suited to remove the offending cause in themselves for a time aggravate the irritation. Thus it is proper in such cases to give before or with the purgative some narcotic, such as hyoscyamus or opium, and further, if necessary, to allay the irritation of its operation by diluents, the warm bath, and other derivants. It is not easy to lay down any rule by which the relative importance of these measures can be decided; but the sedative plan is generally more requisite in proportion to the length of time and the degree in which the constitution has suffered under the irritating influence. Where the irritation is vehement, and disturbs in a serious degree the vital functions, it becomes of more importance immediately to allay this by temporising measures, than to rest solely on those which are more radical, but of slower operation. A child suffering from worms or accumulated fæces may die of convulsions under the additional irritation of a purgative before its evacuant effect can be obtained; but if this medicine be preceded by or conjoined with others calculated to soothe, such as hyoscyamus, Dover's powder, or the warm bath, according to the character of the irritation, its operation will be safe and seasonable. The purgative is, moreover, by the same means, often rendered more effectual for the removal of the irritating matter, since its slower progress enables it to act more generally on the canal, than where an excessive irritability hurries it precipitately through. So also, during the prevalence of violent spasm, an antispasmodic must often be promptly administered without regard to the duration of its effect. To give ether, laudanum, assafoetida, valerian, &c. in spasm of the glottis or bronchi, or in violent palpitation of the heart, may be, in relation to the cause of the irritation, a temporizing measure; but it is using time to good purpose. We have enumerated inflammation among the causes of direct irritation, and we again allude to it for the purpose of remarking, that besides the removal of the cause itself, our attention may sometimes be usefully directed to the quieting of those nervous sympathies by which the irritation is communicated to the system at large. This, we apprehend, is the principle of the salutary operation of opium in continued fevers and the less sthenic forms of inflammation; and did we possess a medicine that should be sedative to the nervous system without exciting or disturbing the vascular, it would furnish a still happier and more satisfactory illustration. There are many cases in which the source of irritation is organic, or beyond the reach of remedies; it is thus with tumours in the brain, spinal marrow, and other parts, accidental productions, cancer, and other forms of diseased structure; here our only resource is in measures which allay morbid irritability. We shall have occasion presently to revert to this subject; but we see no need to dwell longer on means for the removal of irritating influences: they vary with the nature and locality of the influence. There is another mode of treating direct irritations, which it may be convenient to notice in connection with direct irritation, although it is more frequently applicable to the indirect kind, namely, by stimulating applications. In enumerating examples of direct irritation we named various mechanical injuries, and remarked that the object of irritation in these cases, the reparation of the injured part, is sometimes defeated, and the disorder prolonged in consequence of the low power in the vascular system, which is inadequate to take on the reparatory state of healthy inflammation. Here, then, an additional stimulus to the vessels, conjoined, if need be, with a sedative to the excited nerves, will often recall the irritation from its prejudicial wanderings through the system into a local and salutary channel. This treatment is obviously applicable only in cases where inflammation is not in itself a hurtful process, such as mechanical injuries and sores of the exterior, and especially burns and scalds. The efficacy of stimulating applications to the latter is now generally admitted, and we would attribute it entirely to this principle in all the moderate examples of these lesions. The extreme heat has so paralyzed or weakened the vessels, that although they may be entire and congested with blood, they require a new and powerful stimulus to bring them to that activity of function which the reparation of the injury requires. When a part has been disorganized, and is insusceptible of revivification, and the adjoining vessels are weak and inactive, stimulant applications are still more obviously indicated to excite that inflammation which is necessary to effect the sloughing or separation of the noxious dead matter from the living structure. We can see the utility of a similar treatment in other forms of external disease, where the inflammation is at once irritative and powerless. We have already glanced at the treatment of our second order of irritations, that of excessive irritability, for the mixed manner of their occurrence renders it inexpedient to consider each kind quite separately from the other; but we return to the subject, in the endeavour, as far as is possible, to make this sketch of the principles of the treatment correspond with the preceding pathological history. Excessive irritability, as we have there remarked, most frequently depends on inflammation or some of the states akin to it, or (to use the more comprehensive words of M. Andral) hyperæmia in its several forms. In such cases relief is to be sought in the various antiphlogistic measures, applied of course with due relation to the organ whose morbid irritability is to be reduced; and thus evacuants, derivants, counter-irritants, and contro-stimulants, become remedies for irritation. These are considered in the article INFLAMMATION sufficiently to supersede notice here, further than the remark that their anti-irritant may not always be in the ratio of their antiphlogistic effects; and where irritation predominates over inflammation, those are to be preferred which act on the nervous as well as on the vascular functions; thus, counterirritants (and if they be admitted as a separate class, contro-stimulants also,) will avail more than mere vascular depletories in fulfilling the indication in view. For example, in the vehement irritations connected with slight phlogoses of the mucous membrane of the lungs and of the alimentary canal, (notwithstanding Broussais' positive assertions to the contrary,) tartar-emetic frictions for the former, and sinapisms and blisters for the latter, are far more efficacious than local or general bloodletting. The irritations of serous membranes, Of the other remedies of this class we may mention favourably conium, belladonna, colchicum, digitalis, and hydrocyanic acid. Their fitness in various diseases is less extended than that of the medicine already named; and it is particularly restrained by their greater liability to disagree with the stomach. The two first approach in their properties most nearly to hyoscyamus. The three others exert a decidedly sedative effect on the vascular system, but rather through an influence on the heart, the force and number of whose pulsations they diminish, than from any action on the vessels at large. Their beneficial effect is, therefore, best seen in irritations of this organ and of the lungs, which stand in so close a relation to the heart. The directly sedative influence of hydrocyanic acid is, however, sometimes remarkably evinced by its allaying the morbid irritability of the stomach; and it is successfully applied externally to allay the irritation of prurient eruptions. Colchicum is supposed to possess a specific sedative power in the irritations of gout and rheumatism. Whether this may depend on its carrying off through the kidneys an irritant matter from the blood is uncertain; but the diuretic effect of this remedy and of digitalis should not be overlooked. Conium and belladonna, when the system can bear them in sufficient doses, are sometimes very beneficial in allaying irritation of the pulmonary system, whether manifesting itself in spasm of the bronchi, or in an excessive irritability of the mucous membrane, exciting cough. The smoke of stramonium and of tobacco enjoys a similar reputation, but it is decidedly stimulant to the vascular system. Poultices of the recent leaves of various narcotic herbs, but particularly conium and belladonna, are very efficient in allaying the irritation of unhealthy ulcers: the leaves of the latter in form of ointment show great power over both vessels and nerves, in relieving and preventing the chordees of gonorrhoea. which in persons of mobile sensibility frequently | porary relief at the expense of that balance of present the semblance, although they partake little functions which is so essential to health; and of the real character, of inflammation, likewise unless where pain and excited sympathies are receive most relief from this description of anti- useful as guides in the employment of more active phlogistic treatment. The contro-stimulant or remedies, there is scarcely an instance of morbid sedative influence of cold directly applied is ex- irritation unfitted for its use. The main fault of erted equally on the vessels and nerves, and it hyoscyamus is its weakness as a narcotic; it not would be, doubtless, a powerful means of subduing unfrequently fails of its effect, and, perhaps sooner irritations, were it a more manageable agent; as than other remedies of the same class, loses its it is, we see its beneficial influence in the relief power by continued use. afforded to cerebral irritation, and in those of the limbs by applications of ice and cooling lotions. The expediency of using it, (as do the Broussaians) in abdominal and thoracic inflammatory irritations, is very questionable: the risks of repelling the inflammation more inwardly, and of its being aggravated by reaction if the application of cold is unsteady or insufficient, besides the obvious injury to the system of continually abstracting from organs that degree of heat which is almost necessary to their life, are surely sufficient objections against a practice that is far from being generally recommended by the experience of its advocates. External heat, whether dry, as applied by hot flasks, bricks, or air, and acting as a rubefacient, or combined with moisture in fomentations, baths, or poultices, and proving revulsive and sudorific, is a much less exceptionable remedy for internal irritations. In its moderate degrees the latter are more suited to inflammations, as their effect is principally on the circulation, which they soothe and equalize; but in its highest tolerable degree, heat produces a strong impression on the nervous system; very hot flasks, or flannel wrung out of water almost scalding, are among the most powerful of antispasmodics or local, anodynes, and we have seen them produce perfect and immediate relief in the irritative pains of colic and dysmenorrhoea, where many powerful narcotics had failed. As we are now verging on the subject of means directed particularly to lower nervous irritability, we may premise that there are some narcotic or sedative remedies which, if they do not act as such on the vascular system likewise, do not stimulate it; they are, therefore, often admissible in inflammation itself, and are the more strongly indicated when it exhibits the character of nervous irritation. Of these, none for safeness and general applicability ranks before the hyoscyamus. Mr. Travers says, "In the ruffled states of the system generally, but especially in the over-active state of the vascular system, there is a charm in the operation of henbane altogether peculiar. It is feeble as an anodyne, feebler as a soporific, but 'not poppy nor mandragora' soothe and still so unexceptionably as henbane." This remark, although true, requires a comment; the over-activity of the vascular system here alluded to is not one of inflammation, but of irritation, dependent on excess of nervous irritability scattered through the different organic sympathies; and it is in its sedative influence on these that the charm of henbane consists; for it exerts little or no effect on inflamed vessels, that are, as it were, over-active in their own strength. We may almost say that on its little interference with the vascular system its general eligibility depends; for, restraining no secretions, it can advantageously be given alone or combined, without the risk of purchasing tem We pass over others of lesser note to the chief of narcotics, opium. This medicine, although under certain circumstances the most sure and most powerful of anti-irritants, has so many ulterior effects, that more than any other it requires judgment in its exhibition. Its first effect is to stimulate the vascular system, and this is sufficient to exclude it from all those instances of sthenic inflammation where it is wished to retard or arrest rather than to hasten this process. But in the asthenic phlegmasiæ, especially where nervous irritation predominates, the administration of opium is counter-indicated only by the ulterior effects which it may have in arresting the secretions. Combined with ipecacuanha, with antimony, and especially with mercury, it ceases to be liable to this objection, and its operation is often in the highest degree salutary. Even where tive doses of blue-pill, Plummer's pill, ipecacuanha, dandelion, and sarsaparilla, and mineral waters in chronic diseases of the viscera and skin, is more generally acknowledged as an appeal to the various secretions. Before passing to the last class of remedies, tonics, we would advert for a moment to the salutary effect of friction and exercise in allaying morbid irritabilities of a part of the system. They hold an intermediate place between alteratives and tonics, and in affinity with either they well merit consideration. Friction, steadily and moderately applied, is an efficient anodyne. Although injurious in acute inflammations, it allays in a wonderful manner various nervous pains, spasms, and other disagreeable sensations connected with irri it is wanted as a pure anti-irritant, to reduce morbid sensibility in the nerves, we should always prefer it in combination with ipecacuanha, which seems to equalize without injuring its narcotic virtues; and in further combinations, it is not common to experience from this compound the inconveniences that frequently result from laudanum or opium. The muriate and acetate of morphia, equally with Battley's liquor opii sedativus, enjoy the reputation of a purer sedative property than the common forms of the drug possess; but unless where a speedy effect is desired, there are few cases in which we would not place greater confidence in Dover's powder, or tantamount combinations of ipecacuanha and the aqueous extract of opium. It is an almost indispensable adjunct to purgatives in violent gastro-enteric tation and irregular circulation, and it is a valuable irritation where hyoscyamus would be insufficient; and if the stomach will retain it, it seldom fails to quell the excessive disturbance that sometimes follows drastic and unguarded purgation. In dysentery, and in more chronic forms of excessive irritability of the intestinal canal, the proportion of ipecacuanha may with advantage be doubled or quadrupled, as in the dose of one-fourth or oneeighth of a grain of extract of opium, with onehalf or a whole grain of ipecacuanha, repeated according to the urgency of the symptoms. auxiliary to anodyne applications. It is an alterative to the vascular system, inasmuch as it removes congestions and obstructions, and promotes healthy circulation and secretion; and in the regular continuance of these effects by exercise, increased by the contact of pure air, consists the tonic power of these hygeian agents. The utility of tonics in subduing morbid irrita bilities will, if we mistake not, be sufficiently apparent from the pathological views which we have endeavoured to expose. Agents which give tone and strength to the vascular system will destroy the preponderance of that nervous mobility which is the basis of irritation. Under their prosperous influence, disposition and power to act will go together, and within due bounds produce the harmonious balance of even health. Whether certain of them possess a specifically sedative property towards the nervous system, or whether this is their secondary effect after their tonic and astringent influence on the vessels, is beyond our means of decision; but the fact is not less ascertained than important, that the continued use of nitrate of silver or sulphate of copper will cure the epileptic irritations independent of organic cause, and often diminish them where the cause is irremovable, by lowering in the nerves their susceptibility to its impressions. Thus, likewise, bark, carbonate of iron, arsenic, sulphate of zinc, or subnitrate of bismuth, sometimes remove the painful or spasmodic irritations of tic douloureux, hemicrania, sciatica, chorea, and gastrodynia, which the most powerful anodynes, antispasmodics, and counter-irritants fail to effect. The stomach and intestinal canal, likewise, under the influence of a bitter tonic, will often lose various signs of irritation, which, however they may occasionally be accompanied by slight hyperæmia, or fancied inflammations, owe their being to weakness and want of tone. The cold shower or plunge-bath, or cold ablution, is another efficacious tonic; the more eligible, often, because, without loading the system with medicine, it rouses it to the exertion of its own powers in a vigorous vascular reaction, under the habit of which nervous mobility is physically forgotten, and ceases. But it is needless to add to examples which have been adduced only as illustrations of a principle. We must notice a more obscure class of remedies, alteratives, which, whatever may be their mode of action, are unquestionably entitled to a place here. Under this unscientific but convenient title, we reckon the various non-purgative forms of mercury, whether simple or combined with opium, those of antimony and ipecacuanha in acute diseases, and in chronic disorders minuter doses of the same, sarsaparilla, mezereon, chalybeates, and a host of other medicines. The efficacy of the first-named of these in restraining and subduing inflammatory action would obtain for them, among the disciples of the new Italian doctrine, the appellation of contro-stimuli; but this, like cutting the Gordian knot, is only substituting a bold stroke of hypothesis for a solution of the difficulty. It is not impossible that tartar-emetic and mercury may exert on the coats of inflamed or irritated vessels such an influence as directly neutralizes or subdues their disorder, and restores their healthy function; but this is a large assumption to take for granted; and in the absence of any sort of positive proof, we think it safer and as philosophical to arrange the remedies in question under the modest title of alteratives. These remedies are powerful in subduing irritation; and on the basis of the views which we have given of this morbid state, we might equally well frame an hypothesis that they act by restoring a lost balance, and by equalizing the distribution of natural irritability. But we will content ourselves with remarking the fact, that mercury, antimony, and in a minor degree ipecacuanha, tend moderately and equally to restore all the secretions which inflammation and irritation arrest or pervert; whilst opium, deprived in this combination of its restringent qualities, happily allays the excited sensibilities and sympathies of the nervous system. The alteratives pre- We have, finally, to glance at the leading pecu scribed in chronic irritations, although in greater larities required in the treatment of indirect irrivariety, probably act on the same principle; and, tation, or that arising in the reaction after prostra perhaps, the exhibition of what are called altera- tion. The most obvious indication is to promote VOL. III.-12 * H and regulate the reaction, so that it may rise to skin, like other parts, seems to have lost the attri the point of a general and equal recovery of func-butes of vitality. tion, without passing beyond it into a state of irritation or inflammation. The most common state which we have to deal with is that of irregular reaction, local and misdirected excitement amidst general prostration. Whether this excitement consist in convulsion, hiccup, vomiting, delirium, palpitation or cough, it is of the utmost importance that it should be subdued; and to effect this, it is of more avail to direct our efforts to excite the powers generally, by diffusible stimuli, than to attempt to quiet the local irritation by sedatives; for as the other powers rise from the prostration, this 'symptom will generally subside. But should this not be the case, and the local irritation be wearing down the strength, sedatives must be addressed to it: this part of the treatment will not differ from that of morbid irritability already considered. The point which characterizes the treatment of this form of disease is the necessity for counteracting the prostrating influence which paralyzes the plurality of the functions, leaving others in proportionate predominance. This indication resolves itself into the removal, as far as is possible, of this influence, and the further obviation of its effects. Cold, and the resulting prostration, are removed by the same means, the gradual and cautious restoration of heat, beginning by frictions with snow, &c. and carefully restraining the disposition which is commonly manifested to excessive reaction; on this account diffusible stimuli are only sparingly admissible. See CoLD. Of the diffusible stimuli fit to oppose the state of sinking or prostration, the most powerful are ammonia, alcohol, and opium. These are variously applicable, according to the degree to which the depression has extended. Ammonia is the most purely stimulant, and is, therefore, best adapted to cases in which there is least of local irritation, or where this manifests itself in spasms. The complete prostration induced by tobacco, digitalis, and other sedative poisons, and the asphyxia from the fumes of charcoal and sewers, are examples to which the stimulus of ammonia seems to be especially adapted. The carbonate of ammonia is the most common preparation, and it is conveniently combined with alcohol in the spiritus ammonia aromaticus, which is the form most agreeable to the stomach. It is to be borne in mind, however, that it is a chemical agent as well as a vital stimulant; and this circumstance precludes its being given to a very large amount. Spirits in the various combinations, brandy, wine, and ether, is a highly valuable stimulant; and it is the one perhaps most to be depended on in general prostration with irregular reaction. It exhibits some narcotic virtue in its property of quieting the irritated sympathies of this state, and is peculiarly serviceable in arresting the severe vomiting which often severely and fatally aggravates various forms of exhaustion. It is of the greatest importance to watch most assiduously the state of a patient who requires a large exhibition of stimuli of this kind, both to ensure their being supplied often enough, which in case of sinking must be done every five or ten minutes, and to diminish or withdraw them the moment they produce an effect on the circulation, lest they stimulate it beyond the point of moderate and general reaction into a state of febrile excitement. Opium, as it partakes largely of narcotic as well as of stimulant properties, is less adapted to the extremest forms of prostration than to those in which the irritability of the system is misdirected. In the state of sinking, when the respiratory function is failing with the rest, opium might have the effect of destroying the sensibilities and sympathies on which this vital process depends. But for the different partial irritations attendant on general weakness, particularly delirium, spasm, palpitation, and hiccup, opium is generally the most satisfactory remedy. Solid opium and its tincture are here the most expedient forms; and their stimulant effect is most fully developed by small doses frequently repeated. If the antispasmodic property is desired, larger quantities must be given; and it is truly astonishing what doses the system will bear when under the influ ence of spasmodic disease. The prostrating influence of a severe mechanical injury, as of a crushed limb or bad compound fracture, seldom ceases on the removal of the limb; on the contrary, the additional shock of the operation not unfrequently proves fatal. The absence of inflammation leaves the system open to the noxious influence of the shattered structure, which inflicts a stroke felt even after its removal. Were healthy inflammation soon excited, this would probably in a degree counteract or interrupt this influence; and we hazard the suggestion that stimulating applications made to the injured part previously to the operation, might, as in extensive burns, be of more avail than mere internal stimuli. The existence of inflammation in the system has been shown by Dr. M. Hall to protect it in a remarkable degree against the prostrating effects of loss of blood, and the same thing obtains in some measure in other cases of prostration; hence asthenic inflammation may be useful not only as proving power in the system, but also as a general tonic, imparting a stimulus to the heart and vessels. This remark is most applicable to surgical cases, in which inflammation is an important and necessary process; but we see in it The first objects in extreme prostration are, to also an explanation of the utility of artificial in- sustain the functions of respiration and circulaflammations excited by sinapisms, blisters, and tion by diffusible stimuli, until there is a sufficient stimulant frictions, in failure of the powers from recovery of the forces to support these without various causes, and in the state of sinking from further aid. The organic functions of secretion any severe disease. Any of these measures, as and assimilation then generally require some local counter-irritants and general stimulants, assistance; for the effects of the depressing influoften prove beneficial in arresting vomiting, hic-ence sometimes manifest themselves on them after cup, convulsions, or any other partial reaction, the circulation has been restored to some degree amidst general prostration. In the worst cases, of vigour. Here alteratives and tonics come into however, they fail to excite inflammation; for the requisition; and, as in direct irritation, they must be variously modified and combined, in order to diet and regimen which tend greatly to engender ensure the most equal and natural excitement of the several organic processes. Where the pros trating influence still remains in the system, counteracting vigorous reaction, and enfeebling or paralyzing all the conservative powers, these several remedies must be conjoined. Thus, under the noxious influence of gangrene, asthenic erysipelas, or poisoned wounds, it becomes necessary to administer wine or spirits, ammonia, opium, or camphor, with bark or sulphate of quinine, whilst the secretions are excited by calomel or blue pill. Bark has sometimes a signal power in combating with the depressing influences in question; and its efficacy may, perhaps, depend on the same property which renders it so complete an antidote to the causes of intermittent fevers. The irritation of inanition, in respect to its symptoms, may require in great part the same treatment as that from other causes; thus sedatives to the nervous system, and the exclusion of all sensorial excitements, will be equally necessary. But the nature of the causes may modify the indications: as they consist in a loss from the system, the necessity of supplying nourishment for the reparation of that loss, giving to the assimilatory organs the aid of additional stimuli, is obvious. It is necessary to be on our guard against the invitations which these forms of disease sometimes hold out for the use of antiphlogistic measures: these afford but temporary relief to the pseudoinflammations which arise in this state, and which are more safely and effectually subdued by sedatives, a judicious supply of nourishment, and an exclusion of all exciting or disturbing agencies. Thus we may see a disease following extensive evacuations, which puts on the semblance of violent pleurisy, pericarditis, arachnitis, or hydrocephalus, often completely relieved by hyoscyamus or epium, with a sustaining nourishment, such as sage, arrow-root, or jelly, with small quantities of brandy or wine. The state of the circulation is the safest guide in the conduct of this treatment; as long as the pulse is weak or fluttering, with its quickness, and although sharp or jarring in its first impulse, yet leaves the artery in the intervals empty under the finger, the sustaining treatment must be continued, and local pains, palpitation, disturbance of the mind with beating or noises in the head, viewed as partial reactions, to be subdued by opium or hyoscyamus rather than by the lancet and evacuants. But if these symptoms have been relieved, and the pulse has recovered in a measure its steadiness and fulness, the spirits and other stimuli must be diminished or withdrawn, and the rest of the cure left to time and to whatever alteratives circumstances may suggest. These points are more fully described under the heads of the several diseases connected with this subject, and which have been already referred to. The prophylactic treatment of those liable to irritations will generally consist of those means which, by giving tone to the vascular system, remove the preponderance of nervous influence or susceptibility. These are tonic medicines and a tonic regimen in general; but if there be already a loss of balance in the vascular system, it will be generally necessary to direct some alterative to regulate it. There are various circumstances of a general morbid irritability; particularly an [Dr. Mackintosh (Principles of Pathology and Practice of Physic, 2d Amer. edit. i. 431, Philad.' 1837,) states, that he has known several individuals affected with jaundice, who saw every object coloured. Most of the secretions are unquestionably tinged yellow, but not all. The colouring matter of the bile is rarely found in mucus or milk, for example. Yellowness of the conjunctiva is, however, one of the pathognomonic phe nomena. Bile is, also, necessarily present in the blood-vessels of the retina; yet, as the writer has elsewhere said, (Practice of Medicine, 2d edit. i. 625; Philad. 1844,) yellow vision is not common. In the experience of one observer, Dr. J. P. Frank, it was noticed but five times in about 1000 cases. Much difference of opinion has existed in regard to the cause of the phenomenon when it does exist. The most probable supposition is, that the humours themselves are tinged yellow, and it has been suggested, that where vision is not yellow, they may have escaped the tinge. There is some plausibility, however, in the supposition, that the cause may be wholly nervous, inasmuch as pa tients, in other diseases, as in typhus fever, without being in the slightest degree jaundiced, have seen every thing yellow. It is possible that different conditions may be occasionally concerned in the causation.] The The circumstances which predispose the system to an attack of jaundice are numerous. melancholic or leucophlegmatic temperament, under mental excitement, whether of a pleasant or painful nature; an indolent mode of life, sedentary occupations, a full and stimulating diet, |