n H I wSwB flU mm EM Unffl I iiiifiiiilfilli NOTES OF LECTURES THEORY AND PRACTICE OF MEDICINE, DELIVERED IN THE JEFFERSON MEDICAL COLLEGE, PHILADELPHIA. SECOND EDITION, CORRECTED. BY JOHN EBERLE, ML. D. CINCINNATI: PUBLISHED BY COREY & FaiRBANK, 200, MAIN STREET. 7834 t ^v 1 fc 5 EASTERN DISTRICT OF PENNSYLrAJYIA, to wit: BE IT REMEMBERED, That on the twelfth dav of October, (L. S. ) in the fifty-second year of the Independence of the United States of America, A, D/1827, John Eberle, M. D. of the said District, hath deposited in diis Office the Title of a Book, the right whereof he claims as author, in the words foUo.ving, to wit: "Notes of Lectures on the Theory and Practice of Medicine: "delivered in the Jefferson Medical College, at Philadelphia. "By John Eberle, M. D." In conformity to the Act of Congress of the United States, entitled, "An Act for the encouragement of learning, by securing the copies of maps, charts, and books, to the authors and proprietors of such copies, during the times therein mentioned." And also to the Act, entitled, "An Act supplementary to an Act, entitled, 'An Act for the encouragement of learning, by securing the co- pies of map?, charts, and books, to the authors and proprietors of such copies, during the times therein mentioned,' and exiending the benefits thereof to the arts of designing, engraving, and etching, historical and other prints," D. CALDWELL, Clerk of the Eastern District of Tenniylvani*. PREFACE. This little work is published expressly for the use of the students attending the author's lectures on the Theory and Practice of Medicine. It embraces little more than the main propositions and facts, which form the ground-work of the lectures; in other words,- — the text upon which he enlarges and comments in extemporary discourse; and which, especially, the student ought to impress upon his memory. The practice of taking notes, though at- tended with some advantages, is nevertheless, on the whole, calculated to lessen the benefits to be derived from oral instruction. The train of thought and reasoning is interrupted ; and the mind irregu- larly hurried along the current of the speaker's ob- servations — seizing somtimes upon remarks that are comparatively unimportant, at the expense of others of a more useful and interesting import; and losing in a great measure the general spirit and scope of the speaker's discourse, — more especially when the subject is one of general disquisition. These dis- advantages, it is believed, will be diminished, if not wholly obviated, by works constructed on the plan of the present one. Being secure of the text, or pro- positions, the student may yield his mind, without embarrassment, to the explications and discussions of the lecturer. His efforts, too, in recalling to his mind the observations he mav have heard from the Vi PREFACE. „ speaker, will be greatly favored,* by looking c in private, the sketch which is thus placed in hands. The author acknowledges, that this manual does not come up to the idea he has formed, of the pro- per construction of a text book of this kind ; but* such as it is, he flatters himself, -that it will in some degree answer the intentions for which it was com- posed; and with this hope, he respectfully dedi- cates it to those students of medicine, who do him the honor of attending his lectures. TABLE OF CONTENTS. Anasarca, 185 Angina pectoris, - 183 Arachnitis, or Hydrocepalus acutus, - 66 Ascites, - - 186 Asthma, - - 180 Bronchitis, acute, - - 89 ■= chronic, - 90 Cholera, 192 Chorea, - . - 170 Cold, - 11 Colic, flatulent, - - 193 bilious, - 194 Colica pictonem, - 196 Critical days, 26 Croup, spasmodic, - 91 Cynanche tonsillaris, - 93 Cynanche trachealis, - 90 Cystitis, - 104 Diabetes, - - 107 Diagnosis, general, - 13 Diarrhoea, - - 190 Dropsy, - • - 184 Dysentery, - - 79 Enteritis, acute, - 77 chronic, - 83 Epilepsy, - 162 Epistaxis, - - 138 Erethism of the brain, - 70 Erysipelas, - -- 132 Exanthemata — Small pox, - 116 Fever in general, and causes of, - 9 , its general course, - 29 , Intermitting, - 33 •, Remitting, - 40 -, Yellow, - 44 -, Inflammatory, - 47 , Typhus, - 52 ■, Catarrhal, 51 Fevers, Type of, " 29 Vlll CONTENTS. Gastritis, acute, - - . "72 chronic, - 74 Gout, - - - - -111 Hsematemesis, - 139 Hematuria, - 141 Hasmoptisis, - 143 Haemorrhois — Piles, - - 11 Hasmorrhagiaa, - 137 Hemiplegia?, - - - - 157 chronic, - - - 101 Hepatitis, acute, - 99 Hydrothorax, - - - - 187 Icterus — Jaundice, - 205 Indigestion, ----- 201 Inflammation in general, - 60 chronic, - - - 65 of Brain, - - - ib. Mental diseases — Mania, - - - 211 Neuroses — Apoplexy, - 153 Nephritis, ... - 103 Paralysis, - - - - - 157 Paraplegia, - 158 Parotitis, - - - - - 94 Paralysis partialis — local palsy, - - 159 Peripneumony, - - - - 86 Peritonitis, acute, - 95 — chronic, - - - - 98 Pertussis — Whooping cough, - - 176 Phrenitis, - - - - - 105 Phtisis pulmonalis, - 145 Pleuritis, acute, - - - - 85 chronic, ... 90 Pneumonia biliosa, - - - - 88 Prognosis, - " - - - 23 Pulse, - 19 Rheumatism, acute, - 105 chronic, - - - - 109 Rubeola — Measles, - - - 125 Scarlatina, - 128 Scrofula, 208 Softening of the brain, - - - - 71 Tetanus, - 172 Variola, - - - - 116 Variola vaccina, - - - - 121 Varioloid, ----- 123 Varicella — Chicken pox, - - 125 Verminous affections, - - 214 NOTES OF LECTURES, CHAPTER I. OF FEVER IN GENERAL. Idiopathic — (seldom.) Symptomatic, — dependant on: local irritation inflamation, generally seated in the mucous tissues j — frequently in the serous. Proximate Cause: located in the capillary system of blood vessels. (See Practice of Med. Chap. 1.) ^f' The morbid actions of the heart and arteriee are mere sym- pathetic phenomena, dependent on a primary local irritation of a part or the whole of the sanguiferous capillary system. The proximate cause consists: in a deranged condition of the vital properties of the capillary system whence result irregular actions from the impression of normal and innormal irritants. Remote causes of fever: divided into; predisposing and exciting ; There exists, however, no essential distinction between the predisposing and exciting cause. Every predisposing cause may become an exciting cause,by continued or intense action. Predisposition consists for the most part in: local, and rarely in mere general debility. (See Pract Med. p. 28.) 10 OF FEVER IN GENERAL. The origin of all possible cause of fever is quadruple, 1. Retained recrementitious materials, in consequence of the accidental torpor of one or more of the emunc- tones. 2. Substances generated in the system, independent of organic actions, worms, acid, &c. 3. Materials generated out of the body : miasmata, heat, cold, &c. &c. 4. Substances generated by diseased organic actions — contagious. (See Pract. of Med. p. 31.) General nature of these causes. They are irritants: Some of them invariably produce the same disease, as the contagious. Certain distinct febrific causes cannot develop their morbid effects at one and the same time in the same system : measles and small-pox. All morbid agents act primarily on the nervous system. Through the lungs and respiratory passages, The stomach and intestinal canal, The skin, and Peri. rne D l°°d. Phmnlt;,, It >« highly probable that all aeriform morbific agents act on the system through he respiratory organs. Some of them may be absorbed into the circulation, and act upon the nervous extre- mities of the blood ; others may act directly on the nerves of the mucous membrane of the respiratory passages. The former mode of acting, is, I presume, generally, if uot always the case. The causes of fever are divided into three classes. 1. Sensible properties of the atmosphere: heat, cold, moi- ture, electricity, &c. &c. 2. Contagious, — the result of organic actions. 3. Miasmata, — the result of physical changes. Heat. Specific temperature of the human body, 98o, Most agreeable temperature of surrounding air, 65o. Atmospheric heat not a deletereous agent; predisposes to the influence of morbific causes ; increases the secre- tion of bile ; indirect cause of disease, by favoring the generation of miasmata. OF FEVER IN GENERAL. 1 1 Dr. Johnson observes, that solar heat only produces the pre* disposition; while terrestrial exhalatious, and vicissitudes of temperature, call into action the principal diseases of warm cli* mates. (See Pract. Med. p. 39.) Cold. No positive existence — a mere relative degree of temperature ; lessens the action of the heart and arte- ries ; causes a shrinking of the surface of the body ; di- minishes sensibility and contractility; produces irresis- tible disposition to sleep ; and depresses the moral and physical energies of the system, wheu long and intense- ley applied. Suddenly or transiently applied, it ex- cites the nervous system. In alternation with heat, a fertile cause of disease ; the diseases resulting from its influence, mostly pneumatic, catarrhal, or rheumatic; cold water externally applied, or received into the sto- mach when the body is heated and in a free state of perspiration, often proves suddenly fatal. Always more injurious in its influence, when accompanied by moisture. (See Pract. Med. p. 35.) Miasmata. Heat and moisture essential to the production of miasmata* Moisture need not be abundant; in- undated grounds extricate little or no miasmata ; hence the rainy seasons of tropical countries are the most healthy. Miasmata are seldom generated at a temper- ature below 80o ; their precise nature unknown ; there is reason to believe, that they consist of particles of pu- trid vegetable and animal matter, dissolved in aque- ous vapour. Chemical analysis can detect no differ- ence between the air of marshes and atmospheric air. GasparaVs experiments on putrid matters received into the body, support the opinion that marsh mias- mata consist of putrid vegetable and animal matter suspended in the air. Miasmata possesses greater specific gravity than at- mospheric air; they are conveyed to a considerable *It has lately been contended, that moisture is not essential to the generation of mias- mata : but, as I believe, without good grounds. (Ferguson.) 12 OF FEVER IN GENERAL. distance by currents of wind ; the distance at which they are capable of infecting, by being thus carried, is from two to three miles(Bancroft says, but one fourth of a mile;) storms and violent blasts disperse and ren- der them innocuous ; more danger in miasmatic atmo- sphere at night than during day; most danger about the setting or rising of the sun; situations are protec- ted from the effects of miasmata, by interposing obsta- cles, as houses, walls, wood, hills, &c.; long and gra- dual exposure to miasmata, destroys the susceptibility of the system to their more violent influence. Per- sons unaccustomed to them seldom escape disease, when subjected to their action. They produce inter- mittents and remittents, of various grades of violence. (See Pract. Med. p. 40.) Contagion. A deletereous agent, generated by the living body in a state of disease. The diseases produced by this class of causes, preserve a determined or spe- cific character; contagious diseases divided into chro- nic and acute; the later seldom affect the same person more than once; — the former may affect repeatedly ; in the acute, there can be no relapse. Contagious matter either a palpable substance, or an imperceptible efflu- vium; chronic contagious affections always produced by the former, and by actual contact; some acute con- tagious diseases communicated both by contact and and through the medium of the air; that is, both by a palpable virus and an effluvium. Typhus fever, under certain circumstances, contagious; appears to be pro- pagated by effluvia only. Contagious effluvia extend but a short distance, suffi- ciently concentrated to produce disease. The experi- ments of Dr. O'Ryan make it but a few feet — four or five feet; currents of air will convey it much further; contagions rendered harmless by diffusion in the air; hence the utility of free ventilation; contagion attach- es itself to various substances; the substances most GENERAL DISEASES. 13 apt to receive and retain it, are, wool, hair, cotton, wood, cloths, &c; contagion influenced by certain occult conditions of the atmosphere ; contagious disea- ses communicated from the inferior animals to the human species. Disinfecting means; cleanliness; free ventilation; muriatic and nitrous vapors; lime; fumes of sulphur, and heat. (See Pract. Med. p. 56.) CHAPTER II. GENERAL DIAGNOSIS. Diagnostic signs divided into those exhibited by the countenance; the attitude; the nervous system; the dgiestive organs; the circulatory system; the respir- atory organs; the circular surface; the lymphatic system; the secretions. The Countenance. The features to be particularly examined, are: the eyes the prolabia; the nostrils; the lips; the brows. In acute simple fever ; eyes and face red; respiration hur- ried ; motions of the nostrils rapid. Tn acute sympa- thetic fever, these signs are absent. (Hall.) Acute pain, from inflammation in the chest: features much contracted ; the alee nasi acute and elevated, the nostrils contracted and expanded by the acts of respi- ration, sometimes a vivid flush terminating abruptly — heat inconsiderable. Dull pain in the chest: less constriction of the features; 14 GENERAL DIAGNOSIS. an expression of great anxiety ; nostrils widely dilated before inspiration. Effusion into the lungs: countenance livid, anxious, tur- gid, with great dyspnoea, and dilation of the nostrils on inspiration. The phtJiisical countenance. Acute pain in the abdominal viscera; features acute; forehead wrinkled ; brows knit ; nostrils drawn up and acute; under lip drawn down, exposing the teeth. Organic affections of the heart: countenance anxious ; vividly flushed; prolabia livid : face turgid, cedematous. cold. In hydrothorax, the face has a pale-livid aspect, Soporose affections: flushed, livid, tumid, eyes closed or open and fixed, mouth frequently drawn to one side. In syncope: pale, shrunk, cold, and death-like. In chlorosis: pale, exsangueous; icterode; puffy; a pe- culiar darkness occupying the eyelids, and extending towards the temples and cheeks, and sometimes sur- rounding the mouth. Distinction between the icterode appearance, and the dif- ferent shades of icterus, (Hall) the yellowish tinge in in the latter is particularly seen in the albuginia of the eyes; in the former, the eyes remain untinged. The tinge of icterus depends on bile; that called icterode, on a morbid action of the cutaneous capillaries. (Hall.) Chronic irritation of the bowels: puffy countenance; upper lip pale and swollen ; occurs in verminous affec- tions and in scrofula. Attitude. The healthy attitude: Advantages to be obtained from position, in the treat- ment of diseases. Preternatural determination to a part, diminished by ele- vating such part: the head to be raised, in apoplexy; the extremeties, when affected with inflammation. Supine position, with tremulous motion, indicates much muscular debilty. GENERAL DIAGNOSIS. 15 Fever from acute local inflammation; not attended with • with muscular prostration. Characteristic position in hydrolhorax : in slight cases, head and shoulders elevated when in bed ; in severe cases, inability to lie down. The erect position more urgent, when complicated with organic affection of the heart. When sitting up, hands forcibly pressed on the chair on which the patient sits ; or leaning back, with the arms and hands placed behind the back. (Hall.) Thoracic effusion, distinguished from mere organic dis- ease of the heart and lungs, by the effects of firm pres- sure on the epigastric region, and bodily exertion. Effects of pressure, in effusion : general agitation, cough and a sense of suffocation ; not so, or but slightly, in or- ganic affections of the heart and lungs; bodily exertion excites more dyspnoea, and distress in effusion, than in organic affections . Position assumed by the patient, in abdominal inflam- mation, with acute pain: fixed, carefully avoiding all motion and pressure; generally on the back, knees drawn up, and head and shoulders a little elevated. Position assumed in spasmodic pains of the abdomen. constantly changing posture, desirous of pressure on the abdomen, recumbent on the belly, &,c. Position on the back, with knees constantly elevated, in the latter stage of acute diseases, a sign of retention of urine. The Tongue. Attention to be paid to its colour, its sur- face, its shape, and the manner in which it is protruded, A white and slightly loaded tongue, indicative of slight gastric derangement and moderate febrile excitement. A clean, deep red, smooth tongue, indicates inflammation or high irritation of the mucous membrane of the sto- mach and intestinal canal. Tongue seldom much affected in acute symptomatic fe- vers, from wounds or external inflammations. 16 GENERAL DIAGNOSIS. Florid papillae protruding through a layer of white fur, characteristic of scarlatina. (Hall.) Diagnosis, from the appearance of the tongue, between phthisis, and hectic with cough, from hepatic and gas- tric affections: tongue natural in the former; covered with brown fur in the latter. A pale and tumid tongue, with large papillae, indicative of gastric debility — met with in chlorosis. A contracted and pointed tongue, frequently an attendant on cerebral or meningeal inflammation. A flabby and dilated tongue occurs in congestive states of fever. (Miner.) A yellow and bitter tongue, indicative of biliary derange- ment. Morbid^States of the Nervous System. Disturbed Sleep. Coma always denotes oppression of the brain, Wakefulness, a sign of great irritation or exhaustion. Sudden starting in sleep — intestinal irritation from worms, &c. Hurried wakings, with a horrific sense of suffocation, a sign of organic diseases of the heart. Strabismus, double-vision, signs of cerebral affection. Torpor of the sense of touch. Morbid sensations. In strumous disease of the mesentary, an unusual sensibility to cold constitutes a peculiar and very early symptom. (Hall.) Pain may arise from inflammation, from spasm, and from nervous irritation. They have each their peculiar character. Inflammatory pain: tenderness of the part, increased by pressure ; throbbing or burning continuous, and at- tended by febrile excitement. Spasmodic pain: paroxysmal, not throbbing, nor bur- ning, relieved by pressure, and seldom attended with fever. GENERAL DIAGNOSIS. 17 Neuralgic pain: transient but violent paroxysms, darting along the nerves with the rapidity of lightning ; no swel- ling, no heat, and readily renewed by the slightest touch. Inflammatory pain, modified by the nature of the struc- ture in which the inflammation exists. Diagnastic in- ferences. Pain referred to parts remote from that in which the primary affection resides. Alimentary Canal. Nature and appearances of the alvine discharges. Clay-coloured fseces indicate deficiency of bile — met with in jaundice. Diagnosis between infantile remit- tent and hydrocephalus — the alvine discharges in the former are dark brown, or mud- like, and very fceted — in the latter, glairy darh-green, like chopped spinage. (Cheyne.) Watery and reddish stools, like the washings of flesh. Mucous and bloody stools. Respiratory Organs. Accelerated respiration always attended with frequency of the pulse. Irregular and unequal respiration indicates cerebral oppression ; — slow, irregular, and sterterous breathing, attends a high degree of cerebral compression. Abdominal respiration, indicates pneumonic inflamma- tion. Breathing with the intercostal muscles, without the ac- cessory action of the abdominal muscles, indicates ab- dominal inflammation. Peculiar respiration inhydrothorax: inspiration quick, and with great effort; respiration slower, without effort. (Hall.; The effects of corporeal exertion on respiration: produ- ces great dyspnoea in hydrothorax, and still more in organic cardial affections. Wheezing respiration — in asthma, cynanche trachealis. Hurried, panting, and heaving respiration, with sighing, 18 GENERAL DIAGNOSIS. often attends intestinal irritation and exhaustion from haemorrhage. (Hall.) Cough. When the efforts of coughing are anxiously re- pressed^ there is probably inflammation in the chest or abdomen. Spasmodic cough — in pertussis — sometimes from irrita- tion of the stomach. Sputa. White cream-like, in chronic bronchitis: Effects of full inspiration and expiration, as a diagnostic* Cuticular Surface. Its temperature; its colour; its state of dryness or moisture ; its fulness or construc- tion ; its roughness or smoothness. A yellowish tinge indicates biliary derangement ; not to be confounded with the sallowness which occurs in cancer and chlorosis. A purple or bluish colour occurs in infants, from pervi- ous foramen ovale. Dark coloured or purple spots, — extravasations of blood. A pale, semi-transparent skin, particularly of the pro- labia and face, manifests paucity, or very serous, blood — after profuse bleedings and from anaemia. Cold skin, with a feeling of internal heat, denotes inter- nal congestions. Color mordax — in typhus. Permanently dry and husky skin, indicates torpor or chronic disease of the liver. Urine. Small in quantity, and red in inflammatory affec- tions; copious and limpid in nervous diseases. Bilious urine. The various sediments — lithates; phosphates; the former are red or purple — the latter, white or pale yellow. See Dr. Hall's work on Diagnosis. THE PULSE. CHAPTER III. THE PULSE. 19 The pulse varies with the age of individuals; at birth, it beats from 130 to 140 in a minute: mean rate for the first month, is 120; limits during the first year, are 106 to 120; for the second year, from 90 to 100, for the third, from 80 to 90 — nearly the same for the fourth, fifth, and sixth years; in the seventh year, pulse about 78; from the twelfth year, it differs but little from that of adult age, which is estimated at from 60 to 80, according to indivi- dual constitutions, &,c. (Heberden.) The common stan- dard of frequency may be placed at from 70 to 75 beats in a minute. (Falconer.) From the 45th to the 60th year, the pulse gradually becomes slower; after this period, it again rises in frequency. (Floyer.) Generally more fre- quent in women than in men. (Falconer.) Climate influ- ences pulse; more frequent in hot than in cold countries. The time of day: slower in the morning than at other times ; most frequent soon after dinner ; slower during sleep than in the waking state. Bodily exercise accele- rates the pulse; varies according to the 'position of the body ; slowest while lying down ; slower when sitting than when standing. (Dr. Robinson.) Mental excitement influ- ences the pulse ; joy, and anger, render it fuller and more frequent; grief, sorrow, and fear, depress it. Mode of examining the pidse. (Celsus, Rush.) Not to be examined immediately on entering the patient's room ; — the examination to be repeated at short inter- vals; should be felt in both wrists, the arm having its muscles relaxed by proper positions ; two or three fin- gers to be applied to the artery ; thirty or forty pulsa- 20 THE PULSE. tions are to be felt at each examination; examined in different positions of* the body: talking must be for- bidden. Pathological Condition or the Pulse; considered in 'relation : 1. To the force of the pulsations. 2. To the rythm or mode of the pulsations. The most prominent and useful pathological states of the pulse, consist in -.frequency, quickness, strength, fullness, hardness, and irregularity. A frequent Pulse is one in which the pulsations succeed each other with preternatural rapidity; a pulse beating more than 1(>0 in a minute, is scarcely to be counted; great frequency of pulse always connected with great prostration of the vital energies ; frequency, with fulness and strength of pulse, more dangerous than the same degree oi frequency, with softness and moderate fulness. When it rises above 120, in in flammatoryjjfevers, much danger is to be apprehended, (Heberden.) Slow Pulse: occurs from cerebral compression,- — internal venous congestions, and impairment of the vital energies ; as in apoplexy, congestive fevers, and malignant fevers. Quickness of pui.se: often confounded, improperly, with frequency. Quickness refers to the suddenness with which each individual pulsation is made— fre- quency has reference to the number of pulsations in a given time. Quickness, however, is generally atten- ded by frequency. A strong Pulse is one which gives the sensation of preternatural resistance to the finger, during the di- astole; not4o be confounded with a hard pulse. It is hard, when the artery is felt firm under the finger like a tense cord, both in its systole and diastole — some- times called corded. Strength and great frequency THE PULSE. 21 never united, a strong pulse seldom exceeding 115 beats in a minute; a strong pulse indicates energy of the vi- tal powers, and is therefore favorable. A feeble Pulse, the reverse of a strong pulse : it is feeble, when the artery produces a weak impulse against the finger, during its diastole. Feebleness and softness of pulse, not synonymous — the artery may re- sist pressure, and yet pulsate very feebly. The pulse is sojt, when the artery appears to be filled, and yet offers no resistance, vanishing by slight pressure. A very soft Pulse seldom attended with great frequency, or with irregularity; occurring in the ad- vanced stages of fevers, favourable, when joined with great difficulty of respiration, and suffused countenance, in pneumonic inflammation, indicative of much danger. Full Pulse. Never very frequent; sometimes much slower than natural. Small Pulse — the diameter of the artery is smal- ler than natural ; in inflammations seated above the di- aphragm, the pulse is generally full — when seated below it is small. (Borden.) Depressed Pulse: small, and apparently feeble, and occasionally quick, does not depend on actual debility or exhaustion, but on internal venous congestion. — Blood-letting will raise this pulse ; distinguished from a small and weak pulse — by attending to the prevailing diathesis, — by suffering a few ounces of blood to flow, and watching its effects, — and by observing the period of the disease in which it occurs ; if it is small and ob- scure in the beginning of acute diseases, we may "pre- sume it is depressed. Intermittent Pulse: when not attended by other alarming symptoms, not in general a dangerous sign j pulse sometimes habitually intermits; it is said to be of dyspeptic origin ; occurs frequently in old age, and then probably depends commonly on some affection of the heart ; occurs also in affections of the brain ; a very 22 THE PULSE. unfavorable sign, in the advanced stage of fevers, with great prostration ; is said frequently to precede a criti- cal diarhcea. (Senac, Solano, Coxe.) Unequal Pulse: synonymous with irregular pulse. — Characterized by a constant variation of the pulsations, in frequency, quickness, size, hardness, &,c. More dangerous than an intermittent pulse. Dicrotus pulse, twice-beating. Gaseous Pulse : tumid — inflated — soap-bubble: al- ways indicates much prostration. Undulating Pulse: a wave-like rising and falling of the pulse; generally large, soft, and feeble. When very small, it is termed creeping; highly dangerous. A morbidly natural Pulse: occurs in malignant fevers; exceedingly unfavourable; can only be distin- guished from a healthy pulse by the concomitant symp- toms. Shattered Pulse: pulse feels like a shattered quill under the finger — occurs in opium eaters. Obstructed Pulse: artery remains equally full du- ring its diastole and systole. The Compound Pulses The principal are the syno- cha; synochus; synocliula; typhoid !y and typhus. 1. Synocha: hard, full, frequent, and strong; indi- cates high imflammatory excitement 2. Synochus : full, round, active, but not hard: oc- curs in the hot stage of intermittents ; in remit- tents, &c. 3. Synochula: quick, tense, small, hard, vibrating: occurs in sub-acute rheumatism — inflammation of the intestines, peritoneum, &,c. It is the hec- tic pidse. ■4. Typhoid: quick, small, slightly tense, not hard, and somewhat frequent: in the advanced sta- ges of billious fevers — the result of irritation in an exhausted state of the system. GENERAL PROGNOSIS. 23 5. Typhus: small, very frequent, somewhat quick: occurs in the advanced stages of jail, hospital, and other varieties of typhoid fevers. CHAPTER IV. GENERAL PROGNOSIS. The evidence of a single symptom not sufficient to give a decisive prognosis ; the cause, the concomitant phe- nomena, the temperament and habits of the patient, &c. must be carefully estimated. The Countenance. The more it varies from its natural expression, the more unfavourable. Hippovratic coun- tenance — nose pointed, eyes sunk, temples hollow, ears cold and shrivelled, the lobes everted ; skin on the forehead hard, tense, and dry, countenance pale, livid, or leaden: a fatal symptom, in the last stage of acute diseases. One eye becoming smaller than the other, a bad sign; still worse (Stoll) when objects appear less to one eye; lividity of eyelids, lips, and aim nasi f unless in chills, very unfavorable;- pointed nose, and much motion of the nostrils during inspiration, bad. Attitude. Constant position on the back, and sliding to- wards the foot of the bed, unfavourable; it betokens great prostration: same position, with open mouth, di- lated pupils, or involuntary discharges, still worse. In- sensibility, with mouth firmly closed and eyes fixed, a forerunner of convulsions ; great desire to sit up, with: dyspnoea, and livid countenance, fatal in pneumonia diseases; still more certainly fatal, when attended with *24 GENERAL PROGNOSIS. a good pulse. (Baglivi.) Most favorable posture, that which approaches nearest to health ; reaching into the air, and picking the bed-clothes, bad ; always unfa- vorable, when visceral inflammations supervene to simple fevers ; tumefaction of the abdomen, and tender- ness to pressure indicate danger; laborious breathing, with short, irregular, and interrupted acts of inspira- tion, is a bad sign; a still more dangerous sign, is ex- clusive abdominal respiration, attended with strong mo- tion of the alee nasi by the respiratory act ; sterterous breathing, attended with a rattling in the upper part of the chest, is highly dangerous, though not invariably a fatal sign ; short and very accelerated breathing, al- ways a bad sign; free and easy respiration, favoura- ble ; hiccough, in the advanced stages of fevers, indi- cates danger. Constant wakefulness, or somnolency, is unfavourable — when great pain in the head, pulsation of the carotids, and a puffed red countenance attend ih^ latter, there is much danger. Unequal distribution of temperature — a sensp.tion of cold externally, and of heat internally, are bad signs ; — still more unfavorable, when a sense of burning heat on the surface is attended by a feeling of cold internally. Intellectual and moral habits. When these are chan- ged; when old associations are interrupted; new anti- pathies formed ; when the moral become profane and loose in their language, it is a dangerous sign. Partial insensibility of the sensorial functions, more favorable tli an great acuteness in this respect. Into- lerance of light, with involuntary flow of tears, filmy, protruded, or very sunken eyes, very bad. The excretions. Urine: black, chocolate-coloured, fe- tid — or watery and fetid, highly unfavorable; a good sign, when after having been crude and watery, it de- posites a reddish sediment-still more favorable, when attended with a moist skin, of natural warmth. Sup- GENERAL PROGNOSIS. 25 pression of urine, in protracted and violent cases of fe- ver, a very bad sign. Perspiration: when general, with no very low or high temperature of the skin, favorable ; profuse and cold sweats, about the head, face, and on the arms and legs, highly dangerous ; partial sweat, appearing in large drops, a bad sign; profuse, clammy and cold, always dangerous; and when attended with a very small and frequent pulse, fatal. A vine discharges: very liquid, frothy, green-bad signs; watery reddish discharges, resembling the washing of flesh, and attended with tympanitic swelling of the abdomen, a most unfavorable sign. The expulsion of wind with crepitus, a good sign. (Rush.) Bloody stools without tenesmus, in the latter periods of bilious, malignant, or other violent typhoid fevers, highly un- favorable; less dangerous in strictly inflammatory fevers. Involuntary discharge of faeces, among the most unfavorable signs. Vomiting. Black flocculent discharges, from the sto- mach, exceedingly dangerous;— less dangerous, when the black or porracous matter is not flocculent but uniformly mixed with the other fluids thrown up. A rumbling noise in the stomach, when liquids are swal- lowed, a bad sign — never occurs in the early periods of fever, and generally attended with meteorism. Sud- den and very forcible ejection from the stomach is un- favorable — it occurs in yellow fever. (Rush.) Very frequent vomiting, with great tenderness in the epigas- trium, in fevers, a very unfavorable sign. The tongue: covered with a brown or black crust, with deep cracks in it, dangerous ; black and dry, with black sordes adhering to the teeth, highly unfavorable; a dark brown, contracted, hard, and shrivelled tongue, almost always fatal; tongue soft, moist, and light red, favorable ; secretion of saliva, a good sign ; difficulty of putting out the tongue, and then keeping it between the teeth a long time, without retracting it, is a bad 26 GENERAL PROGNOSIS. sign — a total inability to protrude it, alike unfavora- ble; a red, smooth, and shining, or a pointed, dry and red (round the edges) tongue, indicates considerable danger — it is a sign of strong gastro-enteritic inflam- mation. Total absence of thirst, with a dry and rough tongue, is a bad symptom. Besides the appearance enumerated above, a variet)' of other circumstances demand attention, in forming an opinion as to the probable event of diseases. Thus, inflammatory fevers are generally less dangerous than remitting fevers; and these latter, less dangerous than typhus and malignant fevers. In general, the more a fever is connected with local inflamma- tions — or rather, the more serious the local inflammations are, from the importance of the parts they attack, the more danger is to be apprehended. The type, too, must be taken into view. As a general rule, intermittents are less danger- ous than remittents, and remittents less than continued fe- vers. The more irregular the type of typical fevers, the more unfavorable. The appearance and progress of what are termed the crises will also aid in forming a prog- nosis. Unusual or contradictory phenomena are unfavorable; when a patient declares himself well, at the same time that the symptoms indicate considerable disease, it is a bad sign. CRISIS CRITICAL DAYS. The ancients observed certain regular periods in the course of many febrile diseases, at which prominent changes are wont to occur, accompanied by certain evacuations, and followed generally by temporary or permanent abatement of the symptoms. These eva- cutions, and their associated phenomena, are termed : Crises. No febrile or noxious matter, as was once supposed, thrown off by these critical evacuations. Critical discharges theeffect,not the cause of the me- lioration of disease which follows, or attends their occurrence. The doctrine of critical days gener- ally discredited at present; there is probably good foundation for the doctrine. Crises divided into simple and compound; in the simple, the evacua- tion is made through one emunctory only — in the compound, through several. The most prominent precursory phenomena (perliirbalioncs critica) of GENERAL PROGNOSIS. 27 crises are : an increase of all the symptoms — watch- fulness, chills, and rigors —tremor of the whole body — anxiety and jactitation — quick and irregular re- spiration — obtuseness of hearing — vertigo — coma, &c. There are certain days in the course of fevers upon which crises are particularly apt to occur. These are the critical days; crises occur however occasionally on other days. The critical days, ac- cording to Hippocrates, are the 3d, 5th, 7th, 9th, 11th, 14th, 17th, 21st, 27th, and 34th. According to Cullen, the 20th, not the 21st day, is the critical day — he acknowledges no critical day beyond the 20th. Critical days divided into perfect, second- ary, and intercurrent. Galen regarded the 7th, 14th, 21st, 28th, or the septenary periods as the true critical days;— the secondary, are the intermediate days between these septenary periods, i. e. the 4th, 1 1 th, 18th, 25th, &c. The intercurrent days are the 5th, 9th, 13th. (Galen.) All forms of fever appear to have a tendency to some one of the principal types. A single tertian may be regarded as fe- ver in its elementary form. In this form a paroxysm and crisis occur on every odd day. Now if we consider a conti- nued fever as made up of tertian paroxysms, protracted and running into each other, we perceive from its tendency to the original type, how the phenomena of crisis should occur on the odd days. Salutary may be distinguished from insalutary dischar- ges by the following circumstances. To be salutary, they must be neither too copious, nor too scanty; they must correspond with the nature of the fe- ver, — haemorrhage is most salutary in inflammatory, and diarrhoea, in bilious fevers — perspiration is more beneficial in catarrhal fevers than diarhcea. A dis- charge from one emunctory only, seldom beneficial ; perspiration is never salutary unless the urine at the same time becomes charged with a sedimentous matter; and vice versa. '28 GENERAL PROGNOSIS. The evacuations (critical) which usually attend the com- mencement of convalescence, are: Critical hemorrhages : generally preceded by increase of arterial action ; and salutary, partly from the loss of the blood, and chiefly by the new arterial excitement by which they are attended. It is owing to the previous excitement of the arterial system, essential to this kind of critical evacuation, that it cannot be substituted by an artificial abstraction of blood. This fact proves, that such evacuations do not, strictly speaking, pro- duce the amendment which follows, but that they are effects or manifestations, of a previous salutary change in the vital actions. Crisis by haemorrhage is chiefly confined to inflammatory fevers; occurs sometimes in typhus fevers; epistaxis, the most common critical haemorrhage — usually pre- ceded by flushed face, red and suffused eyes — sneezing, ringing in the ears, &c. Critical sweat. The most common crisis ; must be gene- ral over the body, attended with a warm skin and turbid urine. Its approach indicated by: a soft, full, wave-like pulse; a stinging, or itching sensation on the surface, red, warm skin and scanty urine. Critical discharge of urine: must be copious ; the morn- ing urine best for inspection; critical urine exhibits at first, a cloud, floating in the upper part of the vessel — then a globular body about the middle — and finally a sediment; (Vogel, Richter, &c.) should be attended with a soft or moist skin; preceded by pains in the loins; frequent inclination to urinate; uneasy or burn- ing sensation in the genital organs, dry, harsh skin; thirst, and a soft and active pulse. Critical almne discharges: most frequent in bilious fe- vers — occur during the remission of fevers — are copi- ous ; signs of approach, a peculiar trembling of the under lip — stammering — a full, active pulse, pain and noise in the bowels ; discharge of wind — moist tongue —paucity of urine. (Richter.) Critical emesis, very uncommon. GENERAL PROGNOSIS. 29 By crisis, in the most general acceptation of the term, is un- derstood that period in the course of a fever, at which a deter- mination either to death or convalescence takes place, and in which therefore the fate of the patient is determined. This decision must necessarily always occur in the ultimate point of violence of the disease. CHAPTER V. OF THE GENERAL COURSE, TYPE, AND STAGES OF FEVER. Fevers divided in relation to their course into: Acute, and Chronic. The former generally make their attack suddenly, and proceed through their course in a comparatively short period . The latter commence less violently, and pass slowly through their course. In general, the more violent the disease, the more ra- pid its progress. The course of a fever may be divided into five periods. (See Pract. Med. p. 61.) 1. The forming stage — the period between the im- pression of the febrific cause and the development of the fever; — distinguished by certain phenome- na, called premonitory symptoms Its duration very various ; not always attended by signs of de- viation from health. In general, the more pro- tracted the premonitory signs, the more protracted, or slow, will be the course of the subsequent fe- ver, &c. 30 GENERAL COURSE, &C OF FEVER. It is during the struggle between the system and the morbific cause — while the former is gradually yielding to, and passing under the dominion of the latter, that the premonitory symp- toms occur. The most common premonitory symptoms are.- loss of appetite: irregular bowels; yawning, stretching; mal aise; interruption of ordinary ha- bits and appetites, such as disgust for tobacco, coffee, cordial oppression, and muscular prostration, very con- siderable in the commencement. Stiffness and dull pain in the muscles of the neck. The eruption ap- pears on the second or third day of the fever, at which time the fauces exhibit a swollen and inflamed appear- ance, attended with painful deglutition. Pulse fre- quent, and more feeble than in the simple variety. In- tense heat of the surface, and great thirst. Tongue dry, and very florid along the edge ; great restlessness and prostration. Ulcers on the tonsils, particularly if the fever continues beyond the fifth day. White flakes of coagulable lymph, adhering to the tonsils, readily mis- taken for ulcers. The ulcers generally cast off superfi- cial sloughs, as the fever declines, and then heal ; some- times they become foul, and discharge a thin and acrid fluid, which being swallowed, occasions exhausting diarrhoea. Deep and fatal coma sometimes occurs in the stage of excitement. Abdominal inflammation casionally supervenes. Anasarca, a frequent conse- quence of S. Anginosa. Scarlatina Maligna, commences like the former varie- ties. Eruption, at first pale, assuming afterwards a dark or livid red color; very variable in its duration, and time of appearance. Heat of the skin variable, and seldom great. Pulse, at first, active, soon becoming small and feeble. Delirium an early symptom. Eyes dull and heavy, and cheeks livid. Greyish ulcers soon visible on the tonsils — becoming finally covered with dark sloughs. Fauces clogged with viscid phlegm, im- peding respiration. A thin acrid fluid discharged from 130 SCARLATINA. the nostrils, in the advanced period of violent cases. 8. Maligna differs from S. Anginosa, principally in the sudden and dangerous collapse which occurs in the former. The supervention of the collapse, announced by diminution of the heat of the surface, great prostra- tion, frequent and feeble pulse, dark brown or black tongue; petechia and haemorrhage, occur towards the conclusion of fatal cases — seldom before the tenth or twelfth day. Dr. Armstrong's division of S. Maligna, into three varieties, viz. the inflammatory, the conges- tive, and the mixed. Treatment. Emetics, of great benefit in the forming stage, particularly of the anginose and malignant va- rieties. Gentle purgatives, and the warm bath strong- ly impregnated with salt, are also decidedly beneficial in this stage. During the stage of excitement of the mild variety of the disease, purgatives, tepid affusions, cooling drinks, ventilation, a light diet, with rest, are in general all that is required. The daily employment of mild laxatives, and the careful avoidance of expo- sure to cold and damp air, is the best mode of prevent- ing the dropsical swellings, so apt to occur during convalescence. In the stage of excitement of 8. An- ginosa, cold affusions are highly useful. Cold affu- sions and purgatives most beneficial, when used con- comitantly, particularly during the first three days of the stage of excitement. (Armstrong.) After the third day, the affusions should be tepid, unless the general excitement and heat of the skin still remain very considerable. The skin must be above the natu- ral temperature, and dry, to justify the use of cold af- fusions. When visceral inflammation exists, with an active pulse, bleeding will be proper, — when, however, general debility accompanies the local inflammation, our dependence must be placed on the internal exhibi- tion of opium with calomel, and the application of emollient cataplasms over the inflamed organ. Blis- ters useful, in such cases, during the first few days of SCARLATINA. 131 ihe stage of excitement — in the stage of collapse, they do harm ; rubifacients maybe employed advantage- ously. To cleanse the ulcers in the fauces, and expel the viscid matter lodged there, emetics are often decid- edly useful ; gargles, acidulated with nitric or sulphur- ic acid, are beneficial. Moderate portions of wine, and the milder tonics, useful during the stages of collapse, and convalescence. In the inflammatory variety of S. Maligna blood-letting is an important remedy. The benefits of bleeding con- fined to the first twenty-four or thirty hours of the stage of excitement; the blood should be suffered to flow, until a decided impression is made on the system. Purgatives particularly serviceable, during the stage of excitement, in this variety; and calomel is the best article for this purpose. Tepid affusions, to be used during the use of purgatives. The highly inflammatory form of Scarlatina Maligna, when treated by prompt bleeding and purging, in the early period of the stage of excitement, seldom sinks into a low collapse; and when this stage supervenes, after the employment of proper depletion, in the commencement, itis rarely necessary to resort to active tonics or stimulants. When the disease assumes the congestive character — that is, when, instead of manifest febrile excitement, the face remains pale, the skin cool, the sensorial functions blunted, with great anxiety and prsecordial oppres- sion, the warm saline bath, followed by stimu- lating frictions, and the application of bottles or blad- ders filled with hot water, together with the free use of warm diaphoretic ptisans, such as infusions of catnip, balm, or eupatorium perfoliatum, and large doses of calomel, (fifteen or twenty grains) are the remedies to be particularly relied on. Dr. Armstrong advises bleeding, which, though a hazardous remedy, may, with cautious management, do much good. Calomel in large doses, particularly efficacious. Having estab- lished a general febrile reaction, by the means just men" 132 ERYSIPELAS. tioned, recourse should be had to the milder stimulat- . ing remedies, such as infusion ofserpentaria,wine whey, and, as the disease advances, and the signs of prostra- tion become more prominent, carbonate of ammonia, wine, camphor and opium. Capsicum, an excellent medicine inthestage of collapse, both as a gargle, and as an internal remedy. Two table-spoonfuls of red pepper, and two tea-spoonfuls of cu- linary salt, are to be beat into a paste, on which half a pint of boiling water is to be poured, and strained off when cold. An equal quantity of very sharp vinegar being added to this in- fusion, a table-spoonful of the mixture, every hour, is a pro- per dose for an adult. Mr. Stephens asserts^ that he gave it in four hundred cases, many of which it cured, after they had assumed the most alarming state. I have, in a few instances, employed this remedy with signal advantage. Cinchona, formerly much employed in this disease; it is inferior, however, to the carbonate of ammonia and opium, capsicum, serpentaria, and camphor. ERYSIPELAS*. General description. Fever, varying in different cases, from the highly inflammatory to the low typhous grades. Superficial inflammation sometimes preceded, at oth- ers followed by the fever — commencing in an irregu- larly circumscribed blotch, and soon extending itself over a greater or less extent of surface; no pulsation or tension felt in the inflamed part, the pain being of the burning and pungent kind; tumefaction often conside- rable. Small vesicles, or blisters, containing a limpid fluid, appear after the inflammation has continued for some time. When resolution is about taking place, the inflamed and red surface becomes pale or brown- ish-yellow; soon after which the cuticle desquamates 1 . No regularity, either in the duration of the inflamma- tion, or its time of appearance. Erysipelas occurs under several modifications, each ma- nifesting prominent peculiarities, both in relation to the local and general phenomena, viz. ERYSIPELAS. 133 1. Erysipelas phlegmonodes. Fever, of the syno- cha grade; erysipelatous inflammation, generally occurring in the face — sometimes on the extremi- ties. Color, bright red; swelling, about the se- cond day of the fever ; and vesicles about the fourth day ; about the sixth day, the swelling and fever begin to subside, and desquamation of the cuticle takes place by the eighth day. Very rarely ter- minates in suppuration. In old people, sometimes protracted to the twelfth or fourteenth day. Dif- fers principally from the other varieties, in the high grade of febrile excitement which attends it, 2. Erysipelas cedematodes. Color of the inflamed skin, pale red or yellowish brown; heat and burning pain, inconsiderable ; swelling comes on gradually, has a shining surface, and pits, on strong pressure. Vesicles are very numerous and small — burst , on the second or third day, and change to dark colored scabs. When the head is affected, the swelling is so great, as to close the eyes, and render the whole face exceedingly bloat- ed. Vomiting is an early symptom, and delirium and coma often supervene, as the disease ad- vances. The debilitated, and habitually intem- perate, most subject to this variety of the disease. Dangerous, when the head is its seat — rarely so, when the extremities alone are affected, except when it terminates in suppuration. 3. Erysipelas gangrenosum. Usually occurs in the face and neck; attending fever of a typhous grade; slow delirium and coma, almost invari- ably attend throughout its whole course; inflamed skin, of a dark red or livid color ; blisters small but not numerous, often terminating in gangre- nous ulcers. Suppuration and gangrene of the cellular substance very common. Always tedious and dangerous. 4. Erysipelas eraticum. Inflamed blotches appear 134 ERYSIPELAS. ing in succession on various parts of the body — the first blotches generally disappearing before the last make their appearance. 5. Erysipelas neonatorum — a variety of the dis- ease peculiar to infants soon after birth. It al- most always commences about the genitals or um- bilicus, and thence spreads over a greater or less extent of the body. The affected parts swell con- siderably, become hard, are of a dark red color, and very painful to pressure. Generally connect- ed with green and fetid discharges from the bow- els, and colic pains ; it continues from seven to fourteen, or even twenty-one days. Apt to termi- nate in gangrene and tedious suppurations. Suppuration, in erysipelatous inflammation, always com- mences in the cellular membrane; the pus formed is thin and acrid, and never collected in circumscribed cavities. Erysipelatous inflammation, sometimes extends to the in- ternal viscera — not by metastasis, as some have alleg- ed, but by a spreading of the inflammation from the external to the internal parts. The organ most com- monly thus affected is the brain — an occurrence gene- rally fatal. There is a variety of erysipelas, attended with prominent symptoms of disorder of the biliary system, and fever of the synochus grade. This is the erysipelas phleg- monodes biliosum, which has been lately so well des- cribed by Mr. Copeland Hutchinson. The fever in this variety of the disease, resembles the ordinary bi- lious remitting fever. The whole surface, in some cases, acquires an icteric hue. The pain and irrita- tion are great. Causes. A natural predisposition to this a disease appears to exist in some instances. Habitual intemperance in persons of a cachectic disposition, predisposes'to ery- sipelas. In persons either naturally or accidentally predisposed to the disease, it may be produced by lo- ERYSIPELAS. 135 cal injuries, particularly of the scalp. Violent rage has been known to produce it. (Richter.) A peculiar constitution of the atmosphere, and hence its occa- sional epidemic appearance. Intestinal irritation; this I believe to be a very frequent cause of erysipelas ; it is unquestionably so in infants. The contaminated air of crowded and ill-ventilated apartments; hence its frequency in ill- ventilated and crowded hospitals. Derangement of the biliary organs. Some observa- tions on the inflammation produced by the rhus toxi- codendron. Treatment. — The general treatment must accord with the character of the attending fever. It must be strictly antiphlogistic, when the fever is of the synocha grade ; though frequent or copious bleeding is rarely neces- sary, unless coma or violent delirium exists. Cathar- tics are among the most useful general remedies in this disease. Purging is especially beneficial when the face is affected. The saline cathartics the best in the phleg- monoid variety ; calomel to be preferred when symp- toms of biliary disorder attend. Two or three alvine evacuations should be procured every twenty-four hours. Emetics highly beneficial in the beginning of the disease — more especially in the bilious modifica- tion. Diaphoretics are serviceable. The saline mix- ture, with a small portion of tart, antim. a good dia- phoretic. I have derived much benefit from small doses of ipecac, and calomel in combination. When the fever is of a typhoid grade, mercurial laxatives, in conjunction with stimulants or tonics, are to be chiefly relied on; the carbonate of ammonia, and sulphate of quinine , exceedingly valuable in such cases. Opium with sulphate of quinine, particularly valuable after symptoms of gangrene have made their appearance in the gangrenose variety. In the early period,however, of this variety, free purging with calomel, will render the necessity of stimulants and tonics less urgent in the latter stages. 136 ERYSIPELAS. After suppuration has taken place, opium, camphor, and quinine, are to be employed in doses corresponding to the degree of prostration. In every variety of this disease, laxatives are of primary im- portance. From considerable experience in the treatment of this malady, I am satisfied that alterative doses of calomel, with the daily employment of saline purgatives, will do more towards the reduction of the disease, than, perhaps, any other plan of general treatment that can be adopted. The calomel may be advantageously combined with small portions of ipeca- cuanha. One grain of the former, and three of the latter may be given every four hours. Local Treatment. Certain external applications gener- ally decidedly beneficial, the assertion of Bateman and others to the contrary notwithstanding. Cold applica- tions, such as solutions of sugar of lead, cold water, or emollients, generally do harm, The applications must be of a stimulating cliaracter. A solution of corro- sive sublimate in water, in the proportion of four grains to an ounce of water, is an excellent application. The blue mercurial ointment is also a very good local re- medy ; I have frequently employed it with much ad- vantage .* I have also used a weak solution of sul- phate of copper, with prompt success. A solution of lunar caustic, in the proportion of four grains to one ounce of water, will sometimes do much good. I have used it in two instances with manifest advantage. Blisters are often highly useful. They must be laid im- mediately over the inflamed surface. Lard, used by Brodie with benefit. * Both these remedies were first recommended by American physi- cians; the former, by Dr. Schott of Philadelphia, and the latter, by Dr. Dean of Chambersburg. H^EMO RRH AGI.E. 137 CHAPTER XVI HJIMORRHAGIi;. Haemorrhages are divided into active and passive. In the former there is a preternatural determination of blood to the place from which the haemorrhage occurs, with an increase of local vascular action, heat, and co- lor. In the latter, there is no sanguineous congestion, nor increased activity of the capillaries from which the blood flows. Bichat contends that, whether of the ac- tive or passive kind, spontaneous haemorrhages are al- ways mere sanguineous exhalations, and never the consequence of rupture of a vessel. This opinion is not sustained by general observation. Haemorrhages occur much more commonly from the mucous membranes, than from the other structures of the body. Local congestion, in the part from which the blood flows, is almost invariably present. This congestion may be the result of an irritation existing in the part, or of one seated elsewhere. Excessive loss of blood, with the excess of serum — intestinal irrita- tion — organic disease — obstruction. A natural predisposition to haemorrhage exists in some individuals — and this is even hereditary in some in- stances. Remarkable instances of this kind are on record. The predisposition to the different kinds of haemorrhage, varies with the age of individuals. Thus the haemorrhages of young people, occur generally from parts situated above the diaphragm ; whilst in per- sons of advanced age, they are most apt to take place from parts situated below this dividing, muscle. Du- ring childhood, bleeding from the nose is most com- mon; between the age of puberty and thirty years from 138 EPISTAXIS. the lungs; in middle life from the rectum, and in very old people, from the kidneys and bowels. Prognosis. Passive haemorrhages more dangerous than active ones. The cause of this explained. When they depend on organic disease, they are more intrac- table. The prognosis depends, in a great degree, on the organ from which the haemorrhage proceeds; a haemorrage from the lungs being cceteris paribus, more dangerous than one from the stomach. The general indications in the treatment of haemorrhages are, 1. To diminish the momentum of the blood in the general circulation, when it is preternaturally aug- mented ; 2. To lessen the determination of blood to, and moderate the local vascular action in, the part from which the haemorrhage occurs. The diet should be simple and unirritating. EPISTAXIS. Premonitory symptoms of the active variety. Weight and tension in the temples; throbbing pain in the head ; strong pulsation of the temporal arteries; ringing in the ears; vertigo; flushed countenance; tickling in the nose. In weak and irritable subjects, there are, in ad- dition to these symptoms, others denoting a nervous or spasmodic condition, viz. creeping chills; a copious flow of pale urine; disposition to syncope; cold extre- mities, &c. The blood seldom flows from both nos- trils at the same time. Exciting causes. Whatever is capable of causing a pre- ternatural determination of blood to the* head, may produce this haemorrhage. Prognosis. Frequent bleeding from the nose during childhood, is often connected with a natural predispo- sition to haemoptysis and phthisis in after-life. When epistaxis occurs frequently in advanced age, we may presume the existence of visceral obstruction, or pre- disposition to apoplexy. It may be regarded as salu- HJ3MATEMESIS. 139 tary in the stage of excitement, in all forms of fever; in the stage of collapse, it is a fatal sign. Epistaxis most dangerous in debilitated and irritable subjects. Seldom, though sometimes fatal, from the mere loss of blood. Treatment. When this haemorrhage occurs in conse- quence of the suppression of some habitual sanguineous evacuation, it must not be arrested unless it become excessive. When it is attended with a strong pulse, and with manifest symptoms of cephalic congestion, bleeding from the arm, and warm pediluvium, cold ap- plications to the head, cooling drinks, the internal use of large doses of nitre, laxative enemata, and rest with the head in elevated position, are the measures to be principally relied on. Styptics are improper under the circumstaneesjust men- tioned—they are often required, however, in cases at- tended with feeble arterial action, from exhaustion or habitual debility. The most useful styptics are, alum, kino, spirits of turpentine, and sugar of lead. In obsti- nate cases, a blister to the back of the neck, will often succeed after other applications have failed. The inter- nal use of sugar of lead, is an excellent remedy in ev- ery variety of spontaneous haemorrhage. Mechanical compression, by means of dossils of lint introduced into the nostrils, rarely fails to arrest the bleeding. H2EMATEMESIS* Premonitory symptoms. These are almost always pro- minent. The principal are ; weight and pressure in the stomach, want of appetite, or voraciousness, acid eructations, pain in the hypochondria, nausea, anxiety, ringing in the ears, disposition to syncope, small, con- tracted, and irritated pulse, alternate flushes of heat and chills, palpitation, cold extremities, pale and contracted countenance, and finally, increasing anxiety and con- striction about the breast, and obtuseness of the senses. 140 HiEMATEMESlS. The quantity of blood thrown up is generally conside- rable, and almost always very dark — sometimes in clots, occasionally, quite fluid. Relief is felt after the blood is thrown up. The darker the blood, the longer it must have lain in the stomach, and the slower must have been the effusion. A portion of the blood al- ways passes into the bowels, and is afterwards evacu- ated by stool. Causes- Impeded circulation of the blood in the abdo- minal viscera, from visceral indurations; hence its fre- quency in habitual drunkards. Suppressed menstrua- tion ; particularly in females soon after the age of pu- berty, Suppressed hsemorrhoidal discharge; habitual constipation ; pregnancy ; mechanical injuries or erosion of the mucous membrane of the stomach. Prognosis. Not attended with great danger, when it occurs in conseqnence of suppression of the menses, or hsemorrhois; by recurring frequently, however, it leads to dropsy, inveterate dyspepsia, hysteria, hypochondri- asis, &,c. It is not apt to become habitual. It is more dangerous when it arises from visceral indurations^ Treatment. Bleeding, when the pulse is tense and corded. Revidsices, (i. e.) sinapisms to the epigas- trium, or dry cupping ; warm pediluvium, purgative en- emata. Internal styptics, viz. sugar of lead, muriated tincture of iron; spirits of turpentine; alum-whey; mu- riate of soda ; cold water ; decoction of nettles, (urtica tlioica.) Of these I have found the spirits of turpen- tine the most effectual. From ten to fifteen drops are to be used every half hour. Internal remedies are, however, rarely particularly beneficial, incases depend- ing on organic visceral disease. In chachectic females, the muriated tincture of iron is an excellent internal remedy for habitual haematemesis. Emetics lately re- commended by Dr. Sheridan. Purgatives strongly recommended by Hamilton, particularly when the disease occurs in females between the ages of eighteen HEMATURIA. 141 and thirty, and is unattended by visceral disorganiza- tion. I have used them with advantage. HEMATURIA. The haemorrhage may proceed from the urethra, the blad- der, the ureters, or the kidneys. When from the urethra, the blood is unmixed with urine, and flows without any evacuant effort. When from the bladder, there is dull pain or a sense of uneasiness in the region of this viscus, accompanied with painful erections, and burning pain in the glans penis — the blood not being intimately mixed with the urine, but suspended in small flakes or coagula in it. When the blood comes from the kidneys, it is very intimately mixed with the urine, without flakes or small coagnla, and settling down into a uniform mush-like substance at the bottom of the ves- sel in which the urine is left standing. Old people, particularly those who are affected with hse- morrhois, are most subject to this haemorrhage. Cor- pulent and plethoric females are apt to void bloody urine, about the period when the menses cease to recur. Causes. Mechanical irritation from calculi or other causes ; acrid substances conveyed to the bladder, eith- er through the medium of the circulation, or by injec- tion ; organic affections of the urinary passages ; sup- pression of menses or hsemorrhois ; gonorrhoea j denti- tion. (Richter.) Prognosis. Seldom attended with immediate danger. When habitual, it is apt, in old people, to terminate in dropsy. Treatment. Bleeding when the pulse is active, assisted with purgative enemata. When occasioned by calcu- li, opium, with sugar of lead, and the warm hath, are generally beneficial. When acrid or stimulating sub- stances conveyed into the bladder through the circula- tion, or otherwise, are its cause, the free use of mucila- ginous drinks, with opium, will prove most beneficial. 142 HJSMORRHOIS. The muriated tincture of iron, is an excellent inter- - nal astringent in cases not immediately the consequence of irritation from calculi, or other irritating substances. Twelve drops may be given three or four times daily. In habitual hematuria, a caustic issue on the inner part of the thigh, or near the groin, on the abdomen, has been known to do much good. Uva ursi, decoc- tion of peach leaves, and other astringents rarely bene- ficial. iOEMORRHOIS PILES. A discharge of blood, without tenesmus, from small vari- cose tumours on the verge of or within the anus. When these tumours do not discharge blood, they are called blind piles, Qwemorrhoides cobcub?) They are called external or internal, according as they are situated within or without the anus. Premonitory symptoms. Before the blood begins to flow, the patient usually experiences various affec- tions: viz. head-ache, vertigo, stupor, drowsiness, diffi- culty of breathing, nausea, colic pains, pain in the loins, a sense of fulness and heat, itching and pain about the anus, and often slight fever (molimina he- morrhoid alia.') The blood sometimes flows, only when faeces are evacu- ated — sometimes it flows without the discharge of fae- ces. The loss of blood is often very great. I have known it so great as to prove fata! . It not unfrequent- ly induces great debility, terminating in a leucophleg- matic condition, or dropsy. A sudden cessation of haemorrhoidal flux, is apt to be followed by other and more dangerous affections, as apoplexy, palsy, asthma, &c. Causes. These are sometimes entirely local in their cha- racter and operation, viz: pregnancy, parturition, irri- tating purgatives and enemata, protracted constipation, ascarides, sedentary employments, compression of the abdomen, by tight clothing, &c. There exists in some HJEMOPTISIS. 143 individuals a natural predisposition to haemorrhois. In such persons, every thing that has a tendency to promote congestion in the portal circulation, will rea- dily give rise to the disease, particularly between the thirtieth and fiftieth years of age. Females, who men- surate regularly, are less subject to it than males. It rarely occurs in children. Treatment, May we safely attempt to remove or sup- press this disease? When it depends on local causes, and has not yet become habitual, the sooner we re- move it the better. In cases, however, that depend on constitutional predisposition, and that have not become habitual, from long continuance, or frequent repetition or where the general health, or some other chronic af- fection, has been improved by its supervention, it is ne- cessary to proceed with caution in the application of remedies. In many instances the hemorrhoidal dis- charge obviates other and much more dangerous ma- ladies, by removing or diminishing congestion in the abdominal viscera — a source of much more disease than seems to be commonly supposed. The principal indications are: to counteract inflammation, and local plethora in the parts ; to obviate the occasional causes of the disease, and to moderate the discharge, when excessive, by local applications. To answer these in^ tentions, mild aperients, rest in a horizontal posture, simple and unirritating diet, cooling drinks, cold and mildly astringent applications, will in general suffice. When the inflammation runs high, general blood -let-, ting, with emollient and anodyne applications, are be- neficial. ILEMOPTISIS. Haemoptisis is generally preceded by slight chills, cold extremities, constriction in the breast, palpitation, alter-- nate flushing and chillness,an irritated, contracted, and feeble pulse, dryness of the fauces, a salty or sweetish 144 H^EMOPTISIS. taste, a sensation of warmth rising in the breast, atten- ded with a saltish taste, slight cough, and finally, hae- morrhage. Sometimes, however, it comes on suddenly. The quantify of blood brought up, is generally small, and mixed with the natural mucus of the bronchia; occasionally the bleeding is rapid and copious. Predisposition. Some individuals have a natural pre- disposition to this variety of haemorrhage. Such per- sons have narrow and depressed breasts, high shoul- ders, long and slender necks, fair hair, blue eyes, de- licate and fair skin, sound and very white teeth, red cheeks, a clear but feeble voice — they are irritable and passionate, and subject to glandular swellings about the neck, and catarrhal affections, which pass off slow- ly. They are most liable to this haemorrhage, between the ages of fifteen and twenty-five. Exciting Causes. Atmospheric vicissitudes; violent bo- dily exertions ; the abuse of spirituous liquors ; suppres- sion of habitual discharges; repulsion of chronic cuta- neous eruptions; drying up old ulcers or issues ; metas- tasis of gout; mechanical irritation of the respiratory passages, by particles of matter floating in the air, or gaseous substances; intestinal irritation; organic dis- eases of the heart, pregnancy, &c. Prognosis. Rarely fatal merely from less of blood — ge- nerally the first decided step towards consumption, particularly in such as are naturally predisposed to it. When no predisposition to phthisis is present, haemo- ptisis will frequently pass off, without terminating in the former malady. Treatmant. Blood-letting is indispensable, when the pulse is tense and hard. It is necessary to draw blood until the pulse becomes soft. A large sinapism should be immediately applied to the breast. Astringents gi- ven internally will sometimes put a prompt stop to the haemorrhage, particularly after venesection. Sugar of lead is the best article of this kind ; when the pulse is weak, it may be advantageously combined with opium. PHTHISIS PULMONALIS. 145 From one to two grains of the lead may be given ev- ery twenty minutes, until the bleeding is checked. In violent cases, six or eight grains should be given at once. Large doses of nitras potasste, are an excel- lent remedy in pulmonary haemorrhage ; it may be given in combination with tart, antimony. Common salt is a familiar and useful remedy in haemoptisis. In chronic spitting of blood, digitalis, with milk or a farinaceous diet, the occasional loss of small portions of blood, blis- ters to the breast, and the careful avoidance of every thing that can cause inordinate excitement, are the principal remediale measures to be depended on. Wearing flannel next the skin, and avoiding the influ- ence of sudden changes of weather, are circumstances of much importance, in the chronic form of the disease. Nothing, perhaps, is equal to a uniformly warm climate. PHTHISIS PULMONALIS. Consumptive symptoms may arise from various and dis- tinct pathological conditions. They may depend on 1. Chronic bronchitis; % Ulceration of the larynx or trachea; 3. Chronic pleuritis; 4. Inflammation and sup- puration of the substance of the lungs: and 5. Tuber- culous matter in the pulmonary tissue, constituting ge- nuine phthisis pulmonalis. The first variety is generally the result of catarrh, and usually called catarrhal phthisis. This, of all the va- rieties of consumption, is the most sanable, particular- ly so long as the inflammation of the mucous mem- brane does not extend to the subjacent parts, or has not terminated in ulceration. The diagnostic symp- toms in the early stage, are : Countenance pale ; lips bluish; hands and feet often cold, and the temperature of the surface variable; cough deep, and expectoration free from the beginning; slight soreness in pharynx; much oppression, but little or no pain in the chest; cough rarely excited by full inspiration. Cough al- 146 PHTHISIS PULMONALIS. ways severest in the morning, attended with wheezing respiration, until the mucus, collected during the night, is expectorated. In all these circumstances, it diners from tuberculous phthisis. In the advanced stage, it cannot be distinguished from the latter, or genuine form of the disease. Catarrhal consumption often goes on to a fatal termina- tion, without any breach of continuity or ulceration whatever — the pus expectorated being a mere secre- tion from the inflamed bronchial surface. When this variety of consumption is connected with prominent derangement of the liver and stomach, it forms what has been denominated dyspeptic phthisis. In this combination, we have, in addition to the ordinary symptoms of phthisis, dyspeptic symptoms, — such as, furred tongue, foul breath, unnatural stools, capricious appetite, distended epigastrium. The majority of consumptions, in this and similar cli- mates, are of the catarrhal or bronchial kind. When ulceration of the larynx or trachea is its cause, the disease is called laryngeal or tracheal phthisis. This is a rapid and fatal disease, the instances of reco- very being exceedingly few. One of the first, most constant, and characteristic symptoms, is a change of voice — losing at first its clear sound — then becoming hoarse or indistinct, and finally scarcely audible. — When the larynx is principally affected, we have the following characteristic phenomena: pain in the larynx, increased by coughing and pressure; cough most vio- lent in the morning, on rising out of bed ; suddenly and violently excited, by inhaling cold air and irritating va- pors, by swallowing food, and by the use of irritating gargles and acid drinks. When the trachea alone is affected, the pain is always increased by bending the head backwards, or turning it round, and is generally felt about its bifurcation. The cough is not excited by gargles, or the inhalation of cold air and vapours, but readily by active bodily exercise, and by swallowing — PHTHISIS PULMONALIS. 14? the cough not coming on until the food has descended as low down as the sternum, when it is often brought up again. Inspiration, during coughing, is generally stridulous, as in croup. The fits of coughing are fre- quently preceded by sneezing. In coughing, the patient puts his hand to the throat, near the breast. The ex- pectoration generally consists of small portions of yel- low pus, suspended or mixed with a large portion of bronchial mucus. The most frequent causes of this variety of phthisis are catarrh, whooping-cough, croup, and syphilis. Chronic pleuritis, gives rise to the third variety of phthisis. It is the result of effusion into the cavity of the chest — a termination which always takes place, sooner or later, in chronic inflammation of the pleura. - As the effusion increases, the lung on the side on which it occurs, becomes more and more compressed, until it is reduced to so small a bulk, as to seem almost com- pletely destroyed. Sometimes ulceration takes place in the pulmonary pleura, in which case, the effused pur- ulent, or sero-purulent fluid, is discharged by cough- ing. When this occurs, hectic, with its usual train of symptoms, ensue. This variety of phthisis is charac- terized by: increased oppression in the breast, on lying down ; anhelaiion, by ascending stairs , or other bodily exercise; alleviation, in a sitting posture; generally, some soreness of the integuments of the affected side; pain in the side, confined to a certain space ; difficulty of breathing, progressively increased; and, finally, th^ absence of pus in the expectoration, and irregularity in the hectic symptoms. This variety of phthisis is of a very fatal character ; though instances of recovery do sometimes occur, by; 1. A gradual absorption of the effused fluid, the lungs form- ing adhesions with the costal pleura; 2. The escape of the fluid, by the formation of a fistulous passage from the cavity of the chest into the bronchial tubes; 3. By the formation of an opening through the inter- costal spaces, and the escape of the fluid externally. 14S PHTHISIS PTLMONALIS. Iiifl rmmafion, terminating in pulmonary abscess, con- stitutes the fourth variety. This variety is of very rare occurrence. Tubercular phthisis. This variety occurs only in per- sons of a strumous or scrofulous diathesis. Tubercles never formed, withouta naturalpredispositionto them. They are scarcely organized, being probably formed by exudations into the cellular tissue of the lungs. They do not always lead to consumption — remaining dormant sometimes, without materially affecting the general health. Their formation sometimes very rap- • id; in which case the usual phenomena of inflamma- tion generally attend. Tubercles are never absorbed; hence the utter incurableness of perfectly formed tuber- culous phthisis. The conversion of tuberculous sub- stance into a fluid, not the result ofsuppuration,butof a peculiar process of softening. (Laennec.) The sur- face of the cavities of softened tubercles, is lined with a white, opaque, and soft membrane. Pus is afterwards secreted by this membrane. (Bayle.) Under this membrane, another one is formed, as the disease ad- vances, of a white, semi-cartilaginous appearance, which eventually forms a complete lining to the ulcerous exca- vations, and gives them a fistulous character. This latter membrane exists sometimes before the softening has taken place — constituting the encysted tubercle of Bayle. There is often more or less chronic bronchi- tis, co-existing with pulmonary tubercles; and hence puriform expectoration may occur, before these tu- mours have undergone the softening process. (Pearson.) There are two, and sometimes three, morbid processes, in every case of tubercular phthisis; 1. Tubercular ac- tion; 2. Chronic bronchitis; 3. Inflammation of the pulmonic tissue, generally chronic. Although art cannot cure tubercular phthisis, in a state of full development, spontaneous cures have been known to take place, after the tuberculous matter has been evacuated . ( Laennec.) This occu rs in two ways : PHTHISIS PULMONALIS 149 1. By the cavity becoming lined by a semi-cartilagi- nous substance, forming " a kind of internal cicatrix, analagous to a fistula :" 2. By the cavity being obliter- ated by cellular, fibrous, or cartilaginous substance. Exciting Causes. All fixed irritations in the abdominal viscera; repelled cutaneous eruptions; suppression of habitual evacuations; atmospheric vicissitudes; intem- perance in spirituous drinks; sedentary employments; the incautious use of mercury; haemorrhages; depress- ing passions ; the inhalation of irritating substances; ra- pid growth, syphilis; onanism. Of all these causes, suppression of the cutaneous exhalation by cold, is the most common and powerful, in calling into ac- tion this fatal malady in those who are predisposed to it. Characteristic symptoms of the commencement and course of phthisis. Tension and slight aching in the breast; slight, short and dry cough; slightly oppressed perspiration — a sense of tightness being felt in some particular part of the chest, on inspiration. At length moderate febrile symptoms in the evening; the pulse and respiration being preternaturally frequent; cough- ing in the morning, great susceptibility of taking cold; torpor of the bowels; frequently a benumbing and drowsy feeling; tongue moist, covered with a thin white fur. As the disease advances, the cough becomes more and more troublesome; there is great sensibility to low temperature; pearly whiteness of the eyes; skin often hot; lips, tongue, and fauces often dry; slight chills in the evening, followed by febrile exacerbations, with a burning heat in the palms of the hands and soles of the feet; expectoration at first scanty and frothy, finally thick, puruloid, and often streaked with blood, becoming more purulent as the disease goes on; the pain in the chest, and evening fevers, becoming strong- er and stronger; the patient lies easy only on one side- profuse sweats occur during the night; the burning in the palms of the hands and soles of the feet is distress- 150 PHTHISIS PTLMONALIS. ing; the pulse very frequent, tense, and quick; and small during the febrile exacerbations, but slower and languid in the morning, The cheeks have a circum- scribed flush, during the febrile excitement. Besides the evening exacerbation, there is, in most instances, but a slight one about twelve o'clock in the day. To- wards the conclusion, colliquative diarrhoea comes on, the voice becomes hoarse, the fauces aphthous, the feet oedematous; there is sometimes slight delirium; more commonly, however, the mental faculties remain entire to the last moment. Tests for pus. Muriate of ammonia coagulates pus — but not mucus. Pus does not coagulate by heat — mu- cus does. Water added to the solutions of pus in sul- * phuric acid, and a solution of pure potash separately, produces in each a copiate precipitate. Dr. Young's test. — A small portion of pus, put between two glasses, will, when held near the eye, and looked through at a distant candle, exhibit an iridescent spec- trum, of which the candle is the centre ; — mucus does not exhibit this phenomenon. Treatment. One of the most important remedial mea- sures, in every variety of the disease, is, to restore and maintain the regular action of the cutaneous exha- lents. This is to be done by wearing flannel next the skin, by minute doses of tartarized antimony, and by avoiding atmospheric vicissitudes. We must also en- deavor to remove every source of irritation, and to prevent as much as possible, an. inflammatory con- dition of the system — particularly in the incipient stage. With this view, a strictly antiphlogistic regi- men is to be enjoined, together with occasional small bleedings, where the pulse demands it, the use of digi- talis, and mild aperients, with gentle exercise on horse- back or in a carriage. Another important measure, is to divert as much as practicable, the undue determina- tion of blood to the pulmonary system, by means of PHTHISIS PULMONALIS. 151 blisters, cupping, and especially by tartar emetic ointment applied to the breast. Although we cannot expect to cure tubercular phthisis by these or any other remedial measures, when once fully developed, yet by a strict adherence to them in the incipient stage, we may often suspend the disease permanently, or retard itg pro- gress in the more advanced periods. Catarrhal consumption is not so irresistible in its course, and will not unfrequently yield to remedial treatment, even when considerably advanced. The use of mercury discussed — generally injurious in tubercular phthisis, In consumption from chronic bronchitis, balsam copaiva is an excellent remedy. "It appears to have a specific influence over the mu- cous membrane of the trachea and its branches." (Armstrong.) I have myself employed it with decided advantage in this variety of phthisis. The inhalation of the fumes of tar, has of late years'been much extol- led in the cure of consumption. Its power has been overrated. In tubercular phthisis it generally does harm; in chronic bronchitis it may, and no doubt has often done good — but even in this variety of the disease, it generally proves injurious, when the habit of the body is irritable, and the inflammation active. Dr. Hastings speaks very favorably of a combination of extract of stramonium, and pulv. ipecac, compos., in the pro- portion of one-fourth of a grain of the former, with two grains of the latter, taken three times daily. Cincho- na is valuable in the advanced stage of catarrhal con- sumption, (Broussais, Hastings.) A change of cli- mate will sometimes remove the disease, when reme- dial treatment is inadequate. Tracheal phthisis almost invariably terminates fatally. Mercury is said to have been beneficial, particularly in cases dependent on a syphilitic taint. An equable and mild temperature is one of the most important cu- rative means in this, as in the other varieties of phthisis. Blisters should be applied to the throat, and kept dis- charging. Armstrong asserts, that bats, copaiv. is as 153 PHTHISIS PULMONAilS. beneficial in this, as in the catarrhal variety, when em- ployed previous to the occurrence of ulceration. When ulceration exists, large doses of cicuta, with minute portions of murias hydrarg. are said to be serviceable. Phthisis depending on chronic plcuritis, is more amen- able to remedial treatment. Here, our chief reliance is to be placed on external vesicating or irritating ap- plications to the chest . Tartar emetic ointment is the best. Active diuretics are beneficial. Squill, in com- bination with calomel, is a good article for this purpose. Digitalis and squill, useful when effusion has taken place. Prussic acid, is much extolled by some in phthisis. It is, however, a dangerous remedy, and must be em- ployed with the utmost caution ; one sixteenth of a drop is sufficient for a dose. Sugar of lead an excellent remedy to check the colliquative night sweats. Phe- landrum aquaticum, much recommended by the Ger- man physicians in catarrhal (phthisis pituitosa) con- sumption. It is given in doses of from sixteen to twenty grains, three times daily. I have known it do much good in the advanced stage of the disease. Am- pelopsis hcderO) appears to be a useful remedy in this variety of the disease.* (Atkins.) The bark of the wild cherry tree (prunus virginiana) is a valuable tonic in consumption/] - Opium the best euthanasial remedy. * Phil. Med. and Surg. Jour. Oct. 1826. t Vide Eberle's Mat. Med. Article Prun. Virgin. APOPLEXY. 153 CHAPTER XVII NEUROSES. APOPLEXY. Character. Abolition or suspension of the animal func- tions, — the organic functions being uninterrupted ; with laborious, generally sterterous, breathing. Description. Generally preceded by premonitory symp- toms — such "as, vertigo, drowsiness, dull pain in the head, irregular and involuntary contractions of the muscles of the face, turgidity of the vessels of the head, bleeding from the nose, ringing in the ears, loss of me- mory or speech, dimness of sight, indistinct articulation. Sometimes the attack is sudden, without premonitory symptoms. Sterterous breathing, not invariably pre- sent in the attack, as is generally alleged. The pulse, during the apoplectic state, is at first full, slow, regular, and often hard; towards the conclusion of fatal cases, it becomes frequent, irregular, and weak. The face is livid and full ; the eyes prominent, and often blood-shot ; the pupils much dilated, or permanently contracted. The attack may last from a few hours to several days. Apoplexy seldom if ener destroys life suddenly, as is the case with affections of the heart. Most apt to occur between the ages of forty and sixty. Persons who have short thick necks, and are of a full and ple- thoric habit, and indulge freely in eating, drinking, and sleep, are most liable to this disease. Great heat and cold predispose to it. Exciting causes. Whatever tends to determine the cir- culation inordinately to the head, may produce apo- plexy. The most common of these causes are, over- v 154 APOPLEXY. distention of the stomach with r food; the use ofindi- gestihle and Stimulating diet; the intemperate use of spirituous liquors; viohnt straining in lifting, or in evacuating fbeces: violent anger; the direct rays of a vertical sun; extreme cold weather; the cold stage of intermittents ; stooping, or other positions in which the head is in a depending state; impeding the return of blood from the head, by wearing cravats too tight, and turning the head to look back. Apoplexy is also pro- duced by the suppression of habitual discharges; by the healing of old ulcers; by metastasis of gout. Irri- tation in the stomach and bowels is a frequent cause of this disease. Proximate Cause. Interruptions of the functions of the brain, and consequent deficiency of nervous influence in the parts furnished with cerebral nerves. Does this interruption of the cerebral functions depend on com- pression of the brain, or on mere deficiency of arterial blood circulating in this organ, as has been lately main- tained? I believe that both conditions (i. e.) compres- sion of the brain, and deficiency of arterial blood in it, are necessary to the production of genuine apoplexy. Cerebral compression may be the result of mere vascu- lar turgescence, or of extravasation of blood upon, or into, the substance of the brain; or, finally, of serous ef- fusion into its cavities, &,c. Blood is very rarely ex- travasated upon the surface of the brain, or into its ventricles, but almost always into its substance. (Bricheteau, Rochaux.) Diagnosis. Distinguishable from syncope and asphyxia, by the pulse and respiration. The pulse is full, strong, and slow, in apoplexy; in syncope and asphyxia, it is small and feeble, and sometimes wholly suspended. Respiration in apoplexy is slow, laborious, and sterto- rous ; in asphyxia and syncope, it is feeble and almost imperceptible. Apoplexy, not easily distinguished from intoxication; the smell of the breath, habits of the pa- tient, &c. will inform us on this point. APOPLEXY. 155 Prognosis. Generally unfavorable, When the result of mere sanguineous congestion in the brain, it is in general readily relieved. When effusion of serum, or ex- travasation of blood has occurred, it is rarely cured. Extravasation of blood into the brain, is not necessarily fatal, as was formerly thought. The observations of Brichteau, Seres, Rochaux, and Riobe, prove, that when blood is extravasated into the substance of the brain, a cyst is formed around the coagulum, and that this coagulum is afterwards absorbed by the vessels of this cyst. The cyst finally becomes absorbed itself, and leaves a yel- lowish cicatrix or laminated tissue, which is sometimes found to contain a small portion of serum. Apoplexy may be divided into two varieties ; viz. simple apoplexy, which is not accompanied by paralysis; complicated apoplexy, which is attended by loss of motion, on one or the other side of the body. Mr. Seres, of Paris, has ascertained that simple apoplexy depends on serous effusion into the ventricles or cir- cumvolutions of the cerebrum, without any organic le- sion of the cerebral substance. In complicated apo- plexy, the substance of the brain is altered ; excava- tions are found in it, filled with blood of various ap- pearances, according to the time which may have elapsed between the extravasation and death — the por- tions of brain immediately surrounding these clots, be- ing red, indurated, or yellow. Mr. Seres concludes, from his observations on this subject, that: — 1. When- no symptoms of paralysis attend, we may presume that the seat of the di.sease is in the me- ninges, and that the substance of the brain is not altered. This variety, he accordingly calls me- ningeal apoplexy. 2. When the disease is complicated with paralysis, the cerebrum is the part principally or wholly af- fected ; and this variety he calls cerebral apoplexy. 156 APOPLEXY. It appears, from the observations that have been made in the Parisian hospitals, that meningeal apoplexy occurs most commonly in the fifteenth, and after the sixtieth year of age. Cerebral apoplexy generally makes its attack suddenly. Meningeal apoplexy usually comes on gradually. In this variety, the mouth is never drawn to one side, and the patient lies in a straight position . Paralysis almost invariably occurs on the side opposite to the one in which the cerebral lesion exists. This was observed in 171 subjects who had died of cerebral apoplexy, accompanied with hemiplegia. When the paralysis is universal, the extravasation and cerebral lesion occur in the substance of the tuhar anulare, or along the base of the skull. Death, from apoplexy, explained. Tteatment. The chief indications in the treatment of apoplexy, are: to lessen the determination of blood to the brain, and to moderate the momentum of the ge- neral circulation. This is effected by general and lo- cal bleeding, active purgatives, revulsive applications, abstemiousness in diet, and stimulating drinks, &c. During the apoplectic attack prompt and copious bleeding, stimulating purgative enemata, cold applica- tions to the head, sinapisms to the feet, cups applied to the temples and the back of the neck, and an elevated position of the head, are the remedial measures to be relied on. When apoplexy comes on, soon after a full meal, an emetic should be administered ; blood should, however, be previously drawn. Under other circumstances, emetics are improper, as they have a decided tendency to produce cephalic congestion. On this subject, there has been much controversy. I have found castor oil, and spir. turpentine, in combination, an excellent purgative — it having rarely failed in my hands to excite copious purging, which, though of much importance, it is often exceedingly difficult to procure. PARALYSIS. 157 PARALYSIS. Character. Diminution or entire loss of voluntary mo- tion, or of sensation, or of both, in some particular part of the body, without coma. Description. Often the consequence of apoplexy; but frequently also, independent of it. Most commonly, there is only loss of voluntary motion — sensibility re- maining entire, or even morbidly increased. Total abolition of sensibility, very rare. The palsied limbs generally become soft, wasted, and shrunk — often with a peculiar sensation in them, as if insects were creeping over them {formication.) Mental hebetude, frequent- ly in palsy — especially weakness, and sometimes total abolition of the memory. Entire change of the natu- ral disposition, occasionally occurs in this disease. Paralysis is divided, by nosologists, into three varieties, viz: hemiplegia, paraplegia, and local palsy. The question, why the power of motion is sometimes lost, while that of sensation remains, and nice versa, has given rise to much controversy among physiologists. Galen supposed that there were two sets of nerves — one destined to sensation, the other to motion . What this sagacious physician alleged, on mere speculative grounds, has recently been actually demon- - strated by Magendie, and Charles Bell. It appears, from the experiments of these and other physiologists, that each nerve is composed of two distinct parts — the one for motion, and the other for sensation. From this anatomical fact, we perceive in what manner the phenomenon in question may occur. HEMIPLEGIA. Paralysis, confined to one side, including the whole half of the body, generally the consequence of apoplexy; the apoplectic symptoms are sometimes so slight, as to escape notice. Injuries done to the head may produce it. Cerebral compression, or structural lesion, the proxi-. mate cause of hemiplegia. Seres denies that compres^ sion is ever the cause, either of apoplexy or hemiple- 158 HEMITLEGIA. gia; his experiments, however, are not conclusive ; they are contradicted by those of Portal, and of Mr. Astley Cooper. Hemiplegia often comes on gradually, with the usual symptoms of approaching apoplexy; occasionally, its attack is sudden. Anomalous symptoms. This af- fection sometimes terminates in a few days — more ge- nerally several months; and occasionally it remains permanently. Sometimes a greater or less degree of amendment occurs, and then the disease remains sta- tionary. PARAPLEGIA. paralysis of the whole lower half of the body, the parts above the hips remaining unaffected, Occurs most commonly after the middle period of life; and accord- ing to Baillie, more frequently in men than women. Causes. Most commonly seated in the brain, (Baillie, Earle, flalford, Copeland;) sometimes in the spinal marrow, producing an interruption to the passage of the nervous influence along the spinal cord, to the nerves of the lower extremities. The most common of those causes, which act immediately on the spinal marrow, are: thickening of the theca vertebralis ; serous effusions into it, exostosis on the internal surface of the vertebree. The higher these causes exist in the medulla spinalis, the higher will the paralysis extend. When above the fifth cervical vertebra, the hands will be pa- ralysed ; if below the eighth, they will not be affected. The effusion may occur, first between the membranes of the brain, and afterwards sink down in the theca vertebralis, and press upon the lower portion of the spinal cord. When the brain is the primary seat of the disease, pain in the head, giddiness, drowsiness, impaired vision, and defective memory, usually precede the paralytic at- tack. The paraplegiac affection always comes on PARAPLEGIA. 159 gradually — first by stiffness and slight difficulty of di- recting the motions of the lower limbs; by degrees, the assistance of a stick is required to balance the body; the urine is voided with difficulty, and finally passes off involuntarily — the paralysis becomes more and more complete, the faeces passing off unrestrained by the will. PARALYSIS PARTIALIS LOCAL PALSY. Local paralysis consists of want of motion, or of sensa- tion, or of both, in some particular part or organ of the body. It may attack some viscus, or the organs of f^sense, destroying or blunting their respective functions. It occurs in one extremity; in the muscles of degluti- tion; in those of the organs of speech, and even in a single muscle. It most frequently, however, occurs in the muscles of the face. Persons affected with fa- cial paralysis, are deprived of the power of closing or opening the eyelids — of contracting the brow — of ele- vating the nose or lip — of shutting the mouth — of re- taining the saliva — of raising the corner of the mouth — of whistling or blowing, &c. The wing of the nose, on the palsied side, is collapsed; the mouth drawn towards the opposite side; the teeth exposed. The power of masticating remains — the tongue too retains its powers. Causes. Facial paralysis is [produced by some injury sustained by the portio dura, either in consequence of surgical operations, abscesses, bruises, or other injuries in the parotid region. It occurs also in consequence of thickening of the sheath of this nerve ; of necrosis at the canal of the] temporal bone, through which it passes out; and frequently from sudden exposure to cold, producing inflammation of the nerve. It has been produced by a blow on the head; by the suppression of cutaneous eruptions; and by tumours pressing on this nerve. 160 PARAPLEGIA Paralysis of the wrists is produced by the poisonous influ- ence of lead; by bilious colic; and sometimes by dy- sentery. Whatever interrupts the free nervous com- munication between a part and the common sensorium, may produce paralysis in such part. Treatment. Blood-letting of primary importance in the commencement of hemiplegia, preceded by apo- plectic symptoms, and attended with a full and strong, or small and tense pulse. In some instances the pulse is small and feeble, in which case, bleeding is of course to be avoided, or at most used with particular circum- spection. Purgatives, perhaps, still more beneficial than blood-letting. In debilitated, leucophlegmatic, or hydropic subjects, mustard or capsicum may be very advantageously given in union with cathartics. An ordinary dose of calomel and jalap, with from 20 to 30 grains of mustard, or from six to eight grains of capsi- cum, forms an excellent purgative under such circum- stances. Emetics have been particularly recommend- ed in hemiplegia. They must be given in large doses, on account of the unirritable state of the stomach in this complaint. They are useful when the attack of the disease occurs' soon after a full meal, or during the existence of dyspepsia In recent cases, with signs of cephalic congestion, they are hazardous, unless blood be previously drawn. Stimulating enemata are useful remedies. Much advantage may be derived from ru- bifacient, vesicating, and stimulating applications to the paralytic parts. The depletory remedies just mention- ed, cease to be proper after the disease has assumed a chronic character — that is, after the apoplectic sym- toms have disappeared, and the undue determination to the head no longer exists. Means of an opposite character are now to be used, i. e. external and inter- nal stimulating remedies. • The former are sinapisms, warm bathing, blisters, moxa, cupping, galvanism, electricity, and frictions with the flesh brush, dry flan- nel, or with stimulating fluids. Blisters and sinapisms PARAPLEGIA. i61 must be employed with caution, when the paralysis is complete, lest sloughing or mortification ensue. They should be employed only as rubifacients in such cases, In general, mere dry frictions, with flannel or the flesh brush, will do more good than where rubifacients are used. Electricity has been employed with success in this city. It must never be employed in strong shocks ; weak sparks are more efficacious, and less apt to injure. Galvanism is more efficacious than electricity ; it must be applied with only a moderate force. Moxa has been used with success in general paralysis, applied along each side of the spine, near the first dorsal vertebra, by Dupuytren. Among the internal remedies, the following are the most useful: — Rhus toxicodendron. I have succeed* ed in curing two cases of hemiplegia, by the saturated tincture of the leaves of the rhus. The dose is from twenty to sixty drops, three times daily. Professor Ossan of Berlin, recommends it to be given according to the following formula: — B. Tinct. rhois, toxicoden. gss. Tinct. aconit. neamont. Tinct. guaiaci. aa 31J- m, Dose, forty drops every three hours. The nux vomi* ca has of late years been much employed, and not un-? frequently with success, in paralysis. When used in adequate doses, it produces strong convulsive contract lions, more particularly in the paralytic parts. The extract is usually employed. It may be commenced with in the dose of two grains, twice a day, and F gra-? dually increased until the spasmodic contractions come on. The arnica montana, is a favorite remedy with the German physicians in paralytic affections. Mus-> tard seed, internally, has been found useful ; I have em- ployed it with advantage in hemiplegia. Iodine has been used with success, in paralysis depending on tu-? mours or fluids pressing on the brain or spinal cord. Dr. Manson has related some remarkable instances of its beneficial operation. In paralysis of the tongue, a few drops of the ol. cajeput, put on the organ daily, x 162 EPILEPSY. has been found serviceable. Chewing the root of the anthemis pyrethrum, has also done good in palsied tongue. Would not moxaustion over the mastoid re- gions prove beneficial in this variety of palsy ? In pa- ralysis from lead, mercury is an excellent remedy ; the nitrate of silver has also been used with advantage, in this species of paralysis. When the wrists are pal- sied, the application of a splint along the inner side of the fore-arm has done much good. (Pemberton.) EPILEPSY. Character. Convulsions returning at uncertain inter- vals — accompanied with loss of sense and voluntary motion, and terminating in deep sleep. Premonitory symptoms. A confused and wandering state of the mind ; vertigo ; ringing in the ears ; indis- tinct vision; pain in the head; pain and anxiety in the precordial region ; change of the natural disposition ; spasmodic twitches of the muscles of the face ; aura epileptica, and a feeling of terror and alarm are the most common. Symptoms of the paroxysm. The attacks frequently occur at night, while the patient is asleep. If he is sitting or standing, he suddenly falls down, and be- comes more or less violently convulsed. The counte- nance is frightfully distorted, and generally of a livid, and sometimes almost black hue — occasionally it is pale; the veins of the head and neck are turgid; the heart palpitates violently, and the breathing is oppress- ed and laborious, and in violent cases sterterous. A copious flow of frothy saliva occurs towards ilie termination of the paroxysm. As the convulsions abate, stupor or deep sleep comes on, out of which the patient awakes in a state of mental torpor or confusion, which often continues for many hours — the counte- nance exhibiting a fatuous and stupid cast. The dura- tion of the paroxysm varies in different cases, from a fcPILEfrSY* 163 few minutes to Several hours. Sometimes there is but one fit at a time ; at others* three or four, and even more paroxysms, occur in quick succession, before the dis- ease terminates. The fits are in general more pro- tracted in children than in adults. Sometimes the at- tacks are strictly periodical in their recurrence, more ? generally, however, they return at irregular intervals and the duration of these intervals is exceedingly vari- ous. Epilepsies, depending on intestinal irritation and catamenial irregularities, are njost apt to become pe- riodical. (Richter.) The periodicity of this disease is ascribed to lunar influence, by Mead, Balfour, and others. This opinion is not supported by sufficient tes- timony to entitle it to credit Epilepsy is seldom fatal, except by the intervention of apoplexy. By repeated recurrence, it never fails to im- pair the understanding — terminating sometimes in per- fect idiotism. Autopsic phenomena. According to Wentzel, the cere- bellum is much more frequently found diseased than the cerebrum. The pineal gland is often found in a morbid state; tumours and other structural derange- ments are, in some instances, discovered in the cere* brum. In the cerebellum, have been noticed indura^- tions and a peculiar friable matter between its lobes, with destruction of a portion of their substance. In many instances, however, not the slightest traces of organic disorder are discoverable, either in the cere- bellum or cerebrum. Predisposing causes. Predisposition sometimes consti- tutional, and even hereditary, and always augmented by the attacks of the disease. Young people, about the age of puberty, most liable to epileptic attacks. Exciting causes. Some act directly on the brain — the disease being then called idiophatic. Others act on remote parts — affecting the brain sympathetically — this constitutes symptomatic epilepsy. Among the former causes, are: malformation of the skull; depress- i64 EPILEPSY. ed bones ; exostosis from the internal surface of the craiiium; organic derangements; vascular congestions and effusions in the brain, &,c. Among the most com- mon causes of the latter class, are: intestinal irrita- tion from worms and other irritants ; dentition ; suppres- sion of the catamenia i of hsemorrhois, and of perspira- tion ; the drying up of old ulcers and issues; the reper- cussion of exanthematous eruptions, or of chronic cuta- neous diseases, as measles, small-pox, itch, and tinea capitis. Excessive^anguineous and other evacuations ; onanism; various poisons, both vegetable and mineral; habitual intemperance in the use of spirituous li- quors; pregnancy; irritation from biliary concretions and urinary calculi; sudden and violent terror ; anger, and grief; disagreeable and strong impressions on the senses; spiculae of bones, tumours* &.c. pressing upon, and irritating some nerve ; the sight of a person affected with the disease. Proximate cause. Various opinions expressed by au thors. A temporary local turgescence of the cerebra vessels, is probably the immediate cause of the epilep^ tic paroxysm. (Johnson.) According to Mansford, an accumulation of electric matter in the brain, constitutes the proximate cause. Others regard organic derange- ment of some part of the brain as the immediate cause* [ regard the first opinion as the most probable. Diagnosis. Sometimes confounded with hysteria. They may be distinguished by the following circuun stances. In hysteria, there is no foaming at the mouth, nor is the countenance so livid and distorted as in epilepsy; the hysteric paroxysm does not termi- nate in heavy sleep, as does the epileptic. In hyste- ria, there are globus hystericus, involuntary laughing, weeping, and other hysteric symptoms. Prognosis. Not much immediate danger. In relation to its sanability, however, the prognosis is always favor- able. Symptomatic, more frequently cured than idio- pathic epilepsy. Cases depending on catameniai irre* EPILEPSY. 165 gularities, in young females, most frequently yield to remedial treatment. The more frequently it has re- curred, the more difficult the cure. Epilepsies that come on soon after birth, are hardly ever cured. Cases produced by falls and blows on the head, are very generally incurable. From the period of denti- tion, to that of puberty, the most favorable age for the cure of this disease* It is more unfavorable, when the precursory symptoms consist of some affections in^ the head, than when they are felt in other parts, par- ticularly the extremeties. Protracted sleep and stu- por after the paroxysm, very unfavourable. Treatment. In prescribing for epilepsy, we must first endeavor to ascertain its original exciting cause— its duration — the time and manner of the first attack— the constitutional habits of the patient — his age, pur- suits, concomitant disorders , temper, and mode of liv- ing. It is upon these circumstances alone that a ra- tional treatment can be founded. The treatment is divided into palliative and curative. The former applies to the paroxysms — the latter to the intervals between them. The attack may sometimes be pre- vented during the period of the premonitory symp- toms, by bleeding where there are marks of general plethora, brisk cathartics, emetics, a draught of cold Water, and ligatures round the limb, above the part to which the aura (where this sensation precedes the at- tack) has risen. Richter asserts, the emetics are par- ticularly useful in warding off an approaching parox- ysm, in cases that continue from habit, after the origi- nal exciting cause no longer exists. I have known an epileptic person, who could prevent the paroxysm, when he felt it approaching, by a draught of cold water. Jahn mentions similar cases. During the paroxysm, our principal objects is to lesson the preternatural determination to the head, and with it the chance of apoplexy. With this view, bleeding in full habits, an elevated position of the head, with cold applications to it, the removal of every thing which 1#6 ECILEPSY. may compress the veins of the neck, and sinapisms to the feet, may be beneficially employed. No treatment will either materially mitigate or shorten the parox- ysm. The radical cure is to be attempted during the intervals. Where the exciting cause can be ascertained, and is of a nature capable of being removed, this should be im- mediately attempted, as the first and most important curative measure. When gastric irritation from worms, acidity, and other causes, exists as its cause — as is of- ten the case with young children, anthelmintics, emetics or purgatives, absorbents and tonics, are pro- pen In verminous epilepsy, valerian, in union with small doses of calomel and flores zinci, has been found efficacious . When suppressed perspiration has given rise to the disease, diaphoretics should be employed ; here, camphor with tarter emetic, guaiacum, sulphur, together with the warm bath, warm clothing, and dry frictions, particularly serviceable. When repercussion of utaneous affections, or the dying up of old ulcers, was the original cause, issues, yesicatories, pustulating applications, warm bathing, frictions, and stimulating diaphoretics, are the appropriate remedies. When the disease arises from menstrual irregularities, means must be employed to obviate the morbid determina- tion to the uterine system. Here, bleeding is general- ly an indispensable remedy; the warm semicupium, frictions about the back and loins, stimulating enema- ta, the internal use of spirits of turpentine, of tincture of cantharides, and other emenagogues, (after proper depletion,) are peculiarly serviceable. In epilepsy from dentition, blisters behind the ear, leeching, pur- ging, scarifying the gums, and fi a mild diet, are especial- ly indicated. When onanism is its cause, camphor e- ternally, with cold applications to the genitals, and a seton in the back of the neck, have been found bene- ficial. Remedies that are employed empyrically, or that are EPILEPSY. 167 supposed, or do possess specific anti-epileptic powers:— Valerian. A very ancient remedy. It should be given in as large doses as the stomach will bear — a drachm three times daily. It forms a principal ingredient in the famous powder of Ragoloi, which according to Knopf's analysis, is composed of Valerian, sj. Pow- dered orange leaves, ^j. Muriate of Ammonia, grs. ii. and ol. cajeput, gtt. iv. Richter has cured inveterate cases with this remedy. The Misletoe, recommended by De Haen, Van Swieten, Hufeland, Stark, Richter. Cullen thinks it may have done good, from its having early been an object of su- perstition, and thus bringing with it the powerful aid of the imagination. Frazer states that he cured nine out of eleven cases, with the viscus quercinus, in doses of from 9ij. to 31J. twice daily, Dr. Fothergil and Wilan, speak well of its powers in this disease. Animal Oil of Dipple. According to Richter, particu- larly valuable in epilepsies from metastasis of gout, rheumatism, and repelled cutaneous eruptions. Spirits of Turpentine. Lately much extolled for its virtues in this disease. Drs. Latham, Young, Perci-. val, Money, and Prichard, have used it with decided success. Dose from 3Jss. to 3iij. thrice daily. I have lately cured a case with this remedy. Paeony root. Agaricus Muscarius. Both much used, formerly. Artemisia Vulgaris. Has lately^been used with singu^ lar success, in the Polyclinic Institution at Berlin ; and late numbers of Hufeland's Journal, contain several well authenticated cases of its successful employment. It is said to be particularly useful epilepsies, coming on about the age of puberty, and more so in females than in males. The root is given in doses of about thirty grains, four times daily, and gradually increased. Et-, muller says of it — mire in epilepsia valet. Camphor, Musk, Castor, Assafoetida. The first of these articles is said to be particularly adapted to cases 163 EPILEPSY. arising from repelled cutaneous affections, and from onanism. Stramonium, Belladonna. Both these narcotics have been employed with occasional success in epilepsy. 1 once succeeded in removing the disease in a child, by means of belladonna and cuprum ammoniacum. Hufe- land speaks highly of the tincture of Stramonium, and Odhelius cured eight out of fourteen cases, in the hos- pital of Stockholm, with this remedy. Opium. Epilepsy has been cured by this narcotic. — * Darwin cured two cases with it, and Dr. Huxy relates an instance of its successful use. Richter states, that cases produced by mental excitement, pain, or exhaus- tion, are often benefited by it. Phosphorus. This potent article is recommended by Horn, Lobenstien-Loebel, and Van Hoven. It is im- proper in cases attended with general plethora. Zinc. A valuable remedy in this disease. It should be given in large doses. Dr. Guthrie commenced with eight grains of the flores zinci, and increased the dose until it amounted to two scruples a day. Many cases are reported of its successful employment. The sulphate less useful than the flowers of zinc, in epilepsy. Cuprum Ammoniacum. Cullen speaks favorably of its powers in this disease. The number of cases report- ed of its efficacy, is not inconsiderable. I have used it with success in one case. Acetate of Lead. Dr. Rush gave this article with suc- cess in epilepsy. About fifteen years ago, I reported a case which yielded to its powers. This case was strictly periodical — the paroxysms returned at each full moon. Three grains were given morning, noon, and evening, for three or four days previous to the usual period of return, and continued for three days after this period. It was not till the fifth period of re- currence, that the disease was subdued, and the per- son has continued free from the complaint to this day, although he had suffered its periodical attacks for EPILEPSY. 169 seven or eight years before he come under my treat- ment. Tin. Strongly recommended by Dr. Shearman, in a' late Number of the London Medical Repository. He employed the elutriated oxyd of this metal, in doses of from 9ij. to 3j. night and morning; and, he assures us, with much success. Nitrate of Silo er. This article possesses more reputa- tion, as a remedy in this disease, than any other article of the materia medica. It should be given in as large doses as the stomach will hear. We may commence with one grain three times daily, and increase it gra- dually, which may often be done to a surprising extent. Dr. Powel has ascertained, that triple the quantity of this article may be taken without inconvenience, in the form of pills, as in solution. Mercury has been used with success in epilepsy, by Bur- serius, Tissot, Houssel, Willis, Etmuller, Frank, Rich- ter, Cullen, Locher, and others. It is seldom used at the present day. Galvanism has been found beneficial in this disease. It should be applied steadily and constantly. (See Mr. Mansford's work on this subject.) Setons and issues. These are ancient remedial means, in epilepsy. They have, no doubt, been employed with advantage, particularly in cases depending on' re- percussion of chronic cutaneous affections. Jn one in- stance, I have known a caustic issue on the back of the neck aggravate the disease greatly. Larrey speaks very favorably of bleeding from the back of the head, followed by blisters, moxas, or other counter-irritants, on and about the head. Tartar emetic ointment has, by its pustulating effects, cured this disease. (Creigh- ton.). The actual cautery was used by the ancients, and by Dc Ilaeriand Larrey among the moderns, with success, in this disease. The following composition has been employed, in this city, with decided benefit, in epilepsy. R. Pulv. Zin- 170 CHOREA. giberis, Pulv. Salvia? officinal, P. Pern. Sinapi, i" a 3j. M. Dose three tea-spoonfuls every morning, fasting, wiih an occasional purgative. Music. Quarin cured a girl hy music. Other cases, to the same effect, are mentioned by Bruckman and Lich- tenthal. CHOREA. Chorea almost always occurs before or about the age of puberty — rarely beyond the twentieth year of age. It is always gradual in its approach. During the form- ing stage, the appetite is variable; sometimes ravenous; die bowels constipated; vertigo; palpitation of the heart; oppression and anxiety in the precordial re- gion; fulness and tension in the head, with occasional metnal confusion; cold feet; variable disposition; itch- ing in the nose, &,c. The first manifestations of the spasmodic affections are, slight, irregular motions of the muscles of the face, and an awkwardness in the gait — progression becoming starting and hobbling. The irregular involuntary actions gradually increase in violence and constancy, until the arms and legs are al- most in continual motion, and the countenance various- ly and uninterruptedly distorted. The voluntary mus- cles alone are affected. Like epilepsy, chorea, by long continuance, weakens and finally destroys the intellec- tual powers In very protracted cases, some degree of fever generally supervenes, and the muscles waste and become flaccid. During sleep, the irregular muscular contractions often cease. There is something very remarkable in the circumstance, that the irregular motions, which the utmost exertion of the will cannot control during the period of its activity, cease, when it is no longer operative during sleep. It would seem, -that the stimulus of volition is in some degree essential to the disease. Chorea occurs more frequently in girls than boys. In about twenty cases I have seen of this disease, there CHOREA. 171 was but one instance in which the patient was a male. Children of a nervous temperament, are most liable to the disease. Exciting causes. Intestinal irritation from various ex- citing substances lodged in the alimentary canal; fear and terror; repercussion of chronic cutaneous erup- tions ; cold ; suppression of catamenia. It is sometimes the consequence of typhous and other severe forms of fever. Proximate cause. I believe it to be essentially a cere- bral affection, because: 1. The voluntary muscles alone are affected : "2. The intellectual faculties soon suffer: 3. The loss of the power of volition over its le- gitimate dependencies. Prognosis. Not often fatal . When produced by worms, or other irritating substances in the intestinal canal, it generally yields, without much difficulty, to remedial treatment. When caused by cold, also, it is seldom very difficult to cure. Treatment. In plethoric subjects, with a super-excited state of the pulse, bleeding is proper. Generally, how- ever, sanguineous evacuations are not required. Pur- gatives are among the most valuable remedies we possess, in this disease. (Hamilton.) In a majority of cases, the bowels are infarcted with feculent matter, and this appears often to exist, as the primary cause of the disease; hence the utility of daily purga- tion, in many cases. When worms are the cause of the disease, anthelmintics, but particularly spirits of turpentine, with castor oil, are particularly beneficial. Tonics ought to be employed, in alternation with pur- gatives, unless contra-indicated by the state of the sys- tem. The cold bath, bitter infusions, sub-carbonate of iron, quinine, and flowers of zinc, are the tonics usu- ally employed. They are especially advantageous du- ring the period of convalescence. The nitrate of silver has been employed successfully in this disease. (Crampton.) Of the remedies that have been used 172 TETANUS. with success, in this disease, arc the following. Che nopodium ainbrosoides. Dose bj. in powder, three . times daily. (Hufeland, Plenk.) Cardamine jrraten- .lis. The flowers are recommended by £ir G. Baker. Dose oj. Camphor, in combination with Valerian. *(\Vilson, Pitt.) Belladonna Stramonium, Opium, have been recommended, but have very properly fallen into disuse. Cuprum ammoniacum; Wilson relates cases that were cured with this article. (Lonrf. Med. Phys. Jour.') Electricity, very moderately applied, has done good. Rubefacients, bisters, tartar emetic oint- ment, along the course of the spine, are remedies of considerable power in this disease. The diet must be simple, unirritating, and digestible. TETANUS. Character. Tonic spasms of the voluntary muscles, — the powers of sensation and thought remaining unim- paired. Tetanus is divided into different varieties, viz: trismus opisthotonos, emprosthotonos, pleurolhotonos. In the first, the muscles of the jaw are chiefly affected ; in the second, the extensors of the back, producing recur- vation of the body; in the third, those on the anterior part, producing incur cation; and in the last, those on the side are principally affected, causing a lateral cur- vature. It is divided also into idiopathic and trau- matic — the former variety being the result of general causes — the latter, of external injuries. This division has an important bearing both on the prognosis and treatment of the disease. Symptoms. Its approach is almost always gradual, the symptoms being developed in the following order. Slight difficulty of deglutition and change of the voice; an uneasy sensation in the precordial region; stiffness in the muscles of the neck and jaws. These symptoms having increased to a considerable degree of violence, ?ETANt7S. 173 SUtlden painful retractions about theensiform cartilage, with simultaneous retraction of the head, occun De- glutition is painful and difficult, and re-excites the spasms. The spasms acquire more and more violence and frequency, until the retraction of the head, and ri- gidity of the whole body become truly frightful. Tfie mind is seldom affected ; the appetite generally remains, and digestion goes on regularly. Costiveness almost always attends. The muscles supplied with gangli- onic nerves, and those which mom the fingers, re* main free from spasm, until near the fatal termination of the disease. The disease usually terminates before the fifth or sixth day — sometimes it continues much longer; and occasionally it assumes a chronic form. Causes. Various injuries. Contused, lacerated, and punctured wounds, most apt to produce tetanus. A partial division or laceration of a nerve apt to excite it. The introduction of cold and damp air into gun-shot wounds, when casting off their slough, favors the intro- duction of tetanus. (Larrey.) The application of caustic to encysted tumours; compound fractures; the insertion of artificial teeth; amputation; ligatures, in- cluding nerves; cutting corns too closely, &,c. have all frequently produced the disease. Cold and damp night air, after fatigue and exposure to a high degree of atmospheric heat during the day, is the most com- mon general cause. Hence its frequency in tropical climates. Atmospheric heat a powerful predisposing cause of tetanus. Traumatic tetanus generally comes on about the eighth or ninth day after the infliction of the wound; frequently not until it is cicatrized. Proximate cause. Galen, Willis, Hoffman, Frank, and Burserius, referred the original seat of the disease to the spinal marrow, and this opinion obtains pretty generally at the present day. It is supported by the post-mortem appearances, and the circumstance, that the muscles, supplied by spinal nerves, are almost ex- clusively affected. 174 TETANTTS. Prognosis. Traumatic tetanus, seldom cured. The idiopathic form, less difficult of cure. According to Parry, the disease always terminates fatally, when the pulse rises to 120 beats in a minute, on the first day; if, by the fifth day, it does not exceed J 10, a favcraLle issue may be expected. The favorable signs are: a very gradual supervention of the disease; abdomen not very hard; boweJs easily moved; moist and moderately warm skin; sound sleep; an increased flow of saliva; a natural expression of the countenance. When the majority, or all of these circumstances occur, we may entertain hopes of reco- very. The unfavorable sig:is are: a sudden and vio- lent invasion of the disease; great rigidity of the mus- cles of the back, neck, and abdomen; violent pain and retraction in the pit of the stomach; very hard and re- tracted abdomen; spasmodic twitches of the muscles of the neck and jaws, on firm abdominal pressure; hydro- phobic symptoms. (Morrison.) Treatment. Divided into prophylactic and curative — the former refers to the pretention,' the latter to the removal of the disease. Wounds or injuries from which tetanus is apprehended, should be brought to suppurate as soon as possible. For this purpose, sca- rification, free division with the knife, irritating appli- cations, such as spirits of turpentine, caustic, &,c. are employed. When the disease has made its appearance, constitationa are to be used conjointly with the local remedies. The most important of these are: — Blood-It ttiag, employed ad deliquium, in conjunction with mercury and opium, has cured the disease. (Med. and Phys. Jour. 1»2.1. — Medico Chir. Trans, vol. ii.j Purgatices always proper, as auxiliary means, particu- larly in trismus nasc^ntium. (Chalmers, Hamilton.) Opium, is one of the most efficacious remedies we possess in this disease. It must be given in large and frequent doses. Dr. Morrison, who was particularly successful with it, commenced with 100 drops of laudanum, and TETANIA 175 increased each succeeding dose, by one third this quantity every two hours. Mercury, highly and deservedly recommended by many, in the treatment of this disease. It is more efficacious in idiopathic, than traumatic tetanus. It may be ad- vantageously used, conjointly with the warm bath, opium, :&c. Spirits of turpentine, has recently been successfully em- ployed by Drs. Hutchinson, Toms, and Mott. Dr. JYIott's case is a striking example of its usefulness in this disease. After the hot and cold baths, tobacco, opium, bark and wine, and blisters to the spine, had been fairly tried without benefit, a tea-spoonful oftur- psnline,gicen evenjfifteen minutes, relieved the spasms in two hours; and by continuing its use until 123 tea- spoonfuls were taken, the disease was perfectly removed. Wine, and other alcoholic liquors. This was a favo- rite remedy with Rush. Opium is now generally, and I think properly, preferred. When employed, it must be very freely given. Rush gave it in conjunction with bark and mercury. Tobacco, both by the mouth, and in the form of enemata, has been found decidedly beneficial. An interesting example of its efficacy, is related in the third volume of Dublin Hospital Reports, by Dr. O'Beirne. Dr. An- derson used tobacco baths, fomentations, and enemata, with success, in several cases. (Med. Chir. Traps, of Edinburgh, vol. i.) It must be employed with caution. Cold affusions, a very ancient remedy in tetanus. ( 1 iipp. Aphor. Lib. iv. Sect. v. Aph. %, and Lib. v. Sect. ii. Aph. 2 ! ) They were successfully used by Drs. Wright, Cochrane, and Currie. I have known a case cured by salivation and cold affusions, conjointly. Cantharides, given internally, has effected cures. Dr. Brown, (New York. Med. Repes. vol iv.) cured a case with this medicine. It should be given so as to produce stranguary. Prussic acid. Cases of its successful employment in 176 WHOOPING COUGH. this disease, are related by Drs Pattison, and Trezevant. The warm hath* a useful adjuvant; it generally procures temporary relief .Some practitioners have found it to do harm ; particularly Dr. Hillary. The exertion and movement which it requires of the patient, is said, by Dr. Morrison, to do injury. Blist rs along the whole tract of the spine, have done much good in this disease; a more powerful, prompt, and efficacious means of this kind, however, is the ap- plication of caustic potash, as first recommended by Dr. Hartshorne of this city. (Eclectic Keper. vol. vii.) Whatever other remedies may be employed, the appli- cation of this caustic along the course of the spine should never be neglected. The cases which have been reported, illustrative of its efficacy are by no means few. The actual cautery along the spine, is said by Mursina, to have effected a prompt and perfect cure. The good effects which 1 have witnessed from the application of the actual cautery, in deep seated articular inflamma- tion, convinces me that there is no means in our pos- session, by which we can produce so prompt and pow- erful an impression on the inflammation of internal ca- vities and parts, as this potent agent. PERTUSSIS WHOOPING COUGH. Character. A contagious cough — paroxysmal, convul- sive, and suffocative; inspiration during the cough shrill — the cough frequently terminating in vomiting' 'Whooping cough may be divided into three stages: I. The forming stage; characterized by the usual symp- toms of ordinary catarrh ; i. e. lassitude, weakness, and head-ache; sneezing; slight hoarseness; discharge of thin mucus from the nose; restless sleep; inappetency; and generally slight febrile symptoms; the cough is shrill, dry, and comes on in sudden but short parox- ysms, without whooping. This stage lasts from two WHOOPING COUGH. 177 to three weeks: The convulsive stage; characterized by violent paroxysms of convulsive and suffocative cough, the inspirations being difficult and stridulous, and attended with a sense of obstruction or spasmodic stricture of the glottis. These paroxysms return at first five or six times daily, and gradually increase in frequency, so as, at last, to return almost hourly. The approach of a fit of coughing, is always announced by a sense of stricture in the breast, and titillation in the larynx and prsecordise. The paroxysm lasts from a half to four or five minutes, and terminates by vomiting, or the discharge of a large quantity of viscid mucus from the bronchia. Pain is felt in the breast, immedi- ately after the cough. The duration of this stage is very various: in general it lasts from four to six weeks: 3. The stage of declension; this stage begins, when the spasmodic and suffocative character of the cough begins to abate. The declension of the disease is al- ways very gradual; its duration is as various as that of the other stages — commonly from two to four weeks. Prognosis. Whooping cough is seldom fatal, except by the supervention of bronchitis, hydrocephalus, cynanche trachealis, pneumonia, convulsions, or marasmus. — , Sequellce. Glandular swellings, dropsy, epilepsy, op- thalmia, struma, rickets, general cachexy, phthisis, &c. Proximate cause. The opinions on this subject are ex-? ceedingly various. Marcus, Whatt, and others, re- gard it as a peculiar species of bronchial inflamma- tion. Webster regards the brain as its primary dis- ease. Albers considers it as depending on a peculiar irritation of the eighth pair of nerves. Some view the stomach as its original location; and others regard it as a spasmodic disease, allied to asthma, My own opinion coincides with that of Albers. My reasons for rejecting the doctrine of its being an inflammatory af- fection, are stated in the lecture. The inflammatory symptoms which frequently occur in this disease, are not essential, but accidental to the disease. In many 178 WHOOriNO COUGH. cases, not the slightest febrile symptoms occur; and when we reflect on the almost constant agitation and irritation which the lungs suffer from the cough, we have good grounds for believing, that the inflamed ap- pearance of the mucous membrane of the bronchia, so commonly found on post-mortem examination is the effect, and not the cause of the disease. Treatment. It is generally believed, that whooping cough, like the exanthematous fevers, cannot be arrest- ed in its course, but that, when once developed, it ne- cessarily passes through its different stages. This I hold to be an erroneous opinion, being thoroughly persuaded, that it is susceptible of being arrested at any time, whether in its forming, convulsive, or de- clining stage. Bleeding and leeching. Both may be employed with decided advantage, in cases accidentally complicated with inflammatory symptoms, or where much cephalic congestion exists. The disease cannot, however, be subdued by them. Purgatives of the mild kind, are proper, in cases attended with constipation, a loaded state of the bowels, or pre- ternatural determination to the head. Emeties, always beneficial, unless great gastric irritability exists. They free the bronchia and trachea of the viscid mucus with which they are loaded, and perhaps do good by their impressions on the pneumo-gastric nerves. Narcotics. Belladonna is a valuable remedy. It is much used in Germany and France. I have em- ployed it in a number of cases, with great advan- tage. Dose for a child under one year, 1-2 grain; from two to three years, 2 1-2 grains of the powdered root. Conium maculatum, rhus vernix, hyoscya- mus, opium, lactuca mrosa, Pulsatilla nigricans, and solatium nigrum, have all been used and praised as remedies in this disease. Antispasmodics. Assafoetida in emulsion, useful, where WHOOPING COUGH. 179 410 symptoms of febrile irritation exist. Musk, valeri- an, amber, castor, &,c. have been beneficially employ- ed. Not a great deal, however, is to be expected from this class of remedies. Tonics. Cinchona, quinine, flowers of zinc, and arse- nic, are remedies of much value, where no signs of in- ternal inflammation exist. I have given large doses of quinine, with marked advantage. Expectorants, are seldom of much service. Pearson's alkaline solution, and Kerme's mineral, suspended in in a mucilaginous fluid, are among the best of this class of remedies. Lobelia inflata. I have found the tincture of this plant a most valuable remedy in whooping cough. From ten to fifteen drops are to be given, four times daily, to a child between the first and second years of age. Tinct. Cantharides, highly recommended by Armstrong, Chalmers, Millar, Buchholz, Loder, Lettsom, Hufe- land, and others. It must be used until slight ardor urinse occurs. External applications. Frictions, with tartar emetic ointment, along the spine, or over the precordial r&° gion, will generally prove decidedly useful. This prac- tice originated with Autenrieth. (Richter.) Blisters and rubifacients are indispensable, when pulmonic in- flammation exists. Balsam Copaiva, is a remedy of inestimable powers, when the disease has degenerated into chronic bron- chitis, and the expectoration is puruloid. Inhalations. The inhalation of balsamic vapors, the nitrous acid vapor, and the vapor of tar, are strong- ly recommended by some recent writers. 1 have used the nitrous acid vapor with benefit, in several violent cases. The diet should be simple and unirritating ; and great care must be taken against the influence of cold and damp weather. 180 ASTHMA. ASTHMA. Character. Great difficulty of breathing, attended with a sense of suffocation, great thoracic constriction, Wheezing, and cough. Symptoms. The attack usually preceded by premonitory symptoms; such as drowsiness; head-ache; itching of the skin; flatus; heart-burn; acid eructations; sickness; fulness and anxiety about the prsccordia; weight over the eyes, &,c. The paroxysm generally comes on at night, during sleep. It is characterised by inexpressible anxiety ; very labo- rious wheezing, and suffocative breathing; great tight- ness about the chest; countenance bloated and Iivid ; — • — sometimes pale; cold extremities; intense desire for cool fresh air; incapability of lying down; pulse fre- quent, irregular, and often intermitting; abdomen dis- tended with wind; cough, at first dry; a copious expec- toration of viscid mucus occurring in the course of some hours, bringing with it considerable temporary relief The symptoms remit greatly, during the ensu- ing day. On the next night, however, the fit generally returns. In this manner, it often goes on with remis- sions by day, and exacerbations by night, for five or six days; and sometimes much longer. Predisposition. The disease rarely occurs before the age of puberty. The predisposition appears to consist in an irritable and weak condition of the respiratory organs. It seems, in some instances, to be hereditary. Persons of weak muscular power, and disposition to obesity and corpulency, arc most liable to the disease. Exciting causes. Particular conditions of the atmos- phere, in relation to its humidity, electricity and tem- perature; various irritating substances conveyed to the lungs ; suppression of accustomed discharges ; reper- cussion of cutaneous affections; metastasis of gout or rheumatism; general plethora; gastric and intestinal ASTHMAi 18 i irritation; derangement of the digestive functions; cer- tain odours ; indigestible aliment ; anger, and terror. Authors have divided asthma into a great many varie- ties. It does not appear to me, that these distinctions are of any practical utility ; although it is unquestion- ably of much importance to attend to the nature of the exciting cause, in prescribing for the disease. Proximate cause. The opinions on this subject very various. Cullen ascribed it to a preternatural spasmo- dic constriction of the bronchiae. Parry to a vascular fulness of the bronchial membrane, by which the air cells are mechanically diminished. Potter, to general venous congestion of the lungs. Bree, to an irritation seated within the air cavities, caused by a viscid and irritating serum. My own opinion is, that it depends on a peculiar irritation of the pneumogastric nerves, in consequence of which* the regular transmission of the nervous influence to the lungs, is interrupted. This Opinion is founded: 1. On the effects which are pro- duced on respiration, by dividing the eighth pair of nerves, which entirely resemble the phenomena of asthma: 2. The suddenness with which the spasmodic breathing may often be allayed, by certain medicines, as the lobelia inftata: and, 3. The beneficial effects resulting from the transmission of the galvanic influx ence through the lungs. Treatment. Bree affirms, that we can do but little tow- ards mitigating the paroxysm. He is wrong; I have often seen the paroxysm arrested, in less than thirty minutes. Bleeding. When the disease arises from the suppression of some habitual evacuation, and is attended with ge- neral plethora, blood-letting is indispensable. When- ever the pulse is hard and tense, blood should be drawn. Emetics, are much recommended by some. When gas- tric irritation exists, from indigestible diet, or other causes, they are serviceable* Under other circum- stances, they seldom do much good . 182 AiTHMA. Purgatives beneficial, when the bowels are disordered. Bree recommends chalk, in union with rhubarb. Expectorants, a useful class of remedies in this disease. Floyer regarded vinegar of squills as a specific in this disease, which, however, it is very far from being. Diuretics, are serviceable, in dropsical habits. A copi- ous flow of urine, is always a favorable occurrence. Antispasmodics, are seldom useful. In habitual or chronic asthma, opium with ether, has been found bene- ficial. Narcotics. Hyoscyamus, stramonium, tobacco, and opi- um, have been recommended. They are occasionally palliative, particularly in protracted or habitual cases. The root of the stramonium is to be cut fine, and smoked in a pipe. Symplocarpus fatida. I have known the infusion of the root of this plant, give great and prompt relief. Lobelia inflata. I regard this vegetable as decidedly the most valuable remedy we possess, for arresting or miti- gating the asthmatic paroxysm. My own experience corresponds entirely with the statements published by Drs. Thatcher, Stewart, Cutler, and others, of its valu- able remediate effects in this disease. I have known a violent fit of ashma completely allayed in the course of thirty minutes. Coffee. A cup of very strong coffee will often procure much alleviation in this complaint. (Percival.) Digitalis, in combination with small doses of opium, re- commended by Drs. Ferriar and Percival. Prussic acid, employed with advantage by Drs. Oliver and Granville. Galvanism has of late years been employed with much advantage in this complaint, by Dr. Philip and others. The galvanic influence must be communicated with much force. The two wires of a weak galvanic trough, are to be attached, one to a piece of metal placed on the pit of the stomach, and the other on the side of the neck, over the par vagum. ANGINA PECTORIS. 183 The prophylactic remedies are of the tonic kind. Bark, iron, tonic bitters, with occasional mild aperients, mode- rate exercise, and above all, a light and digestible diet, with the use of the cold shower bath, are to be used during the intervals of the attacks. ANGINA PECTORIS. Symptoms . Sudden and violent pain about the sternum, extending to the arms, attended with great anxiety, dif- ficulty of breathing, and a sense of suffocation ; pulse seldom materially affected — sometimes irregular or in- termitting ; countenance pale and expressive of intense anxiety; extremities cold. The attack usually comes on while the patient is walking. At first, it lasts but a few minutes, and returns after long intervals ; but by degrees the fits recur oftener , and become more pro- tracted. Predisposition. It occurs more frequently in males than females; and exceedingly seldom in young persons. Subjects of a gouty or rheumatic habit, with a tendency to corpulency, are most liable to the disease. Causes. Ossification of the coronary arteries, and valves of the heart ; dilatation of its ventricles ; a soft- ened structure of the heart, and other organic affec- tions of this organ, and of the adjoining parts. In some cases, however, not the slightest traces of structural de- rangement are found on dissection. Dr. Johnson thinks, that a neuralgic affection of the cardiac plexus may produce it — an opinion which is, I think, well founded. From all that has been ascertained in relation to this subject, it would seem, that angina pectoris is an affec- tion which may be excited by a variety of causes; and it appears to me probable, that the essential nature of the disease, consists in an irritated condition of the cardiac nerves. Prognosis. The disease is generally believed to be in- curable ; and when it depends on structural derange- ment of the heart, it undoubtedly is so. There are 184 DROPSY. some well attested cases on record, however, which yielded to remedial measures. Death almost always occurs suddenly. Fothergill, Wichmann. Treatment. For the relief of the paroxysm, bleeding, opium, hyoscyamus. a recumbent posture, and perfect rest and quietness, are often found beneficial. To pre- vent the return of the disease, the following remedies have been employed with advantage. Guaiacum; opium, musk, and camphor in union, (Shaefer ;) cicuta, assafoetida, and camphor, (Johnson ;) flowers of zinc and opium, (Perkins;) lime water and antimony, (Smith ;) Frictions with tartar emetic ointment on the breast, (Godwin;) phosphoric acid, (Baumes,Richter;) James's powder, (£mith ;) a rigid antiphlogistic regi- men, (Oclier;) arsenic, (Hufeland, Blane;) prussjc acid ; hyoscyamus ; stramonium ; cuprum ammoniacum, &c. All kinds of spirituous drink are injurious; so are strong mental emotions; inordinate venereal indul- gence ; strong corporeal exertions ; sudden atmospheric vicissitudes ; indigestible and irritating articles of food, &c. CHAPTER XVIII. DROPSY. Pathology of Dropsy. Dropsical effusion is not, pro- perly speaking, a disease, but only an effect of disease. The morbid condition upon which the dropsical effu- sions depend, is either inflammation, or a state of the exhalents closely allied to inflammation. (Rush.) The doctrines which allege, that torpor of the absorb- ANASARCA. 185 ents, or relaxation of the exhalents, is the proximate cause of the effusion, are examined, and their insuffici- ency pointed out. There is, no doubt, always deficient venous absorption, — because that condition of the ca- pillaries, which disposes to excessive exhalation, js es* sentially connected with a congested state of these ves* sels, and congestion, or vascular fulness, always im- pedes absorption. (Magendie.) Observations on the character of the urine, in hydropic diseases. In some instances, the urine contains more or less serum ; in others, it is entirely destitute of it. According to the observations of Blackall, Willis, and Ayre, it is in the subacute and idiopathic forms of dropsy, that the urine js loaded with the greatest quantity of serum. In dropsy from scarlatina, there is generally a large quan* tity of serum in the urine. In local dropsies, not atten- ded with general excitement, the urine is seldom charged with any serum. (Ayre,) When the heart sympathizes with the local or general morbid action of the exhalents, febrile symptoms at* tend. When the morbid excitement of the exhalents does not extend to the heart, the general circulation is languid, and debility and relaxation characterize the disease. The general indications in the treatment of dropsy, are? 2. To procure the absorption and elimination of the effused fluid: 2. To correct the morbid action of the serous exhalents, from which the effusion takes place. Dropsy is divided into three principal varieties: viz. Ana- sarca, ascites, and hydrothorax. ANASARCA. In this variety, the effusion takes place into the cellular tissue. It may be either local or general. A part that is anasarcous, pits on pressure. It almost always be* gins in the feet or legs — the swelling diminishing dur* ing the night, and increasing towards evening. The 186 ASCITES. urine in this, as in the other varieties of dropsy, is al- ways scanty and high colored ; the countenance is sal- low, the general system sluggish, and there is usually much sleepiness. Anasarca is frequently connected with effusion into the abdomen and chest. Causes. Local anasarca may be produced, by whatever impedes the return of the blood from a part — as, indu- rated glands pressing on large veins, ligatures, &c. It arises also from mere general debility; diseases of the heart; phthisis, &c. General Anasarca may result from hemorrhages, diar- rhoea, diabetis, and other circumstances that rapidly exhaust the system. Observations on the manner in which these causes produce dropsy. Sudden suppres- sion of perspiration, particularly after scarlatina, measles, or while under the influence of mercury, a frequent cause of general anasarca. Dropsy from this cause always decidedly phlogistic. General anasarca may also result from the internal use of arsenic — from torpor of the kidneys — from amenorrhoea, general ple- thora, with a relaxed habit, chronic diseases, intestinal irritation, &c. Observations on the modus operandi of these causes. Proximate Cause. A sub-inflammatory action of the exhalents of the cellular tissue, attended with increased exhalation, and diminished venous absorption. It ap- pears to me probable, that congestion in the venous capillaries, performs an important part in the produc- tion of dropsical accumulations. This idea is discussed at length, in the lecture. ASCITES. Abdominal dropsy. Its causes are sometimes local, at pthers general. The local causes are such as impede the circulation through the portal system of vessels — among which, visceral indurations, particularly of the liver and spleen, are the most common. Dr. Ayre de- HYBROTHOftAX. 187 fries that visceral obstructions produce dropsy; they notwithstanding frequently do so. The most common general cause of ascites, is cold, either generally or lo- cally applied. When the result of this cause, its cha- racter is always conspicuously inflammatory ; the blood usually exhibiting the buffy coat; the skin being dry and hot; the pulse frequent and tense, and the urine loaded with serum. Ascites is seldom wholly free from anasarca. Intestinal irritation sometimes gives rise to abdominal dropsy. It occurs as the sequel of peritoni- tis. Diagnosis. Proximate cause. A morbid action of the exhalents of the peritoneum, attended with capillary congestion, and diminished venous absorption. HYDROTHORAX. Serum effused into the cavity of the thorax. It is charac- terized by the following Symptoms. Oppression in the chest ; difficult respira- tion, particularly when lying down, or ascending heights; dry cough; a sense of suffocation, when in a recumbent position; sudden starting during sleep; pulse intermitting, or irregular; thirst considerable} urine scanty; oedema of the feet; a pale bloated coun- tenance, &c. Divided into symptomatic and idiopa- thic. The first arises from organic affections, — the latter from general causes. Causes. Organic affections of the heart. When from this cause, the effusion occurs on both sides. Chronic pleuritis, a frequent cause of hydrothorax. It may also result from a tuberculous state of the pleura, and even from structural disease of the stomach and liver. This is by far the most frequent variety of hydrotho- rax, and is almost always incurable. Idiopathic hydrothorax, is of very rare occurrence, and generally easily cured. The effusion almost alway* 188 HYDItOTHOKAX. occurs only on one side — that side becoming sometimes considerably enlarged, by the pressure of the fluid. General plethora, predisposes to hydrothorax; particular- ly in persons who have passed the middle period of life, and who indulge in the pleasures of the table, and use but little exercise. Diagnosis. A sense of suffocation on lying down, and on firm pressure on the abdomen, will generally distin- guish it from mere organic disease of the heart. Per- cussion produces a dull sound, and the stethescope detects the absence of the respiratory murmur. Treatment. When the heart sympathizes with the primary local irritation, or with the morbid action of the capillaries from which the effusion occurs, blood-* letting is an important remedy. It is indicated in all cases, in which there is tension and quickness of the pulse. Local bleeding* from the thorax or abdomen, recommended by Ayre, in hydrothorax and ascites* Diuretics, are important remedies in hydropic diseases. Their operation is, however, rather palliative than cu- rative — that is, they evacuate the effused fluid, rather than correct the morbid action on which the effusion depends. In full and phlogistic habits, their operation is promoted by bleeding and cathartics. When the effusion is very extensive, and the blood has been de- prived of a great portion of its serum, copious draughts of water promote the operation of diuretics. The mode in which diuresis removes dropsical effusion ex- plained. The most useful diuretics in dropsy, are: squills, digitalis, tobacco, cantharides; acetate, nitrate, and tartrate of potash; colchicum, wild carrot seed, erigeron heterophyllum, and juniper berries. The squill, is the best diuretic in hydrothorax. It is best adapted to cases in which the urine is very scanty, high colored, and sedimentous, and not attended with much febrile excitement. Its virtues are much enhanc- ed, by giving it in Union with calomel, especially in hydrothorax. Very advantageously combined with jgypROTHORAJS. 180 digitalis and nitre. The reason why calomel and squills, in combination, are more beneficial in hydro- thorax, than in the other varieties of dropsy, are three- fold; "1. absorption; 2. diuresis; 3. determination to the glands of the mouth and throat, causing a deriva- tion from the vessels of the pleura." Digitalis. Some greatly extol its virtues in dropsy— oth- ers speak lightly of it. It does not appear to do much good, in subjects of a tense fibre, and robust habit of body. In persons of a contrary habit, with a pale countenance, cold skin, and weak pulse, it often proves decidedly beneficial, (Withering, Maclean.) Digi- talis, is the best diuretic in dropsies following scarla- tina. It is almost always beneficial, when the urine is coagulable by heat, small in quantity, somewhat tur- bid, and depositing a branny sediment, when cold. (Blackall.) It falmost always fails to do good, when the urine, though serous, is pale, crude, and without sediment. It is generally given, in combination with squill or calomel. I prefer giving it in union with nitre and calomel. In feeble habits, it may be advantageous- ly combined with opium. Cantharides, more particularly useful in anasarca, after scarlatina. (Ferriar.) Nitre is an excellent remedy, when the febrile excitement runs high. Diuretic drinks, such as infusion of juniper berries, wild carrot seed, &,c. should be freely allied. Cathartics. Valuable remedies in ascites and anasarca — 'hot so in hydrothorax. Their modus operandi ex- plained. The articles of this class, *most beneficial, are ; tartrate of potash ; elaterium ; gamboge, &c Of these the tartrate of potash is both the safest and the most useful. I have employed the following diu- retic composition, with more uniform, and prompt advantage, than any other article, or combination of articles I have ever tried. R. Tart, potas. 3iss. Sulph. potas. 3ss. Pulv. Scillse, 3ij. Tart. Antimonii, gr. ij» Dose, a tea-spoonful, four or five times daily. This 190 HXDROTHORAX. rarely fails to excite very copious watery stools, and at the same time, free diuresis. It is particularly useful in ascites. I have generally derived much more bene- fit from gamboge, than from elaterium. It is particu- larly useful in ascites. It may be advantageously com- bined with cream of tartar, in the proportion of 2 grains of the gamboge, to 30 of the latter article, repeated every three or four hours. It produces copious watery stools. Mercury, is a remedy of valuable powers in hydropic diseases. Generally given in uuion with diuretics, par- ticularly squills and digitalis. Should be given until the mouth is slightly affected by it. Relaxed and scor- butic habits, inimical to its beneficial influence. Es- pecially valuable, where there is organic disease of the liver. Sulphuret of Iron. I have seen much good done by this article, in cases attended with a relaxed and very debilitated state of the system; particularly in the ana- sarca of females, from excessive sanguineous discharges. It acts as a powerful diuretic, as well as tonic. Diaphoretics, are indicated, when the disease is the con- sequence of suppressed perspiration from cold. Anti- monials, in such cases, act beneficially. Blisters, and rubifacients, to the chest or abdomen, in hydrothorax and ascites, are strongly recommended by Ay re. I have seen much good derived from a blister over the abdomen, in a case of ascites. Tapping. DIARRH03A. Character. Frequent feculent stools, generally copious, always more liquid than natural, commonly attended with griping, but free from tenesmus and fever. Causes. Some act directly on the alimentary canal ; oth- ers indirectly, through the medium of the general sys- tem. Of the former kind, are: indigestible and irritat- DIARRHOEA. 191 ing articles of food; acrid secretions ; worms ; acid, and other irritating substances received into the stomach. Among the more general causes, are: dentition; cold, particularly when connected with humidity; the re- percussion of cutaneous eruptions; various general and local diseases, as phthisis, affections of the liver, &c. It may also be excited by violent mental emotions, as ter- ror and grief Proximate cause. An increased irritability of the in- testines, giving rise to increased peristaltic motion. In protracted cases, the mucous membrane of the intes* tines is generally in a state of chronic inflammation, and frequently more or less ulcerated. (Broussais, Abercrombie.) According to Broussais, when diar- rhoea continues beyond the thirtieth day, it almost in- variably depends on organic disorder of the mucous membrane of the colon. He asserts, that chronic in" flammation of this membrane exists in all cases. This is doubtful. When ulceration exists, it is always most conspicuous in the ceecum, and the lower part of the colon. Treatment. The principal indications are: to subdue the irritability, or phlogosis of the bowels ; and to re move as much as possible, all local irritating causes. These indications are to be fulfilled: J. by determining the circulation to the surface, and thereby lessening the afflux of blood to the vessels of the intestines; and, 2. by prescribing the most simple and unirritating arti- cles of food. To allay intestinal irritability, and deter- mine to the surface, opium, with small doses of calo- mel, or of ipecacuanha, and minute portions of calo- mel alone, are excellent remedies. Mild laxatives should be premised. In the diarrhoea of children, at- tended with a tumid and hard abdomen, laxatives are our principal remedies. Astringents, with mild to- nics, useful, in diarrhoea from mere debility of the stomach. Astringents improper, where there is much griping and tenderness of the abdomen, and in all in- 192 CHOLERA. veterate cases. Absorbents proper, when acidity is the cause. Balsam Copaiva, on excellent remedy in very protracted and obstinate cases. I have used spi. rits of turpentine with much advantage, in such cases, A flannel roller round the abdomen, beneficial in all cases. A farinaceous diet is of the utmost consequence. CHOLERA, Character. Frequent and violent vomiting and purg- ing, with severe griping and cramps in the extremities. Symptoms. Its attack is almost invariably sudden.— There is at first pain and tension in the epigastric re- gion — followed soon by colic pain about the umbilical region, attended with nausea, upon which vomiting and purging speedily ensue, The discharges are at first watery and without bile; nor is there often bile thrown from the stomach, in the commencement. Af- ter the disease has continued for some time, however, bile appears in the evacuations. The most distressing symptom, is the excessively severe cramps which oc- cur in the abdominal muscles, and the extremities, in violent cases. Cholera seldom continues more than 24 hours — it often terminates in death, within two hours. Causes. A superabundance of bile in the stomach, is not, as was formerly, and is still thought by many, the immediate exciting cause of cholera. There is, on the contrary, a. deficient secretion of bile — the liver being in an inactive and congested condition. The torpor of the liver, is generally in direct proportion to the vior lence of the disease. (Johnson.) Treatment. The principal indications are: to allay the morbid irritability of the alimentary canal ; to re-r store the regular action of the skin and liver; and to de- termine the circulation from the internal to the external parts. At first, bland diluents are proper. Opium in large doses, either alone, or in combination with calo? colic. 193 mel; sinapisms to the abdomen ; the warm bath; spiced brandy; nitric acid vesication ; and anodyne injections; are the remedies upon which our dependence must be placed. Of these remedies, opium largely given, and sinapisms to the abdomen, are decidedly the most efficacious. Calomel should be given with the opium. Calomel is a valuable remedy, by itself; half a grain should be given every half hour. Bleeding has been useful in the Asiatic cholera. It is seldom indicated in the disease, as it occurs in our climate. colic. Colic is divided into several varieties, according to the nature of the exciting causes. Flatulent colic, so called from the prominent symptoms of indigestion and flatulency which attend. It is pro- duced by irritating and indigestible articles of diet. — Debility of the digestive organs, predisposes especially to this variety of colic. The colic pains come on, an hour or two after the indigestible diet is taken. Some- times the food passes into the bowels in an imperfectly digested state, and then the pain does not come on so soon, and is felt low down in the abdomen. At first, there is a sense of distention in the pit of the stomach, followed soon by pain, which rapidly increases, until it acquires an intense degree of violence. The pain oc- casionally remits. During the exacerbations, the pa- tient throws himself about, and presses firmly on his abdomen with his hands. Large quantities of air are from time to time forced up, or pass off downwards. Diagnosis. Distinguished from enteritis, by the agita- tion of the patient; by the relief obtained from abdomi- nal pressure, and by the pain frequently remitting. In all these respects, the reverse obtains in enteritis. Prognosis. Generally not dangerous, unless it termi- nates in inflammation, which sometimes, though not often, occurs. It sometimes produces a paralytic state 194 COLIC. of a portion of the bowels, giving rise to habitual cos- tiveness. Treatment. In slight attacks, carminatives and ano- dynes are often sufficient to procure relief Remedies of this kind generally answer well, when the stomach does not contain any irritating substances. When it does contain irritating substances, an ipecacuanha emetic must be given. Purgatives to be used when the pain is below the stomach; they may be advanta- geously combined with aromatics. 1 prefer castor oil and spirit of turpentine, in union. Enemata, always useful. Where the pain is excessive, opium, in very large doses, with calomel, is a valuable remedy — it does not materially impede the subsequent operation of the necessary purgatives. Bilious colic, so called, from the bilious vomiting, and other symptoms, manifesting functional derangement of the liver. The more urgent and peculiar symptoms of this variety of colic, are generally preceded by head-ache, want of appetite, bitter taste in the mouth, thirst, and bilious vomiting. The colic pains are excessively acute ; pres- sure at first gives relief; but the abdomen becomes ten- der to the touch, as the disease advances. Immediate- ly after vomiting, the pain suffers a temporary abate- ment. The bowels are generally immoveably torpid. About the second or third day, the eyes and skin be- come yellow. Tremor, numbness, and paralysis of the arms, occasionally occur in this disease. Eructa- tions are common, and afford temporary relief Causes. Marsh miasmata. It occurs most commonly during the autumnal months, particularly after a long continuance of hot and humid weather. It may, how- ever, be produced also by causes of a sporadic character. It is generally believed, that the liver is in a state of mor- bid activity — that it secretes a superabundance of bile. Dr. Staly contends, that the liver is torpid — that there colic. 195 is a deficiency of bile. I have come to the same con- clusion. That there is functional derangement of the liver in this vari- ety of colic, does not admit of a doubt; but I do not believe the biliary secretion superabundant, but on the contrary diminish- ed and vitiated. That this is the case, may be inferred from the analogy which subsists between bilious colic and cholera morbus. Dr. Gregory observes that bilious colic is closely allied to cholera, occurring along with it, and apparently dif- fering from it only in some unessential features . Now it ap- pears to be well established, I think, that in cholera, the liver is far from being over-active — that it is, in fact, in an engorged and torpid condition, secreting but a very small portion of bile. Excessive irritability of the stomach, and torpor, with congestion of the liver almost always appear in connexion with each other. We have a further support for this opinion, in the fact, that, whenever the alvine discharges become bilious, an amendment takes place. Treatment. The principal indications are: 1. To free the bowels from their irritating contents: 2. To allay the irritability of the stomach and bowels : and, 3. To restore the healthy action of the liver. Emetics are very useful in the beginning, when there is not full spontaneous vomiting. Purgatives are of primary im- portance. They can seldom be given, however, with effect, until the gastric irritability is allayed. £mall doses of calomel, 1-2 grain — given every half hour, answer well to prepare the stomach for the reception of purgatives. Our principal reliance must be placed on the full operation of purgatives. Opium, given in full doses, affords much advantage after free purging; it should always be given in combination with calomel. Mild aperients to be used, for several days after the bowels have been once freely evacuated. Epispastics, sinapisms, and warm fomentations, are valuable aux- iliaries. Bleeding must be fully employed in robust and plethoric subjects, with the view of obviating in- flammation. Alkaline remedies are proper, when acid exists in the prima? viae ; magnesia is the best article of this kind. The warm bath, is a useful auxiliary. The 1S6 COLICA PJCTONUM. utmost caution is to be used in relation to diet and ex- posure, during the period of convalescence. There are few diseases which are so apt to return, from errors in these respects, as the present one. Flannel should be worn round the abdomen. Very cold drinks must be avoided, during convalescence. COLICA PICTONUM. This variety of colic is known by various names; as, painter 's colic, dry gripes, Devonshire colic, colica pictavensis, rachialgia metallica, and saturnine colic. The disease generally comes on gradually, and is gene- rally preceded by symptoms of gastric derangement such as irregular appetite; constipation; foul eructa- tions; transient pains in the abdomen; languor; pale countenance, &c. This variety of colic is attended with constant and extremely severe pain about the um- bilical region ; the abdominal parieties are hard, and forcibly retracted; and the bowels almost immoveably constipated. The pain suffers occasional remissions, but no perfect intermissions, as in the other varieties of colic. It sometimes assumes a chronic form, pro- ducing wasting and palsy of the fore arms. The predisposition to it is greatly increased, by having once suffered an attack. Causes. Lead; hence its frequency with painters, glaziers, and workers in lead factories. Sudden at- mospheric vicissitudes, (Larrey ;) new and sour wines ; unripe fruits, &c. Treatment. The indications are: 1. To obviate inflam- mation: "2. To relieve the spasms of the bowels: and, 3. to evacuate them. Bleeding should be freely employed in robust and ple- thoric subjects — or when the pulse is hard, quick, and tense. Opium with calomel, is a remedy of primary importance. Both these articles should be given in very large doses, with the view of relieving the intesti- DIABETES 197 nal spasm, and bringing on an early mercurial action* Two grains of the former, with the same quantity of the latter, may be given every two hours, until the pain and spasms are relieved. Purgatives to be given after the opiates. They seldom fail to excite purging, as soon as the gums are affected with the mercury, and when preceded by very full doses of opium. Purga- tives should be given in a liquid form. Cold water, dashed on the abdomen and thighs, has been found usefuUn promoting the operation of cathartics. Alum, in fifteen grain doses, every three hours, much recom- mended by Richter. Stimulating enemata, highly be- neficial. The warm bath, a useful auxiliary. To re- lieve the paralysis and other sequella?, mercury is the best remedy. Nitrate of silver has also been success- fully used, for the relief of the paralysis. Pemberton's splinU DIABETES. This disease consists in the secretion and voiding of an unusually large quantity of urine, attended with a very dry skin; great thirst; slight febrile movements; vora- cious appetite ; a sense of weight and uneasiness in the stomach; white and foul tongue: great lassitude; pain and weakness in the loins; irregular bowels; cold feet; dull and heavy eyes ; and towards the last, great wast- ing of the flesh, and debility; vertigo; head-ache ; diffi- culty of breathing; spongy gums; offensive breath; constant drowsiness; and hectic fever. Prout men- tions inflammation and uneasiness about the external orifice of the urethra. Diabetes occurs under two distinct forms, viz: diabetes mellitus, and diabetes insipidus. Of the latter there are three varieties; 1. That in which the urine contains an excess of urea; 2. That in which the urine is albu- minous; and, 3. That in which it is surcharged with phosphates. 196 DIABETES. Diabetes Mellitus. In this variety, the urine is saccha* vine, of a pale straw color, sometimes approaching to a greenish hue ; its smell resembles that of milk. It always contains less urea than healthy urine. Prout, who restricts the term diabetes to this variety, says, that diuresis is not essential to the disease. A natural predisposition to diabetes exists in some indi- viduals. I have known three members, out of one fa- mily, die of this disease. Of the exciting causes, we know little or nothing. Proximate cause. The opinions on this head are ex- ceedingly various. Sydenham, Rollo, Cullen, and others, regard derangement of the digestive functions, and want of energy in the assimilative |powers, as the primary affection. Objections stated to this opinion. I regard diabetes, as a disease essentially and prima- rily located in the kidneys, — the stomach, lungs, skin, and in short the whole system, becoming secondarily affected. The sugar contained by the urine, is wholly the result of a morbid action of the kidneys, for the se- rum of the blood of diabetic patients, does not contain a particle of it, It would seem, that the urea which is secreted with the urine in health, is converted into su- gar in diabetes. The analogy between urea and sugar pointed out. Sugar contains just double the quantity of oxygen and carbon, and the same quantity of hy- drogen, as urea — this latter substance possessing, in addition, a large proportion of azote, of which sugar is destitute. As diabetic urine contains very little or no urea, we may regard the sugar it contains, as a deprav- ed secretion of urea. Prognosis. Diabetes mellitus, is an exceedingly obsti- nate and dangerous affection, the instances of recovery from it being comparatively very few. Treatment. Various and diametrically opposite plans of treatment, have been recommended. Bleeding has been used with success, by Watt. In recent cases of a phlogistic character, it is often beneficial ; not so in DIABETES. 199 protracted cases, or where there is much exhaustion. Topical bleeding, sometimes useful. Opium holds a high rank, as a remedy in this disease. Feriar gave it in union with bark and uva ursi. Prout prefers the pulv. ipecac, compos. Opium, with carbonate of iron, has been used with much advantage in chronic cases, with much debility and nervous irritation. (Latham, Prout.) Sulphate of quinine, a useful article in such cases. Magnesia, strongly recommended by Dr. Trot- ter; I have known it to do some good. Emetics, used successfully, by Richter. Warm bath and frictions with the flesh brush, useful auxiliaries. Exclusive animal diet, is generally admitted, as decidedly the best kind of food in diabetes. Of late, Dr. Starkey has published some cases, from which it appears, that, con- trary to the generally received opinion, a vegetable diet is sometimes more beneficial, than one consisting principally, or wholly, of animal substances. He cured cases with a vegetable diet, and one drachm of phosphate of soda, three times daily. Other remedies have been recommended, such as: cuprum ammonia- cum ; alum in 9j. doses ; tincture of cantharides ; cam- phor ; hepatized ammonia ; phosphate of iron, &,c. Excessive diuresis, with an excess of urea. Urine generally pale ; reddening litmus, when first voided ; free from sediment, being prone to decomposition; and becoming alkaline. The desire to pass urine is fre- quent and urgent; the urine apt to be increased in quantity, by cold weather. The functions of the skin are natural ; the pulse remains unaffected ; no particu- lar thirst, or craving for food ; the bowels are in general regular. Persons of a thin and spare habit, about the middle period of life, most subject to it. Causes. Whatever debilitates the general system, and particularly the urinary organs, as masturbation. Treatment. Tonics, with alkaline remedies and opi- um. Mercury, in alterative doses ; purgatives. (Prout.) Excessive diuresis, with phosphatic salts in the 200 DIABETES. urine. Symptoms. Great general irritability; dys- peptic phenomena; sometimes costiveness; at others, debilitating diarrhoea, the stools being very unnatural in appearance; pain and uneasiness in the loins; coun- tenance sallow and haggard. As the disease proceeds, great " languor, depression of spirits, coldness of the legs, complete anaphrodisia, supervene. The urine is pale, very prone to decomposition." (Prout.) The sediment consists chiefly of the phosphates. Causes. Injuries done to the back — excessive fatigue — depressing mental emotions — irritation about the neck of the bladder, by calculi, and other circumstances. Prognosis. The prognosis is in general unfavorable, particularly when resulting from injury of the back. (Prout.) Treatment. Opium is, according to the experience of Prout, the only remedy that can be employed with any particular advantage, to allay the excessive general irritability which prevails in this disease. Alter the morbid irritability has been allayed, tonics must be given in conjunction with the opium — such as the mi- neral acids, cinchona, iron, uva ursi, and bitters. A stimulating plaster to the back and loins will prove beneficial. A strong infusion of alchemilla arvensis, has been found useful. Hyoscyamus, with uva ursi, very serviceable, where the constitution is sound, and the irritation is confined to the urinary organs. The diet should be digestible, mild, and nutritious. (Prout.) INDIGESTION. 201 CHAPTER XIX. INDIGESTION. Symptoms. Variable appetite — generally none; flatu- lence, distention, acid eructations, and colic pains, after eating. These symptoms characterize the slighter cases of the disease. By repeated errors in diet, or long continuance, it generally assumes a more aggra- vated form ; in which case the stools lose their natural appearance, becoming bilious, very fetid, sometimes of a very dark color, at others too light or greenish, — and often mixed with portions of undigested food ; the skin becomes sallow; the urine high colored, and sedi- mentous; diarrhoea, followed by constipation; griping; a sense of weight in the right hypochondrium ; tender- ness of the epigastrium ; a foul and clammy tongue ; de- bility, particularly after the operation of purges; gene- ral despondency and irritability of temper; emaciation; a haggard expression of the countenance; frequently uneasiness of lying on the left side, and at last inability to rest easily on either side; a shrivelled and dry state of the skin, in protracted cases ; great sensibility to low temperature, &,c. Causes. There are two conditions necessary for healthy digestion, viz : 1. The secretion of a due quantity of healthy gastric liquor; 2. A healthy tone of the mus- cular coat of the stomach. Whatever therefore de- ranges either of these two functions, impairs digestion. The remote causes which are capable of effecting these morbid changes, act either directly on the stomach, or indirectly through the medium of the general system. Of the former kind are rail kinds of substances capable of irritating the stomach — such as irritating and indi- 203 INDIGESTION. gestible articles of diet; the habitual use of spirituous drinks; the excessive use of condiments, opium, and other narcotics; the immoderate use of very warm, or very cold drinks; chronic hepatic disease ; over-disten- tion of the siomahc, by food or drink — of all the causes of indigestion, this latter one is the most com- mon. The circumstance which most commonly gives rise to over-distention of the stomach, is rapid eating; high seasoning, and frequent variety of food is also a frequent cause of over-distention. Over-distention does injury, by weakening the muscular fibres of the sto- mach, and by irritating the nerves of this organ. — (Among the causes that affect the stomach, secondari- ly, through the general system, are: the depressing pas- sions; intense study; excessive venereal indulgence; and whatever debilitates the general system. Proximate cause. Irritation of the nerves of the sto- mach, and debility of its muscular fibres, either exist- ing singly or conjointly. In consequence of these con- ditions, the solvent gastric fluid becomes either de- praved in quality, or deficient in quantity; and the contents of the stomach are not adequately embraced, and propelled forwards to the pyloric extremity. Observations on the multifarious sympathetic effects of gastric irritation, from imperfectly digested food in the primse via?, and on the morbid effects which result from the absorption of imperfectly elaborated chyle into the circulation. Treat3iext. The treatment of indigestion is divided into dietetic and medicinal. In slight cases, a proper attention to diet, with the occasional use of mild aperi- ents, and a rigid avoidance of the exciting causes, will rarely fail to establish a cure. In all cases, whether simple or complicated, mild or violent, an undeviating attention to diet, is essential to the management of the disease. No particular direction in relation to the kind of diet, can be laid down, which is applicable to all INDIGESTION. 203 Cases. Some dyspeptics feel relieved by articles of food, which are altogether intolerable to others. Ev- ery dyspeptic must learn, m a great mensure, from his own experience, what will, or will not, agree with him. The degree of violence of the disease, too, has an im- portant influence upon the power of the stomach, to bear particular kinds of food. What may be taken without inconvenience in the first periods, will general- ly become insupportable in the latter stages of the dis- ease. At first, when mere debility of the stomach exists, the more digestible kinds of animal food, are decidedly the best; but if the disease continues, until a high degree of irritation, or chronic phlogosis, exists in the mucous membrane of the digestive organs, ani- mal food is no longer proper — the disease then requir- ing the mildest articles of the farinacious kind. Ani- mal is undoubtedly more digestible than vegetable food ; and where the gastric irritation is not very considera- ble, it will very generally be taken with the least incon- venience. As a general rule, therefore, we may lay it down, as an established principle, that animal food is the most proper ; and of this, the most tender muscular parts are to be used. The flesh of old is in general more digestible than that of young animals. Mutton, and most kinds of game, are of easy digestion. Pork is generally difficult to digest, yet some dyspeptics bear it better than other meats. Acescent and oily articles are most difficult of digestion. Venison is perhaps the most digestible of all meat. New bread is of exceedingly difficult digestion. Simple roasting and boiling is the best mode of preparing meat for weak stomachs. All kinds of 'fried articles of food, are intolerable. Cheese, milk, cream, and butter, are ge- nerally oppressive. Spices and condiments should be taken very sparingly. Fresh vegetables are very gene- rally injurious, particularly, cabbage, peas, and beans. Of fruits, cucumbers, pears, melons, currants, are the most indigestible. The food should be taken chiefly 204 INDIGESTION. in a solid state. Slow eating, and perfect mastication, are all-important observances for dyspeptics. Not much drink should be taken during meals, or soon after. Moderate portions of good brandy, answer well in slight cases, but are improper in the more aggravat- ed ones. Simplicity in diet is of the utmost impor- tance; and what is of equal, if not of still greater im- portance, is, to avoid over-distending the stomach. Medicinal treatment. In slight and recent cases, gentle emetics and aperients, to remove the irritating contents of the stomach and bowels, with the use of mild to- nics; alkalines when the eructations are acid, and an animal diet, will generally remove the disease. To re- lieve the gastric pains, small doses of opium may be occasionally used. When functional disease of the li- ver exists, alterative doses of blue pill, with the occa- sional exhibition of some gentle laxative, are of great utility. Care must be taken, however, not to continue the use of the mercury, until the general system becomes affected by it. General mercurial excitement, is always improper, in dyspepsia. The nitro-muriatic acid, will of- ten prove serviceable, as a local tonic, and by its action on the liver. When the gastric irritation has assumed the character of chronic inflammation, that is, when the epigastrium becomes tender to pressure, the pulse tense and irritated, the tongue red, &,c. tonics, emetics, animal food, and all stimulating remedies, are injurious. The diet must be of the lightest farinaceous kind; leeches, or blisters to the epigastrium, are often highly useful; the nitrate of potash, dissolved in some mucila- ginous fluid, the occasional use of fluid purgatives, and gentle diaphoretic drinks, with the use of very small doses of the blue pill, must be resorted to. In very protracted cases, attended with a broken down constitu- tion and general irritation, mercury is improper. JAUNDICE. 205 ICTERUS JAUNDICE. Symptoms. Skin and eyes yellow ; faeces clay colored ; urine bilious, communicating a yellow stain; generally slight pyrexia; occasional pain (sometimes very violent) in the epigastrium; indigestion; languor, nausea; a sense of fulness in the stomach ; torpor of the bowels ; colic pains : drowsiness ; bitter taste ; debility, and in- disposition to mental exertion ; disturbed sleep, &,c. The fundamental affection is either an idiopathic or sym- pathetic derangement of the biliary organs, or of the duodenum, by which the bile is either obstructed in its passage into the intestines, or its secretion is sus- pended. The occasional causes are very various. The principal are: intemperance in the use of spirituous liquors; ir- ritating substances in the primse vise ; cold ; suppression of acute and chronic cutaneous eruptions ; acrid bile irritating the common duct; biliary concretions plug- ging up the duct ; violent anger ; injuries and concus- sion of the brain ; spasm of the duodenum, or of the common bile duct; induration and enlargement of the pancreas; grief; terror; constipation; viscid mucus clogging the orifice of the common duct; retained me- conium; indurated liver; and, in short, whatever is capable either of suspending the secretion of bile, or preventing its natural egress from the liver. When it depends on spasm or biliary concretions, the pain i^ occasionally very violent. Proximate cause. The external icteric phenomena, de- pend on the secretion of bilious matter into the sub-cu- ticular tissues, in consequence either of the resorptiqp of bile into the general circulation, or of the retention of its elements in the mass of the blood, in case of he- patic torpor. When this occurs, the general capillary system, and particularly the cutaneous capillaries, per- form the office of the liver vicariously, and free the 206 JAUNDICE. blood of a portion of its superabundant biliary ele- ments, by depositing them into the skin, &c. Observations on the ratio symptomatum. Great wasting of the flesh, and dropsy, are common se- quellse of very protracted and obstinate cases. The jaundice of new-born infants, is generally transient, and of no particular moment. When it depends on chro- nic hepatic disease, it is seldom cured. In general, however, it is not a dangerous affection, though often of difficult removal. Treatment. The mode of treatment should of course be modified, according to the nature of the fundamen- tal hepatic affection. When there is fever, with symp- toms of local inflammation, bleeding and blistering, with mercurial purgatives, must be chiefly relied on. When spasm of the common duct may be presumed to be the primary cause, which is attended with violent pain, constant nausea, and frequent vomiting, opium, stramonium, hyoscyamus; emetics, in nauseating doses; valerian; assafcetida; infusion of chamomile; purgatives; the warm bath; emollient cataplasms, or fomentations to the epigastrium; anodyne frictions, and enemata. When torpor of the liver exists, as the fun- damental pathological condition, (in which case, there is little or no pain experienced,) calomel is the princi- pal remedy — it should be given in purgative doses. Benefit may also be derived from infusion of taraxa- cum; saponaria; alkalies; ammoniac; mercurial fric- tions on the right hypochondrium; antimonials; blis- ters and sinapisms on the region of the liver; and ac- tive purgatives. When biliary concretions exisi, as the cause of the disease, emetics; purgatives, the warm bath; electricity; opium; stramonium; hvoscyamus; alkaline remedies ; copious bleeding; nauseating doses of antimonials; are serviceable. Durande recommends a mixture of vitriolic ether and spirits of turpentine, in the proportion of two parts of the former, to one of the latter, in doses of twenty drops, four or five times daily, SCORBUTUS. 207 as a valuable remedy. Guyton Morveau recommends a solution of the yoke of eggs, in vitriolic ether, as very* efficacious. SCORBUTUS. Symptoms. First stage. Unusual languor, and want of muscular energy; stiffness of the knees; depression of spirits; a pale, sallow, lead-colored, bloated coun- tenance; skin dry, and covered with livid spots and blotches; particularly on the thighs, legs, arms and ab- domen; oedema about the ancles; gums spongy, and apt to bleed on being touched; fetid breath; a disa- greeable putrid taste ; desire for fresh vegetables, and acids; the blood is black, thick, and dissolved, with a great abundance of serum ; pulse soft and weak. As the disease advances, other symptoms, which mark the Second stage, occur, viz: Stiffness of the joints; indura- tions of the muscles; pains in the thighs, back, loins, and particularly in the knees ; oppressed respiration ; colic pains ; sub-cutaneous extravasations of blood ; ulcers, — particularly on the calves of the legs, and thighs, with cedematous, flabby, and bloody edges, dis- charging dissolved blood and ichor; muddy and high colored urine; passive hemorrhages from the gums, nose, rectum, bladder, &,c; sloughing of the gums, the teeth becoming loose in their sockets ; re-opening of old and cicatrized sores ; brittleness of the bones ; syn- cope on the slightest motion. In the third stage, there is extreme debility; frequent syncope; great oppression of breathing; a cadaverous exhalation from the body; sometimes palsy of one or more extremities; emaciation; occasionally dropsy, jaundice, and finally extreme exhaustion, with an irri- tated pulse. Causes. Persons of a debilitated and phlegmatic habit of body, with a disposition to obesity, are most subject to the disease. The occasional causes are: innutritious *208 SCORBUTUS. diet, conjoined with fatiguing labor, and exposure to a damp and impure air; excessive and repeated he- morrhages; impure diet; anxiety of mind, with a se- dentary mode of life ; the habitual and intemperate use of spirituous liquor; the continued use of either exclu- sive vegetable, or much salt animal diet. A damp and impure air, is a powerful co-operative cause with vitiated, or exclusive salt animal food, &c. Proximate cause. A morbid process of sanguification, and a consequent morbid condition of the blood. Treatment. The first and most important of the treat- ment is the removal of the causes which have produced the disease. When it is the result of impure diet, and a vitiated and damp air, more wholesome food and air are necessary. When exclusive salt animal food is its cause, vegetable acids, and a vegetable diet are the ap- propriate remedies. If an exclusive vegetable, or fari- naceous diet, has given rise to it, animal food, with moderate exercise in the "open air, is to be prescribed. All sorts of fermented liquors; acid fruits; alkalescent plants ; pure fresh water ; cleanliness ; free ventilation ; are remedial in this disease. The vegetables which have been found most beneficial, are: scurvy-grass; garlic ; water-cress ; garden-cress ; the fruit of the cloud- berry; (Chamae-morus;) cabbage, in the form of sour Jcrout; cochlearia, &,c. SCROFULA. Scrofula may be divided into two periods,~or states — the one that peculiar diathesis, called the scrofulous habit; the other, the disease in its state of development and ac- tivity. The scrofulous habit, or predisposition, may be acquired from accidental causes, or from hereditary transmission. The scrofulous habit is characterized by the following circumstances ; a particular delicacy and languor of countenance; smooth, soft, and flaccid cheeks; a dull lead-colored circle around the mouth, SCROFULA. 2i)9 with fine red lips; swollen upper lip; inflammation of the edges of the eye-lids— ^-particularly in children; weak digestive powers; scabby eruptions about the head; irregular state of the alvine discharges; slow growth of the body; aptitude to take cold, foc.^— This dormant state of the disease may continue for years, or pass off, under favorable circumstances. More generally, however, it becomes gradually deve- loped, under the influence of various exciting causes; the lymphatic glands along the neck, and other parts become enlarged; and by degrees pass into a state of slow inflammation, terminating in induration, or suppu* ration— the ulcers thus formed, discharge a thin:, milky* and somewhat viscid fluid, — are but little painful, and exceedingly slow in cicatrizing. The cicatrices are uneven, and irregular; the eyelids and conjunctiva be- come inflamed, as well as the mucous membrane of the nose, and bronchia. In a more advanced state of the disease, the salivary and thyroid glands* and the pancreas, and other glandular parts, enlarge; eruptions appear on the skin; emaciation ensues: the extremities of the long bones enlarge ; ulcerations occur, particu- larly in the cartilaginous and glandular structures; some of the bones become carious ; the large joints in- flame and suppurate; the spine becomes diseased; the nose, and palate, are destroyed by ulceration; in short, there is scarcely any part of the body, which is not sometimes the seat of its frightful ravages. The most common course of scrofula, however, is the formation of tubercles in the lungs, and consequent phthisis pul- monalisi Scrofula occurs more frequently in children, than in adults. The scrofulous habit is rarely formed after the period of manhood. The most common causes which produce this morbid habit, are: cold and atmo- spheric vicissitudes; indigestible and unwholesome food; excessive indulgence in eating; confinement and want of exercise; long exposure to a humid atmos* D* 210 SCROFULA. phere; mental disquietude; chronic irritation in the stomach and bowels, from worms and other causes; exposure to cold and humidity, during convalescence from various diseases, particularly measles, scarlatina, whooping cough ; in short, whatever permanently de- bilitates the system, more especially during childhood. Proximate cause. The scrofulous habit, consists proba- bly in constitutional, or acquired excess of irritability in the lymphatic system, in connexion with a weak con- dition of the assimilative powers. Treatment. To counteract the scrofulous habit, great care is required, to avoid the exciting causes. The integrity of the digestive, perspiratory, and hepatic functions, is to be maintained, and the tone of system supported. This is to be done, by the occasional use of mild aperients ; alterative doses of mercury ; warm clothing ; mild vegetable tonics ; exercise in the open air; a simple, but nutritious diet; sea-bathing; the tepid shower bath; dry frictions; alkalines, when gastric acidity prevails. When the disease is established, the same course of treatment is required, with additional remedies, varied according to existing circumstances, When the disease exists in the state of lymphatic glan- dular tumors, iodine, bathing with salt water, leeching, and emollient poultices are often beneficial. In this state, advantage may also be occasionally derived from the extracts of conium maculatum, dulcamara, hyoscy- anius, belladonna, and minute portions of muriate of mercury. In general, however, irritating applications are improper, so long as the tumours remain indolent. When scrofulous ulcerations exist, benefit may be de- rived from liquor potassee; the narcotic extracts just mentioned ; the muriatesof mercury, gold, barytes, lime ; ptisans from tussilagafafara; sarsapririlla; arctium lappa. I have seen more good done, by minute doses of muriate of mercury, and large ones of extract of conium, than by any other remedies. Farr speaks in the highest terms of the efficacy of large doses of the liquor potassre, and mercurial frictions used conjointly MENTAL DISEASES. CHAPTER XX, MENTAL DISEASES. The diseases of the mind may be divided into four classes, viz: mania, monomania, dementia, idiotism. 1 . Mania. General derangement of the mind, cha" racterized by a rapid succession of incoherent ideas — delirium ; violent excitement of the pas- sions, expressed by great agitation ; cries, singing, menaces, and fury. 2. Monomania. Partial insanity — the patient be-? ing insane on one particular subject only. This class comprehends a great many varieties, as no- stalgia, fanaticism, hypochondriasis, misanthropy, &c. 3. Dementia. Imbecility of mind — the reasoning faculties being defective, and memory weak or obliterated. It occurs in very old people ; and af- ter diseases of the brain, as apoplexy, epilepsy, &,c. 4. Idiotism. Defective intellectual development, amounting sometimes to a total absence of mind; and, in some instances, even to a destitution of the instinct, which leads to the gratification of the ani- mal appetites. General symptoms. Sensibility impaired ; appetite, de^ praved, null, or voracious ; constipation ; fever in mania, and in the beginning of monomania; skin dry, and of a yellowish brown color ; in women, suppressed or uv regular menstruation. Causes. Hereditary predisposition, has an important share in the aetiology of mental diseases Mental de^ rangement from hereditary predisposition, is generally 212 MENTAL DISEASES. announced " by whimsicalities of disposition; certain singularities of character; caprice in taste and habits; peculiar and evilly intentioned conduct; little aptitude to the study of the exact sciences; and in unmethodical taste for the arts of display, and the pleasures of imagi- nation." Among the most common occasional causes of insanity, are: violent passions; intense application to one object; jealousy; excessive joy, sorrow, hatred, terror, or sur- prise; religious enthusiasm; unrestrained imagination; poverty; excessive ill treatment; disappointed love, ambition, vanity ; mortified pride ; chagrin ; the crisis of female life, suppression of habitual discharges; re- percussion of chronic cutaneous affections; drunken- ness; parturition; pregnancy; epilepsy ; blows or falls on the head; acute and chronic diseases. Development, Progress, and Termination of Insanity. The development of insanity, in its incipient stage, is generally marked by a change in the habits, tastes, at- tachments, and passions of the patient. As the mental disorder advances, vigilance, head-ache, loquacity, or taciturnity; inconsistency in conduct; wild and ruinous enterprises; a neglect of the ordinary occupations; un- usual prodigality; inconsistent conduct; incoherence of ideas; and, finally, fixed monomanic hallucination, de-» lirium, or general aberration of the perceptive and rea- soning faculties. Insanity is sometimes periodical — at others, it is tempo- rary — passing off either spontaneously, or in conse- quence of remediate treatment; sometimes, it assumes a fixed and incurable state. Chronic, or incurable mania, or monomania, frequently terminates in de- mentation. (Georget.) Idiotism is always iucurable. Dementia is usually preceded or followed by paralysis. Prognosis. Recovery occurs most frequently between the ages of 'jventy and thirty. It seldom terminates favorably aller the fiftieth year of age. When insanity is connected with paralysis, or epilepsy, it may be re-. MENTAL DISEASES. 213 garded as incurable. A recovery of the general health of the system, without a corresponding melioration of the mental hallucination, is an unfavorable sign. It has been observed, that cold is more favorable to re- covery, than warm weather. Pathology of Insanity, Many pathologists contend, that the mind is never deranged idiopathically ; but always in consequence of some physical disorder, whether functional or organic, of the animal system. To this opinion, 1 am myself inclined to give my assent. This subject is fully discussed in the lectures. Treatment. The treatment is divided into moral and remedial management Under the head of moral treatment, are: a soothing, mild, and conciliatory ma- nagement; the absence of all coercive measures, unless imperiously demanded by the violence of the maniacal fury, or attempts to injure themselves or others ; a sepa- ration of the patient from all objects calculated to recal the sentiments, or passions, which gave rise to the dis- ease; a judicious diversion of the mind, from the ob- jects upon which the thoughts are habitually directed, and an encouragement to reflection "upon subjects of personal conduct and thought." To restrain and sub- due the turbulent, it is often sufficient to envelope the head suddenly with a cloth, so as to prevent them from seeing. The most furious generally become calm, so soon as they are thus prevented from seeing. The false ideas and fancies of insane persons, should never be encouraged, nor vehemently contradicted. By watching favorable opportunities, circumstances will generally occur, which, by a few judicious remarks, may lead them to doubt of the correctness of their no- tions ; " and doubt of the correctness of their own per- ceptions, marks the period for persuasion and convic- tion of error." Convalescents from insanity, should be suffered to asso- ciate freely with each other; nothing, says Georget, promotes recovery more than such an intercourse. 214 VERMINOUS DISEASES. Mechanical employments are often of great benefit in the management of lunatics. Remedial management. The remedies most efficacious, are: blood-letting, where there is much arterial excite- ment ; purging ; blisters ; the cold shower bath ; frictions ; tepid bath; mild and digestible diet; enemata. VERMIMOUS DISEASES. Various opinions concerning the origin and formation of worms, in the intestinal canal. It does not appear that they are received from without, because they are never found out of the animal body; and when removed out of the body, they speedily die ; and, lastly, earth worms, and such as live in water, do not change their forms, when received into the intestinal canal. There are five varieties of intestinal worms. 1. Tricocephalus dispar. These worms are from an inch and a half, to two inches in length. About two thirds of their length is almost as thin as a horse hair, the remaining and posterior part being considerably thicker, and terminating in a rounded extremity. They are found principally in the cteenm. They are seldom numerous. 2. Ascaris vermicularis, (oxyitris vermictdaris,) These are exceedingly short — not more than two lines in length, very thin and white. Their usual seat is in the rectum. 3. Ascaris lumbricoides.. These worms are from two or three, to ten or twelve inches in length, round, of yellowish white, or brownish red color, of nearly a uniform thickness, except at the extre- mities, which taper to a blunt point. They are from two to three lines in thickness. They inha- bit the small intestines chiefly; but occasionally ascend into the stomach. 4. Ttenia lata, (Jwthricoceplialus latus.) This worm often acquires a very great length — from VERMINOUS DISEASES; 21 5 twenty to thirty feet and more ; it is from four to six lines in breadth, flat and white, resembling a piece of white tape, and composed of a series of concatenated joints. It inhabits the upper por- tion of the bowels and the stomach. The head is armed with two processes, by which the worm attaches itself to the intestines. 5. Taenia solium, ( T. Cucurbitina.) This worm is rarely, if ever, voided whole; it generally passes offin short joints, resembling, in some measure, the seeds of gourd. Pieces, however, upwards of twenty feet, of this worm, have been voided. The head is small, and furnished with four small apertures. (Oscula.) It inhabits the small intes- tines chiefly. Symptoms. Countenance pale, lead-colored, with occa- sional transient flushes; eyes dull; pupils dilated, with a bluish semicircle around the lower eye-lids; tickling in the nose; tumid upper lip; occasional head-ache, and humming in the ears; copious secretion of saliva; tongue slimy or furred ; breath foul ; variable appetite — being sometimes voracious — at others wholly gone; transient pains in the stomach ; occasional nausea and vomiting; pains in the abdomen — particularly about the umbilical region ; frequent slimy stools, or costive- ' ness ; urine turbid, yellowish, or milky ; abdomen tumid! and hard, with emaciation of the other parts of th£ body ; lassitude ; irritability of temper. None of these symptoms, however, are certain indications of the exis| tence of worms in the bowels — the only certain indica* tion being the appearance of them in the evacuations from the bowels or stomach. The opinion which is expressed by some, that worms /are harmless in the intestinal canal, is without foundation. It is nevertheless probable, that that peculiar condition of the alimentary canal, which favors the production of worms, is more frequently the cause of mischief, tnan the worms themselves. Worms give rise to a variety 216 VERMINOUS DISEASES. of affections, such as chorea, epilepsy; hydrocephalus j emaciation; convulsions ; paralysis, and a vast variety of anomalous disorders. Treatment. In prescribing for the removal or destruc- tion of worms, it is of some consequence to confine the patient to a spare and liquid diet, and to exhibit two or three mild cathartics a few days previous to the exhi- bition of the proper anthelmintic remedies. With these preparatory measures, the ordinary vermifuge re- medies will disappoint us much more seldom than without them. My own plan of treatment for the ex- pulsion of the lumbricoidcs, is to put the patient on a liquid diet, and to give a small dose of Epsom salts every morning, for three days in succession. On the fourth morning, 1 order a decoction of the root of spi- gelia, in the proportion of an ounce of the root to one pint, of water, and boiled down to half a pint. This being sweetened, is to be drunk in the course of three or four hours; and immediately after the whole of the decoction is taken, an active dose of calomel and jalap — or what is perhaps still better, castor oil and turpen- tine, is to be taken. I have rarely failed, by this me- thod, of removing worms, where they existed. The most efficacious anthelmintics, for the destruction of ascarides Iumbricotd.es, besides spigelia, which I regard as decidedly the best, are: sem. santonici; chenepodi- um anthelminticum, dolichos pruriens; calomel, garlic, conferva helminthcordon, and geoffrea surinamensis. The removal of ascarides, is often exceedingly difficult Remedies employed in the form of enemata, are gene- rally more efficacious, than when given by the mouth. My usual prescription for the expulsion of these worms, is to exhibit three or four aloetic purges every second day, together with two or three enemata, composed of a solution of common salt daily. Injections of a solu- tion of aloes — of lime water, or of infusions of any of the ordinary anthelmintics, will occasionally bring away these troublesome little worms. I have, in a few VERMINOUS DISEASES, 21 f instances, brought them away in great quantities, by np jections composed of spirits of turpentine, mixed with milk. The introduction of a bougie, smeared over with mercurial ointment, has been employed effectually against these worms. JN ils Rosen speaks very favora- bly of injections compsed of a drachm of refined su- gar, dissolved in warm milk. For the expulsion of the tape-worm, a great variety of remedies and modes of treatment have been recom- mended. The anthelmintics that have been found most efficacious against this species of intestinal worm* are: polypodium filix mas; spirit of turpentine; tin; valerian, and the bark of the pomegranate root. The latter article has been particularly recommended of* late years, as a powerful remedy against the tapeworm. Whatever mode of treatment be adopted, it is always of much consequence to prepare the patient, by diet and laxatives, before the proper vermifuges are given. A spare and liquid diet, with the daily use of small doses of saline purgatives, for five or six days, will greatly in- crease the chance of procuring the expulsion of the worm, by the use of anthelmintics. The following ig the substance of some of the most celebrated methods of treatment recommended for the removal of this worm* Alston's method. An active purge; next morning, one ounce of pure tin filings; on the second, third, and fourth mornings, half an ounce of the same metal, fol- lowed, on the fifth morning, by an active purge. Des- saulVs method: mercurial frictions on the abdomen* followed by a drastic mercurial purge. Heren* schwand?s method: one drachm of powdered male fern root, mornings and evenings, on an empty stomach, for two days in succession; on the morning of the third day, take the following: R. G. Gambog. gr. xij. Sub- carbonate potass, gr. xxx. Sapon Venet. gr. ij. Misce. Three hours after this, an ounce of ol. ricini. is to be taken. Hufeland's method: a cup of a decoction of garlic in milk, every morning, on an empty stomach* E* 218 VERMINOUS DISEASES. with a table-spoonful of castor oil every morning, noon, and evening, half an ounce of the filings of tin, once daily, and frictions with petroleum, on the abdomen. This must be continued for several weeks. Spirits of turpentine, has been employed with much success for the expulsion of taenia. From two to three ounces of this article, should be given at once; and followed, in two hours, by a dose of castor oil. The bark of the pomegranate root, has been recently strong- ly recommended, for the removal of taenia. FINIS. 347 7