methods of preventing the indulgence of it, by tin masks for the face, iron gags, chaining on plank floors, etc. By using these means, it is true, the habit cannot be indulged in, but the cause that produced the propensity still exists, and the disease cannot be cured so long as these depressing agents are used. Restore the healthy tone of the system, invigorate the subject, put rich blood into his veins, clothe him well, feed him well, and do not overtask him; arouse his feelings of pride, teach him to feel that he is a reasonable and rational being, and, in a majority of cases, success will attend our efforts, and we shall have the satisfaction of rescuing a valuable servant from the grave."

Polydipsia is a term applied to denote a condition characterized by an excessive craving for liquids. Water is drank in a very large or enormous quantity, amounting sometimes to several gallons in the twenty-four hours. In some cases the patient experiences constant or frequently recurring thirst, associated with dryness of the tongue and fauces. He is unable to sleep except for short periods in consequence of the urgency of the desire for drink. The quantity of urine is proportionately great, so that this condition is also denoted by a term expressing the latter fact, viz., diabetes insipidus. The urine voided has but little specific gravity, presenting a clear, limpid appearance like pure water, and contains neither sugar nor any abnormal constituent. In other respects the health may not be notably disordered. The appetite and digestion may be unimpaired, the functions generally are well performed, and the body does not waste. This condition at first suggests to the physician the probable existence of diabetes mellitus, but an examination of the urine leads to the exclusion of the latter disease. The condition may occur in early life or become developed at any age. It has been observed to occur as an intermittent malady, but, in general, it continues for an indefinite period or during life. It does not appear to lead to any disease, and is serious, in itself, only on account of the annoyance and debility which it occasions. Its pathological character, with our present knowledge, cannot be satisfactorily explained. Existing to the extent just described, it is so rare as to belong among the curiosities of clinical experience. In our ignorance of the pathology, there are no rational indications for treatment, and experience has not furnished any reliable means of cure. Opium, valerian, camphor, and other antispasmodics have been found to diminish the thirst temporarily, and some benefit has been derived from the use of various tonic remedies.

Dipsomania is a term sometimes used to denote the peculiar delirium arising from the abuse of alcohol, but it is commonly applied to an insatiable desire for alcoholic drinks, and, used in this sense, it expresses a morbid condition which may be noticed in the present connection. A craving for this class of stimulants is sometimes developed in cases of dyspepsia, and may be the source of intemperate habits. This fact has been already referred to. It is not to be lost sight of in judging of the propriety of prescribing or sanctioning the use of alcoholic stimulants in dyspeptic cases. A morbid craving for alcohol in some form is an element of intemperate habits, whatever may have been their source. The habitual drunkard feels a desire for continued indulgence, which, with an impaired power of self-control and lessened self-respect, resulting from intemperance, he is, after a time, wholly unable to resist. It is useless, under these circumstances, to attempt to reason him into temperance; he may appreciate the force of all the arguments which may be presented, but he lacks moral strength enough to govern an acquired appetite which represents a morbid condition as much as the delusions of insanity. Reason and persuasion, however, may be effective before this condition of dipsomania is reached; that is, they may prevent this con

dition by leading to abstinence from alcoholic stimulants. Dipsomania is to be treated as a disease of body and mind. The cure is to be effected by withdrawing the patient from the use of alcohol in any form, and the employment of medicinal and hygienic measures to invigorate the physical and mental faculties. The treatment must be continued long enough for the cessation of the morbid craving for stimulants, and for the development of moral strength sufficient to enable the patient to adhere to a course of total abstinence, in which consists his only safety. It is evident that successful management is rarely practicable except by means of institutions in which the patient is under the same restrictions as in insane asylums. In fact, dipsomania is to be treated as a form of mental derangement.

There is a species of dipsomania which is constitutional and congenital. The desire for stimulants is paroxysmal, and an irresistible craving is developed by ever so small an indulgence. Persons with this unfortunate idiosyncrasy lose their power of self-control as soon as they feel the influence of alcohol. The only protection against inebriation, in such cases, is rigid abstinence.

Connected with the subject of dipsomania are questions pertaining to the causes of intemperance, and the means of its prevention, which are of the utmost importance to the welfare of mankind, but which do not properly fall within the scope of this work. The morbid effects of alcohol upon the system, aside from the development of dipsomania, will be referred to in connection with different individual diseases, and especially those affecting the nervous system.

GASTRORRHAGIA.

Hemorrhage into the stomach, and vomiting of blood, are denoted by the term Hæmatemesis. The term Gastrorrhagia is in uniformity with the rule of nomenclature by which a hemorrhage and its situation are expressed, and is, therefore, to be preferred. Moreover, the term gastrorrhagia applies to all cases of gastric hemorrhage, whether vomiting take place or not, the blood sometimes not being expelled by the mouth, but passing into the intestinal canal and being evacuated in this direction. In the great majority of the cases, however, in which hemorrhage takes place into the stomach, blood is vomited.

When blood is expelled from the mouth, the first point is to ascertain the source of the hemorrhage. It may be from the mouth or posterior nares. Coming directly from either of these sources, it is traced without difficulty; but if blood be swallowed and vomiting occur, it may sometimes be a question whether gastric hemorrhage exists or not. In cases of bronchorrhagia, blood may be swallowed and vomited. In a child too young to expectorate, bronchial hemorrhage might thus be supposed to be gastric. Examples have occurred, but bronchorrhagia and gastrorrhagia in young children, are both extremely rare. The rupture of an aneurism into the pharynx or œsopahgus, is another source of hemorrhage which may appear to be gastric. But, in general, the question is, whether the blood come directly from the stomach or air-passages. The points involved in this differential diagnosis have been already presented, in treating of bronchorrhagia, and need not be here repeated.' Blood which has been vomited, in most cases presents a dark grumous appearance. Exceptionally, it is florid, like

1 Vide page 205.

arterial blood. It then comes from an artery, and has been vomited directly it accumulates within the stomach.

Gastric hemorrhage, in the vast majority of cases, has no claim to be regarded as an individual affection. It may be a symptom of carcinoma of the stomach, or of gastric ulcer, and, as such, has been already considered. It is an occasional effect of portal congestion in cases of cirrhosis of the liver. It coexists with hemorrhage in other situations in cases of purpura hemorrhagica and scorbutus. It occurs in cases of acute gastritis. It is a prominent event in the natural history of yellow fever, the so-called black vomit, in this disease denoting neither more nor less than gastrorrhagia. Exclusive of these pathological associations, it may occur in place of the menses in cases of amenorrhoea. Instances in which gastrorrhagia is to be regarded as vicarious menstruation, are by no means common. In the majority of the cases in which it follows suppression of the menses, it proceeds from disease of the stomach. Yet, that it may take the place of the menses, must be admitted. Of 27 cases of gastrorrhagia analyzed by Valleix, in 5 the hemor rhage could not otherwise be accounted for; and in all these cases recovery took place. The cessation of habitual hemorrhage in some other situation, the arrest of purulent discharges of long standing, and the healing of old ulcers, have been supposed to stand, occasionally, in a causative relation to gastrorrhagia, but this supposition does not rest on adequate clinical proof. Hemorrhage sometimes occurs from the stomach, as from the bronchial tubes, the Schneiderian membrane, and in other situations, without any apparent pathological connections, neither following nor preceding any appreciable morbid conditions. It is then to be considered as idiopathic, or as constituting an individual affection. Such cases are much more infrequent than cases of idiopathic bronchorrhagia. Hemorrhage from the stomach is an occasional event in pregnancy. Two of the 27 cases analyzed by Valleix exemplified this fact. It may be caused by a contusion received on the epigastrium.

The prognosis, in cases of gastrorrhagia, will depend upon its pathological import. The prognosis is, of course, unfavorable if it be associated with carcinoma, ulcer, or cirrhosis of the liver. If, however, the hemorrhage be vicarious, or not connected with any appreciable morbid conditions, the prognosis, as a rule, is favorable. The loss of blood in proportion as it is considerable or large, induces debility, anæmia, and it may prove the direct cause of death. In a case which came under my observation in consultation with my colleague, Prof. McCready, the patient, a young married female, was seized with gastric hemorrhage when apparently in good health, and the fatal result, which took place in two or three days, seemed to be attributable to the loss of blood. The amount and rapidity of the hemorrhage may be such as to induce sudden death from syncope. On the other hand, a supplementary hemorrhage, if moderate, is not only without danger, but may conduce to the welfare of the system, so long as the menstrual discharge remains suppressed. In determining the amount of hemorrhage, it is to be borne in mind that the quantity of blood vomited is not always a criterion. The blood may accumulate and coagulate within the stomach without being vomited. The hemorrhage may be sufficient to destroy life, although the quantity vomited be not large. Death may take place in such cases as in cases of concealed uterine hemorrhage. The evidence of hemorrhage out of proportion to the amount of blood vomited, is afforded by dulness or percussion over the distended stomach, and symptoms denoting loss of blood, viz., feebleness of the pulse, coldness of the surface, pallor, faintness, etc. The blood thus accumulating within the stomach, if not vomited, passes into the intestines and is discharged by stool. Hemorrhage into the stomach has been known

to occur, and death take place from the loss of blood, without any vomiting. Grisolle cites three examples, one of which was under his own observation.1 The stomach in this case was distended with an enormous clot. The diagnosis, when vomiting does not occur, must rest exclusively on the physical evidence of distension of the stomach by a liquid or solid, conjoined with the general symptoms denoting internal hemorrhage.

The treatment of gastrorrhagia has been already referred to in connection with gastric ulcer. The general principles of treatment having reference to the arrest of the hemorrhage, or the prevention of its recurrence, are the same, under whatever circumstances it occurs. With reference to these objects, quietude of body and mind is important. Repose of the stomach should be secured by the introduction of no more aliment than the wants of the system require, and the food taken should be bland and easy of digestion. In cases in which there is danger from the amount of hemorrhage, entire rest of the stomach is essential, the system being supported by nutriment and stimulants administered per enema. Opium is useful by quieting the peristaltic movements of the stomach. The direct refrigerant effect of iced water taken in small quantities at a time, or of swallowing small pieces of ice, will be likely to be useful. In urgent cases, as a temporary means of arresting the hemorrhage, ice may be applied to the epigastrium. In less urgent cases, revulsive measures may be relied upon, viz., sinapisms and dry cups, applied in different situations over the abdomen. Hot, stimulating foot-baths are useful by way of revulsion. Hemostatic remedies are to be given, taking care not to provoke vomiting by their use. The acetate of lead, tannic or gallic acid, and the astringent preparations of iron (the persulphate or pernitrate) are the most efficient of the remedies of this class. The ergot has been supposed to be useful as a styptic in cases of gastric hemor rhage. Emetics are certainly not rationally indicated, except in cases in which percussion furnishes evidence of the stomach being filled with a coagulum, and their propriety may fairly be doubted, even under these circumstances. Purgatives are contraindicated so long as measures to arrest or prevent the hemorrhage are required.

These measures are to be graduated, in individual cases, by the urgency with which the arrest or prevention of hemorrhage is indicated. Mild, simple measures are sufficient if the loss of blood be small or moderate. If there be grounds for regarding the hemorrhage as vicarious, interference. will be required only to keep it within proper limits. This statement will also apply to hemorrhage occuring in pregnancy.

The treatment in most cases of gastrorrhagia, of course, embraces other measures than those having reference to the arrest and prevention of the hemorrhage, viz., measures addressed to the morbid conditions with which the hemorrhage is associated. The latter are considered under other heads. So, also, measures called for after the occurrence of gastric hemorrhage, having reference to debility and anæmia, dependent on the loss of blood, need not be here considered. After a considerable hemorrhage, the stomach, assuming the non-existence of cancer or ulcer, is enfeebled, and the liability to a recurrence of the hemorrhage is to be kept in view. Careful regulation of the diet, quietude of the body, and the avoidance of all disturbing agencies, are important during convalescence.

Gastric hemorrhage is sometimes simulated by hysterical females, and by malingerers among soldiers and prisoners. Blood obtained from animals, and even human blood, may be taken into the stomach, and vomiting excited by various means. This deception may be suspected in the case of a young female who manifests a morbid disposition to impose on the credulity of

Pathologie Interne, tom. ii.

those around her, as regards her ailments, when the symptoms do not denote loss of blood, when there are no grounds, aside from hemorrhage, to suspect gastric ulcer, and when the menses are not suppressed. Among soldiers and prisoners, it is to be suspected when the usual effects of hemorrhage are not apparent, and when the morbid conditions with which gastric hemorrhage is usually associated, are wanting. The microscope may be of use in the detection of this kind of deception. Bennett cites a case in which a specimen of blood pretended to have been vomited, was found to present the characteristic red corpuscles of the blood of a bird.

СНАРТЕER VI.

Functional Affections of the Stomach and Intestines, continued-Inanition-GastralgiaPassage of Gall-Stones-Diarrhoea-Enterorrhagia.

In addition to the ailments embraced under the head of dyspepsia, are various functional affections of the stomach and intestines. These will be considered in the following order: Gastralgia, including gastric spasm, and, in this connection, the passage of gall-stones, or hepatic colic, may be most conveniently considered; diarrhoea, and hemorrhage from the bowels, or enterorrhagia; enteralgia and the affection known as saturnine or lead colic; sporadic and epidemic cholera.

Before entering upon the consideration of the affections just enumerated, I will offer a few remarks on a pathological condition which is not, perhaps, entitled to rank in the nosological catalogue as an individual disease, but which is an element of all diseases compromising alimentation and digestion. The pathological condition referred to is inanition. The importance of a due appreciation of this condition in medical practice, renders it desirable to devote to it some attention, and it may with propriety be noticed in connection with the functional affections of the alimentary canal.

INANITION.

Health requires the assimilation of nutriment adequate, in quantity and kind, to the wants of nutrition. Every one is familiar with the mental and physical exhaustion felt when abstinence is protracted for a few hours only after the sense of hunger indicates the need of food. Every one knows that the deprivation of aliment, for a period varying according to circumstances, proves fatal. During the progress of starvation, the body loses rapidly in weight, the fat disappears, the muscles diminish in size, exhaustion progressively increases, the heat of the body is notably lowered, vomiting and diarrhoea not infrequently occur, the mental powers are weakened, listlessness and hebetude are sometimes followed by delirium and coma, and, according to Chossat, if the deprivation of aliment be complete, death takes place when one-fourth of the weight of the body at the time aliment was withheld has been lost. The mode of dying is a type of slow asthenia. It is worthy of note that, during the progress of starvation, hunger is not usually a prominent symptom. If felt for a time, it is apt to disappear, and may be followed by a loathing of food. Our knowledge of the natural history of inanition in man is derived chiefly from cases in which starvation is unavoidable, as in