fj Bvo. 1758. — F. / De Choleltthis
1 1 u mi am-. 4to. Tubing. I7o0. — Sinuoi lays and
Ohservat. vol. i. p. 315. — Coe, Treatise on Biliary Concre-
tions, &.c. 8vo. Loud. 17>j7. (-.'ii instructive work). — Gmelin
DeCholelithis Hum. Tubing. 1763.— Petit, Mem. del'Acad.
Rot. di , E) pel imenU on Hum.
Bile. Loni 1772.— Stoll, Rat. Med. in N I. Pract. Vin-
dob. Vii-n. 1777, vol. i. p. 213.— J. <;. Walter, Observat.
Anatom. Berol. fol. 1775, p. 46.— .V. /-.'. Block. Medicin.
Bemerkung. Bvo. Berlin, 4774, p. 27.— Hul/i ,-, Elem. Phy-
<iol. vol. vi. p. 5C4. ( ; also,
Optuculorum Patholog. L tii. p. 324. — G. P a haska, Admit.
Academ. fasc. ii. sect. 1. Pragr, 1783. — Durande, Nour.
Mt-m. de V Acad, de Dijon, 1782, p. 1 ".—//. / ,
tperim. EH. -lto. 1782.
de I 'all uli- in Corp. Hum. in-
veiitis. Hale, 1788, Bvo.— fi. Goldwiz, Neue Verauche liber
der Path, dec G to. 17891—*/. Leake, On Du.
oflheVii era. Lond. 1792. p. 257.— A. G. Riehter, Medi-
cin. und Chirurg. Bemerk. Erst 11. Goct. 1793.— £. Sand- ,
34
[fort, Mus. Annt. Aca.l. Lut;d. Bat. Lcidrr, fol. 1793.— fV.
Saunders,On the Liver, kc. lib ed. p. -'I . -Meckel, in
Mi,,,. ,1,- Berlin, vol. v. el vol. \,. p, 92.— A. V. If,
Be Oholelithis pet Abscessum Ruptum egredientibus, .v.-.
t'p-al. 17;::i 4to. — Fourcroy, in Annales ile Chimie, &c. Paris;
1793, t. wi. i-t nviL—Soemmerring, De C irement. Biliar.
limn mi Corporis. Trajei ti ad U m. Bvo. 1795. -fl
Morbid Anatomy, 5th ed. p. 251. — Thinard, Mem. de la
Soc. d'Arcueil, t. i. p. 64. — V,,,,i,'m M m. de Ii Soci I.
Mil d. d'Emulation, t. vi. p. 404. — BrunU, De I ' dculs Bili-
tres, Ho. Paris, 1803.— U. Biondi, in Giornale di Med. vol.
i. p. 382. — Blumenbach, Medicin. Bibliolhek, b. i. p. 121.
II, her ten, in Transac. of Coll. of I 'In.. Lond. vol.it. p. 137.
—Blagden, in [bid. \ol. iv. p. 181. —J. P. Frank, De Cu-
min!. 11 Morbis, Sec. I. vi. De Relent, p. iii. p. 316. —
Biett el Cadet de Gussicourt, in Diet, des Sciences Med. t.
iii. p. 460. — Craigk, in Kdin. Med. and Surg. Journ. No.
81.— Scott, in [bid. No. 83. p. 297.— Brayne, in Medico-
Chir. Trans, vol. xii. p. 255. (T-.e / interesting cases t f large
calculi.)— Thomas, in Ibid. vol. vi. p. 98. — JVinckel, In
Hiif'/iin'x Journ. ilir Pr. Heilk. b. viti. ; and Dixon,
Lond. -Med. Repos. April, 1824, p.29t. ; and Callaway, in
Lancet, vol. >.ii. p. 2;io. ; and Buffos, in Archives Geni-r.
de Mi decine, t. xi\. p. 459. (Cases of external tumour and
fistulous opening, discharging, at the right epigastrium,
biliary calculi with bile.) — Bricheteau, in Mem. de la So-
ciete j\lril. d'Emulation. t. iv. I'aiis, 1826, p. 194.— Orfila,
Ann. de Chimie, t. kwiv. p. 34, — 1 'aventou. Journ. Pharm.
t. iii. p. Sij'.t. ; et De Chimie Medicate, t. iii. p. 572. — Cnt-
■aeilhier, Anat. Path, du Corps Hum. I. xii. Paris, 1832.
CONCRETIOIXS— Inte sti n a l. Syn.— JJvine
Concretions ; Alvine Calculi, Monro. Calcu-
lous Concretions, Andral. Intestinal Calculi;
Enterolithus, Good.
Classif. — I. Class, II. Order (Author,
in Preface.)
1. Defin. Substances accreted into solid
masses in some part of the alimentary canal,
chiefly owing to imperfect action of the digestive
functions and nature of the ingestu, and giving
rise to dangerous states of disease.
2. I. Calculous Concretions occasionally
form in various parts of the human alimentary
canal ; and, although generally the result of
weak digestive function, hence, a consequence
of disease, they are, in some cases, the chief
cause of extreme suffering and danger. They
are most commonly found in some part of the
intestines, particularly the cajcum and large bow-
els ; but they are sometimes also formed in the
stomach, and there reach a very large size. Bon-
etus, in his Sepu/cretum Anatomicum, relates
two cases, in each of which a stone as large as a
lien's egg, and weighing four ounces, was found
in the stomach ; and a third case, in which this
viscus contained nine calculi weighing together
three ounces and a half.
3. i. Origin and Composition. — Intestinal
concretions are of several kinds, varying ex-
tremely in their nature and origin. In very
rare instances they have assumed the appearance
of bezoars, as in the case recorded bv M.M.
Champioh and Bracconnot, who ascertain-
ed their nature by chemical analysis. In some
cases, they consist chiefly of earthy deposits, in
obscurely crystallised layers, around a distinct
nucleus ; in others, they are formed principally
from those parts of the ingesta which are inca-
pable ol' change during the digestive processes.
The concretions which Dr. Good names intes-
liual calculi, and which consist chiefly of earthy
deposits, are found in the human intestines, as
well as in the alimentary canal of the larger
ruminating animals. They are generally formed
in concentric layers, and are often radiated,
sometimes very obscurely, from nuclei, which
are either gall-stones, or some hard foreign body.
393
CONCRETIONS, INTESTINAL — Ncm be r, Causes, &c.
They are more or less porous, either spheroidal
or oblong, and vary from the size of a pea to
that of a lien's egg ; and sometimes reaching a
much larger size.
4. With respect to their origin, they may be
divided into three varieties : — 1st. Those which
have arisen from nuclei formed either in the ali-
mentary canal, or in the biliary apparatus, such
as ga!l-stoues, inspissated mucus, &c., around
which certain saline and animal particles have
attached themselves during their abode in the
intestines. 2d. Those having nuclei consisting of
foreign bodies, such as fruit-stones, seeds, or the
husks of seeds, fragments of bones, &c, around
which the alimentary particles have collected and
crystallised, so that without the presence of the
nucleus the calculus would not have been formed :
and, 3d. Those which are formed entirely in the
alimentary canal, and which are generally more or
less homogeneous, and present no distinct nuclei.
5. The concretions of the first class have
their nuclei or central part composed chiefly of
cholesterine, the yellow colouring matter and
the resin of the bile, surrounded by layers of a
mixture of the phosphate of lime, and of the
ammoniaco-magnesian phosphate, with animal
matter. Haller supposed that the saline con-
stituents of these, and, indeed, all the other cal-
culi, were furnished by the pancreatic juice ; and
that the resinous parts were derived from the bile.
That such are the chief, although not the only,
sources of these constituents respectively, will
not, I think, be disputed.
6. Those belonging to the second class are
nearly similar as respects their outer layers ;
their centra! parts varying according to the na-
ture of the substance or substances forming their
nuclei. This kind of intestinal calculi are not
infrequent in those parts of Scotland where the
inhabitants live chiefly upon oaten bread ; the
beard and fibres of the husks of the oat resisting
digestion, and collecting together, so as to form
concretions or nuclei, around which saline matter,
with accessions of these fibres, collect. The
external layers of the calculus formed from this
source are generally solid, compact, soft to the
touch, and composed of saline matter: in other
instances, the outer layer has a velvety appear-
ance, and consists of very fine fibres closely
united. Dr. Marcet found these concretions to
consist of compact layers of fibrous substances
and of phosphates. The following is his analysis :
— In 100 parts, 25'20 were animal matter; 3-90,
resin ; 5-lfi, ammoniaco-magnesian phosphate;
45-34, phosphate of lime ; and 20-30, vegetable
fibres. The vegetable fibres were cemented to-
gether by deposits of earthy matter, and the ani-
mal matter.
7. Some of those concretions very nearly ap-
proach those of the third class, and present no
distinct nucleus, being merely an agglutinated
mass of vegetable fibres with inspissated mucus
and earthy phosphates, sometimes containing other
foreign ingredients or accidental ingesta.
8. Other concretions are formed in the intes-
tines of persons who have taken large quantities
of magnesia or chalk, with the view of preserving
an open state of the bowels, or of correcting
acidity in the stomach. The concretions, in these
cases, consist of those earthy bodies cemented
together by thick mucus. These concretions are,
in some instances, merely agglomerated masses ;
in others, they are indistinctly disposed in layers ;
they seldom have an] proper nucleus, and belong
rather to this third class, than to any of the fore-
going. To this division are also to be referred
those concretions which are formed of fascal mat-
ters with earthy phosphates, and inspissated se-
cretions sometimes hardened to the consistence of
calculi.
9. Number, Size, Colour, kc. — There are
seldom more than two concretions in the intes-
tinal canal, but a greater number is occasionally
found. Bo.nf.t met with nine in the stomach,
Lanzoni with ten, and Bilguer with thirty
in this viscus. The first Monro detected by
the touch twelve concretions in the colon of a
boy who was much emaciated ; and various au-
thors make mention of as great, as well as of a
lower number. The colour of the smaller con-
cretions nearly resembles that of iron ochre ;
the larger concretions are generally externally
of a coffee colour, sometimes approaching to
purple ; and occasionally they hate a whitish
surface. The different layers often present a
slight difference in the deepness of shade. They
are sometimes so hard as to admit of an imperfect
polish. Some of the calculi have been found
extremely large. The first Monro met with
them five, six, seven, and even eight inches in
circumference ; and the second Monro removed
from the colon of a woman, one which weighed
four pounds. The larger calculi are generally
more irregular in figure than the smaller. This
may be owing to the additions made to their
surface during the time they remain fixed within
a certain portion of the canal. Where more than
one are found, they often indent each other, or
form, as it were, parts of one long concretion, as
in the instance of the very large one, which weigh-
ed upwards of twelve ounces, and consisted of
three parts, recorded by Mr. Toreet (Edin.
Med. and Surg. Jour. vol. xxiv. p. S7.).
10. ii. The Causes of these concretions are,
sedentary occupations, inactivity, and indolence ;
a slow, weak, and torpid state of all the digestive
functions ; deficient vital energy of the assimilat-
ing organs (§ 4, 5, C); a long, free, and injudi-
cious use of magnesia, prepared chalk, and other
calcareous earths, for the purpose of correcting
acidity of the stomach (§ 7.), Sac. ; portions of
the husk and beard of the oat, from living upon
oaten bread, &c; swallowing incautiously frag-
ments of bones, stones of fruit, or seeds ; and an
habitual neglect of the state of the bowels.
11. hi. Their Local Effects. — When these
concretions reach a large size, they interrupt the
functions of the intestinal canal, preventing the
passage of the feces, and occasion dilatation of the
bowel above the place in which they are lodged,
followed by inflammation, ileus, &c. In more
favourable cases, they expand the intestines sur-
rounding them into a sac, which in process of
time acquires considerable thickness. Dr. Mon-
ro, in his very able chapter on alvine calculi,
describes three ca^es in which the crecum was
extended into the form of a sac, the muscular
fibres of which were hypertrophied, and the
mucous membrane thickened and corrugated.
This sac communicated with the commencement
of the colon by a cireulaiwopening, which, in one
case, was nearly an inch, in another scarcely
CONCRETIONS, INTESTINAL — Symptoms —Treatment.
399
above a quarter of an inch, in diameter. A
similar sacculated extension has been likewise
noticed by tins pathologist at the extremity of the
ilium, near the cariim.
12. Owing to the irritation occasioned by these
concretions, the intestine is often found con-
Btricted around ami immediately below them, as
demonstrated by Schknb and Monro. Ad-
hesion of the concretions to the inner coat of the
vkcos is a much rarer occurrence. Cases, how-
ever, have heen observed by Housings and the
first Monro, where such adhesions existed. Ul-
ceration of the parts in which they are lodged,
owing to the irritation occasioned by them, is
amongst the most common of the local effects to
which they give rise. In some cases, the inflam-
mation induced by them in the internal surface
of the bowel extends to the external tunics, until
it reaches the peritoneal surface, where coagulable
lymph is thrown out, and the convolutions in its
vicinity are agglutinated into one mass, or adhe-
sions to adjoining parts take place.
13. iv. The Symptoms which alvine concre-
tions occasion vary extremely, according to their
nature, and the size they have attained. Some-
times it seems wonderful, considering their great
bulk, that the intestinal canal is not completely
obstructed by them. In some cases, they have
remained for years, with evident symptoms of
their existence. In more fortunate instances,
they have been ejected with the contents of the
stomach after severe retching and vomiting ; or
have passed by stool, after severe dysenteric
symptoms and tenesmus. In almost every in-
stance, the digestive powers are very much im-
paired, and the patient becomes, after a time,
greatly debilitated and emaciated. The pulse,
at first, is but little affected ; but the patient
complains much of pain and tension in different
parts of the intestines, and is subject to occasional
attacks of nausea, vomiting, tormina, or purging.
The pain in the bowels is usually referred to
one part, and is much more severe at one time
than at another, particularly after taking acids,
or food difficult of digestion. Constipation of
several days' duration is often complained of, and
yet the patient has a constant inclination to go to
stool : at other times, or in other cases, there
are frequent watery and scanty evacuations of a
viscid ropy mucus or blood, which sometimes
give a short relief.
14. When the concretion is of a large size,
and the patient is somewhat emaciated, a very
hard, painful, globular tumour may be felt in
the abdomen, most frequently in the course of
the large bowels, upon placing him on his back,
and relaxing the abdominal muscles. It can
seldom be made to change its place within the
intestine, but often appears to do so in conse-
quence of the change of place of the portion of
the intestine containing it, particularly when it is
lodged in the small intestines, or in the arch of
the colon. Some patients are under the neces-
sity of abstaining from solid food, and others
reject the greater part of their food. When the
concretion has existed lor some tune, the bowels
are generally so much obstructed that laxatives
or clysters are necessary to procure a passage.
Dr. MONRO states, that when it changes its place,
and passes down into the sigmoid flexure of the
colon, or into the rectum, it creates excruciating
torture in the region of tin- pelvis and fundament,
and the bowels become obstinately constipated,
and much distended, from the passage being in-
terrupted.
1"). When alvine concretions lodge low in the
rectum, they occasion much pain when the patient
is sitting, and upon going to stool. When this is
the case, an examination per anum is requisite,
which will lead to their extraction by the forceps.
In a case in which the second Monro was con-
sulted by .Mr. Goodsir, the patient passed, in
the course of two or three weeks, nine concretions
in this way, some of which were as large as a
hen's egg. This patient had laboured for many
\\ eeks under very acute pain in the region of the
stomach.
lb'. When the concretions are small, they fre-
quently pass away with the (seal matter, without
occasioning any evident disturbance; the patients,
generally, having complained of nothing further
than long pre-existing dyspepsia and constipation
— the chief causes of their formation. In other
cases, especially when they reacli a large size,
most distressing and urgent symptoms are pro-
duced by them; commencing with those already
enumerated (§ 13, 14.), and terminating with
violent colicky pains, obstinate constipation, pain
at the top of the sacrum and loins, or in the
hypogastrium, sickness, retchings, and, at last,
complete ileus, or all the phenomena of acute
enteritis, or peritonitis. Even the smallest con-
cretions occasionally give rise to fatal conse-
quences. Two cases have occurred to me,
wherein the most acute peritonitis, followed by
the effusion of coagulable lymph, with adhesions,
and terminating in sphacelus of the vermicular
appendix of the caBcum, was occasioned by these
concretions having passed into this part. A simi-
lar case is recorded by Ruysch (Museum, 142.)
17. v. Treatment. — Wo are often without
any satisfactory proof afforded us, during the life
of the patient, of the existence of these concretions
in the intestinal canal, the symptoms they occa-
sion being the same with those proceeding from
various other causes. Their existence is, there-
fore, often merely a matter of conjecture, to which
the deficient energy of the digestive action, the
means resorted to by the patient to palliate dys-
peptic, symptoms, and his accustomed diet, fre-
quently lead ; and we seldom can form any
correct diagnosis, unless they are so large as to
occasion tumours in the course of the bowels, or
are lodged low in the rectum. When their ex-
istence is proved by their discharge, we may
consider the mischief, in a great asure, if not
entirely, removed, unless, indeed, the symptoms
continue, when we may infer one of two causes,
namely, the presence of more concretions, or
the existence of inflammatory action induced by
then in a portion of the intestines, or of intus-
susception.
1^. When the symptoms seem to proceed
from the injudicious use of calcareous or mag-
nesian absorbents) these must be entirely avoided.
Aperients of a different nature should be employ-
ed, particularly the supersulphate of potash, or
the sulphate of soda or of magnesia, with the ad-
dition of dilute sulphuric acid. In order to relieve
the more urgent symptoms, copious injections
400
CONCRETIONS, INTESTINAL — Origin of Fatty.
of an oleaginous, emollient, and purgative kind,
should be thrown up. And, in order that these
may more fully answer the intention, they ought
to be administered whilst the patient rests upon
his knees and elbows, with the pelvis elevated
above the shoulders. If vomiting be present,
care should be taken not to increase this symp-
tom by the administration of medicines by the
mouth. For, by frequently exciting the inverted
action of the stomach, this action will extend to
the alimentary canal, and terminate in fatal ileus.
It is preferable to solicit the action of the bowels
by emollient, anodyne, and aperient enemata,
and by frictions with oleaginous substances, or
fomentations on the abdomen. When we sus-
pect the concretion is owing to the nature of the
food, this cause must be avoided. When the
concretions are seated low in the rectum, their
extraction by the forceps must be tried. Those
arising from the use of oat-bread being, generally,
pnrllv composed of the earthy phosphates, and
considering the solubility of these salts, Mr. Tor-
bet and Dr. Duncan conceive that an impres-
sion might be made on them by a course of min-
eral acids taken by the mouth, or injected by the
anus.
19. The second Monro recommends, in cases
where the concretion is evident to the touch,
forming a distinct and fixed tumour in the bowels,
and where the symptoms are urgent, all other
means having failed, to attempt its extraction by
an incision through the abdominal parietes into
the intestine ; and in this recommendation Mr.
Torbet and Dr. Duncan agree. But, before
resorting to this last means, Dr. Monro advises
the following very judicious plan, which I extract
from the very excellent materials which his son
has laid before the profession : — " 1st, Let the
patient (a female) take every day a quarter of an
ounce (?) of Castile soap, in pills, and of castor
oil. 2d, Once or twice a week, let her take a
purgative composed of sal glauberi, one ounce,
sugar half an ounce, and the same of salad oil,
and whey ft ss., or 1h j. 3d, Three times a
week let her get a clyster of a quart of water, in
which an ounce of linseed and half an ounce of
Castile soap have been infused for two hours.
4th, Let her foment the belly, and take the above
clyster, when she suffers much pain. Let her
diet consist of loaf-bread, milk, whey, broth, soft
eggs, butter, a bit of light-dressed meat ; and if
she take porridge, let her melt a good deal of
butter in it." (p. 50.) Such was the advice of a
most experienced physician in this description of
disease ; and it proved successful in the case for
which it was directed. (See also the Treatment
of Colic and Ileus, and of Constipation.)
20. II. Fatty and Heterogeneous Con-
cretions.— A. Concrete substances, differing
very materially from those already described, are
sometimes formed in the alimentarj canal, par-
ticularly in the large intestines. These are usually
derived from two principal sources, viz. a morbid
state of the secretions poured into the intestinal
tube, or secreted from their internal surface ; and
alterations of the usual state of the ftecal matters,
during their retention in the coRCiim and large
bowels. To these, a third may be added, — the
ingestion of substances into the stomach, which
are incapable of undergoing any material change
during their passage through the canal, excepting
their agglutination into firm balls.
21. B. Concretions of an oleaginous nature,
or varying from an oleaginous to an adipocirous
or even waxy character, are sometimes voided
by persons who sutler from a torpid state of the
bowels, and deficient digestive function. These
concretions are often mistaken for gall-stones, but
are readily distinguished from them by the follow-
ing characters : — They are generally of a globular
form, vary in size from that of a small pea to the
bulk of a large grape, are of a cream colour,
slightly translucent, and of sufficient consistence
to preserve their form and be cut with a knife,
like soft wax.
22. '1 hese unctuous concretions cannot in gen-
eral lie traced to any oleaginous material intro-
duced into the stomach ; yet there is sometimes
evidence furnished of their origin in oleaginous or
fatty substances which have not undergone the
requisite changes in the prima via, but have been
merely slightly changed by the acid existing in
the stomach, and by the secretions poured into
the alinientarv canal, so as to assume the appear-
ance now described. It is possible, however, that
they may be occasionally formed by intestinal
secretion, or by a chemical change effected on
parts of the recrement of the food, after having
passed into the caecum and colon.. Fat, either in
the concrete form now described, or in a state of
fluidity and purity resembling oil, has been occa-
sionally, although rarely, voided from the bowels,
independently of having been taken by the mouth;
although more frequently proceeding from the
latter source ; as instances observed in the course
of practice at the Institution for Children have
proved. Cases of this description have been re-
corded by Dr. W. Scott (Ed. Med. Comment.
vol. iv. p. 334.), Dr. Babington and Dr. El-
liotson (I'lii/os. Trans. 1 S 13, art. xxi.) Dr.
Kd.ntzmanz, of Berlin (Journ. der Tract.
Heilkunde, July, 1821,), Dietrick, and seve-
ral others.
23. Sir Everard Home endeavours to ac-
count for the production of these adipocirous and
fatty concretions, by contending that it is the office
of the large intestines, particularly of the colon,
to convert a considerable portion of the matters
poured into them into fat, by con billing them
with the bile; and the fat thus formed in the large
intestines is taken up and conveyed into the cir-
culation, to be deposited in various parts of the
body, to supply the wants of the economy. But
the production of fat in the intestines seems to be
only tin' result of a diseased action, inasmuch as
it is voided from them, in any of its states, only
during disease — during visceral complaints, and
colicky or dvsenteric allections — and is never ob-
served to be passed from, nor is found within,
these viscera, when they are in their healthy con-
dition. It appears from the history of the cases
on record, as well as from those recently observ-
ed by Dr. Elliotson and .Mr. Lloyd, to be
especially connected with disease of the assimi-
lating viscera, and consequently with imperfect
assimilation ; a portion oi' the chyle, instead of
being changed to healthy blood, assuming an
oleaginous state, as not infrequently observed in
the serum. The fatty nmtter thus accumulated
in the blood, will, in several states of disease, be
CONGESTION OF BLOOD — Irs Nature, &c.
401
eliminated from it by excreting organs— particu-
larly by the mucous surface of the bowels, and by
the liver and kidneyiB-^nstead of being deposited
in the adipose tissue for ulterior purposes, and
will assume either a concrete or fluid form, owing
to modifications of its state as originally secreted,
or to the action of other matters upon it during its
retortion in the bowels or urinary bladder.
84 A singular case has been recorded by
Dr. Kennedy [Medico-Chirurgical Journ. for
Sept. 1817.), of an intestinal concretion, which
was found, upon its analysis by Dr. Ure, to be
similar in its composition to ambergrise.
25. C. Intestinal concretions have been found
to consist entirely of those matters which have
been swallowed from either a depraved appetite,
or bad habit ; thus, concretions causing violent
symptoms, have been produced by the habit of
chewing the ends of threads used in sewing, and
which have formed a firm felt with the mucus of
the intestines and some focal matters. I was
lately consulted in the case of a young lady who
had been long under treatment for obscure ab-
dominal disease, respecting the nature of which
no two of the several eminent practitioners who
had been in attendance agreed. The existence
of accumulated matters in the caecum and colon
seemed evident to me, upon examination, and
from the character of the constitutional and other
symptoms. Purgatives and injections were long
persisted in ; at last several concretions — (about
twelve) — from the size of a filbert to that of a
walnut, were evacuated. Upon examination, they
presented a substance resembling pasteboard, with
u fecal smell, of a brown colour, and containing
earthy particles. On being broken down and
macerated, they were found to consist chiefly of
coarse paper reduced to a pulpy state, but con-
taining fragments not materially altered. The
portions of pulpy paper were agglutinated with
mucus, portions of feces, and a little phospate of
lime. After some time the patient confessed that
she had occasionally been in the habit, about the
age of thirteen and fourteen, of chewing, and
sometimes swallowing, portions of the gray paper
with which she curled her hair. After the evacu-
ation of these concretions, all the symptoms dis-
appeared, and she rapidly recovered. A few
vears ago, 1 attended, with Mr. Annesley, a
similar case to the foregoing, but in a younger
lady. She recovered perfectly by the use of pur-
gatives and clysters.
Biblioo. and Refer.—.*. V. Sailer, Elements Physi-
ologic Corporis Humani, t. vii. p. 17»1. — Walther, De Con-
cremcntis terrestribui in variis Partibus Corporis Humanis
repertis, fol. 1775. — .S'. Fitzgerald, in Edin. Med. Com-
ment, vol. viii. p. 329. — Sir E. Home, in Philos. Tram.
1S!13, »rt. 21. — Manet, On the Chemical IlMory ami
Medical Treatment of Calculous Disorders, 1817. — /)/.* Law-
frier, Menioire sur les Concretions qui se torment darn le
Corps de I'lloinme. Paris, 1825 — J. Porta et Julia-Fon-
tenelle, iu Archives Gen. de Medecine, t. xii. p. 433.— P.
Denis, in Ibid. t. xvii. p. 111. — Torbct and Duncan, in
Edin. Med. and Suri;. Journ. vol. xxiv. p. 84 and 90. — G.
Andral, Anatomic Patholocinue, &c t. ii. Paris, i'42'.i. —
A Monro, (fC. The Morbid Anatomy of the Gullet Stom-
ach, and Intestines, 2d edit. Edin. 1830. (Contains the most
complete account of Intestinal Calculi with which I am ac-
quainted.)
CONGESTION OF BLOOD. Cla ssif. G e n-
eral Pathology : and I. Class, IV.
Order (Author, in Preface).
1. Dei in. Deficient vital tone or power , chief-
Si*
ly of the capillary vessels and veins, occasioning
accumulation of blood in them, and a languid or
more or less retarded circulation, the functions
of the organ or part being thereby proportion-
ately disordered.
2. I. Nature and Relations of Con-
gestion.— It has been stated in other places
(sec arts. Blood, Disease.) that morbid states
of the vascular system, and of the fluid circulating
through it, must be imputed, in a large propor-
tion of cases, to changes induced primarily in the
organic nervous system, which is, anatomically,
most intimately connected, not only with the cir-
culating system, but also with the organs essential-
ly vital ; this connection subsisting by ramifications
proceeding to them both directly and obviously
either from the great central ganglion or from ap-
propriate subordinate ganglia, as" well as indirectly
and less apparently through the medium of the
blood-vessels, on which the organic nervous sys-
tem is every where profusely distributed, the one
accompanying the other throughout the frame.
Thus intimately interwoven, they experience re-
ciprocative changes, and generate a common in-
fluence. The vital organs, as well as their subor-
dinate parts, in the more perfect animals, being
supplied by both these systems, — the most rudi-
mental type and essential requisites of organiza-
tion,— and actuated by their common influence,
are thereby enabled to perform their destined func-
tions ; the superadded or peculiar organization of
each organ being the instrument, which, thus ac-
tuated, performs specific offices in the economy.
3. It results from this, — 1st, that we are not
justified in considering changes in the states of
vascular action, or in the relation subsisting be-
tween the vessels and the quantity or quality of
the fluids circulating in them, apart from the con-
dition of the organic nervous system, which is
thus intimately connected, by structure and func-
tion, both with them and with all vital organs ;
2d, that changes in the vascular system are very
often induced by impressions made primarily upon
the organic nervous system ; whilst, on the other
hand, a morbid state of the former, particularly
in respect of its circulating contents, will most
seriously affect the latter ; and 3d, that, upon
tracing the procession of morbid phenomena, the
first impression made by the exciting cause, and
earliest change from the healthy state, will be
found in the functions of this system of nerves, in
perhaps the larger proportion of cases ; vascular
action, &c, and the secreting and assimilating
functions, being very soon afterwards disordered.
The truth of these propositions will become more
manifest after having surveyed the causes which
induce congestion, the phenomena which accom-
pany it either as coincidences or consequences,
and the results to which it leads ; and we shall
be more fully convinced of the propriety of view-
ins i( as very much more frequently a link mere-
ly in the chain of morbid action, than as a pri-
mary or even an early change.
4. Congestion lias been divided by many mod-
ern pathologists into active and passive, they un-
derstanding by the former that state of vascular
action which coincides with active determination
of blood, according to the meaning I have attach-
ed to it in another article. (See Blood, § 25.)
It may be defined to be a vital excitement with
somewhat of expansion of the vessels, and the
402
CONGESTION OF BLOOD — Its Causes, &c.
circulation of a larger quantity of blood through
them, without any obvious tendency to form new
productions, or to occasion disorganization, unless
inflammation, or some other morbid condition,
supervene, which is very often the case. From
this state — active congestion (see Blood, § 26.)
— in which the vital action of the vessels is
above their healthy standard, there is every inter-
mediate grade, lapsing insensibly into extreme
passive congestion, in which there is deficient
or depressed vital power, the current of the cir-
culation through the weakened vessels being re-
markably languid and retarded. In this state,
the venous and arterial capillaries, having lost the
principal part of their tone or vital tension, re-
act imperfectly upon the mass of blood injected
into them by the heart's action, and become dis-
tended and congested. This state, then, existing
in any degree, down to that which is barely com-
patible with the continuance of the life of the
part, constitutes congestion ; it being thus con-
sidered as a state of sub-action, and not of super-
action, as determination of blood undoubtedly is.
5. i. In respect of the modes of accession by
which congestion presents itself, much diversity
exists. It may occur suddenly, after intense
causes ; slowly, after slight influences or other
disease ; and almost insensibly, after active de-
terminations of blood and inflammatory action.
It may be almost the primary lesion, the impres-
sion made by the exciting cause upon the organic
nerves being the only previous change ; or it may
be one of the most remote, and only antecedent
of, or immediately consequent upon, dissolution.
It is generally the result of directly or indirectly
depressing causes ; and assumes every grade ac-
cording to the intensity of their operation relative-
ly to the organic nervous or vital energies of the
frame on which they act.
6. ii. The textures most liable to undergo con-
gestion are such as, owing to their conformation,
particularly the laxity of their vital and physical
cohesion, admit of the distension of their vessels.
Cellular parts, and organs in which the cellular
structure predominates, as the parenchyma of
various internal organs, particularly the brain, the
lungs, the liver, spleen, and kidneys ; the mu-
cous membranes, especially those of the bronchi
and digestive canal, and the uterus and ovaria ;
are most liable to experience this state of their
blood-vessels. Besides these, however, other and
less yielding structures, as the serous and fibrous
membranes, the skin, the muscles, &c, may be
congested to a certain extent, particularly after
exhaustion of the vital energies of the frame, and
diminution of the vital cohesion of these struc-
tures, either by causes which depress the organic
nervous power, or by noxious agents contaminat-
ing the blood, or by over excitement of the vas-
cular system of the congested part, or of the
whole frame. In one or other of these three
ways, congestion supervenes when it is observed
at the commencement, in the course, or towards
the close, of febrile and constitutional maladies ;
the same causes, and operating in a similar man-
ner, also occasioning congestion of those viscera
which are most liable to it by conformation.
7. iii. The causes of congestion are, therefore,
1st, those which act by primarily depressing the
organic nervous influence; such as advanced age;
the continued or prolonged impression of cold,
mental anxiety, and all the depressing passions
and moral emotions ; prolonged sleep, mental
and physical inactivity ; miasma], contagious, or
infectious emanations ; various vegetable, animal,
and gaseous poisons ; and the rapid loss of the
natural electrical tension of the frame : 2d, those
which mechanically impede the return or circu-
lation of the blood itself, or which change its
quantity and quality, either locally or generally ;
as excessive heat ; general plethora, produced
either by too full living, or by the suppression of
the natural or accustomed discharges, interrupted
circulation through the heart, the lungs, liver, kc;
a long retained posture by debilitated persons: the
use of unnecessary ligatures and tight lacing ; im-
proper and unwholesome food ; contamination of
the blood, by the absorption or introduction into
it of noxious mineral, vegetable, and animal sub-
stances, or gaseous fluids ; and changes taking
place in its constitution, from the interrupted se-
cretion and elimination of hurtful matters from it
(see Blood, § 115. et seq.) — these latter causes
affecting the vital manifestation of the vessels and
nervous systems : 3d, those causes which exhaust
the irritability or vital tone of the vessels, by pre-
viously exciting them above their natural state of
action ; as local determinations of blood, general
vascular excitement ; fatigue from violent or con-
tinued exertion ; pre-existing fever, inflammation,
or other diseases. Thus it will be seen that con-
gestion arises from changes induced (a) in the
slate of organic nervous power, and externally to
the vessels; (b) in the blood itself, and acting in-
ternally on the vessels and structures ; (c) in the
coats of the vessels themselves ; and (d) in two
or more of these simultaneously.
8. iv. The symptoms indicating the existence of
congestion are sometimes very apparent, at other
times very obscure. When it is present in a
marked degree, and in vital organs, the disturb-
ance of function is usually so great as to indicate
it< existence ; but even then the kind of disturb-
ance may be very nearly the same as proceeds
from morbid states, which we shall hereafter
find congestion not infrequently occasions, viz.
sanguineous or serous effusion ; as in the cases
of intense congestion of the encephalon. Upon
the whole, however, it gives rise to partial loss,
or entire abolition, of the functions of the affected
part. Thus, congestion of the brain, when mod-
erate, will occasion a slight state of lethargy, or
vertigo, &c. ; where more severe, epilepsy,
coma, or apoplexy. Congestion of the liver is
attended by more or less complete arrest ^f the
biliary secretion, with tumefaction of the organ.
&c. ; and congestion of the bronchial surface and
lungs, with dyspnoea, asthma, &c. Febrile phe-
nomena seldom accompany congestion, unless
it arise in the course, or towards the close, of
febrile diseases, or be excited by infectious or
miasmal emanations, or is about to pass into an
inflammatory or hemorrhagic state. When it
occurs in large secreting viscera or surfaces, the
function of secretion is either impeded, vitiated,
or altogether suspended ; a return or increase of
the secreting action either restoring the healthy
state of circulation, or converting it into active
determination, or even into inflammation. When
congestion affects several parts, or two or more
important viscera, as on the invasion or towards
the close of malignant fevers, or when the circu-
CONGESTION OF BLOOD — Appearances, &c.
403
latins: fluid and soft solids become contaminated,
the functions of the economy ;ire very gravely
disturbed, and sonic of them almost annihilated :
in such cases, tlic morbid impression made In the
existing causes upon the organic nervous system,
disorders the various functions it actuates, and
even puts a Stop to some of them; the derange-
ment of function being often a coeval and co-
ordinate effect with the congestion. Hence the
arrest or diminution of function becomes one of
the most common indications of the extent of
congestion, even although it may not be the
actual consequence of this slate of the vessels.
}•. v. The appeartmcea presented by congested
parts after death vary extremely with their struc-
ture, and the degree and duration of the conges-
tion. In addition to more or less engorgement of
the small vessels and veins, there are generally
found a darker colour of the contained fluid than
in tin' natural state, considerable tumefaction, and
diminished cohesion of the affected structure, and
alteration of its colour. The change of colour
may he of various grades of deepness, to a brown-
ish or greenish black, as frequently observed in
the liver and spleen; and the loss of vital cohe-
sion may be very remarkable, as in the same vis-
cera, tumefaction being then very considerable.
These appearances are often accompanied with
effusion of a serous, aqueous, or sanguineous
fluid from the congested surfaces; and sometimes
with ecchymoses of a deep colour in or beneath
the mucous tissues, and occasionally in serous
membranes and parenchymatous parts.
10. vi. The general consequences and termina-
tions of congestion are deserving strict attention,
as to this state are to be imputed several of those
more grave and dangerous changes presented to
us in the advanced stages of numerous diseases.
1st, Congestion terminates in the restoration of
the healthy circulation. This is most frequently
the case in respect of secreting parts, as the mu-
cous and villous surfaces and glandular organs;
the return of their secreting functions aiding most
materially the restorative process, by diminishing
the fulness of the vessels, and soliciting an accele-
rated circulation through them. Hence, although
n restoration of the circulation, to some extent at
least, is often antecedent of the return of the
secreting function, yet we frequently succeed in
restoring the former by exciting the latter ; the
stimulus thus imparted extending itself to the
weakened and congested vessels. Parts which
have once suffered congestion in a very marked
degree, very often retain a disposition to expe-
rience it again, upon exposure to its causes; this
disposition, however, diminishing with the lapse
of time, if judicious means of strengthening the
organ be adopted. 2d, Congestion may pass into
active determination, or into inflammation of
Various grades of intensify. This may arise from
changes induced in the state of the blood itself
relatively to that of the vessels; or from the re-
action of the vessels upon the distending fluid,
and the augmented impulse following the tempo-
rary retardation of the circulating current ; or
from the use of irritating and inappropriate stimu-
lants in order to remove the- congestion; or from
inordinate excitation of the secreting functions,
when we endeavour in ibis way to remove opple-
tiou of the vessels. 3d, Congestion frequently
occasions serous or aqueous effusions in the
vicinity of the congested organ, or in the areola
of its cellular tissue. We often observe this ter-
mination in the different internal viscera, and
cavities in which they are situated. It evidently
depends upon the rarefaction of structure occa-
sioned by distension of the parietea, and |o~s of
tone of the congested vessels, most probably as-
sisted by weakened vital cohesion of the tissues,
and diminished crasis of the blood; these con-
ditions either accompanying or following «he
congested state, which very frequently is par-
tially, or altogether removed by the consequent
effusion. 4th, I lacmorrhage may supervene, either
from the surface, or into the substance of the.
congested organ or part; owing either to a con-
stitutional disposition to haemorrhage, arising
from original conformation, the vessels readily
yielding from distension or accidental impulse;
or to the existence in a more or less intense de-
gree of the same changes which produce aqueous
effusion, particularly weakened cohesion of the
tissues, and, consequently, of the delicate canals
conveying the blood through them, and a morbid
state of the blood itself. 5th, Congestion of the
minute capillary canals, either frequently re-
curring, or continuing long, seems to give rise to
various morbid or adventitious structures, par-
ticularly when it takes place in persons of a
scrofulus diathesis, or affected by any other
constitutional taint. In such cases there is a
marked indisposition, both of the part to return
to a healthy state, and of the adventitious struc-
ture to be absorbed. 6th, Retardation of the cir-
culation in congested vessels may be so complete
as to occasion even loss of vitality and gangrene
of the part. We observe this in the congestion
arising from extreme cold, from the exhaustion
consequent on intense excitement, &c.
11. vii. Congestion, and its consequences in
respect of particular structures, are of great im-
portance, and are therefore considered among the
principal changes to which vital organs are sub-
ject. Although the local relations of congestion
fall under their appropriate heads, it may be
remarked, in general terms, that congestion may
occur in any structure or organ during life, with-
out evincing upon dissection unequivocal proofs
of having ever existed; and that it may appa-
rently continue till dissolution, without being very
manifest upon examination afterwards, f-uch is
especially the case in respect of congestion of
mucous and serous surfaces, the vessels of which
empty themselves soon after death, when the pro-
pelling power no longer acts upon them and dis-
tends their relaxed parietes, in consequence either
of the passage of more or less of their contents
into the adjoining veins, or of the escape, through
the extreme canals and pores of these structures,
of the more aqueous or serous parts of the blood
they contained, or of both these changes con-
joined. From this it will bo manifest that many
case-, of recent or not very intense congestion,
wherein we have reason to infer' that the small
vessels have not altogether lost their vital tone,
particularly of membranous parts, will present
upon dissection chiefly fulness of the veins, pro-
ceeding from these parts, with the effusion of
more or leas of a serous, aqueous, or sanguineous
fluid in their vicinity. On the other hand, con-
nection of internal organs may not have been de-
tected ut all during life, or it may have occurred
404
CONGESTION OF BLOOD — Treatment.
but shortly before, or at the time of death, and
jet be very evident upon inspection afterwards.
This is not infrequently observed in respect of
parenchymatous organs and mucous and villous
surfaces. When congestion, however, occurs in
the large viscera, as the brain, lungs, liver, and
spleen, and continues up to the time of dissolu-
tion, it is generally very manifest in them upon
dissection. In many diseases, particularly those
in .which the blood becomes affected previously
to, or continues fluid after, death, and in those
which terminate by asphyxy, congestion of de-
pending parts is a very common post mortem oc-
currence, and one which should be carefully dis-
tinguished from the congestion that has existed
during life.
12. II. Of the Treatment of Conges-
tions.— i. It is necessary always to keep in view
the fact, that congestion is a consecutive lesion,
arising generally from causes which depress the
vital manifestation of the organic system of nerves
supplying the blood-vessels; and that, although it
is very frequently associated with general pletho-
ra, and necessarily implies the existence of local
plethora (see Blood, § 23.), yet, on account of
this depression of nervous power, general deple-
tion, unless to a small amount, is seldom of much
service in the treatment of congestion, unless it be
conjoined with the use of stimulants, derivatives,
and excitants of the secreting functions, a. But
local depletions, particularly when directed in
such a manner as to operate some degree of re-
vulsion from the congested part, sometimes car-
ried to a considerable extent, or repeated as cir-
cumstances require, are among the most requisite
means of cure. 6. When the powers of life are
much reduced, even local depletions should be
employed with caution, and never without having
recourse, at the same time, or previously, to suit-
able excitants and external derivatives. Of these
classes of remedies, the most preferable are such
as tend to equalise the circulation throughout the
viscera, and determine it to the periphery of the
frame. Diaphoretics; the warm or vapour -but h;
warm poultices and fomentations; rubefacient em-
brocations, epithems or poultices, especially those
with Cayenne pepper, mustard, horseradish, &.c. ;
blisters, and warm and rubefacient pediluvia; are
calculated to accomplish these purposes, c. Much
advantage will also accrue from attempting to res-
tore, by emetics, purgatives, or other remedies,
the secretions of the mucous surfaces, and the
functions of the congested organ; as the restora-
tion of these functions, which are generally impe-
ded or altogether arrested, will unload the vessels,
and accelerate the retarded circulation in them.
But it should be kept in mind, that the medicines
that operate in this manner are generally local
and specific excitants; and hence that they, as
well as the stimulants usually given internally,
should be exhibited with caution, and preferably
at the same time that local depletion, with deriva-
tion to the surface of the body and lower extremi-
ties, are being employed. Without attention to
these precautions, we may convert, particularly
in plethoric persons, simple congestion into ac-
tive determination of blood, or into inflammation.
d. The diffusible stimulants that are generally most
serviceable in removing congestions are, camphor,
the preparations of ammonia, the a?thers, weak
infusions of arnica or serpentaria, warm diluents
with saline medicines or the nitro-muriatic acids,
the liquor ammonia? acetatis, small doses of ipe-
cacuanha, with camphor and opium, &c, and
several of the gum-resins and essential oils. e.
In many cases of congestion of vital organs, it
will be requisite, in addition to the foregoing
measures, to direct internal revulsant agents to
remote viscera. Thus, in congestion of the head
or lungs, we shall derive advantage from exciting
the action of the lower bowels by irritating ca-
thartics and injections; and, having prescribed
depletions and external derivation, from a judi-
cious employment of active diuretics, f. In all
cases, it will be necessary to promote the natural
secretions and excretions; inasmuch as we thereby
keep up a regular distribution of the circulating
fluids, and eliminate from them such hurtful sub-
stances as might irritate the vessels and induce
consecutive disease, if they were allowed to accu-
mulate, g. In many instances, benefit will accrue
from the affusion or aspersion of cold or tepid
water over the part enclosing the congested or-
gan, especially when the state of the pulse, and
the seat of congestion, lead us to dread the su-
pervention of haemorrhage, as in congestion of the
brain or of the lungs, h. Besides the external
means already alluded to, various others may be
employed near the seat of congestion; as moxas,
the actual cautery, dry-cupping, stimulating or
rubefacient liniments, dry friction, the warm and
tepid affusion or douche, the nitro-muriatic acid
lotion, chlorine or fumigating baths, electricity or
galvanism; but these are most appropriate to the
more chronic states of congestion. There are
other remedies besides the few cow adduced,
which are suitable to particular states and seats
.of congestion, and which full under different
heads.
13. ii. Having removed the congestion, it will
be necessary to employ means to prevent its re-
currence, for the part once thus affected long re-
tains a morbid disposition. This object can be
obtained only by a careful avoidance of the excit-
ing causes — by preserving a free state of the se-
cretions and excretions — by promoting the diges-
tive functions, and invigorating the system bv
modi rate exercise in the open air, either on foot
or horseback — by the use of mineral waters, par-
ticularly those which combine a tonic with an
aperient and deobstruent operation, as the waters
of Cheltenham, Harrogate, Scarborough, Leam-
ington, Seidschutz, Carlsbad, Bath, Marieabad,
Vichy, and E«ier — by warm clothing, and by
guarding against general vascular plethora.
Bibliog. and Refer. — Stahl, De Motu Toniro Vilali,
indcque pendente Motu Sanguinis particular], Stc Jena",
1692.— Baglivi, Opp. p. OSOT—JZuncber, Dissert, de Con-
gestionibus. Hals-, 1742. — [senflamm, De Comestiynum
Mechanismo. Erl. 1749.— A. E. Buihner. De Congest.
Natura. Cansis et Effectibus. Halae, 1749. — jVico/ki. De
Congestionibiis. Jens', 1761. — Wetziar, De Conjeslioni-
liiis. Lngd. Bat. 1779. — Capptl, De Sanguinis Congest.
Helm. 1796. — Goldhagen, De Tlieoria Congest, qualemu
Praxi inservit. Hals', 1724. — Maraud, Von Badern. p.
397. — Lent in, Be\tiage, Jcc. p. 229. tt seq. — Bloch, Medicin.
Bcmeikunsen, p.' 53. — Brandts, Versuch uher die l.ehens-
kraft, p. 122. — Bttrihez in Mem. d la Soc. Mid. d'Kinula-
tion, t. ii. p. 1. — Hoifr.mrurtncr Ueber die Gehirnv. a<=er-
sucht, p. 121. — Horn, Beitrtge zur Med. Klinik. b. ii. p.
82. 94.— Autenrietk, Physiologie, § S83. 509.— Rcil Ceber
die Lebenskraft, v. Arrhiv. fiir Physiologic b. i. st. 1. p. 129.
— Quensel, in ffuf eland's Jjrurn. dcr Pract. Heilkumle. b.
xiii. st. 4. p. V2S.—Sahbnrzcr, Med. Chir. Zeitung. 1801 b.
iv p. 257. — Alder, in Med. and Phys. Joum. vol. xxi. p
296.— Pring, Principles of Pathology", lond. 1S23, p. 443.
CONSTIPATION — Irs Pathology.
405
CONSTIPATION. — Syn. Con.it '» patio v el Obs-
ti/mtio Aloii Alvua tarda, dura, adttricta,
Var. Ann. Tarda dl»i DejecHo, Vogel. Oba-
tipatio JUvina, Young. Stypsis (from ifTi'upm,
1 ponstringe) Ploucquet Coprostasis, Good.
Hartleibigkeit, Germ. Constipation, Paresse
du Ventre, Fr. Cosfijpim'oRe, Ital. Bound-
Belly, Coetiveness, Obstipation, Fwcal Reten-
tion. A/vine Obstruction.
Classif. — 4. Class, Local Diseases; 5.
Order, Obstructions (Cul/en). I. (7« .•»■■.■,
Digestive Diseases; I. Order, Affecting
the Alimentary Canal (Good). I. Class,
I. Order ( Author).
1. Dkfin. Prolonged retention of the faces;
or slow, imperfect, or difficult evacuation of
them.
2. Dr. Good has made Coprostasis, or Cos-
tiveness, a genus; and divided il into V. Constipa-
ta, and ('. Obstipatas the chief difference being,
that the evacuation is voluminous in the former,
and scybalous or slender In the latter. This di-
vision is nearly the same as that previously adopt-
ed bv Dr. Bateman, viz. into Costiveness and
Constipation. I believe, however, that any dis-
tinction between them is quite unnecessary; in—
asmuch as either the one or the other, even ac-
cording to the import these writers attach to them
respectively, may arise from exactly the same
pathological conditions; and that it will be better
to employ these terms in their usual acceptation,
and to make constipation an intermediate grade
between costiveness and obstipation; or, if any
other di ierence than that of degree be imputed
to them, to consider obstipation as a modification
merely of the others, by attaching to it the idea
of difficult and imperfect void nice of the trees,
as well as of prolonged retention of them — which
latter alone will apply to costiveness and consti-
pation, according to the degree of obstinacy by
which the retention may be characterised.
3. The slighter grade, or costiveness, can
scarcely be considered as a disease in some con-
stitutions, as it is often attended bv a good state
of health in other respects, and seldom continues
so long as to occasion any appreciable disturb-
ance. But, when neglected, it gives rise to
those collections in, and morbid conditions of,
the colon, which have been described in that ar-
ticle, and favours the occurrence of other mila-
dies. Although cases are frequently occurring
in which little disorder results from constipation,
except from the means used to remove it, yet
very serious or even fatal effects not infrequently
accrue from it. I shall, therefore, adopt the
opinion of Collen, and consider the retention
of the feces beyond twenty-four hours, without
the desire of evacuation, as an approach to a
morbid state, and therefore requiring medical aid.
4. Duration, <§*c. — The annals of medicine
abound with cases in which the faeces had been
retained lor an almost incredible time, with-
out any serious or severe symptom supervening.
The occurrence of constipation for several days,
or even weeks, is not rare, particularly in
constitutions, and in weak or delicate females,
who take little nourishment, and as little exer-
cise; and, excepting listlessness with debility,
little disorder is complained of. It is not un-
common to meet with cases, especially in this
sex, where extremely little food is taken, and
where the faecal evacuations are not more fre-
quenl than once a week, or once a fortnight or
three weeks; eliminations of effete matters from
the blood taking place chief!} bv means of the
skin, the surface of the longs and kidneys, and
generally in an insensible manner. But cases
also more rarely occur, where the retention is
much longer, even without any other svmplotu
than great llatiilent and faecal distension, par-
ticularly of the colon, until, suddenly, symptoms
of colic, ileus, or inflammation, come on, and
soon terminate the life of the patient, or put it in
extreme jeopardy. Instances have been adduced
by Rhodius, Pan arom's, S.\ i.muth, D k vil-
li KRS, IS I. A N KARD, I'.UII \ HI), Moss MAN, &C,
of constipation continuing for five, six, or seven
weeks, and even for as many months, without
any fecal evacuation. Dr. Baillie published a
case which continued for fifteen weeks; and Jo-
f. RDF. ns met with cases of fourteen, fifteen, and
twenty-one weeks. Instances of constipation
continuing three, four, five, seven, eight, and
nine months, have been detailed respectively
by Triosn, Chaftal, Smetius, Staniland,
Pomma, Crampton, and Valentin. In many
of those very prolonged cases, the appetite was
very deficient; but in that adduced by Mr. Si-an-
il and, which continued for seven months, the
appetite continued good until inflammation, which
rapidly terminated life, came on. This person, a
young female, never had more than one evacua-
tion every two months, during a period of five
years; till which time she appeared otherwise in
good health. Indeed, in some instances of less
duration than those now alluded to, the appetite
has been much greater than in health. I have
met with several cases of habitual constipation, in
which the patient h id a ravenous appetite, and
yet did not pass a fecal evacuation oftener than
once every four, six, eight, or ten days; but, in
almost every such instance, either the breath has
been loaded with an offensive vapour, or the per-
spiration has been abundant and disagreeable, or
the urine copious and much loaded, — evidently
proving that the disorder was connected with a
rapid absorption from the alimentary canal, and
augmented evacuation by the other excreting sur-
faces, or by the kidneys. The inordinate excre-
tion that takes place l>\ this latter emunctory, and
the constipation, and ravenous appetite accom-
panying it, in diabetes, further shows that a very
large proportion — sometimes nearly all — of the
ingesta will sometimes be so far digested as to
admit of their absorption, their subsequent dis-
charge taking place almost exclusively by the
skin, lungs, and kidneys: a proportionate dimi-
nution of the excreting functions of the bowels,
and consequently of fecal matters in them, being
the result; that portion, however, which does
collect, being retained until it excites them to
action, either by the bulk or by the irritating
properties it may have acquired, when also it
may be the cause of a morbid or perverted ac-
tion. The. above circumstance shows (what, in-
deed, physiological research has proved), that, in
health) persons, the principal part of the fecal
discharges consists of secreted matters, and but a
small portion of them of such parts of the food
as have escaped the changes produced by diges-
tion; and it pimes the accuracy of the opinion
entertained by Cclle.n, at least as respects a
40G
CONSTIPATION — Causes of.
large number of such cases, viz. that costiveness
arises, in great measure, from the absorption of
the more fluid parts of the contents of the bow-
els, whether consisting of the digested aliments,
or of the exhaled or secreted fluids poured into
them.
5. I. Causes. — i. Remote causes. Habitual
costiveness is most common in persons of the
melancholic temperament, of a thin and robust
habit of body, and of a rigid constitution of fibre;
and is often connected with great activity of the
absorbent function. The most prolonged cases
of constipation usually occur in thin delicate fe-
males, and is obviously owing to an asthenic con-
dition of the organic functions, particularly those
more intimately connected with the alimentary
canal. Meckel states, that cretins are very
generally constipated, partly owing to their inac-
tive existence. It is very often caused by the use
of indigestible food, as heavy, or imperfectly
leavened, or adulterated bread, new cheese, nuts,
cucumber, &c. ; by stimulant and astringent ali-
ments and beverages; by the use of narcotics; by
smoking or taking snuff"; travelling in carriages or
on ship-board; by sedentary occupations; too long
indulgence in sleep, and too warm beds; inatten-
tion to the first intimation to alvine evacuation;
venereal excesses; prolonged lactation; excessive
perspirations, or increased exhalation and secre-
tion from other surfaces and parts than the intes-
tinal canal; mental or physical exertions too long
continued; advanced age; pregnancy; and the va-
rious mechanical and organic causes about to be
noticed (§9. et seq.).
6. ii. The immediate causes, or pathological
states giving rise to the retention and imperfect
excretion of the faeces, appear to be the follow-
ino-: — 1st, Impaired or torpid functions of the du-
odenum and small intestine. (See Duodenum.)
In this form of disorder, more or less obvious
symptoms of indigestion are usually complained
of from two to four hours after a meal, and it is
often attended by a slow pulse, slight sallowness
of the countenance and skin, with distension or
uneasiness about the right hvpochondrium, and,
in some cases, with a dull pain in this situation,
and unnatural heat of the palms of the hand and
soles of the feet. The tongue is foul at the root,
while the sides and point are red; the urine high-
coloured, or depositing much sediment, and the
pulse sometimes slower than natural; but occa-
sionally quicker a few hours after a meal. 2d,
Torpid function of the large bowels, affecting
either the ccecum, colon, or rectum, in a more or
less special manner. In this form of disorder,
constipation is usually more prolonged than in the
foregoing, and the sense of distension or uneasi-
ness is referred to the situation of these viscera.
There is also much flatulence, and all the symp-
toms more particularly noticed in the article on
Torpor of the Colon.
7. Constipation may thus arise from an inac-
tive state of any part of the alimentary canal, but
it most frequently and immediately depends upon
torpor of the portion devoted to the function of
fa-cation; and, although a part only of the di-
gestive tube may be chiefly affected, yet disorder
is seldom limited to it, — the functions of the ad-
joining portions, and, in many cases, of the whole
canal, being impaired. It may lie useful, also,
to endeavour to estimate in what this disordered
function may consist, and whence it proceeds;
and although nothing beyond conjecture will
often be advanced, yet will our opinions very
often be well founded, particularly after repeated
observation, and the attempt will therefore be-
come advantageous in pracuce. Impaired func-
tion, then, of any part, or even of the whole,
of the intestinal canal, producing either habitual
costiveness, or the occurrence of prolonged con-
stipation may be owing to one or more of the
following states: — a. To a diminished secretion,
or modified condition of the biliary and pancreatic
fluids; b. To lessened exhalation from the mu-
cous coat of the intestines, and to impaired secre-
tion from the follicular glands of this membrane;
c. To a rapid absorption from the internal sur-
face of the bowels; d. To relaxation, or torpor
of the muscular coats of the intestines giving rise
to distension, followed by imperfect or irregular
re-action on the distending power, and consequent
fecal and flatulent accumulations, particularly in
the large bowels; e. To rigidity of the longi-
tudinal bands of the colon, forming this viscus
into cells, and diminishing the calibre of the
central canal, from each side of which the cells
diverge, — thereby occasioning that state of con-
stipation or obstipation, which is characterised
by scybalous stools, and a difficult and imperfect
evacuation of them; /. To the production and
accumulation of flatus in the intestinal tube,
which, by the distension and inaction of the coats
it occasions, as well as by its mechanical effects
in obstructing the passage of the feces, and im-
pacting them into masses, often proves no mean
obstacle to the regular process of fecation;
g. To the accumulation of mucous sordes on the
surface of the intestines, or the lodgment of
hardened feces in the caecum, cells of the colon,
or rectum; and, lastly, To a varied combination
of two or more of the above states of function.
All these may be resolved into, or referred to;
one morbid condition, viz. impaired organic ner-
vous power, or diminished vital manifestation of
the digestive canal, expressed in one or more of
the above modes, or occasioning these pathologi-
cal conditions.
8. The above may constitute primary or idio-
pathic constipation, or intestinal indigestion; or,
in other words, functional impairment of the de-
fecating process. But constipation is as fre-
quently consecutive of lesions, either (a) of the
structure of the coats of the bowels themselves,
and affecting the calibre of their canal; (6) or of
adjoining parts, causing obstruction, compression,
or displacement of them; (r) and it is also very
often sympathetic of other diseases, which derive
from them some portion of the vital action requi-
site to the regular performance of their functions.
The last of these requires no further notice, as it
resolves itself into the pathological states above
enumerated; but it is very important that the
practitioner should be enabled to recall to his
recollection the various changes which not infre-
quently do occur, and give rise to the same state
of disorder as the functional derangements above
stated; as, upon a recognition of their presence
or of their absence, the prognosis and treatment
will very materially depend. The enumeration
of these will also comprise all that has been found
upon the dissection oT such cases as have ter
minated fatally, fuller details respecting them
CONSTIPATION — Consequences and Terminations of.
407
being riven in other articles:, particularly in that
upon the Organic Lesions of the Digestive
9, .1. Lesions, ch'ejhj of structure, affecting the
bowils and retarding the defacating processes. —
a. Extreme dilatation of one or all of the large
bowels, sometimes independently of much fecal
accumulation ; but most commonly accompanied
with Large collections of hardened frees and gases
v> ; 1 1 r( k. Brendel,Cai.lisen, Abercrom-
BiK, Staniland, and many others.) In cases
of this description, the cn?cum and colon have; fre-
quently been observed from twenty to thirty inch-
es in circumference, b. Scybala, hard bodies,
particularly biliary or intestinal concretions, the
stones of fruit, &C, in various parts of the intes-
tines, especially in the caecum or before its valve,
the sigmoid flexure of the colon, and in the rec-
tum pi-; above the sphincter, and pressing upon
it and the prostate, instances of prolonged con-
stipation have occurred in my practice from the
obstruction occasioned by large balls of Lumbrici
and ascarides. A singular case of this descrip-
tion was noticed by me in the London Medical
Rejwsitory (vol. xvii. p. 243.,) and similar ef-
fects have been mentioned by Lieutaud, Bre-
ra, Rf.nauldi.v, and Bremser. c. Of in-
flammation of an insidious character, and sub-
acute or chronic form, affecting chiefly the mus-
cular or peritoneal coats of some part of the
bowels, particularly of the small intestines; and
either altogether arresting the peristaltic and tonic
movements of that part, or greatly diminishing
their activity, d. Contractions of various parts
of the intestinal tube, but most frequently of the
rectum, next of the colon, and least frequently
of the caeum and small intestines : these may
be small in extent, although great in degree; or
they may lie the reverse. The narrowed part
may be affected by spasm, or by thickening of
one or more of its coats; this latter change being
either so limited as to have the form of a ring
(Home, Baillie;) or extended much wider,
and seated in a large portion of the bowel, or in
more than one part. It may, moreover, be ul-
cerated, callous, cartilaginous, scirrhous, or even
carcinomatous, &C-, and it is always attended by-
great distension of, and fecal accumulations in,
the part above it (Morgagni, Lorry, Stoi.l,
Baillie, Portal, Howship, Calvert,
Annesli v, &c). e. Hsemorrhoidal tumours,
either in a state of inflammation or irritation,
and fissures, &C. of the ami-, will often occasion
constipation : the latter, by rendering the sphinc-
ter of the anus irritable aial spasmodically con-
tracted, so as to oppose the expulsion of the !';;•-
ces retained in the bowel; the former, by pro-
ducing the same effect upon the sphincter, as
well as by presenting a mechanical obstacle when
Beated internally. /. Constriction, or contrac-
tion, of a portion of intestine by adhesions or by
cicatrisation ('I'n k i) e.s ). g. Polypous, fbi
or fleshy excrescences growing from the
surf ice of tin caecum, colon, or rectum; polypi of
the sigmoid flexure of the colon passing down in-
to the rectum (Portal, Meckel, &c); sar-
comatous tumours, and scirrhous and carcino-
matous productions in the rectum or colon, are
irremediable causes of obstruction when they
reach a certain extent, and occasion great, and
sometimes enormous distension of the parts im-
mediately above them, witli fecal accumula-
tions, * ic.
10. B. Constipation is also not infrequently
the consequence of diseases seated exteriorly to
the coats of the intestines, and compressing or dis-
placing them, and of which the following are the
most remarkable: — a. Tubal or extra-uterine
fetation, pregnancy, hernia, &c. b. Pressure on
the rectum, arising from luxation or fracture of the
os coccygis (Ephem. Nat. Curios, dee. in. aim. v.
and vi. oh. 241.). c. The pressure of tumours in
the uterus or ovaria; prolapsed or retroverted ute-
rus ( U u N T E K , W V. DEL, DC HO I.I 7. , M A Ii SIS N A,
and m j self.) d. Various tumours seated between
the uterus, vagina, and rectum (Bader, Bonet,
Burggrave); abscess in the same situation
(Ephem. Nat. Curios, dec. i. ann. hi. ob. 10'7.,
and myself); and too large a pessus in the vagi-
na (Bayard), e. Abscess between the bladder
and rectum (Cohradi, Leske, &c); and en-
largement or other disease of the prostate (Ford,
myself, and others). /. The pressure of enlarged
sacral glands (Cruickshanks), of an enlarged
ovarium descending in the pelvis (.Mueller,
Odier, &c), and of various kinds of tumours —
sarcomatous, steatomatous, fibrous, and cartila-
ginous— developed in the omentum, within the
pelvis, &c. (Laoth, Reidlin, Sciueffer,
Osiandf.r, IIufeland, &c).
11. C. Obstinate constipation may also depend
upon, or at least be connected with, injury or dis-
ease of the spine. In delicate females, it is not
uncommon to find fecal retentions proceeding
from this cause. In many of such cases, much
pain is felt when the spine is examined, indicat-
ing the presence of inflammatory irritation of
the envelopes of the cord, or scrofulous disease
of the bodies of the vertebra;. In cases of this
description, the functions of the intestinal canal
are impeded, or otherwise disordered, by the
morbid influence exerted by the spinal nerves
upon the organic nervous system, through the me-
dium of their communications with this system.
12. II. The Consequences and Termina-
tions of constipation require the utmost atten-
tion, as respects both the prevention of such of
them as are unfavorable, and the recognition of
their early approach. Among the most common
remote consequences of fecal retention, are cuta-
neous eruptions, headachs, vertigo, various dys-
peptic symptoms, chlorosis, hysteria, and chorea.
*Thc following case i- not only extraordinary but instruc-
tive:— M.i' , a medical officer in (lie French service,
was alwavs costive from birth, lie ate largely, bul seldom
{, asset! a itool ofti di i than once in one or two months ; and
,i, abdomen assumed a lanje lire. At the aee of 42. his
I I to three oi four months.
[nl806, aflei medicines nad bees taken to procun a stool,
which had i'"1 bean passed for upwards of four months,
abundant evacuations continued for nine- days, .-nil contained
isini laki a ;■ twelve-month b< fore : bul the
constipation returned, In 1809, the enlarged abdomen be-
inful, vomiting lupei ■■< n< .1. and he dii d al I
!i life, passed re than four,
five, or six stools in the year. On opening the abdomen, a
u nbstructcd the tectum Bboill an inch from
the anus. Immediately above this partition, the rectum was
dilated >- la fill ill the |>> \\ is, an I nearly -ill
the abdi I ined thirty kito-
grummet uf brownish black and very oDensive pultaceous fa-
ces, I. ■ innei iiu fai e ppe ented gangi i nous and i ;
111* lowei pari of the colon was enlarged tothe
size of I he stomach: which, with the small intestines, liver,
diminished in volume and capacity by the
ol the distended rectum. (IIenaii.din, in Diet.
ties Scien. Med. t. vi. p. 267.)
403
CONSTIPATION — Prognose — Treatment.
The straining at stool is liable to produce apo-
plexy and hernia in aged, and haemoptysis in
young persons. When constipation is neglected
or improperly treated, the most serious effects
are produced immediately upon the bowels them-
selves; hemorrhoids, severe colic, passing into
ileus or enteritis, being not infrequent results.
These very serious consequences of constipation
may, however, proceed as much from the use of
too powerful drastic or acrid remedies, to procure
evacuations, as from the faecal retention. I have
repeatedly seen dangerous effects follow a large,
or even a moderate dose of castor oil, which had
become rancid or acrid by exposure to the air, or
by long keeping. When the constipation has
continued long, the most distended portions of
the bowels, either by flatus or accumulated
fa?ces, sometimes pass rapidly and insidiously
into an inflamed state, which, if not speedily
subdued, soon terminates in sphacelation, or in
a kind of sphacelating ulceration. In all cases,
therefore, of obstinate, and even of early con-
stipation, the state of the abdomen — particularly
in respect of tension, tumefaction, hardness,
definite or indefinite tumour, tenderness, heat
and dryness of skin, and pain on pressure, &c.
— should be carefully examined by touch, and
mediate percussion ; and if any of these symptoms
be present, the accession or early progress of in-
flammation, and other unfavorable consequences
now noticed, should be dreaded or even inferred.
If, to these be added nausea and vomiting, heat
of skin, high-coloured urine; an erect, white, or
loaded appearance of the papillae of the tongue;
hard, constricted, or oppressed pulse, even al-
though it may be slower than natural; and more
especially if pain, tension, &c. be present, with
hiccup; inflammatory action of a serious or un-
favourable kind is obviously present, or even far
advanced, and calls for the most decided means.
(See arts. Colic, and Intestines — Inflamma-
tion of.) Nor should we overlook the fact, that
constipation is a very common symptom of en-
teritis, which may actually exist without occasion-
ing much febrile disturbance, or affecting the
pulse; great care is therefore necessary at the
outset, in distinguishing simple constipation, from
the constipation which proceeds from the slow
and insidious occurrence of inflammation of the
nosis will necessarily depend upon the nature,
seat, and extent of these lesions, as far as they
can be ascertained; as, for example, when it is
owing to enlargement of the prostate, contrac-
tions of the rectum and colon, tumours in the
pelvis, &c, an opinion of the result, although
generally unfavourable, will vary according to nu-
merous concurrent circumstances, particularly as
respects a permanent recovery, or an immediate
or remote occurrence of a fatal issue.
14. IV. Treatment. — The means of cure
in every case of constipation are directed with
the intention, 1st, of procuring faacal evacuations
by as gentle and unirritating means as may be
adequate to the purpose ; and, 2dly, after having
fully accomplished this end, of preventing a re-
currence of a torpid condition of the bowels and
digestive organs generally.
15. i. The removal of existing constipation. —
A. The slighter and more common cases of con-
stipation are most benefited by the use of such
means as are generally employed to promote the
secretions poured into the intestinal canal, and to
excite its peristaltic action. About three or four
grains of blue pill, either with or without a little
Castile soap and extract of taraxacum, taken at
bed-time, once or twice a week ; and a draught
consisting of equal quantities of the compound
infusions of gentian and senna, with a little neutral
salt, &c. (see F. 203. 266.); or of the compound
decoction of aloes; on alternate mornings, will
generally be all that is required. Besides these,
any of the stomachic and aperient medicines pre-
scribed in the Appendix may be adopted (see
F. 215. 252. 558. 574.); the patient having re-
course to the shower bath, or cold plunge bath,
_in the morning, and resorting regularly to the
water closet after breakfast.
16 a. In the slight, as well as in habitual and
frequently recurring constipation, it will be useful
to ascertain, as accurately as possible, the par- '
ticular viscera in fault, and what function is de-
ficient (§6. et seq.). When we suspect that the
duodenum and small intestines are especially af-
fected (§6.), the compound infusion of senna, or
the infusion of rhubarb, combined, according to
the circumstances of the case, either with the al-
kalies or their sub-carbonates, or with vegetable
bitters and tonics, or with ipecacuanha, tarax-
intestines, — a diagnosis, which only a careful I acum, and antispasmodics, as here directed, will
examination of the abdomen, and enquiry as to generally remove all disorder. (See also F. 251.
the above symptoms, can furnish. J 391. 506. 562.)
13. III. The Prognosis in constipation is ,T , ,„ „ T , „, . . . , , _ „
. , , . .. . i • , r ^°- 143. \i Infus. Khei (vel Infus. Sennas romp.).
very favourable in slight eases, and in those of \ Aqua- Pimento, 5a 3 vj.: Liq. Potassa- Tt| xx. ; Extract!
short duration, particularly when unattended by Taraxaci ?,j.; Spirit. Mvristicas Sj. M. Fiat Haustus,
nausea or vomiting, or by pain, tenderness, and mane vel hora somni anm^idus.
r .- r .1 1 i l j- 1 "i ^°- !•"• v Infus. Senna> t_ omp. =; vss. ; Sod* Suh-
tumefaction of the abdomen, or by any febrile ■ rar,,on. - js3. . vini IpeCacuanha. 3 j2. ; .Spirit. Amnion.
symptoms: it should be given with great caution Arom. et. Tinct. Hyoscyami aa ~j. ; Tinct Cardamom.
when these symptoms are present, as they in- Comp. 3 ij. M. Fiat "Mist., cujus capiat Coch. iij. larga
dicate the accession of inflammatory action: and '""hTr Infus. Calumo* (vel Infus. Gentian*
it ought to be unfavourable, when the obstruction
is prolonged notwithstanding the judicious em-
ployment of remedies, or when any of the symp-
toms indicating the accession of the unfavourable
terminations noticed above make their appear-
ance; for these states of disease are more dan-
gerous when they supervene on obstinate or pro-
longed constipation, than when they occur in a
simple and idiopathic form. When faecal reten-
t'.r... . .mn.,™ntlv r.*^-.n„A f.nm „„., „f *U« ' vel quartan) |>:ti t cm pro d..,e,w repctatur pro re rata.
bona apparenth proceed fiom any oi the organic _No. I48- '. Mai;U. SulphatisP- j. (ve5 Potass* Sulpha
changes enumerated above (§ 9, 10.), the prog- tis 5 ss.) Infus. R'osar. Comp., Infus. Gentine Comp. aa
Comp.), Infus. Senna? Comp., aa 5 M?s' i I-'O,. Polajsas
Sjss., Extr. Taraxaci 5 ss. ; Spirit Piments (vel Myristice)
n ij. M. Fiat. Mist, de qua sumantui Coch: iij. larga hora
somni, vel primo mane.
No. 146. K Extr. Colocynth. Comp. }>-ij. ; Saponis Cas-
til. gr. x. ; Pulv. Ipecacuanha' gr. vj. ; Extr. Hvoscvami
3 ss. Contunde bene simul et fianl Pilula; xviij , quanun
capiat liinas hoia somni quotidJe,
No. 147. ]{ DeCQCti Aloes Comp. 5 ivjss. : Liquoris
Potassa (vel Suh-carb. Soda) - j. ; Vini Aloe's " vj ; Extr.
Taraxaci " iij. ; Spirit. Pimentae ^ ss. M. Capiat tertian)
CONSTIPATION — T B e a r h E n t.
409
*rj. ; Acidi Sulphuric! Arom. TT) x. ; Tinrt. Senna- (vel
Tinrl. Auiantii) ",j. — ", ij. M. Fiat IlausliK, Omni im i i.lu-
capiendua.
In most instances of constipation depending upon
torpor of the small intestines, ;in«I deficient biliary
secretion, a lull dose of blue pill or of calomel
should be exhibited .it hod-time, and a common
black draught the following morning, at the
commencement of the treatment, with the view
of promoting the secreting functions of both the
liver and the mucous follicles of the bowels; and
a moderate action ought to be kept up for some
time subsequently by the remedies now adduced.
17. b. In those cases in which the large bowels
are chiefly in fault, the preparations of aloes va-
riously combined, the means already mentioned,
particularly R 146, 147., or those recommended
in the articles on the Colon, and on Colic, will
be generally found appropriate. In some instan-
ces, however, it will he requisite to have recourse
to more powerful cathartics than I have yet
mentioned — particularly when irritability of the
stomach, or of the system generally, does not
exist — and to promote their action by enemata.
The following, or F. 140, 141. in the Appendix
may be employed.
no. 149. R I*ii I v. Jalap, zr. xij.; Pulv. Scammonia3 ex.
v.: Potasv Bulphatis "j. ; Olei Carvoph.; et 01. Carui, aa
TTj iij. Tere bene simul, ct fiat Pulvis in quovis vchiculo
idoneo sumendus.
No. 150. R Magnes, Bulphatis 3 vj. ; Infus. Senna?
Comp. - ij. ; Tinrt. Jalap. 5 j- ; Tinrl. Opii TT) vj. — x. (vel
Tinct. Ilvosrvami ", ".) ; Tinct. Castorei, Spirit. Pimenta?,
aa " j. ft. I'iat Haiutus.
No. 151. K K\tr. Colocynth. Comp. ^) ij. ; Saponis
Castil. gr. xij.; Olei Crotonis ett. iij. (vel Extr. Nucis Vo-
mica gr. iij.). M. l'iant Pilula xii. Capiat duas hora de-
cubitus.
No. 1 52. R ]\tanna> " j. ; Infus. Antheniidis ■", xij. ; solve,
et adde Olei Olivje 5 ijsJ. ; Magnesia; Sulphatis 5 jss. Sit
Enema.
18. c. In cases apparently depending upon
deficient tone of the muscular coat of the large
bowels, and imperfect propelling power of the
upper part of the rectum, I have seen benefit
derived from combining the spirituous extract of
nux vomica, or strychnine with the pilula aloes
cum myrrha, or with the compound extract of
colocynth, as directed above in R 151., in place
of the croton oil. When this state is connected
with deficient secretion from the intestinal mucous
surface (§7. b.), small doses of the croton oil,
from one sixth to one half of a drop, combined
with some other purgative, and repeated daily, or
on alternate days, will remove obstructions from,
and restore the secretions of, the mucous follicles.
In cases also where the internal surface of the
intestines are loaded with a viscid mucous sordes
(§7. %.), it acts more efficiently than any other
medicine, particularly when combined as above
(R 151.), or with calomel or blue pill, and re-
stores more permanently the functions of the in-
testines. I have recently met with several cases
of constipation consequent upon attacks of pesti-
lential cholera, and in nearly all of these I have
in&rred the existence of not only imperfect peri-
staltic action of the bowels, but also an accumu-
lation of viscid, mucous, or albuminous sordes on
their interna] surface, — an inference confirmed
by the state of the evacuations. The combina-
tion of purgatives now alluded to has proved more
efficacious in removing this morbid condition,
than any other 1 have employed.
19. d. In children and i/ming females, consti-
pation is generally attended, even if it be not
caused, by deficient secretion from the mucous
l"""'l''"i' i""1 by an accumulation of mucous
sordes (the Suburra inttstinahs of the older
writers, and the Embarras Sabural and Embar-
ras intestinal of French authors) on the internal
surface of the bowels. In these eases, a dose of
ca'0 1, With either jalap or senmmon v, and tri-
turated with sugar, and followed by castor oil, or
the infusion of senna with salts, or by the decoc-
tion of aloes, &c, according to the circumstances
of the cases, will generally procure full evacua-
tions. Hut in many such cases, the repeated ex-
hibition of these will he required before the col-
lected sordes can be removed; and even when
the evacuations have assumed a healthy appear-
ance, it will be requisite to resort occasionally to
purgatives combined with tonics and resolvents —
such as senna, aloes, or rhubarb, with gentian,
cascarilla, cinchona, or calumba; and with potass,
soda, &c, before the functions of the bowels will
be altogether restored.
20. e. When the focal retention assumes the
form of obstipation, and is attended with difficult
or imperfect evacuation; or with frequent desire,
and tenesmus; and with hard, rounded, scybalous
discharges; we may infer the existence of* rigidity
of the longitudinal bands of the colon (§ 7, e.);
and should combine anodynes and antispasmodics
with purgatives. I have commonly derived most
advantage from small doses of castor or olive oil,
exhibited frequently, in some carminative or aro-
matic water, with a little tincture of hyoscyamus
and ipecacuanha wine; and from demulcent,
anodyne, and oleaginous clysters (F. 143, 144.
795.) Flectuaries, also, consisting of the con-
fection of senna, with cream of tartar, magnesia,
extract of hyoscyamus, &c. (see F. 96. 98.), will
generally prove more serviceable, in these cases,
than very active medicines. When the retained
scybalous foces produce irritation of the colon,
the frequent calls to stool, and the scanty, mu-
cous, and watery evacuations, may lead the prac-
titioner to suppose, if he rely upon the account of
the patient only, that diarrhoea, instead of consti-
pation, actually exists, and hence to adopt an im-
proper treatment. In these cases, the warm or
tepid bath, the addition of ipecacuanha, or hyos-
cyamus, or both, to the purgatives given by the
mouth, and the use of clysters with" infusions of
ipecacuanha and linseed, and with olive, linseed,
or almond oil, will generally procure the evacua-
tion of scybalous foces. When the bowels are
distended by flatus, the operation of aperients will
be most assisted by gentle friction of the abdo-
men; and confidence to persist in the use of it will
be given by directing the friction to be employed
with some liniment (F. 298. 306.), or with R 157.
subjoined.
No. 153. R Olei Ricini recentis ""J j — ""J ij. ; tere cum
Vitelli <>vi uniui, et addc terendo, Vini Ipecacuanha TTI x. ;
Tinct. Hyoscvami IT) xv. ; Tinct. Caitorei TT) k.; Aqua!
Pimenta ", xj. M. Fiat Haustus, -1(4 vel 5ta quaque hora
sumendus.
No. 151. R Pota«np Supertart. in pulv. " j. ; Sod* Suh-
carbon. exsic (vel Magnet. Calosnat.) 3 iii. , Confection's
Senna: " j--. ; Confection*) liuta- Z ijss. : Extr. Hyoscvami
gr. xij.; PuIt. Ipecacuanha gr. ij. — iij. ; Tinct. Capsici
7, as. ; Syrup. Zingiberia q. i. ul fiat Electuarium, cuju» ca-
pial |i ul. m quartan] 4tia vel 5tis horis donee plemi dejecerit
v... 156. I! Soda Sulphatis, Manna; Opt, aa'j. , solve
leni nun ralore in Aqua Menth. Virid. s vl?,-i et adde
Tinct. Senna- 3 j. ; Vim [pec u <i inn , " j. Tinct. Capsici
ij. M. Capiat Coch. larga quatuor
S p iri
tcrtiis vel quart's hoi
410
CONSTIPATION — Treatment.
No. 156. R OU-i Amygdalae, 0!ei liicini, Manns Opt.,
na 5 iss. ; Aq. Pimenta ",Yj. M. Fiat Haustus, 4tis, 5tis, vel
fctis hoi is sumemius.
No. 157. K TJneuenti Cetacei 5 jss. ; Olei Carni et Tinct.
Opii iia 3 j-s«. Misce, et fiat Linimeutum, cum quo illinatur
abdomen, urgt-nte llatu.
21. B. a. In the more obstinate or prolonged
cases of constipation, which have resisted the
above, or any other means usually employed to
procure evacuations, we should endeavour to
ascertain, by enquiring into the previous state of
the patient's digestive and intestinal functions,
and by examining the abdomen, rectum, and parts
in the vicinity, the probable cause of obstruction.
The account which may be furnished of the
appearance of the evacuations heretofore, and of
the facility with which they had been evacuated,
as well as of the sensations felt before or at the
time of evacuation, will very materially guide
the judgment of the practitioner in concluding
respecting the existence of organic disease of the
colon or rectum, or in the vicinity of the latter.
Frequent attacks of diarrhoea, tenesmus, or
dysentery, previously to the occurrence of con-
stipation, or of pain in the course of the colon, or
along the sacrum, should always lead us to sus-
pect narrowing, or thickening, or both, in some
part of the colon or rectum (§ 9. d.). In such
cases, we should endeavour to solicit fcecal dis-
charges by oleaginous and saponaceous clysters,
and frictions of the abdomen, rather than by
purgatives taken by the mouth; and we ought
not to be too officious in the use of these ; but
should so study the feelings of the patient, as to
prevent irritation and febrile disturbance — the
harbingers of inflammation — from coining on.
In those cases particularly, examination of the
state of the rectum, and the lower part of the
colon, by the introduction of the long iiexible
bougie, as recommended by Dr. Willa.v, should
not be omitted; and if any stricture exist within
the reach of this instrument, its gradual dilatation
should be attempted. If a stricture be reached, it
may be of service to use a hollow bougie, along
which enemata may be thrown up so as to pass
beyond the seat of obstruction, which might
otherwise not be overcome by them. Instances
have been met with, in which stricture and or-
ganic disease of the colon have apparently existed
ibr some time without constipation having been
complained of; and yet the exhibition, when con-
stipation did take place, of acrid purgatives in
large and repeated doses, has been soon followed
by an unfavourable issue, which, however, might
not have been much longer deferred by any treat-
ment whatever. Cases illustrative of this occur-
rence have been recorded by Home, Sterry,
Annesley, &c. (See references.)
22. b. In almost every instance in which the
bowels still remain obstinately costive after two
or three doses of purgative medicine have been
given, but without any urgent symptom being
complained of, it will be more advantageous to
use gentle means, to trust chiefly to enemata, and
to wait patiently the result, than to prescribe
medicines which will irritate, and invert the action
of the upper part of the digestive tube without
reaching the seat of obstruction. If, notwith-
standing, symptoms of inflammatory action begin
to appear; or if the stomach become irritable;
or if the pulse be oppressed, hard, or constricted;
or if the patient be plethoric and of a sanguine or
irritable temperament; venaesection, or the appli-
cation of leeches to the abdomen, or both, should
be resorted to, and hot poultices and fomentations,
or the warm turpentine epithem, or a blister, be
afterwards placed upon the belly. The patient
may then be left quiet for several hours, in expec-
tation of the action of the purgatives previously
given; or, if the stomach be irritable, soothing
and anti-emetic remedies (F. 178, 179. 357.)
only, or a full dose of calomel with opium or hy-
oscyamus, should be taken, and after a few hours
the enema may be repeated. In cases of obsti-
nate constipation, unconnected with contraction
of the colon or rectum, a large dose of calomel,
either alone, or with opium or hyoscyamus, may
be exhibited, and repeated once or twice, at dis-
tant intervals; each dose being followed either by
castor oil, or by the common black draught, or
by half an ounce of turpentine with an equal
quantity of castor oil in any suitable vehicle.
But where inflammatory disease, or lesions con-
sequent upon inflammation, are suspected to exist
in either the colon or rectum, calomel, or even a
full dose of blue pill, will often aggravate the
mischief, unless emollient enemata be frequently
thrown up. Indeed, I believe, from the experi-
ments and observations I have made respecting
the action of calomel on the alimentary canal —
from remarking its effects in irritating and inflam-
ing the inner surface of the colon and rectum
when taken in large doses— *■ and from the history
of the previous ailments, and treatment of many
of those who have had stricture of the rectum or
colon — that a very large proportion of such cases
has been brought on by the frequent use of calo-
mel as a purgative.
23. c. When we believe that constipation is
-owing to a torpid or paralysed state of the mus-
cular coats of the large bowels, and the accu-
mulation of hardened feces consequent thereon
(§9. a.), oleaginous purgatives given by the
mouth; in some cases, a full dose of calomel,
followed by a turpentine and castor oil draught;
and, subsequently, oleaginous, saponaceous, and
terebinthinate enemata; are generally the most
appropriate means. If, however, these fail, then
small but repeated doses of castor, olive, or al-
mond oil; frequent demulcent enemata; the as-
persion of cold water over the abdomen or lower
extremities; or injections of cold water, may be
tried. (See § 26.). If there be great inflation or
fecal distension of the colon, friction, with the
carminative liniment prescribed above (R 157.),
may also be employed, with various other internal
and external means recommended in the articles
on Colic and Colon. In aged females especi-
ally, hardened feces sometimes collect to such an
extent, and are lodged so firmly in the rectum
and lower part of the colon, as to require removal
by mechanical means. Cases of this kind have
been detailed bvScnuRiGjPE tit, Bishoprick,
Sechevekel, White, &c, and have occurred
in my own practice, as well as in that of many
others. They require the careful introduction
of a marrow-spoon, or some similar instrument,
into the rectum, to break down the faces; and
subsequently the means just stated, particularly
oleaginous and terebinthinate injections thrown
up by the pump apparatus now in general use,
which should be provided with a large and very
long pipe, or with a long, hollow, and flexible
CONSTIPATION — Tn r. a tm e nt.
411
bougie, which ought to be passed as far as possible
up the rectum.
2 1, d. If alvine obstruction be apparently ovv-
iog to organic, malignant, or oilier discuses about
the uterus, its appendages, the vagina, or rec-
tum (§10); or to spasmodic constriction of the
sphincter ani excited by inflammatory irritation
iii its vicinity, or by haemorrhoids, the warm-
bath, semieupium, or tlie hip-hath ; the vapour of
hot water and narcotic decoctions directed to the
anus: anodyne and relaxing injections; and the
extract of conium or hyoscyamus, made into
either a suppository or an ointment, with the
addition of a little of the extract of belladonna ;
may be prescribed, along with such other meas-
ures as the circumstances of the cast; may require.
25. e. When constipation is dependent upon,
or associated with, disease of the spine, or in-
flammatory irritation of the membranes and en-
velopes of the cord, leeches should be applied
near the place where pain is complained of ; or
the patient may be cupped in the vicinity, kept
quiet, and in the horizontal position ; and the ac-
tion of the bowels promoted by the means stated
above (§ lo", 17.), and by terebinthinate injec-
tions. If inflation of the bowels exist, the car-
minative liniment may be employed ; and if ten-
derness, tension, or pain of the abdomen be com-
plained of, leeches, followed by fomentations, ike.
as already advised (§ 22.), should be resorted to.
26. C. Besides the above, other means have
been recommended by authors in various states
of the disease, and found of much service when
appropriately prescribed. Joerdens advises the
frequent administration of assafatida in enemata,
and, in cases of deficient secretion and healthy
action of the colon, it is certainly of essential
use, either alone or in conjunction with purgative;
medicines. Starke recommends the inspissated
ox-gall, both in the form of pills and in clysters.
In the latter form, it is calculated to prove an ex-
cellent adjuvant of other means ; and when com-
bined with aloes, taraxacum, soap, extract of gen-
tian, Sec. (F. 559. 562.), it is very serviceable in
restoring the healthy functions of the bowels, and
digestive organs generally. Wendt directs re-
peated clysters of the decoction of gratiola to be
thrown up. Numerous writers have advocated
the application of cold, in cases of obstinate con-
stipation. ScHENK, A. FoNSECA, Bl.VNKARD,
and Lai son advise the patient to walk or stand
upon a marble pavement or slab ; and Brassa-
voi.es states that SavanaroLA cured the Duke
ofFerrara, by making hum walk bare-footed over
a cold wet marble floor. Sm vi.nmin, Fal-
coner, Percival, and Spence direct the
affusion of cold water over the lower and upper
extremities, and adduce cases wherein the prac-
tice had been successful after other mei sures had
failed. Kite, Bartram, Sancassini, and
Sch.midtji ann recommend cold epithems, and
the affusion or aspersion of cold water, over the
abdomen; and Kaehler, Kur.i;,and Bran-
dis advocate the administration of cold clysmata,
in addition to the employment of cold externally.
The cold anil tepid shower batlt, the cold plunge
bath, and warm and tepid bathing, have severally
been resorted to in aid of other measures, and are
frequently of use, — the former particularly in ha-
bitual constipation, the latter in cases attended bv
difficult and imperfect evacuation, and seemingly
dependent upon rigidity of the longitudinal hands
ot the colon. Electricity and galvaniam have
been employed Buccessmliy by Kite, Sioapd
LA I'i.ni), , Grapj Min JSSBR, and Ci.akkson;
and the injection of tobacco smoke, and of a weak
infusion of the leaves of tobacco, has been advised
byVos Msrtens, Vogel, and other authors
referred to, when discussing the treatment of
Colic and Ileus (which tee). The decoction
of berbery; powdered charcoal (Mitchell
and Daniel), in the dose of one, two, or three
table-spoonsful given every hour in milk or lime-
water ; frictions of the abdomen (Qdelmalz);
inunction of it with linseed or olive oil (Riedlin,
Sic); fomentations consisting of senna leaves
made hot and moist by boiling water, and placed
over the abdomen (Petit); purgative extracts;
tinctures, and infusions, applied to this situation,
either in the form of ointment or fomentation
(Schenck, Alibirt, &c.) ; and enemata con-
taining tartarised antimony (Elias), have also
been employed. The exhibition of emetics was
advised by Hippocrates, Praxagorus, (Ju-
lius Aurelianus, and Alexander Tral-
les ; and of ipecacuanha or antimonial emetics
by Stoll, Sims, Sumeire, Deplace, and
Hosac'K. I have seen benefit derived from in-
unction of the abdomen with an admixture of cas-
tor and linseed oils, to which three or four drops
of croton oil had been added. In a great propor-
tion of the cases of constipation which have oc-
curred to me since 1S17, when I first adopted the
practice, very certain and immediate advantage
has been derived from a full dose of calomel
(either with or without opium or hyoscyamus,)
followed in a few hours by half an ounce of oil
of turpentine, and an equal or somewhat larger
quantity of castor oil, taken either in a cup of
milk, or in a glass of some aromatic water. The
action of these has usually been promoted by an
injection containing castor, olive, or almond oil ;
and, if the operation has not been sufficiently co-
pious, another dose of castor oil has been given,
and the enema repeated.*
* The following synopsis exhibits a succinct view of the
tteatment: — 1. If the pulse be hard or constricted, and if
there he pain, increased on pressure, hleed generally or
IimmIIv. or both — apply blisters or hot fomentations, or the
cold affusion, or cold epithems, Sec. on the abdomen; after-
wards exhibit purgatives, enemata, 8tc. 2. It' constipation
seems to arise from diminished secretion and exhalation, give
calomel or blue pill, carbonates of the alkalies, jalap, the
purgative oils, senna, camboge, elaterium, croton oil, k.c. ac-
cording to circumstances. 3. If it depend upon a rigid fibre
and habit of body, combine purgatives with relaxants and
uauseants — with ipecacuanha, antimony, colcbicum, soda,
Inosi'vainus, ice. prescribe emollient and relaxant medicines
in pre ference to those that are acrid ; and give them with an-
ti-pas dies anil sedatives. 4. When it arises from torpid
peristaltic action and lessened secretion, conjoin tonics, gum
resins, and bitters with purgatives and aperients; myrrh, as-
safoetida, galbanum, fee., with aloes; sulphate of quinine, or
extract oi gentian with aloes; the alkaline solutions, with
tonic infusions ; use friction with stimulating liniments to the
abdomen, or along the spine; resort to the cold salt-water
bower hath, and the tonic and aperient mineral waters
ol Cheltenham, Leamington, Vichy, and Carlsbad. 5. When
it is attended by act unuilations of hardened faeces in the co-
lon, hive recourse to copious soapy or oilv clysters — to the
introduction of a inartow-spoqsj to break down the faeces — to
the injection of mid water bei by the valve-apparatus, with
a loin: bouirie attached to the pipe — to the aspersion of cold
watei mi I be abdomen, or the application of cold to the lower
extremities. Ice. 6, If it proceed from organic change of the
large bowels, or of parts affecting them, solicit evacuation by
emollient and relaxant enemata, and suppositories; soothe lo-
cal and constitutional irritation, preserve the functions of the
stomach, and give the alkaline solutions with couiuiu, bella-
412
CONVULSIONS — Pathology of.
27. ii. The prevention of a recurrence of the
disease should be strictly guarded against, particu-
larly alter active cathartics have been given to re-
move it. Purgatives, aperients, or laxatives, com-
bined with stomachic bitters and tonics (F. 187.
266. 872.), ought to be taken daily, and after-
wards on alternate days, until the functions of the
bowels are fully restored. Ihe patient's diet
should be light and nutritious ; all astringent and
indigestible substances avoided ; and, if the abdo-
minal secretions be deficient, an occasional dose
of blue pill, or hydrarg. cum creta, and a course
of taraxacum, with deobstruent laxatives and ton-
ics (F. 390. 510. 873.), prescribed. Subsequently
a course of Leamington or Cheltenham mineral
waters, or the artificial Seidschutz, Marienbad, and
Carlsbad waters, and in some cases the Pyrmont
and Spa waters, will prove of much benefit. The
shower-bath, upon getting out of bed, or the cold
salt-water bath, will further tend to promote the
digestive and defecating processes. Costive per-
sons, with a large or pendulous abdomen, should
wear a broad belt or bandage around it, which
will serve to promote the functions of the bowels.
The patient should carefully avoid the remote
causes of constipation, attend daily to the first in-
timations to stool, and have an early recourse to
medicine when such intimations are delayed be-
yond the usual time. When the bowels require
the assistance of medicine to preserve them in a
regular state, aloes may be combined with mas-
tich and Cayenne pepper, or with a bitter extract,
myrrh, and assafoetida, and taken daily about two
hours before dinner.
BlBLIOO. AND REFEH. — Hippocrates, TTiQi V0VO03V,
iii. Opp. v. p. 491.— Cceliut Aureliunus, Opp. p. 243. 529.
— Alexander Tralles, lib. ii. cap. 44. — Ballonius, Opp. i. p.
40. — Schenk, Observat. 1. iii. n. 285. — Salmuth, cent. i. obs.
24., cent. ii. obs. 65. 98., cent. iii. obs. 26. 45.— Blunkard,
Collect. Med. et Phys. cent. vi. No. 68.— Panarolus, Ja-
trolog. Pentecost, i. obs. 1. — Smetius, Miscellan. p. 561. —
Bonet, Sepulcbret. 1. iii. s. xiii. obs. 11. p. 589.— Trian,
Observ. Med. p. 25. and 56. — Morgagni, Epist. xxxii. de
Alvi Adstrictione. — Callisen, in Act. Soc. Med. Havn. i.
and ii. p. 329.— Aaskow, in Ibid. ii. p. 9.—Brende!, Observ.
Anat. Med. dec. i. n. 20— .4. F. Wulther, De Intest. An-
eustia. Lips. 1731. — Que/malz, De Frictione Abdominis, &c.
Lips. 1743.— Lieut aud, Hist. Anat. Med. 1. i. obs. 292, 293.
301. — A. Fonseca, De Tuenda Valetud. — Sancassuni, in
Halter, Bibl. Med. Pract. vol. iii. p. 601.— C. G. Ludui?,
De Causis Obstructions Alvins, 4to. Lips. 1770.— Petit,
Traite deMalad. Chirurg. t. ii. p. 101., et t. iii. p. 47. 103.,
et. Md-m. de 1'Acad. de Chirurg. i. p. 239.— Suuvages, t. ii.
p. 363.— Devi/Hers, in Journ. de Med. t. iv. p. 257.— Mar-
teau de Grandvilliers, in Ibid. t. xiii. p. 226. — Laison, in
Ibid. t. lxxxvii. p. 354.— Cullen, Materia Medica, vol. ii. p.
496.— Rocschlaub, Magazin. b. iv. No. T.—Erhard, De Pra-
ternat. et rara Obstipat. Alvi Causa, Six. Erf. 1790. — Stoerek,
Annus Med. vol. i. p. 125.— Block, Med. Beiuerkung, p.
124.— Stall, Rat. Med. par. ii. p. 135., vol. vii. p. 154.—
Weikard, Veimischte Scriften, b. ii. p. 52.— Starke, Klin.
Instit. p. \1i.—Baillie, in Trans, of Soc. for the Improve-
ment ol Med. and Chirurc. Knowledge, vol. ii. No. 14. p.
174. — Meckel, N. Archiv. b. i. No. 3., et Acad, de Berlin, ic.
1759, p. 39.— Stevenson, Edin. Med. Essays, &x. vol. v. p.
893. — Lorry, Hist, de Soc. de Med. vol." ii. — Burggiave,
Medicin. Fiille, p. 232. — Cruickshanks, Anat. of Absorb.
Vessels, p. 119. — Reil, Memorab. Clin. vol. i. fasc. 1. No. 3.
— Theden, N. Bemerkung. b. iii. p. 76. — Ford, in Lond.
Med. and Physic. Journ. vol. iv. p. 390. — Kite, in Ibid. vol.
viii. p. HA.—Leske, Auserl. Abhandl. h. i. p. 61.— Wedel,
Stark's Archiv. b. vi. p. 673. — Riedlin, Millenarius, No. 301.
et 536. — Sims, Observ. p. 20. — Sumeire, Journ. de Med. t.
hi. p. 369.— Odier, Manuel de Med. Pratique, p. 207.—
Moetler, in Baldinger, N. Magazin. b. xx. p. 178. — Osiun-
der, N. Denkwiirdigkeiten, b. i. st. 2. p. 130. — Falconer, in
Mem. of Med. Soc. of London, vol. ii. p. 72. — Sherwen, in
donna, kc. — (From the Author's short Notes of his Lectures
delivered from 1824 to 1829.)
Ibid. vol. ii. p. 9. — Kaehler, in Stark's Archiv. b ii. it 2.
No. 2. — Grapengeisser, Versuche, kc. p. 100. — Alibert, in
Mem. de la Soc. Med. d*Emulation, t. i. p. 182. 443.— fVil-
lan, Miscel. Works by A. Smith, &c. Lond. 1821, p. 446.—
Daniels, in Philad. Med. Journ. vol. v. p. 119. — Wendt, in
Annalen des Klin. Inslitut. 1 hed.—Secheverel, in Journ.
Gener. de Med. &c. t. xix. p. 6. — Huf eland, in his and
Himly's Journ. der Pract. Heilk. Nov. 1809, p. 130.— Par
tal, in Mem. de l'Institut. Nat. de France, 1807. — Pomrna,
in Journ. de Med. Contin. July, 1810, p. 74. — Spence, Med.
Trans, of Coll. of Phys. vol. iii. p. 99. — Gerard, in Duncan's
Edin. Wed. Comment, vol. x. p. 44. — Warren, in Ibid. p.
255. — Hclsham, in Ibid. vol. xiii. p. 282. — Bhhoprick, in
Ibid. vol. xx. p. 340. — Hosack, in Duncan's Ann. of Med.
1796, p. 310., and Lond. Med. Rep. t. xvii. p. 77. — Moaman,
in Ibid. 1797, p. 307.— Clarke, Trans, of Irish Acad. vol. vi.
p. 3. — E. Home, Trans, of Soc. for Med. and Chirurg. Im
provement, vol. ii. p. 182. — Buder, Observ. 39. — Korb, in
Rii-hter's Chir. Bibl. b. viii. p. 120. — Mursinnu, Beobach.
b. i. p. 141. — Bateman, Art. Constipation and Costiveness,
in Rees's Cyclopaedia. — Joerdens, in Hufelavd's Journ. der
Pract. Heilk. b. xvii. st. 2. p. Sl.—Elias, in Ibid. b. x. st. 1.
p. 140.— Mitchel, N. Y. Med. Repos. 1 800.— Stemj, in
Lond. Med. Repos. May. 1823. — Crampton, Dublin Hosp.
Reports, vol. iv. p. 305. — Houship, On Dis. of the Lower
Intestines, and Costiveness, kc. 8vo. Lond. 1820. — Reece,
On Regulating the Stomach and Bowels, kc. 8vo. 2d edit.
1827. — Green. Edin. Med. and Surg. Journ. vol. ix. p. 166.
— Oudnay. vol. xvi. p. 383. — C/arkson, in Ibid. vol. xvi. p.
475. — Annes/ey, and Author, in Researches on Diseases of
India, kc. vol. ii. p. 50. et seq. — Valentin in Bull, des Ann.
des. Scien. Med. t. x. p. 74. — Bompurd. Trait£ des Malad.
des Voics Digestives, kc. 8vo. Paris, 1829, p. 280.— Stani
land, Lond. Med. Gazette, vol. xi. p. 245.
CONSUMPTION. See Pulmonary Consump-
tion, and Mesenteric Consumption.
CONTAGION. See Infection.
CONVULSIONS.— Syn. J5.Turr.,o?, Gr. Spasmi
Clonici, Motus Convulsivi, Distensiones Ner-
vorum, Conductiones, Auct. Var. Convulsion,
Spasme, Fr. Zuckungen, Ger. Convulsioni,
Ital. Convulsion Fits.
Classif. 4. Class, Nervous Diseases ; 3.
Order, Spasmodic Affections (Cullen). 4.
Class, Affecting the Nervous Function ;
4. Order, Affecting the Sensorial Powers
(Good). II. Class, III. Order (Au-
thor, in Preface).
1. Defin. Violent and involuntary contrac-
tions of a part, or of the whole of the body,
sometimes with rigidity and tension (tonic con-
vulsions) ; but more frequently icith tumultuous
agitations, consisting of alternating shocks (clo-
nic convulsions) ; that come on suddenly either in
recurring or in distant paroxysms, and after ir-
regular and uncertain intervals.
2. Convulsions have attracted a flue share of
attention from the medical writers of all ages.
Hippocrates states, that "convulsions arise
either from repletion or evacuation," (Aphor.
sect. vi. § 39.); and Galen, whilst he admitted
the propriety of referring them to these two mor-
bid states, argued for a third, namely, irritation
occasioned by a morbid humour. JEtius ad-
hered to a similar arrangement, but considered
that the third of these pathological conditions per-
formed the principal part. Subsequent writers,
chiefly copiers or commentators on Galen,
adopted his views. Zacutus Lusitams im-
puted much importance to the second morbid
state of Galen, viz. excessive evacuation ; and
considered that a positive or relative dryness of
the nervous and muscular system was occasioned
by it. The writings of Willis and Sylvius
lit i.i Boe made some alterations in the received
doctrine of the origin of convulsions, by referring
more than their predecessors had done to the
nervous system and animal spirits, and less to
CONVULSIONS — Forms of.
413
the influence of morbid humours. It was not,
however, until the appearance of the writing
of F. II 'ikm\n.v, that a spirit of accurate in-
vestigation was manifested in this department of
medical enquiry. This writer, to whom our
science still continues under great obligations,
regarded convulsions as a consequence chiefly of
a morbid state of the spinal cord and its mem-
branes,— an opinion which lias been adopted by
many, and which numerous facts seem to sup-
port, in respect of several manifestations of these
complaints, although it cannot so frequently be
shown that this part of the voluntary nervous
system is that primarily affected.
3. The opinions respecting the nature and re-
lations of convulsions, entertained during the last
centurv, and what has past of the present, have
been so numerous and vague, that the advan-
tages resulting from a review of them could by
no means compensate for the limits they would
occupv. Such of them as deserve notice will
be referred to hereafter. It may, however, be
remarked respecting them, generally, that no
two writers of reputation agree as to either the
import of the word, the diseases coming within
this denomination, or the manner of arranging
and considering them. Under such circumstan-
ces, the systematic and eclectic writer might
be placed in much difficulty, if he had not ex-
tensive and diversified experience to guide him.
Upon this, however, my chief reliance is placed,
even while I endeavour to profit by the labours
of my predecessors, — some of them my followers
in the adoption of important curative means in
these affections.
4. If, in defining convulsion, we state it to be
" an anormal action of muscular or fibrous parts,"
we at once make it synonymous with spasm, and
embrace a most numerous class of diseases, viz.,
those forming Dr. Cullen's order, Spasmodic
Diseases, as well as many of those in which
spasm is merely a part of the morbid state. If
we define it to be " an irregular or anormal
action of voluntary muscles,'''' we shall comprise
all those maladies, which usually put on nearly
a regular form or type, owing to certain pecu-
liarities of the spasmodic action and concomitant
phenomena; as tetanus, epilepsy, &c. But if we
adopt the more confined and precise definition
given above, those disorders only which assume
no regular type; but which, whilst they approach,
on the one hand, those of a regular form, often
pursue, on the other, very eccentric courses, and
even anomalous states. It is impossible to con-
sider the diseases of the frame in a way true to
nature, and at the same time as abstract entities
— as species perfect and distinct of themselves.
They are individually, in truth, merely certain
morbid states, lapsing on the one side insensibly
into others, to which, although most intimately
allied in every respect, different names have been
but too arbitrarily assigned; and passing on the
other side into affections otherwise denominated,
although not materially differing in their natures.
Thus, if we make spasm the essential character
of one great family of diseases, we may dividajit
into subordinate orders, genera, and species, ac-
cording to the parts affected, and the functions
concomitantly disordered, and the permanency,
the rigidity, the relaxations, and the frequency of
recurrence of the spastic action. But still the
35*
essence of disorder will be very generally the
same; and each of these subdivisions — each of
the manifestations of the particular morbid states
made the basis of distinction — will so insensibly
glide into each other, as to defy the possibility of
drawing lines of demarcation between them. The
practitioner will be unable, on many occasions,
to detect in practice the specific differences as-
sumed; and will continually meet, as I have in
many hundreds of instances, with cases which he
cannot refer to one species more than to another,
and which are as much eclampsia as epilepsy, or
as much what are usually called convulsions as
either the one or the other. If we take the cha-
racter of the spasm, in respect of permanency,
rigidity, relaxation, and recurrence, as a basis of
arrangement of all the diseases attended by anor-
mal action of voluntary muscles, we shall have
every grade, passing imperceptibly from the most
acute form of tetanus through cramp, epilepsy,
eclampsia, convulsions, &c, down to the most
atonic states of chorea and tremor. Also, if
we consider the affections called convulsions,
and which are usually irregular in their forms,
with reference to the character of the anormal
contraction of the muscles, we shall perceive
it in some cases of the most violent and spas-
tic nature, frequently of some continuance, the
relaxations being of brief duration, or scarcely
observable ; and in others nearly or altogether
approaching to tetanic. These constitute the
more tonic form of convulsions, from which
there is every possible grade, down to the atonic
or most clonic observed in chorea or tremor.
Thus, then, anormal actions of muscular parts,
like all other morbid actions, may, in respect
of grade, be either above or below the healthy
standard — tonic and clonic marking each res-
pectively; but between which there exists every
possible degree; these terms being therefore en-
tirely relative, and conveying no definite and
unchanging meaning. But, besides varying re-
markably as to grade, the anormal actions of
voluntary muscles may be attended by numerous
phenomena giving them specific characters. Thus,
when accompanied with complete insensibility,
or any other superadded morbid condition, they
have been denominated epileptic, hysterical, &c;
and, from this circumstance, they assume certain
tvpes, but of no very constant or immutable
kind. When, however, they are not so associa-
ted, they constitute a simpler state of disease, and
put on less regular forms, affecting either the
whole of the voluntary muscles, or a greater or
less number of them.
5. T. Forms. — From this, therefore, it is to
be inferred that, although Dr. Culi.f.n, and ma-
ny others, have considered convulsions as cha-
racterised by the clonic nature of the spasms —
by the alternation of contraction and relaxa-
tion without the control of the will — yet this
does tint universally obtain, they sometimes as-
suming states approaching to tetanic, and every
degree of violence, as well as length of duration.
The more regular and sjweific forms of convul-
sion, as epilepsy, hysteric fits, raphania, hiccup,
tetanus, rabidity, &c, are discussed in separate
articles; I shall, therefore, consider at this placo
only those simple and irregular states of convul-
sion which do not fall within its more specific
manifestations.
414
CONVULSIONS— Local
6. Simple convulsions present great diversity
of character. Thev have been already shown to
differ widely in violence and degree; and they
vary as greatly in duration, modes of accession,
and recurrence, as well as in the number of parts
affected by them. Hence they may be acute or
chronic — most frequently the former; partial or
general; continued, recurrent, or intermittent;
uncertain in their accession, or periodic; and
they may, moreover, attack a number of parts
in succession. The circumstances and causes
which originate them will also impart to them
certain characters, which, although frequently
difficult of detection, should not be overlooked.
Thus, they are either idiopathic or symptomatic,
most frequently the latter, even when the primary
lesion illudes observation. But these diversities
of form, although most deservingof attention,
can only partially serve as a basis for the practi-
cal consideration of convulsions. I shall there-
fore view them — 1st, in respect of their partial
or local occurrence; 2d, as to their general mani-
festations; 3d, as they affect infants and children;
and, 4th, as we observe them in connection with
the puerperal states: I shall also notice them as
associated with, or consequent upon, other acute
diseases.
7. i. Partial or Local Convulsions. —
Many of the disorders which have been imputed
a convulsion of individual parts, fall more ap-
propriately under the denomination of spasm. I
shall therefore briefly notice only such as, from
the alternation of relaxation and contraction,
appear to approximate to the convulsive state.
A. Involuntary contractile parts are more sub-
ject to spasmodic action, than to that which
may be said to be really convulsive. Whether
or not certain of the phenomena presented in
various diseases of the alimentary canal, as gas-
trodynia, pyrosis, rumination, retchings, colic,
borborygmi, ileus, the tormina of dysentery,
&c., are more properly convulsive or spasmodic,
must be entirely a matter of opinion, to which
but little practical importance should be attached,
as they are both modifications merely of the same
proximate condition. This remark applies equal-
ly to the anormal actions sometimes presented by
the urinary bladder and uterus; and it is proba-
ble that palpitations of the heart, and angina
pectoris, are chiefly manifestations of convulsive
contractions of this viscus. (See Angina Pecto-
ris, and H k art— Palpitations of.) Thathiccup
is altogether owing to convulsive actions of the
diaphragm, cannot be doubted. (See Hiccup.)
8. B. Voluntary muscles and parts present the
most unequivocal appearance of partial or local
convulsion; although several local affections, de-
nominated convulsive by some writers, are, more
strictly speaking, spasm or cramp of particular
muscles, a. The muscles of the eye-lids, owing
either to the contraction of an ill habit, or to
irritation of the ophthalmic branch of the filth
pair of nerves, are sometimes clonically con-
vulsed— forming the nictitatio of authors, b.
The muscles of the eye-balls are also not infre-
quently similarly affected, particularly in infants
and children — occasioning, particularly during
sleep, rolling of the eyes. This state of local
convulsion Is common during dentition, and dis-
orders of the stomach and bowels. Either a more
severe state of convulsion of these muscles, ap-
proaching to spasmodic contraction of one or
more of them, or a paralysis of their antagonists,
will occasion distortion of the eyes, or strabismus,
with or without irregular oscillations of the iris,
dilated pupil, &c; as in inflammatory and organic
affections within the cranium, and in verminous
disorders, c. Twitching convulsions of the mus-
cles of the face, or those inserted into the lips;
retraction of the angles of the mouth, giving rise
to what has been called the risus sardonicus; are
often observed, ^)ut generally as a symptom of
the invasion or actual existence of most danger-
ous diseases; as inflammation of the encephalon,
or of the diaphragm, and various organic changes
affecting the substance of the brain. Twitchings
of the muscles of the face, however, sometimes
occur in persons of a nervous and irritable tem-
perament, or with an excited brain, without any
apparent disease, d. Convulsive movements of
the tongue are seldom observed unconnected with
irregular movements of other parts, unless in the
diseases now named, and in apoplexy, e. Slight
convulsive actions of the muscles of the lower jaw,
giving rise to grinding of the teeth in sleep, are
veiy common occurrences in persons with worms,
or other diseases of the alimentary canal; or ex-
cited circulation of the encephalon. /. Trismus,
or spasmodic contraction of these muscles, in in-
fants, arises from disorders of the prima via, the
impression of cold, or irritation of the umbilicus,
but does not strictly fall under the head of con-
vulsions, g. A clonically convulsed state of the
muscles of the neck are sometimes, but rarelv,
observed, producing convulsive tremor, or shak-
ing palsy of the head, which is aggravated on
certain occasions of mental perturbation, and
nervous or vascular excitement. (See Palsy,
Shaking, and Tremor.) h. The abnormal
actions which approximate more closely to the
permanent or spastic contractions, and affect
one or more of the cervical and adjoining mus-
cles, are much more common, and are often
induced by a current of cold air, by over-
straining, or by inflammatory irritation about
the bodies, or intervertebral substance of the
upper cervical vertebra?; or from disease about
the medulla oblongata or base of the brain;
or from irritation of remote parts — as of the
genital organs of the uterus or ovaria; or from
strangulated hernia, — an instance of which last
has been observed by myself. In all such ca-
ses, the head is drawn more or less to one side,
or backwards, or forwards; but similar flexures
of the neck often are occasioned by the paralysis
of muscles on the side from which the head is
bent, the tonic or natural action of the unaffected
muscles drawing the head from the paralysed
side. In the one case, however, the muscles are
rigid and strung like a cord on the contracted
side, and more or less pain is complained of
either in them or in the vicinity, particularly on
attempts to bend or turn the head or neck in an
opposite direction; whilst, in the other case, these
symptoms are wanting. These are more pro-
perly cases of spasm than of local convulsion,
as the contraction seldom alternates with relaxa-
tion, but is commonly more or less permanent.
However, cases sometimes occur, which are in-
termediate between permanent spasm and con-
vulsion, especially as a symptom of the diseases
last referred to. i. Convulsive movements in the
CONVULSIONS — General.
415
pharynx and oesophagus, impeding or preventing
deglutition, are frequent in hysteria, and in the
last stage of several fatal diseases, k. They also
affect the muscles of the larynx, the diaphragm,
and other respiratory muscles, either separately,
in rapid succession, or nearly simultaneously.
Some of these affections are transient, and the
result of slight causes ; as in sneezing, coughing,
sighing, sobbing, &o. ; others are extremely dan-
gerous, owing to the nature of the parts affected,
the severity and continuance of the convulsive
movements, and the circumstances in which they
supervene ; as in spasm of the glottis, spasmodic
croup, certain states of asthma, with severe fits
of coughing, singultus, &c. /. Convulsive ac-
tions also occur in the muscles of the abdomen ;
as in hvsteria, common and lead colic, and in
consequence of intestinal worms. The most re-
markable instances of true convulsion of the
abdominal muscles merely, that I have observed,
have occurred in adult persons infested by the
large round worm. m. The muscles of the spine
sometimes experience convulsive actions, but
more frequently spastic contractions, occasioned
by hysteria, disease of the bodies of the vertebra
or membranes of the spinal cord, injuries of
adjoining parts, strangulated hernia, acute rheu-
matism, the passage of biliary or renal calculi
along the ducts, and inflammatory irritation of
the uterus or ovaria. n. Either one or both of
the upper extremities are occasionally aTected by
couvulsions, more commonly both. The fingers
are generally clenched around the thumb, which
is drawn upon the palm; the arm be.ng either
extended forcibly, and the hand turned as in
pronation, or the fore-arm bent upon the arm, or
both these occurring in rapid alternation. Such
are the more tonic convulsions of the upper ex-
tremities; but their muscles also experience slight
and extremely clonic contractions; as tlie subsul-
tus tendinum often observed towards the close of
fevers and diseases of the brain ; the more tonic
or spastic convulsions, particularly when affecting
one arm only, also arising from lesions of some
part of the encephalon, or of the upper portion
of the spinal cord. o. Convulsions of the lower
extremities are characterised by analogous move-
ments, and chiefly affect the flexor and extensor
muscles. The toes are bent downwards, and the
legs and thighs either drawn upwards or extend-
ed, or both the one and the other alternately.
9. Convulsions of voluntary muscles may oc-
cur as now described, or in two or more situa-
tions, or even in different or opposite parts, either
simultaneously or in succession. They may af-
fect one side of the body only, the other being in
its natural state, or paralysed. They much less
frequently attack either half transversely.
10. ii. General Convulsions. — General
convulsions observe no certain mode of accession.
On some occasions they attack suddenly ; but
they are much more frequently preceded by pre-
monitory signs, especially in children and chronic
cases, — a knowledge of, and attention to, which
may be made available in preventing their oc-
currence. They are also sometimes recurrent, or
succeed each other, with more or less rapidity.
11. A. The premonitory tigns are Tertigo and
dizziness, irritability of temper; Bushings, or alter-
nate flushing and paleness of the face; luminous
or other spectra floating before the eyes; various
noises in the ears; partial loss of sight or hearing ;
restless or unsound sleep, or uncommon weight
or drowsiness; fulness or prominence, and rolling
of the eyes; clenching, or grinding of the teeth,
clenching of the hands, &c. during sleep; a tumid
appearance of the countenance and hands ; cold-
ness or cramps of the extremities; slight tremors,
shivering, horripilation, shudderings or horrors ;
nausea, retching or vomiting ; or pain and dis-
tension of stomach and left hypochondrium ; un-
usual flatulence of the stomach and bowels, or
other dyspeptic symptoms; pains in the loins or
back; frequent sighing or sobbing; numbness of
various parts ; stammering or impeded utterance,
loss of memory, and absence of mind; palpita-
tions, or slowness and irregularity of pulse; slow,
laborious, or irregular respiration; and, sometimes,
a copious discharge of limpid urine. In some
instances, leipothymia, or threatened syncope,
precedes the general convulsions.
12. B. a. The more tonic seizure. — The
convulsive movements constituting the paroxysm
generally follow rapidly upon one or more of the
above signs, and vary remarkably as to violence
and duration. During their continuance, the
countenance is very much distorted ; the eye-
balls are prominent, full, wild, staring, and rolled
in all directions; the eye-lids are either open, or
rapidly shut and opened ; the patient grinds and
gnashes his teeth, and sometimes foams at the
mouth, or protrudes the tongue. The alternate
contractions and relaxations of the whole volun-
tary muscles, and contractions and extensions
of all the limbs, are performed with the utmost
irregularity, rapidity, and with so great force,
as often to require the united strength of several
persons to preserve the patient from injuring
himself. In these struggles, the teeth, or even
the bones of the extremities, have been, in some
instances, broken. The respiration is laborious,
interrupted, and sometimes accompanied by a
hissing noise. The countenance, and indeed the
whole scalp, are sometimes tumid, bloated, or
red, and often leaden or livid towards the close
of the fit, particularly in plethoric persons, when
the respiratory actions are much impeded, and
the affection originates in cerebral disease. In
other cases, the face is pale, and the pulse weak,
or small and constricted. The urine and faeces
are occasionally voided with violence during the
paroxysm: occasionally large quantities of limpid
urine are passed. In these, the pulse is generally
full, strong, and commonly slow or irregular. In
many instances, the general sensibility and con-
sciousness are but very slightly impaired, par-
ticularly in the more simple cases, and when the
proximate cause is not seated in the encephalon;
but in proportion as this part is affected, primarily
or consecutively, and the neck and face tumid
and livid, the cerebral functions are obscured,
and the convulsions attended by stupor, delirium,
&c, or rapidly pass into, or are' followed by,
these stairs.
13. b. The more clonic convulsions. — Puch
are the common manifestations of convulsions,
when they are not occasioned by inanition ; the
paroxysms, however, varying greatly in violence,
duration, and frequency of recurrence, according
to the degree of vital energy, and numerous other
416
CONVULSIONS — General.
circumstances. But when they arise from, or are
associated with, exhaustion, excessive discharges,
and evacuations of the vascular system, they as-
sume a somewhat modified character. They are
then not attended hy sopor; the general sensibility
and cerebral functions being but little, or not at
all, affected. The pulse is frequent, small, weak,
broad, or open ; the features are but slightly dis-
torted ; the countenance is pale and collapsed ;
and the limbs and extremities cold, and much
less rigidly convulsed than in the tonic or more
spastic seizures. In many cases, the convulsive
movements resemble a succession of general
shocks, succussions, or shudderings, sometimes
of great violence, and often of considerable con-
tinuance, occasioning the bed or room to shake,
and terminating the life of the patient : in others,
they consist of constant tossings of the limbs and
trunk.
14. C. Duration and recurrence. — The pa-
roxysm may cease in a few moments or minutes,
or continue for some, or even many, hours. It
generally subsides rapidly, the patient experi-
encing, at its termination, fatigue, headach, or
stupor; but he is usually restored in a short time
to the same state as before the seizure, which is
liable to recur in a person once affected, but at
uncertain intervals. After repeated attacks, the
fits sometimes become periodic (the convulsio
recurrens of authors). In adult females, they
commonly accompany the menstrual periods.
When they arise from organic disease within the
cranium, each successive interval is generally
shortened, until then recurrence is so frequent
that the patient is scarcely recovered from the
languor, or other symptoms, consequent on one
seizure, until he has another, which at last either
ends in profound coma, or terminates life.
15. D. The modifications of convulsions are
extremely numerous. In some cases, the respir-
atory muscles are much affected, and the fit is
accompanied with yelling and shrieks, evidently
not proceeding from pain (the convulsio ejulans,
or shrieking convulsion). In other instances,
the abnormal movements shift from one part to
another, or attack various muscles in succession.
In these, the seizure is comparatively slight, and
the cerebral functions not remarkably disturbed ;
the convulsio erratica of Dr. Goon. In rarer
cases, the seizure assumes the form of convulsive
tremor, as remarked by Dr. Prichard ; is at-
tended with a hot perspiring state of the head,
vertigo, and slight stupor ; and continues one,
two, or three hours.
16. a. Besides these, various other forms of
convulsion occur, particularly in persons under
the influence of a morbidly excited imagination,
or religious enthusiasm; and in females endowed
with the nervous and irritable temperaments, with
great mobility of the muscular system, and who
are aflected by nervous or vascular excitement of
the generative organs. On many occasions, these
seizures have been propagated to a number of
persons by sympathy. 'Ihe convulsions which
became almost epidemic in the west of Scotland,
in 1742, and were occasioned by religious enthu-
siasm, are not only instances of a peculiar form
of this affection, but also among the most striking
on record of the influence of imagination, and of
sympathy, or of imitation, in disordering the func-
tions of the body. A number of persons were
attacked nearly at the same time, when hearing
the addresses directed to the imaginations and
passions of their hearers by the followers of
Whitfield ; and always when impressed by the
denunciations of vengeance, and hopes of salva-
tion, which they set forth. The mental agony
which was thereby induced, gave rise, in many,
to the most violent tremblings and agitations of
the body, which were frequently preceded by
faintings, and followed by convulsions, and subse-
quently by sobbing, weeping, and crying aloud.
In some cases, the convulsions produced epistaxis,
which generally terminated the seizure. Such
appears to have been the usual course of the pa-
roxysm, according to the meagre accounts which
have been furnished of it. (See Edin. Med.
and Surg. Journ. vol. iii. p. 442.). The con-
vulsions described by Mr. Cornish as having
been prevalent in Cornwall in 1813 and 1814,
owing to the same causes, hardly differed in any
respect from the above.
17. b. The convulsions which were prevalent
in some of the Zetland Isles during the middle and
towards the close of the last century, but which
have seldom occurred there since that period,
seem to have had some resemblance to the fore-
going, as well as to hysteria. Dr. Whytt has
referred to the frequency of convulsions in these
islands ; and has adduced the extreme facility
with which they were propagated among young
women, cs a proof of the existence of a wonder-
ful sympathy between the nervous systems of
different individuals. The convulsions now al-
luded to, commonly attacked adult females when
at church ; but men and young girls were not
altogether exempted from them. They are de-
scribed very nearly as follows, by gentlemen
who had frequently witnessed them : — Persons
affected, generally fall down in apparent fainting
or swooning fits, and soon afterwards utter wild
cries and shrieks, the sound of which puts all who
are subject to the disorder in the same situation.
Their limbs and bodies are tossed about, the most
frightful screams being uttered by them all the
while. Their heads are also thrown from one
side to the other, and their eyes are fixed and
staring. In this manner they roar and strucrsle
for five or ten minutes, and then rise up without
recollecting a single circumstance that happened
to them, or being in the least fatigued by the
exertions made in the fit. Females are most
commonly attacked in a crowded church, and on
occasions of public diversion and merriment.
18. Similar instances of the spread of con-
vulsions, by the infection of sympathy or imi-
tation have been recorded by writers, and cases
of it have occurred within the observation of the
author. Dr. Haycakth has adduced a remark-
able occurrence of this description. — Twenty-
three females, from 10 to 25 years of age, and
one lad of 17, who had all intercourse with each
other, were seized, in 1796, in Anglesea, with
slight pain of the head, or of the stomach and
left side, followed by twitchings or convulsions
of the upper extremities, continuing with little
intermission, and with much violence, for a con-
siderable time. Ihe disorder was not so violent
in bed; but it continued in some cases during
sleep. The pulse was moderate, the bowels cos-
tive, and the general health not much impaired.
There was usually hiccup ; and, when the con-
CONVULSIONS, INFANTILE — Symptoms and History of.
417
vulsions were most violent, giddiness, with loss of
hearing and recollection. During convalescence,
the least fright, or sudden alarm, brought on a
slight paroxysm. (See Chorea and Related
Affections, &c.)
19. iii. Infantile Convulsions. — Convul-
sions often attack infants of a delicate and irri-
table frame, and those who are seized by severe
internal or constitutional disease, or are suffering
some concealed visceral irritation. They occur
most frequently in children under four or five
years of age, and particularly during dentition.
They decline in frequency from this epoch to the
commencement of the second dentition, or about
the seventh year, when they again are often met
with. Mr. North doubts that any increase
takes place at the seventh year. The above is
the result of my experience, which in great
measure agrees with that of Beaumes,Tissot,
and others. As infantile convulsions present
various peculiarities in their causes, phenomena,
complications, and consequences, and are besides
among the most important morbid conditions
which come before the practitioner, I shall con-
sider them apart.
20. A. Premonitory signs often usher in the
attack, but occasionally no such symptoms are
observed. I suspect, however, that they are
more commonly altogether overlooked, than en-
tirely absent. They consist chiefly of manifest-
ations of generally increased irritability. This
is shown by the temper, if the child be a few
months old or upwards; by want of sleep at night,
and heaviness in the day, or by perfect insomnia;
by a lighter and shorter sleep than usual, the
child starting up on the slightest noises, or as
from a frightful dream, with fits of screaming
without evident or sufficient cause ; by alter-
nately flushed and pale countenance, or un-
wonted animation of the face and eyes, followed
by languor and heaviness ; by a half-closed or
open state of the eyelids during slumber, with
startings and twitchings; by fixed, vacant, staring
eyes, the pupils being either contracted or dilated,
or frequent oscillations of the iris, without being
influenced by the admission of light, or contrac-
tion of one pupil while the other is dilated ; by
stretchings or rigid extensions of the limbs; by
hiccup, or irregularity of breathing, or short
gasps, followed by long laborious inspirations ;
by twitchings of the fingers, or clenching of the
hands, or pressure of the thumb upon the palm,
the fingers being extended and separated from
each other, or frequently moved about; by the
sudden relinquishing of the breast soon after
having sought it eagerly, and the throwing back
the head, with an expression of anxiety, and an
appearance of difficult deglutition; and by ful-
ness of the upper lip, with a pinched nose and
countenance, and slight blueness below the eyes
and about the mouth. Many of these symptoms,
designated by the vulgar, " inward fits," may
with justice be attributed to inflammatory irrita-
tion of the arachnoid, as indeed contended for by
Parent, .Martinet, Lallkmand, &c; and,
in my opinion, especially of the arachnoid of the
base and internal surfaces of the brain. BrachET
and North have enumerated them as premoni-
tory of convulsions, which thev doubtless most
frequently precede ; but in a great many cases
convulsions hold the same relation to inflamma-
tory and febrile attacks in infants, as rigors do to
the same diseases occurring in adults; and hence
these signs must often be common to both, and
also to some other infantile diseases. This is
shown by their frequency in remittent fever, and
other inflammatory irritations of the gastro-iutes-
tinal mucous surface of children.
21. B. The paroxysm of convulsions in chil-
dren is similar to that occurring in adults. In the
most severe cases, there is a violent, involuntary,
and alternating or convulsive action of all the
voluntary muscles extending to some internal or
involuntary parts; in which, indeed, the affection
often seems to originate, or which appear to be
those first affected. In plethoric infants, the face
and scalp are tumid, reddened, and subsequently
livid; the eyes are distorted and staring, or turned
up beneath the upper eyelid, leaving only the
sclerotic visible; the respiration is impeded and
laborious, but very rarely attended by foaming
at the mouth and protrusion of the tongue, unless
the paroxysm be epileptic. The whole surface
often becomes slightly violet-coloured towards
the close of the fit, and the hands tumid. In
many instances, particularly in weak or exhaust-
ed children, the seizure is much less violent, the
countenance being pale and collapsed, and the
convulsions more clonic. There are sometimes
only twitchings of the muscles of the face, and
alternate contractions and relaxations, or rapid
shocks, of a few parts, or of only one half of the
body, or of various parts in succession, with slight
blueness about the eyes and mouth ; but more
frequently the whole body is convulsed, and the
countenance distorted and haggard. The mental
faculties, and general sensibility, in the slight or
clonic convulsions, are generally not interrupted.
They are also, however, frequently obscured, but
only during the height of the paroxysm ; and
sometimes even entirely abolished in the severe
recurrent convulsions attending cerebral disease
— the eclampsia of some authors (§ 24.).
22. C. The utmost diversity exists as to the du-
ration and recurrence of the fit. In some cases it
is only momentary, or of a very few minutes' du-
ration. Tn other instances it continues for several
hours, with frequent remissions. It may likewise
cease, and shortly afterwards return, and thus sub-
side and recur at short but irregular intervals for
several times, and at last cease altogether, or ter-
minate life. Or the first seizure may be so se-
vere as to be fatal. These recurring fits are often
at last attended by insensibility, which is not al-
together, or even not at all, recovered from in
the intervals. This form of the malady is more
common in children than in adults, excepting as
it occurs in the puerperal states, or towards the
termination of tumours and abscesses in the brain.
As the convulsive movements constituting the fit
become less and less violent and constant, and
respiration fuller and freer, the natural appear-
ance of the surface returns, and the child is ena-
bled to cry; it afterwards falls either into a re-
freshing sleep, or, if the convulsions have a
cerebral origin, into a stupid or lethargic state of
various duration.
23. I). There is a species of spastic or tonic
convulsion, which is but rarely met with, affect-
ing chiefly the extremities. It seems more nearly
allied to spasm than convulsion, into which, how-
ever, it sometimes passes ; and occurs, chiefly,
418
CONVULSIONS, PUERPERAL — Description of.
in very young children, and in those approaching
to puberty, particularly those who are nervous
and irritable. I have seen hut few instances of
it; but it has more frequently been seen by MM:
Jadf.i.ot and Tonneli.e. It consists of rigid
contraction of the upper and lower extremities,
of the former only, but more frequently of both.
The hands are slightly bent on the forearm, and
the feet are stretched in the same axis with the
leg. The spastic action of the muscles contin-
ues for several hours, or even days, then ceases,
and returns, and often thus recurs frequently
at short intervals. The intellectual faculties,
the general sensibility, and the muscles of the
trunk, are not affected; and the pulse and natur-
al functions not materially disturbed. The cases
of it which have occurred in my practice, have
all been evidently owing to the irritation of worms,
or morbid matters in the alimentary canal, or to
dentition.
24. E. Another form of convulsions is much
more frequently met with in children, to which
the name of Eclampsia has been given by Rosen,
Sauvages, Brachet, and others, and which
has been considered as infantile epilepsy by some,
and, with more justice, by others, as convulsions
occurring in the more robust children as a conse-
quence of cerebral congestion of an active form.
But it differs from epilepsy, in the absence of
foaming at the mouth, by the irregular and fre-
quent recurrence of the attack, by its longer du-
ration in most cases, and by its uniform connec-
tion with evident signs of fulness of blood, or
acute disease in the brain. This form is seldom
preceded by precursory symptoms of any con-
tinuance. The child cries, its face and scalp be-
come red and tumid, it loses consciousness, and
is seized with violent convulsions, or with tremor
and rigidity, or a succession of spastic shocks of
the limbs. In a few seconds, or minutes, or even
hours, the seizure subsides; but is generally re-
newed at short intervals; the head remaining hot
and pained after each return of the fit, which never
terminates by a critical sleep of short continu-
ance, and in restoration of the healthy functions,
as in epilepsy, unless assisted by active treat-
ment, but is frequently followed by profound
stupor or complete insensibility. From the fore-
going it will be evident that eclampsia is merely
a more severe form of convulsion, differing from
others only in respect of the severity or tonicity
of the muscular contractions, the more complete
abolition of sensibility and of the cerebral func-
tions, and its more uniform dependence upon
congestion of the brain and its consequences
(§ 21.). The eclampsia of children is in every
respect similar to the convulsions of the puerperal
states (§ 29.).
25. F. There are certain phenomena connected
with the accession and the course of the convul-
sive fit that require attentive observation, as they
furnish indications of the pathological state oc-
casioning the seizure, and, indeed, form the basis
for rational indications of cure. These have in-
timate relation to the origin of the paroxysm
either in repletion or inanition — in congestion,
or in anemia of the cerebro-spinal masses; in
which latter the convulsions of children not in
years. When the convulsion is attended with a
congested state of the circulation in the head, it
will generally be readily recognised, both from the
history of the case, and from the premonitory and
concomitant symptoms. The warm, tumid scalp
and face; the flushed countenance ; the con-
tracted pupils and suffused conjunctiva ; quick,
full, or hard pulse, particularly of the carotids;
are evident signs of an excited circulation in the
brain, not infrequently either accompanied with,
or running into inflammatory action. \\ hen the
countenance and scalp are swollen, full, dark, or
livid ; the fnntanelle elevated and tense ; the
eves distorted, prominent, vacant, and stupid ;
the pupils dilated ; the veins of the head and
neck large and dark; the pulse slow, irregular,
or oppressed ; the respiration laborious; the ves-
sels within the cranium are evidently- congested.
Dr. John Clarke, and many other writers, im-
pute the convulsions of children to irritation or
organic change, either directly or indirectly in-
duced in the brain or its membranes, particularly
in the arachnoid, according to M. Brachet. We
shall see, when we come to treat of the proximate
cause of convulsions, that, although this may be
most frequently the case, it is by no means uni-
versally so. For we occasionally meet with con-
vulsions consequent upon exhaustion, and even
anaemia, as in the last stages of chronic diarrhcea
or other diseases; and after large or repeated
depletions, where there is no evidence of irrita-
tion of the arachnoid, or of organic change. In
many such cases there may occur notwithstand-
ing, "especially during the height of the parox-
ysm, temporary and slight congestion of the head,
as shown in the article Blood, (§ 54 — 61.);
but, still, evidence of ar.amia of the brain, and,
indeed, of the general system, will be furnished
in the depressed and relaxed fontanelle; in the
pale, collapsed, and pinched features ; in the re-
tention of consciousness and unimpaired general
sensibility; in the bloodless and dull appearance
of the conjunctiva and cornea; in the state of the
pulse in the carotids, and the low temperature
of the head; and in the pale, shrunk, wasted,
and often bloodless condition of the whole sur-
face.
26. There is a disease to which infants are
liable, that consists of a spasmodic contraction of
the muscles of the larynx and of the extremities,
and which has been confounded with convul-
sions, or with spasmodic croup, and variously
denominated. As the muscles of the larynx are
chiefly affected, and as the disorder consists of
spastic rather than convulsive action, it is treated
of in a separate article. (See Larynx, Spasm
of.)
2". iv. Puerperal Convulsions. — Convul-
sions may come on (a) during the latter months
of pregnancy; (b) during parturition; and (c)
during the first fortnight after delivery. They
may be partial or general, most commonly the
latter; and they may assume various shades of
tonicity, from a state of tetanic violence to the
more clonic form, characterised by alternating
contraction and relaxation ; but they usually
present very nearly the same phenomena as
eclampsia — being attended by loss of conscious-
frequently originate, as shown by Dr. M. Hall, ness, and recurring paroxysms, between which
and subsequently by others, and as I have had sensation is not restored^
frequent opportunities of remarking for many j 2S. A. Premonitory symptoms commonly usher
CONVULSIONS — Complications of.
419
in the seizure; but, in some cases, they are either
absent, or so brief in duration, or so slight, as to
evade detection, Cahossier thinks that they
are scarcely ever wanting altogether. The pa-
tient usually complains shortly — sometimes for
several days — before the attack, of lassitude, de-
pression, and a feeling of indisposition which she
cannot well describe; frequently of disorder of
tlie stomach; often of weight or pain in the head,
or of drowsiness, vertigo, and sparks, or various
dark or bright objects, floating before the eyes.
These symptoms are renewed at intervals during
a day or two, and are occasionally attended by
embarrassment of speech. To these usually are
superadded, shortly or just before the seizure, a
change in the expression of the countenance;
partial or occasional failure of sight, or loss of
sight; sometimes loss of hearing; haggard, va-
cant, and fixed state of the eyes, with a dilated
pupil; ringing or other noises in the ears; some-
times most acute and splitting pains in the head,
with a flushed neck and face; generally sick-
ness, pain, oppression and anxiety at the stomach;
thirst; a full and quick pulse; subsequently a
slower pulse; and swelling of the neck and
countenance; tetanic stillness of the wrists;
cramps in particular muscles or parts; twitch-
ings of the muscles of the face; shocks or shud-
derings through the frame; altered respiration;
loss of consciousness; and all the phenomena
constituting the developed seizure. Dr. J. F.
Osiander states that he has seldom observed a
tumid state of the face and hands wanting as a
premonitory symptom. If the convulsions occur
during parturition, the pains often become feeble
and frequent before the seizure.
29. B. The complete seizure. — To these suc-
ceed involuntary contractions of the muscles of
the face and jaw, instantly followed by spasmodic
succussions, or general convulsions of a violent or
tonic character; sometimes approaching to teta-
nic, but commonly closely resembling eclampsia;
or the universal convulsions of the epileptic or
hysterical paroxysm. The respiration is laborious,
imperfect, sonorous, and hissing, — frequently with
foaming at the mouth, — and the tongue is often
protruded; the eyes are injected, prominent, fixed,
staring, or rolling; the countenance and bend tumid,
red, or livid; the limbs are strongly convulsed, and
tossed about; the heart beats strongly; and sen-
sibility and consciousness are entirely abolished.
After a short time the convulsion subsides; respi-
ration becomes less laborious, and the countenance
less livid; but the coma lose stupor continues; some-
times with slightly stertorous breathing; when,
after an indefinite, but generally a short, inter-
val, the spasmodic BUCCUSsiona and general con-
vulsions return as before, or with slightly modified
severity or duration, and subside into stupor us
before. Thus they may recur two or three times
— more frequently, several or many times —
when the patient either quicklv awakes, uncon-
scious of what has passed, as it' from a slumber;
or passes into a more comatose state; or recovers
partially; sight and hearing, or speech, or both,
being lost lor a time. Or she may experience
some one of the unfavourable terminations here-
after to be noticed.
30. It may be generally remarked, that, upon
the accession of puerperal convulsions, a llux of
blood takes place to the bead and superior ex-
tremities; the veins of the lower limbs becoming
proportionate!) empty, and the pulsation of their
arteries being comparatively small and weak.
Tlie worst forms of the attack are often attended
by !l hrm spasmodic constriction of the cervix
uteri, preventing the expulsion of the fu'tus. M.
Menard states, that, in tlie majority of cases
of death by convulsions previous to delivery, the
child has been found dead, the contraction of the
features and extremities denoting that it had par-
ticipated in the affection of the mother : this,
however, wants confirmation. In some instances,
tlie child has been unexpectedly bom during the
violence of the convulsions, as if expelled by them
with unwonted celerity.
31. C. Modifications. In persons of a nervous
temperament, local pain or irritation, or even ex-
haustion alone, may induce that state of cerebral
affection upon which convulsions are consequent,
without the supervention of plethora, and active
congestion of, or determination of blood to, the
brain characterising the great majority of cases.
In these persons, the seizure is sometimes preced-
ed by sinking, leipothymia, or fainting; the coun-
tenance is neither tumid nor livid; the eyes and
face are unsurl'used, but wild — often sparkling,
staring, or rolled irregularly; the pulse is small,
hard, or constricted; the urine is frequently
copious and pule; and the agitations and tossings
of the limbs greater, but less rigid or spastic,
than in the mixed epileptic and apoplectic forms
described above. In these cases, there is evident-
ly cerebral irritation, or erithism; and, during
the paroxysm, abolition of consciousness : but
the patient generally either partially recovers her
sensibility between its exacerbations or recur-
rences; or awakens out of this state entirely
restored, and without experiencing any of those
sequela; which are left by the more congestive
attacks. In other instances, seizures occur, pre-
senting characters intermediate between these;
but the first described state is by far the most
common. From this it may be inferred that
convulsions, in any of the three periods con-
nected with child-bearing, will evince modified
phenomena, according to the constitution, tem-
perament, habit of body, predisposition, and pre-
vious ailments of the patient. In the plethoric,
epileptic, irritable, sanguine, and robust, it will
present the characters of eclampsia or epilepsy
— the most common — or of apoplexy or coma;
and in the hysterical, the nervous, the delicate,
&c, it will assume these now noticed, which ap-
proach those of a severe hysterical attack. The
convulsions which come on in the puerperal states
from large losses of blood, are either of this kind,
or of one closely resembling it, or intermediate
between it and the epileptic.
32. v. Convulsions associated with oth-
ER .Manifestations of Disease. — Convul-
sions may occur on the invasion, during the course,
and ;it the crisis or decline of a great number of
acute discuses, particularly in children under eight
years, about the period of puberty, and in females
of a nervous and susceptible constitution. Their
connection with irritations, &C. in the prima via,
and with organic diseases in, or affecting the large
nervous masses, i- considered at another part (§ :»7.
•44,45.); but their association with some other
maladies require i more especial notice in a prac-
tical point of view. a. The invasion of various
420
CONVULSIONS — Diagnosis of.
acute distempers is often attended by convul-
sions. Indeed, in some of the severe diseases to
which young children are liable, particularly the
exanthematous fevers and inflammations, convul-
sions usurp the place of the cold stage or rigors
which usher in these diseases in adults, and are
generally preceded by coldness of the surface.
When occurring in this manner, they should be
regarded as indicating one of three things, viz.
a morbid susceptibility of the nervous system,
and predisposition to disease in the cerebrospinal
axis; or an approaching developement of febrile
reaction and of eruption, if the patient be of a
sound constitution; or else an imperfect evolution
of both, with a disposition to visceral irritation,
inflammation, or effusion, particularly of the brain
or abdominal viscera, if the habit of body be in
fault, or if there exist any hereditary disposition,
or vice remaining after previous disease.
33. b. The course of various diseases some-
times becomes associated with occasional or re-
curring convulsive seizures; often of a partial, or
of an irregular, peculiar, or anomalous character;
but frequently, also, such as those described under
general convulsions (§12, 13.). Children, and fe-
males about the period of puberty, are most liable
to these complications. We observe these seizures
in hooping cough and croup; in the remitting
fevers of infants; in mania, and febrile insanity;
in inflammatory and numerous organic diseases
of the brain (§ 37. 44. 45.) and spinal cord;
in verminous complaints, and other disorders of
the alimentary canal; in organic lesions and
calculi of the kidneys and urinary bladder;
and in states of nervous and vascular excite-
ment or irritation of the female organs. In all
these complications, either active congestion or
determination of blood to the head, or irrita-
tion of the cerebro-spinal axis and membranes,
or both these states, may be presumed to exist;
active congestion being occasioned by impeded
return from, with increased impetus of the cir-
culation to, the brain and medulla oblongata;
irritation of these parts being generally propa-
gated thither from some portion of the organic
nervous circle, and through the medium of this
circle, in which it had been primarily excited.
We not infrequently observe convulsions at-
tended or followed by mania and insanity, or
even supervene in the course of these mental
disorders. When this is the case, the convulsive
seizure is commonly of a tonic and acute form,
and approaches nearly to eclampsia and epilepsy,
constituting the maniacal convulsions of authors.
The convulsions which occasionally are observed
in females, in connection with irritation of the
sexual organs, are evidently owing to the propa-
gation of disorder, through the medium of the or-
ganic or ganglial, to the spinal nerves, or to the
cord itself, or even to the brain; as well as to the
extent to which these various parts of the cere-
bro-spinal system are thereby influenced; and
the various forms which the convulsions thus ori-
ginating commonly assume, are to be imputed to
the existing state of local or general plethora, or to
the degree of determination of blood to the head
with which the superinduced irritation is attend-
ed. When we reflect upon the connection of the
organic nerves with the spinal, and especially on
the mode of that connection with the brain itself
and the rest of the cerebro-spinal system, we shall
not be surprised that irritation of the extremities
of the organic nerves, either in some one of the
female organs, or in some part of the prima via,
excites in one person, according to peculiarity of
temperament, hereditary predisposition, habit of
body, or state of vascular plethora, convulsions
of a spastic or tonic character in the limbs and
trunk, the cerebral functions being undisturbed;
in another person, convulsions either of a clonic
or irregular form, consciousness also being re-
tained; or either of these forms, or both of them
variously or singularly mixed, with partial or
complete deprivation of sense and mental mani-
festation, or with a comatose or maniacal deli-
rium superadded. Nor should it be a matter of
wonder that irritation thus originating gives rise
to various other abnormal nervous and muscular
phenomena, such as catalepsy, ecstasy, hysteria,
&c.
34. c. Convulsions sometimes also usher in
the crises of fevers and other acute diseases.
This occurs most frequently in delicate or hyste-
rical females, the abnormal contractions assum-
ing a variety of forms, and often an hysterical
character; but it also not infrequently is observed
in the male sex, especially in young and delicate
persons. This association of convulsions is ge-
nerally dependent upon a severe affection of the
brain in these fevers, and attended by either
coma or delirium; and although they may indi-
cate a favourable change, particularly when ac-
companied with, or immediately followed by,
other critical phenomena, or when they put on the
true hysterical form, yet they may be the outward
signs of an exasperation of the cerebral or cere-
bro-spinal affection, particularly when the mental
faculties and general sensibility are not soon after-
wards restored. Other morbid associations, as
with worms, diseases of the brain and spinal
cord, &c, may be considered as causes of con-
vulsions rather than complications.
35. II. Diagnosis. — Simple convulsions may
with difficulty be distinguished from epilepsy and
hysteria. They cannot readily be mistaken for
tetanus or rabidity. There are many cases,
which the nature of the exciting cause, and the
history of the case, show to be different from true
epilepsy, and yet they cannot easily be distin-
guished from it during the height of the pa-
roxysm; and the remark applies equally to the
hysteric fit. In fact, convulsions present so many
and so slight grades of difference, as to the
spastic contraction of the muscles, and the fre-
quency and rapidity of its alternation with relax-
ation,— as to the presence of, or immunity from,
cerebral disorder, as well as to the nature and
extent of such disorder, — are so intimately
allied in respect of their causes, of the particular
system of the frame upon and by which these
causes produce their sensible effects, and of the
nature of these effects as far as thev become
symptoms or signs of the particular lesion which
occasioned them, that the difficulty of diagnosis
is very great in many instances, excepting to the
acute and experienced observer, whilst it is suffi-
ciently easy in others, a. Generally, however,
simple convulsions will be readily distinguished
from epilepsy, by the retention of consciousness
and general sensibility in. the former, excepting
in the height of the paroxysm in the severer or
more plethoric cases, as in eclampsia and puer-
CONVULSIONS — Terminations — Prognosis.
421
parol convulsions, in which both are lost; by
the genera] absence of the consecutive sleep or
Bopor ofepileps] ; by the irregular and frequently
recurring form of the seizure; by what is Known
of its origin and connection with obvious causes,
and b\ the mode of its attack and of recovery
from it. There are also various symptoms which.
although common to eclampsia, puerperal cou-
vutsions, and epilepsy, are yet peculiarly charac-
teristic of this last; and we find, in addition,
other phenomena which simple convulsions sel-
dom present, particularly the frightful scream
on the accession of the epileptic tit, the ante-
cedent aura or peculiar premonitory signs; the
very sudden and unexpected seizure when the
aura is wanting, the expulsion of the seminal
and prostatic secretions, as well as of the alvine
excretions; the more frequent occurrence of
foaming at the mouth, and severer affection of
the respiratory muscles; the more leaden appear-
ance of the countenance, and the more common
recurrence of the paroxysm at a stated time, than
in convulsions, particularly after the first sleep,
or when the patient awakens or is rising in the
morning. (See Epilepsy — Diagnosis.) -(Con-
vulsions are readily distinguished from hysteria,
by the antecedent copious discharge of pale
urine, the globus hystericus, and the borborygmi;
and by the alternate crying and laughing attend-
ing the seizure of the latter. Some instances of
simple convulsion, arising from irritation of the
female organs, will, however, very nearly ap-
proach, if not altogether run into, the hysterical
character; as we also see many cases of puer-
peral convulsion differing but little from epi-
lepsy, excepting in the frequent recurrence of the
paroxysm in the former before the patient has
recovered from the sopor consequent upon the
antecedent fit, and in one or two of the diagnos-
tic signs noticed above. ■/. The continued or
permanent nature of the spasms in all the forms
of tetanus, and the absence of any tendency to
obscuration of the general sensibility and mental
faculties, during the whole unremitting duration
of this dreadful disease, are sufficient diagnostics
between it and convulsions. d. Rabidity can-
not be mistaken for this affection, if the history
of the case, the uncommonly increased sensi-
bility of the whole frame, the dread of fluids, and
unimpaired cerebral functions, characterising ra-
bies, 1 1" attended to; for, although convulsive
seizures occur frequently in it, they are produced
by so slight external or mental causes — by every
attempt at swallowing liquids — that their nature
and origin cannot be for a moment doubted.
(See Raisidii y.)
36. III. Terminations or Consequen-
ces, and Prognosis. — A. Convulsions, in any
of the forms now placed before the reader, may
terminate, (a) in health; (6) in some other dis-
ease; or, (c) in immediate dissolution, a. Their
termination in health may be marked by no pe-
culiar phenomenon, beyond the non-recurrence
of the seizure. In other cases they are followed
by critical evacuations, particularly haemorrhage
from the nose, mouth, or ears, alter which they
mav never recur, or which may produce an im-
munity from them for a tune. Vomiting and
diarrhoea, or the accession of the catamenia, may
likewise prove critical.
37. b. They often are followed by other dis-
36
eases; or rather the original disorder or change
of structure, of which convulsions arc merely a
part of the sensible and outward sign-:, may, from
its increase, or extension to adjoining parts, occa-
sion other or additional phenomena moid or less
intimately allied to convulsion, as palsy, apoplexy,
coma, loss of speech or of sight or hearing, cho-
rea, or mania, delirium, idiotcy, &c, each of
which may pass into the other, or be variously
associated with one another. Thus loss of sight,
hearing, speech, and idiotcy, may be the conse-
quences in the same case. Also, either of these
consecutive phenomena may arise from the cere-
bral congestion, and its ellects, produced by the
frequent recurrence or by the severity of the fit,
particularly when the respiratory functions are
much impeded in it, and the system is plethoric
and relaxed. My limits will not admit of illus-
trations of these facts, either from mj own expe-
rience, or from the other sources which are re-
ferred to at the end of the article; but they are
of common occurrence, and may, after continu-
ing for a longer or shorter time — in some cases
for many years — in others for a very short pe-
riod, either be recovered from, or terminate ex-
istence. In some cases, convulsions are followed
by a state of leipothymia, trance, or complete
syncope, which, when profound and continued,
may be mistaken for dissolution, and endanger
premature interment. There is reason to sup-
pose that, in some countries where interment
usually follows death at a much shorter period
than in Great Britain, this dreadful fate has over-
taken the patient. In other instances, lethargy,
or torpor, terminates the paroxysm, which, in
rare instances, has been of long duration, and
also may be mistaken for death. Whilst the
convulsions of childhood more commonly give
rise to, or terminate in, loss of one or more of
the functions of sense, in chorea, in idiotcy, or in
hydrocephalus; those attacking adults are more
disposed to pass into either apoplexy, coma, pal-
sy, or mania: and whilst the convulsions of the
former class of subjects are more frequently the
consequence of irritations affecting the abdominal
viscera, those of the latter, excepting in females,
are more generally the result of disease within the
cranium or spinal column, often at a certain stage
of its progress.
38. c. Their termination in death takes place
either through the intervention of one or more of
the diseases noticed above as their consequences,
or, more directly, from the extension of convul-
sion or spasm to I lie respiratory muscles, inducing
asphyxy, or from an overwhelming congestion or
effusion of blood in the brain. This sudden un-
favourable change more commonly occurs in pu-
erperal convulsions than in other forms, excepting
when they proceed from abscesses or turnouts
within the' cranium. Death may also occur from
accidental suffocation during the paroxysm.
39. B. The Proghosis of convulsions depends
chiefly on what is known of their causes, on the
and dent and consecutive phenomena, on the
history of" the case, and the degree in which
the functions of the brain and nervous system
are all'ectod during and after the fit. a. If the
convulsions occur in children, without fever or
any primary or cerebral disturbance, and ap-
parently from worms, disorder of the prima via,
&c, a favourable opinion may be entertained.
422
CONVULSIONS — Causes of.
But when they are preceded by head-affection,
by fever, followed by strabismus, stupor, or loss
of one or more of the functions of sense; when
they are prolonged or recurrent; or are followed
by signs of any of the unfavourable terminations
noticed above, much danger should be appre-
hended. Indeed, all cases depending upon cere-
bral disease are attended by more or less danger,
which in some instances become most imminent,
particularly when the symptoms of hydrocephalus
are present', b. In adult persons the prognosis
is equally unfavourable, when the affection is
evidently the result of cerebral disease, or of or-
ganic changes — and when the fits become more
and more frequent, or severe, with more marked
cerebral disturbance either attending upon or
following them. On the other hand, when they
are symptomatic of disorders of the prima via,
or of the generative organs, a. favourable opinion
may be entertained, c. Puerperal convulsions,
however, should never be considered devoid
of danger, more especially when they occur
after delivery; or in consequence of great ex-
haustion of vital power, or of uterine haemorr-
hage. When they are slight, are unattended by
stertorous breathing, or by paralytic or apoplec-
tic symptoms, and when parturition is so far ad-
vanced as to readily admit of its completion by
art, less danger may be feared. But the prog-
nosis of convulsions generally must be inferred
from a careful review of the diversified circum-
stances of individual cases, especially in respect
of their remote and efficient causes, and of their
disposition to terminate in either of the ways
pointed out.
40. IV. Appearances on Dissection of
fatal Cases. (See Brain, § 4 — 133.) Epi-
lepsy, and Spinal Cord.
41. V. Remote and efficient Causes.
— i. The remote causes of convulsions are nume-
rous : but they often require a certain original or
acquired predisposition of system to ensure their
operation; and various influences which may
only predispose to them in some persons, may
even excite them in others. Jl. Predisposing.
There is every reason to suppose ihut the oil-
spring may derive constitutional predisposition to
convulsions from the parents. Persons of a ner-
vous and irritable temperament, — of a delicate
frame, and largely developed head (Deses-
sartz), — of a relaxed and soft fibre, and ple-
thoric vascular system, — children whose fonta-
nelles are very late in closing, — those who are
naturally of a quick, sensitive, and unstable dis-
position, and whose physical and moral constitu-
tions are readily impressed, — are predisposed by
original conformation. Those infants who have
experienced injury of tlie cranium during partu-
rition (Smellie); persons who have early, pre-
maturely, or inordinately indulged in venereal
pleasures — who have placed no restraint on their
passions, particularly anger, — who have become
debilitated by any* cause (Autf.nreith), — who
have had their cerebral organs unduly and too
early excited, and before the process of develope-
ment was sufficiently far advanced; the present
state of civilisation and precocious mental im-
provement; the greater irritability of the system
accompanying the epochs of dentition; the irri-
table and plethoric .-tales attendant upon preg-
nancy; habitual determination of blood to the
head; previous attacks of convulsion, either be-
fore or after puberty, or in a former pregnancy;
attempts to conceal pregnancy, and the mental
distress and shame attending it in unmarried
women; exhaustion of nervous or vital power by
increased discharges, long continued pain, or
want of sleep; all luxurious indulgences; too
much sleep; inanition and want; prolonged lac-
tation; fluor albus, &c. ; and certain electrical
states of the air, by which the nervous system is
influenced, and rendered more susceptible of im-
pressions and excitement; are the chief causes
which generate a predisposition in the frame. It
has been remarked by Dr. Ramsbottom, and
other writers, that puerperal convulsions were
most frequently produced during warm electrical
states of the atmosphere.
42. B. The exciting causes of the various forms
of convulsion are very numerous; and thev act
in different ways in producing their effects. I have
already stated, that irritation of a part of the or-
ganic or ganglial nervous system will be transmit-
ted by the communicating branches to the spinal
nerves, and produce convulsive actions of the
muscles they supply, without the brain experi-
encing any evident lesion; whilst, in other cases,
the irritation may be conveyed to the brain, either
directly by the organic nerves, or through the
medium of the spinal cord, the cerebral functions
suffering accordingly. But irritation or organic
change of any of the parts, contained within the
cranium will also occasion convulsions, the gene-
ral sensibility and mental manifestations being
then more or less obscured or perverted during
the paroxysm or subsequently. These facts,
which might be illustrated by numerous cases,
the history and results of which I have attentively
observed, naturally point to a division of the caus-
es, first, into those which act upon some portion
of the organic nervous circle, or the viscera which
it supplies; and, secondly, upon the cerebrospi-
nal system itself. But, although it is useful to
make this distinction, particularly for practical
purposes, yet it should not be overlooked, that
irritations affecting the former would rarely be
followed by convulsions, unless the latter posses-
sed a marked disposition to disease, as far as re-
gards increased suceptibility and proneness to
experience alterations from the healthy condition
of its circulation.
43. A. The exciting causes which act more
immediately upon the organic nervous system,
and through it upon the spinal nerves or brain, or
both, are the following: — a. In infants and chil-
dren, the retention of the meconium; a morbid
state of the umbilical cord; unwholesome milk,
or improper feeding; acid or acrid sordes, and
various diseases of the alimentary canal: an over-
loaded stomach; suppressio'n or retention of the
urine; accumulated flatus, or morbid secretions,
and the presence of worms, occasioning irritation
of the bowels; the ingestion of acrid substances
— as very irritating purgatives (Gohl and Lfn-
tilius), or emetics (Riedlin), — acrid one-
mata; noxious or indigestible substances taken as
food; acidity of the prima via; dentition at either
of its epochs, particularly cutting the eye and
molar teeth; the irritation of pained or carious
teeth; and calculi in the urinary organs, &c.
b. In persons about, or^mbsequcntly to. puberty,
and occasionally in children, organic diseases of
CONVUISIONS— Causes of.
12.1
the stomach, bowels, or collatitious viscera ; at-
fections or lesions of ilio heart ; constipation, colic,
ileus, and intus-susception ; incarcerated or stran-
gulated hernia (Graaf and myself) ; organic-,
change of the kidneys, and suppression of urine ;
manustupratio or inordinate sexual intercourse ;
and nervous and vascular excitement, or other dis-
, lii,' female organs, particularly the ovaria
and uterus, c. In puerperal females, a loaded
stomach, or disorder of this organ brought on by
indigestible or unsuitable articles of diet, particu-
larly sliell-tisli (Clarke) ; rapid or premature
distension of the uterus during pregnancy ; long
continued and exhausting labour ; excessive, fre-
quent, and inefficient pains ; distension of the
urinary bladder during or after parturition ; a
loaded state of the bowels ; excessive depletion
or flooding ; venereal indulgences during the last
two months of utero-gestation.
44. B. The causes which act more directly on the
cerebrospinal nervous system are, «,the improper
exhibition of narcotics, and of spirits and various
quack medicines, hy the lower classes, to infants
and children ; the admission of a strong light, or
the impression of loud noises, on very young in-
fants ; the continuance or excess of pain ; inju-
ries received on the head during or subsequent-
ly- to birth ; fear, and sudden fright, or fearful
dreams, b. In adults more especially, and in child-
ren also, the most common causes of this descrip- j
tion are, the influence of imagination and imita-
tion ; the action of the sun's rays on the head ; '
3ive mental labour or anxiety; extreme
bodily sufferings, or long watching ; injuries of the
brain, spinal cord, or nerves ; irritation of nerves ,
by tnmours, abscesses, or hy ligatures in opera-
tions, or injuries of them by wounds and accidents;
incipient curvatures of the spine (Wich.mann,!
Bonet) ; the impression of excessive or long
continued cold, or of a cold bath; the influence of |
particular odours on some constitutions ; the abuse
of spirituous liquors ; the influence of various
poisonous substances on the nervous system, be-
._' to the animal, vegetable, and mineral
kingdoms, as nux vomica, and nearly all the class
of narcotics; deleterious gases and metallic fumes,
as the nitrous oxide, sulphuretted hydrogen, &c, I
the vapours of mercury and lead ; and the irri- !
tating and inflammatory operation of many mine-
ral preparations and acrid vegetables (see Pois-
ons); all emotions of the mind which excite the
nervous power, and determine the blood to the
head, as joy, anger, religious enthusiasm, excessive
desire, ice; or those which greatly depress the
nervous influence, as well as diminish and derange
the actions of the heart, as fear, terror, anxiety, sad-
ness, distressing intelligence, frightful dreams, &c; '
numerous lesions of the encephalon or its mem- |
branes, particularly effusions of fluid, abscesses,
tumours, ossilic deposits, and various other adven- I
titious formations — indeed, nearly all the organic
changes described in the articles on the Brain, Ep-
ilepsy, and Spinal Cord; also exhaustion from
previous disease, particularly by large losses of
blood (ScHROEDEH.) ; inanition and want (Am v-
tusLi -ii 'aim s); the erect position suddenly as-
sumed ; lightning (Grapehgiesser); abscesses
about the neck ; the suppressi >f eruptions and
discbarges, particularly on the head or from the
ears ; the syphilitic poison ; and repulsion ofgout or
rheumatism, c. In puerperal females, many of the
Causes now mentioned are especially productive.
ol convulsions, particularly anxietj or distress of
mind in unmarried females ; violent .straining
during labour ; and sudden changes from the hor-
izontal to the sitting or civet postures.
45. ii. The efficient causes have been partially
alluded to. Their nature may be in some meas-
ure inferred, from what has been staled above.
It seems evident, from a careful consideration of
the exciting causes, of the character and progress
of the symptoms, and the lesions usually detei led
OH dissection, that convulsions arise from several
pathological states, the grosser or more palpable
parts of which only we are enabled to recognise
by the senses ; and that, in addition to these, a
certain susceptibility of the nervous system, par-
ticularly of the cerebro-spinal centres, is requisite,
nevertheless, to the full developement of the seiz-
ure. It is extremely probable that convulsions
frequently arise from some considerable change
in the state of the circulation within the cranium;
and that such change may be either active cere-
bral congestion, — in some cases connected witii
general plethora, but in others not thus associated,
and, even in a few, accompanied with marked
deficiency of blood, — or local or general anae-
mia. Moreover, it may be presumed that the
seizure very often is accompanied with but little
disturbance of the cerebral circulation or functions
at its commencement ; and that it chiefly depends
upon irritation, in some manner induced in the
organic nerves, and, through them, in the spinal
nerves, either partially or generally. We have no
proof of the circulation of even the spinal cord or
its membranes being disordered in these cases, al-
though it may be affected in convulsions, either
primarily or consecutively. In cases which more
manifestly proceed from disease within the cra-
nium, and that of an organic kind, as from tu-
mours, abscesses, aqueous effusion, &c, it by no
means follows that the circulation in the brain is
generally, or even at all, either accelerated or con-
gested, although these lesions may safely be as-
sumed in many instances. In some cases even of
organic change, the general amount of circulation
in the head seems, as far as we can judge from
symptoms, much below the natural standard, and
y'et convulsions will supervene ; whilst in others,
signs of inflammatory action of the membranes
are apparent. In many cases, moreover, judging
from the states of pre-existing disease, from what
is known of the operation of various causes, and
from the symptoms connected with the head, —
the weakand small pulsation of the carotids, the an-
tecedent fainting or leipothymia, the low temper-
ature of the scalp, and pile, sunk, and pinched
features,— it maj be inferred that the vital endow-
ment and the circulation of the brain are momen-
tarilv deficient both in activity and in quantity.
lii. Therefore, while I subscribe to the justice
or the aphorism of Hippocrates, that convul-
sions arise from repletion or inanition as respects
the circulation within the cranium, I would qualify
it, and add, that they often originate thus, but.
thai cither of these state- forms a part only of the
changes that produce them, even when most irre-
fragably present, — that in man) cases the circu-
lation in the brain is not materially disturbed,
whilst the spinal nerves are affected either by
irritation conveyed to them from the organic ner-
vous system or from the spinal cord itself, more
424
CONVULSIONS —Treatment.
frequently the former, — that even when the brain
is disordered, general convulsions will arise only
when the disorder extends to, or influences the
parts more immediately related to, the locomotive
actions of the body, as the spinal cord or its mem-
branes, — and that we cannot contemplate the
origin of convulsions in any way, and leave out
of view changes primarily induced in the organic
nervous or ganglia! system — which changes will
more readily produce, than be produced by, dis-
ordered circulation in the cerebro-spinal organs.
We know that the movements of the fetus in ute-
ro are automatic — are the consequence of irrita-
tions affecting the organic nerves, extending to the
spinal nerves, and, through them, inducing motions
of the limbs. To the production of these, any
change in the brain or spinal cord is not required ;
and a great many cases of convulsion have a sim-
ilar origin, the difference being only as to the grade
of irritation relatively to the susceptibility of the
patient, and to the effect produced. As to the opin-
ion entertained by the older humoral pathologists,
from Galen to Willis, that a morbid state of
the fluids also occasion convulsions, some impor-
tance may be attached to it. We do not, howev-
er, find convulsions much more prevalent when the
blood is manifestly morbid, unless in those cases
where a previous, and, at least, an equal change
has been produced upon either the organic, or the
cerebro-spinal nervous systems. The convulsive
movements that occur in common and pestilential
cholera, in malignant fevers, in rabidity, and in
organic lesions of the kidneys, with suppression of
urine, are proofs of this position. That, however,
a morbid state of the blood sometimes constitutes
a concurrent proximate cause of certain diseases,
in which convulsions either incidentally occur, or
form a part of the circle of advanced phenomena
or effects, may be admitted, in the absence of suf-
ficient evidence to the contrary ; for, when the
blood itself is primarily changed, we may with
reason infer that convulsions will sometimes man-
ifest themselves as a part of the effects thereby
produced upon the nervous system ; but I believe
that convulsions seldom arise from this cause only.
47. VI. Treatment. — i. Of Convul-
sions generally. The means of cure in all
cases of convulsions, are directed with the view,
1st, of subduing the fit, when called to a patient
labouring under it ; and 2d, of preventing its re-
turn. A. To subdue the paroxysm, it is necessary
to have prompt recourse to active measures : but
these should not be employed indiscriminately,
and without taking quick cognizance of the cause,
and the existing pathological states, as far as
they may be readily ascertained. The circum-
stances principally to be observed by the prac-
titioner, are the presence or absence of active
cerebral congestion and sopor, the existence of
general vascular plethora, the temperature of the
head and lower extremities, the pulsation of the
carotids, and the character of the countenance
and of the convulsive motions, These may be
ascertained in a very few moments, and at the
same time that enquiry is being made into the
Cause of the seizure, and the peculiarities of the
case, as respects the age, constitution and habits
of the patient.
4S. a. A person in convulsions ought to be
placed so as to breathe an open cool air, and to
facilitate the restoration of one of the earliest
functions disordered ; and no more attendants be
permitted than are absolutely necessary. Those
susceptible of, and liable to, nervous affections,
should not be allowed to remain in the same room,
or even in the same house, with the patient while
in the fit. — b. When the habit of body and the ce-
rebral symptoms, &c. present no contraindication,
general or local blood-letting, or both, should be
resorted to, and carried as far as circumstances
may warrant. When the cerebral congestion
is very active and extreme, the jugular vein may
be opened ; but the depletion should never be
pushed too far, with an expectation of stopping
the convulsions; nor should it ever be carried to
deliquium, for the system may be thereby injur-
ed, and a return or immediate recurrence of the
seizure be favoured by it. Revulsive bleedings,
as from the feet while they are held in warm
water, may be preferred, if the seizure be con-
nected with difficult or suppressed menstruation.
Local depletions, in other instances, are best
practised by cupping behind the ears, particularly
in children, and upon the nape of the neck, and
between the shoulders. In other instances, when
the brain is not affected, — when the head is
cool and the carotids are pulsating neither more
fully nor more strongly than natural, — the state
of the spinal column should be carefully enquired
after, by pressing a warm sponge along and be-
tween the vertebra? ; and the abdominal regions
and the evacuations ought "to be daily examined.
If signs of inflammatory action exist in either of
these quarters, particularly if they be connected
with plethora, general and local depletion — pre-
ferably the latter, when plethora is wanting —
should be resorted to. But there are many cases,
especially those produced by copious evacua-
tions, by inanition, and the exhaustion of painful
and protracted disease, where depletion would
be most injurious ; and there are intermediate
grades, in some of which local blood-letting
might be either beneficial or of no advantage,
according as the case approaches nearer to the
one extreme than the other. When the convul-
sions are partial, then local depletions are to be
preferred.
49. c. There are certain states of convulsion,
in which it at first seen s difficult to determine as
to the propriety of resorting to blood-letting in
any way. One of the most common of these, is
that characterised by a pule and somewhat sunk
countenance, and by tonic convulsions. This
appearance may mislead the practitioner, if he do
not examine carefully into other symptoms. If,
iu addition to these, the carotids pulsate strongly,
the temperature of the head be increased, the
pupils contracted, and the brows knit, we should
suspect inflammatory irritation of the. arachnoid
— notwithstanding the absence of all plethoric
or sthenic signs — and resort to depletions, and
the means about to be noticed. (See also Brain
— Treatment of Inflammation of its Membranes.)
Another state sometimes occurs, with" very violent
genera] convulsions : a broad, open, throbbing,
and frequent pulse ; pale countenance and sur-
face, often with sopor or delirium, or both.
These symptoms may mislead the inexperienced,
and depletions — occasionally the very cause of
the mischief — may be improperly employed to
relieve it. But when the history and symptoms
of the case are more minutely examined, we shall
CONVULSIONS — TR F. A T M F. N T.
425
find precisely that state which is described in the
article Mi ood (5 f>3— <><).), and that, instead of
congestion, there is general ana-mi i. wiili cerebral
irritation, combining with the physical condition
of the brain, tn determine to it the greater part
of the blood in the system. In other cases, there
is apparently anaemia el* the brain, at least at the
commencement of the fit, and either conscious-
ness is retained, or it is lest from the state of the
cerebral circulation. These forms of seizure may
be called arurmia!; inasmuch as they arise either
from a general deficiency of blood, or from
anemia of the brain, although the vessels of this
organ soon become partially congested from the
/mpeded respiration, and interrupted circulation
through the lungs and heart, at the commence-
ment of the paroxysm. In these, a very opposite
treatment to depletion is required. The obser-
vations of Latham, Hall, (iooch, North,
and the author, on this important practical topic,
have, however, induced the practitioners of the
present day to resort to blood-letting in convul-
sions in a much more discriminating manner than
formerly.
50. d. Next in importance is the judicious
employment of cold and heat — of cold in the
form of cold affusion on the head and spine, and
of heat in that of warm bath or semicupium.
An appropriate use of these is more generally
serviceable, and often less dangerous, than deple-
tions. The cold affusion to the head, and, in
cases where there seems to be irritation of the
spinal envelopes, along the vertebras; and cold,
in the form of epithems, evaporating lotions,
pounded ice to the head, when convulsions are
produced by inflammatory action in the brain or
spinal cord; are among the chief forms in which
this agent is admissible. The cold bath, although
advised by Currie, Loefflf.r, Beaumes,
Baynard, and others, is, in my opinion, a haz-
ardous experiment during the paroxysm, and
sometimes even in the interval. The warm bath,
or semintpium, is frequently of much service,
and particularly when there is either high nervous
irritation, a dry harsh skin, or cold surface or
extremities; and my experience accords with that
of Heilbronn, He NRIS CHEN, I) o e rn E r, and
Sn T/, respecting the propriety of adding a quan-
tity of the fixed alkalies, or their sub-carbonates,
to the water. When the head is much affected,
either by inflammatory irritation of the mem-
branes or active congestion, cold allusion, or cold
epithems or lotions, may be employed whilst the
patient is in die warm bath, or is using the semi-
cupium or pediluvium. In slight cases of convul-
sion, the aspersion merely of cold water over the
face, head, or neck, is often of service. Large
draughts of cold water were recommended by
1 1 < 1 1 ■ f m \ n n ; and the v, as well as water ices, and
cold clysters, have been several times employed
by myself with much benefit. Cold injections are
praised by Larob ins and Marx. Cold affusion,
cold aspersion, and cold epithems. have been pre-
scribed by Currie, Dcpont, Doemling, and
others; but the two former were usually directed
by them to the surface generally, instead of to the
head, — a circumstance which account-; for the dis-
use into which it had fallen, when the practice
was revived some years since by the author.
51. e. If the patient can: swallow, and the mus-
cles of the jaw are not much affected, cathartic
36*
medicines should be given by the mouth; but in
most instances il will be preferable to delay them
until after the seizure, lint I have under DO
circumstances been prevented horn directing a
cathartic and antispasmodic enema to be thrown
up. lather of F. L31 — 136. may be employed
and repeated, if it be not retained, as is frequently
the case. When purgatives can be taken, a
full dose of calomel, either alone or with jalap,
followed soon afterwards by an active cathartic
draught or mixture, consisting of senna, tincture
of jalap, carminatives, and antispasmodics, par-
ticularly the preparations of ammonia and cam-
phor, is, upon the whole, the most appropriate.
But under every circumstance the operation of
these should be promoted by enemata. When
we wish to produce an active derivation from the
head and spine, as well as alvino evacuations,
the croton oil, elaterium, ol. terebinthinae, &c,
may be employed. But, where the object is
chiefly to bring away offending secretions, and
other causes of irritation, and at the same time
to allay disordered action in the prima via, calo-
mel, jalap, rhubarb, and senna, are, perhaps,
the best purgatives we can employ. Their ac-
tion will, in all instances, be much increased, and
a marked change be often produced in the dis-
ease, by an occasional dose of the ol. terebinth,
and ol. ricini, assisted by the enemata already
recommended. If convulsions arise from worms
in the intestines, anthelmintic purgatives, during
both the paroxysms and interval, should not be
omitted. Calomel may generally, with due
address, be exhibited during the fit, and subse-
quently other anthelmintics may be given. Be r-
giu.s and Barton prefer the Spigelia Mary-
landica in such cases; but the other means adopt-
ed in verminous disorders may be employed ac-
cording to circumstances. Emetics are some-
times of service, when exhibited upon the first
intimation of the seizure, particularly if there be
indications of gastric irritation from offending or
noxious ingesta, and acid sordes, or if the par-
oxysms assume a periodic form. Schenck,
Schsffee, Rigel, Conradi, Hufeland,
and Smith, advise them chiefly in such cases.
Thom recommends them to be exhibited to the
nurse, when convulsions attack infants.
52. /. Antispasmodics are sometimes produc-
tive of instant relief, when employed in large
doses, early in or upon the first intimation of the
fit, particularly when it arises from debility, or
irritation in the prima via, or morbid nervous
susceptibility ; but they seldom can be taken
in the paroxysm, unless it bo slight, or arise
from exhausting causes, and then they are oft-
en of great service, especially if they be com-
bined with restoratives and opium, conium, or
livoseyamus. The athers, camphor, musk, assa-
fcetida, valerian, the preparations of ammonia,
bismuth, zinc, &C, are amongst the most effica-
cious in these cases. When inflammatory irri-
tation seems to exist in the membranes of the
brain, 'bey are obviously contra-indicated ; but
congestion of a passive nature, especially when
the pulsations of the carotids are not strong or
hard, and the temperature of the head is not in-
creased, should be no reason for omitting them.
\m extensive experience, however, of the efl'ecU
of the spirit of turpentine in convulsive diseases,
has convinced me that it is the most efficacious
426
CONVULSIONS — Treatment.
and the safest antispasmodic that can be em-
ployed for their removal. If it he given in doses
so large as to act as a purgative, and seldom or
rarely repeated, it is remarkably beneficial in the
cases which arise from cerebral congestion or
irritation; but when the seizure is Connected with
anaemia, or exhausted vital power of the brain,
or general debility, it ought to be exhibited in
small closes, often repeated, and be combined
with restoratives and aromatics. MichaSlis,
Schmalz, Aleers, Hardens, Conradi,
Heilbronn, and Wiedemann, strenuously
advise, in all convulsive affections, large doses of
the fixed alkalies, either alone or alternated with
opium. Of the antispasmodic action of these sub-
stances, as well as of their soothing operation on
the digestive mucous surface, there can be no
doubt. If the convulsions arise not primarily
from organic disease within the head, I believe
that opium thus combined will often be of great
service, and particularly when they proceed from
the nervous susceptibility and muscular irrita-
bility often connected with debility, exhaustion,
and excessive evacuations. The good effects of
alkalies in disorders of the digestive functions,
and the frequent origin of convulsions in these
disorders, or their connection with them, must be
admitted. Moreover, the alkalies, combined with
opium, or hyoscyamus, conium, or belladonna,
and ipecacuanha, &c, are among the surest
means we possess of allaying irritations affecting
the nervous system. Stutz, Bruninghausen,
Doerner, and Henrischen, employ them
also in fomentations to the abdomen, in baths, and
in enemata; they using an ounce of the caustic
alkali to about a quart of water for the foment-
ation. I have prescribed the alkalies frequently
and largely in the convulsions of children with
much benefit. Other antispasmodics, and diller-
ent modes of applying those in common use, have
been adopted by various writers; but as these are
better suited to fulfil the second intention of cure,
I will notice them hereafter.
53. g. Anodynes and narcotics are often of
the most essential benefit, when appropriately
prescribed and combined, or preceded by other
suitable remedies. They are seldom of service
in the convulsions proceeding from active con-
gestion and organic disease within the head; but
when the affection is connected with irritation in
other parts, or when the disorder of the brain or
its membranes consists chiefly of irritation, they
should not be omitted. They are seldom of use,
■ — sometimes even injurious, in puerperal con-
vulsions, and ought to be given with caution to
very young children. In cases where the pro-
priety of exhibiting them is doubtful, any un-
pleasant operation will be prevented by com-
bining them with camphor, or with aromatic
tinctures or spirits. I have derived great advan-
tage from employing them externally, selectini;
for this purpose opium or belladonna, in the
form of embrocation or plaster — generally the
former — applied during the paroxysm, over the
epigastrium and abdomen, and combining them
with rubefacient and stimulating substances, as
camphor, ammonia, Cayenne pepper, &c, or with
any of the liniments or plasters in the Pharmaco-
peias, or in the Appendix, suited to the case (F.
108. 297. 307.). The practitioner should, how-
ever, be cautious in the employment of the more
active of these narcotics, even externally, as very
dangerous effects have resulted from them. Dr.
Thackeray found that tobacco steeped in
brandy, and placed over the epigastrium, pro-
duced a most dangerous state of vital depres-
sion.
54. h. Revulsants, and counter-irritants are
of great service in all states of the disease ac-
companied with cerebral congestion, or irritation
of the membranes of the brain or spinal cord.
Sinapisms to the extremities; rubefacient lini-
ments (F. 299. 305.), and embrocations, particu-
larly those with Cayenne pepper, horseradish,
&c; the turpentine fomentation; the immersion
of the hands and feet, or the lower extremities,
in a salt and mustard bath; dry-cupping on the
nape of the neck, occiput, between the shoulders,
or along the spine; are the preferable means of
this description. These will often, of themselves,"
shorten the seizure; but if they fail of having this
effect, after slight redness of the skin has been
produced, advantage will frequently arise from
placing over it a liniment or embrocation contain-
ing opium, or the acetate or muriate of morphine,
or any of the other anodynes in use, either of
which may also be employed in the form of
plaster, combined with antispasmodics, &c.
55. i. Convulsions arising from exhaustion,
htsmorrhagy, inanition, &c. require restoratives,
stimulants, &c. in small quantity, and frequently
exhibited, with strict attention to the temperature
of the head, which should be lowered whenever
it rises above natural, by cold applications. (See
Abstinence — Treatment of ; and Blood — De-
ficiency of, § 48, 49.) The combination of hy-
oscyamus with gentle tonics; the preparations of
opium, conium, or hop, with those of ammonia
andtamphor; the preparations of valerian or assa-
fcetida with the sub-carbonates of the alkalies;
the muriate or acetate of morphine, with the
aromatic spirits and tonic tinctures; and emolli-
ent and antispasmodic enemata, are most appro-
priate to those cases. In these, as well as in the
more clonic forms of convulsions, the preparations
of iron, particularly the ummonia-tartrite of iron *
alone or combined with hyoscyamus, will be of
much service. The occurrence of these affec-
tions towards the close of febrile or acute diseases
(§ 13. 33.), particularly when they manifest signs
of greatly depressed vital poioer, requires nearly
similar remedies, or such as exert a still more
stimulant and antispasmodic operation. The sul-
phate of quinine, with hyoscyamus and camphor;
the decoction oi' cinchona, or infusion of arnica
or serpentaria, with liquor ammonias acetatis and
aether; warm negus, with aromatics: and stimula-
ting embrocations or liniments over the epigastrium,
may be resorted to in these cases. If convulsions
occur in the course, or towards the arista of fevers,
the treatment must altogether depend upon the
state of the cerebral functions, and the disposi-
tion that may be evinced towards spontaneous
or critical evacuations, to the promotion of which
our means should be directed; taking care, at
the same time, to guard the head from mischief,
by employing local depletions, cold affusion, cold
* A most valuable and hcaVtiful preparation very lately in-
troduced by Mr. AlKEN ; and from its very pleasant, sweet
taste — resembling that of liquorice — extremely well adapted
for children. Dose from half a grain to the or six grains.
CONVULSIONS — Treatment.
427
opithems. and internal and external revulsants, if I
it exhibit appearances of congestion or inflam-
matory irritation; and warm diaphoretics, gentle
tonics, and antispasmodics, and other means of
supporting the manifestations of vital power in
the nervous systems, and of promoting the se-
creting and excreting functions.
5ii. k. When convulsions are produced by
narcotic or aero-narcotic poisons, the immediate
evaluation of the noxious substance by the stom-
ach pump, or by emetics, the cold allusion on the
head, followed by stimulants and antispasmodics,
green tea, or collee, stimulating enemata, and
frictions of the surface, are chiefly to be depended
upon. If they proceed from the fumes of lead
or mercury, antispasmodics, tonics, stimulants,
Strychnine, or. imx vomica, with purgatives, are
most serviceable, particularly when assisted by
the warm bath, and by frictions of the surface
afterwards with stimulating liniments. Serpen-
taria, the arnica montana, and camphor, are often
beneficial remedies in those cases.
57. /. Convulsions either of a partial, a gene-
ral, or irregular and anomalous form, arising from
irritation of the female organs, require local de-
pletions, cooling aperients, and antispasmodics ;
the internal use of soda and nitre ; cold cl\siei<;
the cold affusion or aspersion ; the tepid bath, or
the shower bath, while standing in warm water ;
and draughts of cold water. In a case of general
convulsions arising from inflammatory irritation
about the neck of the uterus, with leucorrhoea,
I directed the patient to take a lemon ice, or to '
drink as much as she could of cold spring water
upon the intimation of the seizure; and she has
hitherto done so with uniform benefit Having
seen her during the paroxysm, and perceiving that
she retained her consciousness, cold water was
given, and swallowed with some difficulty. The
benefit was almost instantaneous. If the convul-
sions be connected with difficult, or suppressed
menstruation, general or local depletions, and af-
terwards the warm general or hip bath, full doses
of the preparations of assafeetida and ammonia,
particularly the spir. amnion, succin., the spir.
amnion, foetid., or the spirit, guaiaci amnion., also
camphor and the boracic acid, or the sub-borate
of soda, have proved the most effectual remedies
in my practice. Rut the means already advised
to prevent congestion or irritation within the cra-
nium should be resorted to upon the first intima-
tion of the fit. Weeding by leeches from tin
inside tops of the thighs are indicated in these
cases; but it can be practised only in the interval.
58. B. The prevention of the paroxysms i< to
be attempted, with due attention to the remote
and proximate causes, the former of which should
be removed as completely as possible, and the
latter energetically but cautiously combated ; re-
collecting always that convulsions are the outward
manifestations of certain lesions of the nervous,
acting on the muscular, functions : and that our
knowledge of BUeh lesions extends not lie\oinl
the inference that they consist of depression or
exhaustion of vital power, or of irritation, or of
congestion, and, occasionally, of two or all these
states conjoined, some one of them predominating
over the others, and being associated with addi-
tional, and even opposite changes. .Many of the
means already noticed are requisite in the inter-
vale, as well as in the paroxysm, especially when
judiciously modified to the circumstances of the
case. a. Vascular <l<i>lition is often required*
and in similar states of disease to those already
pointed out; but it should lie directed with great
circumspection, and to a moderate extent, unless
the signs of ani\e cerebral congestion, or of in-
flammatory irritation, or of general plethora, be
Unequivocal. If, however, opposite slates obtain,
\i/.. exhaustion, and deficiency of blood, very
different means must he employed. In most in-
Btancqs of convulsions, the quantity of the cir-
culating fluid is not so frequently either much
above or much below the usual proportion, as the
influence, — vital or nervous, or by whatever name
it may be called, — by which the distribution of
blood throughout the frame is regulated, is dis-
turbed so as to determine or attract a larger
proportion to one part than to another. In no
peculiarity of constitution is the old doctrine,
'• ubi irritatio, ibi ftuxus," more frequently il-
lustrated than in that in which convulsive com-
plaints are most commonly observed ; and, in
these diseases, we are continually finding fluxion
one of the earliest consequences of irritation. I
have long thought, and on several occasions con-
tended, that, in the common routine of practice,
blood-letting is loo indiscriminately employed to
remove such determinations or irregular distri-
bution of the circulating mass; and that, although
it sometimes succeeds, owing to its being asso-
ciated with other and more appropriate means ;
it often fails, or even augments the mischief, by
increasing the debility and susceptibility of im-
pressions from exciting or irritating causes, that
generally characterises the nervous system of
persons subject to convulsive seizures, 'therefore,
when the abstraction of blood is really necessary,
it should be performed in such a manner, and be
accompanied with, or followed by, such medi-
cines as are most likely to equalise the circulation;
and it is chiefly in this way that many of those
about to be noticed are productive of any service
in the disease. Local depletions, in moderate
quantity, repeated according to circumstances, —
from the nape of the neck or occiput, when the
head is affected, and along the spine, if irritation
of the membranes of the cord is suspected, — and
assisted by such other means as the case may
require, are more generally applicable in the in-
tervals than large v ena sections.
59. b. There are few remedies more beneficial
in convulsions than mild purgatives, or aperients,
taken daily, and conjoined with tonics and anti-
spasmodics. Active purgation, if long persisted
in, w ill lower the vital energy . and thereby favour
the return of the fits : but the more deobstruent
and eccoprotic n edicines of this class, particularly
when thus combined, may be given, so as to
procure two or three fa eulent evacuations daily.
Thus prescribed, purgatives will increase the
patient's strength, and often procure a prolonged
immunity from the seizures. Aloes, with quinine
Or iron, and camphor; or with inv rib, assafeetida,
the tonic extracts, &<•., and occasionally wild
blue pill, or with extract of hop. In, oscyainus, or
conium (F. 450 — 471.): senna, with gentian or
bark, the preparations of ammonia, aether, &.c.
(F. 266. 672.); and either of these with the
liquor potassffl, or the alkaline sub-carbonates,
are moist to be relied on. But advantage will
accrue from changing the forms and mode of
428
CONVULSIONS — Treatment.
combination and exhibition of purgatives from
time to time, and from assisting them with such
Other remedies as the special characters of the
case may require. A full dose of calomel, fol-
lowed by the turpentine draught (§ 51.), may
occasionally he resorted to ; and enemata will
also be of service. In every instance, the ap-
pearance and quantity of the discharges, intestinal
and urinary, should be examined ; and when the
sensibility of the bowels seems to be increased,
oleaginous or mild purgatives, with alkalies and
hyoscyamus, ought to be preferred. Morgagni
recommended, as an aperient, two ounces of
the ol. amygdal. dulc. to be taken every night, —
a medicine well suited to cases of this descrip-
tion; but the ol. olivae, ol. lini, or the ol. ricini,
and even the cod or tusk-liver oil, may also he
thus used. Where we find the tongue much
loaded or furred, active purgatives, particularly
full doses of calomel, with cathartic extracts, &c.,
are especially required in the first instance ; and
mild laxatives, with tonics and antispasmodics,
subsequently.
60. c. In many eases, particularly when the
convulsions proceed from inflammatory irritation
of the membranes of the brain or spinal cord,
bleeding and purgatives will be advantageously
followed by an alterative course of mercury,
pushed as far as to affect the gums, and by low
diet. Much tact is, however, required in deter-
mining as to the cases and period of treatment,
iu which this practice should be adopted. It is
admissible only when the disease proceeds from
the pathological state just mentioned, or is con-
nected with a syphilitic taint, or has originated
in the abuse of spirituous liquors, &c., and the too
great indulgence of the appetite for food; and it
will be injurious in cases of exhaustion, unless
combined with active tonics and nutritious diet.
Plummer's pill, the hydrarg. cum creta, or the
blue pill, may be given, in small and frequently
repeated doses (from half a grain to a grain of
the last, thrice a day), with anodynes, as conium,
hyoscyamus, ext. humuli, and small quantities of
camphor. In more doubtful cases, or when we
suspect that effusion of fluid lias supervened upon
disease of the membranes, the corrosive sublimate
may be prescribed, either in the compound tinc-
ture of cinchona, or with the compound decoction
of sarsaparilla, or diuretic infusions or spirits, ac-
cording to the symptoms and circumstances of
the case.
61. d. Various antispa*rnodic8 and tonics, be-
sides those already adduced, have been directed,
chiefly in the intervals; and others in more com-
mon use have been employed in novel forms.
The cuprum ammoniatum has been prescribed by
Home, Duncan, and Bianchi; the nitrate of
silver, by Powell and Hall ; the animal oil
ofdippel, by Herz ; the oil of rue, by Abra-
hamson ; cajeput oil, by Thunberg ; the
misletoe, by Oolbatch and Home ; and the
preparations of zinc, by Goodsir, Bell,
Beaumes, Dug hid, White, and many more.
Krebs has advised the trunk of the body to be |
enveloped in camphorated cloths, if we suspect
convulsions to arise from intestinal worms. War- \
burg has recommended musk in large doses,
combined with nitre; and Sidren and Frank-
furter the internal use of nux vomica, ap-
parently upon the principle of Hahnemann, |
that similes similibus curantur. Cazals directed
about half a drachm of bismuth to be taken in the
twenty-four hours, with castor. Vogel thought
that benefit has been derived from the flowers of
the while lily; and Baker, Pallas, Thom,
and Home, entertained a similar opinion as to
the effect of the cardamine and anemone pratensis,
artemisia, and the radix paonice. Digitalis was
employed by Shaaj. ; emollients, by Kortum ;
ipecacuanha, by Plenk; and various narcotics
by the majority of authors, chiefly in combination
with stimulating antispasmodics, in order to en-
: sure their effect. Of the substances now enu-
merated, the most deserving of notice seem to be
the preparations of zinc, bismuth, musk, and the
misletoe. Of the former of these I have had
much experience; but, upon the whole, they are
inferior to camphor, valerian, ussafatida, am-
monia, and the etthers, judiciously combined and
assisted by other remedies, particularly when
taken upon the first intimation of the seizure. If
the disease be the result of exhaustion or inanition,
and particularly if if assume a periodic form, the
preparations of cinchona, the sulphate of qui-
nine, iron (Buechner, Reidlin, Loeffler,
Hutchinson, Elliotson, &c), especially the
sub-carbonate in large doses, or the ammonia-
tartrite, and the arsenical solution with potash,
are the most appropriate repiedies, either alone,
or with aperients, or antispasmodics, or anodvnes
and narcotics, according to the peculiarities of
the case. I have, for many years, employed the
infusion of green tea, if the convulsions arise not
from inflammatory action within the head, and
generally with great success. The good effects
of the medicines now mentioned, when they pro-
duce any, are to be imputed chiefly to their in-
fluence in overcoming the susceptibility of the
nervous system, giving tone and energv to the
moving fibres, and increasing the secreting and
excreting functions. In order to ensure their
effects, they should be varied and changed from
time to time, and differently combined with one
another.
62. e. There is scarcely any anodyne or nar-
cotic substance, that has not been employed
in convulsions. The preparations of opium', of
poppy, of belladonna (Stole, Bergius, &c),
of conium (Stoerck, &c), of hyoscyamus,
stramonium (Stoerck, Sidren, Wad en-
berg, &c), and tobacco (Riverius, Currie,
Thackeray, Havgarth, &c), have been
prescribed in various modes and states of com-
bination— with aperients, or stimulants, or tonics.
&c.' — internally and externally — in enemata, and
in suppositories. The most successful modes of
exhibiting either of these substances, in convul-
sions, are internally with camphor, assafoetida,
or the sub-carbonates of the alkalies ; and ex-
ternally, either in the form of liniment, embro-
cation, or plaster on the epigastrium, or along the
spine, combined with the substances just men-
tioned, or with any of the liniments or plasters in
the Pharmacopoeias, or in the .Appendix.
63. /. Various derivatives or revulsants have
been used in the intervals, as well as in the parox-
ysm. Blisters may be employed; but they are not
so generally appropriate jis the production of a
number of pustules by means of the tartar emetic
ointment or solution ( F. 74*1.), or of the croton oil,
rubbed upon the inside of the thighs, or on the epi-
CONVULSIONS — Treatment.
429
gastrium, or along the spine. Several writers have
directed blisters tu the bead ; but the pathological
states admitting of their application in iliis situa-
tion are comparatively rare, and require the most
intimate knowledge of disease, and appreciation
of symptoms for their recognition. It is only
when the vital energy of the brain is profoundly
sunk or exhausted, and not suppressed by con-
gestion, or active determination of blood, or the
pressure of effused Quids, or adventitious forma-
tions, that a blister on the scalp can be of any
service. When applied to the nape of the neck,
or behind the ears, or between the shoulders,
they are seldom of much use, unless kept open
for some time. The pea or nie/.ereon issue in the
insides of the thighs, and antispasmodic liniments
or plasters along the spine, or over the epigas-
trium, are sometimes useful auxiliaries.
64. g. Electricity and gulvunism have been
proposed in convulsions ; but I agree with Qra-
pengiesser in thinking them hazardous. A.<
Cold but/iing has been very commonly recom-
mended ; but it requires discrimination. It will
benefit chiefly those cases which are unconnected
with organic lesion, and which depend upon gen-
eral debility and susceptibility of the nervous sys-
tem. In these the salt water bath should be pre-
ferred, and its use commenced in the tepid state,
the temperature of successive baths being gradu-
ally reduced. The cold shower bulk is more gen-
erally applicable, particularly upon getting out of
bed ; and when it cannot be resorted to, the pa-
tient ought to sponge or bathe the whole head
with cold water every morning. The strictest
attention should, at the same time, be paid to the
state el' the digestive functions, and of the ahbie
evacuations. Cutaneous excretion also ought to
be promoted ; for, not only are all the other func-
tions thereby improved, but contingent disturb-
ance of any of them, and the irregular distribution
of blood, in which convulsions often originate, are
less likely to take place whilst the circulation in
the surfaces is uninterrupted. It is probably from
this mode of operation, as much as from their an-
tispasmodic action, that service has been obtained
from several diaphoretics, particularly the kermes
mineral, and other antimonials, recommended by
Unzer, Gulbrand, Strove, and Harder.
t. Warm butks, hip butks, semicupium, &.c,
when any advantage is derived from ihem in the
intervals, act chiefly in this manner. But I be-
lieve that they will seldom be productive of much
benefit, unless in cases connected with suppressed
eruptions, or the exanthemata, or with irregular
or di.Hcult menstruation, and with disorders of
the digestive canal in children ; and in these the
effects of warm baths will be much enhanced by
stimulating or irritating frictions of the surface im-
mediately upon coming out of them.
65. A\ The almost epidemic prevalence of con-
vulsions during states of religious enthusiasm and
mental excitement, as .-hewn by the occurrences
already referred to (§ 16 — IS.), and by the seiz-
ures that affected many of the Jansenists who
made pilgrimages to the grave of Deacon I'ari>,
daring the persecution of this sect in 1724, as
well as bj the convulsions at one tune so uncom-
monly frequent in the Methodist meetings in va-
rious parts of Cornwall, as described by Mr. Cor-
nish, should lead the physician to recommend
such moral regimen as the circumstances of par-
ticular cases may seem to require. The above
facts, as well as the circumstance recorded by
Boerh lave, of almost all the girls and boj - in
the hospital of Haerlem being seized by convul-
sions from their seeing a girl who had been
frightened into them, will alone show the in port-
ance of separating the affected from females or
other SUSCeptible persons. There can be no
doubt that simple hysterical or epileptic convul-
sions Occurring in one among a crowd of females
will often occasion convulsive seizures in others,
particularly iii those of a delicate frame and
nervous tempera at, although they may have
never previously been similarly disorded. I have
met with such an occurrence more than once.
indeed, the number of these attacks on the public
occasions referred to, is a sufficient proof both of
the influence of the mind in producing them, and
of the propriety of the immediate separation of a
person thus seized, as was judiciously and suc-
cessfully practised by Ur. Haygarth. The
propensity to become affected by convulsions
from seeing one in a fit appears to have been
well known to the Romans, and from its fre-
quency on occasions of public assembly, as much
as from other considerations, they obtained the
name of Morbus Comitialis, which has been un-
derstood as applying only to epilepsy, but which
I believe had a much wider signification, and
comprised all convulsive seizures. That fear or
terror will not only occasion convulsions, but also
remove them, or at least often prevent their
accession, might be inferred a priori, even if it
were not proved by experience. The actual cau-
tery employed by Bokrhaave soon put a stop
to them in the hospital at Haerlem : and their
prevalence in certain of the Zetland Isles was
said to have been arrested by the unceremonious
ducking inflicted upon two or three of those af-
fected ; the fear of being treated in the same way
having effectually prevented others from being
attacked.
66. /. Regimen. — The circumstance of those
convulsions which arise in crowded assemblies
from mental excitement and religious impressions
being often ushered in by faintings, and signs of
congestion of the cavities of the heart, of the
large vessels, of the lungs, &c, should suggest
the avoidance, by susceptible persons, of warm
and crowded assemblies, where the foul and
moist air conspires with moral emotions in de-
pressing the nervous power, and in favouring
congestions of the heart's cavities and large ves-
sels ; as well as the propriety of removal to the
open air, and of having recourse to antispasmodic
stimulants upon the approach of the sinking and
Oppression at the epigastrium and pracordia,
which often usher in the fit. The importance of
administering to the mental affections and emo-
tions— of relieving as much as possible anxiety or
despondency — ought to be pointed out to those
concerned, and the patient encouraged strenuous-
ly to resist the invasion of the paroxysm. Per-
sons subject to convulsions should never receive
indulgence on account of them, but lie made to
know that they ma) be warded oil', by not yield-
ing iii the fee ings which often favour or produce
them. Regular hours of rest, of recreation, and
of eating, should be adopted ; sedentary habits
430
CONVULSIONS OF CHILDREN — Treatment.
avoided ; exercise in the open air taken daily,
and both the mind and body duly occupied with-
out fatiguing either the one or the other. In
some cases, depending upon disease of the brain
or its membranes, the appetite is morbidly in-
creased, and much more food is taken than is
requisite to the wants of the frame. Others are
connected with indulgence in spirituous liquors.
It is almost unnecessary to add, that unless these
excesses be guarded against, and the diet and
regimen duly regulated, medical treatment will
not he efficacious.
67. ii. Treatment of Convulsions in In-
fants and Children. — A. Many of the meas-
ures already recommended in the paroxysm may
be also employed in this class of patients ; but in
a. suitable form, and with strict reference to exist-
ing pathological states. Where we observe the
indications of cerebral irritation and congestion
(§ 21, 24.), cupping on the nape of the neck, be-
hind the ears or occiput ; the warm bath or semi-
cupium, with cold affusion; cold epithems, Sic,
on the head, the hair having been removed or cut
close ; a dose of calomel, or of calomel and scam-
mony if the child can swallow, and a cathartic
and antispasmodic injection ; are suitable reme-
dies. The jugular vein may be opened in robust
or well-grown children ; but care should be taken
not to bleed them to syncope, as a return of the
convulsions ma); be thereby occasioned. Children
ought to be blooded with great caution during a
fit; for although I cannot go so far as to say, with
Harris, that it is dangerous to bleed in the
paroxysm, yet I believe that the convulsions will
occasion a hurtful quantity of blood to flow with-
out any immediate effect, if the evacuation be
pushed with the view either of subduing them, or
inducing syncope. It is. as improper as it is futile
to lay down any rules as to the extent to which
depletion may be carried. It is obvious, that
when the child is plethoric, the head large and
hot, the eyes suffused and prominent, the carotids
throbbing, &c, it may be practised freely, even
in the fit, without risk.
68* a. Convulsions sometimes proceed from the
nature of the ingesta. If this be the case, and if
the abdomen be distended, an emetic should be
exliibited without delay. Seizures not infrequent-
ly arise during the period of dentition, from in-
digestible or irritating substances in the prima
via, and in such cases often commence in simple
flatulent colic. After an emetic has been exhibit-
ed, or even independently of it, a purgative, if it
can be taken, should be prescribed, along with
carminatives or antispasmodics, and a clyster
thrown up. In cases of this description, I have
found a dose of calomel, with soda or potash, or
the hydrarg. cum creta, followed by either of the
following mixtures, a carminative enema, and
friction with an antispasmodic liniment on the ab-
domen or .spine, the most successful means : —
No. 158. R Magnes. Usts Sss. ; Sacchari Albi $j.; Olei
Anisi TT) t. ; tere bene simul, et adde Aqu* Funiculi Dul.
gjw. ; Spirit. Amnion. Foetid. TT) xv. ; Pnlv. Rhei xvj. ;
Syrup Fapaveris Jij. Fiat Mist., cuius capiat coch. uuimi,
ve] duo it.inima, tortus vel quartia hons.
No. 159. K Llk-i Hicini ", iij.— ~ss. •, Olei Terebinth.
5j. — o'i-i tere cum V'itel. Ovi, et adde Aq. Fceniculi ^s.
— 5J-; Sirup. Papaverii et Syrup. Rosa? aa " ij. M. Fiat
Mist., cujus sumai partem quartajn vel teiliam, tertiis \<-l
quartis hori*.
69. b. Clysters, containing valerian, assafcetida,
or a terebinthinate substance, triturated with the
yolk of egg, and any of the carminative waters,
to which oleum ricini or ol. oliva; may be some-
times added, are the most appropriate to those
cases. Much discrimination is required as to the
choice and continuance of cold applications to the
head, particularly if the warm bath or semicupium
be simultaneously resorted to. These combined
means should never be left to the discretion of a
nurse, at least without the personal superintend-
ence of the practitioner in the first instance. In
general, as soon as the temperature is reduced,
and the features become pale and shrunk, or the
fontanelle (if unclosed) level, or at all depressed,
whether the convulsions, or sopor, when present,
disappear or not, the application of cold to the
head, in any form, should be left off, to be again
resumed when the symptoms requiring it recur.
70. c. During dentition, or even before the
teeth approach the margin of the gums, free
scarifications ought to be practised, and repeated
as soon as the seaiified p;uts cicatrise, otherwise
the obstacle to the passage of the teeth will be
thereby increased. If general or cerebral ple-
thora be not present, or has been removed, and
the bowels have been fully evacuated, any of
the alkaline or earthy sub-carbonates, with aqua
fceniculi, or aq. pimenta?, aether, camphor, vxc,
with the extract of conium or hyoscyamus, or the
syrup of poppies, or small doses of laudanum,
may be prescribed with the view of soothing the
susceptibility and irritability of the frame at this
period. Form. 347. 442. 865. have been order-
ed by me very generally in such cases, at the
Infirmary for Children. In very young infants,
convulsions may be occasioned solely by the re-
tention and accumulation of acid and acrid sordes
in the prima via. These are readily removed
by a dose of calomel, followed by oleaginous or
other purgatives, the semicupium, and clysters.
Tissot and Sharp state that they have been pro-
duced by the retention of the menconium owing
to spasmodic stricture of the sphincter ani. This
is, however, a rare occurrence. Emollients, olea-
ginous laxatives, the semicupium, clysters, and
anodyne liniments, are appropriate to such cases.
It has been repeatedly contended for by most
of the older, although denied by many modern
writers, that the anxieties, the more violent pas-
sions, and the irregularities of the nurse, may
change her milk so as to disorder the digestive
organs, and thereby give rise to convulsions in
delicate infants. This fact is established by re-
peated observation. I perfectly agree with Mr.
North, who has taken a very judicious view of
this subject, that it should never be overlooked.
The obvious remedy in such cases is to change
the nurse ; and, if this cannot be done, to re-
move as far as may be the cause of disorder ;
to promote her digestive and excreting functions ;
to tranquillise or subdue any mental disturbance
or febrile action that may affect the state of the
milk, and to prescribe for the infant aperients
with soda or ammonia, or other antacids and anti-
spasmodics. I have often employed the oxyde of
zinc or of bismuth with soda, or the pul\is creta?
compos., and either the pul\ is ipecacuanha' comp.,
or small doses of conium or hyoscyamus, with
much advantage in these cases: or simply thesub-
borate of soda in camptior mixture or aq. fauiiculi.
CONVULSIONS OF CHILDREN— Treatment.
431
71. </. The cold bath is a very doubtful re-
medy in the seizure: it is much less efficacious
than the cold allusion on the head ; and, when
the chili! retains its consciousness, it even some-
times aggravates the mischief. Of the recom-
mendation of Dr. Bronn, to employ gradually
increased pressure on the epigastrium during the
lit, 1 have had no experience : it, however, de-
serves a trial.
72. e. Of the use of blisters in convulsions, as
well as of alkaline rubefacients, as the liquor am-
monae, no favourable idea should be entertained,
as they require the utmost discrimination, and arc
far from being unattended by risk : for, although
they will often cut short the paroxysm, yet they
will also occasionally produce so violent irritation
and inflammation as to be rapidly followed by
sphacelation of the integuments. This is liable
to happen particularly in ill or insufficiently fed,
in delicate and irritable children ; in those of a
gros* or fit habit of body, who have been al-
lowed to feed upon the richer sorts of animal
food too exclusively ; in the state of vital ex-
haustion ohserved in the latter stages of disease,
as well as in the early periods, when the pulse is
very quick, irritable, or sharp, the skin dry and
burning, and the cerebral organs much excited
or oppressed; — under such circumstances, I have
usually directed a liniment composed of equal
quantities of the liniment, saponis et opii (Ed.
Phar.), and of the liniment, terebintbinae, or either
of F. 308. 311. to be rubbed on the epigastrium
and abdomen, or along the spine. Thunberg
advises the cajeput oil to be applied to the epi-
gastric region during the lit ; Hkrz directs the
animal oil of dippel to the same region, and
Abrahams on the oil of rue. Either of these
will frequently cut short the paroxysm, hut I can
assert, from a very extensive experience, that the
liniments I have recommended are the safest and
most efficacious.
73. /. When convulsions occur in the invasion
of any of the exanthcmatous fevers, or upon the
retrocession of the eruption, the treatment must
depend, in a great measure, on the habit and
strength of body, and the extent to which the
brain is affected. If cerebral congestion or irri-
tation, with general heat of surface, exist, local
depletions, tin- cold affusion on the head, whilst
the patient is plunged in a warm bath, to which
some vegetable or mineral alkali has been added,
cooling aperients, cathartic injections, the tartar-
emetic ointment and solution F. 749. rubbed on
the spine, and diaphoretics, are generally most
serviceable. After the bowels have been freelv
evacuated, the carbonate of soda and nitrate of
potash, given in mucilaginous vehicles; the spirit.
aetheris nitrici, with the liquor ammonias acetatis,
in camphor, jalap, &c. ; maj be prescribed. If
the skin be cool, and the puke weak, or if the fit
have occurred after the disappearance of the
eruption, salt and mustard may be put in the hath;
and if the countenance be pale and collapsed, and
the cerebral functions not materially disturbed,
warm and cordial diaphoretics, as the preparations
of ammonia, camphor, serpentaria, &c, exhibited
from time to time. Frictions of the surface, im-
mediately after the patient is taken out of the
bath, will generally promote it~ good effects.
74. g. If convulsions oeeur in the com-' of
hooping cough or croup, we may conclude that
congestion, or inflammatory irritation of the mem-
branes of the brain, has supervened, and should
direct local depletions, the cold allusion on the
head, seinicupiuin, and the sub-carbonates of the
fixed alkalies, with opium, hyoscyamus, or bella-
donna, in minute doses, unless the patient is al-
ready much reduced by repealed or large evacu-
ations, when we may infer that the Convulsive
seizures are connected with auainia, and should
prescribe the treatment already described in re-
lation to this state (§ 55.).
75. h. The convulsions which occur so fre-
quentlv as a consequence of chronic or severe
bowel complain/*, and of exhaustion from other
diseases, and which have been too frequently
imputed to dropsical ell'usion in the ventricles,
require cordial antispasmodics, tonics, and light
nutritious diet. Although sometimes attended hy
more or less ell'usion, arising from the physical
condition of the cranium and its contents, and
serving to prevent any vacuum from being occa-
sioned by the deficiency of blood in the cerebral
\e>-els, vet the convulsions should not be viewed
as proceeding from the effused fluid, but rather
from the irregular and imperfect supply of blood
to the cerebral structure.
76. i. The seizures that follow great losses of
blood in children are generally characterised by
too active determination of this fluid to the cere-
bral structure ; and require the head to be kept
cool and elevated, the bowels to be acted upon,
and restoratives, antispasmodics, cordials, and
tonics to be administered, with the extract of
poppies, conium, or hyoscyamus, according to
the peculiarities of the case.
77. k. If convulsions follow the disappearance
or repulsion of chronic eruptions, we should
dread the existence of inflammatory irritation of
the membranes of the brain or medulla oblongata
or spinalis, with a tendency to serous effusion.
I. oral depletions, the warm bath ; frictions of
the surface, particularly of the part whence the
eruption had disappeared, with irritating lini-
ments ; the use of sinapisms, and deobstruent
purgatives, as calomel, &c. ; are chiefly to be
confided in.
78. /. When the seizures have recurred several
times, particularly in infants, and are attended
by dilated pupil, squinting, slow pulse, &c, their
connection with hydrocephalus may be inferred.
In such cases, even local depletions should be
employed with caution : hut in many instances
they may still be resorted to, in small quantity ;
and followed by alterative doses of calomel, or
hvd. cum creta, diuretics, small doses of digitalis
with spirit, aether, nit., and the use of the liniment
(j\ 311.) lo the head and loins both in the fit
and in the interval.
79. H. The preventive treatment, a. In ple-
thoric, fat, and gross-K\ ing children, should chiefly
consist of a proper regulation of diet, as advised
In lii umii:s. Farinaceous food ought to be
adopted, with only an occasional indulgence of
the less stimulating meats. No rational plan of
treatment, however, can be attempted with the
view of prevention, without strict reference to
the re te and proximate causes of the affection;
the former of which should be carefully avoided,
mid the hitter removed by suitable treatment.
When we detect cerebral irritation, or determin-
ation of blood to the brain, or active congestion,
432
CONVULSIONS, PUERPERAL — Treatment.
cupping, as already directed; the daily affusion
of cold water on, and a constantly cool state of,
the head ; a moderate, but continued, action on
all the secreting and excreting organs ; tranquil-
lity, and the abstraction of all excitement of the
iniiid and senses ; a bland and low diet ; the use
of revulsants, and warm clothing on the lower
extremities; are the most appropriate remedies.
50. 6. In very delicate children, where no
evident inflammatory irritation within the head
exists, a tonic treatment is obviously requisite.
The sub-carbonate or ammonia-tai trite of iron
may be given, either alone, or with other anti-
spasmodics, or any of the other preparations of
this metal. The sulphate of quinine, or the pre-
parations of cinchona, with liq. ammonire acetatis,
and a little of any of the compound spirits of
ammonia ; suitable diet, attention to the state of
the bowels, and change of air, will also be of
service. Calomel, in frequently repeated doses,
either alone, or with purgatives or anodynes, has
been most injuriously resorted to by practitioners,
upon the mistaken notion that convulsions are
always connected with irritation within the cra-
nium, and that this medicine alone can remove
this state; whereas, if calomel be prescribed in
small and frequently repeated doses, it will actu-
ally increase the susceptibility and irritability of
the body generally. When, however, it is given
in full doses at distant intervals, or only occasion-
ally, and either combined with jalap or some
more active purgative, or followed by cathartics
and enemata, it is a valuable remedy. Where
the bowels are thus judiciously acted upon from
time to time, and particularly if this be accom-
plished by a terebinthinated draught, tonics, com-
bined with antispasmodics and anodynes, will be
of the greatest benefit, especially if there be no
disorder of the cerebral functions to forbid their
exhibition. The sulphate or oxide of zinc, or the
sulphate of quinine, or the oil or other prepara-
tions of valerian, or assafcetida, musk, &.c, with
either conium, hyoscyamus, or the extract of
poppy ; the tonic decoctions and infusions, with
the alkalies; and various other remedies already
recommended in the intervals (§ 61. 75.), may
be severally employed, according to circumstan-
ces, after purgatives have been duly prescribed,
and the stools have become natural.
51. c. When we have reason to infer that the
convulsions proceed from intestinal icorms, calo-
mel with camphor, and the other cathartics noticed
above ; the occasional exhibition of an active
terebinthinate draught, followed by enemata,
containing aloes, assafcetida, camphor, &c, and
subsequently, by the preparations of iron, as well
as any other of the remedies and modes of com-
bining them described in the article Worms,
may be directed. It is generally remarked by
the German writers, that worms never form in
the alimentary canal previously to weaning, if
the milk be healthy; and the observation is~con-
firmed by my experience. It is, therefore, after
this period that convulsions can be referred to
this cause.
82. (1. The marked hereditary and constitu-
tional 1 en dency to convulsions in the same family
of children, and the very frequent connection
of this affection with cerebral irritation, or with
dropsical effusion in the ventricles, or between
the membranes, in such cases, have presented
ditiiculties to every practitioner. I believe that
the disease, when occurring in this manner, has
been too frequently ascribed to inflammatory ac-
tion, and a too lowering treatment adopted. Mr.
Hill recommends the arsenical solution, with
musk, in these cases; and I doubt not their utility,
if carefully employed ; but other tonics and anti-
spasmodics, particularly the weaker preparations
of bark, or calumba, with the liquor potassa?, and
small doses of conium, or syrup, papav., or opium,
if the child be not too young, and if the watchful-
ness or erithism of the brain be present, will be
found still more serviceable, especially if the head
be kept cool, the secretions and excretions care-
fully promoted, and the kidneys occasionally ex-
cited by the addition of diuretics to the tonics,
as the spir. a?ther. nit., digitalis, syrup, scillae,
&c, or by the application of a suitable liniment
(F. 311.) to the loins. In several cases of this
description, I have directed, after other means
had failed, and while tonics, as now7 prescribed,
were given, the hair to be cut off, and the lini-
ment to be rubbed upon the head immediately
after the cold affusion. In cases connected \\ ith
inflammatory irritation of the membranes, local
depletions, the cold affusion, &c. (§ 67.) should
precede the above treatment.
83. e. The diet and regimen of children that
have once experienced a seizure of convulsions,
ought to be carefully attended to. The stomach
ought never to be overloaded, either by the
mother's milk or by its ordinary food, which
should be always recently prepared, and easy
of digestion. As cr> ing often brings back the
seizures in infants and young children, it should
be prevented as much as possible. When the
-bowels have been sufficiently evacuated by the
medicines suggested, from one to three grains of
the hydrargyrum cum creta, either alone, or
with the sub-carbonates of the fixed alkalies, may
be given at first every night and morning, and
afterwards every night, or every other or third
night. The head should be always elevated ;
and whilst in bed or indoors it ought to have no
other covering upon it than that with which Na-
ture has provided it. On no occasion should the
warm fur or beaver hats, which are very im-
properly worn by children, be used ; nor ousht
the mental powers to be prematurely or inordi-
nately excited. In a word, the head should be kept
always cool, the mind tranquil, the lower limbs
warm, and the bowels open. A free, temperate,
and healthy atmosphere, with occasional change
of air, is also as necessary as medical treatment.
84. iii. Treatment of puerperal Con-
vulsions.— The more frequent occurrence of
convulsions in a first pregnancy, during a protract-
ed labour, in those who have experienced them
previously; the period of the puerperal state, and
the progress of the labour and state of the os uteri
when they do occur; the characters thev assume
— whether those of eclampsia, ofepilepsv, of hys-
teria, or of simple clonic convulsion ; the causes
which induce them, the circumstances connected
with I hem. and the fact that they, more than any
of the other forms of convulsion, are the result e'f
active determination of the blood to the head —
which, however, is merely the effect of irritation
primarily seated in the abdominal viscera ; are
CONVULSIONS, PUERPERAL — Treatment.
433
all to be taken into consideration in the treatment
of them. The intentions of cure are the same in
tlii-; as in the foregoing stales of convulsion; and
they should be promptly fulfilled.
85. A. In order to cut short the seizure, — a.
After having resorted to suitable means to protect
the tongue, as the introduction of a cork between
the teeth, &C., blood-letting from the arm, but
preferably from the jugular vein, when it can he
easily performed, should be employed, and car-
tied at once to a decided extent relatively to the
vigour and habit of body of the patient; and it
should be repealed after a short interval, if the
convulsions recur, and there be no circumstances
to forbid it. Simultaneously with the flow of
blood, or immediately after it, the allusion of cold
water or the application of a bladder of pounded
ice on the head, and the exhibition of ten grains
of calomel, and from five to ten grains of camphor ,
previously reduced to a powder by a few drops of
spirit, with or without an equal quantity of musk,
and shortly afterwards of two or three drops of
croton oil, should never be omitted. These me-
dicines may readily be administered, by mixing
them in sweet butter, and introducing a portion
from time to time over the root of the tongue,
upon the end of an ivory letter folder, or upon the
handle of a spoon. A cathartic and antispasmod-
ic enema (!•'. 141. 149.) should also be thrown up
without delay; and immediately repeated, if it be
returned. The combined effects of these will
seldom fail of producing a solution of the parox-
ysm. My experience of the excellent effects of
camphor is fully confirmed by Dr. Hamilton,
although Chaussibr expresses an unfavourable
opinion of it, and of all heating antispasmodics;
and the recently published observations of Mr.
Mich ell are strongly in favour of musk, which
he gives in doses of from one to two scruples.
Depletion may be carried further in those states
of the disease which assume the characters of
eclampsia, or which are attended by great fulness
about the head, or stertorous breathing, than in
almost any other malady. Chaussier advises,
after general depletion has been practised, local
bleeding from the nape of the neck and occiput,
or from the epigastric region.
86. (?. As to the propriety of prescribing opium
in puerperal convulsions, very opposite opinions
have been given. Petit, Hamilton, Merri-
man", and Dewees consider it most injurious;
Manning and Bland recommend it; and
Leakk and Burns, with a judicious discrimina-
tion, state, that when the disease is not accompa-
nied with fulness of the vessels of the bead, it may
be exhibited with advantage after blood-letting.
In this decision I concur, and add, that it should
always be given either with camphor, as directed
by Stoerck, or with the sub-carbonates of the
alkalies, as advised by Stutz and Bruning-
hausen, or with both; more particularly when
the convulsions occur from excessive irritability, or
previously to the period of lull gestation, or after
delivery, or when they assume chiefly the char->
acterB of hysteria. Rincb applies it to the abdo-
men, and ilrnt. wr to the soles of the feet.
87. y. Some difference of opinion exists as to
the propriety of exhibiting emetics in this disease.
I)> \ m vn is in favour of them, but Mai R.U EAI .
Chaussier, and Hamilton condemn them,
unless after blood-letting, and when the seizure
37
lias been excited by improper ingesta, — the only
circumstances under which, in my opinion, they
should be given, and in which Dr. BluNDELL
also recommends them. Of the good effects of
active cathartics there cannot be the least doubt.
I have always observed, as Dr. MERRIMAN has
stated, that the stools procured by them are mor-
bid and offensive.
"8S. 8. The next practical point of importance
is, whether or not the patient should be immedi-
ately delivered; and on ibis the sentiments of the
most eminent accoucheurs are at apparent, rather
than actual variance. No person will deny that
the state of the uterus is connected with the cause
of the seizure; therefore it would obviously seem
requisite to remove that state. But the objectors
reply, that convulsions also occur after delivery,
when this state of uterus no longer exists: I have,
however, never met with any, of several cases
of convulsions after delivery for which 1 have
prescribed, that did not arise from analogous
causes of irritation, viz. an over-distended urinary
bladder, the retention of the placenta or of coag-
ula in the uterus, or the accumulation of fa>cal
or irritating matters in the bowels. I therefore
would adhere to the opinion I have often given,
namely, if the above means have failed, and if
the labour be so far advanced as to enable the
accoucheur to deliver immediately without force
or injurious interference, then let it be done. If
the labour be not so far advanced, but yet the os
uteri is considerably dilated, then the membranes
may be ruptured, particularly if they be very
tumid, — if, indeed, they have not been already
ruptured, which is often the case, — and either
full doses of the sub-borate of soda (T) j. to 3 ss.)
given, or the ergot of rye. If the os uteri be
rigid or undilated, the former of these will be
preferable. If, however, the labour has not pro-
ceeded far, then any interference, excepting by
the exhibition of medicinal substances, may be
more injurious than beneficial. La Motte, Os-
borne, Leake, Hamilton, Dubois, Ash-
well, Nauche, Miguel, Burns, Osian-
ders father and son, Dugf.s, and Ramsboth-
am, are favourable to as early delivery as possible
without violence; whilst Bland, Garthshore,
Baudelocque, Hull, Gardikn, Denman,
and Blundell, are against forcible dilatation
of the os uteri, and attempts at delivery in the
early stage of labour. After all, the difference is
more in words than in intention; for the general
object is to hasten delivery, without injurious in-
terference, if the labour be so far advanced as to
render the attempt prudent; and those who have
espoused either side have stated their opinions
wiib such exceptions and limitations, and with
so little precision, as to leave the subject nearly
where the) found it, and to render it no easy
mailer to ascertain under what circumstances
they would either have recourse to art. or trust
In inline. When the' treatment already recnm-
tnended fails, or is followed by an exasperation
of the convulsions, — which will, very seldom
occur if it have been judiciously directed, — then
I conceive that the active interference of art
Should be called to our aid. There is, perhaps,
mi subject on which Opinion! are staled to hi
much at variance as on this, — each succeeding
writer placing those of bis predecessors in oppo-
sition* even where no real difference exists, and
434
CONVULSIONS, PUERPERAL -Treitmz ht
thereby bewildering the inexperienced, in order
that he may have the credit of giving a decision
respecting it.
89. t. Chaussier recommends, in rigidity of
the uterine orifice, the application of a pomade
containing belladonna, with the view of relaxing
the spastic contraction, which, he states, is not
limited to this part, but extends to the whole of the
organ. I believe, however, that the body of the
womb is generally free from spasmodic contrac-
tion. This preparation consists of two drachms
of the extract of this narcotic, softened with an
equal quantity of water, and triturated with about
an ounce of prepared lard. A piece, the size of
a small nut, is to be introduced into a female sy-
ringe, open at the extremity, and conveyed to the
os uteri, where it is to be applied by pushing on-
wards the piston. In about half an hour the
rigidity subsides, and the labour proceeds. Of
this practice I have no experience.' M. Chaus-
sier discourages any other attempt at dilatation
of the os uteri, as irritating the parts, and induc-
ing a recurrence of the convulsions.
90. l. I have never omitted, in any case treat-
ed by me since 1819, to employ the affusion of a
stream of cold water on the head, and the injec-
tion of turpentine clysters, sometimes with cam-
phor, assafcetida, or valerian, and the results have
been most satisfactory, — a much less quantity of
blood having been detracted than is usually re-
quired in such cases. I am not aware that either
of these two remedies had ever been employed
in puerperal convulsions, until long after I had
given publicity to the practice, — a practice which
I know to have been recommended very recently
by those, who, at that time, ridiculed it. In the
more rare states of the disease, which are attend-
ed by a weak quick pulse, pale features, and hy-
sterical symptoms, enemata containing valerian,
assafaetida, or camphor, are very serviceable. In
those which assume the comatose or apoplectic
characters, blisters applied to the nape of the
neck, and sinapisms to the ankles and calves of
the legs, are useful adjuvants of the measures al-
ready recommended.
91. r\. hi all cases occurring previously to,
during or after parturition, the state of the blad-
der, and of the bowels, ought to be carefully en-
quired into. Early in 1823, 1 was called to the
Queen's Lying-in Hospital, by the house pupil,
to a patient who had been seized with puerperal
fever on the second day after delivery, but was
convalescent from it, when she was attacked by
convulsions, brought on by a distended urinary
bladder. I found that the urine had been drawn
off, and that she had been blooded once largely.
The case was one of extreme severity and dan-
ger; the convulsions were unremitting, and at-
tended by profound coma and asphyxy^. The
vein was re-opened, and, while the blood flowed,
a stream of cold water was kept playing upon
the vertex, and, at the same time, a clyster with
turpentine and camphor was thrown up. Thus,
the three most powerful — the almost only, rem-
edies to be confided in, were simultaneously in
operation. The patient rapidly recovered. Pur-
gatives were given by the mouth, upon the solu-
tion of the convulsions; deglutition having been
entirely abolished during the whole seizure. This
was one of the earliest cases in which I had ven-
tured upon the simultaneous employment of these
powerful agents, the use of them in succession
having been generally adopted by me previously.
I allude more particularly to this case, because
of its uncommon severity; of its occurrence soon
after a most dangerous disease, as late as nine
days after delivery, in a public institution, and at
a time when my public recommendation of the
practice apparently received but little attention;
although it will not now be looked on with scep-
ticism.
92. ■&. Of other remedies but little may be
said, as they should be viewed as auxiliaries
merely. I have already expressed myself favour-
ably of camphor (§85.). Burns condemns it;
but, when exhibited after depletion, and at the
same time with the cold affusion on the head, and
cathartic and antispasmodic clysters, it is a valua-
ble medicine. Under the same circumstances,
musk, assafcetida, and the other antispasmodics,
will also be of use; for all risk of their injurious
action on the brain is prevented by the cold affu-
sion, whilst they co-operate with the terebinthin-
ate injections to excite the contractions of the
body of the uterus, and remove spastic constric-
tion of its neck. Of the ergot of rye, my expe-
rience is limited. I have given it only in one case
of this disease, and then it was combined with
borax, — a medicine undeservedly fallen into dis-
repute— but which I have prescribed for many
years. The labour in that case proceeded rapid-
ly, and the patient recovered. Much difference
of opinion exists as to the effects of, and propriety
of giving, the ergot in convulsions. If the os
uteri be dilated, and the external parts free from
rigidity, blood-letting, the cold affusion, and cath-
artic injections, having been actively but unsuc-
cessfully employed, there can be no doubt of the
propriety of exhibiting it. Opinions will always
be at variance as to the benefits derived from
substances recently introduced into practice ; for,
as all medicines are remedies only from their ap-
propriate use, experience of their operation is re-
quired to ascertain the circumstances in which
they are truly of service. In a case of puerperal
convulsions — I believe the first in which the er-
got was exhibited — Dr. Brixckle gave it after
the means usually adopted had failed. Twenty
minutes after the first dose had been taken, uterkie
action came on, and the patient recovered. It
is strongly recommended by Dr. Waterhocse,
of Massachusetts, and by Mr. Michell.
93. i. In cases of unyielding rigidity or callo-
sity of the os uteri. Van Swif.te.n advised an
incision to be made through its margin. Dubosc,
and, subsequently, Lauverjat, Bodix, and
Coutouly, who considered it perfectly justifia-
ble after blood-letting, the warm bath, and other
means usually employed, had failed, have had
recourse to this operation. "M, Coutouly has
recorded four cases (two of which are quoted by
31. Miguel), in which it was resorted to; three
of these recovered. The death of the fourth he
imputed to the circumstance of it having been too
long delayed. M. Nauche also favours this op-
eration in the above circumstances, especially if
emollient and narcotic injections into the vagina
have failed to relax the rigidity.
94. y.. The warm bath, and emollient fomen-
tations, followed by the use of an anodyne lini-
ment on the abdomen, have been recommended
by D e n m a x and Nauche; and the tepid bath by
CONVULSIONS, PUERPERAL — Treatment.
435
Capuron after bleeding has been practised.
Much advantage will accrue from assiduous fric-
tions of the abdomen, more particularly if they
be performed with an anodyne and antispasmodic
liniment (§ 53, 64.), independently of the use of
a warm or tepid bath ; for either of these can sel-
dom be used with advantage in the circumstances
of puerperal patients. In every case the hair
should be cut closely off. This may be done in a
very few minutes; but shaving the head is merely
a loss of time. Burns, Ryan, and Clarke ad-
vise the application of a blister on the head ; but
I believe that it will be required only in extreme
cases ; it certainly ought to be ventured upon only
in such, where the coma is profound, and the pulse
weak, and the patient sinking. The advantages
stated to have been derived by Dr. Clarke from
acrid carthartics, and clysters, are continued by
my own experience. If the convulsions occur im-
mediately after delivery, the placenta should be re-
moved, and the existence of internal haemorrhage
enquired after — if at a later period, the state of the
urinary bladder and bowels, as well as of the womb,
demands attention. In all such cases, active purg-
atives and cathartic clysters are especially required,
but the choice of them should be made with due
reference to the state of constitutional power, and
to the presence or absence of cerebral congestion,
or of exhaustion and nervous susceptibility.
95. ).. When the convulsions attack epileptic
females, they generally have all the characters of
epilepsy or eclampsia, generally with unremitting
sopor and stertorous breathing passing almost into
asphyxy ; and they require the treatment describ-
ed above. When they occur in hysterical females,
they may also assume the same forms, and de-
mand the same method of cure ; or they may
present the features of simple hysteria, particular-
ly borborygmi, quick pulse, &c, with very slight
cerebral affection. In these latter cases, the ner-
vine remedies mentioned in the next paragraph,
will be adopted with advantage, especially after
the cold affusion on the head. Cold enemata may
be also thrown up, as advised in Hysteria. In
the majority of these seizures, neither bleeding nor
artificial delivery is required, unless cerebral con-
gestion supervene, or the patient be strong or
plethoric.
96. i/. Convulsions in the puerperal states may
occur from great exhaustion, from want and inan-
ition, and losses of blood. In these, the practi-
tioner should trust chiefly to the cold affusion, per-
formed only momentarily ; to the keeping of the
head cool and elevated ; to sinapisms on the
lower extremities ; to the exhibition of camphor,
ammonia, the vegetable alkalies, and musk, with
small doses of opium, or of the aethers with hy-
oscyamus or conium ; to the administration of
valerian, assafcetida, or turpentine clysters; to the
warm bath ; to anodyne frictions of the abdo-
men ; and to as early delivery as may be safely
attempted ; the vital energies being supported by
gentle cordials during the remissions. If the
seizure lie complicated \v\lh hemorrhage from the
uterus, or hsmatemeeis, prompt artificial delivery,
the turpentine clyster in the first instance, and tur-
pentine draught in the second, are the most certain
means.
97. B. The prevention of puerperal convul-
sions is of great importance. The means calcu-
lated to attain this object can be put in practice
only when the premonitory symptoms (§28.)
manifest themselves. — a. If these indicate fulness
of the vessels of the head, bleeding from the arm,
or cupping on the nape of the neck, will be neces-
sary ; and in every instance the bowels are to be
freely evacuated. There are few cases of the
disease, at whatever period it may occur, entirely
unconnected with faecal accumulations ; and al-
though this state of the bowels may not excite the
attack, it certainly remarkably disposes to it. Ca-
thartics should therefore be given by the mouth,
and their action promoted by clysters. Dr. Blun-
dki.l advises an ipecacuanha emetic to be taken
in the first instance ; and, where there is a loaded
or disordered stomach, this practice may be adopt-
ed. In addition to these, the warm bath may be
used ; and if, notwithstanding, signs of active de-
termination continue, the cold affusion on the head,
or cold applications, should be also resorted to,
either previously, at the same time with, or subse-
quently to, the warm bath. Dr. Home and Dr.
Blundell favour the exhibition of digitalis in
such circumstances.
98. b. If the premonitory symptoms be char-
acterised by leipothymia or sinking, rapid weak
pulse, particularly of the carotids; coolness of head,
sunk features, &c, — the internal use of camphor,
or musk, ammonia, assafcetida, the aethers, the
warm bath, with small doses of opium, purga-
tives, sinapisms, blisters, and the turpentine fo-
mentation applied on the abdomen, are the most
approved means of prevention.
99. c. If the patient have had two or three at-
tacks at some former period, and if the above
preventive treatment have not rendered the acces-
sion of the disease less probable, Dr. Blundell
advises the membranes to be punctured.
100. C. During convalescence, the states of the
urinary bladder and of the bowels should be care-
fully watched, and evacuated; the diet regulated;
and both body and mind kept tranquil. If cere-
bral symptoms continue for some time afterwards,
the head should be preserved cool, and sponged
with cold water night and morning, and a blister
applied to the nape of the neck, and kept open
for some time, whilst a course of eccoprotic and de-
obstruent purgatives is continued for several days.
BinLioc. and Refer. — i. Convulsions in General.
Hippocrates, Aphor. sec. vi. §39. vol. i. p. 101. edit. Pander,
I/inden. — Galen, De Locis Afreet, l.iii. c. 6. — Oribasius, Sv-
Bop. 1. viii. c. 16. — Paulus jEgineta, 1. iii. c. 19. — Zaeutut
Cuiitanus, Prax. ili»t. 1. i. cap. 11., ]. v. cap. 2. — H'illis,
De Pathologist Cerebri, cap. i. 4. — Baillou, Op. omnia, vol.
iv. p. 134. — .linatus Lusitnnus, cent. vii. cur. 11. (Inani-
tion.)— Sonet, Sepulch. 1. i. sect. xiii. observ.26. Udorgagni,
De Sod. et Cam. Morb. ep. x. art. 21.— Hoffmann, De Con-
vulsiouibus, in Oper. vol. iii. p. 31., et Supp. vol. ii. p. 2. —
Collhatch, Stir le (iui de Chine, in Malad. Convuls. Pari*,
ni9.—Bayn«rd, fin Mot and Cold Baths, &C. Lond. 1722—
J. Jnnrker, De .Morb. Spasmodico-C<>nvulsivB. ice, Hale,
1739. — Monro, in Kdin. Essays and Obeerv. vol. iii. p. 551.
— .s hroeder, De Convulsion, en Haimorrhagia oimia oriun-
di-. Mark 1752.— Marx, De Molibui Cenvuhivis, ice. 4to.
II, I ., 1765.— Stoll, Hat. Med. par. iii. p. 412.— Stoerck, Do.
Stramonio, Hyojcyamo, be. Vien. 17t;2. ; et Ann. Med. vol.
i. p. 15. — li'idinberg, De Strainonii Usu in Morb. Convul.
l'|i . 1772. — Sidren, De Strainonii Usti in Malis Convuls.
Ups. 1773.; et in Act. Med. Suae. t. l-r-Whytt, Works, Ho.
p. 582. — Home, Clin. Exp. Hist, and Diss. Stc. 8vo. p. 153. —
/ hi Med. Observ. and Indniries, vol. i. ait. 11. — GuJ-
brand, in Act. Reg. Med. Ilann. ft. i. p. 2(3. -Hell, in Edin.
Med. Comment, vol. i. p. 120. — Gondsir. in lb. vol. i.p. 467.
—Warburg, Medic. Beobachtung. No. 10.— Clarke, in .Vied,
l-'artn mid Ob. civ. vol. viii. p. 275. — Pallas, Reisen dnrch
RunUnd, it. n. 387. — Unzer, in Hamb. Mag. ft. viii. n. 369.
— Bcrgius, Mat. Med. p. 121. — Arnot, Edin. Med. Essavs,
&c. vol. vi. p. 634. — J. Smith, Ed. Med. Comment, vol. iii.
p. 316.— P. Dagud, ia Ihid. vol. v. p. 84. —White, in Ibid.
436
COUGH— Causes of.
vol. Ti. p. 330. — Armstrong, in Ibid. vol. ix. p. 307. — Albers,
Edin. Annals of Med. vol. vii. p. 406. (From abscess of the
ear.); et Horn's Archiv. b. i. p. 329. — Conradi, in Hufe-
land's Journ. der Pract. Heilk. b. vii. st. 2. p. G.—Har-
gens, in Ibid. b. vii. st. 1. p. 114. — Doerner, in Ibid. b. xv.
st. 4. p. 94. — Henrisrhen, in Ibid. b. xv. st. 4. p. 79. — Mi-
chaelis, in Ibid. b. iii. p. 344. — Wiedemann, in Ibid. b. vi.
p. 418. — Struve, in Ibid. b. xxiii. st. 4. p. 8. — Schmalz, in
Ibid. b. xi. st. 4. p. 169. — Heilbronn, in Hufeland und Harlcs
N. Jour, der Ausl. Med. Chir. Lit. b. ii. st. 1. p. 187.— Prnv-
tl, in Trans, of College of Phvs. of Loud. vol. iv. art. 8. —
Latham, in Ibid. vol. vi. p. 248. — Cornish, in Loud. Med.
and rhvsical Journ. vol. xxxi. p. 373. — Loeffler, in Richtcr's
Chir. Biblioth. b. viii. p. 732. — Krebs, Medicin. Bcobachtun-
gen, b. ii. heft 2d. — Sumeire, in Journ. de Med. t. xxi. p.
224.— Dupont, in Ibid. t. xxxii. p. 130.— Parry, Mem. of
Med. Soc. of Lond. vol. iii. art. 8. (Compression of the ca-
rotids.)— Bianchi, in Brera's Comment. Medici, dec. i. t. ii.
art. 2. — Grapengiesser, Versuche, p. 98. — Plenk, in Ab-
handl. der Joseph-Acad. b. i. p. 318. (Ipecacuanha.) — Thun-
berg, De Oleo Cajeputi. Ups. 1797.— Her:, Briefe, st. 1. art.
l.—Jbrahamson, in Meckel's N. Archiv. b. l.st. 3. art. 21.
— Hufeland, Bemerkune. liber Blattern, &c. p. 349. — Frank-
furter, Med. Wochenbl. b. v. p. 229.— Savary, in Diet, des
Sciences Med. t. vi. par. ii. p. 197.— P. Jolly, in Diet, de
Med. et Chirurg. Prat. t. v. p. 473. — Naumann, in Enryclo-
pad. Wiirterbuch der Med. Wissensch. b. viii. p. 341. —
Thackeray, in Med. and Phvs. Journ. vol. x. p. 410., and
vol. xii. p. 508 — Barton, in Ibid. vol. viii. p. 428. ; Edin.
Med. and Sure. Jour. vol. iii. p. 441. — Clarke, in Ibid. vol.
v. p. 268. — Hill, in Ibid. vol. v. p. 318. — Thomson, in Ibid,
vol. xiv. p. 614. (Dissections in.) — Hat/garth, Of Imagin-
ation as a Cause or Cure of Disorders. Bath, 1800.— Portal,
Anatoniie Medicate, t. iv. p. 69. ct seq. (Results of dissec-
tions in.) — Dessesartz, in Journ. de Med. t. xlvii. p. 114. —
Kindt, in Stark's Archiv. b. v. p. 389. — Kortum, in Hnfe-
land's Journ. der Pract. Araieyk, b. iv. p. 381. — Cazals,
in Journ. Gener. de Med. Dec. 1810, p. 371. (Bismuth.) —
Schaefer, in Hufeland 's Journ. der Pract. Heilk. Feb. 1 810,
p. 105. — Gebel, in Ibid. b. xvii. st. 3. p. 103. (Musk in large
doses.)
ii. Convulsions of Children. — Han-is, Be Morbis
Infantum, p. 102. — Rosen, Traite de Malad. des Enfans, 8vo.
— Beaumcs, Traite des Convulsions dans 1'Enfance, 8vo. Pa-
ris, 1805. — Copuron. Des Maladies des Enfans, 8vo. Paris,
1813, p. 407.— Gardieu, Traite de Malad. des Enfans, t. iv.;
D'Accouchemens, 3d ed. p. 239. — J. Clarke, Commentaries
on the Diseases of Children, 8vo. p. 80. (Too exclusively re-
ferred to cerebral irritation.) — Jacques, in Journ. GeneY.
de Med. t. xxix. p. 280.— Bronn, in Ibid. t. xxxi. p. 457.—
Piorry, De 1' Irritation Enecphal. des Enfans. Paris, 1823. —
Under-.oood, On Diseases of Children, bv Merriman. Lond.
1827, p. 233.— Bracket, Sur les Convulsions des Enfans, 8vo.
Paris, 1824. (A good book, -with too partial a leaning to ce-
rebral irritation.) — J. North, Practical Observat. on the
Convulsions of Infants, 8vo Lond. 1826. (An able and ju-
dicious -.cork.)
iii. Puerperal Convulsions. — J. Leake, On the Acute
Diseases of Females, &c. 6th edit. p. 338. (Convul. from
hamorrh. and inanition well treated of.) — Manning, On
Female Diseases. Lond. 1775, p. 357. — Denman, Introd. to
Practice of Midwifery, 5th ed. p. 569. — Hamilton, Edin.
Ann. of Med. vol. v. p'. 318. — Coutouly, in Journ. Gcner. de
Med. t. xxxii. p. 157. — Frit:, De Convuls. Gravid, et Par-
turientium. Wirceb. 1810. — Mirhae/is, in Siebold's Lucina,
b. vi. p. 37. — Bruckmann. in Horn's Archiv. Jan. 1811, p.
10. — Gasc, Memoires sur divers Points d'Accouchemens. Pa-
ris, 1810. — Gardien, Traite Complet d'Accouchem. t. ii. p.
418. — Stutz, Michaelis, Wiedemann, and Brwninghausen,
in Hufeland's Journ. &.C b. x. No. 4. ; and in Lond. Med.
and Phvs. Journ. vol. v. p. 473. and 557. — J. F. Osiander,
Deutscne Zeitschrift f. Geburtskiinde, b. ii. st. 3. p. 538. — J.
L. Boer, Abh mil. und Versuche Geburtshuf. Inhalts, he.
he. 1791, b. iii. p. 192.— Hufeland, Journ. der Pract. Heilk.
Dec. 1816. — Wagner, De Eclampsia Exquisita in Partu.
Morb. 1817.— J. Clarke, in Trans, of Irsh College of Phvs.
t. i. p. 381.— Merriman, On Difficult Parturition with Re-
marks on the Managem. of Labours, 8vo. Lond. 1820, p.
135. — Dewees, in Amer. Med. Record. No. iii.; and in John
son's Med. Chjrurg. Rev .lune, 1E20, p. 128. Brinchie,
Philadelphia Med. Journ. vol. vi. p. 126. — Gonpil, in Journ.
des Progres des Srien. Med. t. iii. p. 161. — Duges, in Rev.
Med. t. i. 1826, p. 378. ; et Manuel Obsti t. Paris, 1830, p.
275.; et Diet, de Med. Prat. t. vi. p. 537.— Chaussier, Sur
les Convulsions qui altaq. les Femmes Enceintes. Paris,
1824. — Miguel, De Convulsions chez les Femmes Encein-
tes, en Travail, he. 8vo. Paris, 1824.— Blunde/l, Lectures,
in Lancet, vol. xiv. p. 484. et 513. — Burns, Principles of
Midwifery, 6lhed. p. 484.— Ryan, Manual of Midwifery 2d
ed. p. 285.— Michel!., On Difficult Parturition, and the" Use
of Ergot of Rye, he. 8vo. 1828.— Nauche, Des Maladies
prop, aux Femmes, he. 8vo. Paris, 1829, p. 449.
CORPULENCY. See Ob e s i t v.
COUGH.— Syn. 7:1,1. Gr. Tussis, Lat. Bex,
Good. Pneusis Tussis, Young. Der Husten,
Germ. Toux, Fr. Tossa, Ital.
Classif. — 2. Class, Diseases of the Respi-
ratory Function ; 2. Order, Affecting the
Lungs (Good). II. Class, III. Order
(Author.)
1. Defi.n. Violent and sonorous expulsion of
air from the lungs, preceded, rapidly followed
by, or alternating with, quick inspiration.
2. I. Pathology. — Dr. Cullen and several
other nosologists have considered cough as chiefly
a symptom, which undoubtedly it is most frequent-
ly; but I agree with Dr. Young and Dr. M. Good
in believing that it is entitled to be viewed, on some
occasions, as an idiopathic affection. Dr. Good,
however, has ranked it as a genus, and comprised
under it various affections, which are either mere-
ly slight forms of Bronchitis, or the results of
organic changes in the Lungs, and which I have
treated of in these articles, and in those on Bron-
chorrhcea, Catarrh, and Influenza. He
lias, moreover, subdivided it into more varieties
than can easily be recognised in practice, and
has viewed Hoopingcough as a species of
the genus, instead of a distinct disease.
3. Causes. — Cough, in either of the forms
about to be particularised, commonly attends dis-
orders of the air-passages, and of parts in their
vicinity, particularly of the larynx ; also those of
the lungs, and their membranous coverings; and
sometimes diseases of other organs by which the
respiratory functions are affected sympathetically
— or rather, from continuity of tissue or nervous
communication. It is thus occasioned by affec-
tions about the fauces, tonsils, pharynx, and neck;
by the irritation of dentition ; by diseases of the
oesophagus, particularly when inflammation and
ulceration of this part extends to, or penetrates,
the membranous part of the trachea (Kappel-
hout, Mr. Byam, and myself); diseases of the
spine and its contents (Wichmann); by creta-
ceous or calcareous formations in the ramifications
of the bronchi (Morgagni, Bonet, Baillie,
Portal, and myself in several cases, two of
which occurred in gouty subjects); by all organic
changes of the thoracic viscera ; by the acciden-
tal passage of foreign substances, solid or fluid,
into the air-passages ; by the lodgment of the
eggs or larva; of insects in the same situation
(Vogf.l andPERCiVAL, &c); by the irritability
of parts attendant upon the nervous temperament
and debility ; by the influence of irritation and
imagination, — a cause which did not escape the
observation of the acute Montaigne; irregular
or misplaced gout; the irritability of the parts con-
tinuing some time after measles, or inflamma-
tions of the air-passages or lungs; disorders of the
digestive organs, particularly the stomach and liv-
er, &c.(Wixther, Stfin, Pkrcival, &.C.); by
accumulations of bile in its receptacle; by the irri-
tation of worms ; by the repulsion of cutaneous
eruptions, and the healing of old sores, and sup-
pression of chronic or accustomed discharges.
From this enumeration it is evident that cough is
chiefly a symptom of numerous pathological states,
which will be found very fully described under
different beads, as indicated above. The epidemic
cough noticed by some writers falls under the
article Influenza. In the act of coughing, the
COUGH — Causes — Treatment.
437
lungs are passive; and in the idiopathic states of
the disorder they are not organically affected; the
disorder being chiefly seated in the trachea, larynx,
and vicinity. In very many cases, the irritation
Occasioning the cough exists chiefly in the poste-
rior/imox and pharynx, and extends no further
than the epiglottis and rima glottidis.
4. i. A. Dry Cough occasionally occurs in an
idiopathic form, — a. From exposure to cold in
any form; the attendant symptoms not amounting
to complete Catarrh; and it may, or may not, in
a very short time terminate with slight mucous ex-
pectoration. When, however, it arises from this
cause, it usually runs the course described in that
article. 6. It is occasionally produced by acrid
or acid fumes and gases, or by various foreign sub-
stances inhaled, or accidentally passed, into the
trachea, and from several of the other causes
enumerated above (§ 3.). c. It also, in some
cases, — first noticed by Montaigne, and well de-
scribed by Whytt, — presents a strictly nervous
character, particularly in nervous, hysterical, and
irritable persons, d. In those especially, and
also in feeble or delicate constitutions, a short,
frequent, and dry cough is sometimes met with,
without any disease of the lungs, air-passages, or
other organs; and the only change that can be
detected is slight redness at the margin of the soft
palate, or in the posterior fauces; sometimes only
in the pharynx ; and occasionally near the ton-
sils; but this is not uniformly, although frequent-
ly, observed. I Iere it is obvious that the irritation
of these parts extends to the glottis, or to the epi-
glottis only; and that it is either strictly local, or
connected with slight derangement of the stomach
and prima via. In the former case it is idiopathic,
in the latter symptomatic, or at leasta complicated
ailment.
5. B. Dry cough is more frequently symptom-
atic— a. Of the first stage of diseases of the
larynx, trachea, and lungs; of organic changes
of the large blood-vessels of the chest ; and
sometimes of complaints of the more superior
of the abdominal viscera, b. It is frequently oc-
casioned by elongation of the uvula, and the ir-
ritation this part produces about the root of the
tongue and epiglottis. But when the uvula is
elongated, there usually is also more or less co-
existing irritation about the posterior fauces and
pharynx, extending to the glottis or epiglottis.
And it should be, moreover, kept in view, that
these ailments are principally dependent upon,
even although they may not be always produced
by, disorder of the stomach and digestive organs
generally, c. In many instances, also, it will
be found that the cough is owing to irritation of
the mucous surface of the stomach and oesophagus,
although it may not extend so far as to be ap-
parent in the pharynx, or be so severe as to occa-
sion redness of this part. d. Cough is often pro-
duced by diseases of the liver, and by collections
of bile in the gall-bladder and hepatic ducts. In
many of such cases, the cough is severe and
spasmodic, often very obstinate and of long du-
ration; the symptoms of hepatic disorder being
sometimes bo slight as to escape detection, unless
the attention of th'' practitioner is awakened to
the connection; the chief indications of its exist-
ence being the loaded or furred tongue, pains
about the diaphragm, fulness ;it the epigastrium,
and indigestion, e. Lastly, dry cough is often
37*
occasioned, in young and delicate patients, by the
irritation of worms in the prima via. The more
particular consideration of these associations will
be found in the articles on the diseases of which
the cough is merely a symptom.
6. ii. Humid Cough, — a. may follow upon
the preceding; or it may occur primarily from
the usual causes of catarrh. In such cases, it i3
merely a slight form of that affection, the matter
expectorated being mucous or serous, and the
cough unattended by manifest febrile or con-
stitutional disturbance. This form of cough is
very liable to recur, or become chronic, in deli-
cate persons, during the winter (ivinter-cough;)
or from vicissitudes of season and weather; and,
like the former variety, the irritation exciting it
may be chiefly seated in the pharynx and vicinity,
or in the larynx and trachea. • In many cases the
serous, or sero-niucous secretion, following the
cough, entirely proceeds from the fauces and
vicinity, b. In old persons, however, it is se-
creted chiefly by the bronchial surface, and is
then, particularly in its more severe forms, the
affection described under the name of Bronchor-
rha'a. c. Humid cough is generally less frequent,
but more prolonged, and recurs in severe pa-
roxysms. It is sometimes complicated with rheu-
matism and gout. It also presents the same
pathological relations as described in connection
with the dry variety; but it is not so often symp-
tomatic of diseases of the abdominal viscera, as
the foregoing, d. In the old and weak, humid
cough is usually very severe, owing chiefly to the
want of vital power of the respiratory organs, and
of the system generally, to throw off" the mucus
secreted in the air-passages; and which is either
very abundant, from the relaxation of the ex-
treme vessels; or very tenacious, from absorption
of its more fluid parts during its retention on the
surface that secreted it, or from both conjoined.
In such cases, the paroxysms of coughing are very
severe and prolonged; and the affection is liable
to be exasperated upon every change of season
and weather, e. In other cases of humid cough,
the exacerbations are also very severe, particularly
in the morning; but the excretion is thin and frothy.
This is observed most frequently in persons ad-
dicted to intoxicating beverages; and in those de-
bilitated by sexual indulgences. Wlicn humid
cough depends upon hepatic disease, it often as-
snmes this form.
7. II. Treatment. — i. A. The idiopathic
states of dry cough require demulcents, emollients.
with diaphoretics and narcotics or anodynes (see
1'. 238. 244 389. 426., and R 98. and 99. at p.
297.). The coniuro, hyoscyamus, solanum, cenaa-
the, and phellandrium aquattcum (Thbussink
and Fb ibk,) maj severally be employed, and the
functions of the abdominal viscera improved by
suitable means. But the pathological sti.i
well as their causes, on which this form of cough
depends, should be investigated, and the treat-
ment modified accordingly, a. If it follow the
impression of cold in any form, the treatment
described in the article Catarrh (" L5.) will
be appropriate. //. If it be produced by the in-
balation of irritating fumes, or the molecules of
either mineral, vegetable, or animal matters float-
ing in the air, the removal of the cause, and the
nse of demulcents, emollients, and emetics, and
subsequently narcotics, tire most to be depended
438
COUGH — Treatment of.
upon. c. When it assumes a nervous character,
particularly in hysterical and delicate females, the
state of the uterine functions, and the existence of
irritation in some part of the digestive tube, or in
the sexual organs, or spinal cord, should be en-
quired after, and the treatment directed according
to the information acquired. In many such cases,
the exhibition of a gentle purgative, and after-
wards small doses of camphor, ipecacuanha, am-
monia, oxydes of zinc and bismuth, hyoscyamus,
extract of hop or poppy, the sub-carbonate of
soda, &c. variously combined, will be of service.
If there be evident debility, and the cough as-
sumes a periodic form, the preparations of bark
or of iron, the sulphate of quinine, or gentle ton-
ics, with anodynes and narcotics, will be required.
The cold bath, which has been much recom-
mended by Whytt, will also prove beneficial.
d, When it proceeds from irritation of the fauces
or pharynx, demulcents, emollients, &c. with
ipecacuanha, or with diaphoretics and anodynes,
will be required. But the greatest advantage will
be derived from the use of cooling and astringent
gargles, and stomachic purgatives (F. 266.).
8. B. The symptomatic occurrence of cough
must be treated as pointed out in the articles on
the primary affections occasioning it. — a. If it be
referred to the respiratory organs, the means ap-
propriate to their diseases must not be departed
from. b. When we observe elongation of the
uvula, either with or without signs of irritation of
the pharynx, disorder of the digestive functions
may be inferred; and, after having had recourse
to purgatives, cooling and astringent gargles,
prussic acid, and mild stomachics will be useful.
c. The dependence of cough upon diseases of the
biliary organs, whilst it suggests a treatment
chiefly directed to these diseases, will also indicate
the propriety of ascertaining, with as much pre-
cision as possible, their nature. If indications
of accumulated bile in the gall-bladder and he-
patic ducts are detected, calomel or blue pill,
with, or followed by, purgatives, and a course of
alteratives, taraxacum, &c. will be requisite. In
some cases, a gentle dose of either of these cholo-
gogues will produce copious discharges of morbid
bile, and the immediate disappearance of a con-
stant, severe, dry, and harsh cough, of which
alone the patient has complained. In others,
repeated and large doses will be required to ac-
complish this object. In all these, purgatives
should be exhibited until the tongue becomes
clean. If tenderness or pain exist in the region
of the liver, with febrile symptoms towards even-
ing, or restlessness through the night, blood-let-
ting, general or local, ought to precede other
measures ; and the hepatic disease should be
treated with reference to the form it presents,
and as described in the article on Diseases of the
Liver, d. When the cough is attended by a
tumid abdomen, and other signs of worms, the
treatment recommended in such cases, according
to their numerous modifications, must be em-
ployed.
9. In almost all the idiopathic and symptomatic
forms of dry cough, more advantage will be ob-
tained from demulcents, than from heating or
stimulating expectorants, which should always
be laid aside when there is evident vascular ex-
citement of a sthenic or tonic kind. Those ex-
pectorants, however, which are of a mild nature,
or which act chiefly by exciting slight nausea, will
generally be of service, particularly when com-
bined with emollients, diaphoretics, and narcotics;
and there are few conditions, in which the pre-
parations of antimony or ipecacuanha, with liquor
ammonias acetatis, and the warm bath, will not
be extremely beneficial. In this variety of cough,
also, appropriate medicines, exhibited in such a
manner as will favour a prolonged impression on
the palate and pharynx — as in the form of lozenge
or linctus — will thereby have their effects mani-
festly promoted; and advantage will also accrue
from wearing warm, antispasmodic, or rubefacient
plasters between the shoulders, both in this and
the humid variety of the affection.
No. 160. R Confect. Ros. Canin. et Confect. Ros. Gal.
aa ^ j. ; Olei Auivsrdal. Dulc. ~, vj. ; Svtud. Papaveris
Albi ^ss. ; Spirit. /Ether. Nit. ^ ij. ; Acidi Sulphur, dil.
" jss. ; Pulv.Ipecacuanha5gr.ij. j\I. Fiat Lindas, de quo
sumatur pauxillum subind -.
No. 161. K Kmplast. Picis Comp. part. ij. ; Emplast.
Ammoniaci (vel Emp. Amnion, rum Ilydrare.) et Emplast.
Opii aa part. i. M. Eiat Emplastruui perlarguui inter
scapulas impnsiturum.
10. ii. Humid cough, when it presents the cha-
racters of slight catarrh, requires the treatment
described in that article, a. If it frequently
recur, or become chronic, or assume the form of
winter cough, the more tonic demulcents, as the
decoction of Iceland moss, or of the sea moss,
with lemon and candy, — the mistura ferri compos,
with a decoction of liquorice root,; — attention to
the digestive and excreting' functions, — warm
clothing, — and careful avoidance of exposures to
the vicissitudes of season or weather, — are most
to be depended upon. b. When the cough
occurs in old persons, with increased secretion
obviously from the bronchi, gentle tonics, and ex-
pectorants, as myrrh, galbanum, assafcctida, ben-
zoin, the oxide or sulphate of zinc, the terrebm-
thinates, camphor, ammonia, the balsams, and,
indeed, the whole of the treatment described in
the articles on Chronic Bronchitis (§ 91.) and
BRONCHORRHdi are most appropriate, c. When
it is complicated with gout or rheumatism, purg-
atives, combined with tonics or stimulants, in
order to carry off" collections of morbid bile, and
other vitiated secretions; and afterwards the med-
icines now enumerated, or the preparations of
ammonia or camphor, combined with colchicum
will generally afford marked relief. The depend-
ence of this variety upon the diseases already
noticed as occasioning the other form of cough,
requires the several measures pointed out with re-
ference to each of them (§8.). d. If the cough
be very severe, in old and exhausted persons, and
in those who have injured their constitutions by
venereal indulgences, a tonic and stimulant treat-
ment, and the remedies instanced in this para-
graph in increased doses, will be requisite. It
will be found in these, as well as in broken-doirn
drunkards, that the cough will be aggravated by
remedies which in any way depress the vital en-
ergies. In these last, the cough is frequently
connected with hepatic disease, the treatment of
which will depend upon its nature: but. although
depletion may be occasionally required for the
primary malady, the powers of life must be at the
same time supported.
11. In this variety, generally, the mild expec-
torants, w-ith demulcents : the jelly of sub-acid
fruits; the inhalation of oifTollient, stimulating, or
astringent vapours (see Bronchi ris, § 76. 98.)j
CRANIUM AND ENVELOPES. — their lesions.
439
the use of acid beverages; wartn^ rubefacient, sti-
mulant, and tonic plasters) the warm bath, made
gently stimulating by salt and mustard; a light,
demulcent, and nutritious diet, with strict atten-
tion to the functions of the stomach and bowels;
change of climate, or of air, and a judicious
choice of residence according to season, with
gentle but regular exercise, and warm clothing;
are severally of advantage, and some of them of
the utmost importance. (See Bronchi, § 104.)
Bidlioo. and Refer. — Fernel, Consil. xxiv. — Forest,
xvi. n. 1—6. — Hoist, Opera, vol. ii. p. 1 ■„>!!.— miHs, Phar-
marop. Ration, par. ii. srrt. i. cap. 4. — Montaigne, lisjais,
I. i. cap. 20. — lionet, Sepulchret. Anat. I. ii. s. iii. obs. 11,
— Morgwrni, De Sed. et Caus. Morb. epist. tv. art. 22, :li.
— Stein, De Tussi Stouiachali Humida. Argent. 1749. —
Winther, He Tussi Stomachali, &c. Marb. 1719. — Hal-
ler,De Tussi. Goet 1749. — Whytt, Works, 4to. p. -VS2.
— Buchner, De Tussi Humida, 4;c. Halas, 1763.— Finck,
De eo. quod Tussi proprium est ct Comumni. Bamb. 1779.
— Kapi>ilhuut, Becliones Gadaverum Patholoeicee, p. 5. —
VogeL Beobachtnogen, be. No. 7. — Porta/, Anat. Med. t
v. p. B.— Percivd, Essays, Sic. foL i. p. • 7.'. ; ami Med.
and Phvs. Journ. vol. iv. p. 65. — Mu !ge, On Coughs, ic.
8vo. Lond. 1789. — Dotible-iay, Med. Observ. and Inquir.
vol. v. — Doug/as. in Ibid. vol. vi. p. 163. Bell, Duncan't
Med. Comment, vol. xiv. p. 307. — Frank Institut. Clinica
Vilneosis, ann. ii. p. 27. — ll'i hmann, in Loiters Journ. b.
ii. st. 1. p. 31. — Young-. Introducl. to Med. Literature, 8vo.
p. 187. — Stan^er, Trans, of Med. and Chirurg. Soc. vol. i.
p. 13. — 3/. Good, Study of Med. bv Cooper, '3d edit. vol.
i. p. 580. — Brooke, On Liver Cough, Trans, of Irish Col-
lege of Phvs. vol. iii. p. J45.
COW-POX. See Vaccination.
CRAMP. See Convulsions (§ 4.), Spasm,
and Tetanus.
CRANIUM. — Syn. Kqavlov (from y^mos, a
helmet, as defending the brain from injury.)
Die Hirnschale, Ger. Le Crane, Fr. Cranio,
Ital. The Skull.
Classif. Pathology. — Special Pathology
— Morbid Anatomy.
1. The cranium aud its envelopes, the scalp
and the pericranium, are often the seat of diseases
which are of much moment, not only as respects
these parts themselves, but also as regards the
important organs and membranes which they
contain.
2. 1. Diseased Appearances of the En-
velopes of the Cranium. — These are princi-
pally the same as are observed in analogous
structures in other parts of the body. Nearly
the same changes are remarked in the scalp, and
subjacent cellular tissue, as in the integumental
co verings of other parts; and in the pericranium,
as in other parts of the periosteum. These struc-
tures, forming the envelopes of the cranium, will,
therefore, require hut little remark.
3. A. The scalp is subject to the same inflam-
matory states as other parts of the body; and
these require the attention of the physician, from
their occasional extension to the bones of the
cranium and membranes of the brain. Inflam-
mations of the scalp vary in character with the
condition of the vital energies and digestive and
biliary organs. Sometimes this structure is the
seat of active phlegmonous inflammation, but
more generally of the erysipelatous. When ery-
sipelas attacks the scalp, a copious exudation of a
serous or sero-albuminous fluid takes place in its
subjacent cellular tissue. Occasionally this tissue
is affected by inflammatory action of an unhealthy
kind, but limited in extent, and closely resem-
bling carbuncle, and of which I have met with
some cases in children. The scalp is also par-
ticularly liable to certain specific inflammations
of a chronic kind, especially to pityriasis, porrigo,
sycosis, lepra, psoriasis, eczema, rupia, and
syphilitic ulceration. Tumours, generally en-
cysted, sometimes form beneath the scalp, most
frequently between it and the tendinous expan-
sions of the occipito-frontalis, and other muscles
attached to the pericranium. These expansions,
and the muscular structure attached to them,
and perhaps occasionally the pericranium also,
are often the seat of rheumatism and rheumatic
inflammation. They are not infrequently, also,
affected by common inflammation and its con-
sequences, particularly after external injuries.
Dropsy of the cellular tissue beneath the scalp,
independently of inflammation, is very rare. It
has, however, been observed in young subjects,
and received the appellation of hydrocephalus ex-
ternus, and adema capitis.
4. B. The Pericranium is subject to the
same changes as the periosteum in other parts of
the body; amongst these are chronic and specific
inflammations, giving rise to thickening of the
membrane; to nodes, frequently terminating in
suppuration and exfoliation of the subjacent part
of the bone; and, in cases still more chronic and
slight, to unnatural deposits of bone upon the
external surface of the skull. (See Periosteum
— Inflammation of.) Inflammations of an acute
or sub-acute character sometimes, also, atiack
this structure, and, when not arrested in then-
progress, give rise to its separation from the
bone ; and not infrequently, owing to the exten-
sion of the morbid action through the tables of
the cranial bones, to a corresponding separation
of the dura mater from the diseased part of the
skull. It seems probable that morbid action of
any kind is seldom continued long in the peri-
cranium, without the dura mater, which perforins
the office of an internal periosteum, suffering in
a corresponding degree, and ultimately trans-
mitting the disease to the subjacent membranes,
and even to the brain itself. Specific inflamma-
tion also of this structure, of a most painful and
dangerous kind, occasioning death of the portions
of hone beneath the parts chiefly affected, is
produced by syphilis and the inordinate and pro-
longed use of mercury.
5. II. Morbid Changes in thk Cranium.
— The bones of the cranium are subject to various
diseased appearances, many of them having a
close reference to the state of the system, and its
morbid dispositions, and still more so to those
slowly formed lesions which frequently affect the
brain and its membranes. — A. Enlargement, or
rather distension, of the bones of the cranium,
is frequently an attendant upon chronic hydro-
cephalus, and the hypertrophy of the brain some-
times accompanying rickets. "When the accu-
mulation of fluid is great, and has taken place
before ossification is far advanced, this process
frequently commences at several more distinct
points than in the health} state, thus generating
as man] distinct bones. In the majority of these
cases, although the surface of the cranial bones
is irreatly extended, there is a general deficiency
of the ossilic deposit, rendering the skull more
than usually thin. The Museum of (iuy's Hos-
pital contains the cranium of an hydrocephalic
man. who lived to the age of 29 years. Its cir-
cumference is 33£ inches. There is also in the
440
CRANIUM — Mokbid Changes in.
Museum of St. Thomas's, the skull of a child of
two years, that measures 29 inches.
6. B. Deficient deposit of bone, as now re-
marked, is often connected with the foregoing
lesion; in which case it is commonly general, the
whole cranium being more or less thin as well as
enlarged : but the thinness may also, although
less frequently, accompany a natural-sized skull.
The deficient deposit, or thinness of bone, may
also be partial. In this case, partial or cir-
cumscribed accumulations of serum, or tumours,
generally exist beneath the part of the cranium
thus changed; and we have reason to believe that
it is . to the pressure exerted by these that the
unusual thinness is to be imputed. It should,
however, be kept in recollection that the cranial
bones vary exceedingly in thickness, without hav-
ing seemingly diverged from the healthy state.
7. C. Imperfect ossification is chiefly a lesion
of early age, being merely a slow or impeded
developement of the bones, arising from one or
both of the following causes : — a. From deficient
powers of the constitution, in which the process
of ossification either generally or locally in re-
spect of the cranium participates; b. From the
distension arising from the accumulation of fluid.
The imperfect ossification in such cases may con-
tinue to the age of three, four, or five years, and
generally consists merely of a more than usual
openness of the sutures, or a deficient deposit of
bone at the parts most remote from the centres
from which the ossific process proceeds. In
some cases, however, the imperfection exists in
about the middle of one of the bones; a patch of
membrane, or a narrow stripe being surrounded
by bone. When these patches or clefts in the
bone are considerable, or remain for any time
unfilled up, a portion of the membranes often
protrude, forming large watery tumours, owing to
the pressure of fluid effused between or under-
neath the membranes, — a circumstance which
occasionally obtains. An interesting case of this
description, successfully treated by ligature, has
been recorded by Mr. E. Thompson. The ma-
jority of these cases are congenital, but the pro-
trusion is often not noticed until long subsequent
to birth. Sometimes a portion of the brain itself
protrudes, forming a congenital hernia cerebri.
8. D. The bones of the cranium may be
insufficiently evolved. In this case they are
generally formed with more than sufficient ra-
pidity, and their sutures are closed prema-
turely, so that they cannot give way before the
growing brain, which thus becomes, with the
case enclosing it, imperfectly evolved. The
cranium may thus appear unnaturally small, as
is sometimes observed in idiots and epileptics;
but this state may arise not only from early
closing of the sutures, but also from imperfect
developement of the brain itself. Microcephalia
was considered by Hippocrates as a cause of
idiotcy ; and facts, showing that great diminution
of the size of the head is very generally connect-
ed with weakness or privation of intellect, have
been adduced by Gp.eding, Gall, Spurz-
HEIM, Georget, and many others not believ-
ers in the doctrine of Gall.
9. E. The shape of the cranium is often some-
what changed by these and other causes. When
the cranium is much deformed, it is more com-
monly a congenital vice arising either from the
pressure in utero of a deformed pelvis, pelvic
tumours, &c. ; or from deficient developement,
early disease of the embryo, and monstrosity; or
from congenital change of the structures which
it contains. But deformity of the cranium may
also take place after birth, from deficient or irre-
gular developement of the brain, or from the
effusion of fluids in the cranial cavity. The early
closing, also, of some sutures, and the protracted
closing of others, whereby the yielding of the
bones is prevented in one part, and facilitated in
others, are often productive of deformity. Rickets,
dropsy of the brain, softening of some of the
bones, particularly of the base, whereby it is
thrust up into the cavity (Otto), cretinism,
&c, are all often productive of deformity. A
species of deformity has several times come be-
fore me, and generally attended by epilepsy, and
idiotcy, which I have seldom seen noticed. This
consists of obliquity in the halves of the cranium;
one half being much more depressed, both at the
top and base of the skull, than the other. This
deformity is sometimes thus simple, consisting
only of comparative elevation and depression of
the sides of the cranium. But I have observed
it more commonly connected with an equal
obliquity posteriorly and anteriorly; the elevated
or depressed half, either receding or advancing
much more than the other. In cases of this de-
scription, the cranium has also presented a certain
angular form, so that I have been led to de-
nominate the appearance, the diamond-shaped
obliquity or deformity of the skull.
10. F. Hypertrophy , thickening , or enlarge-
ment of the bones, assumes two principal forms.
1st, That of a superabundant deposit of the ossific
matter, giving rise to uncommon density, and to
the disappearance of the diploe, and converting
both tables of the skull into one dense bone,
resembling, but much harder than, ivory. This
appearance of the cranial bones is almost na-
tural to the negro. It is observed, also, in per-
sons advanced in life, who have been subjected
to laborious employments, physical and mental;
and it is often seen in epileptics, in maniacal epi-
leptics, and in some who have been long insane.
It may or may not be accompanied with increased
thickness of the bone. Gredisg found the
skull too thick in 151 out of 196 insane persons;
and Georget observed it one twentieth and up-
wards too thick in 4S0 out of 500, belonging to
the same class of patients. The second form of en-
largement is rather the result of a loose or spongy
formation of the bones, in which, although most
remarkable in the diploe, both tables of the bone
often participate more or less. In this form, the
actual quantity of bony matter is not much
augmented. Increased thickness of the bone
generally obtains here, and sometimes reaches
an enormous extent, and closely resembles in
appearance a piece of pumice stone.
11. G. Irregular deposits of ossific matter are
very frequently observed on both the internal and
external surfaces of the cranial bones, particular-
ly the former. They are often found adjoining
the sutures, sometimes with a mammilated ap-
pearance on the external surface. On the internal
surface, they frequently assume an im^ular bo-
tryoidal form; sometimes they present large
masses, particularly oil the frontal bone, and
encroach considerably upon the cavity. Not
CRETINISM.
441
infrequently these deposits are prolonged into the
form of irregular processes : occasionally the pro-
longation h in the seat of ["articular parts or pro-
OaSBes, as in the Olinoid process. These exostoses
are sometimes very prominent and acute. In
some instances they encroach upon the foramina
through which the nerves and ves-els pass. In
these cases, symptoms of pressure or of irritation
are present, and vary according to the seat, form,
and extent of the ossific deposit Epilepsy, in-
sanity, irregular convulsions, spasmodic contrac-
tions, and neuralgia, are amongst the most promi-
nent effects of these productions.
12. H. Vascular engorgement is sometimes ob-
served in the cancellated structure forming the
diploe, in cases where great congestion, or very
active inflammation, has existed in the head,
membranes, or pericranium ; the vessels passing
from or into the bone being congested, and the
diploe of a deep or purplish red colour.
13. /. A softened state of the diploe is not in-
frequently observed in cases where active inflam-
mation has affected the pericranium, or dura ma-
ter, and extended to the bone. In these cases
the tables of the bone are more friable than natu-
ral. A similar appearance is also observed when
the system has been much contaminated by car-
cinomatous disease.
14. K. Ulceration of the cranial bones is also
not uncommon ; and is generally attended with
more or less absorption, exfoliation, and the de-
posit of irregular bony spicula?. Ulceration and
absorption result very frequently from lupus, and
the formation of bony spieuke generally attends
upon osteosarcoma.
15. L. Curies, or death, of the bone is not in-
frequently observed to follow upon inflammation
extending from the pericranium, or dura mater, to
the bony structure. It is a very common conse-
quence of inflammation of the ear long neglect-
ed, or imperfectly treated. It may be limited to
either of the plates, or it may extend to the whole
thickness of the bone. In either case, the dead
part is detached from the living by the absorption
which takes place around it, and in the surround-
ing inflamed and ulcerated parts. Owing to this
process, a distinct line of separation is frequently
formed, and the dead portion is completely ex-
foliated. While the dead bone is being removed
in this manner, or after its removal, if the dura
mater, which acts as the periosteum of the inter-
nal table, is not destroyed, new bone is deposited,
and thus the mischief is often repaired. — I have
met with two such cases in children.
16. M. Fungus rranii, or medullary sarcoma
of the bones of the skull, is occasionally observ-
ed. It has been described as occurring on the
top of the cranium by Crell, Saniufort,
Wishart, Aeercrombi'E, Landmasn, and
Otto. A distinct tumour is often produced by it
on the internal as well as the external surface of
the skull, — the part forming a spongy growth.
It is ii. ore rarely met with about the base of the
cranium. It may originate in the bones, or their
also observed, generally as a consequence of the
pressure of internal tumours, of an encysted,
scrofulous, or fungoid description, attached to the
membranes underneath, or of aneurisms, &c.
Cases of this description are recorded by Pal-
LF.TTA, Le Cl.F.KC, EtlCHTER, I'f.LLKTAH,
and Otto. After artificial perforations of the
skull, as after trephining, and fractures with loss
of bone, osseous matter is sometimes regenerated,
radiating from the surrounding divided surface of
bone. The exuberant formation of ossilic matter
after fractures of the cranium is sometimes pro-
ductive of serious effects. (See § 11.)
1$. 0. Depressions and fractures require little
notice further than that they are the most frequent
causes of inflammation, and its consequences in
the surrounding membranes, and contained organs,
and of irregular bony depositions. Depression
of the superior and lateral bones of the skull may
take place in early age to a very great extent,
and remain through life, without affecting the
mental manifestations. Several instances of this
have come before me, in some of which the de-
pression was fully larger and deeper than the
bowl of a large table-spoon. One of my earliest
and most talented friends has a depression to this
extent in one of the parietal boiies, from an ac-
cident in childhood.
Bibliog. and Keker. — Le Clerc, in HaUer''s TiifA'iolh.
Chirurg. t. i. p. 469. — Kaufmann, Ve Toanore Capitis Fun—
goso, &c. Helmst. 1743. — Sum! if nit's Exercitafc. Acad. I. ii.
t. 3. — Siebold, in Amemunn's Magazin fiiir die- Wunrlaiz-
neiwiss. Got. 17H7. vol. i. part iv p. 389i — Cheston BroumeT
in 1'liilos. Transac. vol. Ixx. p. 323. — Hf/me, Trans, for Im-
provement of" Med. and Surg. Knouledgev vol. iii. — Sttndi-
fort, Observ. Anatom. Pathol. I. iii. cap. ft. t. ft, H fe, iv.
rap. 10. ; et Museum Anatom. vol. ii. p. 61 — 2. — I'.lvmtn-
buch, De Anomalis ct Vitiosis quiliusdaia aisus ft rniativi
Aberrationibua Comment, p. 17. — Esquirtl, in Diet, de*
Scien. Med. t. xxiii.p. 521. — Qeorget, De la S"eli Sti Pari;,,
1820, p. 478. — Lnndmann, Comment. PaUolog. Anatom-
ise. 41 . Lips 1820. — Pinel, Sur les Vices de Conforma-
tion du Crane des Alienes ; in Bullet, de l» Socit't. Philo-
math. Ann. t. iv. p. 103— 109.— Wtnzel, Ueher dtrr Crete-
nismus. Wien. 1802. — Bail lie, Engravings, Sec. rase-, x.— -
J. P. Frank, Opusrula Posthuma, p. 102. t 4—6-8 o.Vieo.
1824. — Krtbel, De Anatomia Patholng. Oasis ni Capitis, 8vow
Hala>, 1823. — Otto, Verzeichniss der Breslauer Ana*. Pr-j-
paratensamlun?, No. 163. 165. 2l0. 3057. 3068. 8MB, &c—
P.illettn, Exercitat. Pathoiog. v I. i. p. 127.— Jbercromtiet
Path, nd Pract. Researches on Diseases of the Brain, fcc
Edin. 1828. Bn?ht, Medical Reports, etc. t. ii. p 686, he.
— Cruveilheir, Anatomie Pathologique. Lin. «»<> ■ Pai-is,
1830, fol.— Ball 'in^nl 7 and Rutttl, in Transact, of Med. aiij
Ghirurg. Soc. of Kdin. vol. i. p. 68. 71. — E. Thompson, in
Lond. Med. Repos. vol. xxii. p 353. {Very interesting —
(See also Art. Cranium, in PleucquePt Med. Digests; and
in OMo'j Lehrbuch der Pathol. Anat. des Mcnscheo, &c.
Berl, 1830.)
CRETINISM. — Syn. Cagots, Struma Tyrolen-
sium, Gautier. Critin, Cnlinisme, l'r.
Classif. — 6. Class, 1. Order (Good.)
I. Class, IV. Order (Author.)
1 . D k f i N . — Impei feet formation or develope-
ment of the cranium, and the whole of the body,
with mental imbecility, and physical imperfection,
varying chiefly in degree.
2. This Btate of imperfect physical and mental
developement, rather than of diseased action, was
first noticed by Plates among the y >or of Ca-
rinthia and the Valais, where, and in the valleys
internal or external periosteum ; but, in which- j of the lower Alps and Switzerland, it is endemic,
ever of these it may commence, it soon involves Hut it is not peculiar to these places; for it has
them all. When originating in the bones, it been observed in the valleys of the Pyrenees
usually assumes the characters of osteoiarcoma, \ by Ravmohd, in some puts of Salzbourg by
and those of fungux when it commences in the
pericranium or the dura mater.
17. N. Perforations of the cranial bones are
K vol./, and in v. n ions other localities in the cen-
tral and southern countries of Europe, as well as
in Chinese Tartary, according to Sir G. Staun-
442
CRETINISM— Description of.
ton. M. De Sai'ssure, Ackermann, Fo-
dere, Iphof, Erhard, the Wenzels, and
Ksolz, have given us the best descriptions of
this state of mental and bodily deformity, in respect
both of its nature and causes. The brief account
of it by Dr. Good is both imperfect and errone-
ous, and must have been written in perfect igno-
rance of the descriptions of the above eminent ob-
servers, as well as of others deserving of perusal.
He very inaccurately associates it with bronchocele
on the one hand, and with rachitis on the other ;
with the former of which it is not necessarily, al-
though very frequently, connected, and from the
latter it is totally distinct.
3. I. Description. — Cretinism presents va-
rious modifications in kind, and every intermediate
grade between that extreme degree of physical
and mental debasement which is characterised by
the utmost deformity and entire absence of mental
manifestation, the organic or vegetative functions
only being performed, and that condition which
may be considered as very nearly approaching
the healthy constitution of man. There are cer-
tain circumstances which distinguish cretins from
other idiots, viz. a. They present certain bodily
deformities, which are seldom or never observed
in other idiots ; and, b. Their physical and men-
tal infirmities are always the result of endemic
cause*.
4. In general, some degree of goitre is attend-
ant on cretinism, but not invariably. Professor
Knolz states that it is sometimes absent, and oc-
casionally slight, the thyroid gland being enlarged
in no greater proportion than several other glands
are in tire same subject. The stature is seldom
above four feet and a half, often much less ; the
cranium is deformed and has a conical shape —
the forehead being thrown backwards, narrowedv
and flattened, and the occiput being nearly on a
line with the neck ; the flesh is soft and flaccid ;
the skin wrinkled, yellowish, or pale and cadave-
rous, dirty, and covered by chronic eruptions ;
the tongue is thick, and hanging out of the mouth,
which is open, large, and slavering ; the lower
jaw is elongated and prominent ; the eyelids are
thick, the eyes red, small, but prominent, watery,
and frequently squinting ; the nose is flat ; and
the whole countenance is idiotic or expressive
only of lasciviousness. The belly is large and
pendulous ; the neck either short and thick, or
long and thin ; the limbs crooked, short, distort-
ed, &.c; and the gait imperfect and waddling.
The senses are more or less defective, or alto-
gether abolished ; the cretin being often deaf and
dumb, and those who- possess the faculty of
speech expressing themselves imperfectly and
with difficulty. The intellectual functions are
either entirely absent or imperfectly developed,
whilst the organic or vegetative functions are in
a state of increased activity ; cretins being vora-
cious, lascivious, and addicted to masturbation.
They appear to have no other enjoyment than
eating and sleeping ; and their insensibility is
often so great, that they obey not the calls of na-
ture. In some instances, the bodily deformity is
not so remarkable as that now described ; im-
becility, flaccidity of the soft solids, with bron-
chocele, constituting the extent of infirmity.*
* The following account of the " Fexes," or cretins of
Salzbourg, is abridged from that given by Professor KNOLZ:
5. The cretin, like most idiots, seldom attains
an advanced age ; indeed, few of them reach up-
wards of thirty years. Clayton remarks, that
although they die early, they soon present the
appearance of age. They are usually of the
lymphatic temperament, with light hair and gray
eyes ; the female cretin having enormously large
and pendulous breasts. The less debased among
them marry, rarely with one another, but do not
propagate cretinism, the predisposition only to it
being derived by the offspring from the parents.
Malacarne (Mem. de VAcad. de Turin) at-
tributes the mental debasement to the contraction
of the bones of the cranium, which prevents the
cerebral organs from acquiring their natural di-
mensions and functions ; and Ackermann es-
pouses a nearly similar opinion. The conforma-
tion of the body is generally stated not to be con-
genital, although, at birth, the cretin may appear
weak, puny, or sickly. It usually conies on
gradually from birth ; and M. De Saussore
states, that children who, living in the localities
where it is endemic, and are not affected at eight
or ten years, generally escape it ; and that infants
who are brought into these districts at a very
early age, are equally subject to it with those
who are born in them.
— The whole body is stunted, its height Dot exceeding four
feet. There is a total want of due proportion between its
different parts: the height of the head, with reference to the
rest of the body, beinE l-4th or l-5th, instead of l-8th, the
natural proportion. The neck' is strong, and bent down-
wards. The manima? are very voluminous and pendent ; the
upper limbs reach below the knees ; the arm is shorter than
the fore-arm ; the chest narrow ; the abdomen hemispherical,
and of a length not exceeding the height of the head ; the
penis and scrotum come down to the knees; the thighs are,
with the haunches, of a greater w idlh than the shou ders, and
are shorter than the legs, the calves being almost wanting ;
the foot is small, and the toes partly distorted ; the lower ex-
tremities are shorter than the upper half of the body. In
the head, the masticating organs, the lower jaw, and the
nose, preponderate considerably over the organs of sense and
intelligence. The skull is depressed, and forms a lengthen-
ed and angular ellipsis ; the receding forehead presents, in-
ternally, large frontal sinuses, to which the brain has yielded
a part of its place ; the top of the head is not vaulted, but
flattened , the occiput projects but slightly, and runs almost
even with the nape of the neck, as in ruminating animals.
The face is neither oval nor round, but spread out in width*,
the parts of which it is composed being wide and short,
and the maxillary bones projecting greallv. The forehead is
narrow, flattened, and low ; the eyes are unusually far apart,
diverge slightly, and are small, and seated deep in the orbit ;
the pupil is contracted, and not very sensitive to light; their
external angles are situated higher than the internal ; the
eyelids, unless when dropsically swollen, are flaccid and pen-
dent ; the look is a fixed stare without expression, and turns
with indifference from all that is not eatable. The root of
the nose is widened and depressed, the bones of the nose
square; the zygomatic bones are wide, and extremely pro-
jecting : the external ear is large, stands out from the head,
and hearing: is very defective. The elongated form of the
lower jaw of the cretins, and their thick and padded lips,
make them resemble ruminating creatures more nearly than
nun. The tongue is thick, and n.ther cylindrical than flat;
the saliva is continually running from the angles of the mouth.
Enlargement of the thyroid gland is recognised as one of the
>ii;tis of cretinism ' but its size is no sure guide to the extent
of the existing infirmity. The throat presents, also, other ob-
structed glands. The thorax is generally narTow and flat;
the abdomen is usually distended with gases, and largely de-
veloped towards the chest ; the flesh of the extremities is
flabby ; the knee of an irregular shape, and usually bent ;
the finders are very long and lank, and the nails very small.
The upper part of the vertebral column being directed more
or less forward, and the lower part, wilh the basin, being
pushed backward, the sacrum assumes a more horizontal, and
the other pelvic bones a more vertical position, than in the
healthy formation. Besides the masticating and digestive
organs, those of generation are also strongly developed, es-
pecially in the male. (MecleHv. Jarhxuker da k: k.^Esterr.
Staates, b. i. st. 1. 1829, p. "86.)
CRISIS.
443
6. II. Causes. — The principal, if .not the
only, cause of crelinism is dwelling, during in-
fancy and childhood, ill deep, narrow, moist,
and malarious valleys, situated at a lower level
than 3000 feet above the ocean, where the air is
Stagnant, and the solar beams intercepted by the
mountains. .MM. Feurus, Georget, and the
authors already referred to. state, that cretins be-
come numerous in proportion as the valleys sink
below this elevation. In addition to those causes,
may he added the poverty, ill-feeding, drunken-
ness, indolence, dirtiness, sensuality, and low
debauchery of the parents, — circumstances tend-
ing to the production of an infirm and deformed
offspring; the inactivity and tilth into which chil-
dren who begin to evince signs of cretinism are
allowed to sink, and the influence of water hold-
ing calcareous and other mineral substances in
solution. MM, De Saussure and Fodere,
however, deny that the water is concerned in the
production of this infirmity ; but MM. Bally
and Rambi'teau show that much is owing to it
in the causation of cretinism, as well as Bron-
chocele (see that article). The last named
authority states that the offspring of the natives
of Yalais, who intermarry with persons from the
Italian side of the Alps, are more subject to cre-
tinism than those born of native parents; that
females who have husbands from the higher Alps
seldom have children affected by this infirmity ;
tli at wherever cretins are seen, goitre is also
prevalent; but that the latter is found in places
where the former does not exist; and, conse-
quently, that the same causes that occasion goitre,
when present in an intense degree, also produce
cretinism.
7. III. The Treatment of this infirmity is
necessarily preventive rather than curative, and
consists of the amelioration of the physical and
moral condition of the parents ; of the removal
of infants, as soon as signs of the malady mani-
fest themselves, to more elevated and open locali-
ties, and to mountainous districts, to enjoy a purer
air and stronger light; of obliging them to exert
themselves in some useful and suitable employ-
ment, and to pay attention to personal cleanliness;
of frequent ablutions, followed by active and
stimulating frictions of the. whole surface of the
body; of the use of stimulating tonics (Erh arm);
and of allowing them a stimulating and strength-
ening diet, with a large proportion of animal
food. Josias SihleR, who wrote in 1574,
states that the malformation, constituting the physi-
cal infirmity, is sometimes congenital; and proba-
bly it is so occasionally. In such cases, it is not
likely that much advantage will accrue from any
means. M. Rambuteau, however, states that
it is scarcely ever congenital; but it is not un-
likely that experienced observers may predicate,
from the appearance of the newly bom infant,
whether or not it is likely to become the subject
of this dreadful infirmity — may observe that state
of developement and formation, which, if not
actually the incipient malady, is predisponent to
its occurrence.
Dini.ioo. and Refer.— Stnrr, Alpeurehe Vorborei-
tung, par. \v.—De Saiuiura, V., yage dans les Alpes. G<
ii.-v. 17- (i. ( layton, in Mem. <■'( the Lit. and Philos -
of Manchester, 1790, vol. viii. art. 13.— -M'.
die Kretinen, tec. Gtotha, 1790, r6. FWeW, Sui le Got-
trcet le Creiini-me, -v». Turin, 1792.— Erkard, in Bufe-
larul's Jourri. der I'racl. Ileilk. Ii. xiv. st. 2. p. 30.— j'. et
C. JFemel, V, -tier den Orelinismus. Vien. 1°02.— lvhof.
I,',;1('';1""'" Vii.k [804, Michaelu, in Blumnbadft
Bibllotn. b. in. p. 640.— Vireu, in Diet, s, „ ,„ . mi. i. vii.
p. 343.— Qeorgit, Diet, de Medecine, I. vii. p. 184.— Ram-
outeou, in IIm,!. i. u. ,,. 186.- /•'. Seiubure, Der Orerinu-
mtu, 8vn. Wttrzfa g, 1826.- c. Londe, Diet de Mid.
Prat. t. v.p. 550. -J. J. Knoh, in Bulletin dei Scien. Med.
t. (xi. 1830, p. 390.-./. Johnton, Change of Air, or the
Pursuit "I Health; being an Excursion through France,
Switzerland, and Italy, Sic. 6vo. Loud. 1831, p. 56.
CRISIS. — Svn. /wn'fitc, a judgment or decision
(from xolrai, I judge or determine). Judicium,
Judical™, Lat. Entscheidung der Krankheit,
Ger. Owe, Fr. Crisi, Ital.
Classie. — Procnosis.
1. Crisis may be defined a sudden change
during the height of a disease, tending either to
recovery or to death. Critical changes have
been much regarded in the prognosis and treat-
ment of diseases, from the time of Hippocrates,
who first mentioned them, and the days on which
they occur, down to the present period. As-
clepiades, and the methodists, however, de-
nied their influence, and disputed the existence
of critical days. Galen and his followers at-
tached great importance to them. It is recorded,
that, having been called to a patient — a young
man — with two disciples of Themison, Galen
prognosticated a favourable change by a critical
hemorrhage. The opinion was ridiculed by the
two methodists, who advised blood-letting; but it
was soon verified, for the patient had a copious
epistaxis, after which he recovered. It is un-
necessary to allude to the writers who have con-
tended for the importance of this subject : they
comprise most of the eminent names in medi-
cine, from Hippocrates to Collen, Pinel,
Frank, Hildenbrand, andKREYSsic. The
titles of many hundred volumes that have been
written upon it might be adduced in proof of the
consideration attached to it : and although much
more has been imputed to critical evacuations,
and days, particularly by the humoral patholo-
gists, than legitimately belongs to them, and
granting that too devoted an attention to them
has induced many to adopt injudicious indications,
and weak measures of cure, yet some reputation
will be acquired from the prognosis which an ac-
quaintance with them will enable the physician
to give; and much benefit will result to the pa-
tient from the treatment which this knowledge
will suggest.
2. Since the overturn of the humoral pathology,
the doctrine of critical evacuations has undeserv-
edly fallen into disrepute, although the eminent
writers who contributed most to the overthrow are
amongst its most rational and warm espousers.
In our own country, at the present time, too little
attention is paid to these evacuations, and still
less to the periods at which they occur. There
can be no doubt that the former is the most im-
portant ; but the latter part of the subject should
not be disregarded. After all that has been
urged in favour of, or in opposition to, the doc-
trine, I may conclude that, in temperate climates,
a number of diseases, particularly fevers, nm on
for certain periods with regularity, and, after an
exasperation of the symptoms, or some violent
perturbation of the economy, terminate by evacu-
ations of different kinds, which tend to remove
the train of morbid action-, and to n -tore the
healthy functions. In other cases, the exaspera-
tion of disorder is followed by imperfect evacua-
444
CRISES — Description of.
tions, occurring in an irregular manner; whilst in
some it gives rise to additional phenomena of a
dangerous or fatal character : hence crises have
been denominated salutary and complete, im-
perfect and fatal. It was considered by the
older writers requisite to a salutary crisis, that
the evacuations constituting it should be attended
by favourable symptoms, and be copious and
manifest; and not only appropriate to the disease,
but also consistent with the state of the patient.
An imperfect crisis was considered better or
worse : the better state alleviating the malady ;
the worse rendering it more severe and danger-
ous, from the supervention of metastases and
complications. Having described the phenomena
which are critical, I shall next notice the periods
of disease at which they are most frequently ob-
served.
3. I. Crises manifest themselves, — 1st. On
the skin : A. by sweats; B. by acute or
chronic eruptions. 2d. In the cellular
tissue : A. by swellings in various parts; B.
by boils and carbuncles ; C. by gangrene ; and
D. by purulent collections. 3d. In the glands :
A. by buboes; B. by swelling of the parotids;
C by salivation; D. by a flux of urine. 4th. On
the mucous surfaces : A. by increased ex-
cretion— a. from the nose; 6. from the bronchi,
&c; c. from the stomach (vomiting); d. from the
bowels (diarrhoea) ; B. by sanguineous exhala-
tion— a. by flux — «. the hemorrhoidal ; (J. the
menstrual; b. by haemorrhagy ; «. from the nose
(epistaxis); |S. from the bronchi (haemoptysis);
j'. from the stomach (haematemesis); <l from the
intestines ; f. from the uterus (menorrhagia) ;
l. from the urinary organs (hematuria).
4. 1st. A. Sweats are salutary crises in con-
tinued and bilious fevers, in inflammations of the
lungs and liver, in bronchitis, and less frequently
in rheumatism. Fracastori describes an epi-
demic putrid fever which generally terminated
favourably in this manner. Acute dropsy, par-
ticularly anasarca, when caused by interrupted
perspiration, sometimes disappears after copious
sweats. This evacuation is usually preceded and
indicated by a soft, full, open pulse ; by a dimi-
nution of the alvine evacuations; by softness, and
occasionally slight itching, of the skin; and by
increased colour of the cheeks. A salutary sweat
should be distinguished from such as are limited
to the forehead or face, and the neck or breast,
whilst the rest of the body is dry; or those which
cover only the lower extremities : these constitute
merely partial or incomplete crises, and merely
diminish the violence of disease.
5. B. Eruptions. — Miliary and vesicular erup-
tions only are critical : the others are merely
symptomatic, or even form a part of the disease;
as erysipelas, purpura, petechia;, &c. A miliary
eruption is favourable, if the symptoms subside,
if the patient feels an itching or pricking, if they
be general, and do not appear before the seventh
day : if they be unattended by fulness of the sur-
face; and if their subsidence be followed by vomit-
ings, hiccup, or convulsions, they indicate a fatal
termination (Landrf.-Beauvais). Sometimes
a miliary eruption comes out at different periods,
and prolongs the disease, when partial relief fol-
lows it, each appearance being an incomplete
crisis. Many chronic eruptions may not only be
complications of visceral disease, but occasionally
imperfect crises,— they alleviating the internal ma-
lady. They are more rarely completely salutary.
6. 2d. A. Swellings of various parts, as of the
face or neck, the hands, the lower extremities,
&c, have been considered as partial crises in ataxic
and gastric levers, and in exanlhematous diseases.
B. Boils are critical in some complaints, particu-
larly towards the termination of acute diseases,
especially small-pox. C. Gangrenous pustules or
anthrax occur in malignant or pestilential fevers;
gangrenous escars also are met with in similar
cases, as well as in typhoid or adynamic fevers,
particularly about the sacrum, and In places which
have been blistered, or pressed upon. If, in such
cases, the febrile symptoms subside upon the
sphacelation, and if the gangrenous change be
rapidly and distinctly circumscribed, it may be
favourably critical; but if the symptoms continue,
and the pulse becomes more frequent, weak,
small, and soft, the local mischief is entirely
symptomatic, and indicative of an unfavourable
termination. D. Purulent collections are indica-
ted by the continuance of the disease without any
considerable evacuation, or exhaustion; bv a sense
of chill, horripilation or rigor, occurring at inter-
vals, without any manifest cause; by the discharge
of much clear urine; by partial sweats; by a soft-
ness of the pulse; by a remittent or hectic fever,
and by flabbiness of the soft solids. The favoura-
ble changes of this nature occur in the extremities,
and suppurate easily and rapidly. Those that are
unfavourable take place in some internal viscus.
7. 3d. A. Buboes chiefly belong to pestilential
fevers; but they are occasionally observed in the
adynamic fevers of temperate climates. They
indicate a favourable or fatal crisis in the manner
stated with respect to gangrenous escars. B.
dwellings of the parotids occur in low or malig-
nant fevers ; and appear either alone, or with
other critical changes. They are commonly .pre-
ceded by a slight rigor; by severe headach, stupor,
noises in the ears, and deafness, with paleness,
swelling, and sometimes redness of the coun-
tenance. This occurrence is rarely critical, and,
of itself, furnishes no sure indication of the issue:
if accompanied with favourable changes, it be-
comes an additional sign of returning health ; but
if the swelling is slow, or disappears in a very
short time, the other symptoms still continuing, it
is a dangerous circumstance. C. Salivation was
noticed by Sydenham as a principal critical
evacuation in the fevers of 1667 and 1668 ; and
it occurred in the epidemic that prevailed at Bres-
law in 1700. It occasionally supervenes in some
forms of cvnanche, and in bilious and gastric
fevers. D. The urine is sometimes discharged
copiously at the height of febrile and inflammatory
diseases ; and is to be viewed as a favourable
occurrence. It is usually clear when recently
evacuated, but deposits soon afterwards a whitish
or rose-coloured sediment. The symptoms indi-
cating this discharge are very obscure. Some
authors have noticed the "pulsus myurus," which
consists of every three or four successive puls-
ations being progressively diminished. A sense
of weight below the hypochondria : of gravative
tension in the hypogastrinm, and of heat in the
urinary organs, is stated by M. Landre-Beac-
vais to precede this evacuation.
8. 4th. A. a. Coryxi,Qt sero-mucous excretion
from the nose, is sometimes critical in continued
CRISES — Description of.
446
fevers; bat little importance is to be attached to
it. 6. Mucous accretion from the bronchi is fre-
quently a partial crisis ill several fevers, and in
inflammations of the thoracic viscera (see Bron-
chi ami Longs.) c. Vomitings are rarely indi-
cations of a perft -t crisis; they occasionally, how-
ever, favour the developement of those changes
which precede a favourable termination of disease.
The] are sometimes ushered in by a hitter taste
in the month, yellowish fur on the tongue, subor-
bitar pain, and headach, nausea, salivation, cold-
ness of the extremities; and frequency, and oc-
casionally intermissions, of the pulse, d. Diar-
rhaza and copious alvine evacuations are favour-
able crises in nearly all acute, and even in some
chronic diseases. But it is necessary that they
should be feculent or bilious, and homogeneous —
not watery or llocculent : if they approach to a
natural, or have a yellowish brown; color, and
are followed by abatement of fever, &c, a favour-
able crisis may be confidently looked for. The
chronic diseases, in winch they indicate a change
tending to health, are congestions and inflamma-
tions of the liver and spleen, hypochondriasis and
melancholy, slight or incipient dropsies, rheuma-
tism, and gout. They are usually preceded by
borborvgmi, with slight flatulent distension of the
abdomen ; flatulence and eructation ; a sense of
tension and uneasiness in the lumbar region ; liy-
inir pains in the extremities ; and a developed but
unequal pulse, occasionally with irregular inter-
missions.
9. B. Sanguineous exhalations are often critical
in the more inflammatory states of fever, and in the
phlegmasia?. According to Hoffmann andLAN-
dre-Beauvais, discharges of blood from the
nose, the hemorrhoidal vessels, or the uterus, are
equally salutary in ardent fevers. In general,
these haemorrhages are preceded by depression of
the morbid temperature, and erethism of the skin ;
by slight horripilations of the limbs ; by a more
open and rebounding pulse ; and a sense of heat,
pruritus, and tickling, in the part whence the
evacuation is about to proceed, a. The menstrual
flux is sometimes a rapid crisis in fevers and
phlegmasia3. It is indicated by dull heavy pains
in the loins, groins, and tops of the thighs ; by
tension in the hypogastrium ; heat and pruritus
of the genitals ; pallor of the face, and a dark
circle round the eyes ; swelling of the breasts ;
pale, scanty urine ; horripilation, and erethism of
the skin ; and by a quick, sharp, and unequal
pulse. Very frequently the menses appear at
the regular period, or a little earlier, or later, in
fevers and inflammations, withoul affording any,
or but imperfect relief. In these cases, they
should not paralyse the activity of the treatment.
When they occur at or before the usual time, are
abundant, and are attended l>\ evident beneflt,
they should be considered as critical : but if thej
are delayed, or are difficult or scanty, thej are
imperfect crises, and should not interfere with
the measures which the circumstances of th
may require. 6. The hemorrhoidal flux is often
critical in inflammatory fever, pneumonia, hepa-
titis, and other phlegmasia?. Si wn. states that
a return of this discharge is sometimes favourable
in inflammations of the brain, and particularly in
hepatitis, nephritis, melancholia hj pochondj i. sis,
and mania. The observation is certainly correct
This evacuation is indicated by pains in the loins
38
and the groins : by a sense of uneasiness and prea>
sure to wards the ana* and perineum ; by frequent
desire to pass the urine and go to stool ; by flatur
lence and borborygmi, slight pallor of. the face, and
fulness of the hypochondria ; and by fulness and
inequality of the pulse as tostrength. c. Critical
epistaxis was considered of great importance bj
the older physicians, wlm paid much attention to
the symptoms indicating its accession : these are,
redness, with slight tumefaction of the face, and
e\ es ; reddish or brilliant objects floating before the
eyes ; the involuntary shedding of tears ; weight
of the temples, and healing of their arteries : deaf-
ness, or noises in the cars ; slight delirium, or ver-
tigo ; a sense of tension in the neck, with disten-
sion of its veins ; ;i dull pain in the forehead, and
at the root of the nose, or an itching and tickling
in the nostrils ; a quick, hard, full, and an unequal
pulse ; frequent and slightly laborious respiration;
sometimes with tension or oppression, without
pain, at the pneeordia. Occasionally, pallor, and
constriction of the whole surface, coldness of the
lower extremities, ami horripilations, also precede
a critical epistaxis. This crisis is most common
in young persons, and adults whose vital energies
have been previously unimpaired, and who have
been subject to this evacuation. It occurs most
frequently in summer and autumn ; in the more
inflammatory states of fever : in the acute phleg-
masia1 affecting the super-diaphragmatic organs ;
and rarely in hepatitis. If the discharge consists
of a few drops only, it is an alarming symptom ;
and although it be copious, if not soon followed
by amendment, it is unfavourable. When ex-
cessive, and attended by syncope, convulsions,
loss of power, partial or cold sweats, and cold ex-
tremities it is a fatal sign. A syncope, however,
which terminates the epistaxis, is often followed
by recovery (Landrk-Beauvais.)
10. d. Hemoptysis, hcemaiemesis, hematuria,
and intestinal liamorrhagy , are always false or
unfavourable crises. They are generally preceded
by tension and tenderness of the hypochondria ;
and supervene most frequently in adynamic, ma-
lignant, and pestilential fevers ; in confluent small-
pox, scarlatina maligna, and in scurvy : they oc-
cur less frequently in females than in males.
11. A. The above are the phenomena which
have usuallv been considered critical by the older,
and which are admitted by the best modern, med-
ical writers ; as well as the symptoms which indi-
cate their accession. There are, however, still
some circumstances connected with them deserv-
ing of notice, a. The hemorrhagic evacuations
occur most frequently in the spring, or in dry sum-
mers, in persons from 15 to :J"> years of age, of a
sanguine or irritable temperament, and in acuto
complaints, b. 'I he cutaneous evacuation is most
common in summer and autumn, in robust and fat
persons upwards of 30 years of age, and in con-
tinued, remittent, and intermittent fevers, c. A
critical diarrhtea is most frequent in autumn, in
is of a bilious temperament, and in remittent
and intermittent lexers. d. Discharges of urine
are observed in all ages, in all seasons, particu-
larlv winter and spring, and in all acute diseases.
12. B. Critical evacuations are — a. rare, in
pei sons enfeebled by age, or by some other ante-
cedent disease ; in very moist and very cold, or
\ei\ lint climates; during remarkably sudden
and great vicissitudes of weather ; and especially
446
CRISES — Causes.
when the vital energies are much reduced by a
lowering and an evacuating treatment, b. They
are not always similar in the same diseases ; and
they vary in respect of the nature of the discharg-
es, and of the periods at which they take place,
as well as of the organs by which they are pro-
duced. A favourable change in gastric, bilious,
and adynamic fevers, is often attended by alvine
discharges of a homogeneous, fluid, yellowish,
yellowish brown, or brownish black appearance,
— in inflammatory fevers, in young men, by epi-
staxis, often occurring on the seventh day, — in
these diseases, in young women, by a copious
flow of the catamenia taking place on the same
day, — and in men of middle age, by sweats, or by
some other discharges coming on the fourteenth,
or at a subsequent period. Catarrhal and bron-
chial complaints terminate with expectoration, or
with sweats, or a copious flow of urine, &.c.
■ 13. C. The duration of critical evacuations is
very uncertain. The hamiorrhagic, the alvine,
and the urinary, seldom continue longer than
twelve or twenty-four hours, sometimes even
much less. Sweats and expectoration are occa-
sionally of no longer duration ; but, in the major-
ity of instances, these two evacuations are pro-
longed several days before the disease is entirely
subdued. Purulent collections and gangrene may
take place in a few hours, but they generally re-
quire a much longer period.
14. D. Critical discharges cannot be changed
or determined in their route or period of eruption,
by art ; and when they supervene, they cannot
be safely interfered with, unless they threaten
life by their excess. If they be interrupted by
accident, or by an injudicious and meddling prac-
tice, they are followed by unfavourable metas-
tases and complications, or sequelae, sometimes
terminating in organic change, and death. Thus,
when the perspirations which occur upon the
change in fevers, and some of the exanthemata,
are interrupted, effusion often takes place from
serous surfaces, or into the cellular tissue. The
most active vascular depletions can never com-
pensate for the suppression of an abundant men-
strual or hemorrhoidal flux, occurring at the acme
of acute diseases ; — the effects of art are here
unequal to those produced by nature. Hence
the advantage of recognising critical evacuations,
even although we may not otherwise confide in
them. Although it is thus important to attend to
them in our prognosis, and especially in the treat-
ment, when signs of their accession appear, or
when they are actually present, yet the expec-
tation of their occurrence ought never to inter-
fere with or prevent the adoption of judicious in-
tentions and means of cure. Even granting, with
Hah.ni: mann, that they are not to be imitated
by art, still they furnish several useful indica-
tions. " Quo nutxira vergit, eo ducendum es£,"
may occasionally be adopted, after a careful con-
sideration of the changes of which they are the
effects, but not the causes. Much mischief has
accrued from considering critical evacuations as
the causes, and not as the consequences, of
changes that take place in the economy at the
acme of acute diseases. Reil has touched upon
this fallacy, but has not considered the nature of
the changes of which critical evacuations are the
effects, or attempted to explain the manner of
their accession.
15. II. Causes, &c. — A. We have seen that
crises take place chiefly from eliminating or excre-
ting surfaces and organs ; and that they consist of
a copious irruption of either previously suppressed
secretions and excretions, or an accustomed san-
guineous evacuation.; but the causes which oc-
casion, and the changes which precede them, are
not so readily recognised. When we consider
of what they consist, especially in relation to the
fact of their occurrence only in maladies charac-
terised in their earlier stages bv interrupted se-
cretion and excretion, and by morbid excitement
of the vascular system — the vascular excitement
being perpetuated and variously modified bv sus-
pension of the visceral functions now mentioned,
or by local irritation, or by both — we shall arrive
at a tolerably accurate inference respecting the
causes of crises, and the importance that ousht to
be attached to them. There are few7 facts in
pathology better established than that vascular
excitement, when it reaches a certain height, or
assumes an inflammatory form, impedes, inter-
rupts, or even arrests, the natural functions of
secreting or glandular organs : whilst a lower
grade of excitement, unattended by inflammation,
generally increases the functions of the organ
thus affected. Therefore, when excitement con-
tinues to be expressed chieflv in the vascular sys-
tem generally, secretion and excretion continue
impeded or entirely suspended- ; and the effete
materials, which, under other circumstances, are
continually being removed from the circulation,
accumulate in it, perpetuating and modifying the
vascular excitement until it becomes exhausted,
and until the accumulated noxious materials in
the blood irritate the viscera destined to remove
them, and thus incline the balance of excitement
from the general vascular system to eliminating
organs. Hence the occurrence of critical evacu-
ations at the acme of acute diseases ; and hence
their importance as indications of change in the
states, — 1st, of vital power ; 2d, of vascular
action ; 3d, of the circulating fluid ; and, 4th, of
the functions of secreting and excreting viscera.
As crises have been neglected or confided in ac-
cording as they agreed with the doctrines of the
day, and have, in modern times, shared the fate
of the pathology on which they had been so long
grafted, I shall attempt to illustrate this view by
a reference to one of the very common circum-
stances in which they are observed. A person
exposed to the causes of autumnal fever of a
bilious and remittent form, experiences during
the earlier stages the usual symptoms of impeded
or interrupted secretion and general vascular ex-
citement, with evening exacerbations. In conse-
quence of interrupted action of the emunctories,
the blood contains an increasing proportion of
effete materials, particularly of the elements out
of which bile is formed. These for a while in-
crease and modify the vascular excitement, or,
when excessive in quantity, or especially noxious
in quality, even tend to exhaust of depress it ;
but they, at the -same time, being appropriate
stimuli to the biliary and depnratory viscera, serve
to restore their impeded functions, to turn the bal-
ance of excitement in favour of them. — thereby
to reduce the morbid vascular action, to cleanse
the circulating fluid from its imparities, and to
change in other respeefs its condition ; and thus
the disease terminates with an apparent collapse,
CRISES — Causes.
447
followed by a copious discharge from the bowels,
consisting of morbid bile, and of the excretions
from the intestinal mucous surface — the products
of the noxious matters which had accumulated
in the blood, but which is now being eliminated
from i! by a renovated, as well as an increased,
secreting and excreting function. Now, this pro-
cession oi' morbid phenomena is consistent with
what I have repeatedly observed in both tem-
perate and warm climates ; and shows that the
ancients were not so far wrong as many of the
moderns suppose, when they believed that critical
evacuations were beneficial chiefly because they
conveyed a morbid matter out of the system; and
therefore could never be perfectly compensated
for, or imitated by, art.
16. But it may be objected, that this explana-
tion is based -entirely upon the opinion that the
circulating fluid becomes altered, owing to inter-
ruption of the various secreting and excreting
functions ; and that it cannot obtain in those
cases wherein no such interruption appears to
occur. In this case, it is very probable that cri-
tical changes are etl'ected in a great measure by
the vital influence of the frame. Even according
to the foregoing view of the subject, the agency
of the vital endowment must not be left entirely
out of consideration ; for, without its reaction,
through the instrumentality of the different inter-
nal organs with which it is associated, upon the
morbid matters affecting it, those matters could
not be separated from the circulation and expelled
from the system. It seems, therefore, more than
probable that crises consist, in the majority of
cases, of more than the simple excretion of the
accumulated effete matters from the circulation —
such excretion being merely the effects of an an-
terior and still more important and more constant
change. The attentive observer of the pheno-
mena successively occurring during the progress of
disease must have sometimes remarked, in those
maladies especially, wherein the vital manifesta-
tions are particularly implicated, certain perturba-
tions or struggles occurring at their acme, either
followed by recovery, but without any very mani-
fest evacuation — at least to the extent of explain-
ing the circumstance; or passing into exhaustion
and death, sometimes without any organic change
to account for the issue. In such cases, we can
merely infer, that the vital endowment of the
frame resists or opposes changes in the state of
the structures with which it is associated ; that it
does so successfully in the former, and unavail-
ingly in the latter, of these ctises ; and that, un-
less its energies are overwhelmed by very pow-
erful and noxious causes, as occasionally is ob-
served, it thereby tends to prevent the dissolution
of this association to which such changes might
directly or indirectly lead. This vital manifesta-
tion— whether denominated the " nit medicatrix
naturae" or vital resistance, or vital reaction, &c.
— most certainly obtains in a very large propor-
tion of diseases, and is instrumental in the de-
velopement of those changes, which immediately
or mediately conduce to recovery, and which, in
the more extreme cases, are attended by various
phenomena indicating the vacillating predominan-
cy of vital and functional power, or of organic
disease ; the acquired ascendency of either over
the other, occasioning, as the case may be, a
favourable or an unfavourable crises. That such
a Struggle for the ascendency should manifest
itself favourably at certain periods, or on deter-
minate days, in preference to others, can be ex-
plained only by considering it a law of the living
economy identical with, or related to, the period-
icity of vital action observed in the healthy, and
still more apparently in the diseased functions.
17. B. Numerous illustrations of the following
propositions might be adduced, in addition to that
now advanced : — a. Evacuations occurring at
the height of acute diseases are often among the
first indications of, and are, indeed, occasioned
by, the subsidence of local or general vascular
excitement, b. In many febrile diseases, crises
are brought about by the excretion — under the
influence of vital reaction or resistance of the se-
creting viscera — of the effete matters accumu-
lated in the blood, or upon internal organs and
surfaces, owing to interrupted excreting function,
as shown above, c. When a crisis is attended
by apparent collapse or change of action, this
may arise either from the vital reaction of inter-
nal secreting organs occasioning a derivation from
the periphery to the more central parts of the
frame, or, from the previous exhaustion or sub-
sidence of the vascular excitement allowing the
secreting and excreting organs to resume their
functions when excited by their appropriate stim-
uli in the accumulated elements of their respective
secretions, d. When crises consist of sanguine-
ous fluxes or discharges, they are occasioned, in
great measure, by the vascular plethora conse-
quent upon impeded secretion, together with
local determination to, or congestion of, such mu-
cous surfaces or organs as are most disposed, by
original conformation, previous disease, or esta-
blished function, to these changes, e. That a
favourable crisis may manifest itself in one organ
or function, or in two or more, either simultane-
ously or successively, as by sweats, or by alvine
or urinary discharges, or by expectoration, &c.
/. When, during the progress of disease, the
aqueous and albuminous elements of the blood
become excessive, or when noxious matters accu-
mulate, and are not eliminated in the form of
crises as above stated, or by medical aid, they
may so affect the capillaries in the parenchyma
of the organs, or in serous surfaces, as to give
rise to various organic changes and effusions.
These may be viewed as unfavourable crises,
determined to vital organs and internal cavities,
arising from deficient vital energy, or vital resist-
ance and reaction, or predisposition, or constitu-
tional vice of some organ or part ; each of which
may obtain cither alone, or with local or general
plethora produced by interrupted secretion, &c.
is. ('. Critical terminations are observed most
frequently in the more inflammatory, the bilious,
the gastric, and the intestinal forms of fever ; in
.'• rent phlegmasia;, in some hemorrhagic
is, and more rarely in chronic maladies.
They are more commonly remarked in some epi-
demiCS than in others; and are seldom apparent,
;i> justly remarked by I,kntin, in putrid or ma-
lignant diseases, and, I may add, in the pesti-
lential fevers of warm climates. In these, the
depressing and contaminating influences of their
causes, and of the states of the secretions upon
the nervous energy, on the circulation, and subse-
quently upon the soft solids, so far subdue the
vital influence as to render its resistance uuavail
448
CRITICAL DAYS.
ing in the morbid strife ; and it becomes insuffi-
cient to separate and throw of the polluting mat-
ters, which ultimately increase so as altogether
to overpower it. The chronic maladies in which
crises are sometimes met with are — mania, hypo-
chondriasis, melancholy, and idiopathic dropsies.
But there are numerous circumstances which
prevent their occurrence in the above diseases.
It this country they are more rarely observed than
thev would otherwise be, if the treatment of the
diseases in which they commonly occur were left
more to nature.
19. D. Amongst the most frequent causes that
prevent the developement of crises, particularly
such as are favourable, may be enumerated — old
age ; the lymphatic temperament, and leucoph-
legmatic habit of body; previous disease, and dis-
position of structures or organs to organic change.
Constitutional or local vice; the scrofulous, gouty,
or rheumatic diathesis ; exhausted vital power ;
inanition or general cachexy, particularly from
innutritious or unwholesome food ; and a too low-
ering or depletory mode of treatment relatively
to the constitution and circumstances of the pa-
tient, not only obstruct the developement of regu-
lar or favourable crises, but render them imperfect
or unfavourable. The large depletions, and the
copious and repeated alvine evacuations, very
generally resorted to in the early stages of acute
diseases, even although they may frequently ward
off a fatal issue, often manifestly prevent the ac-
cession of regular crises, — 1st, by debilitating the
patient, and thereby rendering the vital resistance
insufficient for their full evolution ; and, 2d, from
the circumstance of these means of cure being
substituted or artificial evacuations or crises, and
preventing by anticipation and substitution those
which are natural.
20. And here a most important question sug-
gests itself, viz. Whether or not it is better thus
to substitute artificial, for the mere cliance of the
accession of natural evacuations 1 As respects
the phlegmasia:, and many diseases, — particular-
ly those, on the one hand, in which vascular ac-
tion is excessive, and those, on the other, in
which it is insufficient, and the vital powers are
greatly depressed, — there can be no doubt of the
propriety of resorting to artificial means to pre-
serve an organ from the disorganising tendency
of excessive action, and to raise the prostrate
powers of life. Besides, it is excessive, and not
moderate and judicious measures, which obstruct
the evolution of favourable crises : the latter are
even requisite aids to nature, in bringing about
salutary changes, and a fehcitous termination of
disease. In respect, however, of many forms of
fever, I believe that the nimia di/igentia of the
practitioner is as often injurious as it is beneficial,
and that it disturbs those changes which can be
effected only by time, and sometimes dispose-;
to metastasis, complications, and unfavourable
crises, by depressing the vital energies, and
checking salutary changes at the early periods
of their evolution, and before they become fully
manifested. This fact was established by Hil-
d en br and in respect of the typhoid and adyna-
mic fevers which were epidemic through Germany
from 1810 to 1816. lie observed, that a much
greater number of cases recovered when left in
a great measure to nature, the physician inter-
ferring no further than to preserve vital organs
from dangerous congestions, than when a medici-
na perturbatrix was adopted.
21. III. The Critical Days (Dies indica-
torii) are those on which favourable changes usu-
ally occur. They are either simply or especially
critical. The third, fifth, seventh, ninth, elev-
enth, fourteenth, seventeenth, twentieth, twenty-
seventh, thirty-fourth, and fortieth, are critical
days ; the seventh, fourteenth, twentieth, and
twenty-seventh being those which are especially
critical. Galen, and some other writers, men-
tion the fortieth, sixtieth, eightieth, hundredth, arid
hundred and twentieth; but these are more doubt-
ful, and can apply only to chronic diseases. The
third, fifth, ninth, and, by some writers, the
eleventh, and seventeenth, are often called inter-
calary days: on these, crises less frequently occur.
The intervening days are non-critical or vacant,
on which salutary changes very seldom take place.
Forestus, De Haen, Bordec, and various
other authors, have entered upon calculations
respecting the terminations of acute diseases on
particular days ; and it results therefrom, that
about three fourths have observed regular periods.
These periods are, however, not always the same
in similar diseases. They vary with the age, the
constitutional powers, the temperament, and the
regimen of the patients. They are earlier, and
much more uniformly observed, in robust persons,
than in those who are weak and advanced in age.
22. That critical changes should so frequently
occur on the days specified, cannot be explained
otherwise than in the way attempted by Cull en.
He remarks that, from the universality of the ter-
tian and quartan periods in agues, we cannot
doubt of there being in the animal economy a ten-
dency to observe such periods ; and the critical
xlays above mentioned are consistent with this
tendency, as all of them mark either tertian or
quartan periods. These periods are, however,
not promiscuously mixed, but occupy constantly
their several portions in the progress of the dis-
ease ; so that, from the beginning to the eleventh
day, a tertian period obtains ; and from the
eleventh to the twentieth, and, perhaps, longer,
a quartan period is as steadily observed.
23. In entering thus fully into the exposition
of the doctrine of crises, according to my belief,
as deduced from observation, and the recorded
experience of the best authors, I would recom-
mend a judicious, but not a too partial, attention
to them, excepting in fevers where morbid action
has so far advanced that a determinate course
must be reckoned upon ; but, when any vital
organ is threatened by disease, either originating
in it, or attacking it consecutively, as in the pro-
gress of fevers and of the exanthemata, or when
the vital powers are greatly, reduced, although
favourable crises may occur, they cannot be
reckoned upon, and the expectation of them
ought not then to prevent the adoption of deci-
sive measures. When, however, they do super-
vene under such circumstances, the knowledge
of the facts connected with them becomes of real
importance, inasmuch as it acquaints us that the
means of cure ought to be directed in such a
way as not to impede or interrupt, but to devel-
ope and promote them. Their occurrence on
certain days, in preference to others, should also
induce us to watch the phenomena of disease at
these periods with the utmost attention. It is true
CROUP — Its Pathology.
449
that critical daws have been denied by many of
the moderns, upon the ground of their not having
observed them. But, as Di*. Cuxlxn has well
remarked, the fault is in the physician. He who
will not observe closely ami comprehensively,
should not throw discredit on the results obtained
by the more accurate and attentive enquirer.
Authorities in matters of opinion are of little
value; hut in matters of fact, as in this case, they
are testimonies — are positive evidences; and
whoever will take the trouble to refer to several
hundred authorities collected by Pl.OUCO.UET, or
even to those below (nearly all of which he has
omitted,) will lind them sufficiently conclusive.
Bim.ioo. and Refer. — Hippocrates, Opera, ed. Fon-
der Linden, t. i. p. 437. 686. et passim. — Galen, I ' r- Diebus
Dccreloriis, 1. iii. — Oribasius, Synop. 1. vi. c. 1. — i<Y«-
castori, Opera, paaritn. — Wekerii, Praclica, 1- ii. cap. 6 — 15.
V,„. i. U. — Ba^livi, Prax. Med. 1. i. c. 9. — Sydenham,
Opera L'niversa. Ed. Lugd. Bat. 1726, p. 163.— F. .'/,;'-
tn. inn, I)e Nat. Crisium, be. Hals, 170';. — Ettmulkr,
■ i el Tumor. Ont. Lips. 1717. — Mead. Works,
p. 200.— Stakl, De Periodb Acuatrum, &c. Haiie, 1708;
l)e Autorratiu Xatura-. Hal.-v, 1C96, 4to. ; et I)e Svnergia
Nat. in Med. Halo, 1005. 4iu.— Boerhaave, Instit. §'931.—
G. Martinc, On the Periods and Crises of Diseases. Lond.
1710. — Button, Ergd a recta Crisium Doctrina et Observat.
Mediciin cerlior. 4to. Paris, 1741. — Delius, De Diebus In-
tercalations, in Advers. fase. iv. — Hebenstreit, Vi- Vita? ad
judicandos Itorbos, leu de Motibus Nat. Criticis, 4(o. Lips,
l" !.i. — Bar leu, Recherchea sur les Crises, in (Euvres Com-
pl&es, Paris. 1818, p. 209.— Van Smeten, Comment, vol.
ii. p. 464. — Li-nlin, Beytr&ge, p. 21. — De Bfaen, De Diebus
Criticis et I'ri-ilnis varus, Rat. .Med. vol. i. cap. iv. p. 50. —
Soemmerring, De Perturbat. Critica et Crisi. Moy. 1786.
—Ecihardt, Veritas Doct. Oris. .Marb. 1796.— Reil, Me-
ntor. Olinica, fasc. ii. p. 23. — Cullen, Works, by Thomson,
vol. i. p. 593. — Hecker, Ann. der Pr. Med. Jul. et Aue.
1820.— Hi ah; Sper.i lie Pathologie, b. i. p'. 2t. — Cappel,
l)c Viribus Corp. Hum. qua dicuntur Medicatrices. Oroet.
1800.— A T. Richter, Die Specielle Therapie, b. i. p. 57.
— Sprengel, [nstitutiones NIeaii . vol. iv. pjfl6. — Hahne-
mann, in HufelancPs Journ. der Pract. Heilk. b. xxii. st.
3. p. 12. — ./. I'. Frank, De Curand. Hominum Morbis,
vol. i. p. 66. — Landre-Deauvais, Semiotique, &.c. Paris,
1813,2d ed. i el in Diet, des Sciences Vied, t. vii. p. 370.—
Hildenbrand, [ustitut. Practico-Medicae, &c. vol. i. p. 66. —
Fourcaxdt, in Mem. de la Societe Mid. d'Emulation, t. i\. p.
411. — Kreytsig, in Encyclopad. Wurterbuch der Medicin.
Wissenschaiten. b. viii. p. 646.
CROUP.— Syn. Affectio Orthopnoica, Bail-
lou. Angina Strepitosa, GbisL Angina Infan-
tum, Wilcke. Cynanche Stridula, Wahlbom.
Angina Suffocatoria, Bard. Angina Infantum
Strangulatoria, Russel. Cynanche, vel Angina
Trachealit, Cullen, Johnston, Rush, &c. Asth-
ma Infinitum Spasmodicum, Simpson. Suffo-
catio Stridula, Home. Asthma Acutum Infan-
tum, Millar and Cookson. Morbus Strangula-
torius, Starr and Rosen. Morbus Truculentus
Infantum, Van Bergen. Angina Polyposa,
Michaelis. -' igina Membranacea, Auct. Var.
Cynanche Laryngea, Dick. Orthopnea Mem-
branacea, Laudun. Tracheitis Infantum, Albe < el
Frank. Angina Laryngea Exudatoria, Hufeland.
Laryngo-Tracldile, BlaucL Empresma Bronch-
lemmilix, Good. Cauma Bronchitis, Young. Die
Hautige Br dune, Huhni l rerm. Tra-
f/ci'. . Croup, IT. Strypsiucka, Swed. Croup,
or Roup, Scott. Hives, Amur.
Classik. — 1. Chut, Febrile Diseas s; '_'.
it- - - of Sanguineous Function ; 2. Or-
der, Inflammations [Cullen.) '.',. Clots, Or-
der, Inflammations [Good.) III. I
I. Ori'kr (Author, in Preface.)
1. Nosoi Dn in. — decelerated, difficult,
xoheezing. or thrill respiration; short, dry, con-
stant. dangOUS or burking cough ; hours': or tit-
.
tered voice; pain and constriction above thr ster-
num, will, symptomatic inflammatory fever ; fre-
quently, towards the close of the disease, expecto-
ration of membranous, albuminous, or glutinous
substances, occurring in children.
2. PATHOLOG. Ukkin. — Inflammation of the
trachea, sometimes of the larynx and trachea,
and frequently also extending to the large bron-
chi, occasioning albuminous and membranous
exudation, more or less spasm of those parts ;
and terminating either in suffocation or ex-
haustion of vital power, generally in a few
days, or within the period constituting an acute
malady.
:!. Lit. Hist. — Although we had no precise
account of croup until the work of Home ap-
peared, yet there cannot be any doubt of its oc-
casional occurrence among children from the
earliest ages ; and that it was confounded with
other diseases affecting the throat and air-passa-
ges. HippocRATK.s states, "Angina Gravissima
quidem est, et celerrime interimit, qu«j neque in
faucibus neque in cervice quicquam conspicuum
fecit, plurimum verd dolorem exhibet, et tlilricul-
tatem spirandi, quae erecta cervice obitur, inducit.
Efoc enirn codem etiarn die, et secundo, et tertio,
et quarto strangulat." And Baillou, after des-
cribing an affection of the respiratory passages,
observed in Paris, in 1576', with the nature of
which he was unacquainted, remarks, " Chirur-
gus affirmavit se secuisse cadaver pueri ista dif-
ficili respiratioue et morbe (ut dixi) incognito
sublati : inventa est pituita lenta, contumax, quiB
instar membranes cujusdam arteria aspera erat
obtenta, ut non esset liber exitus et introitus spiri-
tuiexterno: sic suffocatio repentina." Tliat the
above observations strictly apply to croup, there
can be no doubt. Dr. Blair, of Cupar Angus,
first mentioned, and shortly described, the disease
by its present name, in his medical papers pub-
lished in 1718. Ghisi noticed it, as it prevailed
in the north of Italy in 1747, by the appellation
of Angina Strepitosa ; Starr, in the Philo-
sophical Transactions for 1749 and 1750, by the
name of Morbus Strangulatorius ; and Wilck k,
as it occurred in Sweden during some years pre-
ceding 170'4. After the descriptions furnished
by Home, and bis Swedish contemporaries,
Halen and Wahebom, it received a place
among specific diseases, and became the subj i it
of a number of works, and even of controversial
discussion. The treatises of Simpson1, in !7o'l,
and of Millar, in I7(if), on the acute asthma
of infants, gave rise to this latter occurrence, es-
p ■ i ';> on the I 'ontinent These authors, having
id the i. Hire spasmodic states of this dis-
hed them under the above designa-
tion : Writers differing widely as to
their being distinct maladies, or merelj rat
oup, with predominance of the
sp i smodie • \ his point was warmly
dnctions which the
'l by Napoleon, in 1807, called
forth. My opinions respecting.it will appear in
the sequel.
I. !. Hi8tort of 1 \ mi Pro-
n 1 hi i \sk. — Croup has been
tion b\ II-'-.! i'. as an in-
!l Ltnmution of the interior surface of the trachea
and larvnx. Some authors have divided it into
distinct varieties, namely, 1st, Catarrhal
450
CROUP — History of its Progress.
croup, or a slighter form • of the disease ; 2d,
Nervous or Spasmodic croup, or a slighter state
of the inflammation', occurring in nervous and ir-
ritable temperaments, which influence the form
and issue of the disease, giving rise to a spas-
. modic form of it ; and 3d, Inflammatory croup,
or that in which the inflammation of the air pas-
sages is carried to a greater height, and is always
attended by the production of a membranous ex-
udation. The opinion that croup consists of an
acute inflammation, occasioning the production,
in a number of cases, of a false membrane ; in
others, of an albuminous concretion of various
degrees of density; in some, of a viscid mucous
secretion, and of the inflammatory lesions of the
mucous membrane itself, already described (see
Bronchi, &c. § 3, 55.); has been attacked by
MM. Guersent and Bretonneau, who con-
sider that the formation of a false membrane
is the distinctive character of croup ; and that
those cases in which it is not formed, are merely
what they term false croup. I agree with M.
Bricheteau in considering that the distinction
here contended for is calculated more to puzzle
the inexperienced, than to advance our knowledge.
The experiments of Schwilgue, Jurine, Al-
bers, Schmidt, and Chaussier, as well as
pathological observation, prove that the form of
disease called false croup by the above authors
proceeds from a similar state of morbid action as
that denominated the pure disease, and is merely
a modification resulting from less intensity of the
inflammation, peculiarity of the temperament and
habit of body, the causes occasioning it, and the
greater predominance of the spasmodic or nervous
states. The experiments of the authors now re-
ferred to demonstrate, that the injection of irritat-
ing matters into the air-passages sometimes pro-
duces simple inflammatory irritation ; in others, a
thick, viscid, mucous exudation ; and in many,
particularly in young animals, a complete false
membrane. These differences of opinion, which
are not confined to the writers now mentioned,
but extend to many of those quoted in the course
of the article, will appear, from what is about to
be advanced, as more apparent than real. That
the disease should present numerous modifications,
approaching acute bronchitis on the one hand, and
identical with laryngitis on the other, and varying
characters according to the portion of the air-
passages chiefly affected, the temperament, habit
of body, severity of inflammatory action, and
association with other diseases, is an inference
to which a priori reasoning may lead every prac-
titioner. Without adopting, the confined views
of some writers, or the hypothetical doctrines of
others, I shall be guided chiefly by an extensive
experience in the disease, and consider it under
the following beads : — 1st, The symptoms and
progress of true croup ; 2d, The varieties or
modifications of the disease most frequently ob-
served ; and, 3d, The complicated and consecu-
tive forms.
5. i. The usual Form and Progress of
true Croup. — The simple and usual form of
croup generally commences with more or less of
precursory symptoms, and runs its course in a few
days. It has been divided by authors into differ-
ent stages or periods, more, — I believe, with the
view of giving precision to their description, and
to the treatment recommended, than from any
marked change in the character of the symptoms.
M. Gof.lis has divided it into four stages, viz.
1st, the invading or catarrhal stage ; 2d, the in-
flammatory period; 3d, the stage of the albu-
minous exudation ; and 4th, the period of immi-
nent suffocation. A nearly similar division has
also been adopted by Dr. Cheyne. The diffi-
culty of determining these various stages must be
evident; and yet the advantages arising from a
division of the disease into distinct periods must
be evident, — not so much, however, for the pur-
pose of description, as for the more strict appro-
priation of the means of cure. Premising, there-
fore, that croup, particularly this form of it, is
strictly progressive, with no great change in its
features, until towards its close ; and that, there-
fore, all divisions of its course are merely arbi-
trary, and without any positive grounds in nature;
I sha 11 notice, 1st, its precursory signs; 2d, its
developed and confirmed stnte; and 3d, the state
of collapse and imminent suffocation.
6. A. The precursory period, period of in-
vasion (Guersent,) of irritation (Royer-
Collard,) catarrhal stage (Goelis,) febrile
period (Duges.) These precursory signs are
sometimes well marked, and of a distinctly ca-
tarrhal nature, as observed by Goelis: occasion-
ally they are slight, chiefly of a febrile description;
and either from this circumstance, or from the
shortness of their duration, attract but little no-
tice. The febrile symptoms, .when present, con-
sist chiefly of alternating chilliness and heat, or,
in the more acute cases, of slight chills, followed
by heat of skin, frequency and hardness of pulse,
slightly flushed countenance, want of appetite,
headach, excited or variable spirits, alternating
with sadness, lassitude, &c. Often, in place of
these, or in addition to them, there are a short
cough, hoarseness, sneezing, coryza, sometimes
moroseness, and all the signs of common catarrh.
Upon examining the phraynx and mouth, no
trace of inflammation can be detected in this
form of the disease ; but the tongue is generally
white, and loaded at its base. The eves are
watery, red ; and the eyelids darker than usual.
These symptoms are sometimes onlv of a few
hours' duration, or they may be present for two
or even three days. In very young children,
they may be so slight as to escape detection,
whilst a somewhat different train of phenomena,
such as heat of skin, chilliness alternating with
heat, frequent short fits of coughing during the
night, want of sleep, restlessness, indications of
uneasiness about the throat, furnished by the fre-
quent application of the child's hand to this part,
&c. manifest themselves. The importance of
ascertaining the invasion of the disease have led
several writers to pav much attention to its pre-
cursory symptoms. Vieusseux has attached
much importance to the catarrhal signs, and
change in the voice. But these are not by any
means constant; and, even when present, may be
merely the commencement of a slight catarrh ;
indeed, there is no symptom which cum be relied
upon, as indicating its approach, until the disease
is nearly fully formed.
7. B. The developed state of the disease (the
Inflammatory , of C h e t n e and Ho s a c k . ) — A fter
the above symptoms have existed for a longer or
shorter time, or in a more or less marked manner,
hoarseness, if it have not previously existed ;
CROUF — History of its Progress.
4.51
sometimes a peculiar shrillness or puling of the
voice ; difficult, sibilous, Bonorous respiration ;
and an unusual, dry, loud, clangous or ringing
cough, as if passing through a brass tube, or
sometimes resembling the harking of a puppj ;
are observed. This croupal cough scarcely, ad-
mits of description, although it is readily recog-
nised after having been once heard. The suc-
cussions constituting it are followed by a dry,
hissing, slow, sonorous inspiration, resembling
the sound produced by a piston forced through a
dry pump, or by a crowing noise similar to thai
emitted by a chicken in the pip. Expiration be.
tween the cough is more easy than inspiration,
but with precipitation; the pulse is frequent and
hard ; the skin hot or burning ; the face flushed,
sometimes covered with perspiration; the eyes
are watery and prominent; the carotid arteries
beat strongly, and the jugular veins are tumid.
The head is now generally thrown backwards;
and the child, either by its speech or attitudes,
expresses a^ feeling of anxiety, with pain and con-
striction about the trachea and larynx, which are
often slightly tumified externally. The above
symptoms, which usually fust appear during the
evenino- or night, generally somewhat subside
early in the morning, excepting the frequency of
the pulse, the hoarseness of the voice, peculiarity
of the cough, and the sibilous inspiration. This
remission sometimes continues the greater part
of the day ; but after falling asleep, or to-
wards evening, all the symptoms become more
severe than ever; and the difficulty of respiration,
the sense of suffocation, the anxiety and distress,
are increased. The patient constantly applies
the hand to the throat, which Is sometimes pain-
ful to the touch ; the countenance is bloated ;
the pulse still remains frequent, hard or small;
the cough is short, precipitous, convulsive, ring-
ing, and followed by a crowing, or shrill or
hissing inspiration; and at the commencement of
this stage is generally dry, or attended by a scanty
mucous or sanguineous expectoration ; subse-
quently it becomes husky and suffocative, some-
times "with fruitless attempts to excrete what is
felt in the trachea. The patient constantly
changes his position; breathes with great difficul-
ty, all the respiratory muscles acting with great
force; and at each inspiration, the tumid larynx
descends rapidly towards the sternum, whilst the
epigastrium is drawn upwards and inwards; and,
during expiration, the former is carried towards
the maxilla, and the latter comes on a plane
with the surrounding surface. If any remission
at all occur now, it is much less evident All the
symptoms become more severe. The cough is
now more difficult, suppressed, or strangulating;
the suffocation accompanying it more imminent,
and the stridor or hissing noise of inspiration fol-
lowing it much louder: sometimes it is followed
bv vomiting, and the excretion of a glairy mucus,
occasionally containing flocculent or membranous
shreds. The poise is now very frequent, con-
tracted, sharp, and small. The cheeks and lips
are, particularly during the cough, somewhat
livid, or extremely pale and tumid. There are
also great irritability and somnolency, but no
delirium. The hissing', Bonorous, and croupy
character of the inspiration increases ; and the
voice, which was shrill or hoarse, often be-
comes broken, whispering, suppressed, or puling.
W hen vomiting follows the COOgh, and partic-
ularly when ilu: excretion of glaity, albuminous,
and membranous matters accompany it, a mo-
mentary relief i> obtained) .sometimes followed bj
progressive diminution of all the urgent.symr)toD».
Deglutition, particularly of fluids, is . so times
difficult, especially when the larynx is affected^
and induces the tits of cough and strangulation.
These symptoms seldom continue equally intense
during the whole of this stage, but preaenl several
slight remissions, particularly at its commence-
ment, and in the less severe cases. Throughout
this period, ami, indeed, during the whole disease,
the bowels are constipated, and the urine In small
quantity, of a high colour, and generally albu-
minous. The strthoscope generally furnishes no
further information in this stage than a louder
sound than that already heard; unless when the
disease extends to the large bronchi; when a dry,
tubular, or bronchial respiration, unaccompanied
with crepitous dilatation of the pulmonary cells,
hut attended with perfect resonance of the thorax,
may he detected.
8. C. The third stage, or that of collapse and
threatened suffocation (the Suppurative, of Ho-
SACK and Cheyne,) inay commence from the
first to the seventh day from the invasion, ac-
cording to the intensity of the disease, and consti-
tution of the patient. This period is characterised
chiefly by the absence of any remission, and the
increased severity of all the symptoms, par-
ticularly the acceleration and diminished power
of the pulse and respiration. The pulse is now
small, weak, irregular, unequal, or even inter-
mittent; the cough is less frequent, less audible,
suppressed, but suffocative. The voice is whis-
pering, low, or entirely abolished; and the speech
quick, imperfect, or lost; the motions of the
aire 7wsi and the parietes of the chest are forcible
and remarkable, and accompanied with a similar
descent and ascent of the larynx and epigastrium
to that already described (§ 7.). The head is
constantly thrown back; perspiration flows from
the forehead ; the eyes become sunk, and lose
their animation; the countenance often assumes
a leaden hue; the tongue is dark and loaded,
and its edges and the lips are purplish; the sur-
face of the body is covered with a cold viscid
perspiration; the feet and hands swell; the skin
is extremely pallid, and shows the veins through
it, particularly those of the neck, which are large
and distended; and the stools are dark and of-
fensive. The patient very seldom recovers from
this state; but he sometimes obtains momentary,
much more rarely permanent, relief, owing to
the expectoration of a portion of the albumin
ous, membranous, and muco-puriform matters
obstructing the larynx and trachea. When the
eva-eiinn is free, recovery sometimes takes place
slowly; hut where it is scanty, or when the dis-
ease has extended downwards through the bronchi,
as it usually does when thus severe, the issue is
aily fatal. In this case, the patient tosses
about in great distress; heseizes.on objects around
him, and grasps them convulsively for a moment;
he throws his head back; seizes his throat as if
to remove an obstacle to respiration ; makes
forcible ellorts to expand the lungs; and after a
longer or shorter period of such distress, seldom
above twenty hours, expires, sometimes with signs
of convulsive suffocation, but as frequently with
452
CROUP — Modifications of.
continued increase of the foregoing symptoms,
and evidence of exhaustion of the vital energies,
and in a state of lethargy. The stethoscope gene-
rally furnishes information in this period of the
extension of disease to the larger bronchi. This
extreme state of disease seldom lasts longer than
twenty-four hours. In young children, convul-
sions sometimes occur, and occasionally terminate
life.
9. D. Puch is the usual course of the more severe
cases of common and uncomplicated croup, when
left to nature, or unmitigated by treatment. In its
slighter grades, hoarseness, with a hard ringing
cough, followed by a crowing or stridulous inspi-
ration, present chiefly in the night and remitting
in the day, are almost the only symptoms; the
respiration and pulse being but little disordered
in the intervals, and the febrile symptoms not
very acute. But even these very favourable cases
may experience sudden and dangerous aggrava-
tions; whilst, on the other hand, the severe and
acute disease now described may be soon amelio-
rated by early and decided treatment at its com-
mencement, or by the discharge of tubular, mem-
branous, or puriform matters, at its more advanced
periods.
10. E. The duration of the disease depends up-
on the vital energies of the frame, and varies from
two to eight or nine days; but I have seen it ter-
minate somewhat earlier, and prolonged much
later when partial or scanty expectoration takes
place from time to time. A fatal issue is most
common on the fourth day. I believe that it
very rarely assumes a chronic state, preserving at
the same time its essential characters; although a
somewhat different opinion has been advanced by
Goelis. The cases, however, which he has ad-
duced as instances of the clironic disease, are
evidently either the partial removal of the more
inflammatory, with recurrence of the more spas-
modic, symptoms; or slighter relapses; or the
extension of the inflammatory action to the larger
bronchi, and its continuance in this seat for a
longer period. Albers admits that it may be-
come chronic, and supposes that the false mem-
brane may sometimes adhere to the inflamed
surface, and be gradually absorbed ; recovery at
last taking place, without the excretion of the
albuminous substances in such cases. These oc-
currences, although not impossible, are at least
very rare. Hilden brand supposes, on the other
hand, that it may become chronic after the excre-
tion of the albuminous exudation; inflammatory
irritation still persisting in a lower grade, and
terminating at last in ulceration. This is a much
more probable occurrence; and I believe that I
have met with it on two or three occasions, but
I have never been able to verify it by dissection.
In such cases, the disease continues in a slighter
grade for several weeks, and is characterised by
frequent remissions and exacerbations, emacia-
tion, muco-purulent expectoration, slight sore-
ness in the trachea, and the usual symptoms of
tracheal consumption; the patient sometimes sink-
ing at last, or occasionally recovering by judicious
means.
11. ii. The Modifications ofCropp. — The
forms which the simple or uncomplicated disease
assumes are attributable, as already hinted, to
the particular part of the aiv-passages chiefly
affected, to the temperament and habit of
body of the patient, and the intensity of the
causes.
12. 1st. Croup willi predominance of the acute-
ly inflammatory symptoms (the Acutely Inflamma-
tory Croup of several modern authors.) — This
is merely the more acute or severe form of the
disease, occurring in robust plethoric children
of the sanguine temperament, who have been for
some time weaned, and have had their first teeth,
and during cold and dry states of the air. It is
commonly preceded by chills, and horripilations,
and in older children by distinct rigors; and is
characterised by the more continued and unremit-
ting severity of the symptoms, by the strength of
the pulse, heat of skin, great difficulty and force
of respiration, the vascular injection of the cheeks
and lips, the highly inflammatory appearances of
blood taken from a vein, &c. (a.) When the in-
flammation chiefly, or even partly, implicates the
larynx (the Laryngeal Croup ofGuERSENT and
others,) the strangulation, cough, and all the
symptoms connected with respiration? voice, and
speech, are extremely severe; pain is felt in the
larynx and upper part of the trachea, and there
is sometimes slight swelling in this situation. In
young children convulsions, and in older children
delirium, occasionally occur towards the close.
The disease terminates in from twelve hours to
five or six days, but most commonly in two or
three days. (6.) When the inflammation is con-
fined to the trachea (the Tracheal Croup of sev-
eral Continental writers,) the cough is at first dry,
shrill, or sonorous, as if passing through a brass
tube, and accompanied with sharp and lacerating
pain in the course of the trachea, sometimes
with slight tumefaction. The patient speaks in
an under tone, but there is little hoarseness, and
the voice and speech are not lost, or at least not
so much affected as when the disease is seated
partly or chiefly in the larynx. Heat of skin,
and the usual symptoms of severe inflammatory
fever, are also present. As the disease advances,
the cough becomes more frequent and severe,
but without the distressing sense of suffocation
attending the foregoing modification; neverthe-
less there is still much difhcultv of respiration in
the intervals between the cough, sometimes with
a species of rattle similar to that of bronchitis.
The fits of cough are often followed bv vomiting,
or the rejection of membranous shreds, with a thick,
glairy, and sometimes sanguinolent or purulent
mucus. The excretion of this substance general-
ly is productive of much relief, which is increased
after each discharge, unless the inflammation has
extended down the ramifications of the bronchi;
and then the respiration continues extreme! v dif-
ficult, and the disease assumes all the characters
of an acute bronchitis, and frequently terminates
unfavourably. The progress of cases of this de-
scription is usually not so rapid, nor the termi-
nation so fatal, as of those affecting the larynx
chiefly. All the symptoms evince less severity,
especially when treated early; audit sometimes
continues twelve or fifteen days, but usually from
five to nine. When its severity merely is sub-
dued, the inflammatory action not being alto-
gether removed; or when, from accidental causes,
or the fault of the constitution, it passes down the
bronchi; it may be much more prolonged, and
approach the chronic character; but it will then
present many of the features of the most severe
CROUP — Modifications of.
453
bronchitis, into which, indeed, it will thus pass ;
and, as was Stated in respect of that disease,
whilst bronchitis may be followed by croup, the
latter malady may thus occasion the former.
IS. 2d. Croup with predominance of bronchial
symptoms (the Cynanche Trachelitis Humida of
Rush ; the Mucous Croup of some modern au-
thors.)— This form is not infrequent in young
children of the lymphatic temperament, who are
night, often during the patient's first sleep, fre-
quently withoul well-marked premonitorj symp-
toms, excepting languor, listlessneas, beadacb,
fretfulneas, and sometimes a short tickling cough;
and these inaj be slight, or of short duration.
The child is suddenly wakened bygreal dim
oi breathing, cough, and general agitation, and
continues thus affected for some time; the symp-
toms gradually subsiding towards morning, or
fat and flabby, with a white soft skin. It is often being more quickly relieved by the cough termia
met with soon after the period ojf weaning, and in eting in vomiting. This form of the disease al-
thoae who are brought up without the breast. It ways presents complete remissions during the day,
commences with coryza, and the other symptoms with exacerbations in the evening and night, and
of catarrh, and often with little fever. After these thus assumes a regular type ; hut the remissions
signs have been present for some time, or some- often become less complete and of shorter dura-
times without these being so marked as to attract tion, the exacerbations more frequent and prolong-
attention.il generally attacks the child in the eve- id, and the cough, dilliculty of respiration, general
ning or during the night, and manifests itself in a
decided manner by the sudden occurrence of a
hoarse, suffocating, dry, sonorous, or shrill cough,
with a sibi'ous inspiration. The seizure is usually
severe, and- is attended with manifest alarm to the
patient. The countenance is pale, and covered
agitation, and convulsive movements attendii
them, more severe. There is little or no increase
of animal heat or fever, nor actual pain in the
larynx and trachea, but a sensation of constriction
and uneasiness. The countenance is generally
pale in the remissions, and sometimes tumid and
by perspiration, and the lips are violet. Several livid in the exacerbations, during which the respi-
slighter fits succeed to this first attack ; the voice ration becomes sonorous, laborious, convulsh e,
remains hoarse and low, the respiration sibilous and croaking : the extremities are usually cool,
and slightly difficult ; but a remission usually The cough continues dry, and accompanied with
takes place in the morning, and there is gener- : marked irritability, until the favourable termi-
ally hut little return of the croupal cough until nation of the disease ; when slight or moderate
evening and night, when it recurs, but often in glairy expectoration takes place, but without any
a slighter degree. In some cases, the invasion is membranous substances mixed with it. Thepulse
more gradual ; the remissions but slight, or hardly is very variable ; sometimes small, frequent, and
evident, and the accession of expectoration much constricted; occasionally slow; but generally at
earlier ; the disease approaching nearer, as re- last unequal, weak, or intermitting. The urine
spects its seat and character, to acute bronchitis, is paler than in the common and more inllanima-
There is but little fever, the skin is not much tory states of the disease, in larger quantity, and
warmer than natural, and the powers of life are
not remarkably depressed. The throat and pha-
rynx are unaffected. After the first, second, or
third day, the cough is no longer dry, its fits be-
come shorter, is sometimes accompanied with a
mucous rattle, and begins to terminate in the ex-
pectoration of a thick glairy mucus. The disease
sometimes deposits a nebulous sediment. In this
variety, the nervous and spasmodic symptoms
are present from the commencement ; in the
former, they appear chiefly in the two hist stages;
the more common and inflammatory croup some-
times thus passing into the spasmodic.
15. Such are the usual characters of the well-
now assumes many of the features of, or passes marked spasmodic variety of croup; but cases of
into, bronchitis. M. Guersent considers that
this is merely a false or bastard croup. I be-
lieve that it is a milder form of the disease ; and
that it consists of a slighter degree of the inflam-
matory irritation of the same parts which are
affected in the true croup ; but that, in conse
so pure and unmixed a form are comparatively
rarely met with in practice; as the intermediate
shades between the state of disease now described,
and either of those preceding, are more commonly
observed, at least in this metropolis and vicinity.
I have scarcely ever seen a well-defined case un-
queni e of the much less severity, or some other connected with dentition; or one terminate fatally
modification, of the diseased action, and constitu-
tion of the patient, glairy mucus merely, instead
of an albuminous exudation of a firm consistence,
is thrown out ; and that, when the features of
bronchitis are assumed, the inflammatory action
has extended down as far as the' small bi'onchi.
It. 3d. Of croup with predominant of spas-
modic and nervous symptom:! (the Laryngismus
Stridulus o£ Good; Spasmodic Croup of M i< h-
[, MlCHAellS, I toe BL e, &c.; and the
Acute Asthma of Infants of SlMPflOK and MlL-
i \ a.) This variety of croup has been desi i ibed
without the occurrence of convulsions in its ad-
vanced stages, or towards its termination; and it
has very commonly presented evidence of cere-
bral congestion. On dissection ef fatal case-, M.
Guers i n i states, that albuminous concretions —
sometimes extensive, but more frequently con-
sisting of small isolated patches — are found ill the
larynx: whilst Mil. nn and Hush detected little
or no lesion of the air-passages. In the ven few
opportunities! havehad of examining the state of
parts in the more purely spasmodic cases of croup,
lesiye glairj fluid, with patches of vascu-
by German and French authors, under the name larity, were observed in the epiglottis and larynx,
of Mil.l. vi;"s Asthma and ha- given occasion to
much discussion relative to its being a variety of
croup, or a distinct disease. ' If i'< being the
former, however, there cannot be the lest doubt
It occurs chiefly in children who are weak, irri-
table, subjects of worms, and of the nervous tem-
perament ; and comes on most commonly in the
aid a similar fluid was found in the large bronchi.
Congestions of the brain, particularly about its
base and medulla oblongata, and of the lungs,
Cavities of the heart and large vessels, were also
found; hut these were most probabl) consecutive
changes mere \ .
16. iii. Complications of Ckoup. — A.
454
CROUP — Complications of.
With Cynanche maligna. This complication is
distinctly alluded to by Johnstone, Wither-
ing, Cullen, and several contemporary authors;
and is common in the epidemic visitations of this
disease, or of anginous scarlatina ; the greater num-
ber of fatal cases exhibiting soft fragments of false
membranes, of a greyish or ash colour, covering
the larynx and trachea, and a livid appearance of
parts of the subjacent mucous membrane. This is
one of the most dangerous complications of the
disease. The affection of the air-passages is here
consecutive, and the difficulty of swallowing usu-
ally precedes the characteristic symptoms of croup,
which are generally accompanied with great fcetor
of the breath. — a. In many instances of the ma-
lignant sore throat, the exudation thrown out from
the inflamed surface forms a pellicle coextensive
with the spread of the inflammatory process from
the fauces to the pharynx and air-passages. In
some cases, ulceration, and slight apparent slough-
ing, occur in the central parts, and those first af-
fected; whilst the surrounding surface, and parts
subsequently diseased, become covered by a soft
and easily lacerated exudation. In rare cases the
inflammation commences in the pharynx [Cynan-
che Pharyngeal and spreads to the fauces on the
one side, and down the larynx, trachea, and oeso-
phagus on the other. In these, the pellicular ex-
udation formed on the inflamed surface very nearly
approaches that of croup; oftener, however, it is
of a darker and dirtier colour, softer, and not so
continuous: whilst in some cases it is formed in
patches, is similar to thin sloughs, and is inter-
rupted in parts by a dark, foul, but not concrete
secretion; the subjacent mucous surface being of
a dark, livid, or brick-red colour, or ulcerated, or
even partially sloughed. Sloughing, however, or
even ulceration, although mentioned by several
writers, is comparatively rare; the more frequent
commencement of the faucial or pharyngeal com-
plication of croup being attended by the pellicular
or concreted exudation now mentioned, without
sloughing. The above changes are most remark-
able in the pharynx, and are slighter in the larynx
and trachea ; the exudation being there some-
what paler, and from its colour and appearance
very generally mistaken, both while adherent to,
and whilst being detached from, the inflamed sur-
face, for sphacelated sloughs, particularly as ob-
served in the throat, and described as such. The
complication, with croup, of various states of an-
gina or sore throat — malignant, or epidemic —
whether commencing in the pharynx, or in the
fauces and extending to the pharynx, is not un-
common. Epidemic visitations of it have occur-
red in very modem times, and have been describ-
ed by Hamilton, Deslandes, Bourgeois,
Bretonnf.au, Trousseau, Moronval, Em-
angard, Schmidtmann, and others. — 8. In
some cases the affection originates in the tonsils,
(Cynanche Tonsillaris, &c.) and extends to the
adjoining parts. In the croup epidemic in Buck-
inghamshire in 1793, and described by Mr. Rum-
sey, the croupal symptoms were stated to have
been coeval with " inflammation and swelling of
the tonsils, uvula, and velatum pendulum palati ;
and large films of a white substance were formed
on the tonsils." Similar appearances have like-
wise been noticed by Ferriar, Hosack, Mac-
kenzie, Rorertson, and Bourgeois, and by
myself ; the pellicular exudation extending over
the fauces, down into the pharynx and larynx.
The croup which has been described by Louis,
Hufeland, and others, as occurring in adults,
was thus complicated. The complication with the
malignant sore throat has been observed by me
both in its simple form and in its association with
scarlet fever. Some years since I attended, early
in the winter, some of the children of a numerous
family residing a few miles from town, in a low
and damp situation. They had had scarlatina,
with very severe sore throat, two or three vears
previously. On this occasion, one of the oldest
was seized with malignant angina, extending to
the pharynx, and along the Eustachian tube to the
ear, with foetid respiration, and irritation of the
larynx, producing a constant tickling cough. A
similar afiection spread to four of the younjer
children, and in two of them it was complicated
with croup; the symptoms of which were severe,
continued, and well marked in one, and more
spasmodic and intermittent in the other. In these,
ash-coloured exudations covered the greater part
of the fauces and tonsils, and extended down into
the pharynx. They recovered with difficulty, by
the means hereafter to be noticed.
17. B. Croup may also be complicated with
Thrush. — Cases of. this description are rare. I
have seen only two of which I have taken any ac-
count. This association has also been observed
by Jurine, Double, Pinel, and Royer-Col-
lard, who notice the adynamic or ataxic char-
acter of the fever accompanying it; the adynamic
state being the consequence chiefly of this asso-
ciated disorder supervening upon pre-existing dis-
ease, generally of the digestive mucous surface, and
often, moreover, in a weak and cachectic system.
The patches of pellicular exudation in the mouth
and throat, characteristic of thrush, had extended
down the pharynx, larynx, and part of the oeso-
phagus, in these cases : death having been oc-
casioned by the consequent irritation, and frequent
recurrence of spasm of the larynx. In the only
one I had an opportunity of examining after death,
there was little or no inflammation in the trachea;
but there was considerable vascular injection of
the pharynx, epiglottis, and larynx, which were
covered by a cream-like exudation, their mucous
membrane being softened. The trachea and bron-
chi contained some flocculent viscid mucus ; and
the digestive villous surface, particularly in the
upper part of the oesophagus, stomach, and por-
tions of the small intestines, was softened and in-
flamed. In all the foregoing complications, the
afiection of the larynx and epiglottis is generally
more remarkable than that of the trachea.
18. C. With the exanthematous fevers. — a.
Croup sometimes comes on during the eruptive
fever, or efflorescence of measles.; when it oc-
casionally assumes more of the remitting and
spasmodic character, and is seldom verv severe
or dangerous. In this case it generallv subsides
as the eruption becomes abundant. But it also
supervenes upon the extinction of the eruption ;
or it does not appear until during or after de-
squamation ; and, in some instances, not until
advanced convalescence. When this occurs, the
inflammatory fever soon passes into an adynamic
state, and the disease assumes a severe form, with
spasms of the larynx, often terminating with
convulsions and suffocation. In one instance of
this kind that occurred in my practice, much
CROUP — Tf. R M I N ATION S — PaoGsosis.
455
swelling am! rfdema of the throat appeared ex-
ternally, and aggravated the symptoms; recove-
ry, however, unexpectedly took place, with a free
discharge of glairy mucus, and concrete fragments
of membrane, in another instance, emphysema
oi' the throat occurred, and gradually extended
over the neck, chest, and face. Permission was
not obtained to examine the body* so that the
channel through which the air had passed from the
respiratory passages into the cellular tissue could
not be exactly ascertained. — b. The complication
with small-pox has been very particularly noticed
by PlNl L, \< B] RS, Vi I J08S BOX, and R.OVER-
Collard, and is not uncommon. It usually
ocelli's in the mure severe cases, particularly when
the disease is confluent, and generally comes on
slowly in the suppurative stage. In the more
malignant cases, the difficulty of respiration is ex-
cessive; the' voice very hoarse or suppressed; the
poroxysmsof snftbeation extreme; the cough dry,
or giving issue merely to a small quantity of dirty
serum, or maco-sanguineous matter : and the at-
tendant fever adynamic. On dissection, a mem-
branous substance is seldom found in the larynx
or trachea, but merely portions of a semi-concrete
matter, with spots of intense inflammation in these
parts, the epiglottis, and large bronchi. — c. The
complication with scarlet fever is never met with
itiag this disease be associated with sore
throat, especially when malignant or epidemic
(§ 16.). — d. The association, or rather the su-
pervention of croup on erysipelas, particularly of
the head and face, occurring in adults, has been
observed l>\ Forestos (Opera, 1. xv. obs. 20.,)
Latoor, Stei ENSoir, and Gibson (Trans, of
Med.-Cltlru.rg. Soc.ofEdin. vol. ii. p. 95.). In
tlios-- cases, the inflammation and characteristic ex-
udation spread from the fauces to the air-passage.
1!). D. With other diseases. — a. Croup is some-
times associated with acute bronchitis ; and when
it terminates fatally, it is often in consequence of
extension of the inflammation to the bronchi, and
thence to the substance of the lungs, pneumonia
thus also supervening. But the croup may also,
although much more rarely, be consequent upon
bronchitis, b. It may occur in the course of
pertussis, and it then usually assumes the re-
mittent and spasmodic, or the bronchial forms.
r. Lastly, it may he associated with asophagitis;
but when this is the case the inflammation with
albuminous exudation usually commences in the
pharynx, and extends down the oesophagus, and
to the larynx. This is not an infrequent occur-
rence in children under two or three years of age;
as, indeed, M. GuERSENT has remarked; the
larynx and epiglottis being the only parts of the air-
passages affected ; and these chiefly with spasm,
from the irritation of the portions of false mem-
brane covering or coming in contact with them.
20. II. Terminations lnd Prognosis, —
Croup may terminate — 1st, in recovery ; 2d, it
may pass into or excite some other disease, — a
return to health, or a fatal issue, taking place me-
diately through it ; Bd, in death, either from ex-
haustion ofthe\it;il energies, or from suflbcation.
A. A return to health is indicated by the mild form
of the disease ; by the quiet respiration whilst the
cough is absent ; by the moderate excitement and
frequency of the puke : l>y a looser cough and a
more natural state of voice, followed b) expec-
toration of viscid mucus* and membranous frag-
ments; by a copious and general perspiration on
the thud day. the symptoms being moderate ; by
opi-l ixis on the second, third, fourth, or fifth
days; by the absence or subsidence of violent
attacks of spasm of the glottis, and sulloealion ;
by the simple' and ancomplicated state of the
disease; and the absence of exhaustion, or of
gioat frequency or irregularity of pulse, and of
Other signs of adynamia.
21. 11. It may excite additional disease, or
pass into some other malady, — a circumstance
which, although not necessarily fatal, may greatly
increase the danger. The morbid state of the
system, and general depression of vital power
accompanying most of the complications now
noticed ; the more constant affection, and dispo-
sition to spasmodic action of the larynx, in all
of them ; the interruption caused to the respira-
tory processes, and the attendant or consequent
congestion of the lungs, as well as the marked
disposition they create to consecutive disturb-
ance ; greatly augment their danger generally.
The disorders consequent upon the simple and
complicated states of croup are both direct and
indirect. The direct are — a. Extension of in-
flammatory action to the bronchi and substance
of the lungs, — generally an unfavourable event,
and indicated chiefly by the unremitting persist-
ence of the symptoms, by deep suffocating parox-
ysms of cough, great frequency of pulse, lividity
or leaden hue of the countenance, by the dark
tinge of the lips and tongue, cold clammy per-
spirations, somnolency, and all the characters
of asthenic Bronchitis (§ 37.). When the
bronchial affection does not appear until during
convalescence, it is more slight, unless the causes
have been energetic, and it presents more of the
usual characters and states of that disease. The
consecutive occurrence of either pneumonia or
any of the forms of bronchitis should be carefully
inquired after, by observing the symptoms, and
examining the chest by auscultation. — b. Exten-
sion of disease to the sub-mucous and follicular
structures, occasioning inflammation and ulcer-
ation of these tissues, with symptoms of laryngeal
or tracheal consumption upon the subsidence of
croup, is a much more rare occurrence than the
preceding ; but, when it takes place, a muco-
puriform expectoration accompanies and follows
the characteristic discharge and signs of croup,
with pain and irritation in the larynx and trachea,
recurring exacerbations of suffocating cough, and
difficulty of breathing, chiefly of a spasmodic
description, particularly when the inflammatory
irritation is seated in the larynx or epiglottis,
and the usual symptoms of hectic. The very
marked tendency, also, of the disease to re/apse,
is in a groat measure owing to the persistence
of a slight degree of inflammatory action in the
large bronchi, or in the trachea and larynx, for
some time after the membranous exudation on
the diseased surface has been thrown oil'; the dis-
order being readily aggravated upon exposure- to
the exciting causes. Tins disposition of the dis-
■ return diminishes with the length of time
that has elapsed from the subsidence of tl ri-
ginal attack, hut does not altogether disappear
tor man] weeks^ei even for months, especially
in some constitutions, and in the last and lir-t
months of the year : and even more than one
relapse may take place in weak, irritable, and
456
CROUP— Diagnosis.
nervous frames, but generally in a more spasmodic
form. — c. Besides producing these, it may occa-
sion, although very rarely, abscess in the vicinity
of the larynx or trachea. I believe that dilata-
tion of the bronchi is a much more frequent re-
sult.— d. Of the more indirect terminations and
consequences of this disease, congestions of the
encephalon, giving rise to convulsions and effusion
of serum in the ventricles, or between the mem-
branes, are the most important. In many cases,
particularly in delicate and nervous children, the
convulsive movements seem to commence with
the spasmodic actions of the laryngeal muscles,
and the strangulation thereby occasioned ; the
head and neck being thrown back, and all the
limbs convulsed. Life is in some cases thus ter-
minated by asphyxy. Jurine, Vieusseux, and
myself, have met with cases of hydrocephalus
following the disease ; but they are not common.
22. C. Danger is to be dreaded, when fever is
very high early in the disease, and when respir-
ation is permanently audible, cooing, and labori-
ous, or as described above (§ 7.). When the
disease goes on to the third stage, notwithstand-
ing the treatment ; when it presents any of the
complications (§ 16.) and consecutive affections
(§ 21.) already noticed: when the discharge of
the characteristic exudation does not take place,
or when the expectoration of fragments of it is
not followed by any relief ; when the counte-
nance becomes livid or leaden, the eyes sunk,
the lips and tongue dark, and the pulse very fre-
quent, small, weak, and irregular ; and the other
symptoms of vital exhaustion appear; great dan-
ger exists. A fatal issue is to be expected when
the patient presents the appearances described as
characterising the third stage, particularly those
noticed as marking its close (§ 8.).
23. III. Diagnosis. — The hoarseness, and the
loud, sonorous, and ringing cough ; the forcible
and difficult inspirations ; flushed face ; injected
and watery eyes ; the frequent and hard pulse,
with thirst and inflammatory fever, the heaving
of the thorax and motion of the trachea, in the
developed stage; and the husky choking cough,
the whispering voice, and wheezing respiration,
&c. of the third stage ; sufficiently distinguish
this disease from any other. When it is uncom-
plicated, nothing beyond a slight redness is ever
observed in the throat ; and there is little or no
pain upon deglutition, unless the larynx be much
affected. — a. Croup can scarcely ever be mistaken
for Cynanche maligna, or C. Pharyngea, or any
other form of sore throat, as long as these affec-
tions do not extend to the larynx ; as the great
difficulty of deglutition, and the but little disturbed
state of respiration, independently of the obvious
affection of the throat, &c, are sufficient to distin-
guish between them. When, however, portions
of the concreted exudations in these affections
irritate the glottis, they occasion a short, tickling,
dry cough; and even excite, in some cases, stran-
gulating spasms of the larynx, nearly resembling
croup, particularly when it is complicated with
these maladies. If, however, it be thus associat-
ed, the croupal characters, in addition to the ap-
pearances in the throat and pharynx, will be too
evident to be misunderstood ; the descriptions
already given of these complications being suffi-
cient to point them out. — b. During the eruptive
fever of measles, the tracheal affection is often so
great as to simulate croup ; and in many cases it
even amounts, as already stated, to a slighter form
of the complaint, which usually disappears as the
eruption becomes matured : but attention to the
symptoms will readily show the nature of the
disorder, and how far the affection of the larynx
and trachea should be viewed as a symptom, or
as an important complication of the exanthema-
tous disease. — c. Croup may readily be distin-
guished from bronchitis, by its sudden and severe
attack ; its occurrence in the evening and at
night ; its remissions ; the hoarseness, and the
ringing, dry, and frequent cough; the difficult in-
spirations, and impeded respiration; the altered
voice and speech ; the sensations and symptoms
referrible to the trachea in the former, and to the
sternum and chest in the latter ; and by the ab-
sence of expectoration until late in the disease,
when it is membranous or tubular, and not mu-
cous and muco-puriform as in bronchitis, until
after the discharge of the membranous exuda-
tions. These characters will also serve to indi-
cate the supervention of croup on bronchitis, — an
occurrence which is sometimes observed, although
much more rarely than that of bronchitis on
croup. — d. Laryngitis is with greater difficulty
distinguished from croup than the foregoing, and
in many respects there is little or no difference.
The practical importance of the diagnosis may
not appear great, but it is sufficiently so to war-
rant an accurate distinction. 1st.- True laryngitis
occurs in adults; seldom, in children, in any other
form than associated with either the simple or
complicated states of croup. 2d. It is a purely
inflammatory disease, attended by a fixed burning
pain in the larynx, increased on pressure and
examination ; and, when attacking adults, never
gives rise to a false membrane, unless it be su-
perinduced in the specific and epidemic forms of
cynanche, and then it assumes modified charac-
ters. 3d. It more frequently terminates in the
manner characterising acute inflammations, viz.
ulceration and suppuration, than when the larynx
is affected in croup. 4th. It is more acutely
and constantly inflammatory, the symptoms are
more continued, and it is more benefited by
a purely antiphlogistic treatment, than croup.
5th. It much oftener passes into the chronic
form, than the latter disease. (See Larynx —
Inflammations of.) — e. Chronic laryngeal and
tracheal inflammation — the laryngeal and tra-
cheal consumption of some writers — resemble
croup, in the hoarse voice, harsh dry cough, and
the difficulty of respiration ; but their progress is
much slower, and less acute, than croup ; they
do not present the violent paroxysms towards
night ; they seldom or never are observed in
children; and ulceration of these parts of the air-
passages is always found in fatal cases. — -f Croup
may also be confounded with the diffusive inflam-
mation which sometimes attacks, either primarily
or consecutively, the cellular tissue about the
throat, or with abscesses in the same situation;
either of which may involve the larynx and mem-
branous part of the trachea, or so affect them as
to give rise to croupal symptoms ; but the ex-
ternal appearances, the difficult deglutition, the
state of the throat, and the history of the case,
will at once show the differences existing between,
them. — g\ Pertussis and crofrp can hardly be
mistaken for each other ; the invasion, charac-
CROUP — Causes of.
457
tors, and progress of both diseases being so very
different The prolonged whoop, the unchanged
voice, and the occurrence of the cough in con-
vulsive paroxysms after a meal, terminating in
vomiting and a copious discharge of a clear and
glairy fluid; the complete intermissions, respira-
tion, voice and speech remaining unaffected; the
almost entire absence of fever, and the much
more slight and chronic form, of the latter disease
in its uncomplicated state; are sufficient distinc-
tions. Croup may, however, occur in the course
of hooping cough ; but then its characteristic
symptoms will make it apparent to the attentive
observer, and point out the nature of the resulting
association. — It. The effects following substances
that have escaped into the trachea often resemble
croup; but may be distinguished from it by the
sudden occurrence of pain and suffocation; by
the frequent change of the exact seat of uneasi-
ness with t lie change of the situation of the
tor. igrj body; the dryness of the cough, and the
violence of the strangulation; and by the irregu-
larity, the completeness, and sometimes the long
continuance, of the intermissions. When a
foreign substance passes into the glottis, and is re-
tained there, suttbeation is generally occasioned
either from the size of the substance, or from the
spasmodic constriction of the muscles of the
larynx occasioned by it. — i. Hysteria may also
simulate croup; but the age of the patient, the
history of the case, and the local and general
symptoms, if attentively observed, will indicate
the nature of the affection. — k. The spasmodic
states of croup closely approach to convulsive
spasm of the larynx; but the absence of cough
and fever, the brief tits of strangulation, the com-
plete intermissions, the spasm of the thumbs and
toes, the purplish countenance, and the general
convulsions, will distinguish that affection from
any form of croup. (See Larynx — Convulsive
Spasm of.)
24. IV. Causf.s. — A. a. Croup is more frequent
in cold and moist climates than in those which are
warm. Rapid and frequent vicissitudes of season,
weather, and temperature, have considerable influ-
ence in producing it. Hence its prevalence in the
valleys of .Switzerland and Savoy ; in this country,
particularly on its eastern side; in the other north-
west countries of Europe; and in North America.
But the middle, and even the south of Europe,
are not exempt from it. M. Valentin has shown
its frequency in the middle and southern provin-
ces of France, GoELia in Vienna, and (imsi
in the north of Italy. Sir James M'Grigor
notices its prevalence — probably in a complicated
form, from its occurrence also in adults (§ 25.) —
at Bombay, in 1S00. According to the inform-
ation given by Jurihe, Lentin, Cheyne, and
others, we might be led to infer that it has been
more common in very modern times than for-
merly: the difference may, however, be owing
to its having been mistaken for some other affec-
tion. I believe that it has not been so frequent"
lv met with during the preceding five years, as
it was about twenty or thirty years ago. M.
JcsiHE remarks, that, although the table he has
given of the number of cases from 17G0 to 1807,
shows a nearly progressive increase, yet he has
observed, at Geneva, UO increase during the last
eighteen years preceding the date of his work.
The following evidence, nevertheless, would ren-
39
der it evident that, in some countries at least,
Croup is more prevalent now than formerly. Ac-
cording to the information given by I >r. ( loon son,
a practitioner of forty years" experience in Lan-
caster had never seen" it until 17(io. Dr. Fried-
lander (Journ.de Monipellier, No. IX. p. 27o'.),
states, that it has become yearly more prevalent
in Vienna; and that tin- physician to the Hospi-
tal for Children, who had treated, from 1774 to
1817, nearly 60,000 children, did not meet with a
single case in the three first years of his practice,
saw it but rarely during the next six years, and
yet treated 1665 cases of it in the last five years
of this period. Similar facts are also furnished
by Dr. Goelis. Although croup occurs at all
seasons of the year, it is most prevalent in those
which are cold and moist, or when the alternations
of temperature are sudden and remarkable. I
have observed it more frequently in the months
of January, February, March, April, November,
and December, especially if east or north east
winds prevail after heavy or continued falls of rain.
I believe that the above results are nearly in accord-
ance with those furnished by Ju ri n e ,C r a w f o r d ,
MicHAeLis, Double, andBRiCHETEAU.
25. b. The great susceptibility of early age,
and the narrowness of the larynx previously to
puberty, have generally been supposed to favour
the occurrence of croup. M. Blaud, however,
denies that this latter circumstance has any influ-
ence in causing it. This is doubtless the case in
respect of the production of the disease, but not
as regards its severity and danger, both of which
it evidently increases. It is rare to meet with
croup until after the child has been weaned: I
have, however, seen it in children at the breast,
as early as three, four, five, and six months of
age; but much more frequently at this age in
those who have been brought up by hand; and
in a still greater number of instances, at from
seven months to upwards of a twelvemonth, in
those which have been recently weaned. M.
Duges states, that he met with an instance of it
in an infant of a few days old. The age at which
the disease is most common is, according to my
experience, from one year to nine. But it not
infrequently occurs at both an earlier and a later
period. Van Bergf. n states, that it is often ob-
served from the age of two to five years inclusive;
Home assigns from fifteen months to twelve years:
Crawford mentions some cases from fifteen
months to two years, but gives the age of from
two to eight as the most common: (1n k yn K,from
sixteen months to twelve years; Salomon, from
two to five years inclusive; Mich aclis, from fif-
teen months to ten years: Zobel, from the latter
months of suckling to nine years; VlEUSSECX,
from seven months to ten years: BERNARD, from
one to six years; Barthez,. from two to ten;
Ruhsey, till fourteen; and Caillau, from eight-
een months to eleven years. The foregoing ap-
plii - only to the simple and uncomplicated disease.
When ii occurs in a complicated form, or conse-
cutively upon anginous affections, .particularly up-
on inflammation of the pharynx, tonsils, or fauces,
or on the exanthematOUS diseases, it may, and,
indeed, occasionally does, occur in adult .subjects,
ami in infants of a more tender age. The cases
published by M. Louis, and denominated by bira
croup in the adult, were instances of the angi-
nous complication Although the occurrence of
458
CROUP — Causes of.
uncomplicated croup in adults is very rare, cases
have been observed by Hosack, Mitchell,
Mills, and Latovr.
26. c. M. Bi.aud and Dr. Alters observe,
that boys more frequently contract the disease
than girls, owing to the greater exposure of the
former to its exciting causes. This opinion has
been opposed by MM. Double and Rotkk-
Collard; whilst Dr. Jurink states, that of
ninety-one cases he treated up to 1808, fifty-four
were boys, and thirty-seven girls; and of twenty-
eight cases which occurred in 1808, eighteen were
boys, and ten girls. According to his observation,
also, the greater number of cases occurred at the
age of two, three, and four years; and next at
one, five, and seven. This accords with my own
experience, which is further supported by that of
Goelis, who, from 1797 to 1808, treated 252
cases of the disease, of which number 144 were
boys, and 108 girls.
27. d. The nervous and sanguine temperaments,
or a mixture of the two — the spasmodic charac-
ters predominating in the former, the inflammato-
ry in the latter — with a tendency to a fulness of
habit, seem to predispose to croup. That it will,
however, often come on independently of ple-
thora, cannot be disputed. I have seen it in in-
fants of about four months old, brought up by
hand; and even in these, soon after having lost
much blood in the treatment of other diseases,
especially when cold easterly winds occur in the
spring or autumn, after heavy falls of rain.
Cheyne, and some others, conceive that an
hereditary tendency exists in croup. But this is not
made out: for, as M. Desruelles has judic-
iously remarked, the only proof that can be brought
in support of it, is the circumstance of two or
more children being seized with it in the same
family; an occurrence which may be explained
by the susceptibility of age and temperament,
being often necessarily the same in several of
them; and by their being exposed to the same
agents, and placed under similar circumstances.
28. e. The localities in which this disease seems
most prevalent are those which are low and moist,
near the sea, on the banks of large rivers or lakes,
or near marshes, in the depths of low valleys, or at
the bases of precipitous mountains. Hence the
endemic character, which some writers have im-
posed on it, but which is not strictly applicable; for,
although it is more frequently observed in the above
situations, yet it is also often met with in places
very oppositely circumstanced ; and it cannot,
therefore, strictly be said to be an endemic disease.
29. f. The epidemic prevalence of croup has
been contended for, and denied, by writers. Some
consider it as entirely sporadic and accidental ;
others suppose that it may become epidemic con-
secutively upon catarrhal epidemics, and that it has
no other claims to such a character; whilst many
believe that it occasionally appears in an epidemic
form. That it has so occurred in former times ap-
pears evident. Baillou manifestly observed it
in an epidemic form, in Paris, in 1576; Ghisi, at
Cremona, in 1747; Starr, in Cornwall, in 1748;
Rosenstein,ui Upsal,&c.,in 1762; Van Ber-
gen, in Frankfort, in 1764 ; Walhbom and
Baeck, in some parts of Sweden, in 1768 and
1772; Barker and Most, in some places in the
United States; Autenreith, at Stutgardt, in
2807; Albers and others, in parts of Saxony, in
1807 and 1808; Schmidtmann, in 1811 ; and
various other writers during the last fifty years.
My own observation would lead me to infer, that,
although croup Is generally a sporadic disease, oc-
curring occasionally at all seasons, vet it sometimes
assumes epidemic features, both in respect of its
simple state, and its complications with other spe-
cies of angina, particularly at periods when they
or catarrhal affections prevail — the seasons favour-
able to the production of these diseases most fre-
quently occasioning this malady also. This opin-
ion derives support from the numerous facts fur-
nished by RUMSEY, PlNEL, JuRlSE, GoELIS,
Albers, Royer-Collard, Bricheteau,
Brf.tonkf.au, and other writers referred to at
the end of this article.
39. g-. Several authors, particularly Wi cema n s ,
BoEHMER,FlELD,RoSEN, GoELIS, LoB STEIN,
GuERSEKT,Louis,SHiLTZ,andG. Gregory,
have adduced facts to show that the disease may
occasionally prove infectious. The two earlv
Swedish writers contemporary with Home, name-
ly, Hali.n and Wahlbom, assert its infectious
nature. On the other hand, this property is denied
by Chalmers, MicHAeLis,THiLENius, Dou-
ble, and Albers. It has most indubitablv man-
ifested this property when it has prevailed epidem-
icaJly , and when associated with cynanche maligna,
and some other exanthematous or anginous affec-
tions. On several occasions, however, of its oc-
currence within a short time, in two or more mem-
bers of the same family, it has evidently proceeded
from the same causes acting upon similar states of
susceptibility and disposition. But even the simple
form of the disease has appeared in children who
have slept in the same bed with another affected
by it. Two or three such cases have occurred un-
der my own observation; and others are recorded
bv Goelis, and some other authors now mention-
ed. Whether or not it was produced in these cases
by inhaling the air respired by the affected child-,
or by the causes above stated, may be disputed.
Yet it is probable that the air which has been re-
spired by the affected may sometimes be a con-
current or determining cause of it in others.
31. B. Although the foregoing may be consid-
ered as predisposing causes merely, vet they are
very commonly the only exciting causes which can
be detected. There is no doubt, however, that
the causes which occasion common catarrh and
bronchitis sometimes also give rise to croup. It is
also not infrequently excited by, or at least con-
secutive of, bronchitis, hooping cough, the various
forms of cynanche, measles, erysipelas, and scarlet
fever; and it occasionally also appears during ad-
vanced convalescence from these, especially the
latter; and, indeed, from other acute diseases.
Also running against the wind, crying, and exer-
tions of the voice; cold acting in any manner, or
upon any part of the body, particularly upon the
neck and throat; having the hair cut short during
cold or windy weather ; habitual exposure, and
the laying aside the accustomed covering of the
neck and chest; and even accidental attempts at
swallowing substances of an acrid nature, or of a
very high temperature; have sometimes produced
croup. The retrocession of the above eruptive
diseases, and the suppression of other eruptions.
or of discharges, secretions, and excretions, are
amongst its most frequefit causes.
3 J. V. Pathology or Croup, — i. Lesions
CROUP— Pathology of.
459
obserctd in fatal rases. A precise idea of the
organic changes which take place in the course
of the disease is Deoeasary to enable us to devise,
at the comtneacemeat, appropriate means, botli
for their prevention, and lor their removal when
prevention is unattainable. The lesions observed
in fatal eases, and present in all, to a greater or
less extent, may be referred to two beads. — 1st.
Inflammation with tumefaction, redness, injec-
tion of the blood-vessels, and slight softening of
the mucous membrane of the air-passages. 2d.
An albuminous exudation in the form of a false
membrane, or a thick, glutinous, and Stringy mu-
cus, or both. (See Bronchi and Air-Pass l-
ges — Lesions of § 12.) A. The former of these
is usually observed, varying, however, in respect
both of intensity, and extent ol' surface affected.
In some eases, they are limited to the upper part
of the trachea ; in others, they extend to the
larynx, or to both the larynx and first divisions
of the bronchi, or to the latter merely ; and. in
complicated cases particularly, or when the dis-
ease assumes a seemingly epidemic, or even in-
fectious character, the inflammatory states now
enumerated, with the characteristic secretion, ex-
ist also hi the pharynx and fauces, and advance
downwards to the ramifications of the bronchi.
In the most acute forms of the disease, the mu-
cous surface of the trachea and larynx assumes
the above inflammatory appearances in the course
of a few hours. la the second stage of the dis-
ease, it becomes streaked or partially covered by
an albuminous, and sometimes a sanguinolent
exudation ; and in the last stage, this exudation
has concreted to a more or less complete mem-
brane ; the inflammatory states of the surface
underneath still remaining, but in a less distinct
manner, and occasionally in patches or streaks
only. In some cases, the injection of the vessels,
and tumefaction of the surface, are but slight,
yet the exudation of a thick concrete membrane
exists to a considerable extent; in others, it is thin
and scanty, or almost entirely consists of a thick
tenacious mucus.
S3. B. The morbid exudation varies much in
consistence, in quantity, and the extent of surface
covered by it. In some complicated or consecu-
tive cases, already alluded to, a false membrane
has formed from the fauces to the last ramifica-
tions of the bronchi MM. Bretonneau and
Bricheteau have observed it without any
breacli of continuity throughout the whole of this
extent. I have never nut with an instance
where it was so extensive, without interruptions,
particularly in the bronchi and about the larynx.
In the greater number of the pure uncomplicated
cases of the disease, the concretion exists princi-
pally in the upper part of the trachea. In the
more acutely inflammatory, it extends to the la-
rynx and epiglottis; in others, to the first ramifi-
cations of the bronchi ; and in a few, in both
directions. In the complicated cases, and in
those of an apparently epidemic, and infectious
nature, the throat is equally affected, constituting
the Diphlheritt , or the Inflammation pelUculaire
of M. Buetonnkw;. This false membrane
is whitish, greyish white, or passing to a grey-
ish yellow. Its thickness varies considerably.
Mi< ii \ei.is and Bard consider a line and hail",
or two lines, to be its utmost thickness. I have
certainly seen portions quite as thick, but not
thicker, anil sometimes evidently consisting of
two or more distinct layers. It is thickest in the
posterior and superior part of the trachea, and
thinnest about the larynx and epiglottis, when it
extends thither, and in the lowest and anterior part
ol the trachea. Its consistence and tenacity also
vary extremely, not only in different, but also in
the same case. It is almost universally Si
where it approaches the bronchi, where i't Gener-
ally passes into a thick glutinous mucus. The
more consistent and firm it is, the more perfectly
is it moulded upon the surface from which it was
secreted. But when the consistence is slight, it
forms merely membranous shreds, or soft polypous
concretions, intermingled with a thick glutinous
mucus. The interior of those exudations is gener-
ally covered with a whitish tenacious mucus; and
their exterior, or the surface which has been in
contact with the inflamed mucous membrane, is
sometimes dotted with minute specks of blood.
In some cases, these concretions are found sliil
adhering to the surface on which they are formed;
in others, they are either partially or altogether
detached from it by a puriform mucus.
34. The state of the exudation varies with the
stage of the disease, the intensity of the inflamma-
tion, and the treatment which has been adopted.
Thus, when a child dies very early in the malady,
instead of tiie albuminous coating above described,
a tenacious, or reddish, frothy mucus is only found.
In this comparatively rare case, the spasm of the
air-passages attending the inflammation, together
with (lie obstruction occasioned by this mucus, has
produced asphyxia. It seems that this glutinous
exudation becomes more condensed, and moulded
into a false membrane, or partially assumes this
state, as the disease advances. (See Bronchi
and Air-Passages.)
35. C. In many cases, instead of a membran-
ous exudation, a viscous, muco-puriform matter
lines the trachea only, or both the trachea and
larynx, as remarked by Frank, Vieusseux,
Valentin, Double, Desruelles, Briche-
teau, Blaud, and Odier. This substance is
whitish, greyish, or yellowish grey, and occasion-
ally flocculent. It is not infrequently formed in
considerable quantity in the more acutely inflam-
matory cases (§ 3 2.), and particularly in those
which terminate fatally in some hours. It seems
as if the quantity of thick viscous matter thrown
out on the inflamed surface, together with the
spasm of the trachea and larynx, occasioned suf-
focation before it could be condensed into a
membranous substance. Cases of this description
line been particularly noticed by M. RoTER-
Collakh, and have occasionally come before
me in practice. I have sometimes also observed
a thick, string)-, and adhesive matter, of a greyish
white colour, in the superior and posterior part of
the trachea and larynx, obstructing the passage,
the mucous membrane underneath being nearly
altogether exempt from redness and tumefaction.
[n bo me instances, this matter has presented a
muco-puruorm character, varying in its shade of
colour, but extremely thick and adhesive. A
similar appearance has been remarked by Dks-
ruxllks, Double, Bl \ui>,and Bricheteau.
Owing to the absence of the usual marks of in-
flammation in thi' situation where this accumu-
lation has been met with, it may he presum-
ed that the inflammatory marks had partly dis-
460
CROUP — Pathology of.
appeared after the discharge of this matter ; its
secretion promoting the resolution of the inflam-
matory action, the remaining signs of which had
vanished after death; the accumulated secretion
which had been instrumental in occasioning dis-
solution alone presenting itself, the powers of
life having been insutiicient for its excretion. I
have suspected, from observing the progress of
other cases, that the inflammatory action some-
times had commenced in the bronchi, extended
upwards along the trachea, and that the secretion
now noticed had been chiefly furnished from the
larger bronchial ramifications, and had become so
thick and adhesive when it arrived at the upper
part of the trachea and larynx, as not to have
been expelled by the cough, but to have excited
spasm of the glottis, and thereby produced suf-
focation. In some instances of this description,
more decidedly inflammatory appearances were
observed in the larger bronchi than in the trachea.
It is probable in these, that the secretion found
in the latter situation proceeded chiefly from the
former, and that the injection of the vessels in
the mucous lining of the trachea had disappeared
after death.
36. D. Any very remarkable lesion of the tis-
sues subjacent to the mucous surface has not been
found, unless the disease has terminated in trache-
al consumption. It has been a question whether
or not the false membrane formed in croup is
capable of becoming organized, and united to the
surface that has produced it. We have no con-
clusive evidence of such an occurrence, although
Soemmerring, Aleers, and Bricheteau
are inclined to believe it possible. The other
morbid appearances are chiefly the consequences
of the interrupted functions of respiration and cir-
culation through the lungs ; such as congestion
of this organ and of the brain ; hepatisation of
parts of the lung; emphysema of this viscus; and,
in very young children, enlargement of the thy-
mus gland. The lesions observed in the compli-
cations of the disease, as far as they have not been
already noticed, more strictly belong to the par-
ticular maladies with which it is occasionally thus
associated ; where they are described, and in the
article Membrane.
37. ii. Nature of the Disease. — Different opin-
ions have been entertained as to its inflammatory
nature in all cases, the exact character of the
inflammation, and the extent to which spasm
of the upper parts of the air-passages may con-
tribute to its production. The very slight in-
flammatory signs sometimes found in the part
covered by the false membrane ; the absence of
these, as well as of any fluid or concrete exuda-
tion, in other cases ; the circumstances under
which the disease has sometimes made its ap-
pearance, and the absence of phlogistic symptoms
in its course, an albuminous exudation either
forming notwithstanding, or not at all; have in-
duced several writers to consider it as not merely
an inflammation of the upper part of the air-
passage, but a disease of a peculiar nature, more
or less connected with the state of the system,
although principally affecting the trachea, and fre-
quently the larynx and large bronchi also. The
opinions of Rogery, IIari.es, Hecker, and
many others, amount to this merely; and they
seem not far from the truth. I have remarked,
that, although croup assumes the more unequivo-
cally inflammatory form in strong and plethoric
children, it does not most frequently affect them,
unless they be of the sanguine or irritable tem-
perament ; that it presents every shade or modi-
fication from this, to the least phlogistic, and most
manifestly spasmodic, form ; that even its most
inflammatory state may assume a spasmodic or
nervous character after large depletions, which,
while they diminish, as under every other circum-
stance of disease, the phlogistic diathesis and
symptoms, increase the nervous and spasmodic ;
and that, even when the first seizure has been of
the inflammatory form, yet the relapses, or sub-
sequent attacks, which are sometimes repeated
several times at irregular intervals, have generally
possessed more of the spasmodic character.
38. Another fact, which I have uniformly ob-
served, appears important, namely, that the
quantity of fibrine and crassamentum in the
blood taken from the patient, and of albumen in
the urine, have been great in proportion to the
inflammatory type of the disease, and the dispo-
sition to form a false membrane; whilst in the
more spasmodic varieties, in which an albumin-
ous exudation is seldom found, or at least but
sparingly, and the urine is more copious and
limpid, and less, or not at all, albuminous, the
blood has presented a smaller or less firm crassa-
mentum. These facts evidentlv show, not only
that the state of the blood is different in these
forms of the disease, but that the condition of the
organic nervous or vital power, upon which the
appearances and constitution of the circulating
fluid so closely depend, is also different ; and,
moreover, that the manifestations of both the one
and the other will vary in the different modifi-
cations of croup, conformably with these results.
The combined and reciprocative operation of the
nervous influence, and the condition of the cir-
culating fluid, will give rise, according to the
state of the frame, and the nature and combin-
ation of the exciting causes, to constitutional
as well as local phenomena ; to a state of febrile
action, which will be inflammatory in, generally,
the majority of cases, nervous in others, and pre-
sent more or less of gastric or even of advnamic
symptoms in some, particularly when the disease
occurs in a complicated or epidemic form. The
importance of attending, during the treatment of
particular cases, and of their different stages, to
the characters of the constitutional disturbance —
to the attendant fever, will be evident, as indi-
cating not only the means to be adopted, but
also the nature of the local mischief. Thus, in
the cases attended by inflammatory fever, the
exudation is abundant and rapidly formed ; in
that manifesting the nervous form, it is either
scanty, imperfect, or consists, of a little glairy
fluid, — the spasmodic character predominating,
and cerebral symptoms sometimes supervening;
and in that presenting the adynamic and gastric
form, it is spreading, — being seldom limited to the
trachea and larynx, but often extending to the pha-
rynx, fauces, the mouth, and even to the nostrils
on the one hand, and down the oesophagus and
bronchi on the other. It is in this last form that
the disease presents itself when it is epidemic or
infectious ; and although the adynamic (or the
I malignant character, according to J. P. Frank)
often manifests itself early> yet the antecedent fe-
brile symptoms very evidently evince high action.
CROUP — l'lTll.lUM.v OF.
4G1
39. There is one important point not sufficient!)
adverted to by authors, viz. theverj earl) period
at which the traoheal exudation is often poured
out, iii the inflammatory states of the disease; the
symptoms marking ilu> first or premonitory period
being those indicating the local developemenl of
the malady. Tims, a healthy child has evinced
no disorder for several days, or the disorder has
bean bo alight as to escape observation — it ma]
eve? be more than usually lively and alert on the
dav preceding the night on which it is most severe-
ly attacked; and yet, if an emetic be that instant
exhibited, a large quantity of thick, glairy, san-
guineous, and gelatinous matter will he brought
away from the air-passages; showing that, in
many instances, the early advances of the inflam-
matory action is slow and insidious; that the cha-
racteristic, seizure often does not occur until the
exudation has accumulated to a considerable ex-
tent in the trachea, or the inflammation lias ex-
tended to tin' larynx; and that it is partly owing
to the retention of this matter, — which is evi-
dently thrown out in a fluid form, — that it con-
cretes into a false membrane, each successive dis-
charge sometimes forming a distinct layer. MM.
Gxndris, Andral, and other pathologists,
have remarked, that "the inflammatory action
which gives rise to the albuminous exudation on
the surface of mucous membranes is of a sub-
acute, rather than of an acute kind. I believe that
this is the case in respect of the inflammation of
the trachea and larynx, in croup; and that the
formation of a false membrane is the result not
so much of the sthenic or acute character of the
local action, as of the abundance of albumen and
fibrine in the blood, — a circumstance which partly
accounts for the frequency of relapses in some chil-
dren (§ 41. o.), and justifies Harxes, Heck er,
and others, in considering the disease to consist
of a peculiar form of inflammation. Some writ-
ers, however, suppose that the very acute symp-
toms, and rapid termination of many cases, mili-
tate against these opinions; but it should be recol-
lected that, even in the most severe cases, the
inflammatory action, when it commences in the
trachea, often exists for several days, in the man-
ner already noticed, until it has either extended to
the larynx, or produced such a quantity of albumi-
nous exudation as will obstruct respiration, or
induce, by its irritation, spasm of the air-passages,
. — these effects being the chief causes of the sever-
ity and rapid termination of the disease. This
will become more evident, when we consider the
consequences of interrupted respiration upon the
frame — whether the interruption proceed from
the mechanical obstruction occasioned by the
exudation and false membrane, or the frequent
recurrence or continuance of spasm of the larynx
and trachea; or from inflammatory action, and
its consecutive exudation extending down the
bronchi; or from two or till of these combined.
These consequences are, in fact, the third stage
of the disease; the symptoms of which are the
usual phenomena resulting fmm obstructed respi-
ration, interrupted circulation, and congestion of
the longs; imperfect action nf the air upon the
blood, and the circulation of this fluid in a near!]
venous state, with congestion of the cavities of the
heart, and impeded return of blood from the head.
The circulation, moreover, of imperfectly arterial-
ised blood to the nervous systems occasions lethar-
39«
gy,with sinking of the vital powers, and incream
the disposition to spasmodic) action of involuntary
parts, and to convulsive movements of voluntary
organs; all which (the former especially) become
so prominent a character of the malady in its
advanced stages, and often terminate existence.
Thus it will appear manifest,— and the I
of great practical importance,— that the W
rapidity, and danger of croup, are not the imme-
diate consequences of the activity or acutensai of
the inflammatory action; but of the exudation to
which it gives rise, and of the conformation and
functions of the parts which it affects.
40. Dm .\i,,.lriu.\ n, Albers, and Schmidt,
have considered it worth ascertaining, in how far
t he disease could he artificially produced in the
lower animals; and whether or not, when thus
produced, inflammation exists to the extent of
accounting for the phenomena, or gives rise to a
false membrane. They injected into the trachea
of fowls, dogs, cats, sheep, wolves, &o. various
irritating substances, as the bichloride or peroxide
of mercury (Schmidt) dissolved in spirits of
turpentine, and solutions of iodine, and nitrate of
silver; they moreover made these animals inhale
the fumes of sulphuric and muriatic acids; and
the results were just what might have been an-
ticipated, viz. that in some cases, inflammation
without any exudation was produced; in others, a
fluid, or more or less concrete exudation was found
in various quantity; and in all, the matter in the
air-passages was not sufficient entirely to obstruct
the access of air to the lungs; thus confirming the
opinion justly contended for by Cullen and oth-
ers, that a great part of the phenomena and conse-
quences of the disease is to be attributed to spasm
of the larynx and trachea. Schmidt succeeded
in producing a false membrane only in young ani-
mals,— a fact in accordance with the spontaneous
occurrence of the disease previously to puberty, and
to be referred to the more albuminous state of the
blood often observed at this period. It may be of
importance to know that croup — identical in its
phenomena and organic changes with the disease
in the human subject — occurs also in several of
the lower animals, especially before they are fully
grown. Its occurrence in chickens is Well known
by the name of "Pip." Dupuy, Rush, Valen-
tin. Yocitt, and others, have observed it in
horses and dogs; Double, in lambs and cats;
and GHISl and GHOHIER, in cows. In some of
these animals it has even occurred as an epidemic.
41. Pathological Conclusions. — Another point,
of greater importance than it may at first semi, is
whether or not the matter concreted and moulded
on the inflamed mucous surface he exuded by this
tissue itself, or secreted by the follicular glands with
which it is so abundantly supplied. M. Grim-
\i n has adopted the latter alternative. From
particular attention 1 have paid to this subject,
some of the results of which have been stated in
the article Bros< ui (§11, 12.), I would draw the
latin ,tn it. ami to the
_'\ of croup generally: — (».) That the
mucous mi mbrane itself is the scat of the inflam-
mation of croup; and thai its vessels e\udo the
albuminous or characteristic discharge, which,
from i's plasticity, and the effects of temperature
and the continued passage of air over it, becomes
concreted into a false membrane;— (A) That the
occasional appearance of blood-vessels in it arises
462
CROUP — Treatment of its common Forms.
from the presence of red globules in the fluid when
first exuded from the inflamed vessels, as may be
ascertained by the exhibition, upon the approach
of the symptoms, of a powerful emetic, which will
bring away this fluid before it has concreted into
a membrane; these globules generally attracting
each other, and appearing like blood-vessels, as
the albuminous matter coagulates on the inflamed
surface; — (c) That the membranous substance is
detached in the advanced stages of the disease,
by the secretion, from the excited mucous follicles,
of a more fluid and a less coagulable matter, which
ia poured out between it and the mucous coat;
and, as this secretion of the mucous crypta? be-
comes more and more copious, the albuminous
membrane is the more fully separated, and ul-
timately excreted if the vital powers of the res-
piratory organ and of the system be sufficient to
accomplish it; — (d) That sub-acute or slight
inflammatory action may be inferred as having
existed, in connection with an increased propor-
tion of fibro-albuminous matter in the blood,
whenever we find the croupal productions in the
air-passages ; but that these are not the only
morbid conditions constituting the disease; — (e)
That, in conjunction with the foregoing, — some-
times only with the former of these in a slight de-
gree,— there is always present, chiefly in the devel-
oped and advanced stages, much spasmodic action
of the muscles of the larynx, and of the transverse
fibres of the membranous part of the trachea,
which, whilst it tends to loosen the attachment of
the false membrane, diminishes, or momentarily
shuts, the canal (of the larynx) through which the
air presses into the lungs; — (/) That inflamma-
tory action may exist in the trachea, and the exud-
ation of albuminous matter may be going on, for a
considerable time before they are suspected, — the
accession of the spasmodic symptoms being often
the first intimation of the disease; and these, with
the effects of the pre-existing inflammation, give
rise to the phenomena characterising the sudden
seizure; — (g) That the modifications of croup
may be referred to the varying degree and activity
of the inflammatory action; the quantity, the
fluidity, or plasticity of the exuded matter; the
severity of spasmodic action; and to the pre-
dominance of either of these over the others in
particular cases, owing to the habit of body, tem-
perament, and treatment of the patient, &c; —
(h) That the muco-purulent secretion, which often
accompanies or follows the detachment and dis-
charge of the concrete or membranous matters,
Is the product of the consecutively excited, and
slightly inflamed, state of the mucous follicles,
the secretion of which acts so beneficially in de-
taching the false membrane; — (i) That a fatal
issue is not caused merely by the quantity of the
croupal productions accumulated in the larynx
and trachea; but by the spasm, and the necessary
results of interrupted respiration, and circulation
through the lungs; — (A) That the partial de-
tachment of fragments of membrane, particularly
when they become entangled in the larynx, may
excite severe, dangerous, or even fatal spasm of
this part, according to its intensity relatively to
the vital powers of the patient; and that this oc-
currence is most to be apprehended in the com-
plicated states of the malady, where the inflam-
matory action, with its characteristic exudation,
spreads from the fauces and pharynx to the
larynx and trachea; the larynx being often chiefly
affected in such cases, and, from its irritability
and conformation, giving rise to a more spasmodic
and dangerous form of the disease; — (/) That the
danger attending the complications of croup is
to be ascribed not only to this circumstance, but
also to the depression of vital power, and the
characteristic state of fever accompanying most
of them, particularly in their advanced stages; —
(m) That irritation from partially detached mem-
branous exudations in the pharynx, or in the
vicinity of the larynx or epiglottis, may produce
croupal symptoms in weak, exhausted, or nervous
children, without the larynx or trachea being
themselves materially diseased; and that even the
sympathetic irritation of teething may occasion
the spasmodic form of croup, without much in-
flammatory irritation of the air-passages, partic-
ularly when the prima via is disordered, and the
membranes about the base of the brain are in an
excited state; — (») That the predominance in
particular cases of some one of the pathological
states noticed above (g-,) as constituting the dis-
ease, and giving rise to the various modifications
it presents, from the most inflammatory to the
most spasmodic, may be manifested in the same
case, at different stages of the malady, particularly
in its simple forms, and in the relapses which may
subsequently take place; the inflammatory cha-
racter predominating in the early stages, and either
the mucous or the spasmodic, or an association of
both, in the subsequent periods; — (o) That the
relapses, which so frequently occur after intervals
of various duration, and which sometimes amount
to seven or eight, or are even still more numerous,
may each present different states or forms of the
disease from the others; the first attack being
generally the most inflammatory and severe, and
the relapses of a slighter and more spasmodic
kind; but in some cases this order is not observed,
the second or third, or some subsequent seizure,
being more severe than the rest, or even fatal,
either from the inflammation and extent of ex-
udation, or from the intensity and persistence
of the spasmodic symptoms, — most frequently
from this latter circumstance. The above in-
ferences, however minute or trite they may seem,
should not be overlooked, as they furnish the
safest and most successful indications of cure,
and are the beacons by which we are to be guided
in the treatment of the disease.
42. VI. Treatment. — i. The curative
Treatment of Crocp. I shall first state the
method of cure on which I would chiefly rely in
the different modifications of the disease; and after-
wards notice some of the remedies which have
been recommended by various-writers. Several of
tbrs<> are of great benefit in certain circumstances
of the disease ; but we can seldom depend upon any
one of them: it is on a judicious combination and
sequenceof means that we should chiefly rely: and
upon the adaptation and co-ordination of these in
particular cases. The intentions of cure are — 1st,
to diminish inflammatory and febrile action, when
present; and to prevent, in these cases, the form-
ation of a false membrane, or the accumulation
of albuminous matters in the air-passages; — 2d,
when the time for attempting this has passed, or
when it cannot be attained, to procure the dis-
charge of these matters; — 3d, to subdue spas-
modic symptoms as soon as they appear; and, 4th,
CROUP — Treatment of its common Forhi.
463
to support the powers of life in the latter stages,
■o as to prevent the recurrence of spasms, and to
enable the system to throw off the matters exuded
in the trachea.
43. A. Treatment of the common and inflam-
matory Croup. — a. If the practitioner see the
patient in the fir* Stage (§ 6.), particularly if
hoarseness, or a rough rough, with other catarrhal
symptoms, be present, it will be proper to give
an active antitnonial emetic, with the view of ful-
filling the first of the above intentions. This will
often bring away a considerable quantity of a
thick, glairy, and sometimes slightly sanguineous
matter from the trachea, and will give immediate,
although generally only temporary, relief. If the
matter discharged from the air-passages present
the above appearances ; if the child be plethoric,
the pulse at all excited, and the countenance
Hushed; we should not be deceived by the calm
following the full operation of the emetic, but
should have recourse to blood-letting. In the
majority of instances, cupping between the shoul-
ders or on the nape of the neck, or the application
of leeches on the sternum, to an extent which the
age, habit of body, and strength of the patient may
warrant, will be preferable to vensesection. Under
these circumstances, particularly when the nausea
occasioned by the emetic has hardly subsided,
the abstraction of little more than an ounce,
or an ounce and a half, of blood, for every
year that the child may have completed, will
be borne. In town practice, the local is pre-
ferable to general blood-letting ; but the latter
will be adopted, with advantage, in the country,
amongst plethoric and robust children. The ad-
vantages of depletion and antimonials are attribu-
table to their influence in arresting the inflamma-
tory action, and, from the consecutively accelerat-
ed absorption of fluids into the circulation, to the
relative diminution of the albuminous constituents
of the blood.
44. Immediately after depiction, and an emetic,
the best internal medicine undoubtedly is calomel
and James's poivder — from three to five grains of
the former, and two or three of the latter. This
powder may be repeated every second, third, or
fourth hour, until two or three doses have been
taken. After the first dose, the child should be
put in a tepid bath; and be allowed as much tepid
diluents as the stomach will bear, in which sub-
carbonate of soda may be dissolved, and which
may be rendered agreeable with syrup. If the
powders, given to the extent now mentioned, have
not acted upon the bowels, castor oil, or some
other purgative, assisted by an emetic, should be
administered. These means will seldom fail of
cutting short the disease. If. however, it still
proceed, the means to be employed in the next
stage should be adopted according to the circum-
stance of the case.
45. b. The second or <1< oeloped stage is that in
which medical aid is most frequently resorted to;
and at this period, conformably with what has
been stated (§39.), the disease is actually further
advanced than the symptoms indicate. At its
commencement, however, the first intention of
cure should be attempted; but the most decided
means will he now requisite to attain its fulfil-
ment These should be put in practice, even
although the treatment already recommended may
have been employed in the preceding stage.
An active antimonia! emrtir should be instantly
exhibited, so as to produce full vomiting; and im-
mediately upon the conclusion of its operation,
blood-letting, general or local, must be resorted
to. The abstraction of a neater quantity than
that indicated above (§ 43.) will seldom be
more beneficial ; nor, indeed, will it be bnrne
without producing syncope, which, in children,
especially, should be avoided, as favouring the
supervention of convulsions or reaction. But it
may be requisite, particularly when the patient
has not lost any blood during the preceding Stage,
to repeat the depletion. On this, or on any
future occasion of repeating it, local blood-letting,
in the situations and mode already mentioned
(§ 43.), is now to be preferred. If it have not
been prescribed previously, the calomel and
James's powder should be given every two or
three hours, until three or four doses are taken ;
and the adjuvants directed to accompany and to
follow this medicine in the first stage, should also
be employed in this.
46. Having thus carried depletion as far as
seems prudent, and fully evacuated the prima
via, and a yery obvious improvement have not
taken place, or if the suffocating seizures recur
notwithstanding, a blister should be applied be-
tween the shoulders, on the nape of the neck, or
on the epigastrium, but never on the throat; and
if symptoms of febrile excitement still attend the
seizures, a full dose of tartar emetic should be
given, so as to excite vomiting again, and be re-
peated until it has this effect fully. If the urgent
symptoms and fever still continue, vomiting may
be excited a third or fourth time, at intervals of
two or three hours. The tartar emetic is, upon
the whole, the best medicine for»the purpose in
the early or inflammatory states of the disease,
and may be given in doses of half a grain, in
simple solution, to a child two or three years old,
as advised by Dr. Cheyne, and repeated at about
half an hour, or sooner, if vomiting he not induc-
ed. M. Gv erse NT prefers ipecacuardia, and
advises blood-letting to precede the exhibition
of emetics. Where the inflammatory action is
considerable, this method may be adopted ; but
where we may expect to bring away the exuded
matter by means of an emetic, before it has con-
creted into a membrane, it will be as well to ex-
hibit one without delay, and to keep up a constant
nausea by the same medicines given in frequent
and small doses.
47. If the symptoms continue notwithstanding
the judicious use of the above means, we should
infer the formation of a false membrane, unless
the exacerbation be altogether spasmodic — the
breathing and voice becoming natural, or nearly
so, in the intervals. The measures to be em-
ployed now should have reference to the sepa-
ration and discharge of the concrete exudation,
and the removal of spasmodic symptoms — to the
fulfilment of the second and third intuitions pro-
posed. Bleeding, even if the state of the patient
would admit of it. would not promote these inten-
tions ; and the exhibition of calo I or mercu-
rials, excepting with the view of promoting all
the abdominal secretions and excretions, and
thereby to derive from the diseased organ, would
not materially assist our views, inasmuch as it is
impossible thereby to affect the system of chil-
dren so as to prevent the formation of coagulable
464
CROUP — Treatment of its common Forms.
lymph. In this case, we should assist the opera-
tions of nature in detaching the false membrane.
It has been stated, that this is accomplished by
the effusion, by the excited follicles, of a fluid
matter between the concrete substance and the
mucous coat; therefore those medicines which
have usually the effect of increasing and render-
ing more fluid the mucous secretion of the air-
passages, should now be prescribed. But care
should be taken not to exhibit these, or any other
expectorants, too early, or until depletion has been
carried sufficiently far. They are most service-
able about the termination of the second, and the
commencement of the third stage. The medicines
best calculated to act as expectorants in this dis-
ease are, the preparations of squills, of ammo-
niaeum, of senega, the sub-carbonates' and the
sidphurets of the alkalies, and camphor. The
oxymel or syrup of squills may be given, either
alone, or with some one of the sulphurets, or with
senega, and generally to the extent of keeping up
a slight nausea, unless the exacerbations of cough
and suffocation be severe, when full vomiting
should be produced by their means. I prefer the
emetic effect at this period to be obtained by
squills; as antimony lowers too quickly the vital
power, which ought now to be supported, so as to
enable the diseased organ to throw off the morbid
matter formed upon its surface. A mixture, con-
sisting of decoction of senega, with vinum ipeca-
cuanha} and oxymel of squills, may also be adopt-
ed with equal advantage. When the medicines
fail of exciting vomiting, the pharynx should be
irritated by a feather. I have seen very much
benefit derived from this simple means; and have
considered it more beneficial than any other, in the
third stage, in promoting the discharge of matters
from the trachea. Jurine also places great re-
liance on it. When severe exacerbations, with
spasm and threatened suffocation, occur, it is al-
ways most advantageous to produce instant vom-
iting. The sulphate of zinc has been advised by
M. Guersent, and the sulphate of copper by
Dr. Hoffmann, for this purpose.
48. During this and the preceding stages, the
inhalation of watery and medicated vapours may
be resorted to. At the commencement of the
disease, vapours of an emollient kind are most
beneficial; but when we wish to promote ex-
pectoration, camphor may be added to the sub-
stance used in this way. Home, Crawford,
Pearson, Rosen, Pinel, and Goelis, have
approved of this practice. When spasmodic
symptoms manifest themselves, inhalation, assist-
ed by the tepid or warm bath, is often of use; but
antispasmodics should also be prescribed with the
other medicines, or in enemata. I have never seen
any permanent advantage derived from narcotics
given by the mouth, except from opium or syrup
of poppies, combined with antispasmodics; prob-
ably owing to their lowering the vital energies,
which are always much depressed when nervous
symptoms appear. Great care should be always
taken in exhibiting opiates in clysters to children:
in very young children the practice is attended by
much risk. Opiates are given to greatest advan-
tage with ipecacuanha, as in Dover's powder,
or with camphor or calomel, or with both. I
have likewise found camphor, with James's pow-
der and hyoscyamus, of much benefit in some
cases in which 1 have prescribed it. Thehydro-
sulphuret of ammonia may likewise be tried, in
both this and the next stage of the disease.
49. In many cases, the judicious use of blood-
letting, calomel, antimony, &c. will cut short the
disease, even although the patient may not have
been treated until this period has been far advanc-
ed; and in others, the active use of these means
may give rise to very alarming depression of the
vital energies, even when they may have succeeded
in removing the cause of obstruction and irritation
in the air-passages. In these, stimulants, antispas-
modics, and restoratives must be immediately
resorted to, but with great caution, lest the in-
flammatory action be reproduced by their means.*
* The following case will illustrate the above observation,
and may prove instructive to the less experienced reader. I
have extracted it verbatim from my note-book, with the re-
marks suggested at the time appended to it : —
William Horfson, aged five years and a half, was seized,
on the 17th of Nov. 1821, with hoarseness, fever, and a
ringing, dry cough. The mother opened its bowels with
salts, and gave it some antimonial wine. The following dav,
in the evening (18th ) I saw it. There was much fever,
with flu-lied countenance, and a constant, hard, and ringing
cough, with a sibilous noise on respiration. Pulse frequent
and hard ; skin harsh and dry ; great restlessness, tossing,
dyspnoea, with hoarseness, and the characteristic breathing
of croup. I directed blood-letting from a vein in the arm ;
and the blood was allowed to flow in a full stream till ap-
proaching syncope was indicated, seven ounces being ab-
stracted ; and the following powders were directed to be
t ken every ten minutes, till full vomiting; and subsequently
every three hours : —
Mo. 162. K Hydrarg. Submur. gr.' xxx. ; Antimon. Tart.
gr. iij. ; Ipecacuanha? gr. vj. Misce bene, et divide in Pulv.
viij.
Early in the morning of the 19th I again saw the child.
The powders had been given, as above, until lull vomi ing
had been produced ; and one powder had been taken subse-
quent v. The sense of suffocation had disappeared after the
vomiting. The matters ejected contained much thick, ropy
mucus, with membranous shreds of firm coagulated lymph
floating in it. The cough and croupy symptoms had disap-
peared; the voice was clear, and the respiration easy: but
now the child complained of distressing sickness, with fre-
quent vomiting and purging the stools were first bilious,
offensive, copious, and feculent ; but they had now become
waterv. The pulse was extremely frequent, so as scarcely
to be counted; and so small and thready as hardly to be felt
at the wrist. The countenance was pale and sunk ; the skin
cool and moist ; and all the symptoms of sinking of the
powers of life very manifest. The powders were discontin-
ued, and the following mixture directed : —
No. 163. ]{ Aq. Cinnam. S iijss. ; Spirit. Ammon. Arom.
~ jss. ; Tinct. Opii ri|xv. ; Syrup. Scilla? ",iij. M.
Two teaspoonsful of this were to be taken every ten or
fifteen minutes, until a decided effect from it was evident.
After four or five doses, the stools and sickness were re-
strained, and the child fell into an easy and sound sleep.
A blister was now applied to the sternum, which was to
be removed at the end of four hours, and poulticed with a
bread-and water poultice. The semicupium to be employed
afterwards, and at bed-time. Three grains of calomel, with
one of James's powder, to be taken at night ; and the mist.
camphoras, with liq. ammon. acet., vini ipecacuanha?, and
svrup. papaveris, every three hours. Linseed tea, or barley
water, with sugar-candy or liquorice, for common drink.
20lh. — All the symptoms of croup had disappeared : but
there was still some cough and fever, with occasional
paroxysms of difficult breathing. The bowels had been
open this morning ; pulse 120. and small. Antimonial
wine was added to the mixture; and an injection directed,
with assafcetida, spiritus terebinthina?, oleum ricini, a.d
camphor.
In the evening. — Me had had no return of the paroxysms
since the injection, which was retained above an hour, and
had procured two evacuations, rulse 116; cough less
frequent ; skin more natural. The blistered surface had
risen in some parts, and was inflamed in all.
From this time he continued to recover : diaphoretics,
den ulcents, aperii nfs, and the semicupium, being employ-
ed until convalescence was complete.
Remarks. — It is hv no means unusual to find a recurrence
of the inflammatory and local symptoms, after they have
been apparently mosf completely subdued by mean* similar
to those employed in (he foregoing case ; and even after the
powers of life, and all local inflammation and febrile ic-
CROUP — Trkatment of the Spasmodic Form.
465
50. c. The treatment of the third stage, either
when the patient has not been earlier seen, or
when previous measures have failed, should be
directed with the view of fulfilling the second and
third indications of cure, and at the same time
with due reference to the fourth — the preserv-
ation of the exhausted nervous and vital powers.
The chances of recovery are now very few; but
theae few should not be neglected. Many of the
remedies already mentioned, especially expec-
torants, should also be exhibited in this stage;
and these ought occasionally — particularly when
the symptoms become very urgent — to be given
so as to exert a speedy emetic action; and be
combined with antispasmodics — with either cam-
phor, ammonia, aether, musk, valerian, assafoetida,
the oxide of zinc or bismuth, the sulphurets of the
alkalies, ^c. ; and the same medicines, or the
infusion of valerian, may also be prescribed in
enemata, especially when spasmodic or nervous
symptoms are predominant. When emetics are
required in this stage, those substances which are
exhibited in smaller doses in the remissions, in
order to act as nauseants or expectorants, are
amongst the most eligible — particularly squills,
senega, the sulphate of zinc. The inhalation of
the vapour of ammonia, camphor, or aether, in
that of warm water; or of the fumes of warm vin-
egar, either alone, or with camphor; is sometimes
productive of benefit in this period. Some ad-
vantage may also be derived from sternutatories
blown into the nostrils, as advised by Lentii*
and Thilenius. I have seen, in two or three
instances, the sneezing occasioned by them favour
remarkably the discharge of the false membranes
from the trachea; common Scotch snuff having
been used for this purpose.
51. The tepid bath may be resorted to both in
this and the preceding stage, once or twice daily,
or according to circumstances; and either the
sulphuret of potash, or the sub-carbonates of
potash or soda, may be put in the water; and,
if a tendency to collapse becomes apparent, the
bath should be warm, and some mustard may
also be added. Blisters between the shoulders,
or on the sternum, may likewise be tried; but
they always require great discrimination and
care, in order to avoid unpleasant consequences
from them. They should not, in this stage, re-
main on longer than from four to eight hours.
Home and Thil knits advise them to be ap-
plied to the neck; Lentin and Goblis, to the
neck and sternum; and Rover-Collard, be-
tween the shoulders or on the anus; MaerCKER
states, that he hits derived but little benefit from
them. OLBERsand Roi er-Collard apeak fa-
vourably of sinapisms placed on the lower extrem-
ities. 1 have, however, seen more advantage ac-
crue from rubefacient liniments ( F. 299. 304-.) or
tion, hul been equally depressed. This recurrence of the
acute symptom* seems owing i" either an over active use of
stimulants, or an injndici il them in I he collapse
occasionally following the decided use of I • I « »- » I letting and
antimony. Sometimes it arises from exposure to re, hi oi i
current of cold dry air ; and then, generally a distinct rliil-
lincss or rigo is previously felt Occasionally I havi
it to H i"" early recourse to rood or artii les of > too stimu-
lating and indigestible description. Inattention to the state
of the bowels will also dispose to it ; an I even i bli
plied too near upon tin lently produced
such an i illy in thin irritable children. In no
case would I permit a blister to be placed upon the throat
so firmlv am I persuaded that mischief is occasioned from it
in this situation.
epithems, applied on the epigastrium and chest, or
between the shoulders. During this, as weU as
the preceding stage, a cathartic actum should be
exerted upon the bowels, unless the medicines pre-
viously exhibited occasion diarrhoea, or dyaenterie
symptoms. Medicines of this description are
beneficial, as active derivatives from the scat of
disease, and as evacuants of morbid secretions.
Calomel, with jalap, may be" given, either alone,
with musk, or some other antispasmodic medi-
cine; but, in every instance, the occasional exhi-
bition of an enema should not be neglected. Ol-
bers, ALEERS,and Jurine, strenuously .advise
large doses of musk to be exhibited; and Ke.nd-
rick and Royer-Collari), assafoetida to be
administered in clysters. The affusion of cold
water on the head has been sometimes resorted to
by H vrders, Schmidt, and myself, when the
preceding means have failed, particularly if con-
gestion or other cerebral symptoms have super-
vened, and the exacerbations have assumed chief-
ly a spasmodic form.
52. B. Treatment of the humid and spas-
modic Forms of Croup. — a. In the humid or
bronchial form of the disease, the intentions of
cure are, — 1st, to subdue inflammatory action;
2d, to remove the matters exuded from the air-
passages ; 3d, to calm spasmodic action ; and,
4th, to support vital power. These can be at-
tained only by bleeding, general or local, as
already advised, but never from the throat itself;
in the early stages by antimonial emetics, and
subsequently by those consisting of ipecacuanha
or sulphate of zinc; by calomel, with James's
powder, as prescribed above, and afterwards
with other purgatives, as scaminony or jalap;
by cathartic enemata; by external derivatives;
and, lastly, by antispasmodics and diffusible
stimulants. Of these, individually, little need
be added to what has been already advanced.
More advantage seems to be derived from purg-
atives, in this, than in any other form of the
disease. I have sometimes seen them bring away
a thick, gelatinous, glairy secretion, similar to
that discharged from the air-passages in the ad-
vanced stages. Their operation should be pro-
moted by the administration of purgatives in
antispasmodic clysters, as extract of colocynth.
with asssefcetida, valerian, or camphor; and if
spasmodic symptoms become urgent, tin; sulphu-
rets or sub-carbonates of the alkalies, and either
of the various antispasmodics already mentioned,
may also he taken by the mouth, particularly
camphor, with James's powder, <>r Kermes min-
eral, or ipecacuanha, with spirits of nitre, earner,
or other diaphoretics. The medicated tepid or
moderately warm bath, blisters, rubefacient lini-
ments, the inhalation of simple or medicated va-
pours, may also be resorted to in the manner de-
tailed above. In the lasl stage, when the powers
of life indicate exhaustion, amnion! num. senega,
owmel of squills; and camphor, assafoetida,
musk, ammonia, the aethers, 8tg in full doses;
and rubefacient ami stimul tting frictions, liniments,
and baths, with the reel of the treatment already
railed at this period; are the chief means
in which we can confide.
.">:5. ';. In the spasmodic fbrm of the malady,
the indications of cure are very nearly the same
its now Stated; but the treatment will necessari-
ly vary with the extent to which inflammatory
466
CROUP — Treatment of its complicated Forms.
irritation may be supposed to exist either in or
about the larynx, particularly soon after the ap-
pearance of the disease; or about the medulla
oblongata, in its more advanced course. In that
state of constitution in which this form is most
frequent, bleeding is seldom required beyond that
procured by a lew leeches applied to the nape of
the neck, when we infer the presence of inflam-
matory irritation in the above situations. In this
modification, whether occurring primarily, or in
relapses, antispasmodics, given both by the mouth
and by clysters, are indispensable; but emetics,
and afterwards cathartics, medicated tepid or
warm baths, and inhalations, blisters, or rubefa-
cient frictions and liniments along the spine and
over the epigastrium, and the cold affusion on the
head, also constitute important parts of the treat-
ment. The antispasmodics most to be confided
in, ate, the sulphurets and sub-carbonates of the
alkalies, valerian, assafoetida, ammonia, camphor,
musk, the preparations of aether, the oxides of
zinc and bismuth, and the liquor ammonias aee-
tatis, with excess of ammonia. Mr. Kim is ell
states, that he lias derived most advantage from
the internal use of arsenic, or sulphuret of potass,
aided by regular attention to the bowels, the
shower bath, and by blisters or anodyne frictions
on the spine. Of arsenic I have had no experi-
ence in this affection; but I have given the pre-
parations of bark, and used the other remedies
he has mentioned, with advantage. If the above
means do not soon remove the disease, irritation
about the base of the brain or medulla oblongata
should be suspected, and leeches ought to be ap-
plied on the neck; and calomel, with aperients,
or with mask or camphor, exhibited once or twice
daily, injections being also employed : cerebral
symptoms should be always enquired after, and
energetically treated when detected.
54. C. Treatment of complicated and con-
secutive Croup. — The treatment of the various
complications of the disease must be direct-
ed according to the general principles now
sketched; and with strict reference to the nature
of the associated malady, to the period of the
primary disease at which it appeared, to the
characters of the attendant constitutional dis-
turbance, and of the prevailing epidemic, and to
the well-ascertained fact that local inflammations
supervening in the course of continued or eruptive
levers, although they require depletions, do not
admit of them to the same extent as those which
occur primarily.
55. a. The association of croup with inflam-
mation of the throat, and -exudation of lymph
in this situation, whether originating in the
pharynx, which is rarely the case, or extending
thither and to the air-passages from the fauces
and tonsils, is one of the most frequent forms
in which the disease presents itself, particularly
when epidemic or infectious, and is, therefore,
deserving of particular notice. But the treat-
ment must, in a great measure, depend upon the
degree in which either sthenic or asthenic in-
flammatory action and fever may be considered
to exist. Although great increase of vascular
action is present at the onset, in the majority of
such cases; yet it is often attended by deficient
vital power, and exhaustion soon takes place.
Even in the most sthenic cases, the treatment
which would have been of service at first, is soon
no longer admissible; whilst in other cases, and
in some epidemics, very marked adynamia i3
manifested from the commencement. Much
depends on the precision with which the exact
nature of the case and the state of vital power
are ascertained, and on having early recourse to
judicious measures. As to the predominance of
either of the states of morbid action alluded to, the
frequency and tone of the pulse, the colour of the
exudation in the throat, and of the parts sur-
rounding it, and the continuance of the disease,
are the chief guides. If the inflammation and
exudation commence in the tonsils and spread
downwards, if die exudation be of a light colour,
and the inflamed parts of a lively hue, the pulse
being strong, full, and not very quick, depletions,
general or local, the use of emetics and nauseants,
and the rest of the antiphlogistic treatment, are
required ; but the further the disease departs
from these characters, the darker and dirtier the
exudations appear, the more livid and deeper the
colour of the inflamed parts, the quicker, softer,
and weaker the pulse, the more should antiphlo-
gistic measures be relinquished, unless in some
cases to a moderate extent, and at the very com-
mencement of the complaint; and the more ought
we to have recourse to camphor, ammonia, the
decoction of senega, ammoniacum, \.c.
56. b. The nearer the complicated disease, in its
local and constitutional manifestations, approaches
to the malignant form, the more extreme is the
danger, and the greater necessity is there for the
exhibition of tonics and stimulants. In such cases,
the decoction of senega, the infusion of serpentaria,
or mixture of ammoniacum, mav be prescribed,
with camphor, and any of the compound spirits of
ammonia; or the decoction of bark, with liq. am-
mon. acetatis and tincture of capsicum; or the
sulphate of quinine, with infusion of roses, and the
aethers; or either the chlorate of potassa, or the
muriate or carbonate of ammonia, with camphor,
musk, myrrh, assafcetida, &c. in suitable vehicles.
When the paroxysms of suffocation become urgent,
senega, preparations of squills, or F. 402., may be
given in doses sufficient to produce vomiting, and
repeated according to circumstances; and active
stimulant and antispasmodic clysters be thrown
up. The vapour of camphor and warm vinegar
may also be employed, and various stimulating
and aromatic fumigations resorted to. The mouth
and throat should be frequently gargled, or washed,
by means of a sponge fixed to the end of a piece
of whalebone, with a solution of the chlorurets,
or of the sub-borate of soda in camphor mixture ;
or with a weak solution of nitrate of silver, — a
scruple to an ounce of distilled water, — as first
advised by Mr. Mackenzie; or with Goulard
water, as suggested by Dr. Hamilton; or with
the chloric acid or chlorine in decoction of bark,
or other stimulating detergents; and sinapisms or
embrocations with Cayenne pepper, or rubefacient
liniments (F. 300. et cet.), may be applied on the
nape of the neck, or on the lower part of the chest,
and on the epigastrium. In the complications of
the disease with angina maligna, observed by Lo-
effler and Bretonneau, powdered alum was
directed by them to be blown into the throat; and
various other astringent and antiseptic, powders may
be employed in the same manner. When the cha-
racteristic eruption of scarlatina accompanies the
affection of the throat and air-passages, the treat-
CROUP — Rkmarks on various Remedies fmpi.oyf.d in.
461
merit must be directed according to the same
principles. In all cases of angina, attended with
membranous exudation1, whether the attepdant
constitutional disturbance present sthenic or asthe-
nic characters, the tecaJ treatment advised l>\ Mr.
Mm hi s/ii should be adopted upon the appear-
ance of the exudation on the tonsils or fai s, and
a huge blister should be applied early, as being
the i mist efficacious means of preventing the ex-
tension of this form of inflammation to the pha-
rynx, air-passages, or oesophagus.
57. r. The treatment of the complications villi
ephtka, or villi any of the eruptive fevers, will
depend, as much as the foregoing, upon the state
of vital power characterising the constitutional
affection. The appearance of croupal symptoms
in the course of small-pox — particularly confluent
small-pox — will require nearly the same medi-
cines as have now been recommended (§56.);
and the washes advised to be applied to the
mouth and throat will he equally serviceable in
the aphthous, as in the variolous complication.
When croup is consequent upon either measles,
or hooping cough, vascular depletion is more fre-
quently required than in almost any other com-
plication, excepting that with inflammation of the
throat of a sthenic kind, whether attended by
albuminous exudation or not.
58. J>. The affections consequent upon croup —
or the .states of disease which it excites, or into
which it passes — require not only appropriate rem-
edies, hut also the application of them with strict
reference to the primary malady, and the means
by which it was combated. When it runs on to
bronchitis, the latter affection commonly assumes
the asthenic form, generally terminates fatally, and
requires the tri atrra a! described in the art. Bron-
ch n is ( § 70. et seq.). Its passage into pneumonia
is attended with similar results; and depletions,
unless they have been previously neglected, are not
well home. When diarrhoea or dysenteric symp-
toms are produced, in the latter stages, by the
meansusedto remove the disease, we shall gener-
ally lii ii I the preparations of opium, and the warm
bath, as hereafter to be noticed, of much benefit.
A considerable number of rases, particularly those
complicated with sore throat, terminate in sinking,
or exhaualion of vital power, and not by sullbca-
tion. This circumstance should he kept in view in
the treatment of the last stage ; and its earliest
indications be met with suitable stimulants and
tonus (§ 56. ). In cases presenting imminent
suffocation, the question of tracheotomy should
be entertained ; but at the same time, with the
recollection, that either exhausted vital power,
the extension of disease to the bronchi, and the
accumulation of viscid or concrete exudations in
them, or inflammatory action, or emphysema of
the lungs themselves, may tend individually, or in
combination, to prevent the success of the ope-
ration, independently of the immediate contingen-
cies to which it is liable. (See § 74.)*
*I may here adduce • enmmary of il"- practice adopted
hv the most experienced physician in I i ince ill ilii- i!i--
ease — the aeoior phyaician to the Hospital for Children in
Ii will he leen boo eloselj il agree* with nn own,
in a similar Institution in London: —
ML J LOT5LOT consul
I eaeating more violent symptoms, and hav-
ing fu-
sions: of 3 ipeciaj cum icier. !!• i Uni
of ihc disease, without • ban
leeches, and emetics, are ihe agents lie most fr<
59. Remarks on various Remedies ad-
vised, and on the Opinions of Authors
RESPECTING Till H. — B, Xam:, nuts and imelir.t.
In the firsl Stage of the disease, and in the com-
mencement of the second, l have sometimes found
that tartar emetic, given so as to produce and pro-
long a state of nausea, lias so completely relieved
the croupal symptoms as to prevent altogether the
necessity of having recourse to blood-letting; and
that in other, and more severe cases, the same
diciue. exhibited so as to produce vomiting,
and to continue the nauseating effect for some tune
afterwards,' and thereby to prevent reaction super-
vening upon the emetic operation, has been follow-
ed by ;i similar result. Emetics have been much
recommended alter blood-letting, and the inhala-
tion of vapour, and when the exudation is presumed
to begin to loosen, by I Iom k, LiENTIN, Da k win,
Maercker, I'oktai., Smith, Hecker,Vi-
eossetjx, Rumsey, &.C. When the patient has
not been visited sufficiently early, this plan is cer-
tainly judicious. But when lie is seen In the first
stage, it will he better to attempt to prevent the for-
mation of the false membrane, by exhibiting nau-
seants or emetics instantly, as now advised, and,
unless the inflammatory symptoms are very severe,
before having recourse to blood-letting. This early
exhibition of emetics is sanctioned bv CRAWFORD,
Chkvne,Pinel, Hosack, Thompson, IIufe-
land, Albf.us, Schwilgue, &c. Dr. Gais-
i.ik prescribes, on the invasion of the disease,
tartarised antimony and oxymel of colchicum.
Whilst vascular excitement continues, either this
combination, or the antimony only, in repeated
doses, as suggested by ('it EYH 1: and M ten Aei.i S,
is the best emetic; but when we wish to detach
the membranous exudation, the preparations of
Squills, alone, or with ipecacuanha, are preferable.
In the more spasmodic form of the disease, ipe-
cacuanha, as GoELIS remarks, is as suitable an
emetic as can be adopted : but when it is found
necessary to exhibit such a medicine in the last
stage of the disease, or when it is associated with
angina maligna, or attended by symptoms of de-
pressed vital power, senega, squills, or the sul-
phate of zinc, given with stimulants and anti-spas-
modics, or F. 402., are to be preferred. Goelis
recommends emetics in the first stage of the least
inflammatory forms, and generally in the third
employs in it* treatment. Emetics alow have often *uf-
ficed to slop the disease, especially in weak pale, 01 bloat-
ed subjects but, in opposite cases, he insists on the applii a-
tion of leeches, and allows the blood to ft"w until the chilli
pale, and the pulai loses iU strength. After the
bleeding, In- causes vomili veral limes ii> succession,
:ii intervals of two or three hours : and the practice is attend-
ed by tli cess, relief being very apparent after
, .ii Ii romit.
\\ Ii. ii [he croup has arrived :it the second period, with-
,.iii has Hi.- bei a oppi i i lencr ,./ i false mem-
1 I. . i In . in !„■ applied ; but,
the moment thej fall nil lie hastens i" produce vomiting :
and ii is in this case tli.it In- employs bi -| nsful, every
hi. c ill, .1 hi ■
ticroupal,* until full vomiting is i Ineed. He insists also,
upon il" 'i ] applied to the
i . inal.
\\ In n the dial ase i- rerj
whelhei •" do we should i immenee by hlerding, or by an
vt.. I.', opinion is, ili'i we should first bleed, a
th, i Inld Ik- robust, and if it pn '
the superior parti : on the contrary, In- »...i
mence by vomiting, when lie lubjeel is pali
,,| and \Iedical
•V.
ft Infusi Pol i I ".J- ;
Oxymel. Sciltai 5u>i Anlimon. i .Mi-.cc.
468
CROUP — Remarks on various Remedies employed in.
stage; but he prohibits them in the second or in-
flammatory stage, and when suffocation is threat-
ened towards the close of the disease. When,
however, tartarised antimony is employed, and
nausea is kept up in the intervals between the j
emetic operation, as I have recommended above, i
bleeding being also employed, the reaction dread-
ed by this experienced writer will not come on.
His objections to an emetic in the paroxysms of
suffocation occurring towards the close of the mal-
ady, may be well founded, were antimony or even
ipecacuanha to be then prescribed ; but, when zinc,
squills, and senega are conjoined with stimulants
and antispasmodics, and their operation accelerat-
ed by irritating the pharynx, I have seen the air-
passages thereby freed from the substances ob-
structing them, and the patient saved.
CO. /*. Bleeding, general or local, or both, al-
though indispensably requisite in the great major-
ity of cases, is not always of service. Rumsey
and Huggens remarked its injurious effects in
the complicated cases they treated; and the more
nearly the disease approaches to the spasmodic,
and the febrile symptoms to the adynamic charac-
ter, particularly in the complications, the more
likely is it to be of little benefit, or even injurious,
unless the state of action and habit of body, evi-
dently requires it. In the more inflammatory
states, it should be promptly and fully performed;
the use of nauseating medicines generally pre-
venting the necessity of having recourse to very
large or injurious depletions. Ghisi, Home,
Crawford, Rosen, and others, have preferred
general blood-letting at the commencement; and
Bayley, Middleton, Balfour, and numerous
writers, have recommended the jugular vein to be
chosen. Trebkr, Hirschfield, Werner,
Goelis, and Mali atti, very experienced physi-
cians in Vienna, employ local depletions, except-
ing in the most inflammatory cases; and I agree
with them, differing only in preferring cupping to
leeches. As to the period at which it should be
resorted to, I believe, with Goelis, that little
will be gained by resorting to it before inflam-
matory action is manifested, or after excitement
has subsided. A suppressed and apparently weak
pulse, early in the disease, is often rendered full
and hard by venisection, and a repetition of the
operation required, — a circumstance evincing the
importance of interpreting aright the state of the
circulation. Of forty-seven cases treated by Goe-
lis, in 1S08, seven were blooded from a vein;
thirty-four by leeches only; and six were not
blooded at all. The average quantity of blood
that I have found requisite to take, altogether, as
nearly as I can calculate, is about five ounces in
children of three years, seven or eight in those
of five or six, and about ten ounces in those from
ten to twelve. This result relates chiefly to those
not seen until the second stage of the more in-
flammatory or common forms of croup. I have
met with cases in which blood-letting had been
chiefly confided in, and been carried to the utmost
extent; but it certainly had seldom or ever cured
the disease, when thus employed, and even some-
times had been evidently injurious. The cele-
brated Washington was said to have died of
croup. lie lost, at the age of sixty-eight, about
ninety ounces of blood in twelve hours. An at-
tentive perusal of the cases published by Dr. S.
Jackson (Amer. Journ. of Med. Sciences, vol. iv.
p. 361.) will show the inefficiency and injurious
effects of excessive depletions.
61. y. Calomel and mercurial inunction have
been most strenuously recommended, the former
especially, since it was first prescribed by Rush,
and in larger doses by Stearns, Marcus,
AuTENRFITH, ANDERSON, J. P. FRANK, NEU-
MANN, MichaSlis, and others, who gave it every
three or four hours. Hamilton directs it, in full
doses, every hour or two hours at first, and sub-
sequently at longer intervals; Hecker advises it
in small doses; and Wig and states that it is of no
use. Cheyne prescribes it with James's powder;
Harles and others, with the officinal preparations
of antimony ;Sch;effer, with emetics and musk;
Schluter, with oxide of zinc and other antispas-
modics; MicHAens and Neumann, with expec-
torants; Archer, Marcus, and Hufeland,
with decoction of senega, and mercurial inunction
about the neck; and Augustin, with opium. In
the stages attended by excitement, it is best con-
joined with James's powder or tartarised anti-
mony, as prescribed above ; and sometimes with
opium, or Dover's powder, and subsequently, if
it be given at all', with purgatives ; expectorants,
antispasmodics, &c. being exhibited in the inter-
vals. Goelis conceives that it is useful in dimin-
ishing the tenacity of the croupal exudation, and
in retarding its formation. He moreover suppos-
es, that the daily exhibition of a small. dose of this
medicine subdues the diathesis^ or constitutional
disposition to contract the disease ; and when
croup has been prevalent, and appeared in one of
a family, he has given about a grain at bed-time
daily to each of the other children.
62. 8, Blisters and counter-irritants have been
already mentioned ; but there are certain points,
particularly as respects the period and manner in
which they ought to be employed, that require
to be noticed. There are very few writers who
have not recommended blisters in croup, but quite
as few have done so with the wished for precis-
ion. On this subject Goelis is more practically
minute than any other writer ; and in many re-
spects his experience coincides with my own. I
believe that most advantage will be derived from
as early an application of a large blister as is
consistent with the previous employment of blood-
letting. Directly after the first depletion, there-
fore, one should be applied in either of the
situations advised (§46.); a piece of fine tissue
paper being placed between it and the skin. It
ought to be removed upon the appearance of
redness of the cuticle, and a warm bread and
water poultice placed over the part, and fre-
quently renewed. If blisters be used in the latter
stages, they should be watched with great care,
and be allowed to remain for a few hours only,
and not a minute after slight redness is produced.
I believe that the dangerous effects sometimes
occasioned by them are owing to the want of
these precautions, and to having recourse to them
at a time when the vitality of superficial parts is
soon exhausted, owing to vital depression and to
deficiency of blood, consequent upon excessive
depletion. The liberal use of calomel, particu-
larly when it has not been carried off by purg-
atives, may also, by increasing the irritability of
the tissues, dispose to unfavourable results from
blisters. If prescribed at allk they should be of
full size; they ought never to be applied over the
APPENDIX OF FORMULAE.
In order to prevent repetitions, and to facilitate reference, tin- following collection of Formulas
is here appended and arranged in alphabetical order, in addition to those which it was necessary
to give in tin' body of the work. The Author hns not added any of the formula! prescribed by
the three British Colleges, an they arc already in the hands of every practitioner ; although he
lias always referred to them, and "has followed them, particularly those of the London College, in
extemporaneous prescription — both in such as are prescribed at this place, and in those directed
in the course of the work. The preparations and recipes he has given, both here and at other
places, consist of a careful selection of those which are most approved, contained in the Phar-
macopoeias of various hospitals and foreign countries, and from the writings of a number of
eminent practical physicians, as well as of those which the Author has been led chiefly to con-
fide in during a practice of twenty years. In order to avoid circumlocution, he has retained the
short and characteristic names usually employed, although many of them are by no means
classical.
Form. I. Acetum Antihystericum. (Disp. Fuld.)
R Caston i, Assafoelidae, aa 5 'j- j Galbani 3 ss. ; Herb.
Rutae recentis §j. ; Aceli Vini lb ij. Macera bene et
cola.
Form. 2. Acetum Camphoratlm.
R Camphors Pulver. cum Alcoholis pauxillo solutae,
5 --. ; SaccbariAibi 3 ijss. ; Aceti Vini 5 vss. Solve.
(3j. contains 3*5- of camphor.)
Form. 3. Acetum Camphobje et Ammonia.
R Camphora* Jj., teralur in mortario vitreo, cum Alco-
holis guttis xx. vel xxx. ; Sacchari Albi 555. trio's adde ;
Acitli Acetici Fortioris 3 ij. ; Liquoris Ammonia?
Acetatis 3 in--. ; Infusi Cinchona;, vel Aqua; Dcstilla-
tae Siij-s. Fiat Mist., cujus sumat cger Cochlear, ij.
ampla aecunda vel tertia qu&que hora. (In the last
stage of Febrile Diseases attended with depressed pow-
ers of life.)
Form. A. Acidum Nitro-miriatici M.
It A' i'li Nitrici, Acidi Muriatici, singulorum partes (mensu-
ra) nsquales. Dosis a minim, vj. ad IT) **• his, ter,
sapiusve quolidie, in Itordei Decocti Jiv., cum Syrupo
Simplice.
Form. 5. ACIDUN XlTRO-MCRIATICUM DlLUTUM.
It Acidi Nilro-muriatici, Aqua; Dcstillala-, aa O j. IMisce.
(The nilro-muriatic acid bath is to consist of three
ounces of tliis diluted acid to every gallon of water.)
Form. 6. ./Ether Phospiioratus.
It rhosphuri Puri gr. ij. ; Olei Mentha; Piper. 9j. — Jss.
Solve, et adde dither. Sulphur, g j. M. Vel.
Form. 7.
R Phosphori Puri ir. ij. ; JElhi-r. Sulph. Jj. ; Olei Va-
lerian. IT) nij. M. (In doses of v. to x. drops on su-
Bar-)
Form. 8. Aqua COSMBTICA.
R Mist. Amvedal. Amar. v. 1 Dul.jcolati ?, iij. ; Aquae
1 Anna Flor. Anrantii ■ -l>oracis
Sod* 3j. ; Tinct. Bcnzoini, 3ij. M. Fiat Lolio.
Form. 9. Aqua Styttica.
It Fcrri Bnlphaiis, Alnmin. Bolpbalis, aa ',!•'.; Aqua'
Jxij. Solve el cola j deiu adde A< idi Bidghurici Jj.
Form. 10. Aqua Sttptica Cupri et Zinci.
It Zinri Sulphatia, Cupri Sulplulis, ia "j. ; Aquae Rosa;
Sviij. Solve.
A
Form. 11. Aqua Stvptica Zinci.
It Zinci Snlphalis, Alumina; Sulphat. Calcin., aa 3j-i
AquaeRosaeJ vj- Solve.
Form. 12. Aqua Traumatica Thedenii.
It Acidi Acetici ft iij. ; Alcoholis ft ij. ; Acid. Sulphur
ft ss. ; Mellis despumati ftj. Misce.
Form. 13. Aqua Vanill.e.
It Frucl. Vanillas concis. et cont. 5 vj. ; Potassae Sub-
carbon. Jvj. ; Aquae Destil. O ij. ; Spirit. Vini Ten. O
jss. Macera lent cum calore per triduum, et cola.
Form. 14. Balneum Ioduretum. (Lugol.)
R Solut. Iodinae Rubefac. (Vide Form, inter Solutiones.')
oj-— 5iv- j A1UX Ucm5- "j.— 1.
Form. 15. Balneum Sulphureum.
R Magnes. Sulpbatis 3 iv. ; Potassae Supertart. J) j. ; Sul-
phur. Potassae 3 j- '• 'ere simul, et solve in Cong. j. q.
q. Aquae Balnci.
Form. 16. BALNEUM SULrHURETI PoTASSiE.
R Potassae Sulphurcti 3 j. ad 3 iv. ; Aquae Communis ft L
ad ft cc. Solve. (Nearly the same as the sulphu-
reous baths of Bareges. In Chronic Affections ol the
Skin, and in Chronic Visceral Affections.)
Form. 17. Balneum Sulpiiureti Potass.e et Gela-
tine. (Dupuytren.)
R Polassae Sulphureti, SJ ij. ad 3 iv. ; Aquae Communis
ft c. ad ft cc. Solve, et adde Ichthyocollae ftj. ad
ft ij. iu Aqua; bullientis solutae ft x.
Form. 18. BALSAMUM ASTRINOENS.
R Olei Tcrebinthinae part. ij. ; adde guttalim Acidi Sul-
pblirici part, ijss., in vase vitreo, ope batnei arenar. ca-
lefaclo. Liquori refrigcrato, adde gradatim Alcoholis
part. viij. Macera per dies leptem. (Dosnjn, — 3j.
\chiculo quovis idonco, iu morbis Haemorrhagicis.)
Form. 19. Bvi.samum AsTRINC.ens.
It Olei Terebinthinas, Acirli Muriatici Concent., aa parsj.:
bene, el post Jiem*sdde Alcoholis part. viij. ;
Camphoric part. ss.
, Form. 20. Balsamum Succinatum.
inuCopail .:■, T< tel.inihinae Vcnet., Olei Succini, aa
[isce.l 11) xjcc. ter quotidie in quovu >•■-
htculo idouto. (In Leucorrh'ea, Gleet, Emissions,
ice.)
11
APPENDIX OF FORMULAE. — Balsamum — Djecoctum.
Form. 21. Balsamum Sulphuris, vcl Oleum Sul-
phuric.
R Floriim Sulphuris pars j. ; Olei Amygdal. Dulc.
part. iij. ; Olei Anisi part. ij. Maceraper dies sep-
tem in balneu arenario.
Form. 22. Balsamum Sulphuris Terebinthinatum.
R Floriim Sulphuris part. iij. ; Olei I.ini part. vij. ;
Olei Anisi part. v. Solve in balneo arenario, et
adde OleiTerebinthina; part. ix. Misce. Excitant,
diuretic, expectorant, &.c. Dosis Til x- — XXX-
(Bulsamus Vita. IIulandi.)
Form. 23. Balsamum Terebinthinatum.
R Olei Olivce 5 vj. ; Terebinthiiue g ij. ; Cera; Flavae
g j. ; Bals. Peruvian. 3 ij. ; Camphora; rasa; 3 jss.
Solve Oleum, Terebinth., ct Ceram ; dein adde
alia. (Nearly the same as the Balsam of Chiron,
a long-celebrated medicine.)
Form. 24. Bolus Anodynus.
R Pulv. Jacobi veri gr. iv. ; Camphoric Pulverizat. gr.
iij. ; Pulv. Potassa; Nitratis gr. x. ; Extracti Hyos-
ciami, gr. vij. ; Conserv. Rosar. q. s. uifiat Bolus.
II. s. s. (In Cerebral Affections, &x.)
Form. 25. Bolus Antispasmodics.
R Pulveris Castorei optimi 3 ij. ; Pulv. Radicis Vale-
riana g s.s. ; Camphor, rasa; 3 j. Misce accurate,
et adde Syrupi Papaveris satis quantum ut fiant
Boli granorum duodecim: involvanturpulvereStig-
matorum Croci Sativi.
Form. 20. Bolus Arnice.
R Pulv. Flor. Arnica; Montan., Camphora; rasce, aa
gr. iv. ; Conserv. Rosar. q. s. ut fiat Bolus.
Form. 27. Bolus Bismuthi Compositus.
R Moschi er. x. ; Bismuthi Subnitratis gr. iij. — viij. ;
Opii Puri gr. ss. — j. ; Conserv. Rosar q. 3. ut fiat
Bolus, p. r. n. sumendus.
Form. 28. Bolus Cambocia;.
R Cambogise Gummi Resina; gr. viij.: tere cum Olei Ju-
niperi TT) iij., et adde Potassa; Supertart. gr. xx. ;
Tulv. ScilliB, gr. j.; Syr. Zingiberis q. s. ut fiat Bolus.
Form. 29. Bolus Camphors.
R Camphora? rasa> etope Alcoholis subacte gr. iij. — x.;
Pulv. Flor Arnica; Montana; gr. iij. — vj. ; Con-
foct. Rosa; Canina; q. s. ut fiat Bolus, quartl vel
sextlqulque hori sumendus.
Form. 30. Bolus Catechu Thebaiacus.
R. Catechu Ext. contrit. gr. xv. ; Confectionis Opii
gr. viij. ; Pulv. Cretse gr. iv. : Syrupi Aurantii q.
8. ut fiat Bolus, bis, ter, strpiusve in die capiendus.
Form. 31. Bolus Ferri.
R Ferri Sub-carbon, er. x.— xx. ; Pulv. Aromatici gr.
v. ; Syrup. Zingiberis q. s. ut fiat Bolus, bis terve
quotidie deglutiendus.
Form. 32. Bolus Guaiaci AmmoNiati.
R Guaiaci Cum. Rcsinre gr. viij.— xij. ; Camphora- ra-
sa;, Ammonia; Carbon., aa gr. iv. ; Pulv. Acacia;
gt. iij. ; Confect. Rosa; q. s. ut fiat Bolus, hori som-
ni sumendus.
Form. 33. Bolus Guaiaci Compositus.
R Guaiaci Resin, ront. ;) j. ; Ipecacuanha; Rad. Pulv.
gr. j. ; Opii Puri gr. j. ; Confectionis Rosa; Canina;
q. 8. ut fiat Bolus, seinel, bis, terve quotidie capien-
dus.
Form. 34. Bolus Kino Thebaiacus.
R Tulv. Kino Compos, gr. v. — x. ; Pulv. Crete Com-
poaiti er. xv. ; Pulv. Opii ss. ; Syr. Zineib. q. s. ut
fiat Bolus, bis, ter, sa-piusve in die sumendus.
Form. 35. Bolus Moschi Compositus.
11 Moschi gr. xxiv. ; Pulv. Rad. Valeriana; >) jss. ;
Camphora! rasa; gr. xv. ; Conserv. Rosar. q. s. ut
fiant Boli iij. Capiat unam 4tiquique hori.
Form. 35. Bolus Nitro-camphoratus cum Opio.
R Camphora; rasa; er. iij. — vij. ; Potassa; Nitratis gr.
x.— xv. ; Opii Puri gr. ss. — jss. Conserv. Ros. q.
8. ut fiat Bolus, hori somni sumendus.
Form. 37. Bolus Rhei Compositus.
R Rhei Pulv. gr. x.— xv. ; Pulv. Oreta; Comp. cr. vij. ;
Pulv. Ipecacuanha3C0mp.gr. iij. — vij.; Syrup. Zin-
giberis q. s. ut fiat Bolus, hori somni sumendus.
Form. 38. Bolus Sedatiyus.
R Acidi Boracici 'J j.— 3 ss. ; Conserv. Rosar. et Syr-
upi q. a. ut fiat Bolus, p. r. n. sumendua.
Form. 39. Bolus Sudorificus.
R Camphora; rasa; gr. j. — iij. ; Potassa; Nitratis gr. xij. j
Pulv. Ipecacuanha;, et Pulv. Opii Puri, aa gr. j. ;
Syrup. Zingib. q. s. ut fiat Bolus.
Form. 40. Bolus Valeriana cum Terro.
R Ferri Sub-carbon gr. v. — £ j. ; Pulv. Valeriana;
gss. ; Syrup. Zing. q. s. Fiat Bolus.
Form. 41. Cataplasma Ioduretum.
R Cataplasm. Farina; Semin. Lini tepid, q. s. ; Solut.
lodina- llubef. q. s. Sit Cataplasma.
Form. 42. Cataplasma Sinapeos Fortius.
R Pulv. Sinapeos ft ss. ; Pulv. Capsici Annui, Pulv.
Zingiberis, aa 3 j. ; Acidi Acetici Pyrolignei q. s.
ut fiat Catasplasma, dein adde Olei Terebinthina;
g ij. Misce.
Form. 43. Cataplasma Sinapeos Mitius.
R Cataplasmatis Lini 5 iv.; Farina; Sinapeos 5 ss. M.
Form. 44. Confectio Menthx Viridis.
R Mentha; Viridis Fol. recent, g iv. ; Sacchari Purifi-
cati g xij. Folia in mortario lapideo contunde:
turn, adjecto Saccharo, iterum contunde, donee
corpus sit unum. (Spraoue.)
Form. 45. Confectio Senn.e Composita.
R Sulphuris Sublimati, Potassa; Sulphatis, aa 5 ss. ;
Confectionis Senna; g ij. ; Syrup. Aurantii q. s.
Capiat 5 j- — 5 'j.pro dose.
Form. 46. Conserva Mentha Sativ.e.
R Fol. Mentha; Viridis recentis g j. ; Sacchari Purifi-
cati g iij. Contunde probe annul, fiat Conserva.
Form. 47. Decoctum Alih££.
R Altha;;e Radicis exsiccat. incis. gij. ; Rad. Glycyrr-
hizse contus. 3 iij.; Aqua; Destil lata", O jss. Co-
que leni igne ad O j., et cola.
Decocti Arctii LaPP.E.
5 ij. ; Aqua;
XVj.
Form. 48.
R Rad. Arctii Lappa; 5 jss.
Coque ad 5 xij. et cola.
Form. 49. Decocti Arctii Lapp.*: Compos.
R Rad. Arctii Lap. recent. 5 j. ; Lign. Sassafras., Dul-
camara;, aa 3 iij. ; Rad. Glycyrrh. 3 jss. ; Aqua;
Ojss. Coque ad O j., et exprime.
Form. 50. Decoctum et Infusum Beccabung.v.
R Herb. Veronica Beccabunea; recentis 5 iij.; Aqua> Fer-
VentisOj. Maceraper boras binas, vel coque per
quartam liora> partem et exprime. Capiat g ij. ter
quaterve quotidie ; vel utatur externe pro embroca-
tione, super Ulcerationes Strumosas applicata.
Form. 51. Decoctum Calumbx Comp.
R Rad. Calumbic, Lien. Ouassia; ras.,aa 3U- jCorticia
Aurantii exsic. 3j. ; Rhei Pulv. j) j. ; Potassa; Sub-
carb. 3 j. ; Aqua; 5 xx. Coque ad 5 xv., et cola ;
dein adde Spirit. Lavandul.Comp. 3j. (Niemann.)
Form. 52. Decoctum Cacuminum Pini Compositum.
R Cacum. Pini Sylvest. 5 ij. ; Radicis Symphyti Ma-
jor, g j. ; Aquae ft ij. Coque' per hore' partem
quartam ; exprime, et cola.
Form. 53. Decoctum Cinchona: Aperien-.
R Corticis Cinchona; Pulv. 5 j. ; Aqu;e ft ij. Coque
per partem hone quartam, et adjice Fol. Seun.T-
gss. ; Rad. Zingiberis cont. 3 j. ; Soda' Sulphatis
gss. ; Mnriat. Ammonia- 9 j. Macera per horas bi-
nas, et adde Syrup. Senna; gj. M.
Form. 54. Decoctum Cinchon.i: Compositum.
R Cinchona; Lancifol. Cort. contus. ^ ss. Coque et
Aqua' Puric g xvj. ad consurapt. dimid., adjectis
sub finein coctionis Serpcntaria; Radicis coutus.
gij. Stent per horam, et colaturse ad misce Spirit.
Cinnamom. Comp. 5 jss. y> Acidi Sulphur, dilut.
-3jss. M. Sumantur gij. scxti quique hori.
APPENDIX OF FORMULAE. — Decoctum— Elf.ctuakhm.
Form. .V). Decoctum Cinciion.k et Rhki.
R Corticis Cinchouie Rubra contuste ~ iij. ; Radicia
Gentians incise Jss.; Radicia Bbei PalmatiSijaa.;
Suii carbonatis Potassa 3 j. ; Aqua Fontaine a. q.
Coque per In. ram nri.-iiii ut obtineantur colatura un-
ci a- duodecim, et ooia.
R Bujus Colatura J vss. ; Tincture Canells, Spirit.
Anisi, aa J jae. ; Syrup. Auruntii, 3 «"• M- Capiat
Cochlear, j. vel ij.
Form.. 16. Decoctum Cinchon.*: et Serpentari.*:.
K Cart, cinchona- Pulveriz. 3 vj. ; Rad. Serpentaiia
-, as.; Corticis A uranlii sic. 3 >J-> Aqua- tbjas. Co-
que ad lb j., et adde liq. colati 'I'inct. Ciunainom. 3J.
Form. 57. Dbcoctdm Cydonijb Comp.
r Semin. Cydon. con. 3 ij. ; Rad. Glycyrrh. contus.,
Pici Caries Fruct.,aa$j. ; Aqua Bui. O j. Coque
cum igne leni per ininut. none decern, deinde cola.
R Hujus Decocti 5 vjss.;Sul| borecia Soda; ~j.; Potassa:
Tart. 5 U-; Spirit. .Ether. Nit. 3 ij. ; Syrup. Mori vel
Sue Inspiss. Samb. Nig. J ss. M. Fiat Mist.,cujus
capt. Cochlear, ij. larg.i secundis vel tertiia boria.
(In irritative Inflammation of the Mucous Surface
of the Digestive Organs, Dropsy, &.c.)
Form. 58. Decoctum Deobstruens.
R Radicis Taraxaci, Herb. Fumaris, Fob Sisymbrii
.\astiirt., Fob Cbsrophylli Sylvest.,aa 3 j. Omni
bus bene coacisis, adde Seri Lactis ^ x.vxij. Coque
per ininut. hora vj. ; et postea macera ad refrigera-
tionein, dein cola. Colatura; adde Tartar. Potassa:
et Sod:e Jss.— 3 vj. ; Mellis Optimal 5J. M. Capiat
cyatbum Viti. ij. vel. iij. vel iv. in die. (Van
S » 1 K 1 A X . )
Form. 59. Decoctum Depurans.
R Caul. Dulcamara1, Herb. Fumaris Officin., Cort.
Ulmi coiitr., Rad. Arctii Lappa cone, Rad. Rn-
mii is Patientite concis., aa 5 ss. ; Aqua: Font,
lb ijss. ; Coque ad O jss., et cola. Liq. colat. adde
Syrup. Sarsaparillffi 3 ij. M. Capiat Jj. — J jss.
ler quaferve quotidie\
Form. 00. Decoct. Dulcamara.
R Stipit. Dulcamara" 5 j. ; Corticis Aurantii 3 >j- >
Aqua It.jss. Coque ad Ibj., et cola.
Form. Ci. Decoctum Dulcamara Comp.
R Caul. Dulcamara!, Radicis Arctii Lappa;, aa. 3 vi. ;
Radicis Glycyrrh., Liyn. Sassafras ras., Lign.Gua-
iaci ras., aa 3 ij. ; Aqua; Font, lb ij. Coque ad
colaturie 5 XX. (Aur-ustin. Rheumatism, Sy-
phylis, Cutaneous Affections, &c.)
Form. GO. Decoctum Fii.icis Compositcm.
R Radicis Filicis Maris 3 j. ; Rad. Helenii 3 ij. ; Fo-
lii Absintbii ",<s. ; Seminum Santonici cont. 3 iij. ;
Aqua; 0 jss. Coque ad Oj , et cola. Liq. colati
adde Syrup. Rb.uiini 3 j. M.
Form. f>3. Decoctum Calls:.
R Gallarom contuaarumgsa. ; Aqua Distillate O ijss.
Decoque ad oct. ij., et liquorem cola. Turn adde
Tine tune GallSi ", j. (This decoction, used as a In
mentation, enema, or injection, is of considerable
uae in the treatment of Prolapsus Ani, lleinoi
rboids, and in I.eucorrhcea.)
Form. G4. Decoctum Gcmiiv.i: Comp.
R Radici Gentians Lutes inciasjsa.j AquaFonta-
na> tb j. Coque per aemihoram, deinde Infunde
quantum eufficit super Padicis Calami Aroiu. J iij.:
cola, et post refrigerationem adde /Etheris Sulpb.
3 ij. ; Syrupi Aurantii ", as. Misce.
Form.G5. Decoctum Giinri et Dulcamara Comp.
R Rasur. I.izni (Juiaii 3js<. . Btipil Dub amanc Sjss.
Pad. l.aun Bassafras. concis., Flor. Kmlcm, Pad.
Calami Atom., Pad. Glycyrrh., aa " ss. ; Bemin.
Funiculi J ij. ; Aqua; tb iij. CoqM ad tb iij., ct
cola. Capiat \ j. — J iij. ter quaterve qiiutidii-.
Form. 66. Dbcoct. Helerii Comp.
R Rad. Inula: Itelrnii 3 j. ; Summit. Hyasopl Officin.
3 iij.; Fol. Beder. Terrest. 3 ij.; Aqusq. s. utsinl
Colatura " mj. Coque per partem hone quartam,
el cola : adde liq. colat. Potasss Sob 1 aibon. 3 j. :
Syrup. Toiutan., Syrup. Althae, a&5 j. M. Copial
5J. — 5 ij. ter i|u iterva quotidie. | In Chronic < a
tarrh-, the Pectoral Affections of Debility, A si hma,
Chloro>is, Amenorrhea, &c.)
HI
Form. 67. Decoctum Inula: GoMFOSITI m.
II Rad. inula I'.Mnp. -,jss. ; lljssopi ( Mlicinal. , Flor .
Tilia- Kim, p. a.t 5 iij.; Fob Heder. Terrest. 7, ij. ;
Aqua- it, ij. Coque ad lb jss.; eiprime, nt cola. Co
latum adde Spirit. /Ether. .\it. g as. . Potassa Ni
tratisSj.; Sj rup. Siiii.e JjJ.; Syrup.Althas ~,ss. M.
Form. 68. Decoctum Pectoralp. Elsnehi.
R Rad. Glycyrrh., Croci-Btig., Pad. inula- Helenii,Rad.
ireos Flor.,Seiuin. Anisi, llvssopi (itlicin., aa 3SS.;
Aqua: tb ij. toque ad It, jss. : cola et adde Tincl.
BalS. Toiutan. 5 j. ; Syrup. Toiutan. 5 j. ; Mellia
§j. M. Capiat gj. — Jij., 4tis vel 6Ms horis.
Form. G9. Decoctum Punica Granati.
R Corticis Radicis Punica: Granati recent, et exaic.
Jij. ; Aqua: Com. O ij. Macera sine calore per bo-
ras xxiv. ; dein coque ad O j. et cola. (The whole
to be taken in three doses within two hours.)
Form. 70. Decoctum Quassia Comp.
R Ligni Quassias ras;e 5 ss. ; Flor. Anthemid. 3 VJ- '<
Potassie Sub-carbon. 3 ijss. ; Aq. Foutan. lb ij.
Coque ad dimidiuni, et tola.
Form. 71. Decoctum Santonici.
R Santonici Semin. contus. jij.; Aqua- Destillatie Jxx.
Coque lento igne ad O j., et cola. (In Ascarides.1
Form. 72. Decoctum Sarsaparill.*: Compositum.
R Sarsaparilla: Radicis, concisie et contusie, 5 j''5- i
Glycyrrhizs PadiiiscontusiK Jss.; Coriandri Sem-
inum contus. 3'j-i Liquoris Potassa: 3j- (vel sine);
Aqua: Ferventis O j. Macera per boras xxiv. in
vase leviter clauso, et cola ; !:i|uoris colati sumat
partem 3tiam ter quotidie. (Sprac-ue.)
Form. 73. Decoctum Secalis Cornuti.
R Secalis Cornuti 3 ij. ; Aqua: %vij. Decoque ad % iv
Ab igne remove, et paulo post e fiecibus eftunde.
Form. 74. Decoctum Seneg.e.
R Senegs Radicis cont. 3 vj. ; Aqua- 'iij. Coque ado
j. ; et sub linem Coctionis adde Glycyrrh. Rad.
contus. 3 ss. Exprime, et cola.
Form. 75. Decoctum Spaktii Cacuminum.
R S|iartii Cacuminum concisi 3 j. ; Aqua; Distillata; O
j. Decoque ad octarium dimidiuni, et cola.
Form. 7G. Decoctum Taraxaci Co.
11 Radicis Taraxaci jiv. ; Supertart. Potassa:, Sub-tio-
racis Sodse, aa^ss. ; Aq. ft. iij. Coque ad tb ij. ;
et adde, ut sit occasio, vel Spirit. .-Ether. Nit., vel
Tinct. Scilkc, vel Spirit. Juniperi Comp., vel Oxy-
mel Scillu;.
Form. 77. Decoctum Taraxaci Comp. Stollii.
H Rad. Taraxaci, Pad. Tritici Rep., aa 5 ij. ; Aq.
tbiij. Coque aa tb ij.: cola, el adde colatune Potaa
.-a: Sulph. §88. ; Oxymel. J j. M. (In Visceral
Obstructions.)
Form. "tt. Decoctum Tormentillj:.
\{ Toriiientill.e Padicis i i.imis.i- -, j. ; Aqua; Destillata*
( ) jss. Coque ad octarium, et tola.
Form. 79. Electuarium Ai.calino-ferhatum.
]^ Oxidi Ferris SB. J Potassa- Snb-earbonatis ~ j. j Sub
carbonat. • tolcis ", ij.; Pulvis Zingiberis Jjss.; Byrup.
Aurantii 3 iijss. M. Fial Elect, cujue capiat Coch.j.
minim, inant- noiteque. (Chlorosis, Chorea, &.C.)
Form. HO. ExBCTUABIOM Anthf.lmi nticum.
R Pulv. Valerian.e, Semin. Santonici contus., ia JSS. ;
Potassa: Bulphatia 3 iij.; Pulv. Jalap. ;•) iv.-,
Oxymel. s.iiia- Ilv.; Pulv. Glycyrrh. (vel Extr.
Glycyrrh.) 3 ij. M. ut Bat Eleauarium. (Forchil-
dren, one to two drachma; and for adults 5 as.
three or fOUt tunes daily.)
Form 81. Eli-ctuarium Antispasmodicum.
r Pulv. Cinchonas j j. ; Pulv. Valeriana 5 ss. -, (\>n
feet. Riit.-r, - j. . ffonfect. Roe. Gall. Jss. ; Confect.
Aurantii 3 iij. , <>iei Cajeputi " -s. ; Byrup. Auran-
tii ", ijss. vel q. h. ut fiat Electuarium mollc. Ca-
pi.ii ",j.— 1 1 j - mam1 noeteque. (In Epilepsy, Cho-
rea, Hysteria, Flatulency, dec.)
IV
APPENDIX OF FORMULAE. — Electuarium — Emplastrum.
Form. 82. Electuarium Aperiens.
R Magnesia;, Potassa; Supertart., Flor. Sulphuris,
Pufv. Rati. Rhei, Pulv. Flor. Anthemidis, aa gr.
vj. ; Syrup. Aurantii 3 iij. ; Olei Pimentee TT) ij. M.
Sit Electuarium pro dose. (Hecker.)
Form. 83. Electuarium Aperiens.
R Manna; 3 vj. ; Syrup. Senna? 3 iij . ; Olei Amygdal.
Dulc. 3 ij. Tere bene, et adde Aquee Fceniculi 3'j-;
Sacchari Albi 3 jss. Sit Electuarium, cujus capiat
infansjj. — 3ij. pro dose.
Form. 84. Electuarium Arnicje Composit.
R, Pulv. Flor. Arnica; 3 iij. ; Pulv. Cinchona; g ss. ;
Pulv. Rad. Serpentariae3iij. ; Confect. Aromat.
3 j. ; Syrup. Aurantii 5 v. Misce. Capiat 3j — 3 ij-
2dis ho lis.
Form. 85. Elect. Bechicum.
R Manna; Optima; 5 j.: tere cum Aq. Flor. Aurantii q. s.,
et adde gradatim Pulv. Acacia; gss.; Extr. Glycyrrh.
3 j. ; Syrup. Tolutan. q. s. Sit Electuarium molle,
cujus capiat pauxillum urgenti Tussi. Interdum ad-
de Pulv. Ipecacuanha;, Extract. Conii, vel Extr.
Lactucee.
Form. 86. Electuarium Cinchonje Aperiens.
R Cinchona; Lancefol. Cort. in Pulv. g j. ; Valerian.
Rad. Pulv. 3 iij- > Confectionis Senna; 5 jss. ; Con-
fect. Aromat. 3 ij. (vel Confect. Piperis Nigri 3 iij-);
Syrupi Senna; g ijss. vel q. s. ut fiat Electuarium
molle. Cujus devoret Cochlear, j. vel ij. minim.
mane meridii, et nocte. (In Ague, diseases of De-
bility, &c.)
Form. 87. Electuarium Cinchona Compositum.
R Cinchona; Cordif. Corticis Pulv. 5 j.; Confectionis
Rosa; Gallics g ss. ; Acidi Sulphunci diluti 3 j- ;
Syrup. Zingiberis g jss. M. Fiat Electuarium.
Dosis 3j. — 5'j- ter; quaterve in die.
Form. 83. Electuarium Cinchona: cum Fehro.
R Cinchona; Corticis pulv. 5 j.; Ferri Sub-carbon. 9 ij.
— 5U- j Syrup. Zingiberis q. s. ut fiat Electuarium.
Dosis 3 j- — 5'J- u's terve quotidie.
Form. 89. Electuarium Deorstruens.
R Potassa; Supeitart. gjss. ; Sulph. Pracip.gj. ; Sub-
boracis Soda; 3 ijss. ; Syrup. Zingiberis q. s. ut fiat
Electuar.- Cochlear, j. vel ij. minima h.s.
Form. 90. Electuarium Feerifugum.
R Pulv. Cinchona; 5 ij. ; Pulv. Rad. Serpentar., Pulv
Cort. Canellae, aa5ij- ; Cam phone rasa; '£) ij. ; Opii
Puri gr. iv. ; Syrup. Zingiberis, et Syrup, aa q. s. ut
fiat Electuarium, cujus capiat 3ss. — 3JSS- pro dose.
Form. 91. Electuarium Febrifugum Hoffmanni.
R Pulv. Cinchona; 3 vj. ; Pulv. Flor. Anthemid. 3 ij. ;
Caryoph. in Pulv., Ext. Centaurii Min., aa 3ss. (vel
Pulv. Centaurii 3JSS-); Succi Inspiss. Sambuci Nig.
5 ss.; Syrup. Limonisgjss. M. Capiat 5 j. -Itishoris.
Form. 92. Electuarium Febrifugum Trilleri.
R Cinchona; Pulv. 5 j. ; Pulv. Flor. Anthem. 3 ij-; Pot-
assa; Nitratis, Ferri Ammoniati, aa 3 j- j Syrup.
Aurantii 5 ijss. M. Fiat Electuarium, cujus capiat
Cochlear, j. — ij. min. pro dose.
Form. 93. Electuarium Ferri Ammoniati Composi-
tum.
R Myrrha? Pulv. 3 jss. ; Ferri Ammoniati sr. xxxv. :
tere siniul, et adde Pulv. Radicis Rubi;e 3 jss.; Pulv.
Castorei 3 ij. ; Syr. Zingiberis g jss. vel q. s. ut fiat
Electuarium ; de quo sumatur, bis quotidie, ad My-
ristica; Nuclei magnitudinem.
Form. 94. Electuarium Ferri Tartarizati.
R Potassa; Supertart. gij. ; Ferri Tartarizati ~ iij.; Zin-
giberis 9j ; Syrup. Aurantii q. s. ut fiat Electua-
rium molle, cujus capiat 3 j 3 ij. bis terve in die.
Form. 95. Electuarium Nitri Camphoratum.
R Camphora* rasa; et ope Alcoholis pulverizat. gr. vj. —
xij. ; Potassa; Nitratis 3jss.; Confect. Rosa; Gallica;
gjss. ; Syrup. Simp. q. s. ut fiat Electuarium. Do-
sis, moles Myristica; Nuclei subinde capiatur.
Form. 96. Electuarium Purgans.
R Confectionis Senna; 5$ ij. ; Pulver. .Talapse3j.; Pot-
ass. Supertart. pulv. g ss. ; Syrup. Zingiber. 5 j.
M. Sumat Cochl. j. min. bis vel ter die.
Form. 97. Electuarium Scillje Compositum. "
R Potassa: Supertart. contrit. g Hi- > Juniperi Bac. et
Cacumin. pulv. g j- : tere bene simul,et adde te-
rendo Pulv. Jalapa; 3 ij. ; Oxymel. Scilla; g ij. : Sy-
rup. Zingiberis q. s. ut fiat Electuarium. Dosis 3 j- —
3 iij. bis, ter, quaterve in die.
Form. 98. Electuarium Sennje Compositum.
R Senna; Fol. pulver. g ss.; Potassa; Supertart. pulv.
3vj. ; Pulv. Jalapa; Rad.3ij.; Soda; Sub-boracis
5J.; Syrup. Zingiberis 5 ij. Misce. Dosis a 3j- —
3'j. pro re nata.
Form. 99. Electuarium Terebinthin.1:.
R Pulv. Tragacanth. 9 iv. ; Aq. Pura: f. g j. M. Fiat
mucilago; tunc gradatim adde Ol. Terebinth, f. 5 j.;
et contere cum Saech. Purif. 3 ij. ; Pulv. Curcuma;
gr. x. ut fiat Electuarium.
Form. 100. Electuarium Terebinthinatum.
R Olei Terebinthina; gj.; Mellis despumati gij. ; Pulv.
Rad. Glycyrrh. q. s. ut fiat Electuarium.
Form. 101. Electuarium Valerian.*: Compositum.
R Pulv. Rad. Valerian. Minor. 3j.; Pulv. Sem. Santo-
nicae 3 ij. ; Pulv. Rad. Jalap, gr. xxx.— xl. ; Oxy-
mel. Scilla; q. s. ut fiat Electuarium.
Form 102. Electuarium Vermifugum.
R Sulphatis Potassa; cum Sulphure, Pulveris Radicis
Jalapae, Pulveris Radicis Valeriana;, aa 5j. ; Oxy-
mellis Scillitici, g iv. M. Sumantur adulti ss.,
quatuor vices de die,et puerie 3 j . ad 3 ij . (Stoerk.)
Form. 103. Elixir Aloes Compositum.
R Croci Stig. pars j. ; Potassa Acet., Aloes, Fellis Tauri
inspiss., aa part. ij. ; Myrrhs, part. ij. : Spirit Vim
(vulgo Brandy diet.) part xxi'v. Infunde et macera
secundum arteni, et cola. 3j. — 3 ijss. pro dose.
Form. 104. Elixir Pectoralis Wedellii.
R Assafcetida; gij. ; Flor. Benzoes, Opii Purif., Cam-
phora;, Croci Stig., Rad. Scilla:, Olei Anisi, aa
9 ij. ; Bals. Peruv. gss. ; Spiiit. Vini Rect. ft> ijss.
Macera, et cola.
Form. 105. Elixir Proprietatis Rhubarbarinum.
ft Aloes Socotrin.gj. ; Rhei 3 vj. ; Myrrhs 3 iijss. ;
Croci Stigmat. 3 iij. ; Sub carb. Potassa1 3 ijss. ;
Vini Madeirensis ftj.; Alcohol, g iij. Macera per
dies Septem, et cola. (In dos. 3j. — 3 ij. Vermi-
fuge, emmenagogue, &.c.)
Form. 106. Elixir Tonicus.
R Aloes, Myrrh*, aa 3 ij. ; Summit. Absinthii, Sum.
Centaurii Minoris, Cinchona; in Pulv., aa g ss. ;
Corticis Aurantii Amane 3 iij. ; Croci 3 ij. ; Vini
Albi Hispan. ft ij. Macera in sole per boras
xlviij. : dein adde Sacchar. Alb. g viij., etcola.
Form 107. Emplastrum Ammonia:.
R Ammonia; Muriatis 3j. ; Saponis Duri 3 ij.; Emplas-
tri Plumbi g ss. ; Emplastrum et Saponem simul
liqua, et paulo antequam concrescant immisce Sa-
lem in pulverem tenuem tritum. Extensum super
alutain parti affecta; quamprimum applicatur, et
pro re nata repetatur.
Form. 103. Emplastrum Anodynum Fortius. (Rich-
ter.)
R Emplastr. Galban. Comp. (vel Emp. Cumini) g j. ;
Camphorse 3 j- ; Amnion. Sub-carbon.. Opii Puri,
aa 3 ss. ; Olei Cajeput. gtt. xl. Fiat Emplastrum
secundum artem.
Form. 109. Emplastrum Anticolicum.
R Gum Ammoniaci, Gum. Galbani, aa g j. : Terebin-
thin. Venet. et Terebinthin. Commun. aa 3 x.: len-
to igne liquefactis, arijice Assafcetida1 g jss. ; Croci
Stiam. giij. ; Olei Mentha; Pip., et Olei Rut.T.Sa
3 ss. — 3j. et omnia misce.
Form. 110. Emplastrum Antihtstericum.
R Galbani, Sagapeni,aa g j. ; Assafoetidse g ss. ; Olei
Ruts 3 ss. — 3j. ; Areti Vini q. s. ad Gum. Resin.
liquefaciendum : dein adde Terebinthiiue Com-
mun. gj. ; Cera; Flava-gwj. : Pulv. Myrrhfe gss. :
Pulv. Castorei 3 jss. : Olei Succini " ss. Misce.
(The YVurtembergand Manhcim Pharm.)
APPENDIX OF FORMULAE. — Empiastrum — Ehema.
Forill. 111. F.MPLASTRUM Aromaticum Compositum.
R Emplast. Arom. (PA. Z>u&.), vel Emp. Cumini gss.;
Sulphuris Sublimat. 3 ij.; Olei macis TTJ XXXV.
Fiat Empiastrum.
Form. 112. Emplastrum IIelladonnv..
R Extr. Belladonna part. iij. ; Amnion. Carbon, pnlv.
pars j. Misce, et fiat Emplastrum. (To very pain-
ful parts.)
Form. 11^. Emplastrum Camfhobje.
R Olei Oliva: 3 .xij. ; Minium 3 viij. Liqua, et masss
refrigerate ad j ice Camphors g rjss. : soluts in
pauzdlo Olei. Misce beni. (Stahl.)
Form. 114. Emplast. Dkff.nsivum.
R Minium g viij.; Aceti 3 iv. ; Olei Olivs ft j. Li-
qua, et adde Cers Flavs 3 ij. ; Camphors 3 ss.
Misce bene.
Form. 115. Emplastrum Deobstruens.
R Potasss Sulphureti, Pulv. Conii.Jia 3 ijss. ; Cam-
phors Pulveris, Terebinthins, aa 3 >v- > Saponis
Albijss.; Cera: Flavs £j.; Emplast. Simp. J i v. M.
Form. 110. Emplastrum Picis.
R Picis Ahietins vel Nigrs 3 vj. ; Cera; Flavs 3 j. ;
Terebinthins Vulg. 3 iij. ; Liquefac simul, et fiat
Emplastrum.
Form. 117. Emplastrum Resolvens.
R Emplast. Ammoniaci cum By drarg., Emplast. Picis
Comp., Emplast. Calbani Comp., aa. partes squa-
les. Fiat Emplastrum.
Form. 118. Emplastrum Roborans.
R Emplastr. Picis Comp., Erupl. Galban: Comp., Emp.
Cumini, aa partes binas ; Oxidi Ferri Kuliri ; TI111-
ris, aa partem unam ; Olei Pimento q. s. ut fiat
Emplastrum.
Form. 119. Emplastrum Rubefaciens.
R Emplast. Aromat. Comp. (F. 111.) 5SS Forma in
Emplast., clein asperge cum Antimonii Tartnrr/.a-
ti ~ j. ; Camphors Pulveriz. 9j.; Sulphur. Subli-
niati 3ss. in unum admixtis.
Form. 120. Emplastrum Stibiatum.
R Emplast. Picis Comp, part. xj. ; Terebinth. Venet.
part. iv. ; Antimon. Tartarizat. in Pulv. part. j. I.i-
quefac Emplastrum et Terebinthinam, etaddeAn-
limunium. (.Niemann and Auuustis.)
Form. 121. Emulsio Amvgdalo-Camphobata.
R Amygdal. Dulc. decor, 3ss. ; Amygdal. Amar. N' iij.;
Aqua Fontame Jvijss.l. a. Emulsio, in Colatura ad-
misce Pulv. Cumini Arabici "ij.; Camphors (cum
paul. Alcohol. subnets) •) j. ; Sj rup. Papaveris Albi
"ss. M. El sit Emulsio, de qua sumat quovis lii
bono Cochleare unuin, prsgressa vitri commotionc.
Form. 122. Emulsio Antichabfhai.is.
R Sem. Phelland. Aquat. con. g J. j Gum. Acacia; 3 j. ,
Aq. Ferv. ",i\'. Macera.et cola. Colaturs adde Sy-
rup. Altha-a- s »■■ '• Vinl Ipecac. 3 ij. M. Capiat
Colli, ij. larga 3tiis vel itis boris.
Form. 123. Emul9io CamphobaTA.
r Olei Amygdal. Dulc. gas. ; Gum Acacisq.s. ; Cam-
phors sir. x. — }) J. 1 tere ip<ne simul, el adde Aqns
Fsniculi et Aquas Laurocerasi 3 ij.; Syrup. Al-
thss3ss. M. Fiat Emulsio.
Form. 124. Emulsio Camph.. rata. (Aucustin.)
R Camphors Subsets xr. xvj. ; Amygdal. Dulc. Jss. ;
Aqua Fior. Sambuclgvj. Sit Emulsio.
Form. 12o. Emulsio Camphor»ta Comtosita.
r Camphors gr. x, — !-)j.: subige in Alcoholii f. 3*s. ;
et adde lerendo Mucilag. Acacia " 'j. ; Olei Amj g
dal. Iiuir. " as. ; Byron. Althsx ", ss. : Aqua Lau
rocerasi, Aqua rosmculi, aa ", ijss. M. Capiat
Coch. j. vel ij. '-''i'~ vel iti« boris.
Interdiiiu adjlcintur vel Vinum [pecacnanhs, vel
Vinum Antimonii, vel Potasss Nitres, vel Byrupua
Papaveris Albi.
A*
Form. 136, Emulsio Nitbo-Camphobata,
R Camphora Subsets, Potassa Nitratis, ...1 •) j ;
Pulv. Cum. Acacia; 3J»i infus. Pectoralis vel
Aqua Fior. Aurantii, gvjss. ; Syrup. Aitlm.s 3j.
M. Fiat Emulsio.
Form. 127. Emulsio Pectoralis.
R Spermaceti 3J- ; Gum. Acacia- 3 ij. ; Olei Amygdal.
I)ulc. 3J. ; Syrup. Simp., Syrup. Tolutan., aa JH, ;
Aq. Fffiiliculi g ivss. M. Fiat Emulsio.
Form. 123. Emulsio pro Tussi.
R Olei Amygdal. Dulc. 3 jss. ; Vitelli Ovi unius ;
Aqua; Fior. Aurantii J V. ; Mucilag. Arac is 3>s. ;
Villi Ipecacuaiibic 3jss. ; Syrup. Althteagss. M.
Form. 129. Emulsio Seuativa.
R Mist. Amygdal. Dulc. ; Mist. Camphora: ail 3 ijss. ;
Mucilag. Acacia: 3 ss. ; Morphins Aeetaiis gr.
j. — ij. ; Syrup. Toiutaii. 3ss. Solve Morph. Ace-
tat, in Olei Amygdal. XI) XX. ; deinde adde alia.
Form. 130. Enema Aloes et AsSAFCBTIDS Comp.
R Extr. Aq. Aloes 3ss. ; Assafaetida 3J?s. ; Camphors
rasa: gr. xij.; Olei Olivie 5 jss. ; Decocti Avens
5 xij. Misce. (In Flatulent Colic, Ascarides, &c.)
Form. 131. Enema Antihvsteiucum.
R Fol, Ruts, Pol. Sabins.aSXss.; Aqua: Fervid, q. s.
Coque ad 3 xvj. ; et adde Assafcctid. 5 'j- > Olei Oli-
vs 3'j- Misce.
Form. 132. Enema Antispasmodicum. (1.)
R Tinct. Opii 3j. ; Infus. Valer 3 x. ; Mucilag. Aca-
cia; 3J. M.
Form. 133. Enema Antispasmodicum. (2.)
R Tinct. Opii 3 ss. — 5 j- > Infus. Cusparis, Decocti
Althaea: OfT., aa^v. M. Pro Decoct. Altb. inter-
dum utatur vel Decocto Malve, vel Decoct. Hordei,
vel Infus. Ipecacuanha-.
Form. 134. Enema Assafcktid.-k, vel Fcstiduv.
R Assafostids Gummi Resins 3 U- ; Decocti Malvs
Composit. §x. ; Spiritus Ainmonis Compos. 3j-s.;
Tincturs Opii 5gs. Misce pro Enemate.
Form. 135. Enema Assakcetidx et Tebebintiii^.t.
R Aosafcetida: 3j- — 3'j- j Camphora: rass gr. xij. : tere
cum Decoct. Avens 3 viij. ; dein adde Olei Terc
binth. Jss. ad 5jss. Misce, et fiat Enema.
Form. 136. Enema Assafojtid.'e Compositum.
R Assafa-tida- 3j.— 3>j. ; Camphors rass gr. x. ; De-
cocti AvensS xij. Misce pro Enemate. Interdum
adde Olei Terebinth. 3 ''j- — 3 jss- 1" flatulent
Colics, Worms, &.C
Form. 1:17. Enema Bf.i.ladonw.i.
R Fol. Belladonns exsic. gr. xij. ; Aq. Fervid. 3 vj.
(In retention of tlie urine from Spasm of the
Sphinct. Vesics, or Spasm of the Rectum.)
Form. 138. Enema Camphor..*: CoMr.
R Camphors rass gr. xij. : Olei Juniperi Anpl. 3 M- J
Infus. Valerians 5 x.; Mucilag. Acncisjj. M. Fiat
Enema.
Form. 139. Enema Camphoiiatum.
R Acidi Acetic! Cainpliorati (F.2.) Jas. — 3J ! Infu*.
Valerians 3 viij. M. (Auoustin.)
Form. 140. Enema Catharticum.
I; Decocti Ualvs Composit. ( x. ; If agnesis Sulpbatis
" j. ; Olei Olivs f. 3'j- Misce. Fiat Enema.
Form. 141. Enema Colocvnthidis Compositum.
R Colocvnthidis Pulpa- incis. 3j. ; Aqus 3 xij. Coqim
paullsperel cola: dein adde Sods Murlatis (vel Bods
Bulpbatis) 38B. ; Syrup. Kliamni Catli.Jss. Misc<:.
Form. 142. Enema contra Pi-asmos.
i; Camphors rass gr. v.— x. ; Potasss Nitratis 3 sa. ;
( llel Olive; ^,j. : tere simul, et adde Infusi Valeri-
ans, Decocti Malvs Comp., ia 3 vij. M.
Form. 1 !:!. EnSH * F..M01 i.ii:m.
R Fior. Anthemidis, Bemln. Lini contus.. Si 3 ««. ;
\ .piii- Fervid. ", vj. Macera el cola, dein add*
Opii gr. vj.— xvj. M. Flat Enema.
VI
APPENDIX OF FORMULAE. — Enema — Haustus.
Form. 144. Enema Emollio-Aperiens.
K- Decoct. Malvns Comp. 5 xij. ; Sods Tartariz. gss. ;
Olei Olivas gij. M. Fiat Enema.
Form. 145. Enema Opiatum.
U Tincture Opii f. ~j.; Mucil. Amyligvj. Misce. Fiat
Enema, tepid, injiciend.
Form. 14G. Enema Saponis.
R Saponis Mollis 5 j.; Aquas Ferventis Oj. Solve, et
tepidum exhibe.
Form. 147. Enema Sedativum.
R Seminum Lini contus. g j. ; Aquas Ferventis 5 viij.
Macera per horam : dein cola, et solve in Colat.
Sub-boratis Sodas 9 j.; Opii Extr. gr. ij.— iij. M.
Fiat Enema. Vel.
Form. 148. Enema Sedativum Camphoratum.
R Infus. Lini Comp. gx.; Tinct. Opii 3ss.; Sub-bora-
tis Soda; 3 ss. ; Camphoras rasa gr. x. M. Fiat
Enema, bis terve in die injiciendum.
Form. 149. Enema Terebinthinatum.
R Camphoras rasas 9 j. ; Olei Terebinth. g ss. — gjss.;
Olei Olivas gjss.; Decoct. Avenas 5 viij. Fiat Enema.
Form. 150. Enema Tereeinthin.se.
R Terebinthinas Vulgaris g j. (vel Olei Terebinthinas
f.gss.); Ovi unius Vitellum. Tere simul, et gra-
datim adde Decocti Avenas tepid. g x. Injiciatur
proEnemate semel in die, pro renata. (When it
is required to evacuate the lower bowels, 01. Rici-
ni 5 j. will be found a useful addition.)
Form. 151. Enema Terebinthino-Camphoratum.
R Olei Terebinth. 3 j. ; Olei Olivas gjss. ; Camphoras
rasas gr. xv. ; Decoct. Avenas 5 viij. M. Fiat
Enema.
Form. 152. Enema Theeaiacum.
R Opii Puri gr. j. — iij.; Mucilag. Acacias gss.; Lactis
Tepefact. 5 vj. Misce pro Enemate.
Form. 153. Enema Vermifuga.
R Had. Valerian., Herb. Absinthii, Herb. Tanaceti,
Cacum. (vel Sem.) Santonic, aa 3 "j- j Aq. Fer-
vid, g xii. Macera per boras binas, et cola. Liq.
colat. adde Salis Commun. gss. Fiat Enema.
Form. 154. Exirictum Aloes Alkalinum Comp.
R Aloes Spicati Extr. contrit. 5 iij.; Zingiberis Radicis
concis. gss.; Myrrhas Pulv., Croci Stigmat.,55 3 vj.
Potassas Sub-carbon, (vel Sodas Sub-carbon.) gss. ;
Macera per triduum leni cum calore, dein cola. Li-
quoram defascatain consume, donee idoneam habeat
crassitudinem. (Dosis gr. x. ad xxx.)
Form. 155. Extractum Dulcamara:.
R Stipit. Dulcamaras, pars j.; Aquas Bullient. part. viij.
(Split the shoots of dulcamara longitudinally, and
macerate them in the water for twelve hours ; boil
for a quarter of an hour, and express the fluid. Af-
terwards boil the residue with four parts of water,
and finally express. Mix the two liquors, and evap-
orate with a gentle heat to a proper consistence.)
Form. 156. Extractum IIellebori Nigri Backeki.
R Radicis IIellebori Nig. exsic. ft ij. ; Potassas Sub
carbon, ft ss.; Alcohol. (22 grad.) ft viij.
Backer directs the above to be'digested in a sand-
bath for twelve hours, shaking it frequently, and
afterwards to he expressed and strained. Eight
pounds of white wine are to be poured upon the
residue, and digested with it for twenty-four hours
in a sand-bath, and afterwards to be expressed and
strained. After a few hours both these tinctures
are to be mixed together, and evaporated with a
gentle heat to the consistence of an extract. This
is the best preparation of Hellebore. Dose from
10 to 15 grains.)
Form. 157. Fomentum Camphoratum.
R Camphoras gss.; Acidi Aceticigij.; Aceti Commun.
g\. M. (Augustin.)
Form. 158. Gargarisma Acidi Muriatici.
R Infus. Cinchona' gvj.; Acidi Muriatici 17) xx.; Mol-
lis gss. .M.
Form. 159. Garg. Acidi Muriatici Compositum.
R Acid. Muriatici f. g jss.; Decoct. Cinchonas, Infus.
Rosas Compos, aa f. g iijss.; Mellis Rosas f. gj. M.
Fiat Gargar.
Form. 160. Gargarisma Antisepticum.
R Decocti Cinchonas gvj.; Camphoras gr. xx.; Ammo-
nias Muriatis gr. xv. M.
Form. 161. Gargarisma Astringens.
R Infusus Rhatania:, g vjss. ; Acid Sulph. Dilut. gss.;
Syrupi Mori g j. M. Fiat Gargarisma. (For Re-
laxation of the Uvula and Fauces.)
Form. 162. Gargarisma Astringens Zoeellii.
R Aluminas Crud., Potassas Nitrat., aa g ss. ; Potassas
Supertart. 9 ij.; Aceti Distil, g ij. Solve, et adde
Aquas Rosar. gij. M. Fiat Gargarisma.
Form. 163. Garg. Boracis Sodje.
R Boracis Pulver. 3 ij. ; Aquas Rosas f. g vij. ; Mellis
Despumat., Tincturas Myrrhas, aa f . 5 ss. M.
Form. 164. Gargarisma Catechu Thebaiacum.
R Infusi Rosas f. g vij.; Tincturas Catechu f. 3vj.; Aci-
di Sulphuric] diluti f. 3 j. ; Tincturas Opii f. 3 jss.
Sit Gargarisma saspe utendum. (A. T. Thomson.)
Form. 165. Gargarisma Commune.
R Aquas Puras g xxij. ; Sub-boracis Sodas 3 x. ; Tinct.
Catechu g j. — g iij. ; Tinct. Capsici Annui 3 j. —
3 iij.; Mellis Rosas g jss. — g iij. Interdum adde,
loco Boracis Sodas et Tinct. Catechu, Acidum Mu-
riaticum, vel Acidum Sulphuricum.
Form. 166. Gargarisma Potass.*: Nitratis. (1.)
R Potassas Nitratis 3 jss. ; Mellis Despumat. f. g ij. ;
Aquas Rosas f. gvj. M. Fiat Gargarisma.
Form. 167. Garg. Potassje Nitratis. (2.)
R Potassas Nitratis 3 U-; Decocti Hordei f. g vij.; Oxy-
mellis Simplicis f. gj. M. (Brande.)
Form. 168. Guttle Acetatis Morphinje.
R Morphinas Acetatis gr. xvj. ; Aquas Destillatas 3 vj. ;
Acidi Acetici diluti 3 ij. M.
FDrin. 169. Guirs jEtheris Terebinthinatji:.
R Olei Terebinthinas pars. j. ; yEther. Sulphuric] (vel
^Ether. Nitrici) part. iij. M. (Nearly the same as
that recommended by M. Durande in Jaundice
and Biliary Calculi.)
Form. 170. Guttje Anodynje Acetatis Morphini.
R Morphina' Acetatis ur. xvj. ; Aquas Distillate g j. ;
Acidi Acetici IT) i'j- ; Spiritus Vini 3 jss. M.
(Misce. In doses of from five to thirty drops.)
Form. 171. Guttje Antiloimic je.
R Pulv. Camphoras gij. ; Spirit. Rect. g viij.; Liquor.
Amnion, gij.; Ol. Lavendul. 5 ij. M. Fiant Guttas,
quarum capiat xx. ad 3 j- quovis in idoneo vehiculo.
Form. 172. Guttje contra Spasmos.
R Olei Cajeputas, Tinct. ^Ether. Valerians (Vide
Form.) Spirit. Amnion. Succinat., 55. gj.; Olei
Anisi 3 i j . M. (TT) x. ad x.x.w.)
Form. 173. Guttje contra Spasmos. (Stole.)
R Liquor Ammonias Carbon., Tinct. Castorei, Tinct.
Succini, Tinct. Assafcetidas, aa 3 iij. M. TT| L.
bis terve in die.
Form. 174. Guttje Nervinje.
R Camphoras, Croci, 5a 3 js*- i Moschi, Myrrhas, 55
9 iv. : tere cum Sacchar. Albi gss.; et Spirit. Vini
Rectific. 5 ij. : dein adde terendo Olei Lavand.,
Ol. Juniperi, Ol. Rosmarini, Olei Origani, 55 ~ iij.;
Olei Succini, Olei Cajeputi, 5a 3 j. ; Olei Limonis
gss. ; Olei Terebinthinas -,ij. ; Sacch. Albi gss. ;
Spirit. Vini Rect. 3 ij. Macera et setva, sine
colat., in vase bene obturato.
Form. 175. Haustus Acidi Nitrici et Opii.
R Tinct. Opii TT1 xx.— xxx. ; Tinct. Caryoph. (Vide
Form.) 3 ij.— g ss. ; Acid^Witrici TT| xx. ; Aquas
Piraentffi gj. M. Fiat Haustus.
APPENDIX OF FORMULA:. — Hai stub,
vii
Form. 176. Hausti ■ Aoidi Nitric i et Opii.
R Aiiili Nitriri Diluti 5 j. ; Tinct. Opii Jss. ; Infus&s
Caluraba ~ ass. Misce, ft. Uaustus tec in die capi
end us.
Form. 177. Haobtcs Ahodtnus.
R Mist Camphors ", Ix.; Potassa Nitratia gr. vj.; Spirit
. I't lu ris .--iiij.ii. Compos. 5j.j Tinct. < 'i»" 1TJ x. — xij.;
Byrup. Papaveris "i.i- Fiat Uaustus, hor4 decubi-
tus sumendus.
Form. 178. Uaustus Anti-emesin.
R Infus. Aurantii Com p. " \.; Spirit. Mentha Virid.
3j. j Liq. Potassa 1]) \. ; Magnes. Carbon. 3 j. ;
'J'iiict. Hyosciami 3ss. ; Extract. Humuli gr. viij. ;
Syrup. Ziugib. 3 j. M. Fiat Haustus.
Form. IT!'. II LUSTUS A.NTI-EMETICL'S.
R Magnes. Carbon. J^j.; Extr. Humuli gr. vj.; Liq. Pol
assteTt] viij. ; Tinct. Hyosciami gas.; Spirit. Men-
tllsB Vn ill. ", j. ; I niiis. Aurantii Comp. (vel. Infus.
Caryoph. Comp.) 3 x.; Syrup. Zingiberis 3 j. Al.
Form. 180. Haustus Aperiens.
R Extract. Rad. Jalapa jir. xv. : tere cum Amygdal.
Dulcis Num. iv.; Aquas Cinnam. Jj. Fiat Haustus.
Form. 181. Haustus Aperiens ex Jalapa et Aloe.
R Pulv. Rad. Jalapa- gr. xvj. ; Aloes Socot. gr. x.:
tire probe cum Extract. Glycyrrh. 3 ss. ; Tinct.
Rh»i_3j.; 01. Carui IT] ij.; Aqua. Cinnam. gj. M.
Fiat Haustus.
Form. 182. Haustus Aperiens ex Scammonia.
R G. R. Scammon. <>r. xij. : tere cum Glycyrrh. Ex-
tract, gr. xx.; Tinct. l!l]ai~ij.; Syrup. Zingiberis
3J. ; Aq. Cinnam. ^j. M. Fiat Haustus.
Form. 183. Haustus Astringens.
R (luercns Corticis cont. §ss.; Aqua: Ferventis 5 xiij.
Macera per boram, et cola.
R Hujus Colatune ~xj. ; Tinct. Catechu ", ss. ; Tinct
( irilaiiiom. Comp. 3 j- ; Syrup. Aurantii Cort. 3 j.
Fiat Haustus.
Form. 184. Haust. Boracicus.
R Infus. Lini Co., vel Infus. Altha-a Co., 3 jss. ; Sub-
boratis Soda & j.; Spirit. .Fth.-r. Nit.gss. ; Syrup.
Papaveris, Syrup. Aurantii, aa~, ss. M. Fiat Haus-
tus, ti Miis vel quartis boris capiendus.
Form. 18.3. Haustus cum C.ii.imiia ft Ferro.
R Infusi Calumbs f. 3 xj. ; Ttncturae Ferri Muriatis
TT) xv.; Tincturi Calumba f. 3j. Fiat Haustus,
bis die sumendus.
Form. 186. Haust. Camphors Comp.
R Camphors ;:. iij. — vjj.; Tinct. Calumba, Spirit. An-
isi,5u "jss.; Aqua Piments, Aqua Month. Virid.,
phoram cum Tincturd e( Spir
itu ; dein adde gradatim Aquas. Fiat Haustus,
lior.'i somni, vel urgenti vomitu, sumendus. Si sit
occasio, adde Tinct. t»pii ii| x.— xx., vel Tinct.
Hyosciami IT) xv. — xxv.
Form. 1ST. II n itub Carmiwatiyos.
R Magnes. Sub carbon. ~j. ; I'nlv. IMi.ii gr. x.— 3 S3.;
Olei Anisi IT) iij.; Liq. Potassaj Til xij.; Aqua Am
monia TT) xx.; Aqu e Anethi ~ ij. Al. Fiat Haustus.
Form. 188. Hausti -* 1 ' 1 . mo i .
R Vini Colchiei lain. xxv. — xxxv. ; Magnes. Carbon.
'»j.; Aqua Cinnam., Aqua, aa ~,\j. M.
Form. 189. Hads n h m ...
R Potassa Sulphati la Carbonati
Aqua Anetbi 5 J---; ' ""''• ' ■||ll"i!' " 3 1 is. 1 Vini
Colchiei TTI xxv. Fial Haustus cum Acidi Tartaric]
grams quindecera in Aqua semifluid unciasolutis,
in irapetu eflervesci mi. 1 sumendus.
Form. 190. I' - ' ' Mi.
R Infos, conii . ; Liq. Ammon. \
— - iij. Tiiu-t. Hyoacyami vel 1 onii, IT) xv.; Syrup.
Papaveria 3 --. M. Fial Hai 1
Form. 191. Hi iComt bt Hyosctami Oomf.
tracti Conii, Bxtractl Hyoacyami, aa gr. v. ; Mo
eil . imul donee quam
optimi'- miaceantur, et deinde adde Liquoria im
moni.-e Acetalto.Aqua Pura,5if. -, as. ; Syrupl
Kin 1 lit Hauatun, quarts qu&qui
sumendus. (Paris.)
Form. 199, Hai -i i i Dbobitbj iki it To*icua.
R Rad. Angelica 1 ontusl 3 Use. lumba
concisi 3 Jss. j Rad. Rhaicont. 3 ij. j Bwearum
Capsici cont.gr. \\\.; Aqua Ferventis octarium
dimidium. Macera per home duaa, deinde cola.
R Hujus Infus. 3 \. ; Tim t. Calnmfa . , , 1
Sulphatis gr. xxv.j Syrup. Aurantii 3 J. M. Fiat
Haustus, bia quotidU a
Form. 193. Haustui Diaphorbticub.
R Infus. Serpentaria Comp. (F. 262.) J J.; Liq. Am-
nion. Acet. 3 iij- I Syrup. Aurantii ~,j. M. Fiat
Haustus, his terve in die Sumendus. (Dyspepsia.
with dry, harsh skin; languor; and debility of pulse.)
Form. 194. Haustus Diureticus. (1.)
R Potassa Acetatisgj, ; Oxymel. Colchiei 3 ij.: tere
enm Aqua Foeniculi Dulcis 3 j.; Spirit. Juniperi
Comp. 3 iij. M. Fiat Haustus, bis terve in die SU-
im llllllS.
Form. 195. Haustus Diureticus. (2.)
R Aciili Nitrici Diluti, Spiritus jEtheris Nitrici, 5i
3j.; InfusQs Digitalis 3 iij.; Aqua Destillata 3 ix.;
Syrupi Zingiberis 3 ij. Al. Fiat Haustus, ter in
die sumendus.
Form. 196. Haustus Diureticus. (3.)
R Potassa; Aeetatis 3 ss. ; Infusi Quassia:, Aq. Cinna-
inonii, aa f. 3 vj.; Aceti Si ilia-, Spiritus /Ftheris Ni-
trici, aa f. 3 ss. Al. Fiat Haustus, ter in die capien-
dus.
Form. 197 Haustus Diureticus. (4.)
R Tinctures Jalapa: f. 5 ij. ; Aceti Scilla? 3 j- J Aqua
Mentha Yiriilis f. -Jss. Fiat Haustus.
Form. 198. Haustus Emeticus excitans.
R Pulv. Iiadicis Ipecacuanha 3 ss- j Ammonia: Sub-
carbon. 3 j. ; Aqua- Mentha riper, ^ijss.; Tinct.
Capsici f/-)j.; Clei AntheniidisTT) x. Al. Fiat Haus-
tus emeticus. (In Poisoning from Narcotics, &x.)
Form. 199. Haustus Guaiaci Compositus.
r Tincture Guaiaci f. £j. ;Mellis 3j. : teresimul, et
adde Decoct. Senega f. "Jss.; Ammonia Sub-carbo-
natis tir. \). Fiat Haustus, se.xti quaquehora bu-
mendus.
Form. 200. Haustus Infusi Cinchos.e cum Acido
.Mr r.
r Pulveria Cinch*bna r, j. ; Confectionis Rosteg jss. ;
Aquae Ferventis O* : tere bene, et per boram, in
vase clauso, infunde.
\l Liquor. Colati ", xj. ; Tinct. Cinchona 3 j. ; Acidi
Muriatici Diluti 1I| viij. Al. Fiat Haustus, ter
quotidie sumendus.
Form. 901. Hausti - Im 111 Cusparije Compositus.
\\ Corticia Cuspaj is contus. ", ij. ; Rad. 1 lalnmbaa con-
tus. 3jss.; Rad. Rhai ", j. . Seni. Cardam. contrtt.
---.. s. in. Vnisici l.qua Ferventis Sxv.
,M.n i-ra pi r hoi.i-iluas. it 1 ola. Hujus Inliisionis "j.
Tinct. Cinnam. " jss. ; Spirit. Arum. Aromat. Ill
xxv.; Syrup. Aurantii "j. Fiat Haustus, ter quotidie
sumendus. (In all diseases of Debility, excepting
Hectic Fever, and in Relaxation of Mucous Sur-
fai
Form. '.'!;'-. HAOSTtra I a > 1 11 0*1 1 Daai Alkamrui.
rx [nfus. 1 va 1 1-1 ". |ss.- ■ el Soda Sub-
1111 ", --. ill I'irii t.
Opii t a in ph or., vi I Extr. Conii); Syrup. Papa
- ... Fiat Haustus, ter quaterve quctldie' Bumen-
ilu-. In V flee til I unary Organs, and
of the Ah i' agi
Form. 903 I' iTua Iitruai Utjc Ubbi Colin
I; [nfus 1 'v;>- 1 rsl(F.9C7. 3xlv.; Acidi Sulphur. Dil.
tTl xx.; Tinct. Digitalis TTI xv. ; Syrup. Pap
verl SJsb. M. Fial Haustus, ter quaterve quotidii
Bumendus. In Larj ngitis, Bronchitis, 4tc.)
Form, '.'ii I. II mh 1 . on I mis >.
i; Liquor. PotaaMB Hydriodat. lodinr. Concent.
F. 398. HI vj. — xv.; Vquat Destillata "j.; Syrup.
3 ij. M. I Mi Haustus.
Form. 00.r>. Hauitt/i !••
I; Potassa TartratteSJ.: Infus. Senna Compos., Aqua
Plmenta, .... 1. 3 >j. ; Tinct. Jalapa f. 3 j. Al
Fiat Haust. laxans.
via
APPENDIX OF FORMUL2E.— Haustcs — Infusum.
Form. 20G. Haust. cum Plumbi Acetate.
R Plumbi Acetatis gr. j. Solve in Aqua? Rosa? f. 3 j. ;
et adde Oxymellis Simplicis f. 3 j. ; Tinct. Opii
TT) v.: Tinct. Digitalis TT) x. Fiat llaustus, quartis
vel sextis lioris suuiendus.
Form. 207. Haustus Q.uini.« et Zinci.
R Zinci Sulpha tis gr. J.— j.; Quinia? Sulphatis gr. ij. ;
Infusi Rosa? Compos, f. 3 x. ; Tincturffl Auratitii,
Syrupi Aurantii, aa f.3j. M. Fiat JIaustus, quart*
quique Dora suuiendus.
Form. 208. Haustus Sedativus.
R Extr. Conii, Extr. Hyoscyami, aa gr. iv. ; Mucilag.
Acacia; 3 U-: tcre siinnl, deinde adde Liquoris Am-
nion. Acet. 3 iij- j Mist. Camphors 3 v- i Syrup.
Rha?ados3j. M. Fiat Haustus, quart! vel quin-
ta quique bora suuiendus.
Form. 209. Haustus Sedativus Emolliens.
R Infus. Lini Co., vel Infus. Althaea? Co.,3Jss.; Sub-
boratis Soda> })'}.; Spirit. /Ether. Nit. 3ss.; Syrup.
Papaveris, Syrup. Aurantii, aa 3 ss. M. Fiat Haus-
tus, tertiis vel quartis lioris capiendus.
Form. 210. Haust. contra Spasmos. (1.)
R Aqua? Mentha; Virid. 3j.; Liq. Amnion. Acet. 3ij. ;
Spirit. Amnion. Arom., Spirit. /Ether. Sulph. Co.,
Spirit. Lavand. Co., aa 3 ss. ; Tinct. Opii Tt] XX.
M. Fiat Haustus, statim suuiendus, et pro re nata
repetendus.
Form. 211. Haust. contra Spasmos. (2.)
R Infus. Caryophyl. 3 jss. ; Spirit. Pimento', Spirit.
Rosmarini, aa3ss.; Tinct. Opii TT) XX.; Olei Caje-
puti TTJ x. M. Fiat Haustus ut supra sumendus.
Form. 212. Haustus contra Spasmos cum Pilula
Camphor.*:.
R Mist. Camphora; 3 j. ; Spirit. /Etheris Sulphur.
Comp., Tinct. Camphora; Comp., aa 3 j. ; Tinct
Hyoscyami 3 ss.; Syrup. Papaveris 3 jss. M. Fiat
Haustus, cum Pilul. sequenl. sumendus.
R Camphora? rasa? cr. j.— iij. ; Amnion. Sub-carbon.
gr. iij. — vj. ; Mucilag. Acacia; q. s. M. et fiat Pil.
j. vel ij.
Form. 213. Haustus Stimulans.
R Aq. Cinnam. g jss. ; Magnes. Carbon. 3ss. ; Spirit.
Amnion. Arom. 3 ss. ; Spirit. /Ether. Arom. 3 j. ;
Olei Rosmarini TTJ vij. M. Fiat Haustus statim
sumendus.
Form. 214. Haustus Stomachicus.
R Calnmb;p Rad. concisijj.; Acori Calami Rad. con-
tusi 3ss.; Rhaei Rad.contusi V)jss.; Cardam.Sem.
contrita? 3ss.; Aqua?-fervenfis octarium dimidium.
Macera per horam, et cola. Huj us In fusion is 3 xij.;
Tinct. Aurantii 3 j. ; Potassa- Sub-carbon, (vel
Soda; Carbonate gr. xij. Misce. Fiat Haustus,
bis terve quotidie sumendus.
Form. 215. Haustus Stomachicus Apf.riens.
R Soda? Tartarizatae 3 ij-: Sodte Carbonatis V) ij.; Aqua?
Anethi %ss.; Infus. Anthemidis 3j.; Tinct. Calum-
ba? ; Tinct. Aurantii Co., aa3 j. M. Fiat Haus-
tus cum Ac id i Tartaric i, gran is quindecim in Aqua?
semiflird untia solutis, in impetu effervescentia;
sumendus.
Form. 216. Haustus Terebint hinatus Aperiens.
R Olei Terebinth. 3 ij.— 3 v. Olei Kicini 3jss.— 3 ss.;
Olei Limonis et Olei Cajeputi aa TT) iv. ad xij. ;
Magnes. 3ss.; Aqua? Mentha? Virid. 3j. — 3ij. M.
Fiat Haustus, pro re nata capiendus. (In puerpe-
ral, infectious, and malignant Fevers.)
Form. 217. Haust. cum Uva Ursi.
R Pulv. Fol. Uva? Ursi at. xv.— r>j.; Potassa" Nifratis
pr. xij.; Pulv. Tragacanth. Couip. ^ j.; Aq. Anethi
3jss. M.
Form. 218. Infusum Amarum.
R Summit. Absinihii Artem. " j. ; Corticis- Aurantii
3ss.; Rhei 9 ij. ; Rad. Centiamp 3 j. : Aqua? Fer-
ventis 3 xij. Macera per horam, et cola.
R Liq. Coluti 3 jss. ; Potassa- Sub-carbon, gr. xij., vel
Liq. Pntassn? TT) xxij. ; Tinct. Aurantii Co. 3 j. ;
Spirit. Anisi - j. ; Syrup. Zingih. 3 ss. M. Fiat
Haustus, bis terve quotidie sumendus.
Form. 219. Infusum Angelica Compositum.
R Fol. vel Rad. Angelica; Arch. %ij.; Rad. Serpentar.
gss.; Florum Sambuci Nig. 5 j. ; Potassa? Sub-car-
bonat. 3 'ij-j Aqua; lb ij. Macera per horas tres, et
cola.
R Liq. Colat. 3jss.; Spirit. Juniper. Comp. 3 j. ; Tinct.
Opii Co. TT) x. Fiat Haustus. (In Atonic Dropsy,
&c.)
Form. 220. Infusum Anthemidis Compositum.
R Flor. Anthemidis 3 ss. ; Semin. Anisi cont. 3 iij.;
Fol. Menth. Virid. Jss. ; Caryoph. cont. 3 j. ; Au-
rantii Cort. sic. 5 ij. ; Aqua? Fervid, ft, jss. Macera
per horam, et cola.
Form. 221. Infusum Armoraci;e Compos.
R Sinapeos Semin. contus., Armoracia? Radicis con-
cis., aa 3 iij.; Aqua? Ferventis Oj. Macera per
horam, et cola.
R Colatura? 5 vij. ; Spirit. Ammon. Arom. 3jss.; Spir-
it. Pimenta? 3 iij. M. Capiat Coch. ij. ampla ter
quotidie.
Form. 222. Infusum Arnic.e (Ph. Mil. Dan.)
R Flor. Arnica? 3 j. ; Flor. Anthemid. 3 ss. ; Herb.
Mentha? Piper. 3 ij. ; Aqua? Fervid. g x„ Macera,
etcola. (Dosis 3 j.— 3 jss.)
Form. 223. Infusum Arnice Compos.
R Arnica? Montan. Herb., Summit. Artemesj. Vulg., 5a
g ss. ; Herb. Centaurea? Benedict., Rad. Calain.
Aromat., aa3ij.; Aqua; Fervid. 5 xvj. Maeera per
horas binas, et cola. Liq. colat. adde Tinct. Au-
rantii, Spirit. Pimentae, aa§ss. ; Spirit. Rosmarini
3ij. M. (Dosis 3 ss.— gjss. bis terve in die.
Form. 224. Infusum Artemisi j: Vulgaris Co.
R Summit. Artemes. Vulgar. 3 vj. ; Herb. Centaurea;
Bened.3iij.; Aqua? Fervid. 5 xvj. .Macera per ho-
ras binas, et cola. Liq. colat. adde Spirit. Juniper!
Comp. 3 j.; Olei Rosmarini TT) xii. M. (In Epi-
lepsy from Exhaustion, Chlorosis, &c.)
Form. 225. Infusum Barberis.
R Barberis Corticis contus. gss.; Aqua? Ferventis Oss.
Macera per horas binas in vase leviter crauso, et
cola. (Dosis, f. §j. ad 5 ij. bis ter quotidie; inter-
dnm cum Soda? Sub-carbonate, vel Potassa; Sub-
" carbonate, vel Tinct. Calumba?.)
Form. 226. Infusum Calami Aromatici.
R Calami Radicis contusi 3 iij. ; Aqua? Ferventis Oss.
Macera per horas duas, et cola ; dein adde Tinct.
Calami 3 ss.
Form. 227. Infusum Calami Aromatici Compositum.
R Rad. Calami Arom. concis. 3jss. ; Flor. Anthemid.
3j.; Aurantii Cort. exsic. 3 j.; Caryoph. cont. 3ss.;
Aqua? Ferventis O ss. Macera per quartam hone
partem, et cola. Liquori colato adde Potassa; Sub-
carbon. 3j.— gij.
Form. 228. Infusum Caryophtl. Comp.
R Caryoph. contus. 3j.; Cort. Aurantii sic. 3ij.; Semin.
Coriandri et Sem. Anisi cont., aa 3ss.; Aqua- Fer-
ventis ft j. Macera per semi-horaui, et cola.
Form. 229. Infus. Cinchona cum Q.v i.nin.e Sul-
phate.
R Cincbomr Cordifol. Corticis in Pulv. 3 vj. ; Confec-
tionis Rosa? 3 jss.; Aqua? Ferventis O j. '1'ere bene,
et digire per horas duas in vase clauso ; dein cola.
R Liq. Colati " vj.; Sul|>hatis Ouinina? gr. viij.; Acid.
Sulphur. Diluti TT) xviv. Fiat Mist, cujus Coch. ij.
larga tertiis vel quartis horis suinend.
Form. 230. Infusum Conn.
R Conii Fol exsiccat. 3ij.; Anisi, et Coriandri Semin.
contus., 5a3 jss. ; Aqua? Ferventis O ss. Macera
per boras duns, et cola. (Dosis 5 j. adgij. bis, ter,
quaterve in die.)
Form. 231. Infusum Diosm«: Cremtx.
R Fol. Diosma? Crenata- 3 ss. ; Aqus Ferventis O ss.
Macera per horas quatuor, et cola. (Dose 3J- — 5 jss.
Form. 230. Infusum Gentian.*: Alcalinum Compos.
R Radicis Gentians concis. 3 ij. ; Corticis Aurantii
sic. 3j-: Semin. Coriandr. contus 3 j. j Rosmarini
Cacuinin. 3J-: Potassa; Sub-carbon, (vel SodaSuli-
carb.)3j.; Aquat Ferventi^J xij. Macera per bora*
duas, et cola.
APPENDIX OF FORMULAE. — I mi' s, (
IX
Form. 233. IsFisriiCiuin Compositum.
R Guaiaci Ligni ra--. t> • bs.; Glycyrrhiza Radicis con
tusa 5 j. ; Sassafras Cortiela verse conciss J bs. ,
Coriandri Semini :ontU8orum ",j.-, Liquoris I !al
cis <i vj. [ofunde per dies trea dein cola; cujus
Buroal ager quatuor sexve unciaa pro dose, et bis
die repetatur. (Spbague.)
Form. 234. [rfusi u Hederj:, i i :l Gleoomo: Hxde-
RACE.X, CUM ACIDO llVDROCYANICO.
R Otoconia Hederacea vel Heders Terrestris X ss. —
")\j. ; Radicis Glycyrrhiza 3 iij.; Aqua Ferventis
0 j. Macera per horas tres, el cola.
R Liq. ColaliSjss.; Acidi Hydrocyanic! IT) lj. — viij. ;
Syrup. AltYiss Officin. 3 jss. M. FiatHaustus,
sexto, vel octava quaque bora aumendus.
Form. 235. Ikfusum Juniperi.
R Juniperi Baccarum contusaium Jij.; Aqua Ferven-
tis Oj. Macera in vase leviter clauso per boraa
duns, tt cola; dein adde, Spiritus Juniperi Com-
posit. f.gj.; et infuper, pro re Data, Potassa Su-
pertartaria 3 ijsa. (Ltosis, tiuidunc. ij. ad iv. ter
quaterve-quotidie.)
Form. 236. Infusum et Mistura Juniperi Composit.
R Baccarum Junip. contus. "ijss. ; Semin. Anisi con-
tus.,Sen)in. Fceniculi cont., aa 3 jss. ; Aquas Fer-
ventis Oj. Macera per boraa tres, dein cola.
R Liq. Colati. 3 xiij. ; Potasss Nitratis ~, jss. ; Bods
Sub-carbon. 3 jss.; Tinct. Scills 'jss.; Spirit. Ju-
nip. Co. 3 'Jss- ! Tinct. Opii TT) xxv. Fiat Mist.
cujus capiat Cyatbus subinde.
Form. 237. Ikfusum M.vrrubii.
R Marrubii Herba? exsic. § ss. ; Aqua; Destillat. Fer-
ventis i) bs. Macera per coram, et cola.
R Liq. Colati J jss. ; Tinrt. Camphors Comp. 3 j- ;
Ext. Glycyrrh. «r. x. M. Fiat llanstus, ter in
die suniendus. (Cbronic Bronchitis, and Catarrh
With inordinate Secretion.)
Form. 238. Infusum Melissa: Compositum.
R Melissa? Officinalis exsic, Radicia Glycyrrh. con
tus.,aa 5 i.is-. ; Sem. Anisi cont., Bern. Fceniculi,
Hem. Coriand. cont., aa 3 ss. ; Aquas Bullientis
Jb ij. Infunde per horam, et cola.
Form. 230. Infusum Menth.e Caryophyllatum.
R Folior. Mentha; Virid.sic. 3>ij-i Ross Gallics Petal.
sir. ~jss.; Caryophyllorum contus. 3 jss.; Aurantii
Cort. sic. 3 jss.; Aqua; Ferventis Oj. Macera per
horam, et cola.
Form. 210 Ikfusum Menth t: Compositum. (1.)
R Pol. Menth. Virid. exsic, Radicia Glycyrrh. concis.
et cont., aa " bs.; Semin. Anisi et Semin. Coriand.
contus. aa ", j.; Aquae Ferventis q. s. ut fiat Colatu-
rae < > j. ; Adde Magnes. tt Stuck, Album pro tormin-
ibus infantum ; aut interdum Acidi Sulphurici
Arum. "j. pro nausea vel vomitu.)
Form. 241. [rfusi m Mimhi: Compositum. (2.)
R Mentha Virid is exsiccat. contuse 5 jss.; Rosas Gal
lies Petalomm exsiccatorum 3 j. ; Aquae Fen entia
Oj.; Acidi Sulphurici Diiuti - ij.: Bacchari Purifi
cati " jvs. Mentha; et Rosa Petalia auperinfunde
Aquam cum Acidi dimidio mistam. Macera ; dein
Liquorera effunde,et Baccharum et Acidum re-
man, adjice. (Dosla a tiuidunc. j. ad ij. bis, ter,
sapiusve quotidiA.)
Form. 242. Ikfusum M*ktakthidis.
R Menyanthidis Foliorum -, ss. ; Zingiberls Radicia
eoncisa '•) ij.; Aqua Ferventis, O --. Macera in
clauso per horas duas, el cola, tn doses of
".i- '" ". i"'., united h ith Spii I N itricl
" j. ad 3 ij., in Rhi Irthritii Vffections,
and in Cachectic and 1 '111
Form. 213. Ikfusum Millei ilii Compositum.
R Herb. Millefolii 31J.; Herb. Rosmarinf, Herb. Thyml
Vulg., fia 3 j- j Bemin. Coriand. cont. 3 J- i Aqua?
Ferventis fo J. Firfunde p t cola.
Tinct. Mom
■ i.-j.— -ij. Tint Haustus, primo mane quotl-
die cap. In Chlorate, Amenorrheas, &c.)
Form. 2)1. [kFOIUM Pbotorale. CI.)
R Herb. Malva On*., Herb. Badiete Altbaa,
Rad. Glycyrrh., Si T 1. \ Bemin. Anisi 5 M.; Aqua:
Fervid, quantum vi lis. Macera.
Form. 245. Ihfusi 11 1 . (0.)
R Rad. Althaa, Herb. Melissa, Herb. Menth s.-it
Flor. Sambuci, Flor. *mi Bemin. Anisi
Jss. M. Bint loco The*.
1 orm. 246. twrueuii Quassi 1 1
R Radicia Calumba conch. 3J. ; Llgni Quassia XJss
Aq. Ferventis q. a. ut sinl Colatura , i Ijes. : adde
Z1nc1Sulpbatisgr.lv.; Acidi Sulphur. Vrom. 31 •
Tinct. Aurantii Co. 3 iij. M.
Form. 247. Ikfusum Quassij cum Ao.ua Cal'cih.
R Ras. Lign. Quassia Jss.; Aqua Call is Viva ", vij. ,
Stent in digestione per boraa xxiv. 1 cola, 1 1 addi
Aqua? Menth. Virid-JiJ.; Byrup. Aurantii 3
Form. 213. Im-usum Ra atari a.
R Rhatania Radicia contusa ' iij. ; Aqua Ferventis
0 ss. Macera per boraa sex, in vase leviter clauso.
et liquorem cola.
Form. 249. Ikfusum Rhei.
R Rhei Radicis eoncisa? 3 jss. ; Aqua Ferventis O sa.
Macera Radicem per boras dnas in vase leviter
clauso, et cola : dein addi Sacchari Ubissimi3ij.;
Olei Mentha Viridis tri t. viij. aolutas in Spiritu
Mentlue Piperita? 3 j. Tunc misceantur.
Form. 250. Infusum Rhei Alkali num.
R Rhei Rad. concis. et contus. r, jj.; Potassa Sub car-
bon. 5 j.; Aqua Fervid. 0 ss. .Macera per horas
quatuor: cola, et adde Tinct. Cinnam. Jss.
Form. 251. Infusum Rhei Alkali rum.
R Lnfus. Rhei 5 vij. ; Potassa Sub-carbon. 3 ijss. ;
'I'inct. Senna et Syrup. Senna aa 3 iijss. M.
Form. 252. Infusum Rhei Comp.
R Rhei Rad. concis. et contus. §ss.; Cort. < 'nulla? Al-
ba? cont. 3ij. ; Flor. Anthemid., Corticia Aurantii,
aa g iij- 1 Semin. Fceniculi cont., Sem. Coriandri
cont., aa ^j.; Aqua Ferventis ib jss. Macera per
horas quatuor, et cola. I.iquori colato adde Pot-
assa? Sub-carbon. 3 ij ; Tinct. Cinnam. 3 j. M.
Form. 253. Infusum Ros.e et AubaOTII Comp.
R Rosa? Gailica Petal, sic. ^iij.; Aurantii Cort. exsic.
" ij.; Limonis Cort. recent. ", j.; Caryoph) 1. contus.
3jss.; Aqua Ferventis O jss. Macera per horam,
et cola. Liquori colato adde Sacchar. Albi " j.
Form. 251. Infusum Rutje Comp.
R Herb. Ruta?, Flor. Anthemid., Radicis Calam
Aroni., 5a 5iij. Macera cum Aqua Funiculi •= x.
per horas tres, et cola. Liq. Colat. adde Campho-
rs 9j. ; prius in Mucilag. Acacia? q. s. solium ;
Spirit. .rEther. Nit. 5 ss. M.
Form. 255. [irrusi u Saltije Compositum.
]\ Herb. Salvia, Semin. Sim ., Aqua Fer-
vid. II. .i. Macera per horam, el cola. Liq. colat.
adde Spirit. Arnioracia Comp. -, ij. M, Capiat
1 lot b. ij. — iij. ter quaterve in die.
Turin. 25lj. Inklsum Sambuci nil Aniim. Tart.
U Flor. Sambuci Jj.; Aqua Fervid, q. a. at ^it Colat
: mi adde Oxymel. Simplicis, Oxym. Bcilliti-
ci,aa",j.; Auiiii i Tart. gr. ij. M. Capiat Cocb.
j. Ollllll bill...- \< ..I -UN.)
Form. 257. Infusum Sahtomi i Simim m c.imposi-
K Semin. Artem. San ton lei cont., Rad. Valeriana' Opt..
• -. [nibnde in vase clauso cam Aq. Fervid.
Six.: cola, et adde Aqua Menth. Virid.Jij.; Extr.
i.'ui.i ■ - j. ; Tinctura Valeriana Vmmoniati "iij.
M. capiat pro dose, in Hysteria,
Chlorosis, Amenorrnoea, Worm-.
Form. 258. iaroioM Summuli ■ Alkalikom.
\\ Sarsapaiillc Radii st contusa X iv. ; Gly-
cyrrbiza Radii ia contusa $J.; Liquoris CalctsOiv.
Macera per bora- xxiv. in vase leviter clauso, sa'pe
agitand.
■ tkv.1 v. Comp.
K Rad. Benega, Rad.Serpentaria,Si $«■.; Aqu
viil. < 1 j. Macera In vase clauso per boram, etcola.
Liq. cuiat. adde Camphors " as. : priua aolotte in
iEtberi* Sulphur. 3 iij. ; kqua Cinnam. JJ.j Sy-
rup. A 11 In ic et Syrup. Papaverls SSJ H. M. Ca-
piat Cochlear, ij. larga 4tis horia. (Hecker.)
X
APPENDIX OF FORMULA. -Infcsum- Linctus
Form. 272. Injectio Aceti Ptrolignei
Form. 260. Infusum Sennx.
R Senate Foliorumg ss. ; Coriandri Seminum contus.
3 j. ; Zingiberis Rad. contus. 3 j. ; Extracli Gly-
cyrrhiza?3jss.; Anna; Fervenlis O ss. Macera per
horam in vase leviter clauso, et liquorem cola.
Form. 2G1. Infu sum Senn.e cum Manna.
R Manna? 5 ij.; Fol. Senna; 3Jss.; Potassa? Supertart.,
Seminum Anisi contus., aa 3 ijss. ; Semin. Cor-
iand. Sat. contus. 3jss.; Aqua? Ferventis O ij. In-
funde per lioras quatuor, et cola.
Form. 2G2. Infusum Serpentaria: Compositum.
R Serpentaria? Radicis, Contrayerva? Radicis, singulo-
ruin contus. 3 ij.; Aqua; Ferventis O ss. Post ina-
cerationem in vase aperto per boras dims, liquorem
cola, et adde Tinct. Serpen taria? 3 ss. vel 3 j.— (Cum
Liq. Amnion. Acet. &.c.)
Form. 263. Infusum et Haustus Spartii Composit.
R Spartii Cacurn. concis. 3 j. ; Marrubii Vulvar. Fol.
3 ss. ; Aq. Ferventis O jss. Macera per lioram, et
cola.
R Colatur.T 3 xj. ; Spirit. /Ether. Nit. 3 ss. ; Spirit. J11-
niperi Comp. 3j. Fiat Haustus, ter quaterve quo-
tidie sumendus.
Form. 2i4. Infusum Spic-.km.c Compositum.
R Spigelian Radicis concis. 3 ss.; - enn.i- Folior. 3 ij. ;
Aurantii Corticis cone, Santonici Seminum con-
tus., Fceniculi Semiii contus., aa3 j. ; Aqutp. Fer-
ventis 3 .\ij. Macera per horas duasin vase leviter
clauso, etcula. (Dosis Cyathns Vinos, singulis au-
roris, jejuno ventriculo.— In Luinbrici. Sprague.)
Form. 265. Infusum Tilije Compositum.
R Florum Tilia? Europ. 3 ss. : Rad. Altha?a? Officio.
3iij.; Flor. Au.ran.3ij.; Aqutp Ferventis ft ij. Ma-
cera par horain ; exprime et cola.
Form. 256. Infusum et Mistura Tonico-Aperiens.
fi Senna? Folioium 3 ijss. ; Genti ma? Radicis concis.
3 iij-; Aurantii Corticis evcis. 3 ijss.; Limonis Cor-
ticis recentis 3 iijss. ; Semin. Coriandri contus.
o ijss. ; Zingiberis Rad. ronciste 3jss. ; Aqua? Fer
yentisO ij. Macera bene in vase clauso per noctern
integram (vel per horas octo); exprime bene, et co-
la. Liq. col it. adde Magnesia? Sulphatis, Tinct.
Cardamom. Comp. aa 3 iij., Spirit. Vini Rect. 3 iij.
M. (Dosis gj._ gjss. pro re nata.)
Form. 207. Infusum Vvx Ufsi.
R Uvs Ursi Folior. 3 ij. ; Aqua? Ferventis O ss Ma-
cera in vase clauso, per boras fres.prope ignem,et
cola. (Hub the Alkaline Carbonates in Nephri
tic Cases, &c. ; and with Hie .Mineral Acids, &c
in Affections of the Air Passages.)
Form. 268. Infusum Valerian.*:.
R Valeriana? Radicis contusip 3 ss. ; Aqua? Ferventis
Oss. Macera in vase clauso per horas cfuas. Li-
quon colato, adde Spiritus Lavendula? Composita-
Syrupi Aurantii, aa 3 ss. (Dosis ffuidunc. ij. ter
quaterve qiiotidie\
Form. 269. Infusum Vai.erian.-e Compositum.
R Radicis Valeriana?, Rad. Calami Aromatici, aa con-
cis. et com. 3j.; Flor. Arnica? Montana- 3 ij .; Aqua-
Ferventis 3 xij. ; Liquor. Potass* 3j. Macera per
floras binas vel tres ; exprime, et adde Athens Sul-
phur. 3 ,,j . et interdmn Spirit. Lavandul. Comp
3 "J-, vel Extr. Rut.e vel Extr. Taraxaci 3 iij. M.
(U0SIS3S8.— 3jss. ter quaterve in die.)
Form. 270. Infusum Valerias.* et Serpentari.*
Comp.
R Rad. Valerian Rad. Serpentaria-, Flor. Sambuci
hini'.^t3^' V1"* Ff rvid. ^ ix. Macera per boras
b mas, etcola. L.q. colat. adde Acidi Sulph. Arom.
b£h Vni\'r",,- T,veris 5 ss- M. (Fevers, Hys-
teria, and other Nervous Affections.)
Form. 271. Infusum Zingiberis.
R Zinaiberis Radicis roncisie 3 jss. ; Aqua- Ferventis
Oss. Macera per boras duns in vase leviter clauso
et cola: turn adde Tinctune Zingiberis, Synm
ejusdem, 5a 3ss. (This is the best vehicle for giv-
ing the Liquor. Ferri Oxygennti, and it is also a
very grateful aromatic in cases of Flatulency )
R Acidi Pyrolignei, part.j.— ij.; Mist. Camphora?, Aq.
Kosar., aa part, ij.— iij.; Tinct. Camphora? Co.
part. ss. — j.
Form. 273. Injectio Argenti Nitratis.
R Argenti Nitratis
Aqua? Destillata;
Solve.
No. L
5"j-
No. 2.
5»j
No. 3.
3J-
3»i-
Form. 274. Injectio Astringens.
R Infus. Ouercus, ut supra, 3 iv. ; Pulv. Gallarum gr.
xxx.; Tinct. Catechu 3 ij. Fiat Mist, ex quo inji-
citur pan x ilium, vel per vaginam vel per anum, in
Sanguinis Fluxu.
Form. 275. Injectio Boracica.
R Aqua?Rosar.3iv.; Aq. Flor. Aurantii 3 ij.; Sub-bo-
ratis Soda? V) ij. ; Tinct. Camphora? Comp. St ij _
3ss. M. Fiat Injectio.
Form. 276. Injectio Zinci Acetatis Composita.
R Zinci Sulphatis, Plumbi Superacet., aa 3 ss. ; Cam-
pboia?3ss. ; Opii £ ij. Solve in Aqua? Bullientts
Oj. : cola, et fiat Injectio, ter quaterve in die
utenda ; phiala agitata.
Form. 277. Ioduretum Hvdrargtri.
(Internally, in doses of from one erain to three and
externally in ointments.— (Vide Unguent. lod
Hydr.) For the best account of the preparations
and uses of Iodine, consult Dr. O'Shaugnnessy's
excellent translation of Lugo! on Scrofufa.)
Form. 278. Ioduretum Plumbi.
(Internally, in doses of from half a grain to five "rain*-
and externally.— (Vide Ung. Iod. Plumbi.)
Form. 279. Julapum Sedativum.
R Camphora- gr. vj. ; Spirit. /Ether. Sulphur. Comp.
3.ISS.; Potassa? Nitratis gr. xij.; Aqua? Flor. Auran-
V.' 5 'y '•' &Tup' A1tl>^s r> "j.; Syrup Papaveris 3 ij.
M. I ml Mist., cujus capiat tertiam partem omni
bora, vel bihoris.— (Pierquin.)
Form. 280. Linctus Acidi Muriatici.
R Mellis Rosa? 3 x. ; Acidi Muriatici IT) xx. ; Syrupi
Rhceados 3ij. M. Simul agita, ut fiat Linctus.
Form. 281. Linctus Boracicus.
R Cetacei3ijss.; Pulv. Tragacanth. Comp. 3 iij • Sy-
rup. Tolutan. 3 j. : Sub-boracis Soda? 3 ijss. ; Con-
feet. Rosa- 3 v. ; Syrup. Althaja? 3 j. vel. q. s. Fiat
Lin. tus, dequo lambat sa?p4. (Sore Throat, Oeso-
phagitis, &c.)
Form. 282. Linctus Camphoric e us.
11 Camphora? gr. xij.; Pulv. Gum. Acacia- 3j- Syrup.
Altha?ne3ij. Misce bene. (Niemann.)
Form. 283. Linctus Chlorureti Calcis.
R Chlorureti Calcis gr. iij.: solve in Aq. Destil. 3 j. ;
et adde Mellis 3 jss. M. Capiat infans cochleare
uniim minimum subinde. (In softening of the Di-
gestive Mucous Surface.)
Form. 284. Linctus Demulcens. (1.)
R OleiAmygdal. Dul., Svrup. Altba-.-e, 55 3 ij.; Syrup
Papaveris 3 xj. ; Vini Ipecaciianh. 3 jss. ; Vjtelli
Ovi unius. M. Fiat Linctus.
Form. 285. Linctus Demulcens. (2.)
R Cetacei 3 ijss.; Pulv. Tragacanth. Comp. 3 jss.: Sy-
rup. Papaveris et Syrup. Tolutan. Sa 3ss. ; Potass'^
Nitratis ;^ij.: Confect. Rosar. 3 vj. ; Syrup, simp,
q. s. ut fiat Linctus ; de quo lambat pauxillum,
pro re nata.
Form. 286. Linctus Demulcens et Aperiens.
R Syrup. Viola? 3 ijss. ; Olei Amygd. Dul.3j.; Syrup.
Scilla et Syrup. Senna- ai gss. M. Fiat Linctus.
(Infantibus.)
Form. 287. Linctus Fmolliens. (Brendellii.)
R Saponis Venet. }) iv.; solve in Olei Amvcdal Dul-
cis3jss.; Manna- Purificat* 3 ss. ; PMasse Super-
tart.3ij.; Syrup. A)tha?a?3J. M. Fiat Linctus.
APPENDIX OF FORMULAE. — Linctus — Liquor.
XI
Form. 988. Limits M viuui *: tr [PECAdO 4 mi k,
R MyrrheG. H.~j.: l'uiv. [pecacuon. gr. vj.; Oxymel.
Scillm, MucUag. Acacim, Syrup. A 1 thee, ia 3 vj.
Fiat Linctus, aequo lambat pauxilium sepe.
Form. 389. Linctus Oleosus. (I.)
R Olei Aim gdalarum, Syrupi .Mori, SS f. 5 jss. : Con-
fectio. Fruct. Ross Canine 3 ij- ; Pulv. Traga-
c;uiiii Comp .5 iij. Misce. Cochlear, minim, suh
indO deglutiaiur.
Form. 990. Linctus Oleosus. (2.)
R i llei Olivai Jjss.; < ixymellisScills, Syrupi Papaveris,
ii t. 3j. Dosis, Cochlear, parv.j.urgenti tusse. [In
common < latarrhal i !ough, attended with abrasion
of the Fauces, and thin copious Expectoration.)
Form. 991. Linctus Opiatus.
R Syrupi Papaveris t". ' ij.; Mucil. Acacia Ver. Jjss. ;
('out'. Fruct Boss Caninie, unc. j. ; Acid. Sulph.
Dilut. t". 3 ij. Misce. Dosis, Cochlear, minim,
aubinde.
Form. 292. Linctus Opiatus cum Scilla.
R Syrupi Papaveris, t". 3j. ; Syrup. Morigvj. ; Syrup.
Limonis 5 s*- i Oxymellis Scille, I". 5 ss. Misce.
l>o>i<. Cot blear, minim, tusse urgenti.
Form. 293. Linctus Pec.toralis.
R Pulv.Sem. Anisi, Pulv. Sem. Fceniculi, Extr. Gly-
cyrrh., aa 3ss-> Pulv. Sum. ('ami 3 ij.; Potnssie Ni-
tratisjj.; (>l. Anisi 3ss.; Syrup. Althee J vss. M.
Fial Linctus. Capiat 3 j. pro re nuti.
Form. 294. Linctus Potass.*: Nitratis.
R Potasse Nitratis Contr. 3 jss.; MellisRosef. 5 j. ;
Oxymellis Simplicis !'• 5 jss. M. Capiat Coch.
minim, pro re nati.
Form. 295. Linimentum Ammonije cum Oleo Ter-
EBINTBI N-*:.
R Liquoris Aiiimnnin-, f°. g ss.; ( )liv;e Olei, f. 5J. ; Olei
Terebinthine, r. Jss.; Olei Limonis, 3 ss. Ayita
siuiul donee niisceantur.
Form. 296. Limmentum Ammonije et Terebinthi-
N.t CoMP.
R Liquoris Amnion. 3j.; Olei Olivic 5 ij. Misce liene,
et adde Spirit. Camphors ~ ij. ; <Hei Terebinth.
5 iij. ; Saponis Durijv. MiBce bene. Olei Caje-
puti "j. ; Olei Limonis J jss. M.
Form. 997. Linimentum Anodtrum. (I.)
R (i|)ii gj. ; Camphora 3 ij.: Lig. Ammonia g iv. ;
Saponis Duri J iv.; Olei Terebinthine 3 viij.j Olei
Limonis Jss.; Spirit. Rosmarinus Spir. Lavandul.
ia^xij. Misce.
Form. 998. Lihimehtum Ahodthum. (2.)
R Linimenti Saponis Comp. T,j.; Liquoris Ammonite,
3 iij. ; 1 llei Caryopbylli 3 j.; Tincture Opiig as.
M. Fiat Liniment.
Form. 999. Linimenti m Camphora Fortius.
R Camphors rasa' 3 ij ss. : solve in Tlnct. Cantharidis
3 ij. el Tinct. « 'apsici Annui 3jss.; deln adde I. mi
inent. Saponis Comp. Jss.; el gradatim, miscendo,
Liquoris Vmmonite 3 yj.; Olei Olive 5 xj. M. Fiat
Linimentom, cum quo lllinatur pars afiecta bis
terve quotidie.
Form. Dill. LlRTMERTDM CaRTHaRIDOM TeRBBIRTH.
R Tinct. Cantharid 3 iij. ; Olei Terebinth. % j. j Am-
monie Liq. 3jss.; Saponis Duri 3 J-; ' "',| Cajeputi
£ss. M. Fiat Linimentum. (Altered from At
01 -UN.)
Form. 301. Lirimertuh Febrikugom.
K Antimnnii Tartarfzati gr. xxv.: solve in Vque Des-
lil. 3 ij. vel q. -• | deinde tere bene cum Adipia
Pre par. 3 j. et fial Linimentum. The antimony
1- partially absorbed without producing any Pliiu-
(josis. Vide Unguent. Antimon. 'i'art.)
Form. 3ll2. Linimentum Iodiri.
r Linimenti Saponis Co. 3 j. ; lodinl gr. vnj. vel. x.
Misce.
Form. 303. LlNIMCRTOBB PhoIPHORATUM.
R Olei iilivarum Optimi 3 viij. ; Phnsphori exclfl cr.
xx. Solve cum calore, cola ex (rigldo, el fial Lin-
imentum. (In Paralyse locale, Marasmo, Rheu>
mat is mo, et Arlliritule Chronlco.)
Form. 3111. LlRIMBRTOM PrBETRBI,
R Tincture Pyrethri, 3 vj.: Lintmeml Camphora Siv.s
Liquoris Ammonia ■ ", ij. Misce; it. Linimentum.
Form. 305. Linimentum Robspacieri.
R Camphors 3 j.; Olei Olive et Liq. Ammon. ■
OleiMacisTD xxxv. Misce. (Externally to parta
in deep-scaled Inflammation.)
Form. 30fi. Linimentum Saporis et Ca.mi-hor.ie
Comp.
R Saponis Med. gj.; Alcoholis Beet. gvj.; AqueDes-
til. etCamphote Si 3 j. Solve leni cum calori, et
adde Olei Rosmarini }) iv. ; ( llei Thymi ';) j. ; Li-
quor. Ammonia- 3 ij- Misce bene.
Form. 307. Linimentum contra Stasmos.
R Olei Olive, Obei Terebinthine, Liquoris Ammo-
nia?, Tinct. < ipii, Liniment. Saponis Com posit., u-a
Jss. Fiat Linimentum.
Form. 308. Linimentum Stimulans.
R Linimenti Camphors Compositi, Linimenti Saponis
Compositi, aagjss.; Olei Cajeputi, Jj< Fiat Lini-
mentum stimulans.
Form. 309. Limmentum Sulphuro-Saponaceom.
(Jadelot.)
R Sulphurcti Potassegiij.; Saponis Albi, Olei Oliv.T,
aa. }bj.; Olei Volat. Thymi 3 j- M.
Form. 310. Linimentum Taracci.
R Tabacci Foliorumjj.; Axungie Porcine ft>j. Melt
together, and simmer until the leaves become fria-
ble; then express. (Amst. Ph.)
Form. 311. Linimentum Terehinthinv. Comp.
R Liniment. Saponis Co., Liniment. Camphora: Co.,
aajjss. ; Olei Terebinth. 3 ij- ; Saponis Duri 3 ij. ;
Olei Limonis et Ol. Cajeputi 3 j. — 3 ij. M. 1'iat
Linimentum.
Form. 312. Linimentum Tererinthino-Phospho-
ratum.
R Olei Terebinth. J ij.; Camphora- rasa- 3 ij.; Liniment.
Amnion. Fort. J ij ; Saponis Medicin.J ij. ; Phos-
phori 1*1111 •.-r. \. — \ij. Soiuti in olei Cajeputi, vel
In Olei Caryophyl. 3 ij. vel ij.s. M. (In Chronic
Rheumatism and Epidemic Cholera.)
Form. 313. Linimentum Thekaiaci m CVMPOSITl'M.
R Opii Puri }) ij. ; Camphor., Succini, aaj.ss. ; Spir-
it. Vinijvj. Misce pro Linimento.
Form. 314. Lirimertum Volatile.
1^ Olei Olive J iv. ; Camphors 3 U-i Aque Ammonia
3ijss. Misce.
Form. 315. LiqvOB A< in ITU MoBPRIR I ■
R Morphine AcetntiHgr.xvj.; Aqua DestillBt. f. 3viJ.;
Acidi Acetici TT1 v.; Spirit. Vini Rectif. f. 3 j.
Solve. (Dosis b TT| v. ad IT) v\.)
Form. 316. Liqoos Artimorii Tartabibati.
II Antitnonil Tartarizatl vr. xxxij. ; Aqute Desttllate
3 \n . . Spiritas Reel 1 i'u at. S'j'i ' i varum Passant m,
deiuptis acinis, unc. ij. Maiera per h< lidoiiiadam,
el cola.
Form. 317. Li^oon Balsamii o-Abomaticoi. — Bnl-
stliHUttt Vita lliitfinnnui.
\l Balsam. Peruvian, "j ; (llei Snci in.. < >hi BrUte,
Olei Rosmarini, Olei Lavand., Olei Caryopfl ,Olei
Pimenle, ■■•• 5 as. ; spirit. Vini Beclificat. 3 *Jss.
Misce bene. (In doses of from 10 to 30 drops on
Sugar, 01 hi a suitable vebii It . |
Form. 318. Liquon Bobacis Sod ■ Comp.
\\ Sub-boracis Sodc ", vj. : Potaess Stipertart.
Aque Distil. O J. (I)osu ", j. - 3 irj. pro inlanti-
bus; el ' ss. — 3 iij. ter die pro Adullls.
Form. 319. Ltqt os Calcis Muriatii. (Uehdoei.)
]\_ Acidi Huriaticl, Aqua Deslillate, j.i 3 iv. j Marmo-
n> Albi Pulv. q. s. ad salurandum.
XH
APPENDIX OF FORMULAE. — Liquor — Mistura.
Form. 320. Liquor Camphors TEtherea.
R Camphore rase 3j. ; zEtheris Sulphuricigj. Solve.
_ Capiat TT) xx. — xl. silper Saccharum vel in Vini
Hisgan. Cyatho. — (Proposed by Bang, and adopted
in most ot" the continental Pharm.)
Form. 321. Liquor Ferri Oxygenati. (Beddoes.)
R Ferri Sulphatisg ss. ; Acidi Nitrosi Fortissimi (per
pond.) g ss< 'i'ere probe simul in mortareo vitreo
donee effervescentia peracta ; dein adde gradatim
Aque' Destillate gjss. Afterwards filter the liquor
through white paper, placed in a glass funnel. The
(lose is from four to ten drops, three or four times a
day, in an Infusion of Ginger, or Infusion of Quas-
sia and Cloves. — (In Worms, Hemorrhages, &c.)
Form. 322. Liquor Hydrargyri Oxymuriatis.
R Hydrargyri Oxymuriatis gr. iv. ; Acidi Muriatici
TT) vj. ; Aqua; Destillate, f. g j. ; Spirit. Tenuioris
gvj. ; Tincturse Croci 3 ij. Tere prob£ simul in
mortario vitreo ut fiat solutio. Incip. sumendo
TT] xx. nocte manequeex haustu InfusQs Lini, vel
Decocti Glycyrrhize ; posteaque pro re nata. augea-
tur. (Sprague.)
Form. 323. Liquor Hydriodatis Potass.*:.
R Potasse Hydriodatis gr. xxiv.; Aque Destillate g j.
M. Solve terendo in vase vitreo. (Dosis TTJ x.
— xxx.)
Form. 324. Liquor Hydriodatis Potass^: Ioduretus.
R Potasse Hydriodatis gr. xxxvj.; Iodini gr. x.; Aqua;
Destillate, f. 3 x- Solve terendo in vase vitreo.
(In doses of 10 git. to 30 ter die.)
Form. 325. Liquor Morphinje Citratis.
R Morphine Pure gr. xvj. ; Acidi Citnci Crystal, gr.
viij.; Aqua Destil. f. gj.; Tinct. Cocci q. s. Solve.
(Dosis Tlj v. — xxv.)
Form. 325. Liquor Plumbi Acetatis Dilutus.
R Liquor Plumbi Acetatis, f. 3j- ad 5 ij. ; Acidi Ace-
tici Diluti, 3 iij. ; Spirit. Rectificati, g jss. ; Aque
Destillate g xiv. Misce.
Form. 327. Liquor Potass.*: Chloratis.
R Potasse Chloratis 3 j. ; Aquas Destillat. g xij. (In
indolent Sores as a lotion, and internally in three
times its bulk of vehicle.)
Form. 323. Liquor Potassje Hydriodatis Ioduretx
CoNCENTRATUS. (LuGOL.)
Ji Iodine 9j.; Potasse Hydriodatis J) ij.; Aque Des-
tillat. 3 vij. Solve. (This solution contains one
twenty-fourth part of Iodine. Dose for an Adult,
six drops in sugared water in the morning fasting,
and six an hour before dinner ; increasing the
dose, every week, two drops, until it reaches to
thirty or thirty-six daily.)
Form. 329. Liquor Potass.*: Hydriodatis Ioduretje.
Dilutus. (Lugol.)
No. 1. No. 2. No. 3.
R Iodine - - - gr. J gr.j. gr. j. $
Potasse Hydriodatis gr. jss. gr. ij. gr. ijss.
Aque Destillate g viij. 5 viij. 5 viij.
Solve.
Form. 330. Liquor Zinci Acetatis.
R Zinci Sulphatis Purif. gr. xxiv. ; Aque Destillate
giv. Solve.
R Plumbi Superacetntis gr. xxxij. ; Aque Destillate
g iv. Solve. Misceantur solutiones ; ouiescant
paulisper ; dein coletur liquor.
Form. 331. Lotio Acidi Hydrocyanici.
R Acidi Hydrocyanic, f. gss. ; SpirituS Rectificati, f.
gj.; Aque Destillate, f. 3 xss. Misce, et fiat Lotio
diligenter utenda.
Form. 332. Lotio Antifhlogistica.
R Liquoris Plumbi Subacetatis 3 vj.; Liquoris Ammo-
nite Acetatis giv.; Aque Pure lb ij. Misce.
Form. 333. Lotio Antipsorica.
R Potasse Sulphureti g iv. ; Aque O j. ; Acidi Sul-
phuric] 3iv. Misce. Fiat Lotio, bis terve quotidie
utenda. (Dupuytren.)
Form. 334. Lotio Boracica.
R Sub boraris Sode " j.; Aq. Rosar., Aq. Flor. Auran-
tii, aa 5 iij. M. Fiat Lotio.
Form. 335. Lotio Eyaporans.
R ./Etheris Sulphur., Liquor. Amnion. Acet., Spirit.
Vini Rect., aa 3 jss. ; Aque Rosarum giijss. M.
Fiat Lotio.
Form. 336. Lotio Evatorans Astringf.ns.
R Ammonia; Muriatis 3 ij- ; Liquoris Ammonie Acet.
g iij.; Aque Pure 3 xij. Misce.
Form. 337. Lotio Flaya.
R Hydrargyri Oxymuriatis gr. xv.; Liquoris Calcis ft j.
Misce.
Form. 338. Lotio Hydrargyri Camphorata.
R Hydrargyri 3 ij. ; Acidi Xitrici giv. ; Aque Destil.
U x. Treat the Mercury with the Nitric Acid, and
add the distilled Water ; afterwards add from gss.
togijss. of Camphor. (In Chronic Cutaneous Af-
fections, applied twice daily.)
Form. 339. Lotio Sedativa.
R Acidi Hydrocyanici3J. — 3iJ-> Mist. Amydal. Amar.
gvijss.; Hydrarg. Oxymur. gr. iij. — v. Fiat Lotio,
ope spongie partibus affectis applicanda.
Form. 340. Lotio Terebinthin^ et Camphors.
R Camphore giv.; Spirit. Vini Rect., Olei Terebinthi-
ne, aa § iv. M. Fiat Lotio, in Morbis Cutaneis
Chronicis utenda.
Form. 341. Lotio Terebinthinata.
R Olei Terebinthine, Alcoholis, 5a giv.; Cainphoras
3vj. Fiat Lotio. (In Pthiriasis, &.c.)
Form. 342. Mistura Acetatis Morphine.
R Morphine Acetatis gr. ij.; Acidi Acetici 3?s.; Mist.
Camphore 3 vss.; Tinct. Humuli 3>>j-> Syrup. To-
lutan. 3J- M. Fiat Mist., cujus capiat Cochlear,
unum amplum 3tiii. vel quarta. quaque hora.
Form. 343. Mistura Acidi Boracici.
R Acidi Boracici 3 j-; Mist. Camphore 5 iv. ; Syrup.
Aurantiigj. M. Capiat Cochlearia ij. 2da vel 3tii
quaque hora. (In Cerebral Affections. Chaussier.)
Form. 344. Mistura Acidi Hydrocyanici Comp.
R Acidi Hydrocyanic! TT| viij. — xx.; Vini Ipecacuan-
he 3 ij. ; Spirit. iEtheris Sulphuric! Comp. 3 iij. ;
Mist. Camphore, Mist. Amygdal. Dulc.,aa giij^s.;
Oxymellis Scille 3 ij. — gss.^M. Capiat Cochlear.
- j. vel ij. vel iij., ter quaterve quotidie.
Form. 345. Mistura Acidi Muriatici.
R Acidi Muriatici, f. 3 j. ; Decocti Hordei O j. : Sac-
chari Purificati, g ss. Misce. (Dosis a. fluidunc.
ij. ad iv. bis ter, sepiusve quotidie.)
Form. 346. Mistura Acidi Nitrici Comp.
R Extract! Hyoscyami 3 ss. ; Acidi Nitrici Diluti 3 j. ;
Aque Destillate gvss. Syrupi Zingiberis 3 iij. Jl.
ft. Mistura. (Dosis unc. j. secundis horis, durante
paroxysmo.)
Form 347. Mistura Alkalina Anodyna.
R Tincture Opii 3 ij.; Liquoris Potasse gss.; Spiritus
Myristici "ss.; Aque Pure gxjss. Misce. (Dosis
&3J- a(i 3U- Lis terve in die.)
Form. 34$. Mistura Alkalina Cardiaca.
R Mist. Camph. g vjss.; Sod. Sub-carhon. 5jss. ; Am-
nion. Carbon. J) j. ; Tinct. Calumbe g ss. ; Spirit.
Anisi, Tinct. Cardamom. Co., aag ss. M. .Mist.
Capiat Cochlear, ij. magna, bis terve quotidit*.
Form. 349. Mi3TURa Aloes et Guaiaci Comp.
R Tincture .Vois Comp., Tinct. Guaiaci, Spirit. Am-
monie Aromat., ail gss. ; Tinct. Ferri Ammoniati
5iij. M. Capiat 5j. vel 3ij. ter de die, in vehiculo
quovis idoneo.
Form. 350. Mistura Ammoniaci Comp. (1.)
R Mist. Ammoniaci g vjss.; Potasse Nitratis 3 j.; Aeeti
Scillfe 5 iij. ; Spirit. Junip. Comp. 5 j. ; Tinct. Opii
TT) xij. Fiat Mist, cujus capiat Cochlear, amplum
3tiis vel 4tis horis.
Form. 351. Mistura Ammoniaci Composita. (2.)
R Gnmmi Ammoniaci 3 h • Oxymellis Scille " j. ;
Vini ipecacuanha "j.; Aque Flor. Sambuci " ivss.-.
Syrup. Papaveris ~ ij. M. Capiat egor qualibet
hora Cochleare unum. (Chronic Pectoral Com-
plaims.)
APPENDIX OF FORMULAE. — Mistura.
xvu
Form. 352. Mistura Ammonite Muriatis.
R Muriatis Ammonia', Kxtr. Clycyrrh., aagj.; DeCOCti
Althaea 5 vj.j Oxymel. simp, g j. (vel Oxvmel.
Scilla.) M. (Catarrhal Affections.)
Form. 353. Mistura Anodyna.
•R Mamies. Carbon. 5 jss. ; Tinct. Hamuli 3iij. : Aq.
Menth. Virid. 5 iij. ; Infus. Caryophyl.g iijss. M.
Fiat Mist., cnjus capiat Cochlear, ij. larga pro re
natft, vei urgenti nausea.
Form. 354. Mistura Anodyna. — (Infantilis.)
R Testa: Praparata 3 ij. ; Syrupi Papaveris Alb. 5 j. ;
Spiritus Amnion, Foetid. 3j. ; Olei Anetiii, Olei
radical. Dale, ia TTJ iij. ; Aqua; Dislillata 5 iij.
Fiat Mistura.
Form. 355. Mistura Anodyna Acetosa.
II Mist. Camphors 3 iv.j Liquor. Ammon. Aret giij.;
Acid. Acet. 3 ij. ; Spirit. /Ether. Nit. 3 ij. ; Vini
Ipecacuanha 5 ij. ; Extracti Conii gr. xxx.; Syrup.
Tolutan. 3 y. M. Fiat Mist., cujus capiat Coch-
lear, ij. vel iij. larga 4ta vel quinti. quuque horl.
Form. 356. Mistura Anodyna cum Zinco.
R Zinci Sulphatis gr.vj. 3 Mist. Camphoric gvij.; Acidi
Sulphur. Aroni. f. 3ss-j Tinct. Hyoscyami 3 jss. ;
Tinct. Camphora Coinp., 5 iij-; Syrup. Limonis 3 ij.
M. Capiat Cochlear, ij. larga ter quaterve quotidie.
Form. 357. Mistura Anti-emesin.
R Magnes. Carbonat. 3 Jss- > Spirit. /Ether. Sulph.
Comp. 3 iij- ; Tinct. Cardamon. Co. 5 ss. ; Spirit.
Anisi, 3 v. Olei Carui TTJ x. ; Syrup. Zingiberis
5 ijss. Mist. Camphora gjss. ; Aqua Mentha! Vi-
ridis gvss. Fiat Mist., cujus sumantur Cochlearia
duo ampla urgenti riatu vel nausea.
Form. 358. Mistura Antiphlogistica. (1.)
R Potassa Nitratis3ss. ; Liquoris Ammonia Acetatis
f. gjss.; Vini Antimonli Tartarizati f. 5J1J.; Mistu-
ra Amygdalarum f. 3 vj. Fiat Mistura, cujus sit
dosis Cochlearia tria magna quarta quaque hora..
Form. 359. Mistura Antiphlogistica. (2.)
R Liquoris Ammonia; Acetatis, Aqua Mentha Viridis,
aaf. gij.; Aqua; Destillata f. g iijss.; Potassa Ni-
tratis^ ij.; Vini Antimonii Tartarizati 5 "j- Fiat
Mistura, cujus sit dosis Cochlearia tria ampla tenia,
vel quarta. quique hora.
Form. 360. Mistura Antiseptica cum Acido Pyro-
ligneo.
R Acidi Muriatici, /Etheris Sulphur., aa 3 U- ; Aqua;
Pimentas 3'vss-> Aqua Cinnam. g ij. ; Syrup. Au-
rantii gj. M. Sumantur Coch. duo omni bihorio.
Form. 361. Mistura Aperiens.
R Magnesia Sulphatis g v.; Magnesia Suh-carbonatis
3 iijss. ; Aqua Destillata O ij.; Spiritus Cinnamo-
mi, Spiritus Anisi, aa3 ij. Fiat Mistura. Dosis a
oj-ad gij.
Form. 362. Mistura Aperiens Salina.
R Florum Anthemidis gij.; Radicis Zingiberis concis.
gj.; Aqua Ferventis'o ijss.; Macera per noctem ;
exprime, et adde Magnes. Sulphatis g ij. ; Soda
Sulphatis gjss. ; Potassa Sulphatis 3 v. M. Ca-
piat Cyathum primo mane. (After each dose take
an hour's exercise in the open air, and breakfast
afterwards.)
Form. 363. Mistura Aromatica.
R Infus. Caryoph. § iv. ; Aqua Cinnam. giij. ; Tinct.
Cinnam. 3 ij. ; Magnes. Carbon. 3 jss. ; Confect.
Arom. gr. xij. M. Fiat Mist., cujus sumat Coch.
ij. larga.
Form. 364. Mistura Arsenicalis.
R Liquor. Arsenicalis 3 jss. ; Tinct. Cardam. Comp.
3 v.; Aqua Cinnam. 5 iij. ; Aqua Destillata g iv.
M. Fiat Mistura. Dosis Cochlear, ij. (f.gj.)3tiis
vel 4tis horis.
Form. 365. Mistura Arsenicalis cum Opio.
R Liquoris. Arsenicalis TTJ xl.; Confectinnis Opii'Oiv.;
Aqua Mentha Viridis giv. M. Fiat Mistura." Ca-
piat pars 11 a post jentaculum, prandium, et crenam.
(Dr. Clechorn.)
Form. 366. • Mistura Assafcetidje.
R' Assafcetida 3 j. ; Liguoris Ammon. Acet., Aqua
Pulegii, ii 5 iijss. M. Cap. Cochleare unum vel
duo pru (lose.
Form. 367. Mistura Assafcf.titi.'e Comp.
R Assafcetida' 3j.; tere cum Aqua Menth. Virid.gij.i
dein adile Tinct. Castorei 3 iij.; Tinct. Yaler. Am-
nion. 3 ij. ; /Ether. Sulphur. 3 j. Fiat Mist., cujus
capiatur Cochleare unum amplura secundis horis.
Form. 36S. Mist. Assafcetidje et Valeriana Comp.
R Tinctura Assafcetida, Tinct. Gentiana Compos.,
Tinct. Valeriana, Spiritus Ammonia Arom., aa f.
gss. M. de qua sumatur Cochleare unum mini-
mum ex aqua tosta- cynllio.
Form. 369. Mistura Balsami Peruviani.
R Balsami Peruviani f. 3ij. vel iij.; Mellis Despuma-
ti, g j. Situul diligenter tere, et gradatim adde
Aqua Destillata gvij. Dosis a. fluid, gj.ad gij. bis,
ter, quaterve quotidie.
Form. 370. Mist. Balsami Tolutani.
R Tinctura Balsami Tolutani 3ij.; Mueilaginis Acacia?
vera; g j. Misce ; Adde gradatim, Aqua Destilla-
ta g iv. ; Tinctura; Opii Gamphoratte prislin., Sy-
rupi Simplicis,.aa 3 iij.; Ammonia Sub carlumatis,
3 ss. (vel sine.) Misce. Fiat Mistura, cujus ca-
piat Coch. ampl. ij. ter in die.
Form. 371. Mistura Bechica.
R PulverisTragacantha Compos. 3 ij.; AquaDestilla-
tagxij.; Syrupi Simplicis 5 vj. Misce. lnterdum
adde, vel Nitratis Potassa 9 iv., vel Tinctura Opii
TTJ xl., vel Tinctura Hyoscyami 3 j-, vel Tinctura
Camphora Comp. gss., vel Oxymellis Scilla; 3 vj.,
vel alium medicanientum idoneum.
Form. 372. Mistura Camphorje.
R Camphora 3j. '• tere cum Spirit. Eectificati TTJ xx.;
Magnesia Sub-carbonatis jj) ij.; et Sacchari Furifi-
cati 3 ij. : dein adde gradatim, Aqua Destillata;
FerventisOj. M. Fiat Mistura.
Form. 373. Mistura Camphorje Composita.
R Camphora rasa gr. xij.; Magnes. 3j.; Gum. Acacia
inpulv. 3j.; Mist. Amygdal. Dulc. gvjss.; Tinct.
Opii TTJ xxx. (vel Tinct. Hyoscyami 3 j.); Syrup.
Papaveris Alb. 3 iij- M- (in Affections of Mu-
cous Surfaces, &c.)
Form. 374. Mistura Camphorata.
R Camphora gr. viij. — xvj. ; Alcoholis TTJ vj.; Sas-
char. Albi, Pulv. Acacia, Magnes. Albi, aa 9 ij. ;
Aqua Pura g vijss. M.
Form. 375. Mistura Camphorata. (Ph. Dan.)
R Camphora Pulverizat. 3SS-; Gum. Acacia, Sacchar
AIbi,aa 3ij.; Magnes. 3ss.; Decocti Althaa Oni
cinalis g vijss. M. (lnterdum adde Tinct. Opii, vel
Tinct. Hyoscyami, vel Vinum Ipecacuanha, vel
Spirit. /Ether. Nit., vel /Ether Sulphur., vel Extr.
Conii. &.C. &x.)
Form. 376. Mistura Carminativa.
R Magnesia Sulphatis g jss. ; Magnesia Carbonatis
3 ijss.; Tinctura Cardamom) Comp. 3 jss. ; Tinct-
ura Castorei IT) xl. ; Olei Anisi TTJ x.; Aqua Ane-
thi % xij. ; Aqua Purse g viij. Misce. Dosisagij.
ad gss. 4tis vel 6tis horis.
Form. 377. Mistura Carminativa Deopstruens.
R Infus. Mentha Caryophyl. (F. 239.) g vij. ; Potassae
Super-sulpliatis 3 ijss.; Acidi Sulphur. Dil. 3 j. ;
Spirit. Pimenta, Spirit. Carui, aagjss.; Spirit JVIy-
ristica3ij.; Sacchar. Albi 3 ij. p'iat Mist. Capiat
Cochlearia duo larga 3tiis vel 4tis horis.
Form. 378. Mistura Cathartica.
R Olei Cinnamomi TT) viij. ; Sacchari Purificati 5 ss.
Misce. Adde gradatim Infus. Senna g x. ; Soda;
Sulphatis "jss. ; Magnes. Sulphatis gj. ; Tincturae
Jalapa gj. ; Tinctura Senna, f. gjss. Misce. Fiat
Mistura, et per chartam cola. Dosis gjss. ad g ij.
Form. 379. Mistura Cathartica Ammoniata.
R Olei Mentha Viridis TTJ x. ; Olei Mentha Piperita*
TTJ v.; Sacchari Purificati 3 iij. Misce; turn adde
Infus. Senna gvij .; Soda Sulphatis gj.; Tinctura
Senna 3 v. ; Spiritus Ammonia Aroinat. 3 iij.
MNce. Fiat Mistura; cujus sumat partem 4tam
3tiis horis, donee alvus respondent.
XIV
APPENDIX OF FORMULA. — Mistura.
Form. 380. Misttra Cinchonje.
R Cinchona Flav» Sn pulv. sublit. gyj.j Confectionis
Opii 5 ij. ; Pulv. Cinnam. Comp. 3 j. j Ammonia;
Carbon, gr. xij.; Vini Rubr. Op. g xij. M.
Form. 381. Mistura Cinchonje Alkali na.
R Myrrhs in pulv. 3jss.; Liqaor. Potassa; Sub-carbon.
3 iij.; Decocti Cinchona: 5 vss. ; Tinct. Cascarills
3 iij. Fiat Mist., de qua sum. Cochlear, duo ampla
bis de die.
Form. 38-2. Mistura Cinchonje Aperiens.
R Confectionis Ross Gallics 3 j.: contere cum Decoc-
ti Cinchona; Ferventis, 5 viij. : stent simul per
min. hor. decern, et cola.
R Liquoris Colati 5 vij.; Acidi Sulphurici Diluti,f.5j.;
Magnesia; Sulphatis 3 iv. ; Spiritus Myristica;,
f. 5 ss. M. Fiat Mistura, cujus sumat Coch. ampl.
iij. terin die.
Form. 3S3. Mistura Conii Ccmposita.
R Extract! Conii 3«s. ; Sods Sub-carbonatis 5ss. — j. ;
Decocti Glycvrrh. §vss.; Spirit. Pimenta; 3 iij. M.
Dosis§ss. ad gij. ter quaterve quotidie.
Form. 384. Mistura Cretje Comp.
R Cretas Praeparat., Gum. Acacia;, Sacchar. Purif.,
aa§ss.; Olei FcBniculi ITJ viij. ; Aqua; Pimenta; et
Aqua: Cinnam. aa§ viij.; Tinct. Aurantii § j. M.
Form. 385. Mistura Decocti Cinchonje Ammoniata.
R Decocti Cinchona; 5 iv.; Liq. Ammonia: Acet. gjss.;
Spirit. Ammonire Aromat. (vel Succinat., vel Fce-
tid.)3iij.; Spirit. Rosmarini 3 ij. M. Fiat Mistura.
Form. 386. Mistura Decocti Cinchona Composi-
ta. (1.)
R Decocti Cinchona; 5 iv.; Liq. Ammon. Acetatis 5 ij.;
Spirit. .<£ther. Nit. 3 i j . M. Fiat Mistura.
Form. 387. Mistura Decocti Cinchonje Composi-
ta. (2.)
R Pulv. Cort. Cinchonas 3 vj. ; coque cum Aq. Fonta-
nae gxvj. ad reman, unciar. octo ; et subfinem coc-
tionis adde Pulv. Itadicis Serpentarias 3 iij. ; Pulv.
Radicis Rhei Opt. 3jss. Cola cum express.; dein-
de adinisce Liquoris Amnion. Acet. 5 ij. ; Syrup.
Cort. Aurantii gj. Misce. Capiat aeger altera
quaque hora. Cochleare unum.
Form. 3S8. Mistura Decocti Cinchonje cum Ace-
to Pyroligneo.
R Decocti Cinchonas 5 vjss.; Acidi Acetici Fortior. (vel
e Ligno destil.) 3 ij.; Spirit. Rosmarini, Spirit. Pi-
mentos, aa 5 U- M. Fiat Mistura.
Form. 389. Mistura Demulcens.
R Pulveris Tragacanthi gr. xv. ; Sacchari Albi gr. xij.
Tere, et paulatim adde Mist. Amygdal. Dulc. gij. ;
Mist. Camphors § iijss. ; Syrup. Althasas 5 ss. M.
Fiat Mist. Demulcens.
Form. 390. Mistura Deobstruens. (1.)
R Extr. Taraxaci, Extr. Humuli, aa 3 ij. Tartar. Tar-
tarizat. 3j.; Aquae Fcsniculi 5 vss. ; Vini Antimo-
nialis Huxh. 3 ij. ; Oxymel. Scilla; 5 j. M. Fiat
Mist., cujus capiat Coch. j. vel ij. 3tiis vel 4tis
horis.
Form. 391. Mistura Deobstruens. (2.)
R Radicis Rhei 5 j. ; Fol. Senna; 3 vj. ; Aqua; Ferv.
§ xij. Infunde per horas iij. et cola.
R Hujuslnfusi 5 x. ; Extract. Taraxaci, Ext. Chelid.
aa3iij.; Ext. Flor. Calendul. 3ij. ; Acet. Potassae
3vj.; Tinct. Calumbas 5ss.; Spirit. Junip. Co. §j.;
/Ether. Muriat. 3 jss. M. Capiat Cochlear, j. vel
ij. larga ter de die. (In Glandular Enlargements,
particularly those of the Abdomen.)
Form. 392. Mistura Deobstruens. (3.)
R Extr. Taraxaci 3 ijss. ; Ext. Sarsas, vel Spartii Sco-
parii, 3 ij.; Potassa: Tart. 5jss. ; Suh-boracis Soda;
3 ss. ; Aquae Fceniculi Dul. g vj. ; Vini Antimon.
3 ij. ; Oxymel. Scilla; 5 j. M. Capiat Coch. ij. —
iij. 3tiis vel 4tis horis.
Form. 393. Mistura Diaphoretica.
R Liquoris Ammonia; Acetatis giv. ; Vini Antimonii
Tartarizati 5 ss. ; Vini Ipecacuanha; 3ij. ; Syrupi
Papaveris 3 ss.; Aqua; Destillatae % xv. Misce. Dosis
a3j- ad 5]. 3liis, 4tis, vel dtis horis. Interdum adde
vel Spiritual /Etheris Nitrici, vel TincturumOpii.
Form. 394. Mistura Diaphoretica Anodyna.
R Liquoris Ammonia' Acetatis 5 iv.j Vini Antimonii
Tartarizati, Vini Ipecacuanha;, aa 3 ij- ; Spiritus
jEtheris Nitrici ~,ss. ; Syrupi Papaveris 5J.;Extrac-
ti Conii gr. xiv.; Aqua; Destillata 5 xij. Misce.
Form. 395. Mistura Digitalis et Colchici Comp.
R Inl'us. Digitalis, Liq. Ammonia;, Acetatis, aag ijss. ;
Potassae Acetatis 3 ij.; Aceti Colchici 3 ij. ; Opii
Tinctura; TT| vij. Fiat Mist., cujus sumanturCoch
ij. larga bis terve in die.
Form. 39G. Mistura Diosmje Crenatje.
R Infus. Diosma Crenata: 5 vjss. (F. 231.); Pulv.Tra-
gacanth. i) ij. ; Tinct. Dioamas Crenata; 5 ss. M.
(In Rheumatism, and Affections of the Mucous
Surfaces, particularly those of the Urinary Organs.)
Form. 397. Mistura Diuretica. (I.)
R Antimon. Tartarizati gr. j.; Potassa- Supertart. 3jss.;
Sub-boracis Sodae 3 ss. ; Infus. Juniperi 5 xijss. ;
Spirit. /Ether. Ait. 3 iij-; Tinct. Opii Comp.TTJxxvj.
— ad L. M. Capiat Coch. j. larg. 2da quique hora.
(Altered from Augustin.)
Form. 398. Mistura Diuretica. (2.)
R Potassae Supertart. 5 ij- ; Sub-boracis Sodae 3 j- »
Aqua; Fceniculi 5 viij. ; Spirit. Junip. Comp. et
Spirit. /Ether. Nit. aa5iij. ; Syrup. Papaveris 5 ss.
Form. 399. Mistura Diuretica. (3.)
R Baccarum Juniperi contus. 3 vj.; Carui Semin. con-
tus. 3 ijss.; Anisi Semin. cont. 3jss.; Aquae Ferven-
tisOj. Macera per horas tres, et cola.
R Colatura- f. 5 xij.; Spiritus Juniperi Compositi f. % ij.;
Potassa; Nitratis £) ij. ; Syrupi Scilla3 f. 5 ss. Fiat
Mistura, de qua sumatur Cyathus subinde.
Form. 400. Mistura Diuretica. (4.)
R Infus. Digitalis, Aquae Anethi, aa 5 iijss. ; Potassae
Acetatis 3 ijss. ; Scilla; Aceti (vel Acet. Colchici)
3 iij. ; Tinct. Opii TT| x. Fiat Mist., cujus capiat
Cochlear, ij. larga bis terve quotidie.
Form. 401. Mistura Diuretica. (5.)
R Gum. Acacia; 3v ; Saponis Med. 3ss ; Sub-carbonat.
Potassae 5 i j . ; Potassa: Nitratis 3 ij.; Infus. Juniperi
Ibij. (In Gout, with double its quantity of Potash,
- and a stomachic tincture and Tinct. of Colchicum.)
Form. 402. Mistura Emetica Excitans. (1.)
R Zinci-Sulphatis 9 ij. ; Aqua; Menth. Pip. f. 5 ivss.
Solve, et adde Vini Ipecacuanha-, Tinct. Serpen-
tarias, aaf. 5 ss. ; Tinct. Capsici f. 9 ij. ; Olei An-
themidis TTJ xii. Misce ; et fiat Mist., cujus capiat
partem tertiam velquartam intervallis brevibus.
Form. 403. Mistura Emetica Excitans. (2.)
R Antimon. Tartar, gr. xij. : solve in Aquae Mentha?
Piper, f. 5 ivss.; et adde Vini Ipecacuanhas, Tinct.
Serpentariae, aa f. 5 ss.; Tinct. Capsici f. 3 ij.; Olei
Anthemidis TT) xii. M. Capiat partem quartam vel
tertiam, intervallis brevibus, ad effectual plenum.
Form. 404. Mistura Expectorans.
R Mistura- AmygdaUe Amara- f. 5 v.; Vini Ipecacuan-
ha', Tinctura; Scilla-, aa f. 3 j. ; Syrupi Tolutani
f. 3vj. Misce. Sumat Cochleare magnum urgente
tussi. (In Humoral Asthma, and the latter Stage
of Catarrh.)
Form. 405. Mistura Febrifuga. (1.)
R Camphorae P)j. ; Pulv. Gum. Acacia- 3 j. ; Mist.
Amygdal. Dulc. 5 iij.: Potassa; Nitratis 3 ij. ; Aq.
Flor. Sambuci Nig. giv. ; Syrup. Papav. Alb. (vel
Syr. Limonis) 5 ss. M. § ss.— 5 j. 3tiis vel 4tis
horis.
Form. 406. Mistura Febrifuga. (2.)
R Mistura; Camphora- J xxiij. ; Antimonii Tartarizati
gr iij ; Potasba \itritis3vj Spiritus TtheriG Ni-
trici 5 ss. ; Syrupi Limonum 5 ss. ; Misce. Inter-
dum adde, vel Vinum Ipecacuanha;, vel Tinctu-
ram Diaitalis, vel Tincturam Opii, vel Syrupum
Papaveris.
Form. 407. Mistura Febrifuga. (3.)
R Ammonia1 Mnriatis, Succi Glycvrrh. Tnspiss.,53 ~j.;
Aqua; Font. 5 v. Solvc^et adde Vini Antimonii
gij.; O.xvmel. Scilla- 5SS. M. (Decker.)
APPENDIX OF FORMULAS. — Mistura..
XV
Form. 408. Mistura Fehrifuga. (Peysson.)
R Antimonii Tartarizati gr. j.; G9m.TragRcanth.9ji;
Aqua Commun. S vjj.j Tinct. Opii IT] xx.; Syrup.
Papaveris 5 vij. M.
Form. 409. Misrntv Fehrifuga Nervina.
K Campbora Rasa ;•) j.— ;■"> i j - ; ViteJ. Ovor. q.s. Subt-
le, el :n i <it- Decocti Cinchona s$ vjss. ; Tinct. Opii
Comp. (Vide Form.) 3ss.; ^Ether. Sulphur. 3j. ».
Capial J 88. — ",jss. otis vol litis horis.
Form. 410. Mistura Guaiaci Ammoniata.
R Guaiaci Gummi Resina, Pulveris Acacis, aa 3 ij- >
Decocti Glycyrrhiza, <» ss. ; Liquoris Ammonia
Sub carbonatis " n,.ss. Tare Guaiacum el l'ulv. Ac-
cacia com Liquore Ammonia.', et gradatim adde
Decoctum.
Form. 411. Mistura Guaiaci Comp.
R Gum. Guaiaci, Gum. Ammoniaci, Gum. Acacia;, aa
3ij.: solve terendo in Aqua Foeniculi § vjss., et ad-
de Vini Antimonii Tartar. § ss. ; Syrup. Althrere
3vj. M. Capiat Cochleare unum amplum teriiis
vel quartis horis.
Form. 412. Mistura cum Hydrargvri Oxymuriatis.
R Decocti Glycyrrhiza 5 v.; Aqua; Cinnamomi §ij. ;
Liquoris Hydrargyri Oxymuriatis (Form. 322.), Sy-
rupi Aurantii, 55 5 ss. Misce. Ft. Mistura, cujus
sumat Cocfa. ainpl. ij. vel iij. statim post cibum,
bis terve in die. (Sprague.)
Form. 413. Mistura Infusi Cuspar.'Je Composita.
R Cusparia Corticis contus. gj.; Aurantii Corticisex-
siccati^ss.; Aquo? Ferventis Octarium j. Macera
per lioras quatuor in vase clauso, et cola.
R Colati Infusi, f. 5 vij.; Tinctur. Cinnamomi, Syrup.
Aurantiorum, aa f. § ss. ; Creta? Prreparata; 3j- M.
Fiat Mistur., de qua sumatur Cyathus (Cochlearia
iij. — iv.) ter vel quater quotidie.
Form. 414. Mistura Infusi Salicis Comp.
R Coit. Salicis contus. 5 iij. ; AqureOij. Decoquead
octarium j.; dein adde Caryophyl. contus. 3ss., et
cola.
R Colati Liquoris f. 3 vij.; Tinctura; Aurantii f. 3VJ- ;
Syrupi Aurantii f. 3 ij. M. Sumat quartam par-
tem ter die.
Form. 415. Mistura Infusi Senegje Comp.
R Had. Polyg. Senegas cone. 3 j. ; Rad. Glycyrrhiza;
£ss. Coque cum Aqua Fontan. 3 xvj. ad rema-
nent, unciarum octo. In colat. dissolv. Flor. Salis
Ammon. Depur. 3U- ; Pulv. Tamarind. 3 j- ; Tart.
Emetici gr. j-; Syrup. Althrere §j. M. Capiat reger
alteift quique liora Cochleare unum.
Form. 416. Mistura Infusi Serpentarije Comp. (1.)
R Olei CinnamomiTf| vj.; Sacchari Purif. 3iij.; teren-
tnr bene, et ad. Int'iis. Serpentarire (F. 21.2.) 5 vij. ;
Spirit. .Ethcris Muriatici ?,ss.; Tinct. Capsici 5ss.
— ~,j. M. Fiat Mist., cujus capiat Coch. ij. — iv.
teitiis vel quartis horis.
Form. 417. Mistura Infusi Serfentari.i: Comp. (2.)
R Infus. Serpentarire 5 vj. ; Tinct. Opii Camphorata;
3 v. ; Spirit. Aramouis Arom.3 ijss. ; Syrup. Au-
rantii ?,j. M. Capiat partem quartam tertiis vel
quartis horis.
Form. 418. Mistura Infusi Uy.e Ursi.
R Infusi Uva Ursi ", xiv. ; Potassa Carbon, gr. xxv.;
Extract) Conii, gr. iij., grad. auget. ad vj.; Extract.
I'apaveris lt. v. ad \.; Syrupi Zingiberis, 3 ij. M.
Fiat Haust. ter in diehauriend.
Form. 419. Mistura Infusi Uv.r. Ursi Composita.
R Uvre Ursi Fol. 3 ijss.; Radicis Rhei conris. et cont.
"j.; Aqua Ferventis ",. xij. Macera per boras ij. in
vase clauso, deinde cola.
R Liquoris colat. ~, vijss. ; Soda; Sub-carbon. 3 Jss- j
Tinct. Opii TT) xlv. (vel Hyoscyami 3jss.); Tinct.
CamphoraComp. 5uj.; Syrup. Tolutan. 3J»s. M.
Fiat Mist., cujus capiat Cochlearia duo magna
quatuor vices in die.
Form. 420. Mistura Laxans.
R Infus. Boaarum Com. " vjss. ; Acidi Sulphur. Dil.
TT| xx.; Potassa Sulphatis "iij.; Tinct. Aurantii
Gump. "iij. M. Flat Mist., cujus capiat Cochlear.
ij. larga tertii^ vel quartis horis.
Form. 421. Mistura Mucilaginis Anodyna.
R Mucilaginis Trogacanthe 3 ijss.; Oxymellis Scilbje
5 ss. ; Syrupi Papaveris £j. Muce. Ft. Mistura,
cujus capial Coch. amp. sapius urgenti tusse gra-
datim deglutiendum.
N. R. — For the sake of expedition, if the mucil-
age of Tragecanth should not be at hand, itspiace
maybe supplied by Pulvis Tragacantha Comp.
3jss.; Aqua Destil.S ijss. (Spbaoub.)
Form. 422. Mistura Myrrh-e.
R Myrrhre 3 jss.; Decocti Glycyrrhiza' ferventis f. 3vss.;
Simul terfe, et cola. Dosis f. % j. bis vel ter quotidit*.
Singulis dosibus interdum adde, Soda; Subcarbon-
atis gr. xij., vel Acidi Sulphuric! Aromatici minim,
xv., vel Tinctura: Opii Camphorata f. 3*s. Misce.
(In the latter stages of Phthisis Pulmonalis,
when languor or debility is a very prominent symp-
tom, the above mixture, combined according to
circumstances, is an excellent medicine.)
Form. 423. Mistura Nervina. (1.)
R Mistura; Camphor® f. § iij.; Mistura; Assafcetida
f. §ij.; Tinct. Valeriana;, Spiritus Amnion ire Com-
pos., SpiritusyEtherisCompos.,55 f. 3ij. M. Fiat Mis-
tura, cujus sumantur Cochlear, duo ampla subinde.
Form. 424. Mistura Nervina. (2.)
R Mistura; Camphors f. § vij. ; Spiritus ./Etheris Sul-
phurici, Spiritus Ammonia; Compos., aa f. 3 ijss. ;
Syrupi Croci f. Jss. Fiat Mistura, de qua sumantur
Cochlearia duo vel tria magna, urgente agitatione.
Form. 425. Mistura Oleosa.
R Olei Oliva vel Olei Lini, Aqnre Pimentre, 55 O j.;
Potassa; Subcarbonatis 3 vj. Misce. Dosis § j. ad
gjss. AvlipldogUta fit addendo Liquoris Antimo-
nii Tartarizati, ^ss. ad 5 ij- Jlnodyna fit addendo
Tinctura; Opii iff xx. ad §ij. Volat'dis fit usu Spir-
itus Ammonia; Aromatici loco Potassa; Subcarbou-
atis.
Form. 42R. Mistura Pectoralis. (1.)
R Rad. Althrea; 5 jss. ; Semin. Anisi Cont. 3 iij. ; Aq.
Fervent, q. s. nt sit colaturre § xij. Adde Mur. Am-
monia! 3 ij.; Succilnsp.Glycyrrh.gss. M. (Aust.
Phar.)
Form. 427. Mistura Pectoralis. (2.)
R Decocti Lichenis g xj.; Vini Ipecacuanha; 3 >J- ;
Extr. Conii 9 j.; Olei Anisi TT) xij.; Syrup. Althare
et Syrup. Papaveris aa 3 iij. M. Capiat Coch. iij.
vel iv. quater in die.
Form. 428. Mistura Phosfhorata.
R Phosphori gr. ij. ; Olei Terebinth. 3 ss. ; Olei Oliva;
3 ijss. ; Aq. Fervent, q. s.; Gum. Acacia; § ss. ;
Aqua? Anethi 5 iv.; Syrup. Zingiberis 5 j.; Olei Ca-
ryophyl. Tt] vj.
Form. 429. Mistura Purgans. (I.)
R Infus. Senna; f. 3 ivss. ; Magnes. Sulphatis % j. ;
Aqua? Mentha1 Sativ. f. 3 ijss. ; Tinctur. Senna' f.
5ss. M. Sumat Cochlear, iv. primo mane, et
repet. post horas tres, si opus sit.
Form. 430. Mistura Purgans. (2.)
R Fol. Senna;, Conserva; Mentha; Sativa; (F. 4G.), 5a
5ss.; Sem.Coriand. contus. 9ij.; Aqua Ferventis
5 viij. Macera per lioras duas, et cola.
R 1'ifusi suprapnescrip. % vij. ; Soda Sulphatis 3 j. ;
Tinctura; Senna; 3 vj. ; Tinct. Cardam. Co. 3 ij. ;
Sp. Ammonia Arom.3 ij- M. Ft. Mistura. Capiat
partem 4tam secundis horis, donee bene solutus sit
alvus, etpro re nata. repetendam.
Form. 431. Mistura Refrigerans.
R Caraphora rasa' gr. x. — }) j.: tere cum Mucilag. Aca-
ii;i-iij ; Muriatis Ammon. 3 j-— 3 jss.; Aq. Flor.
Aurantiar., Aq. Com., aa J iij.; Syrup. Aurantii
§ss. M.
Form. 432. Mistura Resolvens.
R Flor. Arnica; 3jss.; Aq. Fervid, q. s. ut shit colatu-
rre 5 vijss. Adde Potassa; Sub-carbon, ^j. ; Spirit.
Lavandul. Co. 5 jss. M. (In Engorgements of
Grands, &c.)
Form. 433. Mistura Rhei Composita.
R Rhei Radicle contritngss.; BodwSub-carbonattaSJ.;
Decocti Glycyrrhlza, f.i*. et "ij.; Tinctura Au-
rantii, ",vj'. Misce. Dosis :\ f."ss. ad f.",j. semel,
bis, vel ter quotidie. (This is a pleasant and effi-
cacious method of administering small doses of
Rhubarb in Dyspepsia.— Sprague.)
XVI
APPENDIX OF FORMULAE. — Mistura — Pilulje.
Form. 434. Mistura Rhodii Cdmp. (1.)
R Tincture Rhodii, 3 iij.; Mucil. Acaciewj-.Jyj. Te-
rentur probe simul; adde gradatim, Infusi Cary-
ophyllorum giv. ; Syrupi Zingibers §ss. M. Fiat
Mistura. Suinai partem 4tam ter in die urgente
ttatu.
Form. 435. Mistura Rhodii Comp. (2.)
R Tinctura? Rliociii 5 ss. ; Mucil. Acacia" rrr. 3 vj.
Tere bend, et adde gradatim, Infus. Uvae Ursi | vj.;
Syrupi Papaveris gvj. M. Fiat Mistura. Dosis
partem 4tam ter quaterve in die. (In Asthma, and
in Chronic Catarrhs, &c.)
Form. 436. Mistura Salina.
R Mist. Camphors givss.; Liq. Amnion. Acet. giij. ;
Spirit. yEther. Nit. 3 iij.; Potassa? Nit. 9ij.; Syrup.
Limonis^ij. M. Fiat Mist., cujus capiat Coclile-
aria ij. larga quarti quique hora.
Form. 437. Mistura Salina Antiseptica. (1.)
R Infus. (vel Decorti) Cinchona? 5 vij.: Soda? Muriatis
3 ij. — 3 iij. ; Potassa? Muriatis Jss. — 3 j. Solve,
et adde Tinct. Serpentaria? gss. M.
Form. 438. Mistura Sauna Antiseptica. (2.)
R Infus. (vel Decocti) Cinchona5, Mist. Camphora?, aa
giijss.; Potasses Nitratis, Potassa Muriatis, aa3ij.;
Tinct. Serpentaria? gss. M.
Form. 439. Mistura Salina Antiseptica. (3.)
R Mist. Camphora? 5 vij. ; Potassa? Oxymuriatis 3jss. ;
Soda? Muriatis 3 ij.; Tinct. Serpentaria? 3 ss.; Spirit.
Lavand. 3'j- M.
Form. 440. Mistura Salina Febrifuga. (1.)
R Mist. Camphora* givss.; Liq. Ammon. Acet. 3Uss-i
Magnesia? Sulphatis 5 ss. — 5 j.; (vel Potassa?
Sulph. 3 ijss.;) Spirit. ^Ether. Nit. 3 iij. M.
Form. 441. Mistura Salina Febrifuga. (2.)
R Mist. Camphora? givss. ; Liq. Ammon. Acet. giij.;
Soda? Sulphatis (vel Soda? Phosphatis) 3 vj.; Spirit.
./Ether Nitrici 3 iij. INI.
Form. 442. Mistura Sedativa.
R Magnesia? Subcarbonatis, Creta? Pra?parata?, Pulv.
Acacia?, aa 3 ij.; Spiritus Ammonia? Aromat. 3jss.;
Tinct. Assafcetida? 5 iij. ; Syrup. Papaveris § ss. ;
Aqua? Destillata? O j. Misce. Dosis a gss. ad gj.
3tiis, vel 4tis, vel 6tis horis. Interdum adde Tinct.
Catechu, &c. &c.
Form. 443. Mistura Strychnine.
R Strychnina? Purissima? gr. j.; Sacchar. Purif. 3jss.;
Aqua? Destil.gij.; Acidi Acetici gtt. ij. M. Capiat
Cochlearia minima ij. mane nocteque.
Form. 414. Mist. Terebinthine Venet^e. (Clos-
sius.)
R Terebinthina? Venet. 3j. — 5Jss.; VitelliOvorum q.
s.; et adde Aqua? Mentha? Piperita? g ivss. Capiat
Cochlear, j. vel ij. pro re natl. (Against Worms
and Chronic Affections of the Mucous Surfaces.)
Form. 445. Mistura Tonica. (1.)
R Infus Cascarilla? (vel Gentiana? Comp.) g vij. ; Pot-
assa? Sub-carb. 3j. — 3JS3-j Tinct. Aurantii Comp.,
Spirit. Pimenta?, aa 5 iij- M.
Form. 446. Mistura Tonica. (2.)
R Infusi Cascarilla? O jss. ; Acidi Sulphuric! Aromat.
3 ij. Misce. Dosis a. Cochlear, ij. parv. ad Cochl.
iij. magna bis die.
Form. 447. Mistura Vermifuga.
R Rad. Valer. Min., Semin. Santon., aagss. Infunde
Aq. Font. Fervid, gviij.: disrere per horaiii. dein
cola. Liq. colat. adde Assafcetida? 3 j. in Vitell.
Ovisoluta?. Fiat Mistura.
Form. 418. -Mistura Vinosa.
R Vini gvj.; Ovorum duorum Vitellos; Sacchari Pu-
rificat. *ss. ; Olei Cinnamom. TT| iv. ; Tinct. Cap-
sici 9 j. M. Dosis gjss. ter quaterve, aut sa?pius
quotidie, urgentibus Languoribus.
Form. 449. Oleum Camphore.
R Acidi Nitrici qnhntum velis ; Camphora? q. s. s. ad
Acidi satnrandum. Decant, and preserve in a
closely stopped bottle. (Fef.)
Form. 450. Pilule Aloes cum Ferro.
R Aloes Spicati Extracti 3jss.; Myrrha? Gummi Resi-
n;e pulv. 3 ij. ; Extraiti Gentiana? 9 iv. ; Ferri
Sulphatis 9 ij. ; Theriaca? Purificat. q. s. Simul
contunde, et in Pilulas cxx. divide. Dosis 4 ij.ad
iv. semel vel bis quotidie.
Form. 451. Pilule Aloes cum Ferro Compositus.
R Massa? Pilul. Aloes cum Myrrha, Pilul. Ferri Comp.,
Pilul. Galban. Comp., aa 9 U- ! Soda? Sub-carbon,
exsic. 9j.j Olei Junip. Sabin. TT]iv. Contundesi-
mul, et fiat massa squalls, in Pilulas xxx. distrib-
uenda. Capiat a?gra binas, mane nocteque.
Form. 452. Pilule Aloes et Ferri.
R Ferri Sulphatis, Potassa? Subcarbonat., aa 9 j. ;
Myrrha? pulver. 3j. ; Aloes pulver. 3ss. M. Et
divide in Pilulas xxx. ; ij. vel iij. pro dose node
nianeque.
Form. 453. Pilule Aloes et Moschi Composite.
R Pilul. Aloes cum Myrrha 3j. ; Camph. rasa? gr. xij.;
Moschi gr. xxviij.; Balsam. Peruvian, q. s. M. Fi-
ant Pilula? xxiv., quarum capiat binas omni nocte
Form. 454. Pilule Aloes et Scammonie Comp.
R Aloes Spicat. 9j. ; Scammon. gr. xij. ; Extr. Rhei
9ijss. ; Baccar. Capsici pulv. gr. viij. ; Olei Cary-
oph. TT)vj. M. Fiant Pilula? xviij., quarum su-
mantur bina? hora decubitus, p. r. n.
Form. 455. Pilule Alterative. (1.)
R Massa: Pilul. Hydrarg. Sub-mur. Comp. 9ij.; Sapo-
nis Castil. 3ss. ; Extr. Sarsa? et Ext. Taraxaci aa
5jss. Misce bene, et divide in Pilulas lx. quarum
capiat binas vel tres, ter quotidie.
Form. 456. Pilule Alterative. (2.)
R Scillre Radicis exsic. gr. vj. ; Fol. Digitalis gr. xij. ;
Hydrarg. Sub-mur. gr. vj.; Myrrha?. pulv. gj. Tere
simul, et adde Assafcetid. 3ss. ; Extr. Gentiana?
q. s. Fiat massa a?qualis, ef divide in Pil. xviij.,
quarum capiat unam mane, meridiem et nocte.
Form. 457. Pilule Ammoniaci Composite.
R Gummi Ammoniaci 3 j.; Saponis Castil., Fellis Bov.
inspissat., Pilula? Hydrarg., Pulv. Folii Conii.,Ex
tracti Conii, aa 3 ss. ; Extr. Taraxaci 3 ij. ; Sul-
phur. Antimonii Aurat. 9j. ; Theriaca? Purif. q. s.
Contunde in massam a?qualem, et divide in Pilulas
" lxxx. ; quarum capiat binas vel tres, ter quotidie.
(Deobstruent, dissolvent, &x.)
Form. 458. Pilule Ammonie et Anthemidis.
R Ammonia? Sub-carbonatis Pulver., Extracti Anthe-
midis, aa 3ss. Fiat massa in Pilulas xij. dividen-
da, quarum sumatur una bis vel ter die.
Form. 459. Pilule Ammoniareti Cupri et Zinci.
R Ammoniareti Cupri, Oxydi Zinci, aa gr. vj. — xij.;
Sacchari Albi, Pulv. Tracacanthn?, aa gr. xij.; Mu-
cilag. Acacia? q.s. lit fiant Pilula? xij., quarum capiat
unam bis terve quotidie. (Epilepsy, Chorea, &:c.)
Form. 460. Pilule Anodtne.
R Camphora- rasa? gr. ij. -vij.; Potassa? Nitratis v.-viij.;
Extr. Hyoscyami gr. iij. — gr. viij. ; Syr. Papaveris
q.s. Misce. Fiant Pilula? iij. — vj., h. s. suniendas.
Form. 461. Massa Pilularum Anodvnarum.
R Opii Cnirti in pulv. subtiliss. 3 ss. ; Extracti Hyos-
cyami 3ijss. ; Saponis Duri, Iridis Flor. Pulv., aa
3j. Contunde, ut fiat massa, in Pilulas se.xagin-
t.i tequal es distribuenda.
N. B. — Ten grains of the mass contain one grain
of opium amijire of the extract of henbane.
Form. 462. Pilule Anody.vo-Aferientes. (1.)
R Pulv. Ipecacuanha? ex. x. ; Extracti Colocynthidis
Comp. 3j.; Extracti Hyoscyami 3ss.: Pilula? Hy-
drarg. 9j- ; Saponis Castil. gr. x. ; Olei Carvoph.
IT) iij. Contunde in massam a?qualem, et divide in
Pilulas xxx., quarum capiat unam, duas, vel tres
pro dose.
Form. 463. Pilule Anodyno-Aperientes. (2.)
R Pulv. Ipecacuanha1 gr. viij.; Extr. Colocynth. Comp
9ijss.; Extr. Hyoscyami "ss.; Fellis Taur. inspiss.
9i- Contunde simul. et divide massam in Pilulas
xxiv., quarum capiat unajri^luas, vel tres pro dose.
APPENDIX OF FORMULAE. — Pilulje.
xva
Form. 464. Pun r. A\iim.<nii Alterative.
r Bulptaiir. Aureat. Antimun. >) j.; Florum Sulphuris
- i|. ; Camphorffi rasa' ;•) j. ; Extract i Taraxaci (vel
l.\ir. saisi ~,nj". l -'iat massa equalis, et divide
in Pilulas icv. Capiat binas vel ires ter quotidie.
Form. 465. Pilule Antimonii et Guaiaci Compos-
i i X .
R Sulpbaret. Anr. Antimonii 9 j. ; Florum Sulphur.
5 iij.; Etesin. Guaiaci, Extr. Conii, 55. 3ij. ; Syrup.
Allhss q. s. Fiat massa aqualis, et divide in Pi-
lulas c.\.\. Capiat binas vel tres ter die.
Form. 466. Pilule Antimonii Sulphureti Comp. (1.)
R Antimonii Sulphur. Prscip. (jr. v. ; Pilul. Hydrar-
gyr., Extract, Hyoscyainf, 5£ 9 j. Misce ut Sat
massa eequalis in Pilulaa decern dividends, quajrum
sumatur una ter die.
Form. -107. Pilula Antimonii Sulphureti Comp. (2.)
R Sulphureti Antimonii Precipitati, Hydrargyri Sub-
niiiri.tr is, .ii gr. ss. ; Extracti Conii gr. iv. Fiat
I'll ii lu ter die sumenda.
Form. 468. Pilule Antispasmodics.
R Gum. Ammoniaci 3 j. ; Benzoini, Pulv. Myrrlue, 55
'•) ij. ; AsaafoBtida 3 ss- S CamphonB 9 j. ; Tinct.
Opii TT) xij. Misce. Divide in Pilulas lx., quarum
capiat ieger,omni trihorio, pilulas duas vel ties.
Form. 4iJ9. Pilule Antispasmodics Piero.uinti.
R Camphors Potassa? Nitratis, Digitalis Purpur., aa
3ss.; Pulv. Cinchona Flay. 3 j. ; Extract. Genti-
ans 3ij.; Syrup. Simp. q. s. M. Fiant Piluls lx.
Form. 470. Pilule Aperientes Comp.
R Pilul. Hydrant., Pilul. Aloes cum Myrrh!, aa 9 j. ;
Pilul. Cambog. Comp. gr. xvj.; Pulv. Mastiches
gr. vj. ; Olei Caryopbil. TT] ij. M. Fiat Massa
squalis, et divide in Pilulas xxiv., quarum capiat
binas hori soinni quotidie.
Form. 471. Pilule Aperientes Alterative.
R Pilul. Hydrarg. 9j- ; Antimonii Tartarizati gr.jss.;
Extr. Jalap.-e J jss. ; Fellis Tauri inspissati 3 ss- i
Saponis Castil. gr. xv. Contunde in massam squa-
len], et divide in Pilulas xl. ; quarum capiat binas
vel tres onini nocte.
Form. 472. Pil. Argenti Nitratis et Belladonne.
R Argenti Nitratis pulv. gr. ij. ; Pulv. Radicis Bella-
donna? 9 j- i Extr. Glycyrrh. 3 j- Misce bene, et
divide in Pilulas xxxvj. ; quarum capiat unani ad
tres bis terve quotidie. (In Pertussis and Epilep-
sy. M. Bories.)
Form. 473. Pilule Argenti Nitratis Composite.
R Nitratis Argenti pulv. gr. v.; Opii Puri gr. x.; Cam-
phors rase, N'ncis Myristics, 55 9 jss.; Pulv. Aca-
cia 3s--". ; Syrup. Simp. q. s. M. Divide in Pilulas
xxxvj., quarum capiat imam ad tres his terve quo-
tidie.
Form. 474. Pilul.*; Argenti Nitratis et Gentian.*:.
R Argenti Nitratis gr. ix.; Opii Puri gr. v.; Extr. Gen-
tian::-, Extr. Glycyrrb., aa 5 jss. Divide in Pilulas
Iv., quarum unam ad tres vel quatuor, bis terve
quotidie. (Niemann.)
Form. 475. Pilul.i: Argenti Nitratis Opiate.
R Argenti Nitratis pulv. gr. x.; Moschi3j.; Opii 3 jss.;
Camphors 3ij.; Pulv. Acacia 3ss. ; Syrup. Simp.
q. s. Misce bene, et divide in Pilulas Ixxx., quarum
capiat unam ad quatuor bis terve quotidie. (Van
Mons, Cadet de Gassicourt, et Ratier.)
Form. 476. Pilule Arsenicales. (1.)
R Arsenici Alhi gr. ij. ; Opii Puri gr. viij. ; Saponis
Medic. «r. xxxvj. Divide in Pilulas xxiv., quarum
capiat j. — iij. pro dose.
Form. 477. Pilule Arsenicales. (2.)
R Arsenici Alhi gr. ij.; Opii gr. xij. ; Ammonia- Mur.
X m. : Mucil.-iL'. Acaeie ;•) ij. ; Syrup. Simp. q. s.
M. Divide In Pilulas xxx., quarum capiat unam
vel binas ter die.
Form. 478. Pili;ljc Arseniatis Ferri. (Biett.)
R Proto-Arseniatis Ferri gr. iij. ; Extr. Hamuli ~, ij. ;
Pulv. AltbssXss.; Syrup. Auran. q. s. M. Divide
in Pilulas xlviij. quarum capiat unam in die.
B*
Form. 470. Pilule Assafcetide cum Cinchona.
K Assafii'tids Gumiiii Itesina "j.; Extracti Cinchona
Opt. 3lj. Saponis Duri, 3ss. ; Olei Pulegii TT) xij.
Thenar. I'uiilirat. q. s. ut ti.it massa: in Pilulas
xlviij. divide ; quarum capiat iij. vel. iv. nocte
maneque.
Form. 480. Pilule Assafcetide Composite.
R Assafa'tid., ('astore, Valeriana', Sueeini, Sapulveriz.
gas.; Camphors gr. x.; Olei Cajeputi q. s. M. Fiant
Pilulas xxxvj. ; quarum capiat hiuas pro dose.
Form. 481. Pilule Assafcf.tide cum Felle.
R Assaltetid., Fell. Tauri inspissat., 55 3j.; Pulv. Rhei
9 j.; Syrup, q. s. M. Fiant Pilul. xl.
Form. 482. Pilule Assafcetide et Valeriane
Comp.
R Gum. Assafcetids, Pulv. Valerians, 55 3 j. ; Extr.
Aconiti gr. vj.; Pulv. Scilla: gr. viij.; Castorei 3ss.;
Ammonia: Stihcarbun. gr. xvj.; Syrup. Papaveris q.
s. M. Fiant Piluls xlviij., quarum capiat binas ad
quatuor pro dose. (In Spasmodic Affections of
the respiratory Organs. — Richter.)
Form. 483. Pilule Astringentes.
R Extr. Cinchons, Ferri Ammoniati, Alumina: Sulph.,
Pulv. Aromat., aa 3 Jss- Olei Caryoph. q. s. M.
Fiant Piluls l.xxxiv.; quarum j. — ij. pro dose.
Form. 484. Pilule Balsime Comp.
R Myrrhs Gummi Resinrr pulv. 9 ij.; Galbani, Assa-
fo>tida,55 V)j.; Capsici Annui Pulv. gr. xv. ; Bal-
sami Peruviani 3j. M. Fiant Pilula xxx.; equibus
sumantur bina vel tres, bis terve de die.
Form. 485. Pilule Balsamice. (1.)
R Extr. Aloes 3 ij.; Extr. Rhei 3 j.; Balsam. Perm*, et
Benzoini, 55 3ss.;Croci Stigmat. et Myrrha,553j.;
Extr. Opii gr. v.; Spirit. Vini et Syrup, q. s.TTJlxxx.;
quarum capiat unam ad quatuor pro dose.
Form. 486. Pilule Balsamice. (2.)
R Terebinthina Chiensis, Spermaceti, 55 5'j. ' Pulv.
Myrrhs 3 J- > Olibani Pulver. q. s. ut fiat Piluls
lxx. ; quarum capiat unam vel duas omni tenia vel
quarto, hora.
Form. 487. Pilule Balsamice Camthorate.
R Acidi Benzoini 3j.; Camphors, CrociStig., Balsam.
Peruvian., G. Ammoniaci, 55 3 j. ; Mucilag. Aca-
cia; q. s. M. Fiat massa Equalis ; divide in Pilu-
las xxxvj., quarum capiathinas pro dose.
Form. 488. Pilule Belladonne.
R Extr. Belladonna? gr. vj.; Pulv. Rad. Glycyrrh. 5SS.;
Succi Inspissat. Samhuci Nig. q. s. ut fiant Piluls
xij. Capiat unam ad tres pro dose.
Form. 489. Pilule Benzoine et Terebinthine
Comp.
R Myrrhs, G. Ammoniaci, aa 3 .iss- > Benzoini 3 j. ;
Extr. Gentians "-) ij. ; Terebinth. Venet. 3 jss. ;
Pulv. Rheiq. s. Fiat Massa squalis, et divide in
Pilulas gr. iv. pond. (In Hypochondriasis, Habit-
ual Constipation, &c.)
Form. 490. Pilule Bismuthi.
R Bismuthi Sub-nit., Castorei, 55 gr. j. — ij. ; Pulv.
Glycyrrh. et Mellis q. s. ut fiant Piluls ij., tertiis
vel quartis horis sumends.
Form. 491. Pilule Brucike.
R Brurina- Pura, gr. xii.; Conserv. Rosar. P)ij. Misce
bene, et divide in Pilulas xxiv. squales. Capiat
unam ad quatuor pro dose.
Form. 492. Pilule Cambogie Composite.
R Camhogis 3.1-: solve in Olei Ririni pauxillo, et adde
Pilul. Aloes cum Myrrhl, Pilul. Galban. Comp.,
Pilul. Il\ iliaru., 5a p)ij. Contunde hem1 siuinl, et
divide in xlviij. Capiat unam ad tres pro dose.
Form. 493. Pilule Camthore et Antimonii The-
BAIACE.
R Camphora rasa gr. iv. ;'Pulv. Jacob] Veri gr. iij.
Opii Puri gr. ss. ; Syrup. Simp. q. s. Fiant Piluls
ij. quart.'i vel se.xti qtuque hora sumenda:.
Form. 494. Pilole Cam'fhore Comp. (Brera.)
r Camphors, Bj.; Potasss Nitratis 9 ij.; KermesMl-
neralis t'r. vj. j Pulv. Glycyrrh. et Mellis. aa q. s.
M. Divide in Pilulas xviij., quarum capiat duas
terti.iquaque hori.
XV1U
APPENDIX OF FORMULAE. — Pilule.
Form. 495. Piluls Camphors et Ipecacuanhje
Comp.
R Pulv. Ipecacuanha? Comp. gr. iv. ; Camphors rasa;
cr. j. — iij. ; Syrup. Papaveris q. s. M. Fiant 1'i-
juta; iij., quaria quique hora sumenda?.
Form. 49li. Piluls Camphorj: et Nitri.
R Camphors Subacta:,PotassrK Nitratis, aa gr. ij. — v.;
Conserv. Rosar. q. s. M. Fiant PiluliB ij. vel iij.
Form. 497. Pilule Castorei Thebaiacs.
R Opii gr. ss.; Castorei Rossici gr. vjss. ; Pulveris Di-
gitalis gr. j.; Syrup, q. s. Fiant Pilula; dus, bis vel
ttr die sumenda;. (In Spasmodic Asthma, and
Dyspnoea.)
Form. 498. Pilule Catharticje. (1.)
R Hydrarg. Suhmur. gr. viij.; Extr. Res. Jalap, gr. x*vj.;
Gum. Guaiaci gi.'xxiv.; Mucilag. Acacia; q. s. M.
Divide in Pilulas xij. Capiat binas vel ties pro re
nata.
Form. 499. Pilule Cathartics. (2.)
R Cambogis Gum. 5j?s.; Scammon. 3j.: solve terendo
in pauxillo Olei Junip: dein adde Aloe's Socot.
3ijss.; Gum. Ammoniaci 3 jss.; Potassa; Sulphatis
3j. ; Oxymel. ScilUe q. s. ut fiat massa cequalis.
Cujiiat pro dose gr. x. ad gr. xxx.
Form. 500. Piluls Colocvnthidis Composite.
R Colocvnthidis Pulps 5SS. ; Aloes Spicats Extracti
Scammon is Gummi Resins, aa 5J.; Saponis Duri
3ij.; Olei Caryophylli 3 j- Aloe, Scammonia, et Co-
locynthis pulpa in pnlverem redigantur; turn cum
Sapone atque Oleo conterantur ; denique cum Mu-
cilagine Acache subigantur in massam.
Form. 501. Piluls Colocvnthidis cum Hvdrar(;vro.
R Massa Pil. Colocynth. Composit. 3iy-j Hydrargyri
Protoclilorid. (Calomel) 3 j- Simul contunde in
mortario lapideo, donee massa squalis sit ; et in
pilulas lx. squales distribuenda. Dosis, ab j. ad iv.
pro re nata.
Form. 502. Piluls Cufri Sulphatis cum Opio.
R Cupri Sulphatis gr. vj.; Opii Puri gr. iv.; Pulv. Tra-
gacanth. Comp. V)j.; Mucilag. Acacis q. s. ut fiant
Piluls xij. ; quarum capiat unam ter die, postea
quater quotidie1, vel tertiis aut quartis horis. (Chro-
nic Diarrhoea and Dysentery.)
Form. 503. Piluls Deobstruentes. (1.)
R Antimonii Tartanzati gr. iv. ; Pilul. Hydrarg. 7>j. ;
Saponis Castil., Gum. Ammoniaci, Assafi :-tida ■,
Ext.r. Aloes Purif., aa 5ss. Misre bene, et divide in
Pilulas lxxv.; quarum capiat binas ter die.
Form. 504. Piluls Deobstruentes. (2.)
R Extr. Aquosie Aloes 3 ij. ; Gum. Ammoniaci ^ij. ;
Myrrhs, Mastiches, Benzoini, Rhei, aa gr. }) j. ;
Croci Stigm. gr. xvj.; Potassa; Sub-carbon. 9ijss.;
Mellis q. s. ut fiat massa squalis. Capiat gr. x. ad
xx. pro re nata.
Form. 505. Piluls Deobstruentes. (Barthez.) (3.)
R Kermes Mineral, gr. j.; Hydrarg. Suhmur. gr. ij. ;
Extr. Fumaris (Extr. Taraxaci) gr. x. Fiant Pilul.
iij., pro dose. ,
Form. 506. Piluls Deobstruentes. (Recamier.) (4.)
R Saponis Castil. 3 ijss.; Gum. Ammoniaci 3j.; Aloe's
Extr. Purif. gr. xv. ; Assafeetids 3ss. ; Pulv. Rhei
5j. ; Croci Sativi 3ss. ; Syrup, q. s. M. Fiant Pi-
luls lxxxiv., quarum capiat binas bis quotidie.
Form. 507. Piluls Deobstruentes. (5.)
R Saponis Hisp. "'ij-; Gum. Ammoniaci 3j- ; Aloes
3j. ; Rhei Pulv. 3 j. ; Assafrrtida?, Croci, aa 3ss. ;
Syrup, q. s. M. Divide in Pilulas c. Capiat binas
ail quatuor bis terve in die.
Form. 508. Piluls Deobstruentes. (6.)
R'Saponis Medirinalis 3iv. ; Gum. Ammoniaci ~ij.';
Extracti Conii, Extr. Aconiti Napel.,aa 5Jss.; Mas
ss Pilul. Aloes cum Myrrha 3 j. Contunde in
massam squalen! , et divide in Pilulas granarum
quatuor. Capiat binas mane nccteque, augendo
unam quotidie donee xv. vel xx. sumantur in die.
(Dr. Lowassv, in Glandular Tumours and Scir-
rhous Formations.)
Form. 509. Piluls Deobstruentes. (Stoll.) (7.)
R Antimonii Sulphureti Pracipitati£)j. ; Saponis Ve-
netii 3 U- ; Gummi Acacia; 3j-j Mucilag. Gum.
Tragacanth. q. s. Fiant Piluls L. Sumat tres
inane et nocte. (For Cutaneous Eruptions, Rheu-
matism, &c.)
Form. 510. Piluls Deobstruentes. (8.)
R Hydrarg. cum Creta gr. xvj. : Soda; Sub-carbon, ex-
sic. V)j. ; Extracti Taraxaci 3j. M. Fiant Pilulas
xx.; quarum capiat binas vel tres omni nocte.
Form. 511. Piluls Deuto-Iodureti Hyprargvri.
R Hydrarg. Deuto-Iodureti gr. ij.; Extr. Humuli 9ij.;
Pulv. Glycyr. q. s. Misce bene, et divide in Pilu-
las xvi. ; quarum capiat binas mane nocteque, et
augeat dosin ad tres vel quatuor.
Form. 512. Piluls Diaphoretics.
R Oxydi Zinci, Extracti Aconiti, aa xij. ; Sulphureti
Antimonii Aurat. gr. vi. ; Extracti Humuli 3j. ;
Syrup. Papaveris q. s. Contunde bend simul, et di-
vide in Pilulas xviij. ; quarum capiat unam secun-
da vel tertia quique bora. (In Chorea, Sciatica,
Hysteria, and Rheumatism.)
Form. 513. Piluls Diaphoretics Sedativs.
R Kermes Mineral., Extr. Opii, aa gr. ij.; Potassa Ni-
tratis gr. v.; Syrup, q. s. Fiant Pilula; ij. pro dose.
Form. 514. Piluls Digitalis et Camphors Comp.
R Pulveris Digitalis gr. vj. ; Camphors gr. xv. ; Ex-
tracti Hyoscyami 9 jss. Fiant Pilula; duodecim.
Sumat tres omni nocte. (In Maniacal and Spas-
modic Affections.)
Form. 515. Piluls Digitalis et Mvrrhs Comp.
R Myrrha; G. R. gr. ij.— iv. , Pulv. Digitalis gr. j. ;
Extr. Hyoscyami gr. iij. — v. ; Syrup, q. s. Fiant
Pilula; ij., bis terve quotidie' sumenda;.
Form. 516. Piluls Diuretics.
R Scills Rad pulver. gr. ij.; Pulv. Foliorum Digitalis
gr. j.; Piluls Hvdrargyri gr. vj. ; Olibani Pulver.
9ss. ; Olei Juniperi TT) iv. Fiat massa in Pilulas
quatuor dividenda, e quibus capiat ij. hor.l somni,
-superbibendo haustulum Mistura Diuretics, No.
398 vel 399.
Form. 517. Piluls Diuretics Alterativs.
R Potassa; Supertart. 3 j. ; Sub-boracis Sods f) jss. ;
Pulv. Rad. Polygals Senegs 3 j. ; Pulv. Radicis
Colchici exsic. ''§ ij. ; Pulv~ Scills gr. xvj. ; Extr.
Taraxaci 3 iij. Fiat massa squalis, et divide in
Pilulas c; quarum capiat tres ter quotidie.
Form. 518. Piluls Dulcamars et Antimonii.
Pt Antimonii Sulphurat. Xiz., Pulv. Stip. Dulcamaras,
aa 3j.; Extr. Dulcamara; 3 U- > Syrup. Tolutan.
q. s. M. Fiant Pilula? lx. (Richter, in Scrofula.
Also in Cutaneous Diseases.)
Form. 519. Piluls Emmenagogs.
R Aloes Socot., Myrrha;, aa 3 jss.; Galban., Gum. Am-
moniac, aa £) ij.; Sub-boracis Soda? 3 Jss- j Ferri
Sulphatis 3ss. ; Ferri Oxydi 9j. ; Rhei 9j. ; Olei
Ruts et Olei Sabins, aa TT] xij. ; Saponis q. s.
Fiat massa a'qnalis, et divide in Pilulas cxx.; qua-
rum capiat binas vel tres bis terve quotidie.
Form. 520. Piluls Extr. Gentians et Humuli
Comp.
R Extracti Gentians 3 >j- ; Saponis Medicin. 3 js^ ;
Fell. Tanri inspiss.; Ext. Aloes Purif. aa 3 j.; Ext.
Humuli "jss. .Misce, et divideinPilulaspond.gr.
iij.; quarum capiat binas vel tres mane1 nocteque.
Form. 521. Piluls Ferri Ammoniati.
R Ferri Ammoniati 3j ; Extracti Aloe's, Extracti Gen-
tians, aa 3 ss. Contunde simul, et divide massam
in Pilulas triginta j quarum sumat duas ter quoti-
die. (In Dyspepsia, Hysteria, Scrofula, and Me-
senteric Obstructions.)
Form. 522. Pi lols Ferri Ammoniati Composite.
R Ferri Ammoniati " j.; Extr. Gentian, et Extr. Aloe's
aa J) ij. Contunde simul, et divide massam in Pil.
xxxvj.; e quibus bina;, bis Terve quotidie sumantur.
APPENDIX OF FORMULAE. — Ph.ol*.
XIX
Farm. 9$. Pilule Ferri Aperif.ntes. (1.)
R Ferri Sulpbatis, Potasss Sulphatis, aa 5 j.; Galbani,
Assal'd-t 11I r, au ~ j^s. ; Ammonia' Munatis " ij. ;
Hasan Pilul. USes cum MyrrhJ ", nj.; Theriacs
Purif, q. s. Contunde in massam squalem, et di-
vide in Pilulas ol.j quarum capiat binas bis terve
quotidie.
Form. 594. Pilule Ferri Ai-erientes. (2.)
R Ferri Sulphatis, Potasss Sulphatis, aa3j.; Galbani,
tasafcstids, aa "jss.; Extr. Gentians 3 ij.; Massai
Pilul. Aloes cum Myrrha ~, iij.; Theriacs Purif.
q. s. Contunde in massam squalen), el divide in
Pilulas cl.
Form. 525. Pilule Guaiaci Comp. (1.)
R Gum. Guaiaci "ij. ; Saponis Veiiet.~j. ; Catomela-
nos, Sulphur. Antimonii Aur., Pulv. Had. Sene-
gs, Camphors, aa gr. xvj.; Aceti Scillre q. s. Fiat
inaaaa squalls, et divide in Pilulaa Ixxx. ; quarum
capiat duas vel tres bis terve quotidie.
Form; 586. Pilule Guaiaci Comp. (2.)
RGum. Guaiaci " ij.; Calomel., Sulpll. Antimonii Anr.,
•al^ss.; Hucilag. Acacie q. s. M. Fiant Piluls 1.
capiat ij. — iv. pro dose. (Cutaneous Affections.)
Form. .">27. Pilule Guai.vci Composite. (3.)
R Guaiaci Gummi Resina- pulv. 3 ij. ; Pulv. Opii
Crudi fir. vj.; Hydrargyri Protochlorid. (t'aloinel)
gr. xij. ; Antimonii Tartarizati gr. iv. ; Tinctur.e
Myrrhs q. s. ut fiat massa, in Pilulas xxxvj. divid-
enda. Dosis, ij. vel iij. nocte maneque.
Form. 523. Pilule Guaiaci et Antimonii Comp.
R Pulv. Jacobi Veri 3J-i Resin. Guaiaci in Pulv.,
Massa PilUl. Aloes cum Myrrha, ua 5 jss.; Syrup.
Simp. q.s. Fiat massa squalis, et divide in Pilulas
xlviij. Capiat binas ad quatuor pro dose. (Emmena-
goguc, Stomachic, Aperient, and Antirheumatic.)
Form. 529. Pilule Hellebori f.t Aloes Comp.
R Extr. Rad. Hellehor. Nig., Aloes Ext. Purif., Ferri
Ammoniati, aa3j-5 Croci Stigmat. 3ss.; Opii Puri
gr. v.; Syrup, q. s. M. Fiao.t Piluls 1., quarum ca-
piat binas vel tres.
Form. 5150. Pilule Hydrargyri Anodtki.
R Pilul. Hydrargyri, Pulveris Ipecacuanha; Compos.,
Extract. Hyoscyami, aa gr. v.; Fiat massa in Pilu-
las iij. dividends* Sumantur hori somni.
Form. 531. Pilule Hydrargyri Oxymuriatis.
R Hydraigyri Oxymuriatis, Ammonia; Muriatis, ai
gr. v.; Aqua; Destillats, f. 3SS- > Glycyrrhizs Ra-
dicle Pulveris &iv. ; Mellis Opt. ~ss. Cogantur in
massam, quaiu divide in Pil.xl.; e quibus sumatur
una ter die.
Form. 532. Pil. Hydrargyri Phosphatis Composite.
R Hydrargyri Phosphatis gr. ix. ; Antimonii Tartari-
zati gr. j. ; Opii Crud. in pulv. subtiliss. gr. vj. ;
Confectinnis Fructi Ross I anina q. s. ut fiat mas-
sa, in Pilulas sex sqnales distribuenda. Quorum
una, bora decubitus sumenda.
Form. 533. Pilul.*: Hydrargyri et Scilljc.
R Sods Sub-carbon, exsic. 3SS- i Saponis Duri v> y. ;
Pilul. Hydrarg. ur. xxiv. ; Pulv. Scills Rad. exsic.
gr. xij.; Olei Juniper) q. s. :\I. Fiant Piluhe xxiv.,
quarum capiat unam ter die.
Form. 534. Pilule Hydrargyri Sibmuriatis Com-
posite, seu Pilule Plu.mmeri.
R Hydrargyri Sobrauriatis3ss.; Antimonii Sulphureti
Prsclpitati 5j. ; Guaiaci Gummi Resins contrits
3ij. ; Saponis 388.; Olei Juniperi, TTf xxx. ; Tbe-
riac. Purificat. (Treacle) q. s. ut fiat massa, in Pi-
lulas sexaginta dividenda.
Form. 535. Pilule Hvdriodatis Ferri.
R Ferri Bydriodatis gr. xxx. ; Croci Stigm. pulveriz.
r, j.; Sacchari Albi 3 iij.; Hucilag. Tragacanth. u.s.
Contunde in massam squalen), et divide
In Pilulas xc; quarum capiat unam binas vel tres,
bis terve quotidie. (Chlorosis, Aiucnorrhooa, Scro-
fula, &x.)
Form. 5:)!". Pilule Kino Composite.
R Kino, ;.)ij.; Cninphonr rasa- et subnets 3ss.;Oxid.
Ziuci)ss.; Con feet. Aroinat.';)j. M. Divide In Pi-
lulas xx. capiat binas mane nocteque. | Ai?oo»tin
in Diabetes. Also ill Affections of .Mucous Surfaces.)
Form. 537. Pilul* Morphine cum Digitals.
R Acetatis Morphinsgr. j.; Pulv. Pol. Digitalis gr. vj.;
Camphors rass gr. \.. Pulv. Acacis gr. viij. ; Sy-
rup. Tolutan. q. s. Fiat massa squalls. Divide in
Pilulas vj., quarum capiat unam tertiia lioris.
Form. 538. Pilule Mykiuie et Balsami Comp.
R Myrrhs 3jss.; Benzoini9ij.', Balsam. Copaibs 3 j.;
Fxtr. Glycyrrh. 9iv. Plant Piluls xliv, secundum
arteni. Capiat a;ger binas bis terve quotidie.
(Asthma, Chronic Bronchitis.)
Form. 539. Pilule Nervine. (Stoll.)
R Gummi Atnmoniaci, Gummi Assafcetids, aa 3jss. ;
Saponis Veuet. 3 ss. ; Pulv. Castorei, Ammonite
Carbon., aa gr. xxv. ; Mucilag. Acaciie q. s. M.
Fiant Piluls Ixxx.; e quibus sumantur bins tertiis
vel quartis lioris, vel ter die.
Form. 510. Pilule Nervine Antimoniate.
R Gummi Galbani 3jss. ; Gummi Sagapeni, Saponis
Venetian., ua",j.; Pulv. Uliei 3ss.; Antimon. Tar-
tarizat. in aqua font. q. s sol. gr. vj. — x. ; Succi
Liquoritis 3 j. Misce. Fiant Piluls gr. iij. : sumat
unam ad tres ter quotidie.
Form. 541. Pilule Nucis Vomice.
R Extr. Res. Nucis Vomica; V)ss. ; G. R. Assafcetida;
gr. ~ jss. Syrup, q.s. Fiat massa a?qualis, et di-
vide in Pilulas xxx. Capiat unam bis terve in die.
(Cardialgia Spasmodica, &x.)
Form. 542. Pilule Nucis Vomice Composite.
R Morphins Acetatis gr. j. ; Ext. Nucis Vomica; gr.
ij. ; Olei Oliva,' gr. x. Solve ; et adde Extr. Rad.
Hellebori Nig.(JSd. Ph.) 9j. ; Pulv. Glycvrrh. gr.
viij.; Mellis, q. s. Fiat massa a^iualis, et divide in
Pilulas xij ; quarum capiat unam bis terve in die.
(In Chlorosis, Amenorrhcea, &.C.)
Form. 543. Pilule cum Oleo Crotonis.
R Pilul. Aloes cum Myrrha "jss. ; Saponis Castil9j. ;
Olei Crotonis Tiglii TT|yj.; Pulv. Glycyrrhiza; q. s.
M. Fiant Piluls xxx. Capiat binas vel tres omni
nocte. (In Amenorrhcea.)
Form. 544. Pilule Plumbi Acetatis et Digitalis.
R Plumbi Acetatis gr. iv. ; Pulveris Digitalis gr. vj.;
Pulveris Opii gr. iij. ; Confectionis Rosa; Canina;,
q. s. Misce, et divide in Pilulas sex aequales ; qua-
rum sumatur una ter in die.
Form. 545. Pilule Plumbi Acetatis et CoLCHicr.
R Plumbi Acetatis gr. xii.; Pulveris Colchici gr. xxv.;
Pulveris Opii gr. iii. ; Mucilaginis Acacia; q. s.
Misce optitne, et divide in Pilulas sqnales duode-
cim. (In active Hemorrhages, in Phthisis, &c.)
Form. 546. Pilule Plumbi Superacetatis.
R Plumbi Superacetatis gr. viij.; Opii Crudi pulver. gr.
iv.; routed. Fruct. Rosa> Canina; q. s. In Pilulaa
viij. divide. Dosis, j. ij. vel iij.semel, bissa;piusve
in die.
Form. 517. Pilule Purgantes.
R Fel. Tauri inspissat.; Aloe's Extr. Purificat., aa3j.,
Extr. Colocynth. Comp., Saponis Castir.,aaV)j. M.
Fiant Piluls xxxvj.
Form. 548. Pilule Rhei Resolventes.
R Pulv. Rhei, Soda; Acetatis, Fellis Tauri inspiss. aa
3ij.; Pulv. Gum. Acacia; q. s. Fiat massa Pilular-
is. (Ph. Dun.)
Form. 549. Pilule Rhei Bai.samice.
R Pulv. Rhei, Pulv. Gum. Acacia;, aa. partes equates;
Balsam. Copaiba? q. s. ut fiat massa pilularis.
Form. 550. Pilule Scammonie.
R G. R. Scammon. cr. xv. ; Sacchar. Alhi gr. x. Tere
prolie ; deinde adde 01. Carui ffjiv. Fiant Piluls
vj., quarum sumat ij. omni liora.
XX
APPENDIX OF FORMULA. — Pilule.
Form. 551. Pilule Soills Composite.
R Rad. Scill® recent. 3ss. ; Gum. Ammnniaci, Succi
Glycyrrh., aa 3j.; Sulphur. Antimonii Aur., Pulv.
Niicis Myristici, aa ^ j. ; Syrup. Papaveris q. s.
M. Fiant Piluls 1., quarum capiat binas ad tres
ter quaterve in die.
Form. 552. Piluls Scills cum I^cacuanha.
R Scillfe Radicis Pulveris, Zingiberis Radicis Pulveris,
aa 3j. ; Ipecacuanha; Radicis Pulv.gss. ; Saponis
Duri, 3jss. ; Olei Juniperi, TT] xxx. Contunde, ut
fiat massa, in Pilulas Ix.dividenda.
Form. 553. Piluls Sedativs. (1.)
R Extr. Opii gr. j. ; Nitratis Potass® gr. vj. ; Campho-
rs rasa? gr. v. ; Syrup. Papaver. q. s. ut riant Pilu-
1® iij. pro dose.
Form. 554. Piluls Sedative. (2.)
R Camphor® Subact® J)j. ; Potass® Nitratis 5 ss. ;
Extr. Hyoscyami, Extr. Anthemidis, aa 9 ij. ; Sy-
rup Papaveris q. s. M. Fiant Pilul® xxxvj., qua-
rum capiat binas 4tis vel rjtis lioris.
Form. 555. Piluls Sedative. (3.)
R Camphor® ras® et subact® gr. x.; Extr. Hyoscyami
9j.; Extr. Papaveris Alb. gr. xij. M. Divide in Pi-
lulas xij., quarum capiat binas vel ties hora somni.
Form. 556. Pil. Sods Cakbonatis cum Hyoscyamo.
R Camphor® 3ss.; (Sp. Rect. q. s. ft. terendo pulv.)
Sod® CarbonatisSJss. ; Extract! Hyoscyami, H> > j - ;
Saponis Duri 5J. ; Olei Juniperi Ttyxxx.; Pulveris
Irid. Flor. q. s. ut ft. massa, in Pil. xxx. ®quales
distribuenda; quarum sumat iij. nocte mandque,
cum Infus. Lini vel Decoct. Alths®, propotucom-
muni.
Form. 557. Piluls Stahlii.
R Peroxid. Antimonii, Aloes Socot., Resin. Guaiaci,
aa3j.; Croci Stig., Myrrh®, 3ss.; Bals. Peruv. q. s.
ut fiat massa ®qualis. Divide in 1.
Form. 558. Pilule Stomachics. (1.)
{Frank's Grains of Health .- — Grana Vitm Mesne.)
R Aloes 3 iij.; Mastiches, Petal. Ros. Rub.,aa3j.; Fel-
lis Tauri inspissat. 3 jss. Misce bene ; divide in Pi-
lulas c. ; quarum capiat ij. vel iij. ante prandium.
Form. 559. Pilule Stomachics. (2.)
R Extr. Gentian® 5 ij. ; Fellis Bovin® inspiss. 3jss. ;
Scammoni® 3j. Contunde in massam ®qualem, et
divide in Pilulas Ixxx. ; quarum capiat binas quo-
tidie, vel primo mane, vel ante prandium.
Form. 560. Piluls Stomachics. (3.)
R Limat. Ferri 3ij. ; Pulv. Canell® 3 j. ; Fellis Bov.
insp. Jss.; Syrup, q. s. M. Fiat massa Pilularis.
(Chlorosis. &c.)
Form. 561. Piluls Stomachics. (4.)
R Limatur® Ferri 3 j. ; Pulv. Rhei, Extr. Gentian®,
Fellis Tauri insp.aa 3 iij. M. Fiat massa Pilularis.
Form. 562. Piluls Stomachics. (5.)
R Fellis Tauri inspissat., Extr. Aloe's purif., Extr.
Gentian®, Saponis Venet.,aa 3 ss. M. Fiant Pi-
lul® xxx., quarum capiat binas bis in die.
Form. 563. Piluls Stomachics Apebientes.
R Ext. Fumari® Officinalis, Extr. Jalap®, aa 3j. ;
PuJv. Capsici Annui, gr. xvj. ; Sod® Sub-carbon.
exsic. 3ss. Misce secundum artem,et divide in
Pilulas xxxvj.; quarum capiat duas vel tres hora et
semisse antd prandium.
Form. 504. Piluls Stramonii.
R Extract! Stramonii 3 j. ; Saponis Duri3ij. ; Acaeite
Gummi pulv. J)j. ; Glycyrrhiz® Radicis pulv.9ij. ;
Mncilas. Tragacanth. q. s. ut ft. massa, in Pilulas
lx. dividehda. Dosis, j. nocte maneque, vel ter die.
Form. 565. Piluls Strychnins.
R Strychnin® Purif. ?r. ij. ; Conserv. Rosarum 3 j.
Misce bend, et divide in Pilulas xxiv.
Form. 566. Piluls Styracis Compo9its.
R Styracis 3 jss.; Olihani, Benzoini, Croci, Extr. Gly-
cyrrh., Martiches,aa 3 ss.; OpiiPuri p)ij.; Myrrh®
9ij.; Balsam. Tolntan.^j. Tere bene simul, ut sit
massa equal is. Divide in Pilulas lxxx., quarum
capiat unam binas vel tres pro dose. (Each pill
contains half a grain of opium.)
Form. 567. Piluls Sudorifics. (I.)
R Hydrargyri Protochlorid. (Calomel) gr. xij.; Anti-
monii Tartarizati gr. jss. ad gr. iij. ; Opii Crudi in
pulv. subtiliss. gr. vj. Misce ; turn adde Confect.
Fruct. Ros® Canin® q. s. ut ft. massa. In Pilulas
vj. squales divide, quarum capiat j. hora somni.
Form. 568. Piluls Sudorifics. (Dumeril.) (2.)
R Kermes Mineral. (F. 636), Sulphur. Aurat. Antimo-
nii, aa.V)j-; Extr. Opii gr. xij. ; Extr. Hyoscyami
3U- Divide in Pilulas lx. Capiat j.— ij. bisterve
in die.
Form. 569. Piluls Sulphatis Strychnins.
R Strychnin® Sulphatis gr. ij. ; Confect. Rosar. 3j. ;
Misce probd, et divide in Pilulas xxiv. squales.
Capiat unam pro dose.
Form. 570. Piluls Terebinthinatje.
R Gum. Guaiaci 3 j-; Terebinthin® Vulg. 3jss.; Pulv.
Glycyrrh. q. s. ut fiant Pilule xxxvj., quarum ca-
piat binas vel tres ter quotidid.
Form. 571. Piluls Terebinthins et Camphors
cum Opio.
R Extr. Opii 9j.; Pulv Rad. Glycyrrh. 3jss.: tere cum
aqu® pauxillo, et adde Terebinth. Venet £)ij.; Cam-
phor® ras® gr. xv.; Croci Stigmata 9j.; Mastiches
gr. x.; Pulv. Acaci® gr. x.; Olei Juniperi q. s. Tere
bend simul, et fiat massa ®qualis. Divide in Pilulas
lx.; quarum capiat binas ad tres bistervequotidid.
Form. 572. Piluls Tonics Aferientes. (1.)
R Qninin® Sulphatis 3 ss. — 3 j- i Potass® Sulphatis
3jss. ; Gum. Galbani 3 iv. ; Extr. Gentian®, vel
Anthemidis, 3 j. ; Mass® Pilul. Aloe's cum Myrrha
5 iij. ; Theriacre Purif. q. s. Contunde in massam
ffiqualem, et divide in Pilulas cxx. ; quarum su-
niantur bin® vel tres, bis terve quotidid.
Form. 573. Piluls Tonico-Apebientes. (2.)
R Quinin® Sulphatis 3 j. ; Aloe's Extr. purif. 3ss->
Extr. Gentian® 3j- M. Fiant Pilul® xxiv., quarum
sumat unam vel binas omni meridie.
Form. 574. Piluls Tonics Aperientes. (3.)
R Ferri Sulphatis 3j. ; Extracti Absinthii (vel Gen-
tian®), Extr. Aloes Purif., aa 3 jss. ; Syrup. Croci
q. s. M. Divide in Pilulas lxxxv., quarum capiat
binas, tres, quaterve pro dose.
Form. 575. Piluls Tonico-Aperientes. (4.)
R Quinin® Sulphatis, Extr. Aloe's Purif., aa 9ij.; Extr.
Gentian®, aa 3 jss.; Syrup. Simp. q. s. Divide in
Pilulas xlviij.; quarum capiat duas vel tres pro dose.
Form. 576. Piluls Tonico-Aperientes. (5.)
R Quinine Sulphatis 9j. ; Mass® Pilul. Aloes cum
Myrrha 3ij.; Extr. Gentian® 3j. M. Fiant Pilu-
ls xxx., quarum capiat binas bis quotidid.
Form. 577. Piluls Tonics cum Cupro.
R Cupri Sulphatis gr. x.; Pulv. Rhei 3j.; Extr. Anthe-
midis3ij.; Syrup. Simp. q. s. M. Fiant Pilul® xl.,
quarum capiat j. ad iij. (In Leucorrhoea, ifcc. by
Augustin; and in Gleet, Chorea, &c. The Am-
moniated Copper is substituted for the Sulphate in
Chorea by Niemann.)
Form. 578. Piluls Tonics cum Sulphate Zinci.
R Zinci Sulphatis 3j.; Extracti Gentian® 9iv.; Extr.
Anthemidis 9ij. Contunde massam, et divide in
Pilulas xl. ; quarum sumantur du® bis die, cum
Haustu infra pr®scripto.
R Infus. Gentian® Composit. 3 x. : Acidi Sulphurici
Aromat. TT)xij. ; Tinctur® Zingiberis 3j. M. Fiat
Haustus.
Form. 579. Piluls Tonico-Emmenagogs.
R Quinin® Sulphatis, Mass® Pilul. Galhan. Comp.,
aa3ss. ; Mass® Pilul. Aloes cum Myrrhsl3j. ; Olei
Junip. Sabin® q. s. M. Divide massam in Pilulas
xxx., quarum capiat binas mand nocteqne.
Form. 580. Piluls Uvs Ursi et Rhei.
R Pulv. Uvb Ursi, Pulv. Rhei, aa 3ss.; Saponis Castil.
gr. xxv. ; Mueilag. Acacia- q. s. M. Fiant Pilule
xx.; capiat binas bis quotidid.
Form. 581. Piluls 1'vj: I'rsi et Sods.
R Pulv. Fol. Uvs Ursi, Sod® Sub-carbon exsic, Sapo-
nis iluri. aa ']■ j Mueilag. .Acacia' q. s. M. Fiant
Pilul® xl., quarum capiat Unas bis teive quotidie\
APPENDIX OF FORMULA. — Pilule— Pulvis.
xxi
Form. 589. Pii.ri.r. Valeriana. Composite.
R l'ulv. Valeriana gr. ixx. ; Castorel gr. v\. ; Oxidl
Zinc! gr. xx. ; Syrup Simp. q. b. M. Fiant PHuIh
xviij., quarnni capiat tres ter quotidie. (Dupuy-
tren.)
Form. 583. Pilul.*: Valeriana et Zinci.
r Pulv. Valeriana ;>)ij.; Castorei gr. xv.; o.\id. Zinci
;•) i.; Olei Cajeputi lT)v. \ Syrup. Simp. ii. s. Di-
vide in Pilulas xviij., quarum capiat trea quater in
die. (Nearly the same as those used by Dupuy-
TREN.)
Form. 581. Pilul.e Zinci et Mvhhh.e.
R Zinci Sulpliatis gr. xij. ; Myrrhs in pulverem trita
3 jss. ; ( 'ont'ect. Rosa q\ s. ut fiant Pilula xxiv. ;
4 quibus sumantur bina? bis quotidie.
Form. 585. 1'il. Zinci cum Mvbhha et Ipecacuanha.
R Zinci Sulpliatis gr. xij. ; Myrrhs inpnlv.trit. 3J. j
l'ulv. ipecacuanha gr. xvj. ; Extr. Hyoscyami })j.
Syrup. Papaveris q. s. M. Fiant Pilula xxiv. j e
quibus samatur una ter quaterve quotidie.
Form. 586. Pilulje Zinci Sulphatis Compositje. (1.)
R Zinci Sulpliatis gr. xij.; Moschi 3 ,iss- > Camphors
5 ss. M. et divide in Pilulas XXX vj., quarum su-
mantur dus bis vel ter in die.
Form. 587. Pilule Zinci Sulphatis Compositje. (2.)
R Zinci Sulpliatis gr. xij.; Pulv. Ipecacuanha gr. vj.j
l'ulv. Myrrhs ;)ij.; Extr. Lactuca £)ijss.; Syrup.
Tolutan. q. s. Contunde in niassaiii squalem, et
divive in Pilulas xxiv.
Form. 588. Potus Antiphlog. Diureticus.
R Decocti Asparagi Officin. ft ij. ; Potasss Nit. gij. j
Spirit. /Ether. Nit. 3 i i j . j Oxymel. Scillsgss. Sit
pro Potu comniuni.
Form. 589. Potus Decocti Sarsj: Comp. (Tisane de
Feltz.)
R Antimonii Sulphureti 5 iv. ; Aqua; Com. ft xij. ;
Sad. Sarsaparilla 5 iij.; Radicis China Orientalis,
Corticis Lig. Buxi, Ichthyocolls, aa §jss.; Oxymu-
riatis Ilydrarg. gr. iij. (Enclose the Antimony in a
muslin lias ; and boil the whole, excepting the
Corrosive Sublimate, until the water is reduced to
one half: strain the decoction, and add the Subli-
mate. The properties of this decoction will not be
materially affected by omitting the Radix Chins
and Cort. Buxi ; or Sassafras or Guaiacum may be
substituted, and Extractum Taraxaci added.)
Form. 590. Potus Diureticus. (1.)
R DecoctiTritici Repen. ftijss.; Potasss Acetat. sjss.;
Spirit. .'Ether. Xit. 5 iij.; Aceti Colchici *ss.; Vini
Xeres 5VJ.; Oxymel. Scills 5 jss. Fit pro Potu
communi.
Form. 591. Potus Diureticus. (2.)
R DecoctiTritici Repcntis O ijss. ; Potasss Supertart.
5J.; Potasss Nit. 3 iij. > Sods Sub-boracis 3 ij.; Sac-
char. 3 iv. Sit pro Potu ordinario.
Form. 592. Potus Febrifugus. (1.)
R Potasss Nitratis 3 iij.; Seri T.actis O iij. ; Succi Li-
monis^ijss. M. Sumat pro Potu ordinario.
Form. 593. Potus Febrifugus. (Stoll.) (2.)
R Pulps Tamarindorum Jss. veljvj.; Potasss Nitra-
tis3ij. vel 3iij.; Seri I.actis () ijss. M. Omni bi-
horio vasculum cofiffianum.
Form. 594. Potus Mann.*: et Tamarindorum.
R Mannrp, Conserv. Tamarind. Indie, 5a ^jss. ; Seri
Lactia lb jss. Digere et cola. Capiat cyathum
subinde.
Form. 595. Potus Refricerans.
R .\ci<li Muriatici 3J.; Spirit. ^Ether. Nit. 3 ilijss.; De-
cocti Hordei Comp. g xxiv. M. Capiat cvatlmm
pro ro natl. (In Febrile Affections.)
Form. 5911. Pultis Acidi Bbnzoini et Camphor*.
R Acidi Benzoic! gr. vj. ; Camphors gr. ij. ; Sacchari
Albi;>j M. Fiat Pulvis. Dispens. tales doses
trcs. Capiat sger altera quaque hori unuin.
Form. 597. Pulvis Aluminje et Quininje.
R Alumina' Sulphatis gr. vlij.— xij.; < luiiiins Sulphatis
gr. j. — iij.; Gum. Arab., Sacchar. AIM, SB gr. xij.
rial Pulvis. Dispens. tales duodecim. Capiat ager
tenia quaque hort pulverem unuin. (In Adynamic
Fevers, Hsmatemesis, Passive Hsmorrhages, &c.)
Form. 598. Pui.vis Ammoniareti Cupri cum Zinco.
R Cupri Ammoniareti, Oxydi Zinci, 5a gr. ss.— j.;
Sacchari Albi gr. x. M. Fiat Pulvis. (Epilepsy
and Chorea.)
Form. 599. Pulvis Antihydropicus.
R Potasss Supertart. %).; Potasss Nitratis, Sub boracis
Sods,aa3ij.; Pulv. Fol. Digitalis 9 j. Tere bene
simul, et divide in Cartulas xij. ; quarum capiat
imam bis terve quotidie, in quovis decocto vel in-
fuso.
Form. fiOO. Pulvis Antimonii et Camphorje.
R Sulph. Aurat. Antim., Radicis Ipecacuanha, aa gr.
j. ; Camphors rass gr. j. — iij.; Sacchari Albi "j.
M. Pulv. Dispell, tales doses sex: sumat sger al-
tera quaque hori Pulverem unum. (In Chronic
Inflammations of the Respiratory Organs.)
Form. 601. Pulvis Antimonialis Compositus.
R Pnlveris Antimonialis 3 v. ; Antimonii Sulphureti
prscipit. 3j. M. Dosis gr. v. pro state adultl.
Form. 602. Pulvis Antiphlogisticus.
R Potasss Nitratis § iij. ; Potasss Tartratis 5 ivss. ;
Acidi Boracici J j- Tere in Pulv. subtiliss. (In
doses of 3ss. in Cutaneous Affections, <Sr.c.)
Form. 603. Pulvis Antispasmodics. (Stahlii.)
R Kermes Mineral, gr. j. ; Potasss Nitratis, Potasss
Sulphatis, aa gr. x. Misce bene.
Form. 604. Pulvis Apehiens.
R Pnlveris Jalaps ^ iij. ; Submuriatis Hydrargyria j- ;
Pnlveris Zingiberis 3 ij. Misce. Dosis, a gr. iv.
ad gr. xx.
Form. 605. Pulvis Asari Compositus.
R Asari Folior. exsiccat, 5 iij.;Origani Folior exsiccat.,
Lavanduls Florum exsiccat., aa^j. Simul teren-
tur, et fiat Pulvis. (In Chronic Ophthalmia and
Toothache, as a sternutatory, &c; to produce a se-
cretion from the Schneiderean membrane.)
Form. 606. Pulvis Belladonna.
R Pulv. Rad. Belladonns gr. iv.; Pulv. Rad. Glycyrrh
et Sacchar. Albi, aa gr. xxviij. Tere bene simul
Dosis gr. iv. — xx., bis in die.
Form. 607. Pulvis Belladonnje Compositus.
R Pulv. Rad. Belladonns gr. vj. ; Pulv. Ipecacuanha
gr. vj.; Pnlv. Rad. Glycyrrh., Pnlv. Sacchar. Albi,
5a3ss. ; Sulphur. Pra-cipit. V)ij. ; Olei Anisi, Olei
Succini, aa IT) iij. Misce. In dosis gr. v. — xx.
Form. 608. Pulvis Belladonnje Compositus.
(Hecker.)
R Pulv. Fol. Belladonns gr.j. — iij.: Moschi, Campho-
ra\aa gr. v.; Sacchar. Albi 3ss. Tere bend, et divide
in Cartulas viij. (Antispasmodic. Pertussis, &c.)
Form. 609. Pulvis Bismutiii.
R Bismuthi Sub-nit. gr. j. ; Magnes. Calcinat., Sac-
char. Albi.aa gr. x. M. Fiat Pulvis; tertii vel
quart! quaque hori sumendus. (Ooier.)
Form. 610. Pulvis Bismuthi Compositus.
R Bismuthi Sub-nitrat., Moschi, aa gr. j.: Extr. Hyos-
cyami gr. ss. ; Magnes. Sub-carbon, gr. v. M. Fiat
Pulvis, tertia quaque hori sumendus. (Marcus.)
Form. fill. Pulvis Boracis etSabin.e.
R Pnlveris Foliorum Sabina, Pulv. Zingiberis, SSgr.
vij. ; Soda Boracis 9j. Fiat Pulvis, his difi su-
mendus. (In Amenorrhcea with a languid pulse.)
Form. 612. Pulvis Calomelanos cum Digitale.
R Hydrargyri Submuriatis. Sacchari Albi, S3 5J.; Pul-
veris Digitalis 53s. Misce. Dosis, a gr. j. ad gr. v.
Form. 613. P-.ilvis Calumb/k Compositus.
R Pnlveris Calnmlis 3J.; Pnlv. Rhel Jss.; Sods Sub-
carhonatis 3iijss. Misce. Dosis, a gr. vj. ad 5ss.
bis de die.
XXII
APPENDIX OF FORMULAE. — Pulvis.
V
Form. 614. Pulvis Cimphorx.
R Camphoric 3 ss.; Sp. Rectif. q. s. Ft. terendo pulv.;
ilein adde, Sacchari Purificat. 3 J- > Pulv. Acacire
5jss. M. Fiat Pulvis, et in cart. x. requalis dis-
tribuendus.
Form. G15. Pulvis Camphors et Zinci.
R Campliorrp ras.p V)j.; Zinci Oxidi gr. xv, M. In Car-
tnlas iv. distribue; quarum sumatunam horasomni.
(In Epilepsy supervening about puberty, and con-
nected with venereal desires and indulgences.)
Form. 616. Pulvis Carminativus. (1.)
R Magnes. gr. viij.; Seminum Anisi contus., Seminum
Fceniculi cont.,aa gr. ij.; Croci gr. j. ; Sacchari Al-
bi gr. vij. Contunde bene simul, et sit pulvis. Ca-
piat dimidium statim, et. alterum post horam. (For
the Termina of Infants, &c.)
Form. 617. Pulvis Carminativus. (2.)
R Magnes., Sacch. Albi, aa3j.; Pulv. Corticis Canel-
Ite, Semin. Fceniculi cont. gr. xx. ; Olei Anisi
TTJviij. Tere bene simul, et divide in Carlulas xij.;
quarum capiat unam bis terve quotidie, vel urgent,
torminibus.
Form. 618. Pulvis Carminativus. (3.)
R Sem. Anisi, Sem. Carui, Sem. Coriand., Sem. Fceni-
culi, aa 5 j. ; Cort. Auran., Rad. Zingib., aa gvj. ;
Crete Prspar. g Jss- j Magnes. g ss. ; Macis 5jss. ;
Sacchar. Alb. § ij.: tere bene simul. Dose, 3j. — 3 ij.
Form. 619. Pulvis Catharticus.
R Submuriatis Hydrargyri, Pulveris Cambogire, Pulv.
Jalaps, Pulv. Rliei, Pulv. Cinnamomi, aa 5 ij.
Misce. Dosis, a gr. v. ad 9j.
Form. 62n. Pulvis Cinchona Compositus.
R Pulv. Cinchons gjss. ; Pulv. Mosch. gr. xv.; Cam-
phors p)j.; Ammonis Carbon, gr. xxv.; Olei Suc-
cini et Olei Mentha; aa TTJvj. Misce probd, et di-
vide in Pulv. viij.
Form. 621. Pulvis Cinchon-e cum Soda.
R Pulveris Cinchonas, Soda? Subcarbonatis, aa partes
a?quales. Dosis, i gr. v. ad JJss. bis terve in die.
Form. 622. Pulvis Corticis Cusparle Comp.
R Pulv. Cort. Cusparis gr. x.; Cinnam. Comp. gr. vj.;
Olei Pimento TTJj. M. Fiat Pulvis, ter de die
capiendus.
Form. 623. Pulvis Creti et Rhei Compositus.
R Crete Prspar. gss.; Saponis Amygdal., Pulv. Rhei,
aa 3 j. ; Hydrarg. cum Creta 9 j. ; Olei Fceniculi
TTjviij. ; Sacchar. Albigij.: tere bend simul. Ca-
piat gr. vj. ad 3 ss- pro dose bis vel ter die. (Pro
Infantum Diarrhoea.)
Form. 624. Pulvis Cretaceus.
R Crete Preparate, Acacis Gummi Ver. pulv., aa giv.;
Sacchari Purificati contriti, § iij. Misce. Ft. Pulvis.
Form. G25. Pulvis Cyanureti Zinci.
R Zinci Cyanureti gr. vj. ; Macnesis Calcinate gr.
iv. ; Pulvis Cinnamomi, gr. iv. M. Fiat Pulvis,
qnartA quaque hora sumendus. (In Gastrodynia,
Dysmenorrhcea, Dyspepsia.)
Form. 626. Pulvis Deobstruens.
R Gum. Guaiaci ?, ij.; Flor. Sulphur, 3jss.; Calomela-
nos £)j.; Radicis Ireos Flor., Semin. Fceniculi, aa
3j*s.; Opii Extr. sr. ij.; Sacchar. Albi §ss. Tere
bend simul, et divide in Pulv. vj.
Form. 627. Pulvis Diureticus. (1.)
R Potasss Nit., Potassre Supertart., aa ►) iv. ; Pulv.
Scills gr. viij.; Pulv. Zing. gr. xvj. Misce bend, et
divide in Cartulas viij.
Form. 628. Pulvis Diureticus. (2.)
R Potasss Supprtart. 'jss.; Pulv. Scillre exsic. gr. ij.;
Pulv. Digitalis gr. j. ; Pulv. Zingiheris gr. v.
Fint Pulvis, ter qnaterve quotidid sumendus ex
tberiaci.
Form. 629. Pulvis Eccoproticus
R Potassre Supertart. gj.; Magnes. Sub-carbon., Flor.
Sulphur., aa § ss.; Potassre Nit. 3 >j. Misce, et di-
vide in Cart. vj. (In Hemorrhoids, &.c.)
Form. 630. Pulvis Ecphracticus. (1.)
R Potass® Supertart. 5 ss. ; Soda; Suh-boratis, Magne-
sia; Sub-carbon., aa 5U-; Pulv. Flor. Anthemidis,
Pulv. Semin. Fceniculi, aa 3ij.; Sacchari Albi gss.;
Olei Juniperi, et Ol. Anisi, aa TT] xv. Tere bend
simul. Capiat 3j. — gij. bis terve quotidid.
Form. 631. Pulvis Ecphracticus. (Sellii.) (2.)
R Magnes. Sub-carbon., Potassre Supertart., Sulphur.
Sublimati,I'ulv. Rhei, Pulv. Flor. Anthemid., Pulv.
Seminum Fceniculi (vel potiiis Sacchari Albi^ss.;
Olei Fceniculi Dul. TTJxxiv.), aa gss.; Olei Junipe-
ri TT) xviij. Tere bend simul. Capiat 3j. — 3ij.
bis terve quotidid ex vehicnlo quovis idoneo. (In
Obstructions, Jaundice, Piles, &c.)
Form. 632. Pulvis Excitans.
R Boracis Sodre gr. xv. — Bj. ; Pulv. Sabinre gr. vj. ;
Pulv. Castorei, Pulv. Rad. Zingib. aa gr. x. M.
Fiat Pulvis. Sumat regra de die Pulveres binos in
vino vel cum melle. (Stimulans et emmenagogus
in Menstruorum defectu ex Leucophlegmasia.
Hartmann.)
Form. 633. Pulvis Infantilis.
R Rhei Radicis Pulveris 3 ij.; Magnesis Suh-carbona-
tis^x.; Zingiheris Rad. Pulv. Jss. M. Fiat pulvis.
Capiat gr. vij. ad Jss. pro dose.
Form. 634. Pulvis Ipecacuanha cum Calomelane.
R Hydrareyri Sub-muriatis 3 j. i Pulv. Ipecacuanhre
3 ij.; Pulv. Cinnamomi 3jss.; Sacchari Albi 3 ijss.
M. Dosis, a gr. ij. ad gr. x.
Form. 635. Pulvis Jalap.e Compositus.
R Jalaps Radicis Pulveris 5 j.; Potasss Super-tartratig
§ij.; Capsici Raccarum Pulv. gr. xij. Omnia, scor.
sim trita, permisce. Dosis a 3SS- ad 5j- mand.
Form. 636. Pulvis Jalapa et Calomelanos.
R Pulv. Rad. Jalapre gr. xv. — xx.; Hydrarg. Submur.
gr. ij. : tere probd cum Sacchar. Alb. 3ss.; et adde
Pulv. Acacia; ^j.; 01. Carui TT]ij. M. Fiat Pulvis,
statim sumendus.
Form. 637. Pulvis Kermes Mineralis. (Hydro-Sul-
phuret of Antimony. Berzelius.)
R Aqua; Pluvial, part. 280 ; Sub-carbon. Sods part.
128 ; Sulphureti Antimonii pulver. part. 6. Dissolve
the Soda in the water whilst boiling; and boil the
Sulphuret in the solution for half an hour, stirring
it frequently. Filter the boiling liquor in a vessel
containing warm water which had been previously
boiled. Decant the water after it is cooled. Wash
the precipitate which is formed, first with cold wa-
ter, afterwards with warm water, until it passes
off quite insipid. Lastly, press it, and dry it in
the shade. (Stimulant, Emetic, Diaphoretic. Al-
terative, Becchic, Expectorant. Dosej. — iv.gr.)
Form. 638. Pulvis Kermes Mineralis et Camphors.
R Kermes Mineral, gr. ij. ; Camphors Subact. in Pulv.
gr. iij.; Potassre Nit. gr. v. — xij. M.
Form. 639. Pulvis Kermes Mineralis Camphokatus.
R Kermes Mineral, gr. iij.; Camphors Pulverizat. gr.
viij.; Potassre Nitratis cr. xxiv.; Sacchar. Albi 3 ss.
Tere bend, et divide in Pulv. iv. Capiat unam,
quater in die.
Form. 640. Pulvis Lemtivus Hvpochondriaccs.
(Klein.)
R Flavedinis Cort. Aurant., Radicis Rhei, Potassre
Tartratis, aa3ss.; Olei Cajeput. TT] iij. M. Ft.Pul-
vis pro una dose.
Form. 641. Pulvis Lientericus.
R Pulveris Traeacanth. Comp., Pulv. Rhei," aa giij.;
Pulv. Ipecacuanhre comp. 3 j-: Hydrareyri cum Cre-
t&gj. Misce. Dosis, a er. v. ad 3ss. 3tiis, 4tis, vel
6tis horis. Interdum.adde Extract. Catechu, &c.
Form. 642. Pulvis Nitro-Opiatus Ipecacuanha,
vel Pulvis Doveri.
R Ipecacuanha^ Radicis contrite 3 j-: Opii Crudi contri-
ti gr. xlv.; Potassre Nitratis^S V'U- et gr. xv. Tere
v
APPENDIX OF FORMULAE. — Pui.vis — Solutio.
XXlll
simni, at Sal palvla. (A scrapie of this powder
contains pain and a half of opium, two grains
of Ipecacuan, and sixteen grains and a half of al
tratc of potass, i
Form. 643. Pulvis Poroam.
R Hydrarg. Sub mun, Cambog.G. R. nulveriz., Pnlv.
Zingiberis, Sa^ss.; Sacchar. Purif. ;)j. Terebend
suiml ; etaddeOlei Fceniouli Dulcis TTjxx. Dosis
gr. v. ad iv.
Form. 644. Pulvis Refrioerans. (1.)
R Aoidi Boracici §ss. ; Potassa; Nitratisgj.; Potassie
Bupertart. 3 ij. Hisoe bend. Capiat §j. — 3j. pro
ill ISC.
Form. 645. IYlvis Refrigerans. (2.)
R Potassa; Su pert art ratis pulverizati uncias duas ; Ni-
tralis drachmas tres. Misce, et divide in partes xij.
nquales.
Form. 646. Pulvis Resolvens, vel Deobstruens.
R Potassa Supertartratis pulverizati ", ivss.; Sods Sub-
boracis£jss.; Antimonii Tartar izati gr. iij. Misce
prole, 1 1 divide in partes Equates viginti.
Form. ('• IT. PulVii Rhei Compositus.
R Pulvis I'lu'i ~ iijss.; Hydrargyri cumCret&gj.; Pot-
assa Subcarbon. ' jss. ; Pulv. Cinnamomi 5 ss-
Misce. Dosis, a gr. v. ad gj. bis vel ler die.
Form. 648. Pulvis Rhei et Magnesi.c.
R Pulv. Rhei J} j. — fjss. ; Magn. Sub-barb. gr. xvj. —
~ss. ; Semin. Fosniculi, Sacchari Albi, aa gr. x. ;
Olei Cassis Cinnam. TT|j. M. Fiat Pulvis.
Form. 649. Pulvis Rhei et Sulph. Potass.*:.
R Pulv. Rhei gr. vj. — x. ; Potassa; Sulphatis gr. x. —
}>j. ; Pulv. S.iii. A nisi gr. vj. ; < llei Fosniculi TT|j.
Si. Fiat Pulvis, bisterve quotiilie sumendus.
Form. 650. Pui.vis Scamhonijs com Calomel. (1.)
R Scammon. Gum. Resins pulv. ^ij.; Hydrarg. Sub-
mur. (Calomel), Sacchari Purifieati, 5a 3 j- M.
Fiat Pulvis. Dosis gr. x. ad gr. xx. inane.
Form. 651. Pulvis Scammoni.*: cum Calomel. (2.)
R Scammon. Gummi Resinoe pnlv., Hydrarg. Proto-
chlorid. (Calomel), l'otass;e Supertart., aa 3 ij.
MiSCC lane snniil, et sit Pulvis.
Form. G.V2. Pulvis Scammonije et Jalapj:.
R G. R. Scammonete gr. xij. ; Pulv. Rad. Jalaps;
gr. xViij.j Potassa Supertart. gr. xxv. Tere probe
in pulverem tenuissimum ; dein adde Pulv. Zingi-
bers gr. viij.: divide in partes tres aequales, qiiaruiii
sumat j. secunda vel tertia q. q. liora, donee plead
dejecerit alvus.
Form. 653. Pulvis Sedativus.
R Hydrarg. cum CretaSj-i Pulv. Ipecacuanha Comp.
£)ij.; Magnes. Carbon 3ss. Tere bend simul. Do-
sis gr. iv.— xij., pro Inl'antibus.
Form. 654. Pulvis Sekecs: et Camphors.
R Pulv. Rad. Senegte, Sacch. Alb., aa gr. xij. ; Cam-
phors rasa! gr. ij. M. Fiat Pulvis. Dispensentur
tales doses tres. Capiat teger, interjectis duabus
horis, pulverem unum. (In Chronic Affections of
the Chest.)
Form. 655. Pulvis Sod.'e Compositus.
R Soda; Suh-rarbon. exsircat. 3VJ. ; Hyrirargyri Sub-
muriatis*j.; Pulv. Cretae comp. Jj. Misce. Dosis,
a gr. v. ad 3j.
Form. 656. Pulvis Sod.*: cum Hydrargvro.
R Sod.T Sub-rarbon. exsic. ~iv. ; Hydrarg. cum Creta
3 ij. Misce bend. Dosis, gr. vj. — ad gr. xij. pro
Inl'antibus bis quotidie.
Form. 657. Pulvis Specificus Stomachicus. (Po-
terii.)
R Protoxid. Ferri, Antimon. Crud., aa partes ORquales
vel unam ; Potassa; Nitr. part. vj. Detona sea de-
flagra, et lava.
Form. 658. Pulvis Sulphatis Potass.*: et Fehri.
R Ferri Sulphatis 5 vj.; Potases SuTpbati? "xij. Tere
bend simul, et adde Acldl Sulphuric! iT'wxvj. M,
Dosis })j.— ",jss. bis, ler, quaterve in die.
Form. G59. I'ii vis Sulphatis (iuiMN.r. Antimon iati.
R Quinine; Sulphatis gr. xij.; Antimonii Tartarizat.
gr. ij. Misce bene, el divide m partes vj. fflquales
Capiat unam -Mis vel 3tiis boras Inter pajoxysmoa
Form. 660. Pulvis Sulphatis Quinin.v.f.t Monpiii.c.
R Quinine Sulphatls-gr. iv.— xij. ; Morphines Sulpha-
tis, gr. j— ij. Misce, it divide in dos. iv. vel vj.
Form. 661. Pulvis Sulphuret. Aureat. Antimonii,
vel Deuto-Sulphuret. Antim. (Berzelius.)
R Liquoris restantis post prsecipitat. Mineralis Kermes
diet, quantum velis; infunde Acid. Acetiei quant
turn sutliciat, vel donee nil nmplins prai ipitatioms
appareal Lave bene materiam precip. et exsicca.
(.\. H. the Precipitated Sulphuret of Antimony of
the Lond. Ph. is an admixture of Kermes Min. and
the Golden Sulph.)
Form. 662. Pulvis Tonicus.
R Ferri Sulphatis exsiccati "iij.; Potassa; Sulphatis
JiJ*. ; Pulveris Cascarillajgiijsa. Misce. Dosis,a
gr. iij. ad gr. x. bis terve in die.
Form. 663. Pulveres Tonics.
R Pulv. Cinchona; F.vtr. Glycyrrh., a.a ^ i ij - ; Pulv.
Rail. Valerian,. :)ij-; Sacchar. Albigss. Tere bene
simul, et divide in Cartulas ix. Capiat unam ter
quotidie. (Heller and Niemann.)
Form. 664. Pulveres Tonico-Aperientes.
R Pnlv. Cinchona 5 j. ; Pulv. Rheijijss. ; Ammonia?
Muriatis 3 jss. Misce bene, et divide in Cartulas
xij. (Hang et Jadelot.)
Form. 665. Pulvis Valeriana et Zinci.
R Valeriana' Pulv. |j.; O.xid. Zinci V)j.; Moschi, Sac-
chari Purif., aa gr. x.; Olei Cajeputi TT] xii. Tere
simul, et divide in Cartulas vj. : quarum capiat
unam ter die.
Form. 666. Pulvis Zinci Oxvdi Compositus.
R Oxydi Zinci gr. xij.; Magnes. Calcinate 3 ss.; Pulv.
Calumbas gj. Tere bene simul, et divide in Cartu-
las xij ; quarum capiat unam ter quaterve in die.
(De Haen.)
Form. 6G7. Pulv. Zinci Sulphatis Comp.
R Mvrrhte G. R. 3j.; Pulv. Ipecac, gr. vj. ; Zinci Sul-
phatis gr. vj. ; Pulv. Glycyrrh., Sacchar. Albi, ai
3jss.; Tere optime simul ut fiat Pulvis. Divide in
Cartulas ix., quarum capiat unam ter quaterve in
die ex theriaca.
Form. 668. Sapo Olei Crotonis Tiglii.
R Olei Crotonis Tiglii partes ij.; Lixivii Sapnnariipars
j. Contere, et fiat Sapo. Dosis gr. ij. vel iij.
Form. 669. Sapo Teredinthin-e.
R Potassa; Caustics* % j.; Liquefac lento igne,et adjice
Olei Terebinthina; 3 iij. Misce bene donee refrix-
erat. (Used both externally and internally.)
Form. 670. Sapo Terebinthinata.
R SaponisCastil.gj.; Olei Tercbinthina;§ij8s.: adde
Solutioni Potassa; Sub-carbon. 3 ij. ; Camphoric
rasa>;-)ij. Misce bend. (Used externally and in-
ternally.)
Form. 671. Solutio Iodine. (Luool.)
No. 1. No. 2. No. 3.
R Iodina; - - - - gr. ij. gr. iij. gr. iv.
Potassa? Hydriodat. - gr. iv. gr. vj. gr. viij.
Aqua; Destil. - fcj. ibj. tbj.
Solve. (Chiefly forexternal use ; for injections in
Scrofulous Fistula;, &c.
Form. 672. Solutio Iodinjb Caustica. (Luool.)
R lodina; 5 j. ; Potassae Hydriodatis 5 j. ; Aqua; De-
stillata; Jij. Solve.
Form. 673. Solutio Iodina: Rubefaciens. (Luool.)
R Iodin.-e 3iv. ; Potassa; Hydriodatis 5 j- j Aqui De»
stillata; 5 vj. Solve.
XXIV
APPENDIX OF FORMULAE. — Solutio — Tinctura.
Form. G74. Solutionis Muriatis Morphina.
R Muriatis Morphina- gr. .\. ; Aq. Destill;it. Calid. TTf
1000. Solve. (Hose twenty-live minims — equal
to J of the Muriate.)
Form. 675. Solutio Sulphatis Morphina.
R Sulphatis Morphina; Ver. gr. iv. ; Aqua; Bestillata;
gj.; Solve. (Of the same strength as Laudanum.)
Form. C7G. Spiritus jEtheris Muriatici.
{Ohm, Spiritus Febrifug. Cluttoni.)
R Acidi Sulphurici, ftj. gxij. (per pond.) ; Acidi Mu-
riatici fbj. (per pond.); Spiritus Kectilicati cong. j.
Biatilletur liquor, secundum artem.
Form. G77. Spiritus Ammonia Anisatus.
(Ph. Cont. Omn.)
R Olei Anisi 5 iij.; Spirit. Ammonite gvj. Solve.
Form. 678. Spiritus Castorei Ammokiati.
R Castorei contr. giij.; Croci Stigm. gj. ; Herb. Ar-
temisia § vj. ; Potassse Bub-carbon. 3 ij. ; Spirit.
Tenuior. gxxx. 'Macera per dies vj. et cola. Bein
adde Spirit. Ammonia;, Liquoris Ammonia;, aa
§vj. M. DosisSj.— 5ij.
Form. 679. Spiritus Castorei Comp.
R Castorei contr. giij. ; Croci Stigm. § j. ; Herb. Ar-
temisia; gvj. ; Spirit. Tenuior. ft ijss. Macera per
dies sexi et cola. Beinde adde Olei Anisi, Olei Ju-
niperi, Olei Ruts, aa 3 j. M. Bosis 3 ss.— 3 jss.
3tiis vel 4tis horis.
Form. 680. Spiritus Terebinthinatus.
R Olei Terebinthin.-e § jss. ; Spirit. Vini Rect. 5 vj.
Distilla leni cum calore. Dosis in H|vj.— xx. (In
Jaundice.)
Form. 681. Spiritus Terebinthinatus Comp.
R Saponis Albi 5 ij. ; Opii § ss. ; Spirit. Vini Junip.
(vulgo Hollandii) § xijss. ; Spirit. Terebinth. Rect.
giv.; Campliorie^vj. Macera bene, et cola. (Ex-
ternally as a Liniment ; and internally in Colics
and Nephritic Complaints, in doses of from 10 to
21) drops, and in Hropsies.)
Form. 682. Suppositorium Opiatum.
R Opii Puri gr. ij. ; Saponis Huri Hisp gr. iv. Simul
coatunde, et nat massa pro Suppositorio.
Form. 683. Suppositorium Plumbi Compositum.
R Emplastrum Plumbi part. viij. ; Abietis Resinre
cont. part. ij. ; Opii Puri pulveriz. part, ss.— j.
Solve emplastrumet resinam ; deinde adde Opium,
et forma in Supposit.
Form. 684. Syrupus Belladonna.
R Fo). Belladonna; 3ij. ; Rad. Bellad. 3 j. ; Sacchar.
Albi ftj. Aqua; q. s. ut sit decocti ft j.
Form. 685. Syrupus Morphina AceTatis.
R Morphina; Acetatis gr. iv. ; Syrupi Clarificati gxvj.
Misce ut fiat Syrupus. (In doses of from two tea-
spoonsful to a table-spoonful every three hours, or
only at bedtime.)
Form. 686. Syrupus Morphina Sulphatis.
R Morphina; Sulphatis gr. iv.; Syrupi Clarificati g xvj.
Misce. (In the same doses as the Acetate. May
be given alternately with the Acetate.)
Form. 687. Syrupus Papaveris.
R Extracti Papaveris Veri (in vacuo praep.) gj. Solve
in Aqua?. Bestillata; Ferventis O j. ; cola, et adde
Sacchaii Purificati ft ijss.
Form. 688. Syrupus Potassse Sulphureti.
R Sulphureti Potassse 3 j.; Aqua; Hysopi vel Fcenicnli
g ij. Solve, et adde Sacchar. Albi g iv. ; et mace-
ra in Bain. Aren.
Form. 689. Syrupus Quinina.
R Syrupi Simplicis 5 viij.; Onininne Sulphatis gr. xxxij.
Capiat Cochlear, ij. minima, bis terve de die.
Form. 690. Syrupus Rhei Compositus.
R Rad. Rhei concis. et contus. 5 iij.; Fol. Senna; gij.;
Cnnellte Corticis cont. gss.; Semin. Fceniculi cont.
gj.; Potassa; Sub-carbon. 5'j.i Rad. Zing, concis.
3J.; Aqiiie Ferventis Ibij. Macera per boras viginti
quatuor loco in calido, et cola. Liq. colati adde
Manna; 5 iij.; Sacch. Purif. ft iijss. Fiat Syrupus.
Form. 691. Syrupus Senna et Manna.
R Fol. Senna; giv.; Semin. Funiculi cont. gjss.; Sem.
Anisi cont. 3"j-i Radicis Zingiberis 3 jss. ; Aqua?
Ferventis O iij. Digere per horas quatuor; expri-
me et cola. Hein colaturse adde Manna; Optima
gvj.; Sacchari Albigxxij.; et fiat Syrupus.
Form. 692. Syrupus Sulphureti Soda.
R Soda; Pura; (cum Alcoh. praep.) 3j- ; Aq. Destillat.
3 v. ; Liquefac leni igne, et adde Sulphur. Puri
quantum solved potest'. R Liquoris gj. ; Syrup.
Communis 5 xxxj. Misee bene in vase bene obtura-
to. (Hoses of 3 j. — 3 ij- for infants, 5 j. — 5 iij. for
adults.)
Form. 693. Tinctura Acetatis Ferri Comp.
R Acetatis Plumbi g ss. ; Ferri Sulph. 3 iij. ; Aceti,
Alcoholis, aa gij. ; Aq. Rosar. 3 vj. Solve Acet.
Plumbi in aceto cum leno igne ; dein adde Sulph.
Ferri in Pulv., cujus, post solutionem, infunde Al-
cohol, cum Aq. Rosar. permistum.
Form. 694. Tinctura Acetatis Morphina Com-
posita.
R Morphina; Acetatis gr. xvj. : solve in Aqua; Bestil.
3iij.; Acidi Acetici iT|v-; Spirit. Lavandul. Co. f.
3 vj. ; Spirit. Myristicte, vel Tinct. Cinnamom.
Comp.Svij. M. Bosis TT(x.— 3j.
Form. 695. Tinctura tEtherea Valeriana.
R Radicis Valerian, pulver. gj. ; VEtherici Sulphurici
non-rectificat. 5 v j . ; Alcohol, rectif. g j. Macera
per triduum et tola.
Form. 696. Tinct. Aloetica Alkalina. (Saxon Ph.)
R Croci Stigmat. in pulv. pars j. ; Aloes Socot. in pulv.
part, jss.; Myrrlur pulv. part, ij.; Sub-carb. Potassae
part. iv. Misce, et pone in locum humidum ut de-
-liquescat ; dein infunde Aqua; Ferventis part. xij.
Macera per horas duodecim, et adde Alcoholis
Concent, part, duodecim. Bigere leni cum calore
per dies tres, et cola. In dos. 3ss — 3JSS-'
Form. 697. Tinctura Alkalina Potassa.
R Totassa; Caustics 5 ss. ; Alcoholis Concent. 5 iv.
Macera per dies septem in balneo arenario.
'Form. 698. Tinctura Alkalina Stibiata.
R Antimonii Crudi g j. ; Potass® Sub-carbon. 5 ij.
Melt in a crucible, and reduce them to yellowish
scoria; ; then powder them immediately in a hot
iron mortar, and pour upon them rectified Alcohol
gvj. Macerate for three days, and filter.
Form. 699. Tinctura Amara.
R Aloes Socot. giv. vel v.; Gum. Myrrhs, Mastiches,
Benzoes, Rad. Calumbre ccncis.aa gij.; Rad. Gen-
tianaegjss.; Croci Stigm. gj.; Spirit. Vini Gallics
(Brandy) ft ix.; Spirit. Vini Hollands (Hollands)
ft iij. Macera per mensem, et cola. (The celebrat-
ed " Brogue Amdre" of the Jesuits, and an excel-
lent tonic and aperient.)
Form. 700. Tinctura Ammosiaci Alkalina.
R Gummi Ammoniaci giij.; Liq. Potass® Sub-carbon.
% ijss. ; Myrrhae g j. ; Alcoholis O j. Macera per
dies septem, et cola. Bosis 3 ss.— 5 jss.
Form. 701. Tinctura Balsamica. (1.)
R 01eiTerebinthina;gj.; Tinct. Myrrhajgij. ! Tinct.
Benzoini Comp. giv. Macera in loco calido. (In-
ternally, and to Indolent Sores, &.c.)
Form. 702. Tinctura Balsamica. (2.)
R Balsam. Tolutan. gss.; Balsam. Peruvian., Sty raeis
Balsam.. Flor. Benzoe's, Myrrhie, 5a 3 iij. ; Croci
Stigmai.gij.; Spirit. Vini rect. " xx. Macera per
dies tres, et cola. ( Wirtefg^trg h Ph. ncartij.)
k,
APPENDIX OF FORMULA. — Tinctura.
xxv
Form. 703. Tinctuba Hu.sami Tolutani.
R Balsaini TolUtan. "J ; Bemin. Anisi coin. T,j.; Flor.
Jtfii/.oi is ~, ss. ■. Spirit. Rectiflcat. Oj. Digere, do-
nee aolvatur Balsamum ; dein cola.
Form. 704. Tinotoba Hklladonn*:.
r Belladonna Foliorum exsiccatorum 5 ij. : Spiritus
Tenuioria li j. Macon per dies quatuordecim, et
cola.
Form. "05. Tinctuba Henzoica Anodyna.
R Camphors rastu^jss.; Ipecacuanha?, Balsam. Tolu-
tiii. u.i 3 ss. ; Acidi Benzoini aa ~ ij. ; Opii Puri,
Croci Stig., "", ijss.; i )lci Anisi 3j.; Spirit. Villi Ten.
)b ij. Macera bene, et cola. Dosis TTj vj. — xxx.
(The Tinct. Opii Benzoica Compos, of the Aust.
1'iiab. anil Tinct. .dnodyno-SudoriJic. of various for-
eign Pharmacopoeias.)
Form. 70G. Tinctura Brucin-t..
R Brucins Pura gr. xij. ; Alcobolis (s. g. 837) f. 3 j.
Solve. ( 5 j. contains gr. jss. of Urucine. Dose
5ss.— §ij.)
Form. 707. Tinctura Calami.
R Calami Radicis contusi 5 iv.j Spiritus Tenuioria o ij.
Macera per dies quatuordecim, et per cliartam cola.
Form. 708. Tinctura Camphor.*: Thebaic.*:.
R Opii Pulveriz. 3 iij. ; Camphone 3vj.; Corticis Ca-
nelhc contus., Croci Stigmat., aa 3 ij ; Caryophyl
lorum, I'nlv. Capsici, ai 3 jss. ; Potassa? Sub-car-
bon. ~, ij. ; Olei Anisi 3jss. ; Spirit. ViniTeuuior.
(vel Sp. Vini Gallics, vel Sp. Vini Hollandia?),
O ij. Macera leni cum calore per dies viij. ad xij. ;
dein exprime et cola.
Form. 709. Tinctura Caryophyi.lorum.
R Caryopliyllorum contus. 5 iij.; Spirit. ViniTenuior.
O ij. Macera bene\ et cola.
Form. 710. Tinctura Cascarillje Alkalina.
R Corticis Cascarills cont. g iv.; Potassa; Sub-carbon.
Jss.; Spirit. Tenuior. Ibij. Macera bene, et cola.
Dosis 3J.— 3iij.
Form. 711. Tinctura Castorei Alkalina.
R Castorei contus. 3'U-: Potassa1 Sub-carbon. 3>'j- >
Croci StiL'in. " ij.; Spirit. Kosiiiarini tbij. Macera
per triduum, et cola. M. Dosis3ss. — jij;
Form. 712 Tinctura Centaurii Cacuminum.
R Centaurii Cacumin. (flowering tops of Centaury),
5 iij. ; Spiritus Tenuioria U ij. Digere per dies
quatuordecim, et cola.
Form. 713. Tinctura Cinchonin.* Sulphatis.
R Cinchonina- Sulphatis gr. xxxvj. ; Alcoholis Rect.
3 iij.; Solve. Dosis 3J- — 3'U-
Form. 714. Tinctura Conii.
R Conii Foliorum exsiccatorum gij.; Carriamomi Sem-
inum contusorum 3 ''j- > Spiritus Tenuioris O j.
Digere per dies septem, et per cliartam cola.
Form. 715. Tinctura Digitalis jEthehea.
R Fol. Digitalis exsic. et pulv. part. j. ; ."Ether. Sul-
phur, part. iv. Macera per triduum, et cola. (Do-
sis, TTJ xv. — \xx. ter die. (Several continental
Pharioacopcpias.)
Form. 7Hi. Tinctura Diosm.-e Crenata.
R Fol. Dlosmm Crenata! 5 U-i Spirit. Tenuioris ( I i. Ma-
cera per dies septem, et cola. (Dose 3j. — J iij.)
Form. 717. Tinctura Diuretica.
R Olei Juniper! ",ss.; /Etheris Nitrici, Tinctura- Dijri-
talis /F.therea?, aa 3 iij. M. (Dosis 3 ss- — 3J- ter
quaterve in die. IIufeland.)
Form. 718. Tinctura Ferri /Ether.t.a.
R Acidi Muriatic! J ij.; Acidi Nitrici dilut. ^ jss.; Ferri
RimatUrS. q. s. Dissolve the iron in Hi. RCids,
evaporate to dryness ; afterwards deliquesce the
residue by exposure to the air, and mix the <l <• 1 i -
quesced liquor with double its weight of Sulphuric
jEthcr: agitating the (fixture frequently until it
assumes a golden yellow color : then decant, and
add dou le the quantity of rectified tlr.ohol. This
Tincture may he used previous!) to the addition of
the Alcohol, or subsequently. In the Rtate of either
the dose i- from Ifi to 2 • drop; , in thai of /Elhe-
real Tincture, from 21 to 31 drops, [q diseases of
Debility, an I Spasmodic Vffeuions.
Form. 719. Tinctura Fructus Vanill.e.
R Fructus Vanill.e ciuicis. et contus. pars j.; Alroho-
lis part. vj. Macera leni cum calore per (lies octo,
etcola (.Nervine, Analeptic, Excitant, Jtc. Pfaff.)
Form. 720. Tinctura Cai.rani Composita.
R Galbanl Gummi Resins 5 jss.; Pimentn Baccarum
contus. 5j.; Cardamoml Semin. contus. Jss.; Bpir
it. Rectif. Oj. ; Aqua Destil. O ss. Macera dies
quatuordecim, et cola.
Form. 721. Tinctura Galls.
R Gallarum contus. J ij. ; Spirit. Tenuioris O ij. Ma-
cera per dies octo, et per cliartam cola.
Form. 722. Tinctura Iodin.<e Fortior.
R lodin.T ;.)ij. ; Spirit. Rectiflcat. 3 j. Solve, terendo
in vase vitreo. 3j. contains live grains of Iodine.
Dose njvj. — xxiv.
Form. 723. Tinctura Iodin.e Mitior.
R Iodina? gr. xxiv.; Spirit. Rectif. f. §j. Solve, teren-
do in vase vitreo. M. 3j. gr. iij.
Form. 721. Tinctura Lobeli.e Inflate.
R Ilerh. Lobelia? Inflata? exsic. 5 ij.; Spirit. Vini Ten.
Oj. Digere per dies decern, etcola. (Emetic in dos-
es of3j. to 3ij.; Antispasmodic in doses of rrjxx.
to 3ss.; and Diuretic in smaller quantities.)
Form. 725. Tinctura Myrrhje Alkalina.
R Myrrhsegj.; Potassa' Suh-carb. 3 vj.; Aqua? Ferven-
tisgiij. Tere ; dein macera in baineoaren. ad mel-
liscrassitud., et adde Spirit. Tenuior. 5X. Macera
bend, etcola. Capiat 3j.— 3ij. ex lnfus. Antliem-
idis. (In Scrofula, &c.)
Form. 72fi. Tinctura Nervosa. (Riemerii.)
R Spirit. Cornu Cervi Rect. part. iv. : adde gradatim
Alcohol. Rect. part, xvj.; Camphora? part, ij.; Olei
Junip. pars j. Solve.
Form. 727. Tinctura Nucis Vomica.
R Extract] Nucis Vomica? exsic. gr. iv.; Alcoholis (368)
f. 3J. Solve. (3j. Tinctura? ad gr. ss. Extracti.)
Form. 728. Tinctura Opii Camphorata. (Sive Elix-
ir Paregoricum Pharm Pristin.)
R Camphone 9ij.; Opii Orud. ill pulv., Acidi P.enzoici,
aa3j.; Olei Anisi 3ss., Potass. Sub-carbon. 3j. Om-
nia in mortario simul optima terentur ; paulatlm af-
funde Spiritus Tenuioris O ij. : stent in digestione
per dies decern : turn adde Radicis Glycyrrhiza? in-
cisa? 3'v-j digere iterum per dies septem, et cola.
Form. 729. Tinctura Orn Composita. (Vel Lauda-
num Liquidum Verum Sydenhamii.)
R Opii Puri contrit. % ij. ; Croci gj. ; Cort. Canella?,
< arv: pit', lloriim 5a§.JBS. ; Spirit Vini Rect 5iv'
Vini Hispan. tbj. Macera cum leni calore per dies
xvj.; dein exprime et cola. (TTfxv. equal to 1 grain
of pure Opium.)
Form. 730. Tinctura Phellandrii. (Marcus.)
R Semin. Phellandrii Aq.^ss.; Alcoholis 3 vj. Macera
per horas xxiv., et adde Vini Burgtindire 3 vj. Ma-
cera per dies tres, et cola. Capiat til x.— It. (In
chronic Bronchial, and Pulmonary Affections.)
Form. 731. Tinctura Ouinin* Sulphatis.
R ftuininre Sulphatis gr. viij.; Spiritus ViniSJ. M.
Fiat '1'inctura.
Form. 732. Tinctura Uuinin.e Sulphatis Acid.
R Ouininm Sulphatis gr. xlviij. ; Tinctura Aurantil
Comp. Jvss.j Acidi Sulphuric! Dilut. 3 ij. M. Fiat
Tinctura. (Dosis3ss. ad 3ij.)
Form. 733. Tinctura Rhatakub. (Sprague.)
R Rhatanire Radicis contus. 3 iij. ; Spiritus Tenuiorfs
OiJ. Dicere per dies oeto^et per cliartam cola.
This Tincture is strongly impregnated with the
medicinal virtues of the root. It is a very grate-
ful tonic, when given according to the following
formula : —
R lnfus. Rosa' "x. ; Acid. Pulph. Aromnt. HJaV. ;
Tinct. Rhataniie, Syrup. Rh(rados,ii3j. M. Fiat
haustus, ter in die iiauriendus.
XXVI
APPENDIX OF FORMULAE. — Tinctcra — Usguf.ntum.
Form. 731. Tinctura Khaianls Aromatica.
(Spragde.)
R Rhatani.T Radicis contuses 5 iij. ; Canells Corticis
contuss 5 U- ; SpiritGs Tenuioris O ij. Digeie per
dies decern, et per chartara cola. Tlie following is
an agreeable method of exhibiting this tincture : —
R Infus. Aurantii Compo.siti 5 vj.; Tincture Rhatanis
Aromat., Syrup. Zingibens, aa g j. Misce. Fiat
mistura; cnjus sninat cocli. unipl. iij. tcr in die,
urgente languore vel tlatu.
Form. 735 Tinctura Uhei Anisata.
R Radicis Rliei concis., Radicis Glycyrrhizs concis.,
aa^ij.; Seminiim Anisi contua., Sacchari Purif. aa
5J.; Spiritus Tenuioris octarios ij. Macera perdies
quatuordeciin, et cola.
Form. 736. Tinctura Riiodii.
R Riiodii Ligniras. Jiv.j Spiritus Rectificati Oj. Ma-
cera per dies quatuordeciin, et percliartam cola.
Form. 737. Tinctura Sabinje Alkali na.
R Olei Essent. Sabins 3ij. ; Tinct. Alkalius 5 vij. et
3ij. (F. 696.) Solve. Dosis TTJxx.— xxx.
Form. 73S. Tinctura Senna Amara.
R Fol. Senns part, vj.; Radicis Gentians concis. part.
iv.; Corticis Aurantii exsic. part. ij. ; Cardamom.
Semin. contus. part.j.; Spirit. Vini Ten. partes
xlv. Macera per dies quatuordeciin, et cola.
Form. 739. Tinctura Stramonii.
R Datura Stramonii Seminum contus. g ij. ; Spiritus
Tenuioris O j. Macera per dies quatuordeciin, et
cola.
Form. 740. Tinctura Strychnine.
R Strychninre Purs gr. ij.; Alcoliolis (sp. gr. 838.)
f 5j. Solve. Dosis TT) viij. ad xxx.
Form. 741. Tinctura Tadacci.
R Fo!. Nicot. Tabacci gij.; Alcoliol. Rect. 0 j. Mace-
ra per dies septem ; cxprime et cola.
Form. 742. Tinctura Taeacci Composita.
R Tabacci Foliorum concis. % ss.; Camphors rasa; Jij.;
Spirit. Hectif., Aqua? Destil., Sa §iv. Macera per
dies octo, et cola.
Form. 743. Trochiscus Catechu Extracti.
R Catechu Extract. Pulv. §iij.; Rinnamomi Corticis in
pulv. 3jss.; Olei Cinnainomi TT) v.; Sacchari Puri-
ficati?xiv. ; Mucil. Tragacanth (]. s. Fiat massa
in Trochiscos formanda. (Sprague.)
Form. 744. Trochiscus Ipecacuanha.
R Ipecacuanhas Radicis Pulv. 5 i v.; Sacchari Purifica-
ti ftij.; Mucil. Tragacanth. q. s. Misce secundum
arte n 1 ut fiat Troch. 480. (Each lozenge contains
half a grain of Ipecacuanha. In recent Coughs
and in Diarrhoea.
Form. 745. Trochiscus Lactuca.
R Extract. Lartucs Concentrat. (Prohart's), Extracti
Glycyrrhizffi, Pulv. Acac;s Ver., aa 3iv. Use opti-
ng terantur simul, et cum aquitiat massa, in Tro-
chiscos foruianda.
Form. 746. Trochisci Nitro-Camphorati.
R Extr. Opii sr. vij.; Camphors rass 2r. xxvj.; Pntas-
ss Nitratis 'Oijss. ; Sacchar. Purif. "iij.; Mueilag.
q. s. Misce bene, et divide in Tabnlas 1.; quarum
capiat vj. — x. per diem. (Chaussier.)
Form. 747. Trochiscus Potassa Nitratis.
R Potasss Nitratis Pulv. " iv.; Sacchari Purificati ft j.;
Ha?c optirne terantnr simul, et cum Mucil. Traga-
canth. fiat massa in Trochiscos formanda.
Form. 748. Tr.ncmscus Zinci Pulphatis.
R Zinci Snlnhntis Purif. "iv.: Sacchari Purificati ft ij.
Hsc optime terantur simul. et cum Mucil. Traga-
canth. fiat massa in Trochiscos formanda! (This
mass should he equally divided, so that each Io-
fcenge may contain gr. |of the Zinc.)
Form. 749. Unguentum Antimonii Tartarizati,
VEL I'EBRIFUGUM. (1.)
R Antimonii Tartarizati gr. xxv. Solve in Aquae Des-
til. q. s. ; deinadde Antimonii Tartarizati in pulv.
subtiss. redacti 5jss.; Adipis Prsparat. 3-x. Misce
bene, et fiat Unguentum. (Produces Phlogosis, and
its antimony is partially absorbed.)
Form. 750. Unguentum Antimonii Tartarizati. (2.)
R Antimonii Tartarizati in pulv. 3j.; Adipis Prspar-
at. 5J. ; Camphors rass et subact. 9j. ; Olei Caje-
putl IT) xv.; Moschi gr. iij. Misce bene.
Form. 751. Unguentum Antimonii Tartarizati. (3.)
R Antimonii Tartarizati 5 jss. ; Adipis Prsparati £ j. ;
Balsami Peruviani TT)xv. M,.
Form. 752. Unguentum Akgenti Nitratis.
R Argenti Nitratis Pulv. gr. xl. ; Adipis Prspar. § j.
Liq. Plumbi Acet. 5 ij. M. Fiat Unguentum.
Form. 753. Unguentum Balsami Perutiani.
R Balsami Peruviani, 3j.; Unguenti Elemi Comp. 5 vij.
Unguento balneo in aquoso liquefacto ; adjice Bal-
samuin Peruvianuin, et fiat Unguentum.
Form. 754. Unguentum Belladonna. (1.)
R Belladonna? Fol. recent. ; Adipis Prsparats, aa Jiv.
The leaves are to be bruised in a maible mortar;
after which the lard is to be added, and the two
incorporated by beating. They are then to be gen-
tly melted over the fire ; and after being strained
through a cloth, and the Belladonna well press-
ed, the ointment is to be stirred till quite cold.
(Sprague.)
Form. 755. Unguentum Belladonna. (Chaussier.)
(2.)
R Ext. Belladonna; 5 ij ; Aqua? Pestil. 5 jss. Terecum
Unguent. Simp., vel cum Axungia, 5 ijss. M.
Form. 756. Unguentum Calomelanoset Camphora.
R Calomelanos, Camphors, aa 9 j. ; Olei Caryoph.
TTJiv.; Unguent. Simp. 5 ij- M.
Form. 757. Unguentum Calomelanos cum Cam-
phora.
R Calomelanos 5 ij. ; Camphors g j. ; Unguent. Simp,
(vel Ung. Sambuci Flor.) 3 vj. M. Fiat Unguentum.
Form. 758. Unguentum Camphors Compositum.
R'Saponis Albi rasijjss.; Camphors rass 3 iij. ; Olei
Terebiiithins gss. Misce paulatim, et adde Am-
monisjj., M.
Form. 759. Unguentum Comitissa.
R Olei Piments, Olei Olivs, aa % ijss.; Cevs Flavre
%j. Solve, efadde Pulv. Piments 5 iij.; Pulv. Gal-
larum, Pulv. Nucis Cupressi, Pulv. Sem. Plantasi-
nis, Pulv. Fol. Toxicodend., aa 3 jss. ; Sulphatis
Alnminis 3j.; Camphors rass 3 j. Misce bene, et
sit Unguentum.
Form. 760. Unguentum Cippi Acetatis ; vuJgo,
Unguentum -■Eruginis.
R Cupri Acetatis, Hydrargyri Protochlorid. (Calomel. 1,
aa3j.; CeratiResius "J.; Terebiiithins Vulgaris
gss. Liquefac Resins Ceratum in balneo aquoso,
et Terebinth i nam adjice ; tunc Cupri Acetatem et
Hydrargyri Protochloridem (prius commistas) in-
sperge, et omnia misce.
Form. 761. Unguentum Reobstruens. (I.)
R Ammonis Muriatis pulverizat. 3 j. ; Unguenti Hy-
drarg. Fort. " j.; Kxtr. Cicuts 3jss. Misce bent, et
fiat Unguentum. (Dr. Hunefeld. Tumours, In-
durations, &c.)
Form. 762. Unguentum Deobstruens. (2.)
R Unguenti Hydrare. Fort. part. xciv. ; Ammonis
Muriatis pul veriz.. part. vj. Misce bend. (M. Du-
PUYTREN.)
Form. 763. Unguentum Gallx Opiatum.
R Gallarum in pulv. subtil. 3 iij. : Opii Crudi Pulvcr.
3j. Unguenti riuuibi Acetatis j,iij. M. Fiat Un-
guentum.
Form. 764. Un-oven-i M Raixje Opio-Camphoratum.
R Pulv. Nucis (Jallarum "i.-. Camphoraerasset subse-
ts in pauxillo Alcriholis v\j. : Pulv. Opii r"ri. Potas-
s:v Nitratis Pulveriz.. aa 3 ss. ; Adipis Pr.Tnaratae
- iij.-. > Hci Piments HI '.ii. — xyj. Misce bene, et sit
unguentum ter quaterve in die applicandum.
APPENDIX OF FORMULAE. — Unguentum — Vinum.
xxvu
Form. 7(V>. Unguentum HYro-ciiLORinis Sulphdkis.
li Sulpburis Hypo-chloridla ~,j.; Unguenti Simplicia
",j. Misce bene. (Lepra, Psoriaris, and other chro
nil- eruptions.)
Form. 766. OrgubhTUM IIvdriodatis Potass.*:.
R Potassaj HydriodatisSss.; Adipia Prsparatfe 5 jss.
Form. 767. Unguentum Iodine.
j! IoiIium gr. \i.j. ; PotasBte Hydriodatis 9 iv. ; Adipia
Bulllas recent, prrepar. Jij. M.
Form. 7G8. Unguentum Iodinje Opiatum.
r lodinii" gr. xv. ; Potasses Hydriodatia 3J-; Adipia
recent, prsp. ^ij. Misce bene, et adde Extr. Opii
gr. xxx.; 'Fnici. Opiijj. Sit unguentum.
Form. 769. Unguentum Iodureti Plumbi.
R Iodureti Plumbi 3 ij. — 3 "j- > Adipis Suil. recentis
pnepar. 5 ij- -Misce.
Form. 770. Unguentum Nervinum.
R Unguenti Althss (vel Ung. Sambuci) 5 iv. ; Liq.
Ammonia: Jj. ; Camphors, I'etrolei, Spirit. Tere-
binth., aa Jss. ; Olei Kosmarini 5 ij. ; Olei Berga
mothu^j. M. (Hufeland.)
Form. 771. Unguentum Fopuleum.
R Gemma), vel Occulor. Popnli Halsamifers, vel Ni-
gnecontus. Ibss.; liutrei recentis tbj. Liquefacsi-
11111I lento igne, vel in balneo arenario, et exprime.
Form. 772. Unguentum Populeum Compositum.
R Gemma; Popnli Bals. vel Nig. recentis ftjss. Con-
tnnile eum Adipis Prsparat. ftiij.,et adde Fol. re-
centis Hyoscyami Nigri, Fol. recentis Belladonna:,
uijiv. Contunde simul, et macera leni cum ca-
lore donee dispareat lmmiditas; dein exprime.
(All the German Pharmacopoeias.)
Form. 773. Unguentum ad Porriginem. (Chap-
man's.)
R Sulphuris Sublimati, Unguenti Picis Liquid.-?, aa
r;jss.; Saponis Mollis, Ammonin: Muriatis, aagss.
Misce. Fiat Unguentum.
Form. 774. Unguentum ad Porriginem Galeatam.
(Barter's.)
R Hydrarsryri Prntochlorid. (Calomel.) 3 ij.; Aluminis
Exsiccat., Plumbi Sub-carbonatis, aa jss. ; Tere-
binthins Venet. 5vj.; Cerati Cetacei §jss. Misce.
Fiat Unguentum.
Form. 775. Unguentum Proto-Iodureti Hydrar-
gvri.
No. 1. No. 2. No. 3.
R Proto-Iodureti Hydrarg. - 9ij. Qiij. 9iv.
Adipis Suills recent. - gij. g ij. §ij.
Misce.
Form. 77G. Unguentum Sulphurkti Iodin.e.
R Sulphuria Iodine gr. xv. — xxv. ; Axungisjj. M.
Form. 777. Unguentum Zinci Iodatis.
R Zinci Iodatis 3 j.j Adipis Prsparats 3 j. M.
Form. 778. Vinum Aloes Ai.kalinum.
R AloSsSocot., Croci Stigm., Myrrhs, ai §j. ; Pptas-
soi Sub-carbon, "jij.; vini Alb. Hispan. lb ij. Ma-
cera per dies xij. et cola. In dos. 3 ij. — 5 j. (In Py-
rosis, Dyspepsia, &.C.)
Form. 779. Vinum Aloes et Sod.e Compositum.
R Sods Sub-carbonatia Jiij. ; Ammonia: Carbonatis
givss. ; Myrrhs 3yj.; Aloe's Extract! 3VJ-; v'ni
Allii (Skerry, Anglice), t". gxxiv. Macera per dies
septem, et cola. (The dose is from one fluid
drachm to half a fluid ounce.)
Form. 780. Vinum Anthelminticum.
R Extr. Aloe's, Assafcetids, Radicis Gentians, Cam-
phors:, Corticis Aurantii sic, Castorei, aa 3J-; Cro-
ci Stig. V) j. ; Spirit. Vini Ten. lb iij. ; Vini Oporto
}b iij. ; Macera leni calori, et post boras xij. cola.
Capiat 3J- — 3 i'j- In Decocti Anthemid., «cc.
Form. 781. Vinum Diureticum Anti-arthriticum.
R Potasss Sub-carbon. 3 ijss. ; Pulv. Itbei, Juniperi
Baccar. cont., aa 3 Jss- ; Rad. Zedoarii concis. et
contus. 3'j- ; Canellta in pulv. 3 iij- i Scillas Rad.
exsic. 3j. : Vini Xeres 5 xxxij. Macera bene\ et
cola. 5J. — Jij. bis terve quotidie.
Form. 782. Vinum Ferri Citratum. (Pkar. Ifirtem.
et Niemann.)
R Ferri Limatune %iv.; Aurantia Amara, No. it. Ex-
corticatis Aurantiis, cortices et succulenta caro
fructuum cum Limatura Ferri in pastam redi-
gantur mortario in lapideo. Dies post tres infunde
Vini Madeirensis 5 xij. ; Tincturs Aurantii 3 ij-
Macera per diem integrum, et cola. Dosis 3ss. —
3jss.
Form. 783. Vini Ferri Comp.
R Sub-carbonatis Ferrigj-i vel Ferri Fragmentor.
§ iij. ; Radicis Calami Arom. § ij. Infunde Vini
Albi Hispanici lb ij., et stent in digestions per dies
6 — 8. Exindt* sumantur quotidie uncia una vel
dus, et suppleatur vinum.
Form. 784. Vinum Quinine.
R Vini Madeirensis 5 viij . ; Quinins Sulphatis gr. x\-j.
ADDENDA TO APPENDIX OF FORMULA.
Form. 785. Balsamum Odontalgicum.
R Opii Puri, Camphors rasa>, aa £)j. : solve in Spirit.
Rect. Terebinth. 3jss.; Olei Caryoph. et 01. Caje-
putiaa3ss. ; Balsam. Peruvian. 3 ij. Misce bene.
Form. 786. Bolus Camphor* Compo3itus.
R Camphors er. v.— xv. ; Hydrarg. Submur. gr. v
xx.; Opii Puri gr. j.— iij.;' Conserv. Rosarum q. s.
ut fiat Bolus.
Form. 787. Bolus (Jamphor.*: et Hyoscyami.
R Camphors Subnets gr. v — xij.; Extract. Hyoscyami
gr. 9. — x.; Potasss Nitratis gr. v.— viij.; Conserv.
Boe&r. q.fl. M. Fiat Bolus, horlsomni sumendus.
(In Puerperal Mania, and in Mania after evacua-
tions, and accompanied with cold sponging the
head.)
Form. 788. Bolus Catechu.
R Catechu Extr. gr. viij.— xij. ; Confect. Aromat. gr.
viij. Syrup, q. s. M. Fiat Bolus.
Form. 789. Bolus Moschi et Camthor^e.
R Moschi gr. v. — x. ; Camphors rass gr. iij. — viij. ;
Spirit. Rect. TT) j. ; Confect. Ros. Gall. q. s. Cam-
phoram cum Spiritu tere, et deinde, secundum ar-
tem, fiat Bolus.
Form. 790. Electuarium Deobstruens.
R Potasss Stiprrtart. ^j.; Snb-boracis Sods 3 iij.; Sul-
phur. Prcecipit. 5vj.;ConfectionisSenns5Jss.; Sy-
rup. Zingiberis gyj. ; Syrup. Papaveris 3 "j- M.
Fiat Electuarium, enjus capiat cochlearia duo min-
ima oiuni nocte.
XXVI 11
ADDENDA TO APPENDIX. — Electuarium — Haustus.
Form. 701. Electuarium Ferri Sub-carb.
R Ferri Subcarbonatis, Syrupi Zingiberis, aa 3 ss. ;
Confectionis Aurantiorum 5 ij. M. Fiat Electu-
arium, de quo capiatur moles nucis moschats bis
vel terquotidie.
Form. 792. Emplastrum Antimonii Tartariz.
R Emplast. Picis Comp. quantum veils ; Super Alu-
talu extende, et Antimon. Tartar, pulvere leviter
insperge. Fiat Emplastrum.
Form. 703. Emplastrum Picis et Petrolei.
R Picis Liquids 5 ij.; Galbani gj.; Sulphuris, Succini,
aa 3 ij. ; Semin. Cumini cont., Pulv. Flor. Anthe-
midis, aa 5 jss.; Petrolei 3 ss. Liquefac. Galbanum
cum Aceti q.*., eumque misce cum Pice liquida ;
dein adde alia, et misce bene.
Form. 704. Enema Commune.
R Sods Muriatis 3 vj.— gj.; Decocti Avensgx.; Olei
Linigjss.— gijss. M. Fiat Enema.
Form. 795. Enema Ipecacuanha.
R Rad. Ipecacuanhas Contrite 3 j. ; Aqus Ferventis
5X. Macera per horim et fiat Enema.
Form. 79G. Fotus Conii.
R Conii Folior. exsic. § j. Coque ex aqua; Oijss. ad
Oij., et cola.
Form, 797. Gargarisma Capsici.
R Capsici Baccarum contus. gr. xv.; Aquas ferventis
gix. Infunde per boras ties, et cola.
R Liquoris Colati 5 vijss. ; Acidi Muriatici TTLxxv. ad
ft] xxxv.; Tinct. Myrrhs 3 iijss. ; Mellis Ross gss.
M. Fiat Gargarisma. (The Borax Sods, Extractum
Catechu, or any other astringent, may be substi-
tuted, according to circumstances, in the place of
the Muriatic Acid.)
Form. 798. Gargarisma Cum Chlorureto Sod.e.
R Liquoris Chloro-Sodaici (Labarraquii) 3xij.; Aqus
Destillat. 5 vj.; Mellis §ss. M. Fiat Gargarisma
sspe utendum.
Form. 799. Gargarisma Stimulans.
R Infusi Petal. Ross Gallics 5 vjss ; Acidi Muriatici
Diluti $ij.; Tinct. Capsici 3jss.; Mellisjiij. Fiat
Gargarisma sspe utendum.
Form. 800. Gargarisma Zinci Sulphatis.
R Zinci Sulphatis 3j.; Aqus Ross fgvij.; Oxymellis
Simpl. f 3J. M. Fiat Gargarisma frequenter uten-
dum.
Form. 801. Guttje JEthereje.
R Camphors rass 3 j. ; Spiritus ^Ether. Nit. f gss. ;
Tinct. Valerians f 5 i j . ; Aqus Fontans 3 jss. M.
Capiat 3 ss. ad 31J. pro dosi.
Form. 802. Gutt.e jEtheris Aesinthii.
R Olei TEther. Absinthii 3ss.; Spirit. yEther. Sulphuri-
ci, et Spirit. Vin. Red., aa 3 ij.' M. Sumat sger gut.
xx.— xxx. omni hora, aut omni bi aut trihorio.
Form. 803. Gutt.e Antispasmodics
R Spirit. Ammon. Snccin. 5vj.; .Ether. Sulphur, gj.;
Olei Anthemidis 3j.; Tinct. Opu Comp. 3 ij.; Extr.
Papaveris Albi3j. M. Capiat Tt] xx.— xlv. in cya-
tho Infus. Anthemidis, vel Infus. Flor. Sambuci,
vel Decoct. Hordei Comp., &c. (Grimaud.)
Form. 804. Gutt.e Odontalgics.
R Opii Puri et Camphors aa gr. x. Solve in ppuxillo
Alcoholis, et adde Olei Caryophil. Jj. ; Olei Caje-
puti3j. Misoe bene\
Form. 805. Haustus Acidi Oxtmuriatis.
R Aridi Oxymuriatis Fluid. 3 ss. ; Aqus Destillat.
gxij.; Syrup. Papaveris Albi3ss. M. Fiat Haus-
tus 5tis vel Ctis horis sumendus.
Form. 800. Haustus Arsenicalis.
R Confectionis Aromatica; V)j.; Aqus Menths Satiys
f 5 j. ; Tincturs Opii, Liquoris Arsenicalis, aa
ITfvj. M. Fiat Haustus, terquotidie sumendus.
Form. 807. Haustus Balsami Peruvian!.
R Balsami Peruvian) IT) v. ad V)j.; Mucilaginis Acacia;
3jss. Teresimul; et adde, Mist. Camphors 3 vj.;
Spiritus Anisi 3 jgs. ; Aqus Anethi (vel Aq. Cin-
nam.j gss Fiat Haustus, ter qualerve de die ca-
piendus.
Form. 808. Haustus Belladonnje et Cincho.nje.
R Decocti Cinchons 3xiv.; Extracti Cinchona gr. x.;
Tincturs Belladonns ITJxx. (See F. 704.) ; Tinc-
turs Aurantiorum 3jss. M. Ft. Haustus, ter in die
capiendus.
Form. 809. Haustus Diaphoreticus.
R Vini Ipecacuanha;, Vini Antimonii Tartarizati, aa
TT|x.; Liq. Amnion. Acet. Sijss.; Mist. Camphors
gj.; Tinct. Hvoscvami TT|xxv.; Spirit. -Ether. Nit.
3ss.; Syrup. Aurantii3j. M. Fiat Haustus, quar-
tis horis capiendus.
Form. 810. Haustus Emmenagogus.
R Decocti Aloes Comp. gj. ; Sub-boratis Sods 3j.;
Tinct. Aloes Comp. gj.; Tinct. Castorei 3j.; Tinct.
Croci 3 ss. ; Aqus Cinnain. 3 ij. Fiat Haustus
omni nocte sumendus.
Form. 811. Haustus Hvoscvami et Anisi.
R Extracti Hyoscyami gr. iij.— v.; Tinct. SeillsTT]x.—
xij.; Spirit. Anisi 3jss. ; Aqus Anisi g jss.; Acidi
NitriciTT) viij. Fiat Haustus, horis tertiis vel quar-
tis durante paroxysmo Dyspnces, &c. capiendus.
Form. 812. Haustus Nervinus.
R Spirit. Ammon. Fo?tid., Spirit. Colchici Ammonia-
ti, Spir. Aether. Nit.,aa 3 ss. ; Liquor. Ammonia*
Acet. 3 ij. ; Mist. Camphors Jj. ; Syrup. Croci 3j.
M. Fiat Haustus, bis terve in die sumendus.
Form. 813. Haustus Pectorai.is.
R Balsam. Peruvian, (vel Bals. Tolutan.)3ss.— 3 s?.;
Olei Anisi TT)v.— x.; Extr. Conii gr. iij.— vj.; Mu-
cilag. Gummi Acacia: 3ij. ; Aqus Piments et Aq.
Foeniculi aa gss. M.
Form. 814. Haustus Quassia et Ferri.
R Tincturs Ferri Muriatis Trjvj.—xij. ; Infusi Quas-
sis,Aqus Cinnam., aaf 3vj.; Tincturs Calnmbas
f Jj. M. Fiat Haustus, mane et meridie sumendus.
Form. 815. Haustus Salinus.
R Potasss Sub-carbonatis J-)j.; Succi Limonum recen-
tis f. 3ss.; Misturs Camphors f 3 j.; Potasss Ni-
tratis gr. x. ; Syrupi Rhaados f3j. M. Fiat
Haustus, quarts quaque bora sumendus.
Form. 816. Haustus Salinus Aromaticus.
R Potasss Subcarbonatis $ j.; Succi Limonum recen-
tis f g ss. vel q. s._; Aqus f 5 j.; Spirit. Myristics,
Syrupi Auiantii, aa f 3J. M.
Form. 817. Haustus Salinus Demulcens.
R Mist. Amygdal. Dulc, Mist. Camph., aagss.; Vini
Ipecac. TTJx. ; Potasss Carbonatis gr. xv. ; Syrup.
Scills3j. M. Sumatur cum Succi Limonis coch.
uno amplo, in erfervescentis impetu ipso.
Form. 818. Haustus Salinus Sedativus.
R Potasss Nitratis gr. vj.— xv.; Sods Sub-carbon, gr.
x _3jss.; Tinct.' Hvoscvami 5 ss. (vel Tinct. Cam-
phors Comp. pristin". 3j.); Mist. Camphors, Aqus
Menth. Virid.,aa3vi. Syrup. CrociSss. M. Fiat
Haustus teitiis vel quartis horis sumendus.
Form. 810. Haustus Setjativus.
R Ammonis Carbonatis gr. xv. ; Aqus Destillat. gj. ;
Spirit. Myristics 3J.; Syrup. Aurantii gss.; Extr.
Conii "r.'iij.— vj. Fiat Haustus, ter quaterve quo-
tidie sumendus, cum Succi Limonis recentis coch-
leare uno magno, in eflervescentis impetu.
Form. 820. Haustus Sedativus ccm Magnesia.
Tl Macnes. Sub-carb. 3 ss.; Aqus Mentl1.Virid.3xj. ;
Spirit. Anisi 3 jss. ; Olei Caryoph. TTJ j. ; Syrup.
Zingib. 3ss. M. Fiat Haustus.
Form. S21 Haustus Sedativus et Refrigerans.
r Potasss Nitratis 2r. x. ; Tinct. Opii iTf vj. ; Syrup.
Papav. Alb. 3ij.; Mist. Camphors ~x. Misce. Fiat
Haustus, omni Ota hora suniendus.
ADDENDA TO APPENDIX. — Had stus — MibtuiU.
XXIX
Form. BS8, Iliisirs 'r.iMcrs Ai.kai.inus.
R Potassa Carbonatis ;■) j.; Infus. Gentiana Compos.,
Aqua Pimontre, 5£f 3 vj.; Tinctur. Rhasi f~.i. M.
Fiat Haustus, meridie et bora Bomnl Bumendus.
Form. 893. [npueuM Aroelics Sylvestris.
r Radicia Angelic. Sylvest., Calam. Aromatici, S3
~ iij.: i ii i°n rule ciini \qu«e Font. Ferventis J vj. Stent
per horam in vase clauso; cola, el adde Liquoris
Aiamonio Acetat. 5Jss>i dEtherls Sulphur, 3jss.;
Syrup. Cort. Aurantii "iij. M. Fiat Mist. I a
l)i.it a'ger qullibet bora cochlear, uiuim.
Form. 894. Infvsum Amsi Compobitum.
r Seminum Amsi ~ jss. ; Folior Melissa Officinalis
~ j. ; Aqua Communis calida tt, ij. Infunde per
quadrantem bora: cola; et adde Sacchari Albi,
quantum libet.
Form. 825. Infusum Galls.
R Gallarum contus. j ij.; Aqua; Ferventis lb j. Macera
per boras, viginti quatuor, et cola.
Form. 826. Infus. Serpentari.k.
R EadicisSerpentaria?3'Ut.! infunde cum Aquie Fer-
ventis j viij., ebiill. paul. Cola, et adde /Ether.
Sulphur, "ij. ; Tinct. Camphoree 5 j- M. Capiat
jeger qualibet bora cochleare uuum.
Form. 827. Infusum Turionum Pini Abietis.
R Turion. Pini Abietis ",iij.: infunde Aq. Fervidns Jx.
per semi-bor.; dein exprime, cola, et adde vel Po-
tassa Sub-carb., vel Potassa Sulphatem, vel Spir.
.Ether. Nit., vel Sp. Junip. Comp., ut sit occasio.
Form. 828. I.njectio Astringens.
R QuercQs Cort. cont. " vj. ; Aqua: Destil.Jx. Coque
jpr- r partem bora; sextain, et cola.
R Colaturajjiv.; Infus. Lini Jiv. ; Extr. Conii 3 jss. ;
Sub boracis Sodas 3J- AJ.
Form. 829. Linctus cum Ipecacuanha.
R Olei Amygdalarum, Syrupi Limonum, sing, f 5 j. ;
Pulveris Ipecacuanha lt. vj.; Confectionis Rosie
Oanina Jj.; Pulv. Tragacantha Comp. 3 iij. Alisce.
Cochleare minimum subiiule deglutiatur.
Form. 830. Linctus Refrigerans.
R Pulpm Tamarindorum, Syrup. Althnsas, aajij. ; Po-
tassa Supertart. 3 jjss.; Potassas Nitratis 3 jss. M.
Sutnat oiiini trilRino duo cochlearia parva.
Form. 831. Linctus Terebinthin.i:.
R Olei Terebinth. ~ ij — J j. ; Mellis Despumati J j.
Jijss. ; Pulv. Radicis Glycyrrh. q. s. ut fiat Linc-
tus : de quo sumatur cochleare parvum vel medium,
nocte, mane, meridieque.
Form. £32. Ljnimentum Opiatum.
R Tinct. Opii Comp. Jss.; Camphorffi ~, ij.; Olei Amyg-
dal.Dulc.Jij. AI. Bit Liniiuentuin.
Form. 833. Lotio Acidi Hydrocyanici.
R Acidi Hydrocyanic! 3 ij. — Plumhi Acetntis, ar. jtvi.;
Aquas Destili. ", vijss.; Spirit. Yin. Rect. 3 ij. Fiat
Lotio, parte aifecta' applicatura. (Thompson, in
Cutaneous Eruptions.)
Form. 834. Lotio Acidi Nitro-AIuriatici.
R Acidi Nitro Mnriatici Diluti (!•'. 5.) 3 ij. — Jss.;
Aqua Calida J xvj. AI. Fiat I.otio, quamprimum
pneparata sit, ope spongias, utenda.
Form. 835. AIistura Alkali ha Anodyna.
R Bods Carbonatla 9 j. (vel Potassa Carb. gr. xvj.) g
Histura Amygdalarum t'Ji-s.; Tinct. Hyoscyami
Trj tx. — "ss. ; Tinctur. Cardam. compos. f 3ss.
Fiat Haustus, bis vel ter die sumendus.
C2
Form. 836. Miitcra Ammoniaci et Conii.
\l Acidi x 11 ii<- j - j. ; Aqua Pulegiijiv, Misce; dein
tere cum Am nun 1 5 j., 1 1 adde Extr. Conitgss.'
Syrup. Tolutan. gas. M. Capiat cocb. uuum in
decoct. Althae, ice.
Form. MIT. Mhtiiia Anohy.na.
i; Aqua Menth. Virid.Jvjss.; Potassa Nitratis 9 ij.;
Spirit. .Ltheris Nit. -ij.; Tinct. Hyofcyami 3jss. ;
Bucci [nspissati Samb. Nig. 3jss.; Extracti Tarax-
aci, Syrup. Aurantii, a5 " ij. ,M. Fiat Mist, cujus
capiat cochlearia duo larga ter quotidie.
Form. 838. AIistura Anti-Cardialgiam.
R Magnesia 3j. ; Aqua Anethi 5 ivss.; Potassa Ni-
tratis-jss. ; Liqudr. Potassa 3 j-i Tinct. Calumba
3 ij. ; Spirit. I 'ami et Spirit. Amsi aa " i jss.; Spirit.
Lavand. I lomp. "",.!.; Sj rup. Zingiberis 3 ij- Misce.
Capiat cochleare uuum aiupliim suliinile in cyatho
Decoct. Hordei Comp., prius agitata pliiala.
Form. 839. AIistura Antidysenterica. (1.)
R Oilier. Sulphuric! 3 ij.; Tinct. Opii Comp 3 iij.;
Sacchar. Aih. Jss.; Gum. Acacias 3 08S- j Olei An-
themidis 171 xv. ; Extr. Humuli 5 J8S. ; Extr. Cate-
chu V) j. ; Pulv. Canella Cort. 3j%i Aqua; Menth.
Virid. 5 vjss. Misce bene. Capiat cochlearia dua
tertiis vel quartis horis.
Form. 840. AIistura Antidysenterica. (2.)
R Alist. Camphora J v-; Liq. Amnion. Acet. g ij.; Spir-
it. /Ether. Nit, " ijss. ; Vini Ipecacuanha; 3ijss. ;
Tinct. Humuli 3'USS- \ Extr. Humuli JJj. ; Syrup.
Papaveris 3 iij. M. Fiat Mist., cujus capiat coch-
learia duo larga tertia quuque bora.
Form. 841. AIistura Anti-Icterica.
R Potassie Acetat., Extract. Taraxaci, aa % ss. ; Extr.
Conii gr. x. — xx. ; Aqua; Funiculi 5 vjss. ; Syrup.
Sarsre et Syrup. Senna; aa 5 ss. Al. Capiat cochlear,
jj. vel iij. ampla 4tis horis.
Form. 842. AIistura Assafcetid.e et Conii.
R Assafcetidas ~ ij.: solve in Liquoris Ammonias Acet.
% jss. Aquie FcBiiituli % iijso ; Extr. Canii 9 j. —
3 ss.; Syrup. Senegas 5 ss. Alisce.
Form. 843. AIistura Bals. Peruviani Comp.
R Balsami Peruviani Ver. 5U-; Alell is Despumati 3 vj.
Alisce, et adde gradatim, Alisturas Alyrrhas (F.422.)
^vj.; Tincturas Aurantii J j. Alisce. Fiat Alistura,
cujus capiat cocb. j. ad iij. ter quaterve in die.
Form. 844. AIistura Belladonnje.
R Extracti Fol. Belladonnas gr. ij. adiv.; Aloscbi opti
ini gr. vj. ad xij. ; Sacchari Albi, satis quantum ut
terendo obtineatur pulvis congener: deinde adde,
paulatim miscendo, Int'usi frigidi Rad. Valeriana
^iv ; Spirit. /Ether. Sulphur. 3 j-! Syrup. Papave-
ris^ iij. AI. Capiat icger cochlear, ij. vel iij. lar-
ga 3tiis, 5tis, vel Otis horis.
Form. 845. AIistura Camphor.e Ammoniata.
R Camphoras Y) }.; Alcoholis TTJvj.: tere, et adde Mos-
chi"ss.: tere cum Sacchar. Albi ^ j. ; Alist. Amyg-
dal. Dulc. s iv.; Spirit. Amnion. Arom. ^ ij.; Syrup.
Aurantiar. §ss. AI. Capiat §ss. — Jj. 4tis horis.
Form. 846. AIistura Cardiaca.
H Potassie Carhonatis 3 jss- > Alisturas Camphoras
fgvss ; Confectionis Aromaticas 3ij.; Spirit us .My
ristica' f Jss. AI. Fiat AIistura, cujus suinaturcoch-
learia tria ampla cum cochleare nno Succi Limo-
num recentis, in actu effervescentias.
Form. 847. AIistura Chloridis Potass.e et Sod.e.
R Liq. Cblor. Sodas Jss.; Aquas Deatil.giv. ; Potassa
Cblorid. ^,j. ; Aquas Pimenta Jiijss. AI. Capiat
coch. j. — iij. 2dis, 3tiis, vel 4tis lioris.
Form. 848. AIistura Cinchona ciim Acido.
R Infus. Cinchona' Jvij.; Acidi Mnriatici Diluti 3j->
Tinct. Capsici "ss.; Tinct. Crocf, vel Serpentarias,
3iij.; Syrup. Papaveris 3 Uss, M. Flat Mist, cujus
capiat coch. ij. vel iij. ampla, 4tl q. q. borl.
Form. 849. AIistura Cinchona: et Acidi Sulph.
\l Decoctl Cinchona " vss.; Acidi Sulphur. Aromat.
-j.: Tinct. Opii TI) XXX. Al. Capiat tertiam partem
ter quotidie.
XXX
ADDENDA TO APPENDIX. — Mistura — Piltjlje.
Form. 850. Mistura Copaib.t..
R Copaibs \'<t. 3 iij. ; Mucilaginis Acacia Ver. gjss.
Misce. Addegradat. Aqus Cinnamonri § iijss.; So-
ds Sub-carbonatis 3 j. ; Spiritiis Lavandula Com-
jmsitre 5 ij. TincturtB Opii 3 j. ad 5 JSB. Misce. Fiat
Mistura, cujus capiat unc. j. ter quaterve in die,
agitat. phial.
Form. 85!. Mistura Ctdoni.'e Infusi Comp.
R Seminum Gydonia contus. 3ij ; Radicis Glycyrrhizs
contus. 5 j. ; 1'ici Caries Fructus 5 j. : Aqua; O j.
Coque leni igne per minula hora decern : dein cola.
Hujus Decocti 5 vjss. Potasss Supertart. 3 ij. Sub-
boratia Bods 3j. j Spirit. .-Ether. Nit. 3 ij. ; Syrup.
Mori vel Syr. Limonisgss. M. Fiat Mist.
Form. 852. Mistura Decocti Cinchon.e.
R Decocti Cinchona 3 vss. ; Tinct. Cinchona 3 iij. ;
Confect. Arom. 9jss.; Spirit. Amnion. Aroin. 3jss.
M.
Form. 853. Mistura Decocti Genista.
R Spartii Scop. Cacumin. 5 j. ; Aqua? O j. coque ad
3 viij., et adde Acetatis Potassa 3 ijss. Spirit. Ju-
nip. Comp. 3 vj. M. Capiat Coch. ij. vel iij. larga,
ter quotidie.
Form. 854. Mistura Diaphoretica.
R Vini Ipecacuanha 3jss. ; Spirit. jEther. Nit. 3'jss.;
Liq. Amnion. Acet. 5 ij.; Liq. Antimon. Tart. 3jss.;
Mist. Camphora 5 ivss.; Syrup. Papaveris3iij. M.
Capiat cochlear, j. vel ij. tertia quaque hora.
Form. 855. Mistura Diaphoretica Anodyna.
R Mist. Superscript. (F. 854.) 5 vijss.; Tinct. Hyoscy-
ami 5 jss. (vel Tinct. Camphora Comp. 3 vj., vel
Extr. Conii 3 ss.) Fiat Mist.
Form. 856. Mistura cum Digitale et Kekm. Miner.
R Kermes Mineral.gr. vj.; Mucilag. Acacia 3 i i j - ; In-
fus. Digitalis 5 iv.; Syrup. Althaa §j. M. Capiat
cochleare nnuin amp. omni bihorio. (In Pneumo-
nia, Pleurisy, &x. by Brera.)
Form. 857. Mistura Expectorans.
R Assafcetid.3ijss.: trituratione solve in Aqua Menth.
Virid. 3ivss.; et adde Vini Ipecacuanha 3 j.; Spir-
it. JEther. Nit. 3 ij..; Tinct. Castorei 3 ij. ; Syrup.
Tolutan. §j. Fiat Mist, cujus capiat cochleare
unuin ainplum 2dis vel 3tiis horis.
Form. 858. Mistura cum Hydriodate Potassje et
Acido Prussico.
R Aqua Destil. 3 ivss. ; Solutio Hydriodatis Potassa
TT] xv. ; Acidi Prussici Medicin. TT) x — xij. ; Succi
Inspissati Lactucs gr. xij.; Syrup. Altliaa",j. M.
Capiat 3 ij. — 3 iij- omni hora, velgss. omni bihorio.
Form. 859. Mistura contra Htdropem.
R Fol. Digitalis 3 j. ; Corticis Cinchona Pulv. 3 vj. ;
Aqua Ferventisgxij. Macera per horain, et cola.
Liquori colati adde Potassa Supertart. 3 iij. ; Sub-
boratisSoda 3j. ; Tinct. Cinnam. Co.; Spirit. Ju-
nip. Co., aa3iij. ; Tinct. Opii Co. TT)xxv. M. Ca-
piat cochlearia duo larga ter quaterve quotidie.
(Nearly as Augustin.)
Form. 860. Mistura Infusi Anthemidis Comp.
R Flor. Anthemidis 5 ij. j Pulv. Rad. Valerian. 3 iij.;
infunde Aqua Fontan. calida 5 viij. Macera pau-
lisper, et cola.
R Hujus Infusi 3 vij.; Tinct. Camphora Comp., Tinct.
Castorei, aa. 3U-; Syrup. Aurantii 53s. M. Capiat
ager qullibet hora. cochleare plenum.
Form. 861. Mistura Infusi Calumbje et Hyoscyami.
R Infus. Calumba 5 vijss.; Tinct. Hyoscyami 5U-; So-
da Sub-carbon. 3jss.; Tinct. Aurant. Comp. 3 ijss.;
M. Jss. ter quaterve in die. (In diseases of Irri-
tability.)
Form. 862. .^Mistura Infusi Calumb-E Comp.
R Infus. Calamba g iv. ; Aqua Mentha Piper, vel
Aqua AnethiS iij-.; Spirit. Anisi 3 ij.; Liquor. Am-
monia vel -Liquor. Potassa 9 ij. j Syrup. Cort.
Aurantii 3 ss. M.
Form. 863. Mistura Infusi Valerianae.
R Infus. Valeriana 3 vss.; Liq. Ammonia Acet. gjss.;
Liq. Antimonii Tart. 3 Jss- ; Tinct. Hyoscyami
"jss. ; Aq. Pimenta gss. ; M. Fiat Mist, cujus
capiat ager altera quaque hora cochlearia duo.
Form. 864. Mistura Muriatis Ammonite.
R Ammonia Muriat. 3jss. ; Acidi Muriatici 3ss. ; De-
cocti Hordei Comp. tb j. M. Capiat cochlear, iij.
ampla 2dis vel 3tiis horis.
Form. 865. Mistura Salina Sedativa.
R Potussa Nitratis, 3ss. — 3ij.; Soda Sub-carbon. 3J.
— 3 ijss. Mist. Camphora, Aqua Menth. Virid., aa
5 iijss.; Extr. Humuli ^ij.; Syrup. Zinpeberis 3 iij-
M. Fiat Mist, (Inteidum adde Tinct. Hyoscia-
nii, vel Tinct. Camphora Co.)
Form. 866. Mistura Sedativa.
R Mucilaginis Acacia f 5 j.; Olei Amygdalarum, Syrup.
Papaveris Albi, aa f 3 ss.; Tinct. Hyoscyami f 3 jss.;
Vini Ipecacuanha f 3 i j - j Aqua Destillata fgvss. ;
Acidi Citrici q. s. ad gratam acidulat. Misce. Fiat
Mist, cujus sumat coch. unum medium subinde.
Form. 867. Mistura cum Soda Sub-borate.
R Mist. Camphora, Aq. Anethi, aa 3 ijss.; Sub-boratis
Soda 9 ij.; Vini Ipecacuanha 3Jss-> Syrup. Papa-
veris 3jss. M. Fiat Mist, cujus capiat cochlearia ij.
vel iij. quartis horis.
Form. 868. Mistura cum Soda Tartarizata.
R Soda Tartarizata Pulver. 3 vj.; Mistura Amygdala
fgvss.; Spiritus Myristica fgss. M. Sumatter-
tiam partem secunda quaque bora.
Form. 869. Mistura Stomachica. (1.)
R Calumba Radicis contusa 3 ss. ; Calami Aromatici
cont. 9 j.; Capsici Annui Bac. cont. gr. x.; Aqua
Ferventis f gviij. Macera per horasduas ; deinde
cola.
R Liquoris Colatura 3 vss.; Liquoris Potassa Snbcar-
bon. 3ijss.; Tinct. Myrrhs 3j. ; Extract. Conii gr.
xv.; Syrup. Cort. Aurantii 3 ij. M.
Form. 870. Mistura Stomachica. (2.)
R Infus. Cascarilla 3vij. ; Soda Sub-carbon. 3 ijss. :
Tinct. Calumba 3 ss.; jEther. Sulphur. 3 ij.; Tinct.
Aurantii Co. 5 iij. M. Fiat Mist., cujus capiat
cochlear, ij. larga bis quotidie.
Form. 871. Mistura contra Tenesmum.
R Mist. Camphora § v. ; Liq. Ammon. Acet. g ij. ;
Tinct. Hamuli 3 ijss.; Tinct. Camphora Com. Jss.;
Extr. Humuli 3 ss.; Syrup. Papaveris 5 iij. M. Fiat
Mist., cujus capiat cochlearia duo larga tertia qui-
-que hora.
Form. 872. Mistura Tonico-Aperiens.
R Decocti Cinchona, Infus. Senna, 5a 3 iijss.; Potasss
Sulphatis 3 iijss.; Tinct. Senna gss. M. Fiat Mist,
cujus capiat cochlear, iij. larga bis quotidie.
Form. 873. Mistura Tonico-Deobstruens.
R Extr. TaraxaciSiij.; Extr. Gentiana3j.; Soda Sub-
carbon. 3j. ; Aqua Aurantii 3 vij. ; Spirit. JEther.
Sulph. Co., Syrup. Rosa, aagss. M. Capiat 3 j.
— § jss., ter die.
Form. 874. Mistura Zinci Composita.
R ZinciSulphatis gr. iv. ad vj.; Infus. Rosarum Comp.
gvij.; Vini Ipecacuanha 3jss.; Extr. Lactuca3jss.;
Syrup. Tolutan. 3 i j . M. Fiat Mist, cujus capiat
cochleare unum vel duo larga tertiis vel quartis
horis.
Form. 875. Mistura Zinci Opiate.
R Aq. Rosarum, Aq.Cinnamom., aa 5 iijss.; Zinci Sul-
phatisgr. vij.; Tinct. OpiiTTlxxxvj.; Tinct. Cinna-
mom. Co. 3 ij. ; Syrup. Aurantii 5 jss. M. Fiat
Mist, cujus capiat cochlearia ij. ampla bis did.
Form. 876. Pilule Alkaline Anodynje.
R Soda Sub-carbon, exsic. 3j. ; Saponis Duri 5j.; Ex-
tracti Hyoscyami 3 ss.; Olei Junip. q. s. M. Fiant
Pilula x'l., quarum capiat binas vel tres omni noc-
te. (Nephritic and Calculous Affections.)
Form. 877. Pilul-e Aloes cum Ferro Composite.
R Aloe's 5 ij. ; Assafcetida et Myrrha, aa3 ss. ; Ferri
£plphatis3j.; Caryophyllorum in pulv. 9 j.; Pulv.
Capsici cr. xxvj. ; Bals. Canad. q. s. M. Fiant
Pilula lxvj., quarum capiat binas vel tres pro dosp.
(Chlorosis, &c.)
Form. 878. Pilul.*: Anodtk.c.
R Ehlv. Jacobi Veri gr. iij. ; Extr. Stramonii er. ss.:
"Ext. Hvoscvami (vel Conii) gr. iij. Fiant Pilula ij.
hor;\ sonini sumenda. „(In painful Cutaneous
Eruptions.)
ADDENDA TO APPENDIX. — P. lclje.
Forill.879. PlI.IL.V .\NOnYNO-Al.TERATIV.i:.
R CainphOra ras:r ;:r. vj.; Hydrarg. mm Cret.i «r. xij.;
Bods Sub carbon, exsic. gr. \. ; Pulv. Acacis e.r.
iv.; Extr. Hyoscyami gr. iv.; Syr. Simp. q. a. M.
Plant Piluloe xij., quarum capiat tres station, et
borft somni.
Form. 880. Pilul.k Aperientes.
R Pulv. Radicis Rhei -ss.; Extractl Aloes Aquosi ar.
wiij.; Saponis Medicati " ss. ; Syrup. Simp. q. s.
M. riant Piluls xx., quarum sumaatur bins vel
tics, bis in die.
Form. 881. Pilul.e Aperientes cum IIyoscyamo.
R Extract. Gentians Jss.; Extract. Colocynth. Comp.
►) ijss. ; Pulv. ipecacuanha; sir. viij. ; I'ilul. Hy-
drarg. 5j.; Extr. Hyoscyami })ij-; Saponis Castil.
gr. xij. M. Fiat inassa eequalis, et divide in Pilulas
xxxvj. quarum capiat binaa vel tres hort somni.
Form. S82. Pilul.*: Astringentes.
R Alumlnis contriti nr. v. ; Myristics Nucl. contr. gr.
iv.; Extr. Gentians q. s., (vel adde etiam Opii Pa-
ri gr. j.) riant Piluls time pro dose.
Form. 883. Pilule Relladonn.e Extracti et
ClNCHONi'..
R Extracti Belladonna ar. j.ad ij. ; Extracti Cinchona
Ver. ;)i- M. Fiat Pilulas viij.; capiat ij. litis horis.
Form. 884. Pilul.e C.uinonu:, Aloes, et Ammoniaci.
R Cambogis, Aloe's, et Ammoniaci, in pulvere. partes
squales: solve in Aceto~; dein liquorem cola, et
consume donee crassitutlineiii irioneam lialieat.
Divide in Pilulas cr. iv. Capiat binas ad quatuor
pro dose. (Diuretic, Purgative.)
Form. 8S;>. Pii.ulje Camphor.e et Ammoniaci.
R Massa- Pilula; Aloes cum Myrrh&3j. > Gummi Am-
moniaci y> j ; ("amphorae gr. x. ; Syrup. Simplicis
q. s. Misce. Fiant Piluls xx. ; omni mane capiat
tres vel quatuor. (Stoll.)
Form. 88G. Pilulje Camphor.*: et Opii.
R Camphors, Potasss Nitratis, 5ii 3ij ; Saponis His-
pan. 5ss.; Extr. Opii Aquos. 3> :-> Syrup. Tolutan.
q, s. M. Fiant Piluls cxx., quarum binas vel tres
lerquotidi£. (Cadet de Gassicourt.)
Form. 887. Pilul.e Cimphob.uetQi'in'is.e.
R Camphors ras.-cj-lj.; tiuinina- Sulphatis V)ij.; Mas-
s.T I'ilul. Aloes cum Myrrhl "iss ; Syrup. Zingibe-
ris q. s. M. Fiat massa squalis et divide in Pilu-
las xxxviij., quarum capiat imam bis quotidh*.
Form. 8S8. Pilulje Chalyeeat.v..
R Sub-rarbon. Ferri ^ss. ; Pulv. Cnnella; Alba; 5'i.i- ;
Alois Sorot. 3 jss. ; Syrup. Croci q s. M. Fiat
massa a-qualis.
Form. 889. Pilulje Colocynthidis cum Sulphur /e.
R Extr. Colocynth Comp 3j. ; Sulphur. Sublimati 'j.;
Potasss Sulphatis j iv. ; Syrup, q. s. Divide in
Pilulas I.
Form. 890. Pilul.*: Colocynthidis Extr. et Hyo-
scyami.
R Extract. Colocynth. Compos. V)ij. ; Extract Hvoscv-
ami;-»j. Misce, et divide in Pilulas xij. Sumat
unam vel duas pro re nati.
Form. 891. Pilul.e Df.obstruentes. (1.)
R Saponis Venet. ~.j. : Piltil. Hydrarg. er. viij.— xij. ;
Gummi Ammon. " »••-. ; Masss Pilul. Aloe's cum
Mynh.V) j. ; Terebinth, q. s. M. Fiant Piluls
xxx.; capiat tres vel quatuor de die.
Form. 892. Pilul.e Deorstrif.ntes. (2.)
R Pulv. Gummi Guaiaci 9 j.; Pulv. Gummi Imrnon-
iacigj.; Ammonis Oarbnnatls ur. xv. ; Massa- Pi-
lula. .Mil s cum Mvnh, •) ijss. ; Tinct. Noes
Comp. q. a. M. Divide in Pilulas xl.: 4 quibus su
mantui tres tcr in die cum vasculo infusi Anthem-
idis. (Altered from Stoll.)
Form. I 93. Pilule Diuretics: et Antispa'sm.
R Pulv. FuL Digitalis, Pulv. Ra* Scills, 55 gr. xfj.j
Extr. Hyoscyami ►) J, Divide in Pilulas xrj. Ca-
piat biiias tertiis horis. i'Breha.)
Form. 894. Pilule Dim^Ticr. cum IIvdharcyro.
R Gummi Ammoniaci. Extracti Taraxai i, Pan
net., 55 ;•) |. : Pulveris Scilhe gr. vj. ; Pi
drargyri er. xv. ; Olei Junip. q. s. M. Fiaiit Pi-
luls xvjij.
Form. 895. Pilule Expectorante».
R Pulveris Scills })j.; Ammoniaci Gum. Res. 3 jss. ;
Extract Conii ;■) ij. Contundesimul,el divide mas-
Bam in Pilulas squaiestriginta: quar sumat duas
sextis horis. (In Asthma and Chronic Catarrh.)
Form. 896. Pilul.* Gentians et Aloes.
R AloBs Ext. PuriC, Gentians Extr., 55 Jj. ; Saponis
Castil. }) jss. M. Divide in Pilulas xxxvj.; capiat
unam ad ties, pro re nat4,
Form. 897. Pilul.e Guaiaci et Aconiti.
R Ext. Aconiti gr. j. ; Pulv. Guaiaci gr. viij.; OleiCa-
jeputi q. s. ut fiant Pil. ij. Capiat unam mane
nocteque.
Form. 898. Pilul.*: Humuli Comp.
R Ammon. Sub-carb. «r. vj.; Extr. Uhei gr. viij.; Extr.
Humuli gr. xij. M. Fiant Piluls vj., quarum ca-
piat tres bora somni.
Form. 899. Pilul.e Hydrargyri Composite.
R Pilul. Plummeri 3 ss. ; Pulv. Jacobi Veri gr. xij.;
Extracti Conii gr. xxij.j Saponis Castil. cr. vj. Con-
tunde siniul, et divide massam in Pilulas xij.
squales, quarum binie omni nocte sumantur.
Form. 900. Pilule Ipecacuanh.e Comp.
R Pulv. Ipecacuanha; gr. vj.; Pulv. Ipecacuan. Comp.
Extr. Papaveris, aa 3 j. ; Extr. Humuli Jss. ; Olei
Anisi q. s. M. Fiant Pilula; xxiv.; quarum cainat
unam quartis horis, vel binas aut tres hori somni.
Form. 901. Pilule Morphinje et Ferri Sulphatis.
R Sulphatis Morphias gr. ij.; Olei Amvgdal.q. s.: ad
solut. dein adde Ferri Sulphatis gr. vj.; Pulv. Gly-
cyr. gr. viij. ; Mellis q. s. ut fiant Piluls viij. Ca-
piat unam tertii quique hora.
Form. 902. Pilul-e Morphin.e Sulphatis.
R Sulphatis Morphins gr. j.; Pulv. Ipecacunnhs gr.
iij. Extr. Aconiti »r vj.; Olei Amygdal. HnLTTlvj.;
Pulv. Glycyrrh.et Mellis aaq. s. ut fiant Pilulce viij.
Capiat unam otiis vel 4tis horis.
Form. 933. Pilul.e Moschi Composite.
R Moschi, Pntassa>Nitratis,55.gr. vj.; Camphors rasa?
gr. vj.; Conserv. Ros. q. s. Fiant Piluls vj.
Form. 904. Pilul.e Mubjatis Calcis et Conii.
R Calcis Muriatis gr ij ; Extr. Conii gr. iij.— v. Fiant
Piliila- dine, his in die sumendic. (Scrofulous Ob-
structions.)
Form. 905. Pilul.e Nervine. (1.)
R Assafo?tid;e Jss.; Castorei «r. vj.; Extract. Hyoscy-
ami er. x. ; Extract. Anthemidis '& j. ; Syrup. Pa-
paveris q. s. M. Fiant Pilulas xij.; capiat a'gra
duas mane nocteque.
Form. 900. Pilul.*: Nervin.-e. (2.)
R Assafmtids J^ij.; Camphorn» Pubacts Lrr. x\-j.; Mos-
chigr. vj.; Mucilag. Acacisq. s. M. Fiant Piluls
xvj., 6 quihiis sumatur una omni bihorio.
Form. 907. Pilul.t: Nucis Vomica et Aloes.
R Pilul. AloSe cum Myrrha }} iv. ; Extracti Nucis
Vomica; ar. x. M. Fiant Piluls xxxvj. ; quarum
capiat unam ad duas, mane nocteque.
Form. 90s. Pilul.* Sars.t: Composite.
R MnsssPihi!. Hydrarg. gr. viij.; Extr. Taraxaci, Extr.
Snrsapirllls.aa ;•) v. Al. Fiant Piluls xlviij.,qua-
ruiu capiat tres quater in die.
Form. 909. Pii.ii.i: Scill.t: et Galbani four.
R Pilul. Galbani Comp. "j.; I'ilul. Scilbc Comp. 9 ij.;
Ol. .luniperi TT|v. M. Divide in Pilul. xxiv., qua-
• rum sumat binas ter quotidid.
Form, 910. Pji.tl.t: Sod.b cum Rheo »t Hvosctamo.
li Sods Sub-earhon. exsic. J) ijss.; r'nlv. Rhei ~i. ;
Fxtr. Flyoscvami 'O g. M.-Dinidf in Pilulas xxxvj.,
quarum, ter quotiilic, binir siimEfeur.
Form. 911. Pitui e Ptomaohice.
R Pulveris Rhei, Pulveris ZinEihefls,aa 3ss.; Extracti
Anthemidis ' j ; Olei Anisi q. s. Fiat massa, in
Pilulas squales tiiginta dividenda, quarum capiat
trestmte' prandium ([uotidii. (In Qyspepsia),and
Chlorosis, t^c.)
i
.#
ADDENDA TO APPENDIX. —Pclvis — Visum.
•,0. Pilulje Sii.rntKK.Ti Antimonii.
.mtinion. Sulplrtlret. crud., Extract. Dulcamara?,
partes equates. Sint Pilula; gr. iij. Capiat iij. vel
iv. ter die.
Form. 913. Pixuxje Thebaiac.i: Composite:.
R Cumuli Aintnoiiiari 3j. ; t'umphora; 3'sS.J Moschi
Muse, gr xx. ; Pulv. Opii gr. x. , rials. Peruviani
q. >. M. Fiant PH. gr. iij. feu mat aeger uiiain Imr.l
undecima, iterum vespere bora quinti ; et cubitum
petens suniat ins.
Form. 914. Piluljb Tosici.
R Extracti Gentians, Pnlv. liliei, aa 3 ss. ; Sapcnis
Castil. 9j. M. Fiant Pilula; xviij., quarum suniaii-
tur bina; ter quotidie.
Form. 915. Potus Aperiens.
R Mann»3J8S.; Potassa? Supert. gss.; Seri Lacti O ij.
M. Capiat cyathum pro re nata.
Form. 916. Potts Tamarindorum Comp.
R Potassa; Tartar., Pulp. Tamarind., Gum. Arab., aa
5j. Solve in Aq. Font. Fervid, lb ij. et adde Oxy-
mel. Simp. 5 ij. M.
Form. 917. Pulvis Ammoniaco-Camphoratus.
R Amnion. Sub-carbon, gr. iv. ; Camphora? Pulveriz.
gr. ij.; Sacch. Alh. gr. xxiv. M. pro dose ; vel tiant
Pil. ij. cum Mucilag. Acaciae, omittend. Saccharo.
Form. 918. Pulvis Anticatarrhalis.
R Kermes Mineral, gr. iij. ; Florum Sulphuris. Pulv.
Rad. Glycyrrh., ai gr. xij. Fiat Pulvis, ter die su-
mendus. (Quarin and Barthez.)
Form. 919. Pclvis Aperiens.
R Magnes. Sub-carbon. 9 ij.; Potassa; Sujjertnrt. 9j.)
Pulv. Rliei, Pulv. Rad. Glyryrrh., aa gr. vj.— xif.
Fiat Pulvis omni nocte iumendus in theriaci com-
muni.
Form. 920. Pulvu Cawimbje et Ferri.
R Fevri Tartarizati gr. x.— xv. ; Pulv. Calumba? gr.
.xij.— 3j. Fiat Pulvis, ter quotidie capiendus.
Form. 921. Pclvis Camphor* et Antimonii.
R Camphornp rasa; gr. xvj.; Potassa; Tartar. 3j. ; An-
timon. Tartarizat. gr. j. M. Probe, et in cartulas viij.
divide ; qiiarnm sumatur una tertia quaque horii.
Form. 922. Pulvis Diaphoreticus.
R Kermes Mineralis, Camphors, aa gr. iij. ; Gum.
Acacia;, Saccbar. Albi,aagr. viij. ; Olei Fceniculi
yq j. m.
Form. 923. Pulj^s Lientericus.
R Hydrarg. cum Creta gr. iij.; Pnlv. Tpccacuan. Comp.
gr. vj.; Pulv. Rheiur. v.; Pulv. Cinnatuom. gr. vij.
M. Fiat Pulvis, bis vel ter die dumendus.
Form. 924. Pulvis Moschi Compositus.
R Moschi gr. vj.— xij.; Pulv. Rad. Valerian. 9j.; Cam-
phorae gr. vj. M. Fiat Pulvis.
Form. 925. Pulvis MtbrH.e et Ipecacuanha.
R Pulv. Myrrha? gr. xvj.; Pulv. Ipecacuan. gr. iv. ;
Potassa1' Nilratis in pulv. 9 ij. ; Pulv. Opii gr. j.
Misce bene, et divide in doses a-quales quatuor.
Capiat unam quart! quaque fieri.
Form. 92f>. Pulvis pro Tormisibus..
R Magnes., Sarrliari Alhi,aagr. viij. ; Pulv. Canella?
Corticis gr. ij. M. Fiant Pulvis.
Form.. 927. Pulvis Resolvens. (Stahlii.)
R Pulr. Antimonialis,Potass,T X it rat.; Ocul. Cancror.
Pra?p., aa 3 j.: tere bene sunul. Dosis B j.
Form. 928. Pulvis Salinus.
R Potassa' Chloridis lt. v.— xij. ; Sodas Muriatis pr.
viij, — xx.; SodiE Carbonatis gr. x— xv. ; Olei Pi-
iiicut.T, vel Cajeputa?, vel Sine, TT|ij.— v. M. Fiat
Pulvis pro re natasumendusin decocto llordei vel
j'.-sculo Bov.
Form. 929. Pulvis Sod.*: Nitratis Compositus.
R Soda' Nitratis gr. v.— £)j. ; Pulv. Cinnaro. gr. vj. ;
* Pulv. Ipecacuanha; gr. ss.— j. ; Olei Pimenta? TTJj.
M. Fiat Pulvis ter quaterve in die sumendus
(Diarrhoea, Dysentery.)
Form. 930. Pulvis Valeriana Compositus.
R Pulv. Rad. Valerian. 3 j. — g ij. ; Magnes., Mur.
Amnion., aa gr. v.; Olei Cajeputi TT)ij. M.
Form. 931. Solutio Belladonna Extracti.
R Extracti Belladonna? Jj. ; Aquae Destillat* gj. M.
Fiat Solutio.
Form. 932. Solutio Camrogi.e Alkalina.
R Gum. Res. Cambogias 3ss.: solve in Liquor. Carbon.
Potassa? §ss. Hujus solutionis capiat TTlxx., qua-
ter in die, quovis in vehiculo idoneo. (Both Diu-
retic and Cathartic. Hamburgh Dispensatory.)
Form. 933. Solutio Hvdro-Sulphatis Calcis.
A Hydrosulphate of the Protoxide of Calcium.
R Sulphur. Fulveriz. Ibj. ; Calcis Vivi ft ij. ; Aq
Fontaine tb xv. Coque per partem hora? qnartam,
et cola. (Pierquin's Antipsoric Milk. Hahne-
mann and Passing recommend it as a eargle in
salivation ; and a dessert or table spoonful of it is
to be taken internally in some soup (mutton or veal
broth), in cases of poisoning by mercurials. } i.y
Form. 934. Solutio Refrigerans.
R Nitrat. Potassa: ^ss.; Muriatis Ammonia? 3"j-: Aq.
Pur. 5 viij. Solve leui cum < alore, et adde Catiipho-
ne Pulverizat. 3jss.; Alcoholis q. s. .Macera. Ca-
piat 5 j. — 5 iij. in decocti Hordei cyatho.
Form. 935. Syrupus Antimoniatus.
R Kermes Miner. 3 j.; Svrup. Scillae, Syrup. Althas.T,
aa^jss. M. Capiat Coch. j.— iij. minima, ter qua-
terve in die. .
Form. 936. Tinctura Astrincens.
R Catechu, Myrrhs, aa 5 ss. ; Pulv. Cinchoaae 3 ij. ;
Balsami Peruvian. 3 jss.; Spirit. Armoracia?, Spirit.
Vini Rectiricati.aa §jss. Misce, et digere. (For
Sponginess of the Gums.)
Form. 937. Trochiscus Astringent.
R Catechu Jij. ; Moschi 3'j- ! Saccbar. Albi g iijss. ;
Mucilag. G. Tragacanth. oas. Misce. Fiant Tro-
chisci parvuli. "(For Relaxation of the Uvula,
Hoarseness, &.C.)
Form. 938. Unguenti ChlorupvEti Calcis.
R Cblorureti Calcis in pulv. subtil, redac. 3'jas.; Tur-
hilh. Mineral, in pulv. 3 ij. Misce bene; dein tere
cum Axong. § ijss. ; Olei Amygdal Dulc. § j. M.
Fiat Unguentum.
Form. 939. Vinum Ferri.
R Tinctur. Ferri Muriatis f 3J. ; Vmi Albi Hispan.
13 xv. M.
^•^"V-C I.
X
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