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UNITED STATES OF AMERICA
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FOUNDED  1836
WASHINGTON,  D. C.
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        S. HENRY DlfcSON, M. D.

PROFESSOR OF THE
INSTITUTES AND PRACTICE  OF MEDICINE
Metrical Course of t!jr State of SouUj-CTaroUna.

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PATHOLOGY.
  The Science of Pathology of necessity presupposes and is founded upon
an acquaintance with the doctrines of Physiology.
  As Physiology is the history of the several organs of the animal body
and their functions in a natural and healthy state; so
  Pathology consists in a knowledge of the morbid conditions of the or-
gans, and their functions.
  Disease has been varionsly defined; it always implies some irregularity
or aberration in the performance of one or more of the functions of the
body.
  This irregularity of action may be owing to obvious  alteration in the
structure of some of the parts of the body, or it may occur without our
being able to detect any change in the structure  of any part.  Hence the
distinction of Diseases, into Functional and Organic—and hence the impor-
tance of a close inspection of the  condition of the parts  of bodies which
have died from disease—a description of which constitutes the useful  and
interesting  department of Morbid Anatomy.
  Disease may be local or general.   Is local when the cause producing it
acts with special force upon some single part or organ, while  yet no parti-
cipation in  the  morbid consequences is extended to other parts. Is general
when the primary  local  affection has  been  communicated or extended
throughout the system.  Each of these may produce the other. It is proba-
ble that all diseases are primarily local, and afterwards radiated or rendered
universal by nervous sympathies.   General disease may also produce local
affections, as in hepatic and splenic inflammation from the concu.ssions  of
fever, and in gout and scrofula.
   Causes of Disease divided in the books into Remote and Proximate.
  The proximate cause  has been absurdly enough regarded as the disease
itself.   I would  d- tiote it as being the first essential link in the chain  of
morbid actions, whose results become obvious in the symptoms of disease.
The consideration of proximate cause—a very complicated and obscure
subject—is better deferred, therefore, until we enter upon the consideration
of  maladies s pi.rately.
   Remote causes—distinguished into the Predisposing and Exciting—terms
happily chosen as suggesting clearly  enough their own meaning. As to the
specific agency of these modes of causation, I infer that disease in the ab-
stract may be attributed to the disturbing influence of exciting causes, while
the  mode and seat of the  disease generated will be determined by the exis-
ting predisposition upon which the former has acted.  Yet we cannot al-
ways draw a line clearly between th^m.   Predisposition  may be so strong
as to develope disease without the  need of application of any transient ex. 
to
PATHOLOGY.
 i-itenicnt—as in gout, scrofula, &c.—and on the other hand an exciting or
 occasional cause shall have power to produce immediate predisposition, or
 rather perhaps of itself to determine the nature of subsequent and conse-
 quent disease, as in small pox and other contagions.
   Brown, Broussais, Parry, and other Pathologists have taught that the ef-
 fect of all such  causes is only an increase or enhancement of the natural
 actions—in other words that morbid differs from  healthy action  merely in
 intensity or degree.  This is an important and mischievous error.  That
 morbid causes occasion difference in nature or kind of action,  as well as in
 degree, I infer from the changes which take  place in the secretions of dis-
 ordered surfaces, which are altered in properties—obvious and  chemical;
 and from the newness and peculiarities of diseased  structures which  are
 built up, as in fungus hematodes, cancer, &c.
   Predisposing causes may be internal or external—original or accidental.
 Individual peculiarities of structure give predispositions, as Ave see in con-
 genital shortness of neck  which tends to occasion apoplexy, narrowness of
 thorax to admit  readily respiratory disorder, &c.   Minuter  peculiarities
 which we cannot see,  we deduce from the results as observed.
   Predispositions, evidenced by known tokens,  constitute temperaments.
 The consideration of these belongs properly to  Pathology,  though treated
 of usually among the subjects of Physiology.  Perfect health  is incompat-
 ible with the exquisite or notable developement of any temperament.
   Sex—Age—Colour—each exhibit  well marked and notable predisposi-
 tions.
   All the individual predispositions, whether  internal or external,  may be
 transmitted hereditarily—of this the examples are indefinitely numerous.
 Idiosyncrasies are either the result of internal peculiarity of conformation,
 or of sympathetic association—and thus present instances of both original
 and accidental predispositions.
   Numerous farther  examples of acquired  or accidental  predispositions
 may be adduced in recurrent or paroxysmal diseases, such as hysteria,  ma-
 nia, intermittent fever, &c. which become habitual, as  the  phrase is;  that
 is, which generate a predisposition of irresistible  strength.   It is  possible
 also that this is often done by effecting some minute changes of structure in
 the parts chiefly affected, as in rheumatism^ &c.
   Among external sources of predisposition we enumerate  climate, topo-
graphical peculiarities  of surface of country and soil, <Spc. hence  national
 temperaments.    State of society—many diseases are the product of civili-
 zation  and refinement, and so absolutely  artificial;  conditions  of  life  and
 occupations, quantity and  quality of food, epidemic distemperature of the
 air.
    Epidemics are local and general.  The local we may sometimes trace
 to the obvious qualities of the atmosphere, as  to Heat, Moisture, Electrici-
 ty, &c; at  others to undetected miasms or exhalations from animal  and
 vegetable matter.  We may instance among  local epidemics,  mal'aria fe-
 vers, yellow fever, dysentery, sore throat, the plague and typhus.
   Of general epidemics the origin is not known.   They are not to be pro-
 perly ascribed to any of the sources above mentioned.   They are refera-
 ble to no traceable condition  of the atmosphere; nor limited to  any particu-
 lar topography.   They are catarrhal fever. Tndian cholera, pneumonia tv-
 phoides, &c. 
L'ATHOLOGV.
4
     Epidemic predispositions the  most forcible known.  Few  constitutions
   escape their  impression.   They modify  all diseases or supplant them.
   They need little or no aid from  exciting causes of disease.   After a time
   they decline and die away, probably from the wearing out of the suscepti-
   bility to their influence occasioned by habit.
      Exciting causes.—Among these we instance alternations—changes of
   any kind.  Change of climate  a very familiar cause in the present day of
   emigration.  Vegetables and the lower animals are thus affected as well
*  as man.    The evils  thus occasioned  may be lessened by certain precau-
   tions, but all emigrants to distant or contrasted climates must expect a sea-
   soning, or an attack of some endemic before they can attain a complete as-
   similation or  adaptation of constitution to their new circumstances.
   Heat.—High temperature produces apoplexy, phrenitis,  inflammatory fe-
             ver, hemorrhage.  It affects  the internal   viscera by  increasing
             the force and frequency of the circulation, and by their  sympa-
             thy with the skin, whose exhalations it increases largely;  thus it
             it gives rise to hepatic, gastric and intestinal derangements.
   Cold—causes pernio and other external inflammations, and by constricting
             the surface  and interfering thus with the perspiratory function,
             gives rise to a host of diseases of undue determination—pleurisy,
             enteritis, catarrh, <kc.
   Alternations of temperature.—The effects above described are more certain
             and intense  if thus  produced.  Heat  applied  after cold is per-
             haps the more dangerous of the two changes.
   Food—of improper quality, or in improper quantity.   Scurvy arises from
             salted meats, &c.—dyspepsia from undue use  of acids and sea-
             soning—eolics, &c. from meals too large for the stomach.
   Intemperance in drinking.—Vinous and alcoholic  fluids are  dangerous in
             proportion to the intoxicating power.  Their  immediate effects
             are upon the stomach and brain, but acting  upon predisposition,
             they may occasion an infinite variety of maladies.
   Dress, manners, customs, amusements, fyc.  if  not properly regulated, all be-
             come in their turn exciting causes  of disease.  The female stay
             or corset has been animadverted on much more than it deserves.
             Properly arranged it gives support as well as adds  neatness and
             beauty  to the form.   It may be so tightly drawn as to interfere
             with locomotion  and  respiration, and  to oppress the abdominal
             viscera; the steel piece may  also be too  broad, and thus injure
             the breasts.
   Occupations  are  among exciting  causes.  Millers, stone-cutters,  needle-
             grinders, cotton-ginners are subject to bronchial and pulmonary
             inflammation from the mechanical irritation of particles inspired.
             Painters, gilders, &c. are injured by the fumes of the metals they
             employ.  Manufacturers in  general suffer both from  confine-
             ment  and from monotony of life with utter hopelessness of change
             or improvement of condition.
   The Passions must be enumerated here.  I regard  them  as all .stimulating
             in their immediate influence, and as directed primarily  to the sen-
            sorial organs.
   Anger, Grief and Joy produce  apoplexy, hemorrhages, phrenitis. 
I
I
 8                          PATHOLOGY.

 Love—a dangerous passion even if successful; when otherwise often gives
          rise to insanity.
 Fear affects the muscular, circulatory and digestive  systems,  relaxes the
          sphincters;  has been known in a few hours to give the hair a sil-
          very whiteness and the  whole  frame the aspect  of  sudden and
          premature old age.
 Poisons—divided into the mineral, animal and vegetable, to which I would
          add  a fourth,  the gaseous, or  atrial—as the sources of some of
          them are not well known, while their form is obvious.
 1. The vegetable poisons.—Some act by inhalation, as the upas and  man-
          cinella; others by contact with the skin,  the cerbera  ahovai,
          mannarilla, cashew nut, rhus radicans and  rhus vernix, mustard,
          &c.—these irritate and inflame.  Others still upon the stomach
          and  intestinal tube—these are our emetics  and cathartics; and
          others on the nervous system—these are the narcotics, which re-
          lax,  intoxicate, and produce stupor, coma and convulsions; lastly,
          others require to be introduced into the circulation, as the woora-
          ra and ticunas.
2. The animal poisons are  reserved for future consideration  in another
          connection.
3. The mineral poisons are  muUiplied in number by  chemical processes.
          The metals are in their proper state harmless, but the salts of ma-
          ny of them are poisonous, as of mercury, lead, arsenic in a high
          degree of intensity, copper, antimony.  The pure alkalis and the
          acids are irritating and corrosive.
4. The arial poisons.—Some of these are of known  chemical origin and
         qualities, as the several irrespirable gases; others are in both these
         respects obscure and undetected, as epidemic  contaminations and
         malaria.  Of the first class the most common is the carbonic acid
         gas,  and the other forms of union of carbon and oxygen so often
         met with in mines, wells, vaults, &c.—these affect with asphyxia.
         The precaution should be taken of sending into suspected places
         a lighted candle; if this cease to bum, quicklime should be thrown
         in sufficient quantity to absorb  while slaking the superabundant
         carbonic acid gas.   Charcoal burned in ill ventilated apartments
         consumes the oxygen and  combines  with it so rapidly  as fre-
         quently to have occasioned  thus  loss of lives.   Air which has
         been breathed becomes soon unfit for respiration.  A terrible in-
         stance of the  effects of confinement in a  close  apartment is re-
         corded in history as having occurred in Calcutta upon its surren-
         der to the Suba of Bengal in 1750. 146 of the English garrison
         were confined in a narrow dungeon during a hot, airless and mis-
         erable night—123 perished before morning.
  MaVaria.—This term preferred in compliance with modern u^a^e to the
word miasm, which has both etymologically  and in the writings of many
physicians an  extension so wide as to include all  anial contamination,
Avhether chemical, contagious or epidemic.
  MaVaria, defined as a peculiar distemperature of the Air of  certain re-
gions, derived from sources to be considered in  order, traceable  only by its
effects, and as  yet undetected by any chemical or nieehanit al investigations. 
PATHOLOGY.
9
Us nature is unknowrn—its very existence has been made matter of dispute
—all the influences ascribed to it have been attributed to the mere agency
of moisture, or of moisture associated with heat;  an error evidently owing
to the  concomitance  of these exciting causes, and their tendency to pro-
mote its efficiency.
  The principal source of malaria is believed to be  the decomposition of
vegetable matter.  The growth and production of vegetables, as well  cs
their subsequent decay, are fostered by  the presence of moisture and the
action  of high temperatures.  Effluvia, thus disengaged, produce all the
forms of fever,  and  many  other diseases;  so  well  known as being thus
generated, that their occurrence is regarded as proving the presence of ma-
laria, an  identical agent.   Local and limited sources are, in this way, capa-
ble of  originating much evil: thus,  in a confined cellar,  or the  hold of a
ship, decaying vegetables create fever.   Hence, malaria fevers  appear in
summer  and autumn,  and are intense in proportion to  the temperature of
the country affected.   In hot countries we have the plague,  yellow fever,
bilious remittent, &c.—in colder regions, intermittents of chronic charac-
ter, hepatitis, jaundice, &c.   Cold, when sufficiently  intense, puts a check
on the  influences of malaria.   Heat farther promotes the action of malaria,
by generating a predisposition in the system favourable to it, by relaxing
and debilitating  the skin and liver.   Moisture is not only necessary to its
production,  but  likewise becomes the medium  in combination with which
this poison acts upon  the body—a combination, it would seem, of essential
necessity to give it effect.   Hence the known insalubrity of  fogs and dews
in malaria regions; hence the advantage of a  certain degree of elevation
from the exhaling soil.
   A certain  degree of concentration, and a certain  amount  of  dose, are
necessary also to the efficiency  of  malaria.  It is in  this property chiefly
that a  Virus, technically so called, differs from a poison;  the former being
independent  of  both  these  circumstances: thus  the  smallest particle  of
variolous or vaccine  matter,  however diluted,  can  infect the whole body.
Calms are favourable to the concentration of malaria; winds and storms
waft it away,  disperse and dilute it.
  Malaria probably acts upon the  skin  primarily.    Thus we account for
the insusceptibility of the negro race, who perhr.ps differ from  the white
more in  this point than any other.   It also acts more readily during sleep,
when the functions of the skin go on with energy.
  Any thing which depresses the vital power, may be said to assist its in-
vasion—fatigue, want of food, of rest, of  clothing, &c.
   Habit  diminishes in the white man rather the violence of its effects, than
the susceptibility to its action.   Many residents  in  the low country have
regularly annual attacks—these are  of no great severity, but infallibly un-
dermine the constitution.   A stranger is  attacked violently.   Latent period
doubtful—differs probably in proportion to intensity of cause applied, which
may at once excite, or may only generate predisposition.  Trees are found
to oppose an efficacious barrier to the invasion of malaria.   I am uncer-
tain whether this is owing to the mechanical impediment  which they offer
to its passage, or whether it  is better accounted for by the  supposition of
the existence of some attractive force, which causes the miasma to adhere
to their foliage,  or by the suggested evolution of some  efficient counter
agent.   This last conjecture may assist  us to explain the healthtulncss of
                o 
10                        PATHOLOGY.

our pine barrens; among the favourable circumstances in whose position 1
Avould enumerate the terebinthinate exhalations from the trees, as probably
balmy, tonic, and salutiferous.  Among other  sources of malaria,  the  de-
composition of decaying volcanic matter has been suggested, and  applied
well to the phenomena familiar in Italy.  The country about Rome is not
marshy, but  volcanic;  so of Civita Castellana, &c. &c.   Ferguson  de-
clares the only necessary condition to be,  "paucity of water succeeding its
abundance."   Some Medical philosophers  would substitute the agency of
specific animalculi  for all miasmatic and epidemic influences; and Dwight
has proposed animalcular putrefaction as a source of mal'aria.
   May there not be some common product of the several chemical actions
going on in these cases,  serial and  of obscure nature and qualities, whose
identity is proved by the identity of effects  it every  where gives rise to?
   Animal Putrefaction.—History, both ancient and  modern, offers  us  fre-
quent instances of pestilence produced by this cause.  The burial grounds
of Paris,  London and  New-York, proved to be injurious to the health of
the vicinity.   The Catholic Churches on the continent,  often require to be
disinfected.   The processes which  immediately  precede, and those which
accompany or  follow death,  tend  to  generate a poisonous quality in ani-
mal matter.  The flesh of diseased animals, is unfit to  be used as food,
and become injurious when so used—in one instance, a specific disease is
thus communicated,  "milk-sick,"—a gastritis.   Among  anatomists, a very
severe and not unfrequently  fatal  affection, is produced by puncture and
inoculation in dissection, with the scalpels, «kc. imbued with the fluids of a
subject.   The absorbents  inflame,  and the glands, a cutaneous  eruption
comes on, attended with violent inflammatory fever and great prostration of
strength.
   Animal Poisons.—Divisible into two classes.   1st. Those which result
from natural  and healthy, but peculiar actions.  These  are secretions in-
tended for attack or defence, as the  sting of the bee, wasp, &c, the venom
of the snake.   2d.  Such as are produced by diseased processes—the milk
and butter of a milk-sick cow, the saliva of a rabid animal of the feline or
canine tribe, vaccine and variolous matter, <kc.   Some of these are conta-
gious.
   Contagion.—Defined  to consist in a peculiar  matter given out by a dis-
eased surface,  which possesses the power or quality  of generating in  a
healthy body a diseased condition, similar to that whence it derived its origin.
   To prevent confusion in the use of language, I would follow the  distinc-
tion proposed by W. Philips, in  which contagion is pointed out as the mor-
bid poison, and infection as the act of communicating disease.   Hydropho-
bia is contagious in the feline and canine tribes, but  a human subject affec-
ted with it, is incapable of commu.iicating it.
   The matter of contagion may be either  palpable or impalpable.  Vac-
cine, chancre, gonorrhoea, psora offer examples  of  purely palpable conta-
gions.  These are  transmissible only by  actual contact of the  morbid
secretions, with some portion of absorbing surface.
   Scarlatina, rubeola, parotitis, pertussis give out  an imperceptible ema-
nation, which affects the healthy subject, we know notexactlv how.
   Variola, plague,  varicella produce a virus  of palpable form, which is
capable of infecting in both  ways, either  when directly applied, or after
having become impalpable by solution, and  diffusion in air. 
                            PATHOLOGY.                         11

   Modes of infection.   1st. By actual contact or inoculation.   2d.  By
near  approach.   Contagions  of mixed and impalpable character,  are
capable of infecting  at a certain distance; which, from  experiments care-
fully made by Haygarth, Russell,  and others, would not seem to be very
great.   I suppose it  to be somewhat influenced by cleanliness and ventila-
tion, which must affect the accumulation and concentration of the conta-
gious atoms.  3d. The mixed and impalpable contagions which are almost
all febrile in origin and character, possess also, as I believe, the power of
contaminating the atmosphere widely, and thus produce local epidemics—
probably by effecting some peculiar change in the condition of the air.
Contagious diseases  often become, in this way, Epidemic also.   4th.  By
fomites.   All forms  and modes  of contagion are capable of adhering to.
and being absorbed by certain sub-lances, which, by this impregnation,  be-
come\fomites.  Thus preserved, they are said to retain all their virulence.
Bed and body clothes  of woollen stuff are  specially calculated  to absorb
and retain them;  they are said also to adhere to the very walls of an apart-
ment, the ceiling and the floors.   The precautions to be taken are readily
suggested.—Cleanliness—Washing  with abundant water, aud the use  of
lime, (the only specific disinfecter known)  in some of its forms.  The
clothes of a physician,  it should be always remembered, may  by thus
entangling contagious particles, convey them, and communicate disease.
   The questions concerning  contagious disease, are of very  great impor-
tance as they bear upon the commercial, and ordinary intercourse of nations.
   Superfluous regulations of a restrictive nature have often been stigma-
tized as cruel—the imputation will lie more properly against such as are in-
adequate.  Every community has a right, and is indeed bound in duty,  to
establish its own quarantine regulations.
   Some of the contagions are endowed with the property of destroying in
a system once affected by them, the tendency, or disposition to a recurrence
or  second attack—thus variola, rubeola, pertussis, parotitis.  From  the /i*jA ?\
singular  fact that vaccine  exhibits a protective influence in this malteeto//^w^*
shield from, or at any  rate to modify, small  pox, some have inferred their
identity, explaining the obvious differences,  upon the conjecture, that the
former, in a course of successive transmissions through the systems of the
lower order of animals, as the horse  and the cow, has undergone  these  al-
terations in external  character and symptoms.  The majority of contagions,
and especially the non febrile, give no  protection  against second attacks,
but may recur with indefinite frequency.
  Parasitic animals  should be classed among exciting causes of disease.—
Some fanciful pathologists have attributed many diseases to  animalculge,
as dysentery and psora.   The ancient morbus pediculosus very rare.
   Worms.   The  lumbiicus is the principal, and is capable of producing in
an infested child almost any form of disease,  according to predisposition.—
Vsco rides and taeniae give rise to peculiar symptoms. 
]2           PATHOLOGY—DE SEDIBUS MOKBORT M.
                   DL sed:btts morborttm.

  The fluids of the body preponderate very considerably, being in a ratio of
!» to  1 to the  solids, as  some physiologists calculate.   This estimate I re-
gard. however, as somewhat exaggerated.
  The primary seats of the vitality of  the different portions of the animal
structure, are the Sensorial and Circulatory system.   Every part of every
tissue, depends immediately  upon its nerve, and the blood sent to it, for its
life, and these, the nerves and blood, are dependent upon each other. , Each
atom which is gifted with life, receives it from nerve and blood.
  These, then, must be the primary seats of disease.
  Diseases purely functional—as the  spasmi generally, amaurosis—dys.
pepsia, may be said in  the first  instance to affect  exclusively the sensorial
system.
  Structural diseases,  on the other hand, affect the vascular system.
  Sensorial and vascular derangement intermingle together, and  produce
each other.
  There are nervous affections of the whole or part of the circulatory sys.
tern, as syncope, palpitation and fever.
  And vascular  derangements of the whole or part of the sensorial system,
as apoplexy, phrenitis,  neuralgia.
  Fttnctional affections of nerves may run on  into, or produce vascular and
structural derangements.   Too  intense light, will  occasion opthalmia.—
Functional affections of the vascular  system, by continuance, can scarce-
ly fail to produce structural disorder, as in fevers, inflammations. <kc.
  It  has been much disputed whether the fluids can  ever be the primary
seat of disease—no one can doubt that  they uudergo certain obvious chang-
es in its  progress.   Whether any such changes  are to be estimated as a-
mong  the primary and essential circumstances, is the true question, and I
am disposed to  answer in the affirmative.  The ancient advocates of  the
humoral pathology carried their views on this subject  quite too far, attribu-
ting all diseases to alterations in the qualities of the fluids, some of which
 cannot be proved to occur at all, whether as cause or effect.  But  it is fash-
 ionable in the present  day  of exclusive solidism, to go equally far into the
 opposite extreme.  Truth  lies as usual  in the medium.   Chyle varies in
 quality,  according to the food whence it is obtained.    Blood must vary, al-
 so, as derived from chyle.   Scurvy, and some cutaneous affections, are the
 direct result of confinement to improper diet.   Blood is also liable to mam
 and important changes of  condition, referable to the  more or less perfect
 performance of the  function of respiration.  That important diseases mav
 thus arise, cannot be rationally doubted, which shall  depend directly on the
 state of the blood.  Typhus may take its origin  in confined habitations as
 well as  in impure, insufficient diet.
   Diagnosis—consists in such knowledge of the seat, nature and It
 of any given disease,  as shall enable us, to distinguish it from'every th •
 Pain will often  point out the locality of disease.   The imperfect  perf  ^ 
             PATHOLOGY---DE SEDIBUS  MORBORUM.          13

ancc of known physiological function, is, however, still more important as a
diagnostic symptom. Sympathies of noted  and recorded occurrence wheth-
er understood or not, often serve as valuable mi ides.   But we arc liable to
be misled by each of these marks.   Some important and dangerous diseases
occasion little or no pain.  Some painful affections, imply little or no dan-
ger.  And the morbid sympathies which connect the organs are in numer-
ous instances highly irregular and obscure.
  The usefulness of pathological anatomy—the examination of bodies dead
of disease, carefully considered.
  It cannot, except in a  very few. and properly accidental cases, teach us
any thing of the causes of disease.
  Among the effects of disease which it detects  and developes, it  cannot
help us to distinguish between incidental and essential lessons of structure.
As to impediments to function merely, it gives no information.   Nor can it
ever aid us in tracing the primary locality or  origin of disease;  nor in fol-
lowing up its effects in successive series of consequences.  The true value
of morbid anatomy lies in connection with observations carefully made and
exactly noted during the progress of any given case, collated w ith reference
to the cause of  the attack, its mode of  commencement, and its entire and
minute history.   By an  observation of frequent  or constant coincidences,
we are taught to direct  our attention to organs liable to become implicated
in future cases of similar character.  The physician therefore, should not
neglect to unite  these offices; he should take careful and precise notes at the
bedside of the sick, nor consider himself as having performed all his duty
until he has instituted a minute examination of the dead body.
   The tendency of all disease is, to death  or disorganization.   The old
 dogma of the existence of a restorative power in the  constitution,  a vis
 medicatrix naturae, combated.
   The cessation of disease (unless when brought about by remedial treat-
 ment) attributed merely to  the removal  of the cause which producd it.
 Sometimes the exciting cause is taken away—at others, the predisposition
 upon  which it acted disappears,—is, as  we say, exhausted or worn  out.
 The well  constructed, admirably ordered  mechanism of the animal body,
 resumes  its natural action, when  the impeding or disturbing influence
 ceases to act.
    It is absurd to suppose disease to be in any case a natural or spontaneous
 action of the living body, or to imagine any principle  prepared or provided
 to procure its  removal—doubly absurd to suppose  that such principle
 should act, such effort be exerted through,  and by means of the very pro-
 cesses in which disease consists, and through which it developes itself.
    Morbid causes  produce death in two  ways.  Disorganization to a cer-
 tain extent,  is evidently incompatible with a subsequent  resumption of the
 functions of any  given system of parts.   But, besides this, the mere inter-
 ruption of an important function for a time is  often fatal, without any le-
 sion of any part or organ,  as in suffocation from drowning, and in some
 cases of syncope,  &c
    Death from disease, must vary'in its attendant circumstances, with direct
 reference tolhe modes in which it is brought about.
    Euthanasia,  or death from old  age, is owing to defect of action in the
 organs of supply, and the consequent failure of all the functions.
    Death defined  to consist in a cessation of excitabilitv, the  loss of the 
14          PATHOLOGY--DE SEDIBUS MORBORUM.

capacity of being impressed  by,  and of reacting upon stimuli applied.
The phenomena of death do not constitute that state; they may be all pre-
sent when animation is only suspended, and the subject capable of resus-
citation.   Interment should, in all cases, be  postponed  until decomposition
commences.   Interment, in cities  or populous  towns, should  be strictly
prohibited—the ancient  practice of burning dead  bodies, ought, on many
accounts, to be preferred. 
I'ATHOLOGY--PHENOMENA OP DISEASE.           l.j
                   PHENOMENA OF DISEASE.

  Considered practically, Diseases are mere collections of symptoms, the
proximate or common cause of which is exceedingly obscure, and difficult
to be traced.  These phenomena  may, in this place, be considered  in the
order of the  physiological  systems and  functions which  they disturb or
affect, and their rationale attempted to be given.
  1st. Of the disordered conditions of the Digestive system and function—
Anorexia,  nausea,  gastric oppressio.i, vomiting of matter of various char- £
acter and  appearance, shew irritation of the mucous digestive membrane/
and  consequent  vitiation of its secretions.   Altered appearances  of the
tongue described, with the inferences to be drawn from them.  When the sur-
face is covered with a light thin white coati;;g, a moderate degree of gastric
derangement is present; if there be a thick yellow or brown fur, with a bit-
ter  taste in  the  mouth,  the hepatic actions are disordered; a moist, soft,
swollen tongue,  with the edges indented  by pressure against the teeth, de-
notes a disturbed state of the whole digestive tube, and sometimes accom-
panies sore  throat.   Inmost Fevers, the edges and point are fiery  dark
red, while the upper surface is furred.  In the advanced stages of Typhus
and of Dysentery often, and very regularly in those of gastritis and enteritis,
the tongue is clean  and red, and the appearance of papillae lost in a smooth
surface like that of the lip;  in protracted cases, it sometimes becomes dry,
cracked, ulcerated,  coated  with sordes.   Teeth, discoloured, carious, pain-
ful, when  the digestion is bad, covered with dark tenacious sordes in ty-
phus.   Gums—in Scurvy and the various Cachexies, spongy, swollen, dis-
posed to  bleed.   Ulcers on the  lips, cheeks and lining membrane  of the
mouth, denote gastric and  intestinal derangement—this is a very common
consequence of it among children.
  2d. Of the circulatory function.  Syncope the cessation of action of the  ;
heart.  Palpitation, its convulsive action.  The pulse  derives its import-
ance as a  symptom  of disease, from the almost universal sympathy, which
extends diseased actions  in other  systems, so as to affect more or less the
circulatory.  The pulse  of an infant newly born,  beats about 140 strokes
in a minute—declining from that  time, the average adult pulse is about
75 to 80.
  In health, the pulse is modified by a great variety of circumstances.
Idiosyncracy.—In some persons it beats 100, in others not more than  40.
Sex.—The female pulse  is  somewhat more frequent than that of the male.
Stature—In tall men it is less frequent, in dwarfs more so.
Muscular  Exertion—makes it beat with great rapidity.
Sleep—makes it slower.
The Passions and Emotions—add to its frequency, and  perhaps its force.
Temperature—Heat augments—Cold (continued) diminishes its frequency.
Diurnal changes.—The pulse  is  usually  somewhat more frequent in  the
          evening.
  These agents  affect chiefly the frequency of the pulse in health. 
16         PATHOLOGY--PHENOMENA OF DISEASE.

  The Healthy pulse is  regular—that is, the intervals between the strokes
are precisely equal;  it is vigorous,—that is. it resists  with determinate op.
position, the influence of force  applied to  compress it; it is jull  that is.
the artery is completely, but not unduly dislended by its blood.
  The svstole of the heart occupies a given portion  of  time, contracting
steadily without harshness or hurry.
  A morbid pulse may readily bs distinguished then by comparison.
   [t is more or less frequent—than i:i health.
       more or less hard or  resisting.
       -----------quick (abrupt or jerking.)
       -----------full.
                  in interval.
                  in force.
Irregular.
       Intermitte.it.
  These comparative phrases address  themselves to the judgment, convey
a definite meaning, and are easily remembered and referred to.
  These several morbid qualities of the pulse may be variously combined,
so as to offer a great variety; the attempt to give fanciful names to which.
has introduced some disorder and  confusion.
  The oppressed—depressed—gaseous  and undulatory  pulses  of Rush
described.
  Plethora, in strict  propriety, always a relative term, implying a want of
proportion  between  the quantity, or the stimulating quality  of the blood,
and  the tone of the heart and vessels.   Hence it  is often met  with in
weak and debilitated constitutions.
  I doubt the possibility of an absolute Hyperamia, or undue abundance of
blood.
  Anemia—The deficiency of sound  or nutritious  blood,  often results
from hemorrhagies natural or artificial, and from disease.   The fibrine and
red globules, would  seem to be slowly supplied.
  The Blood undergoes many changes in disease.  Becomes buffy  or sizy.
This is usually explained on the supposition that its coagulation being slow
the red globules fall to the bottom, leaving the yellow lymph on the surface;
this explanation shewn to  be unsatisfactory.  Becomes incoagulable from
great fatigue and extremely violent inflammation—in death also from light-
ning, and from a blow on the pit  of the stomach, but remains florid or black,
and does not assume a buffy crust.  Blood is black  in typhus; attenuated
and dissolved, as the phrase is, in scurvy; loses its salts and serum in cholera.
  Hemorrhage—a symptom more alarming than dangerous in itself, occurs
in opposite states of the system—when active, less serious  than if pas-
sive—in the former case, may have good effect, as a mode of local deple-
tion.
   3d.  Of the respiratory function.  This function, is closely connected with
both the circulatory and sensorial, and partakes readily in any disorder of
either.   Dyspnoea and orthopncea defined, and  accounted for.
   Cough,  the  most  common symptom  of pulmonary irritation  yet not
always present.                                              '  *
   Expectoration  of mucus—thin, bloody,  offensive,  ichorous fluid__of
pus—this may either be from an abscess, from the circumference  of a tu-
bercle, or from the unbroken mucous surface: it does  not prove abscess or
ulcer to exist. 
              PATHOLOGY--PHENOMENA OF DISEASE.           17

   4th. Of the  sensorial functions.  Pain is the most general symptom of
 disease—the expressions indeed being almost  synonymous; yet, owing to
 the complexity  of morbid sympathies, it, bv no means, denotes of course
 the  principal locality of disorder.  The degree of pain depends upon the
 general sensibility of the patient, and upon the local sensibility of the part
 affected;  it is also modified, both  in kind and degree, by the nature of the
 case, so that  it  bears no regular proportion to the danger of the attack.
 The  loss of sensibility, whether local  or general,  must augur unfavour-
 ably.
   Permanent dilatation  of  the pupil is untoward as being probably  occa-
 sioned by compression of the brain—permanent contraction by meningeal
 inflammation.   Insensibility to light, as evinced by a fixed state  of  pupil,
 also unfavourable.  Hallucinations of various  kinds, amounting to deli-
 rium and to insanity, are more to be dreaded when low and gloomv, than
 if cheerful or violent.
   5th.  Motory  Function.   Great muscular prostration  is always  to  be
 dreaded.   Relaxation of the various sphincters, indicates a high degree of
 danger.   Paralysis is still more unfortunate, whether of one half the body
 transversely divided—Paraplegia, usually affecting the lower limbs, or He-
 miplegia; which is confined to the right or left side, and both extremities.
 Trembling  of the head a common circumstance in the debility of old age
 —of the  hands  and tongue, often from  intemperance.  Cramps,  or tonic
 contraction of  particular muscles, result from many various  irritations—
 are often  connected  with digestive disorder and uterine irritation.  Con-
 vulsions and spasms more  common in childhood, derived from numerous
 causes; in general, more alarming than imminently dangerous.
   6th. Excretory functions.   Very difficult to assign any rationale of the
 /coldness and corrugation of the skin in ague, or the generation of so much
 cutaneous .head-in certain fevers,—most observable in yellow fever.   Rush
 makes the remark, which is confirmed by my own experience, that a cool
 moist state of the skin in the disease just mentioned is indicative of great dan-
 ger.  Inordinate sweating the principal circumstance noted in the ancient
 fatal  epidemic hence called Sudor Anglicanus.   The  perspiration under-
 goes changes of  quality, as well as of quantity, assuming a yellow or brown-
 ish hue, becoming acid, and offensive in smell.   The skiu itself, suffers
 changes of colour, being yellow as in Jaundice—pale white, and semi-trans-
 parent, as in Dropsy—orange, in yellow and bilious fevers, and hepatic dis-
 orders and from intemperance—and livid, mottled and spotted, in petechial
 fevers.
   The urine was of old regarded with special attention,  and the most pre-
 cise indications of the state  of the patient supposed to be drawn through it.
 It becomes abundant and limpid in nervous diseases, as in hysteria and some
 head aches, scanty and high colored in fevers, loses its urea in diabetes,  in
 one form  of which it contains much sugar; deposits sediments of varying
 colour, under circumstances  not exactly defined.
  Much affected in dropsies,—containing varying proportions of serum, &c.
  Strangury—unfavorable  in the  commencement of fevers, favorable  in
their advanced stages.
  Total suppression, declared by most, to be a fatal symtom.   I have, how.
ever seen recoveries after it.
                3 
18          PATHOLOGY—PHENOMENA OF DISEASE.

  The Alvine Excretions—offer important observations in warm climates es-
pecially.  Much influenced by the states of the liver, as well as of the intes-
tinal canal.   Long continued impediment to the  process of foecification, or
the remarkable stercoraceous change undergone by the ingesta, ahvays de-
notes danger.   Clay coloured stools show torpor of the liver—vitiated se-
cretions of bile, color them dark green, and make them offensive and acri-
monious.   They are black under some particular states of enteric imflam-
mation, as in yellow fever, containing floculi or granulae of black color.   In
dysenteric irritation they are mucous, and bloody, and sanious.  A pecuhar
pink colored, highly offensive ichor, shews instant danger, being occasioned
I believe by actual gangrene of some portion of the mucous membrane.
This may come away also, in small flakes  in the stools—or portions of fi.
brine or coagulable lymph.  In dysentery, Ave meet also with scybala; these
arc sometimes described, as lumps of hardened fceces, at others, as consist-
ing of caseous, or of fatty matter.
   In children the stools are often acid and  green, at times, serous and co-
lorless.  Purulent matter may come away from the intestines, either when
ulcerated or highly inflamed.
   The countenance of the patient should  be remarked, as expressive of his
condition.   Any obvious change is unfavorable.   The countenance of ma-
lignant fever is always notable.
   "Risus Sardonicus" described as a grim, sarcastic smile, produced by in-
voluntary contraction of the muscles of the lips and cheeks.   The "Hippo-
cratic countenance," consists in hollow sunken eye, pinched up nose, fallen
temples, tense  pale forehead, lividness of fuce; universally, as far as I have
observed, the forerunner of death.
   The Decubitus or Posture in bed.—Inability to lie down unfavorable,—so
 is confinement to either side—lying on the  back, with knees drawn up, and
 sliding to the most depending part of the bed, shew great debility.   Restless-
 ness and jactitation, bad symptoms; it is worst of all, w hen the patient ex.
 presses an anxious desire to move from bed to bed, and  from one room to
 another.
    (General rules given, for the examination of the patient.
    Periodicity—the tendency to periodical  revolution,  one of the most re-
 markable phenomena of disease.
    Diurnal Revolutions observable both in  health, and disease, as  may be
 noted in the pulse, and  in general in all our habits and customs.   They are
 likewise obvious in all fevers, continued, remittent and intermittent.   Con-
 tinued fevers, show some abatement in the morning, and augmentation in
 the evening.   Remittents, refer to the types of intermittent with which they
 are most closely connected.   Intermittcnts have their special hours of access:
the quotidian in the morning, the tertian, a little before noon, the quartan in
the afternoon.
   Septenary Revolutions are not less clearly  distinguishable.   The  men-
struation of the human female, occurs regularly on the 28th day—its antici-
pations and postponements are  usually of 7 or  14 days.  The relapses of
fevers occur at the tame periods usually.
   The first I attribute to ! isolation, the iufiuen. e of the Sun.   The- second,
in like manner to Lunation, the  influence of tiie Moon.
   The combined influences of the two. liable, perhaps to other comp'ica- 
              PATHOLOGY--PHENOMENA OF DISEASES.         19

tions more obscure in their nature, will :;ccou?it  tor all the types of fever,
and all the phenomena of periodical repetition of disease, as well as of cri-
sis, or the agency of Critical days.
   The Condition of Convalescence briefly described us one of extreme mo-
bility and susceptibility,  and as requiring the special notice and attention of
the practitioner.
* 
20             MODUS  OPERANDI OP MEDICINES
              MODUS  OPERANDI OF  MEDICINES.

  Medicines have been enumerated among the causes of disease; they all
produce it in the sound, or healthy system, how is it then they effect in the
sick, the restoration of health?  There is no such power  existing in any
known ;.ge:it, as shall be displayed  in the mere production or increase  of
vitaliiy, or healthy action, in an animal body; nor is there anything in na-
tore, properly deserving ;he title of Antidote, except in reference to its chem-
ical iiliinities.   Medicaments then must  be useful by  an  indirect agency;
then-  effect being always regulated  by, and dependent upon the condition
ol in.> recipient.
   The immediate, influences exerted may be arranged under the following
heads.                                -         S                ^   B
1st, Abstraction—darkless,  silence, fasting,  recumbent posture, cold, the
          lancet, leeches and cups,-cathartics, diuretics, &c. &c.     J
2d, Stimulation—wi.ie, alcohol, bark, opium, electricity, heat, &c, &c.
3d, Revulsion—the most  important perhaps  of  therapeutical principles.
          'i he use of cathartics in fever,  of these and emetics in inflamma-
          tion, of the lancei, leeches and cups, (as properly under this head,
          as the first.) of sinapisms,  blisters, acupuncture, &c.
 1th,  The Homoiopathic  Action—as  exemplified in the application of bella-
          donna m scarlatina;—of vaccine to prevent or modit'v, small pox;
          of emetics to remove nausea—and of cathartics to cure diarhoea.
          ^ e; H nnoiopathists reject altogether, and protest against the doses
          ordinarily employed bv the other schools, and exult in the discov-
          ery, that (he most beneficent effects, can be procured from atoms,
          or indefinitely mi.iiite portions  of medicines; exhibiting the thou-
          sand! part of a grain, or of a drop of our common drugs.
5th,  The Contra Stimulant Inilucnec—exhibited best, perhaps, in the use of
          very l.ir^e doses of opium in tetanus, and of antimonials in intes-
          tinal spasm. The f.alians  of the contra-stimulant school, are found
          i:i the  opposite extreme, to the German practice of Hahncman.
           ill 'V administer boldly, the most enormous quantities of the reme-
          dies indicate  d. with the purpose of combating directly the force of
          morbid impressions made upon, or morbid actions going on in the
          system.
(till, The  '[Iterative !:fct—such as we attribute to mercury, and the me-
          tallic  preparations generally—fo  the mineral  acids also, and in-
          d"ed such as may be obtained from a great number of medicines,
          as guaiac, iodine, camphor, cathartics.  By the word alterative 1
          would  mean the substitution of the effect of the medicine, for the
          effect of  the originally acting  cause.  To be regarded as an  al-
          lerativo, a medicine must be capable of producing then, a forcible
          impivssio,,. wlceh may be  kept up at will, by  its continued exhi-
          bition, and which  shall  readily subside, on  withholding it.  By
         the combination of these powers, its value  is given.
  Il is doubtful whether the three last modes of action may not, Avith pro-
pri; >v. be ail resolved i..to  the form  of Revulsion. 
MODUS OPERANDI OF MEDICINES.
21
  The modes of administration by which we apply our ordinary remedies,
are four, viz.  1st. By the prime vise or surface  of the alimentary canal.
2d. By the cutaneous  surface.  3d. The pulmonary surface.   4th.  By
introduction into a vein, or insertion into a wound.
  There are, besides these, some mechanical, and in  a certain sense, che-
mical remedies, not directly referable to either of the above heads as fric-
tion, percussion, acupuncture, electricity, and galvanism.
  Medicaments may act when applied in either of the above modes.—1st.
Upon the extremities of the nerves  immediately, and through the sensorial
system upon the whole body.  2d.  By introduction into the circulation and
actual mixture with the mass  of fluids.
  Instances of the first kind may be found in the instantaneous death which
follows the swallowing  a large quantity of alcohol,—the  same result is
produced by touching the eye or tongue of  an animal with  strong prussic
acid—and in the effects of stimulating volatiles upon  the body through the
olfactory nerves.
  The  latter, I believe, is common in  the agency of our ordinary medi-
cines.  The effects of medicine, introduced-into the  stomach, are exactly
similar or identical with  those which, they produce when injected into a
vein.  Opium, dissolved and thrown into a vein, produces sleep and stupor,
—ipecacuanha vomiting—jalap and castor oil purging—and arsenic more
readily brings on  gastric inflammation when inserted into  a wound, than
when swallowed.
   It is only on these tissues  or systems, the vascular and  sensorial, that
medicines can act primarily.   They affect the  first, by actual  admixture
with the circulatory fluids.  They  affect the sensorial system by a direct
impulse or impression  upon the extremities of the nerves, which we do
not understand,  and cannot describe.  They are separable, then, fairly into
two classes, as they affect one or the other of these systems.
   Friction,—percussion,—acupuncture—act upon the nerves directly sub-
jected to their influence.   These they irritate, vascular determination  en-
sues, (ubi irritatio ibi fluxus) and thus  prove remedial on the principle of
revulsion.  Acupuncture is maintained, by many theorists, to  owe its effi-
cacy to electric impressions.   Electricity and galvanism seem to exert as
pervasive an influence over living,  as upon inanimate matter, and act with
wonderful force upon all  the solids  and fluids  of the living body.   They
are stimulants of high value and general adaptation.
  The  operation  of each and every medicament, is specifically directed
upon some particular  organ of the  body.   Besides this specific  operation,
which  it  has a tendency to  produce under all  circumstances, there  are
other influences which may be derived from it, depending either upon the
quantity employed, or upon the condition of the recipient.
1st.  The Direct or Specific Operation of Medicines—we see in the emesis
         from tart anlimon  and ipecac—in the  sleep and stupor from
         opium, in the dilatation of the pupil from belladonna,  &c.  We
         may even  point out more minutely, distinctions as to  the modes
         of effect, when their action is upon the same organ, thus ergot
         causes  the uterus to  contract,  affecting its fibrous structure—
         guaiac acts upon the secretory vessels,  causing them to pour out
         their due fluids—cathartics act differently on the bowels.
2d. The Indirect or Consecutive—these may, or. may  not, include 
22             MODUS OPERANDI  OF MEDICINES.

3d.  The Poisonous.                                              ,     _.
   Among the indirect effects  of medicines, those namely, which depend
on dose and condition  of subject, we  may mention the emetic effect of
castor oil, of calomel—the  catharsis from the latter, the diaphoresis from
antimonials.
   There are some medicines of which we know no poisonous effect, pro-
perly speaking, as of bark,  ol: ricini,  calomel, &c; while  others readily
exhibit such an influence as opium,  alcohol, iodine, prussic  acid;  it is one
of the triumphs of our art,  to  be able to regulate the indirect influences
even of these, so as to educe beneficial results.
   In regard to the effects of medicines, one important observation should
be kept in mind by every practitioner.   That certain of the most powerful
and valuable articles  of the materia medica are accumulative in their ope-
ration,  and  thus  become dangerous.   Thus  mercurials shall sometimes,
when administered in repeated doses, seem inactive, exhibiting no obvious
effects until at once we have ptyalism, ulceration of the lining membrane
of the mouth, and caries  of the teeth—the system having become, as it
were,  slowly saturated with it.  Thus it is with arsenic, and thus  also
among others with digitalis.  The first shall be given in  vain, as  it might
appear, for some days, when on a sudden there will  be  pain and  disorder
of stomach, with  great prostration and swelling of the face and eyelids.
   Digitalis will, at times, act neither as diuretic, nor  in any other way, un-
til its  administration  being  persevered in, vertigo comes on, dim vision.
intermittent  pulse, palpitation, and perhaps coma and  convulsions. 
£*-<■
i //art
\j3J'hck^r'±
snraiLAniiroo
PRACTICE.
 
 
NOSOLOGY.
   Some classification and arrangement are essentially necessary to assist
the progress of learners in all sciences.
   It has been found difficult to agree upon the principles on which diseases
shall be arranged.
   I  prefer to all others the Physiological Nosology which distinguishes the
tribes of diseases, according to the seats which they occupy;  the orders
of parts (or systems) which they affect.'the functions which  they dis-
turb or impede.
   I shall treat of them in succession as they affect—
I.    The Circulatory organs and their functions.
II.   The Digestive.
III.   The Respiratory.
IV.   The Sensorial.  This class nearly coincides with the "Neuroses"
         of Cullen, Parr, &c.
V.    The Motory—comprising the diseases of bones, joints, muscles, ten-
         dons, ligaments.
VI.   The Generative.
VII,  The Excretory—comprehending  the  cutaneous  affections, those ot'
         the urinary organs, and the  local diseases of the large intestines. 
PRACTICE  OF  PHYSIC  OR  THERAPEUTICS.
  Before attempting the cure of a disease, it is necessary that we should
carefully distinguish it from every other; the Diagnosis, then, of every case,
must be considered separately in this relation.
   1. The Diseases of  the Circulatory System  are  of paramount import-
ance, and require our earliest attention.   I proceed to treat of those which
are hereafter most frequently  to come  under your notice, in  the following
order.   Fever, Svncope, Angina Pectoris, Hemorrhage.  Hydrops  and
Scrofula.
   It is impossible to enter properly into the consideration of these  topics,
without premising a few remarks on Inflammation, which either  as cause
or  effect, as coincident  or consequence, is so generally combined with the
principal forms of circulatory or vascular disease.   ,.< -,
                 INFLAMMATION.
    1  (■•  t-i-cy''   _;
    h-  seat  maintained  to  be in the Capillary System—the nutrient and
 «; cretory arteries, the vasa va-orum.  Its nature unknown.   Much dispute
 as (o  the question  of increase or diminution  of excitement, and action,  in
 inflammation.  It does  not depend upon, nor consist, in degree of action;
 yet, it would  seem, that there is always, at least in the  first instance, in-
 creased  action.   The smaller vessels like the heart, are endowed with the
 power of expansibility—the capacity  of  active dilatation.   We  cannot
 otherwise account for the  phenomena—for  it is  absurd to suppose  the
 heart  or larger vessels capable  of elective propulsion  or determination of
 blood  to any particular  part of the body.  The minute vessels then expand
 in  the production of inflammation, as  they do in blushing—redness from
 friction and stin.u hints;  but (here is some superadded essential condition, or
 blushing, would be inflammation.
   There are  two conditions or states  of  a  part, which precede or give
 rise to  inflammation.  The most common is Irritation—a  term  which
 implies  lliiiv organic  excitement a-Urn. of the nerves of the part, and has
 been used by some pathologists  as synonimous with inflammation.   The
 second is  Congestion—where (here  has been from whatever cause an
 undue  proportion of the  sanguineous fluid forced  into (he  structure  of
 anv or,rau thus  engorged, or unnaturally  distended—as in  inflammation
 of "the  liver, spleen, and other internal viscera, from  the concussions of
 intermittent  fever, or the shock of cold  applied  to  the surface.   It is
iihiio-t superfluous to remark,  however, that  neither of these is of nc-
r,'v,itv followed by  inflammation.   The  internal  organ may  disgorge 
                    PRACTICE---INFLAMMATION.                27

 itseif and return  to a natural condition; the irritated  part  may  be sooth-
 ed  into tranquillity without any  exhibition of vascular  excitement;  or
 this  may be so temporary and transient, as  not to deserve the name of in-
 flammation.  The redness  from slight friction on the surface, or  from
 acupuncture, is not inflammatory any more than the vascular excitement of
 the whole system from wine  or exercise,  is properly fever.
   All inflammation is in nature morbid, as we know both from the symptoms
 and the results.   Surgeons recognize a healthy inflammation, but the phrase
 is rude and unscientific.  Union of opposite surfaces by  the organization of
 effused lymph or fibrin, is made incidentally useful in surgical operations,
 as for the cure of hydrocele, artificial anus, &c;  but cau no more be  call-
 ed healthy inflammation, than that which mutes the pleura costalis with the
 pleura pulmonalis—indeed they are  absolutely  identical.   Union by the
 first intention, has been attributed to inflammation, but  incorrectly.   The
 vessels of divided surfaces  are placed in  apposition, so that circulation
 goes on,  and among the other functions, restoration  is  effected by the de-
 posit of nutritious matter from the vessels.   A finger or piece of flesh being
 cut off and replaced, sometimes adheres.  But in this case union must pre-
 cede inflammation, or  only one surface can inflame.   Indeed inflammation
 impedes the occurrence of union by  first intention.  It occurs always to a
 certain extent no doubt, but merley as a coincident effect of  the violence
 applied  to a  living body.   Inflammation formerly  attributed to  spasm of
 the  vessels—error loci of part of  the blood, lentor or inspissation of that
 fluid.  It is probable that spasm of the excited vessels does take place; that
 is, that they act more or less irregularly or convulsively when thus irritated.
 Error loci we know  to  exist,  for the  red  globules  are seen in vessels
 which did not previously admit them;  but this  is  an event or consequence
 of inflammation rather than a cause.   There is no proof of lentor or Inspis-
 sation of the blood.   The  circulation in  the  part, so  far as we know, is
 not obstructed notably.
   The general symptoms of inflammation are the same, whether its seat be
 internal or external—Pain, Redness, Swelling, Heat, Throbbing.  The pain
 differs in kind and degree  according to the structure of the part affected,
 its sensibility, and the  general sensibility of the patient.  It is in propor-
 tion to the suddenness and extent of  the changes which take place, being
 of course greater  in acute than chronic cases.   It  results from the excite-
 ment of the vessels of  the nerves, which, by their  dilatation, produce  ten-
 sion and pressure on the nerves.
  The redness and swelling arc  easily accounted  for  by referei.ee to the
 vascular fulness and determination which exist.   The heat  of the pa it. i.j
 somewhat heightened,  as depending on the vascularity of the part, and the
 form and fulness of local circulation.   It never can be higher than the heat
 of the interior of the body,  and is most nolably increased at  the furthest  .■.',
 point from the heart.    Throbbing results from the admission of a. forcible'  ^
 current, impelled by the heart into vessels which were before too sni.d1 <o   '-..
 admit of such impulse.
  The local  effects of inflammation  are modified by the .structure oi  di   &
 part in which it occurs, and  by  the nature of the  cause which has m-ccu-  /
 ced it.  In illustration of the first, wo may refer to what  are call  i die V_a„
 terminations  of inflammation of the Serous tissue—these arc most e  tn-
1M-.;:!•." adhesion and dropsy—sometimes puruhut ■■■i?\\\-'vr.—rarely n'cra- 
28
PRACTICE---INFLAMMATION.
tion   In inflammation of Mucous tissue, we have very commonly purulent
secretions and ulceration—rarely adhesion, &c.   In the Skin erysipelas
and phlegmon-r-in Parenchymatous masses, abscess and  schirrhus.  The
modifications from cause  are  still more  marked and precise.   In certain
predispositions we have arthritis, cancer, &c—each peculiar.   From cer-
tain  morbid agents we have specific modes of  inflammation, as upon the
application of arsenic, tart antimon, lytta,  &c.  Sphacelation seems to be
determined, for the most part, by the intensity, rather than the nature of the
cause.   It may be defined as  a species of disorganization, of which death
is a  necessary consequence.   Disorganizations  are effected (as in scrofu-
lous and schirrhous degeneration) without depriving  the part  of its vita-
lity,  and death may occur without  disorganization.   Sphacelus implies a
union of the two circumstances.
   Inflammation may, or may  not, be attended with the excitement of gen-
eral febrile disorder.  After  wounds  and  injuries,  especially in vitiated
constitutions, and at an interval undetermined and varying, fever is apt to
come on with  shivering  or without it,  the skin  becoming hot  and  dry,
the  pulse  hard, frequent  and quick, the face flushed, and the eyes red,
with headache and perhaps delirium.  This  is  one of the types of Symp-
tomatic  Fever, assuming a Continued form, that is, without intermission or
regular and definite remission; it is closely analogous to,  if not identical
with, the febrile  derangement, connected with the long list of internal in-
flammatory diseases, hence called pyrectic, ae Pleurisy, Gastritis, &c.   In
these latter, the fever supervenes usually with great promptness soon after
the  invasion of the disease.    Hectic, the second of the types ofSymptoma-
tic Fever, is Intermittent,  and attends protracted inflammation both internal
and external.  It shall receive special  notice hereafter.
   In the  general treatment  of inflammation, we refer  to three modes of
remedial management.  1st. By abstraction of excitement, V. S.—Leeches
—Cold—Low Diet—Purgatives—Emetics—Nauseants,  &c.
   It is  under this head chiefly that I  would include the  agency of Opium
as a remedy for inflammation.  The first step in the lighting up  of inflam-
matory disease is, often a mere irritation, which  is capable of being entirely
nubdued  by the  anodyne and soothing  influences  of this most valuable
drug.   In its farther progress too, inflammation is liable to be aggravated
 by pain, which is the result  of morbid excitement of the nerves of a part;
and this can often be allayed  promptly and entirely by opiates.   The state
of sleep which they so admirably induce,  is singularly adapted to promote
the  subsidence of all undue action of  any  of the organs, and especially of
the  hrain, whose  agitation so readily disorders  every  fibre of the system,
and whose restored tranquillity is so often  the harbinger  of general repose.
   From opium, also, we  may obtain by  proper  management of its indirect
 operations, very  great benefit as a diaphoretic, and as a most impressive
stimulant—but these effects are referred to under the following heads:
   2d. Revulsion, as by  V.  S.—Purgatives—Diaphoretics—Stimulants-
 Sinapisms—Epispastics, &c.
   And  3d. By alterative  influence, as  in the mercurial  treatment, snd in
the  substitution of a new and transient form of  inflammation, as  when wo
 apply a blister to  erysipelatous  surfaces, and arsenic to a cancerous ulcer,
a.id stimulants generally to indolent ulcers  and chronic inflammations.   In
strict propriety, perhaps thse are but  modes of revulsive affection. 
PRACTICE--FEVER.
29
FEVER.
      The phenomena of fever, prove the co-existence of two prominent con-
    ditions;
      The coincidence of diminished energy of the. sensorial; with
      Morbid excitement, and increased action of the circulatory systein.
      This combination, in which  it  is difficult to denote the first link, forms
    (he proximate cause of fever.
      It is probable, that the earliest disturbance of the function  occurs in the
    extreme vessels, the nutrient, and secretory,  and excretory, denominated the
    capillary system.
      Fevers, properly divided into Idiopathic, and Symptomatic.   The distinc-
    tion intended, is generally recognized in marked cases, as when we refer
    on the one hand to fever from local injury, succeeded  by inflammation, and
    on the other, to the regular  recurrence of  an habitual quartan.  Certain
    intermediate instances are often dwelt on, in which the peculiarities of these
    classes are much softened down, as in pleurisy, dysentery, &c.  The best
..,   definition therefore, which can be  offered, is that which connects Sympto-
    matic fever essentially, with some obvious, regular, and early local inflam-
    mation—Idiopathic fevers, being such as do not  shew distinctly any such
    connection.  The latter head will then comprise Intermittents, with the
    exception of Hectic, Remittents generally, and among the Continued fevers
    Typhus, Catarrhal Fever and Pneumonia Typhoides.  Examples of the true
    Symptomatic Fever are given in Pleuritis, Hepatitis,  Phrenitis, Gastritis,
    Enteritis, the Exanthemata, &c, with the Inflammatory Fever which occurs
    immediately, after a severe  injury, and  the Irritative or Hectic, which
    comes on later.  Most of the above are however arranged  in  preference
    according to the locality of their characteristic phenomena as Phrenitis, &c.
    and the Exanthemata.
      It has been much disputed, whether the  first step in  the formation of fever
    is the production of debility, or of irritation.  The true nature of incipient
    febrile action, is unknown.   A majority of the remote causes of  fever, it is
    true,  are of a stimulant, or irritating, or exciting quality—but not all—Ty-
    phus, the "famine  fever" of Ireland, is the result of agents of opposite ten-
    dency, and large losses of blood are very apt to be followed by fever.
      Cullen's definition of fever examined.  Fevers do not always begin with
    a cold stage.   When they have so commenced the animal heat of the surface
    is not always augmented.  The frequency of the pulse is sometimes dimin-
    ished.
/     Nothing is more strongly characteristic of fever than the general dimin-
    ution, and depravation of the secretions of all the surfaces and glands, hence
    the thirst, the clammy mouth, furred tongue, nauseated stomach, constipa-
    ted bowels, harsh dry skin, paucity of urine which is high colored, &c.
      The ancient notion of the  tendency of Fever to  run a certain course and
    sub.side spontaneously, objected to—if.^ curability maintained, and  the per. 
30
P R A C TIC E---FE V E R.
 turbing system of treatment zealously vindicated.   Fever occasionally cut
 short by venesection, emetics, cathartics, cold bath, mercurials, &c.
   The doctrine of Critical days, disputed.   Crisis defined as a sudden and
 notable change occurring spontaneously in the  course of fever, and exhib-
 iting a remarkable influence on its character and termination.   The change
 may be  either favorable  or otherwise.   The  question is,  whether these
 changes are to be expected on certain calculable days.  These days if we
 collate the writings of the principal and most zealous supporters of the doc-
 trine, are the 3d,  4th, 5th, 6th, 7th, 9th, 11th, 13th, 1.4th, 15th, 17th, 20th.
 and 21st, thirteen  days in twenty one; the non-critical days are the 8th, 10th,
 12th, 16th,  18th, 19th, six in number.   We cannot wonder  then, if, as is
 asserted, a majority of crises do occur on the so called critical days.   The
 weight of authority is pretty equally divided on this point.   The regular ob-
 servance of the types of fevers, all which, refer originally to the intermittent
 form, however obscurely, I think has been the cause of the belief in critical
 days.
   The diurnal and septenary revolutions have been spoken of;  to the com-
 bined influence of. these, I attribute  the types of fever.   Continued fevers
 usually have  reference to the quotidianjntermittent.—Remittents to the ter-
 tian with  its modifications double and triple, and perhaps sometimes to the
 quartan.—Remittents when they become obscurely remittent by protraction,
 running, as the phrase is, into a continued type,  exhibit in a rather indistinct
 way this reference to intermittent type, and these imperfectly marked  refer-
ences have been called crises.
   The Remote Causes of  Fever shall be enumerated under each  specific
 head.
   The Effects of fever, the local derangements developed during its progress,
and displayed in post-mortem examinations, vary both with  predisposition
and exciting causes.
   The Brain in its substance  and upon the membranes which envelope it
shews vascular engorgement, and sometimes the  results of inflammation.
   The Mucous membrane  of the Stomach and Intestines, suffers various
lesions from  similar  inflammatory determination, and other  modes of  de-
rangment.
   The Pleura and Peritoneum arc also attacked—the Lungs and the mu-
cous lining of the Trachea.  The Liver, especially in warm climates, is often
notably altered in appearances, being increased in size, in weight, A:c. &c.
   These local affections are not necessarily inflammatory, they are  conges-
tive, perhaps as often.
   In Crampton's account of a Dublin epidemic, the following estimate of the
relative proportion in which the organs were affected, is given.  Out of 755
cases, 76 were of the abdominal viscera, 129 of  the chest, 550 of the head.
Among us, owing to influences of climate and determinations thereby o-iven,
the proportions would be reversed.   Here the Abdominal viscera are chief-
ly affected (the Stomach and Liver.)  next the Head, lastly the Chest.  I
believe the former never escapo derangement in the warm months.
   Fcvr.us divided into Intermittent, Remittent, and Continued.   These types
are fairly distinguishable, although there are cases in which the distinctive
inarks are very slight.
   An Intermittent presents repeated paroxysms of fever,  with intervals V-
 iween  of absence  or apyrexia. 
PRACTICE—FEVER.
31
  A Remittent is characterized by notable  and regular exacerbations, and
diminutions of febrile excitement, there being no complete apyrexia, but an
observable approach to that state.
  A Continued fever is so denominated when there is no notable or prom-
inent difference at regular periods in the degree of febrile intensity.   The
influence of diurnal revolution is however, generally observable, there being
slight morning remissions, and evening exacerbations.
//  /- fy*"-  ^^ *>+**"*' ■ 
32             PRACTICE--OF INTERMITTENS.
OF  LNTERMITTENTS.
   lntermittents assume various types according to the periods they occupy.
They are divided into three stages—the  cold, the hot, and  the  sweating.
The whole time from the commencement of the cold stage  of one parox-
ysm, to the commencement of another, including the interval of apyrexia, is
technically styled the paroxysm of an intermittent.
   1.   The Quotidian occupies 24 hours in this way, returning daily.
   2.   The Tertian           4* returning every second day.
   3.   The Quartan          72 returning every third day.
   Each of these has its usual hour of access, and its relative duration and
violence of stages.   The Quotidian comes on in the morning, has  the short-
est cold stage, but the longest exacerbation or febrile excitement, continuing
about 18 hours; interval  about six.
   The Tertian comes on, about, or  a  little before noon, duration about 12
hours; its interval is long.
   The Quartan attacks in the afternoon, with the longest cold stage has the
shortest duration; continues seldom more than  nine hours.
   These are the original types, which are variously complicated; we have
the double tertian, the attacks on alternate days corresponding  in time of
access, violence, duration, &c.
   The triple  tertian, two paroxysms on one day, and one on the  alternate.
   The double quartan and the triple quartan are also mentioned.
   The Paroxysm of an  intermittent described.   The cold stage marked by
the following symptoms—languor, muscular feebleness, yawrning, stretch-
ing, and sighing, paleness of the face, with lividity of the lips and ends of
the fingers, shrunken countenance with cutis anserina, a sense of  chilliness
increasing to violent trembling and shiverings of the whole body, uneasiness
at stomach, amounting  to nausea sometimes, and vomiting.  Pain in the
head, and over the back and limbs, pulse small,  and feeble, and quick.
   Hot stage.   The chills alternate with flushes of heat, gradually pervading
the whole surface which is glowing and dry,  pains in the head and limbs
increase with turgidness and  redness of the face and eyes, vomiting goes on,
and bilious matter is thrown up mixed with mucus and other contents of the
stomach, there is thirst, and the pulse has become frequent, full and hard.
   Sweating stage.   After some  time a moisture is felt upon the  forehead,
breast, and arms, which  progressively extends over the whole body, and the
sweat flowing freely, the symptoms above enumerated go off leaving the
patient weak.
   Masked or  disguised intermittents—present  instead of the above regular
succession of phenomena, some single symptom of great intensity, occasion-
ed by morbid determination to, or affection of some part, as of the eve, the
stomach, the  brain, &c.   We distinguish  these by their  periodical recur-
rence and regular abatement, and the previous exposure of (he  subject to
(he causes of intermittents. 
PRACTICE---OF INTERMITTENTS.
33
    (Jauses of Intermittents.  Malaria the principal.  May arise from alter-
 nations of temperature, moist clothing, fatigue, &c.
    General prognosis.   Favourable,  allowance being made for their obsti-
 nate tendency to recur, the season of the year—vernal being more easily
 curable than autumnal  attacks,—and climate.  In hot and  moist  coun-
 tries, as on the coast of Africa, intermittents  put on often a malignant and
 fatal character.
   And in very damp districts of more northern latitudes, as in Holland and
 England,  (Lincolnshire) though less immediately destructive,  they are
 tenacious and sometimes fatal.
   Special prognosis.  Favourable.   Mildness of symptoms, postponement
 of time of access,  completeness of apyrexia.   Unfavourable.  Extraor-
 dinary violence, anticipation of period of access, unpleasant  feeling and
 uneasmess during apyrexia, coma in cold stage,  with difficult breathing,
 delirium in hot  stage, great exhaustion while the patient sweats.
   Effects of Intermittents.   Patients sometimes die in the cold stage, from
 congestive  determination to vital organs, the brain and lungs; they may
 sink exhausted, (though this is rare) at the close of the sweating stage, or
 when the  vomiting has been  severe.  Enlargements of the  liver  and
 spleen—are ihe most  common  consequences of the repetition of parox-
 ysms of intermittents;  these may be either indolent or inflammatory;  drop-
 sies, jaundice, hepatitis, dysentery may also be mentioned here.
   Treatment of Intermittents.   During the cold stage, external heat to the
 extremities and general surface, sinapisms, opium highly extolled, the
 tincture preferable, camphor may be  combined with it.   If the stomach be
 oppressed,  a  quick  emetic.  The tourniquet has been applied to the limbs
 by Kellie.   The lancet has been used of late  freely  by Mcintosh and oth-
 ers.  Its effects doubtful, if not dangerous.
   During  the hot stage—if special  determination to the head in  robust
 subjects, the lancet may be used,—cold applications,—water pound on the
 head; and  in proper subjects, the cold bath employed in this  si ^e to ad-
 vantage; a cathartic may  be  given, diaphoretics, assisted with  cooling
 drinks; opium administered by Lind, of great utility in feeble,  old, habi-
 tual cases.
   In Intermittents of malignant character, the symptoms of  overwhelming
 congestion and  of typhoid prostration,  must be met  by a resort to stimu-
 lants of the highest power.   Sinapisms and other modes  of external irri-
 tation, brandy, ether, and laudanum internally, in no  timid doses.   The
 stimulating diaphoretics, camphor and the vol alkali, with hot wine whey,
 and  stimulating enemata  are also of  use here.
   During the intermission.  Cinchona is our most important remedy.   The
 only objection to its employment,  consists in the inflammatory determina-
 tion kept up sometimes to some organ as the liver, spleen, stomach, lungs,
 brain.   This being subdued, it should be freely resorted to.  It is given in
 substance, in infusion, tincture and extract.  The sulph. of quinine extrac-
 ted from it, is a medicine of inestimable value, on account of the concen-
 tration of valuable tonic powers; dose 1 to 3  grains every two  or three
 hours.  Larger  quantities excite the stomach and determine to the head.
   Pi peri ne—shews its best influence in combination with quinine.   It  is
too much a stimulant to be used throughout the apyrexia. but  may be added 
34             PRACTICE—OF INTERMITTENTS.

with much advantage  to the dose of quinine, just before the paroxysm is
expected.  It forms thus a very useful combination.
   Serpentaria—not valuable alone, but  useful in combination with cin-
chona.
   Sulphur—second only to bark  in the cure of intermittents, and particu-
larly serviceable, as it may be given when bark ought  not, in cases of im-
perfect apyrexia.  Is  well applied in all  masked intermittents—when min-
gled with cinchona, forms an impressive  combination.
   The carbonate and prussiate of iron, and the sulph. of zinc,—are highly
recommended.
   Arsenic—a. very powerful remedy; it should be cautiously administered;
—best adapted  to the most  obstinate chronic habitual forms of intermit-
tent.
   The above means failing,  the patient should be subjected to a mild mer-
curial treatment, or sent to take a long journey, or a sea voyage. 
PRACTICE--OP REMITTENTS.
35
OF  REMITTENTS
                  BILIOUS REMITTENT FEVER.

   Belongs especially to warm climates; produced almost  exclusively  by
 malaria, aided by the  occasional or exciting causes formerly enumerated,
 heat and alternations of temperature, moisture, &c.  Strangers from cold
 countries, or  from upland districts, are predisposed  to  its more  violent
 forms, and should carefully avoid the adjuvant agencies  which bring it on or
 aggravate  it—should live temperately, but not  abstemiously—shun ex-
 tremes of temperature, dampness, dews, night air,  &c.   Blood-letting, pur-
 gatives and mercurials objected  to as prophylactics.  They predispose
 by reducing the system and rendering it susceptible.
   Symptoms.  Commences sometimes with, and often without a rigor  or
 chill; then  follow languor and  weariness—gastric uneasiness—pains  in
 the head, back  and  limbs—skin  becomes  hot and dry—pulse  full and
 bounding, and abrupt  and frequent—restlessness—vomiting—thirst—
 tongue at first white and  lightly  coated; soon covered with a thick yel-
 low or brown fur—its edges red and  indented as if swollen and prest
 against the  teeth.  Bowels constipated—stools, when obtained,  greenish
 and acrid.   The exacerbation continues about 12  to 18 hours.
   Remission or abatement of symptoms, then takes place in a greater  or
 less degree.   The return  of exacerbation refers  to the tertian period  of
 access, at, or a little before noon—observing the double tertian type in the
 correspondence of alternate days.   Cases not unfrequently occur bearing
 analogy to the Triple Tertian, when we have on one day two exacerbations
 and on the next but one.  In the exacerbation, if the disease  is not
 checked, the vomiting becomes more frequent—there is heat at the epigas-
 trium, and pain on pressure—the headache is intolerable—the eyes  cannot
 bear the light.  The tongue is dark brown, black along its central line—
 dries, is chapped or cracked.   The bowels are costive, or the stools thin
 and watery.   Respiration is more  and more embarrassed with sighing—
 restlessness—the  pulse sinks,  becoming  small  and  feeble.   There  is
 great prostration,  with  muscular twitchings; the  fatal termination occurs
 in from 7 to 13 days—average about 9.
   Typhoid state or stage.   After many repeated exacerbations, the patient
 sinks  sometimes into  a  condition thus designated, in which the symptoms
 resemble those of typhus.   It more frequently happens  among old resi-
 dents, the termination taking place more promptly, (whether favourably or
 otherwise) in youth and strangers.  The disease  may be, in this modified
 form, prolonged to 30 and 35 days; average  15 or 20.
   Malignant Remittent.  The skin cold and clammy—countenance pale
 and livid and shrunk, pulse  frequent and fluttering—low delirium or slu-
 por, syncope—sometimes painful local affections, of the head, stomach or
bowels.  Fatal rapidity in many cases, one  or two exacerbations destroy-
ing the patient. 
3(>               .PRACTICE—OF REMITTENTS.

  General  prognosis in Bilious Remittent.   Favourable.   Proportion or
deaths throughout the south and west, as small as in any part of the world
In our own citv, not more than one in 30 or 40, perhaps even less.
  Individual prognosis.   Favourable when the remissions are distinct and
prolonged, with tranquil sleep and sweating; if the bowels are moved easily
and the evacuations assume foecal appearance and quality—if the stomach
become quieter, and the tongue cleaner and less red.
  Unfavourable when the remission is imperfect and short—when the sto-
mach is specially  irritable—when there is much wandering of mind or deli-
rium; inordinate  frequency  of  pulse is a bad symptom—recoveries  are
rare when  it transcends 130 or 140;  so are great tenderness of epigas-
trium or tympanitic swelling, with or without vomiting, obstinacy of intes-
tines, laborious breathing, coma, subsultus, fatuity, &c.
  There is considerable liability to  relapse.   This is  to  be  dreaded when
digestion is weak,  tongue  furred or red, bowels irregular; occurs  more
frequently on 7th or 14th day.
  Effects of remittents.  Run sometimes into intermittents.   Give rise to
jaundice, dyspepsia—pulmonary complaints, when there is predisposition—
enlargements of liver and spleen, hepatitis, splenitis, dropsies.
  Necrotomy.   The vessels of the brain and its  membranes  engorged,
those of the gastro enteric  mucous membrane, in similar condition.  The
spleen and liver enlarged, discoloured, full of dark blood, heavy, indurated
sometimes, at others softened  and brittle.  The  bile discoloured and viti-
ated, tenacious, floculent, granulated.
   Treatment.   The first indication both in point of importance and time.
is the reduction of the force of morbid excitement.  This may be effected
by the following remedies:
   Venisection.    Not  a general remedy.  Adapted to cases of robust, ple-
thoric strangers;  to cases,  also, in  which  at the invasion,  or during  the
early stages of the attack, the local determinations are specially violent
and painful, as when there is delirium or mania, or coma, or great epigas-
tric  tenderness, &c.   When resorted to, should  be employed freely,  the
blood permitted to flow until the pulse yields.  And in precisely the same
cases, local blood-letting by cups and leeches, will be found useful after
venisection.
   Cold bath.  May be considered a general remedy.  Contra indicated by
feebleness from age, or other circumstances, by a moist skin, by chilliness.
Should not be repeated if it produces a continued sense of coolness.   Affu-
sion preferable—next immersion.  Its value,  as a remedy, cannot be exag-
gerated.
  Emetics—not often called for.  If the stomach be oppressed, with im-
perfect vomiting, may  be useful both by cleansing it, and by determinino- to
the skin and bowels.  Should  be abstained from if there is pain at the epi-
gastrium, increased on pressure. The antimonials are in general preferred.
   Cathartics.   Absolutely  necessary  in the treatment of Fever.  Great
care must  be  taken to choose the  least irritating and most efficient.   I
would avoid the combination so generally used in the southern country in
domestic  practice  and  on plantations, of drastic Purgatives with harsh
Emetics.   I would select such articles as cause  least nausea or gripin^.
Calomel, Pulv. Rhoei, and the Epsom Salt, may be given so  combined and
alternated, as to produce all the good effects  which we can hope for, from 
PRACTICE---OF REMITTENTS.
37
the evacuation of the Bowels, and the  disgorgement of the Liver,  and the
abdominal viscera; and may be prescribed in such doses, and at such inter-
vals, as to keep up a permanent and highly salutary determination to the
Intestinal Canal.   But it is not  necessary  to persevere in what is termed
Active Purging; and  if the Bowels yield  readily, we should discontinue
the exhibition of Cathartics, and resort to such other  remedies as may be
indicated.   Much harm may be  done by urging the use of Purgatives too
far, especially if there be much nausea and vomiting, with great epigastric
tenderness, and the stools are frequent  and  small and mucous, and attended
with pain, or griping, or faintness, or vomiting.   Yet,  on the other hand, it
is an error  more mischievous, to neglect entirely this very valuable class
of Medicines, and to leave the patient  to suffer all the  unmitigated evils of
abdominal  congestion and engorgement, and the irritation  of  accumulated
morbid secretions in the Alvine Canal.
   The Mucous Intestinal surface, is one to which revulsive determination
may be excited very safely, and to the great relief of  more important and
delicate organs.  Its secretions may be increased to such  an  amount  too,
without any injurious consequences, as to form a very  impressive means of
depletion.
   Diaphoretics may  be administered in  union or alternately with your ca-
thartics.  The  saline and sedative are at first to be chosen, as the Nitrat.
Potass, with Infus. R. Serp. the  Acet.  or Citrat. Potass, the Acet. Ammon.
and Nitrous ^Ether.  The use of these means should be continued through
the remission, and so timed as to produce their fullest effect just at the pe-
riod of exacerbation—the  room being  kept dark, cool,  silent, and  well
ventilated, and cool drinks and ice  allowed.   The vapour bath a good adju-
vant to your diaphoretics.
   If the exacerbation be often repeated, and your patient's strength seem
about  to yield,  resort to the stimulating diaphoretics—Camphor,  the Vol
Alkali, Tinct. Opii Camph. with Infus. R. Serp. et Cinchonse.  His drinks
may be stimulating and nutritious, as arrow root with wine, wine whey, &c.
   Epispastics  should now be used as  well for their stimulant, as their
revulsive influences.
   When stimulants become necessary, such  must be chosen as shall  least
irritate the stomach.  Of these capsicum and Spts. Terebinth are ascertained
to be the most generally admissible. Under such circumstances the Tinct.
Cantharid.  may be occasionally used  with advantage. By  giving rise to
inflammatory irritation of the urinary  organs, it acts both as revulsive and
stimulant.
   The irritability of stomach in bilious remittent, is one of the most  em-
barrassing symptoms.  If it depends on  irritating contents, an emetic, or a
repetition of emetics will be called for; but this is very rarely necessary.
If connected with inflammatory affection of the stomach as shewn by heat
there, and pain increased on pressure and motion, resort must be had at
once to the mercurial treatment, our best hope of relief—in the meanwhile
applying an epispastic without delay.   If slight and merely distressing by
preventing the exhibition and effect of purgatives, desist awhile, apply a sin-
apism, employ purgative enamata.  Let the patient drink cold soda water,
finally give  opium either alone or with calomel in pill.   In such circumstan.
ces, various expedients have succeeded, a capsicum pill, a laudanum glyster,
the spiritus mindereri, lime water, &c. 
38
PRACTICE---OF  REMITTENTS.
   Constipation is another troublesome symptom.  If it presents itself while
the pulse is full and hard, and the strength good—bleed freely and to relax-
ation.   Dash cold water on the legs and abdomen, give purgative glysters,
administer large quantities of fluids in this way, by DeHaen's or other pro-
per apparatus.   Do not hope to overcome it by increasing the dose of ca-
thartics—you may thus destroy the stomach.   Vary them—using the mild-
est and least offensive.
   Hiccup in the latter stages is very harassing.   I have seen it continue 3,
5 and 9 days, and yet the patient recover; combat it by musk,  opium, and
the volatile oils.
   The mercurial treatment—must be resorted to, if the attack be malignant
or specially violent; if the patient be feeble  or cachectic, or in bad health
previously  to a  severe onset; if the disorders of the place or season be unfa-
vourable—in Sydenham's language, if the epidemic constitution of the air
be bad; if the case be unusually protracted,  or runs into the typhoid state.
The dose should be proportioned in frequency and amount to the exigency of
circumstances from 2 to 10 grains every 2 or 3 hours, until the symptoms
of incipient ptyalism shew themselves.   Calomel thus employed does not
interfere with any of the other remedies indicated.  The objections to this
mode of treatment discussed  and answered.   Its  occasional inefiicacy ac-
knowledged; its evils of use, as well as of abuse described.  The question
is, however, as to its efficiency, and the necessity  of resorting to it.  That
it implies  some suffering, and perhaps some risk, will not  be  denied, but
these  should be compared or contrasted with the probability of the fatal
termination which it so often averts.  Confessed to be attended  with much
uncertainty in the case of young children; advised therefore in such cases,
unless otherwise obviously hopeless, its administration be abstained from.
   Country Fever.  In  this city we meet often with a very insidious and dan-
gerous modification of bilious remittent, originating in transient exposure  to
the intensely concentrated malaria of our low country, as by sleeping a night
or more upon a plantation after the frosts of spring have ceased.   Observa-
tion shews that such a case is attended with peculiar hazard, and the return
to our city atmosphere is universally believed to endow it with special ma-
lignity.  The  progress of the  case  is irregular, the remissions uncertain
both in degree, time of occurrence and duration.  The type exceedingly
complicated, obscure  and confused.  A  like aggravation of the  endemic
Remittents of the far west, is said to result from similar removal to the
healthy uplands, from low miasmatic spots, during the Latent period, and
before the  febrile influences  of malaria have developed themselves in the
system.
   The prognosis—unfavorable—proportional mortality very great.
   Safest to treat such cases, however mildly they may commence  as of the
worst kind.  My usual resort is to the mercurial treatment, eagerly employ-
ing the first opportunity to give the bark, either in infusion, "or the sulph.
quinine.   I rarely delay its exhibition beyond the very first remission after
the stage of excitement is past.
   It has been mentioned, that our remittent often runs into a typhoid stage.
It is sometimes from the very beginning of a typhoid  character- these are
called congestive cases, and  have been described as "malignant."   In the
first stage of such attacks, the hot bath (110° to 120° Fahrenheit) should  be
employed,  and  synapisms applied extensively, the bowels moved and exci- 
PRACTICE—OF  REMITTENTS.
39
ted by stimulating enemata; and the stimulating diaphoretics, either combin-
ed or alternated with calomel in full doses.  In some instances of this na-
ture  the most energetic and persevering use of stimulants is demanded.
   During convalescence attention is necessary to prevent  relapse  or recur-
rence of fever.   The bowels must be kept soluble, though active purging
is not admissible.   Of tonics—the  sulph.  quinine, the chalybeate prepa-
rations, and the elixir vitriol are preferable.
   The exercises of gestation at first in a carriage or boat, afterwards on
horseback, are, however, the best tonics.   The diet must be carefully reg-
ulated as to quantity; its quality may be determined by  reference  to the pa-
tient's habits of living.
   A slow or chronic irritative fever continuing to harrass the patient, evin-
ces  the existence of some visceral obstruction or inflammation of obscure
character.  The blue pill in small dose nightly,  combined with  Dover's
powder or some other preparation of Opium in such quantity as to produce
a gently anodyne effect will probably give relief.  In  the meantime the
Diet should be very light, and all prudent avoidance of excess or exposure
enjoined.
   The mercurial sore mouth may be washed  with some astringent gargle,
 as the sulph. zinci, acet. plumbi, or alum, theJmineral  acids, infus. cincho-
 nae.  After all the means proposed however, there is much need of patience
 on the  part of the  sufferer, as  it is slow  of subsidence under any mode of
 management. 
40               PRACTICE--OF  REMITTENTS.
                  REMITTENT OF CHILDREN.

  Lmaxtile Remittent—olim Worm Fever.  Attacks between the third
and twelfth year.   Begins with irregularity of appetite, furred tongue, often-
sive  breath—the nights are restless and wakeful—the skin being then hot
and dry, with much thirst and head ache, the pulse frequent and jerking;—
the  child  starts frequently in its sleep, and grinds the teeth; the bowels are
costive, or irregular, with loose acrid stools.  As the disease progresses the
abdominal disorder becomes more and more  prominent, the belly is hard
and tumid, the face and feet are puffed and oedematous—there is loss of
strength—a light delirium is present, with screaming at intervals, or there
are stupor and coma; convulsions supervene  and death soon follows.
  The disease is ranked among the remittents  on account of the distinctness
of abatement of febrile symptoms, alternating with obvious exacerbations.
The period of remission is not regular.  The exacerbation comes on some-
times about noon, but most usually at night, its  general duration is from 9 to
12 hours.
  Causes.—Infantile Remittent may arise from any derangement of the
digestive system, at the age above specified—costiveness allowed to become
habitual—the use of unripe or rotten fruit—unwholesome diet generally—
want of cleanliness of person, or of ventilation, especially in the sleeping
room.   It is sometimes produced by the irritation of Worms,—Lumbrici,—
present in undue number in the intestines.
  Prognosis—generally favorable.  Signs of danger are such symptoms as
betoken special derangement of the sensorial  function,  great restlessness,
delirium, coma, subsultus  tendinum, convulsions, strabismus, dyspnoea.
  Treatment.—Our principal  remedy is the purgative,  which must be ad-
ministered freely.  Calomel is necessary, combined best with castor oil or
rhubarb.  The neutral salts may not be trusted to alone.
  The tepid bath is highly useful in general—sinapisms if there is much
local determination—cold affusion, if the head is affected, upon that part.
Anodyne, mucilaginous enemata, if the bowels be loose and irritable.
  If Worms are  ascertained to be present,  combine  some  antlielmintic
with the cathartic  means—spigelia  (the efficacy of which is not however
confined to its vermifuge property) melia azedarac, turpentine and camphor.
The  infusion R. Serp. etvnchon, with some alkali, should be given as soon
as an intermission of fever occurs, or even in good and distinct remissions. 
PRACTICE--CONTINUED FEVERS.
CONTINUED  FEVERS.
41
YELLOW FEVER.
   Its nature, history, and type much disputed.   It is a distinct form of Con-
 tinued fever—not to be confounded with typhus on the one hand, nor with
 bilious remittent on the other.   It is an endemic of the region we inhabit.     /   A
 It consists  specifically of a single paroxysm,  which is never  repeated, l4fv(J&//A
 long or short.
   The cause of yellow fever is peculiar.   In our climate it is not conta-
gious,—neither absolutely,—nor under any contingences.
   For its production the following conditions are demanded:
   1st. Heat.   Some have asserted  with precision, that it will not pre-
vail when the temperature is below 80° Fahrenheit; but this is not posi-
tively made out.
   2d. Moisture.  It certainly is most apt to arise in wet summers, though
to this rule  also there  are exceptions.  When it commenced among us in
1828, the season had been unprecedentedly dry.
   3d. Malaria.   It  is met with only  in malaria situations.  But malaria
alone, or  merely aided  by heat  and moisture, is not capable of generating
it, or it would reign annually over  our lower and middle country,  wher/Ml_^
bilious remittents abound.
   4th. A fourth condition is then essential to its generation; this consists
in the peculiar  circumstances of a city atmosphere,—the state depending
upon a crowding together of human habitations.  Yellow Fever is the dis-
ease of cities and towns, not of villages and country places.   In the  appa-
rent exceptions of its prevalence in ships at sea, and in marine and other
hospitals  in uninhabited places, as at Onrust and  Edam, we still  have all
the conditions above specified.
   The nature of this last essential cause is unknown.  Its mode of action
is probably twofold—both upon the  bodies  subjected to its influence,  in
which it  creates predisposition, and  also  may give developement to the
attack; and upon  the air with  which it may  be mixed, contaminating it,
and  assimilating it to  its own impure  poisonous state.  Yellow Fever
almost always commences at some foul wharf or ship, or in some ill venti-
lated lane or alley—whence, as a centre, it spreads in all directions.
   In the hot climates in which it occurs, the natives of cities subject to its
invasion, enjoy  the privilege of exemption  from its attack.  In the West-
Indies and New-Orleans,  this immunity is perfect;  in Charleston, nearly
so.  In colder climates and  northern  cities, the case is far otherwise;  all
are alike and equally liable to it.  The  following  suggestion  is offered  to
explain  this circumstance.  The influences of climatic heat and  cold are
opposed,  or contrasted in their effect  on the human constitution.  The
Southerner retains from summer to summer the habitudes generated by the
agencies of heat, as his winters are neither intense or permanent enough
                    0 
42             PRACTICE--CONTINUED FEVERS.

to alter these habitudes.  The Northern man, on the other hand is conti-
nually undergoing the  alternate affections ^j^^^n^
though shorter, being  as hot  as they are m  low latitudes, ana

"reS-y o*er eoderaic for, of Fever, „~£—j~
 tends  to destroy the predisposition  of a stranger to Yellow fever.
 predispo^on^, however, gradually lost by long  residence and complete

 ^Ne^roeT'are rather less liable to it than whites,-they may however,
 be attacked if born in the interior and removed to town.   No African is
 known to have been seized with  it.                     „
    The Prophylaxis consists  in the careful avoidance of all  ordinary excit-
 ins causes.  Temperance—but not abstemiousness recommended.  Low
 diet V. S., Cathartics and Mercurials, so  far from being serviceable, are
 dangerous  and  injurious means.  The heat  of the sun by day, and the
 damp dews of evening and night must be shunned.
    History  and Symptoms.   Yellow Fever presents itself under two modifi-
  cations which depend probably in great measure  upon the  state of system
  of the subject attacked, but partly perhaps also upon the intensity ot the
  causes applied.  The modifications are familiarly referred to in the phra-
  ses Inflammatory and Congestive,  which  are fairly enough characteristic
  of the distinctions between  the  two  in appearance, symptoms,  progress,
  and necessary treatment.
     Of the  inflammatory form.  The paroxysm may, or may not, commence
  with chilliness, to which soon succeed\heat and  dryness of skin,  with gas-
  trie  uneasiness and  pains of head, back and limbs, rapidly becoming in-
  tense,—anxiety,—restlessness,—flushed, turgid face—red  and watery eye,
  its motions painful.
   Head often  attacked severely; patient being  maniacal, or  delirious, and
            screaming with sharp pangs,—confusion of thought no uncom-
            mon symptom from the very first.
   Stomach—irritable with frequent  vomiting, w hich occasions pain—there is
            heat and burning there, with a feeling of w eight and hardness—
            and pressure on the epigastrium cannot be borne.
   Respiration usually hurried and embarrased, sometimes slow  and laboured,
            —sighing and oppression at precordia.
   Skin__pungently hot and harsh, soon becomes yellow or  of  an  orange or
            bronze hue.
   pulse__not to be trusted.   In  the worst  cases little altered; in milder at-
            tacks, full, hard, jerking and frequent.
    Tongue__at first soft and  swoln and indented  by the teeth—edges fiery
            red—centre furred and brown.
    Thirst__water is urgently desired as  much for the coolness it  imparts to
            the burning stomach, as for the relief it affords to thirst.
    Bowels—usually torpid and moved with difficulty.  I  have seen  a case
            begin with diarrhoea.
    Countenance—marked, and expressive  of anxiety, distress, gloom, impa-
             tience, sadness,  wildness,  terror.
       Such is a description of the first stage—following the  description given
    by writers, who recognize a division into three  obvious stadia.
       This  stadium comprises the whole o£ the febrile paroxysm  or  excite- 
                PRACTICE—CONTINUED  FEVERS.              43

ment—its duration from 4, to 60 or 70 hours; the average  is probably 36
to 40.
  Second stage—by many  considered, but improperly, as  a state of re-
mission.   "It  is a stadium without any fever."  (Lining.)  It commences
with a gradual abatement of the preceding symptoms.  Head is somewhat
relieved—pains  in back and limbs disappear perhaps.  Skin  becomes
cooler, perhaps moist and  soft.  Pulse  nearly natural,  but  increases in
frequency and grows weaker.  Respiration easier.   Pain and burning of
stomach lessened—vomiting attended  with less effort.   Countenance less
turgid.  Eye less red, and assuming a yellow tinge.
  The patient is less anxious and distressed,  and begins to indulge hopes
of recovery.   This stadium lasts  but  a  few hours, never more than from
24 to 36.
   The third stage—is distinguished from  the  second, by no marked
line.   The symptoms of prostration are gradually shaded more and more
deeply, the pulse sinks, is quick, unequal and depressed.  Skin takes on a
mahogany hue,  which disappears on pressure, and returns slowly.  The
Tongue sometimes  soft,  swoln, moist, indented, brown on the top, with a
dark streak along the central line, often clean, and of a deep  fiery red, as
also the whole mouth and lips—perhaps dry and cracked.   Stomach ex-
cessively irritable, its contents ejected, without the effort to vomit, either
by  sudden contraction or hiccup.  The  black vomit comes on.  The".
bowels yield with black,  acrid,  and  offensive  discharges,  the surface is
cold and clammy, there is low muttering.   Hemorrhage often bursts  from
every outlet, and death comes to the relief of the sufferer.                '
  In the Congestive form, the tokens of open, inflammatory excitement
seem wanting,  the system  bei ig prostrated before the excessive force of
the morbid cause.
If the  head be the centre of deterrni nation,  there is lethargy, stupor, coma,
         convulsions.
If the  stomach, th^ sy mp, >in3 resemble those of poisoning with arsenic or
         other corrosive  poison; there is no regularity of progress.
The lungs occasionally bear the onus of the attack,  livid face,  difficult
         breathing, suffocation.  -./'-.■             ./
  These cases are all marked, i.i a peculiar degree, by the mahogany  or
bronze hue of the ski ),occasi >ied, I believe, by sluggish or suspended ac-
tion  of the capillaries, perhaps by actual paralysis of this system of ves-
sels.   It is a most gloomy symptom.
  Under these circumstances, the  patient usually utters little  or  no com-
plaint—there may be no vomiting—the epigastrium bears  pressure—the
bowels are costive—the tongue  dark,  red, smooth and dry—the counte-
nance  stolid and fatuous,  the skin insensible to irritation,—or, if inflamed,
becoming gangrenous and sphacelated.
  Anomalous cases, forming pathological curiosities, occur in this terrible
disease.  I have seen  a patient walking about to the very moment of his
death,  carrving with  him  a vessel to receive the blnck  vomit which he 
44
PRACTICE---CONTINUED  FEVERS.
threw up frequently  and copiously.  Others die complaining  of a single
symptom, as headache and the like.
  The duration  of Yellow Fever varies much.  It  may terminate in a
few hours.  It may  run  on into a typhous condition, and last from 20 to
25 days.  The majority of deaths occur here on the 5th and 6th days.
  Convalescence tedious, and  apt to  be harrassed  by  abscesses  on  the
surface.  Relapses never occur.  Second attacks  are  rare,  and do  not
happen  to subjects remaining in the  same locality.  When the residence
is changed,  the immunity  from second attacks is much impaired, if  not
lost.
  Prognosis.   Yellow fever, the most dreadful form of fever, taking preced-
ence even of the plague in proportional mortality.   The  deaths at different
times of its occurrence and in different localities stated at 1 in 3, (Gibraltar
1804) 2 in 3, (Philadelphia, 1820)—70 per cent, (Xeres de la Frontena,
1820.)  In our city will not average one year with another more than 1 in
8—different epidemic seasons differ much  however in proportional morta-
lity.   It is greater of course in the congestive forms.
  The newly arrived stranger, the much exposed, as sailors, the intempe-
rate, are in the greatest danger.  With  reference to this latter circumstance
national habits are of importance—the Irish, Germans, English and Scotch
suffer most;—Frenchmen and Italians least.  Young children when attack-
ed are in great danger.
  Unfavorable symptoms.  Much pain, heat and tenderness at the epigas-
trium.   Weak pulse. Skin relaxed and moist, unless this be attended with
notable general relief and the strength  .hold out.  Shortness of first stage,
or febrile paroxysm.  I saw  a patient  recover, however, in whom it had
lasted but 4 hours.   Suppression of urine, or rather want of the secretion,
considered by Rush a fatal sign; I have met with it in three instances, two
of which recovered.   We must not confound it with strangury  which is
almost always favorable,  yet  I have lost  a patient  after its occurrence.
Spots on the skin, petechia3 vibices, &c.   Finally black vomit.   This symp.
torn deserves a separate consideration.
  Black  vomit consists of black specks or flakes swimming in a brownish
fluid resembling soot and water, coffee grounds,  &c.   It  is not, as was
once supposed, composed of portions of the villous coat of the stomach, ero-
ded and sphacelated and mingled with the fluids of that cavity, for recover-
ies occur after its having taken place,  and I have collected it from sto-
machs entirely uneroded.
  It is not  bile in  any manner vitiated  or altered, for it has been found in
the  stomach when the pylorus was closely contracted, and has been traced
into the gastric vessels.   It is often in the stomach and intestines when  the
gall bladder and  ducts are filled with ordinary bile.   It differs besides in all
its qualities from bile, however changed.  It is not  blood effused into  the
stomach  and there acted on,  for  in distinct hematemesis the blood under-
goes no similar  change, retaining its purple hue, however lono- it may  re-
main in the organ,—to suppose a peculiar fluid thrown out in the diseased
s omach which shall  be capable of so changing blood is merely offering two
conjectures to  explain one phenomenon.  It is more simple to suppose  the
black  fluid as I believe it—to be the result of a specific action of the oastric
vessels,—a distinct secretion.   It is so characterised before leavino- the ves-
sels, being traced into their very calibre.  It has been maintained to con- 
                PRACTICE--CONTINUED  FEVERS.             45

siitute in its secretion the termination of a specific form of inflammation, and
though this may be the fact in the  gastritis  and enteritis of yellow  fever,
yet it does not apply to its occurrence in other circumstances, as in preg-
nancy, rupture of uterus, dropsy, &c.
  I have not seen black vomit  occur in yellow fever earlier than the 16th
hour—the 20th and 30th.   It makes its appearance for the first time most
frequently during the second stadium, improperly considered as a remission,
toAvards its termination—or  at the commencement of the third stadium.   I
have seen six recoveries from it; many more have occurred in the practice of
my friends.
  Autopsy.   Brain usually with its membranes engorged and inflamed,—
Avater has been  found  in the ventricles, and rupture of blood vessel Avith
extravasation.
  The Lungs and Pleura sometimes found to have undergone  some inflam-
mation.
   The Stomach invariably more or less inflamed on its inner surface, some
times on its outer also;  so Avith the duodenum.   I  have never seen gan-
grene or spacelus.
  The Liver often healthy—so of the gall bladder.
  The  Urinary Bladder—not unfrequently inflamed and contracted.
   Treatment.   In the inflammatory form V. S. is usually considered an
essential remedy.   It may be indicated as in bilious remittent, but I  do not
regard it as generally necessary  or  useful.   Local bloodletting is unobjec-
tionable; and cups or leeches may be applied to the head and abdomen.
   The cold bath has proved in my hands equally effectual with  the lancet,
and safer. Affusion at first or immersion,  afterwards aspersion or spong-
ing should be employed as the  case progresses.
   Cathartics form an indispensable part of the treatment.   The articles
best retained  by the irritable stomach,  and in part therefore,  for that reason
preferred by  me, are  calomel  and the sulph. magnes. these prescribed in
alternate doses will act promptly, freely, and effectually.
   Emetics are injurious, unless Avhen  the patient has eaten a full meal just
before the attack, and the Amounting has not been sufficient to  empty the
stomach.
   Diaphoretics  are useful.   The pulv. antimon. is best Avhen it  can be
borne.  The saline draught, the acet. ammon. infus. R. serp, aether nitres
may be employed.
   But our reliance cannot be placed on any other mode of management of
this terrible disease than that commonly referred to  as the mercurial treat-
ment—to  this therefore I resort early.
   Calomel should be given in doses of from J^i to "i, repeated with a fre-
quency proportioned to the violence  of the case, until the disease is subdued.
It is a dangerous error to cease from its exhibition Avhen ptyalism has mere-
ly commenced.
   It is objected  to this mode of management that  it  is  too  slow.  I have
produced  the alterative influence of the remedy as  shewn by ptyalism in  15
hours—20, 24, and 30 hours.  This is early enough in  the majority  of the
cases.  Armstrong with much less  urgent employment of it talks of sue-
ceeding "within the first and  second  days."  The  best adjuvants are the
cold bath and the saline purgative.
   Those Avho complain of the  danger  and ill effect of these large doses are 
46
PRACTICE--CONTINUED FEVERS.
chiefly such as have never used them or seen them  used.   They find the
medicine too powerful in doses of 1,  2 and 5 grains; Ave find it, alas! defi-
cient in power, though administered in 3ss and 3i doses.
  If it be alledged that some die in spite of its use, Ave have but to acknowl-
edge that man is mortal, and will die of curable diseases occasionally, and
in spite of our best skill and most energetic medicaments.
  It is farther  true, that if the case has progressed too  far for restoration,
the effects of the remedy will add not a little to the sufferings of the patient;
nay, he may die with  a sloughing cheek, and gums, and tongue; but this no
more detracts from the value or propriety of the plan of treatment,  than the
sphacelation of a blistered spot from the value  and propriety of epispastic
applications, and is to be explained on the  same principle, namely, that the
vascular action has fallen so low under the circumstances, as to be incapa-
ble of supporting the local inflammation superinduced.
  The permanent ill  effects of mercury are rare and  much exaggerated,
they have never occurred in my own practice.   I have seen in consultation
two such deaths (in a  young child  and a youth of 14) as I have above allu-
ded to.
  In children I should not resort of choice to the mercurial.   Its alterative
influence is seldom well developed in these cases.  The milder purgatives
used freely in  the first stage, and afterwards the combination of an Alkali
Avith an Anodyne diaphoretic, such as a weak solution of Carb Potass with
a small  proportion of Tinct. Op. Camph. form my usual treatment of this
class of patients.  If the intensity of local determination requires it,  the Lan-
cet may be used or Leeches may be applied to relieve the Head and Stom-
ach.  While the skin continues pungently hot, the cold bath will be exceed-
ingly  beneficial, and even after the earlier excitement has subsided  we shall
find much advantage in occasional sponging with ardent spirit.  The rest-
lessness of the latter stages too, is often subdued and comparative tranquility
procured by immersing  the little  sufferer in the tepid bath.   But in bad
cases, even among children, I would press  the mercurial.  I have seen two
children under five years of age saved even after black vomit had occurred,
by persevering until ptyalism Avas brought  on in both.
  The acetate of lead is much extolled by Irvine and others, I have not suc-
ceeded  with it.
  The tinct. cantliarides may be employed in  the latter stages both as a
stimulant and to procure revulsive determination to the urinary organs.
  The spts. terebinth is highly useful Avith similar views, and under similar
circumstances.
   Certain measures in the meanwhile may be instituted for the relief of par-
ticular symptoms or local affections.  To relieve the violent headache, shave
the head, pour cold water on it, apply pounded ice, leeches to the temples, a
blister on the back of the neck.   For the irritability and pain at stomach—
apply leeches ad epigast. and sinapisms.   The  alkaline  solutions, the alka-
line draught, opiates occasionally, and in the latter stages capsicum in pill,
and infus. and turpentine, may be used Avith advantage.
   Muscular pains, sometimes intolerable—relieved by sinapisms and opiates.
   In  the congestive form of yclloAv fever, the hot bath is invaluable.  Sina-
pisms, stimulants by the mouth and in enemeta,  and mercurials.  An active
emetic has succeeded in rousing the insusceptible system.
   The apartment must be kept in all cases Avell ventilated  and perfectly 
                PRACTICE---CONTINUED FEVERS.             47

clean, so also the bed and body of the patient.  Recoveries from yelloAV
fever have occurred under such extraordinary circumstances, that the con-
dition of the sick man can never be known to be absolutely desperate.  He
must never therefore be abandoned. 
48            PRACTICE--CONTINUED  FEVERS.
                         CATARRHAL  FEVER.

   The most frequent of epidemic fevers—most common in Avinter  and
 spring, and  in cold  climates.  I have, hoAvever, seen it epidemic here in
 every month of the year in different years.   When generally prevalent, is
 called Influenza.
   Causes.   May be produced by exposure  to  damp and cold and alterna-
 tions of  temperature;  but is not, in  the majority of instances, dependant
 in any degree upon the sensible qualities of the atmosphere.
   History and symptoms.  Catarrhal Fever commences usually with chil-
 liness, headache, sneezing, coryza, red  and Avatery eyes, light soreness of
 throat and larynx, Avith cough and rattling of mucus in the chest—at  first
 no expectoration; afterAvards of mucus and  mucopurulent  matter—tongue
 red on the edges and covered Avith Avhite  fur—pulse  frequent, hard—skin
 hot and dry—pains  in  the back and limbs—unaccountable depression of
 spirits—exacerbation at nightofwith restlessness and cough, and some  gas-
 tric uneasiness—with tension and stricture across the chest.
   It sometimes happens, that the whole force of  the attack is determined
 to the Head assuming a peculiar form.  There is extremely violent pain
 in the forehead, usually of one side; the eye of that side, and the skin  sur-
 rounding it looking red and inflamed.   The pain  is depressing and insup-
 portable, and takes on an intermittent or distinctly remittent character, the
 exacerbations recurring for the most part in the morning or forenoon, and
 exhibiting  an  obstinate tenacity.   It  is obviously  seated in the frontal
 sinus.   The voice is altered in a characteristic manner.
 f ■ General prognosis favourable—fever subsides, expectoration  becomes
' easier and thicker, skin moist, respiration  free, sleep refreshing, appetite
' returns.   In adults rarely fatal,  unless by  exciting more serious disease.
 In the predisposed, apt to produce phthisis in its several forms—especially
 chronic  bronchitis.   Asthma has  folloAved.   In  pregnant  Avomen, may
 bring on uterine  hemorrhage and abortion, Avhether by its specific irrita-
 tion, or by the mere mechanical  agitation of repeated coughing, is not de-
 cided.   In old  people and very young children, may suffocate by engorge-
 ment of  air cavities, olim Peripneumonia Notha. / In infants, the symptoms
 of croup often mingle themselves Avith the other circumstances denoting
 the invasion of Catarrhal Fever.  The determination to the head is some-
 times so great, as  to give rise to coma and convulsions.
    Treatment.  Catarrhal Fever  may often  be arrested in its forming stage
 by the free exhibition of opium, and indeed of other stimulants—but the
 opportunity for the use of these is transient.  In the more common inflam-
 matory  form V. S. is often  advisable—if the  tongue be  much furred or
 the breathing difficult, an emetic—next purgatives—these may be combined
 Avith diaphoretics—the latter persisted in—and combined Avith  anodynes
 and demulcents when  the excitement is, in  a certain  degree, subdued.
 Dover's  poAvder is here  an  invaluable medicine.  If the local irritation
^^^TSF
V 
                PRACTICE---CONTINUED FEVERS.             49

run high, a blister may be  applied to the chest or the back of the neck,
according as the thorax or head is most affected.
   The peculiar catarrhal affection  of the Frontal Sinus, above described,
is of very  difficult management.   The Lancet  will procure  a  certain
degree of relief.  Cups or Leeches applied to the temples, are of some
service.  It will be necessary to determine to the BoavcIs by  an active
Cathartic.   These depletory measures being premised, I  give at bedtime
a full dose of Dover's Powder, employing Pediluvium, and keeping Avarm
Cataplasms  with Mustard applied to the lower extremities.
   The chamber should  be kept at a regulated  temperature  during the
treatment, say 60° of Fahrenheit, but Avell ventilated.  Bed curtains ob-
jected to.  Convalescence carefully protected from exposure.
   Catarrhal  Fever sometimes puts on a typhous or Ioav character—more
frequently in Europe and in large cities—here rarely, unless among expos-
ed negroes.   In such cases, the Hot Bath, Sinapisms, Stimulants and  Sti-
mulant Diaphoretics,  with Opiates, must be promptly and perseveringly
employed.
   In children, Catarrhal Fever takes  on a  modified  character—there  is
much gastric and intestinal disorder—the tongue is much furred and be-
comes ulcerated, so also  the  lips and mouth—the stomach  irritable'—the
breath fetid—the stools  dark green, and offensive, or thin and acrid—the
pulse incalculably rapid—the thirst  intense—the  breathing hurried  and
difficult,  with great restlessness.   In  these cases the Emetic is necessary,
and  will probably require repetition.  The Warm Bath,  also, is exceed-
ingly useful.   The mild Purgative  must be  perseveringly administered,
alternated at night with an Anodyne Diaphoretic.  If convulsions super*
vene, Cold Water must be poured on the head from a height. 
.70             PRACTICE—CONTINUED  FEVERS.
                        TYPHUS FEVER.

  A favourite arrangement of Fevers among writers, from Cullen down to
Good, contemplated three forms—the Synocha, or purely Inflammatory—
Typhus, or purely Nervous—and Synochus, a compound of the character.
istics of the tAvo.  According to the vieAvs formerly advocated, I regard
all Fevers as of this mixed or Synochus form.
   Typhus may arise from any of the causes Avhich produce debility direct,
or from abstraction of accustomed stimuli—bad innutritious scanty food—
cold or fatigne long continued—deprivation of fresh pure air.   These cir-
cumstances depress the energies of the sensorial system, and the symptoms
of such depression are prominent.  It is the Famine-fever of the Irish—
prevails among the free blacks in the northern  cities to an immense extent,
and in  camps, jails, foul ships and hospitals.  It occurs among our planta-
tions sometimes, from the filth of the  negro houses; and a removal to new
huts is found both remedial and prophylactic.
   Typhus  Fever is contagious—it is also of epidemic dissemination.
   It is distinguished into two grades, characterized by difference in inten-
sity, and differing materially in the  manner in Avhich, in their progress,
they affect the parts of the body.
   Typhus  Mitior—vulgo, Nervous Fever—usually occurs  sporadicaUy,
comes on  slowly and very gradually;  anorexia, with  furred tongue and
unpleasent taste in the mouth precedes—there is chilliness, Aveakness and
langour, depression of spirits.   Oppression at precordia—sighing.  The
pulse is frequent, small and weak—the skin becomes hot and  dry—there is
headache,  or vertigo, or light delirium.  The boAvels are,  for  the most
part, torpid; sometimes loose, Avith very offensive dark stools.  About the
10th or 11th day, the muscular debility becomes very  great, Avith tremors
or subsultus tecdii.um, the pulse very rapid, the tongue dries, is of a deep
red hue, and chapped or cracked—the teeth and lips covered with a dark,
tenacious sordes—gloom, and arxiety Avith muttering delirium, picking the
bed clothes, and catching atiim-.guniry objects in the air, coma, and death.
   Prognosis generally favourable inl\j:hus miiior.
   Typhus  Gravior—vulgo Putrid Fever—scarcely ever sporadic—spreads
rapidly by contagion or epidemic influence.  Commerces Avith alternatioi s
of heat and cold, succeeded by  a  pungently hot, harsh, dry skin.  The
countenance expressive of arxiety and distress,  the face turgid Avith dark
red flush,  eyes  heavy and red, headache severe,  mind disturbed and de-
jected, pulse small, hard, tense,  frequent, irregular—tongue coated Avith
thick brownish  yelloAV  fur—gastric oppression great,  Avith  nausea, and
retching—boAvels torpid.                                              i
   In  a short time, 3 or 4 days, tongue becomes dark, red,  clean, smooth,
dry, cracked—mouth and teeth encrusted A\ith sordes—pulse sinks, and is
feeble  and  undulatory and  very  rapid.   Syncope on  moving—subsultus
tendinum—hurried respiration with  sighing aud  sobbing, or coma Avith 
PRACTICE—CONTINUED FEVERS.              51
slow and laborious breathing, breath fetid,  petechia? and vibices, hemorr-
hages of black blood, death from the 5th to the 30ih day.
  Autopsy.   In different cases different organs are found most  affected.
In some, there is Arachnitis—in others, effusion into the ventricles  and upon
the surface of the Brain—in all, there is vascular trugescence;  a softening
of some part of the Brain is occasionally met Avith.   The Lungs are often
found  engorged,  and sometimes hepatized.  The  Abdominal Viscera
rarely escapes  injury,  especially in  protracted attacks;—the mucus mem-
brane of the Stomach and Intestines, shewing various  conditions  of dis-
ease from mere vascular injection—Avith or without thickening and soften-
ing,  to ulceration and even partial  sloughing.  I once saAv a  perforating
ulcer in the Ileum, Avhich indeed is their more frequent seat.   The patient
was apparently convalescent from a severe  and protracted Typhus Fever;
Avhen, after eating an orange, he Avas suddenly seized with violent abdomi-
nal pains, and  died in a  few hours.   On  examination, I found  several
pieces of the orange in the peritoneal cavity, Avhich had  evidently escaped
through  an  ulcer of about 1-3 of an  inch  in diameter  of ragged edges,
situated near the loAver end of the ileum.
   Prognosis in Typhus Gravior—doubtful.   All  symptoms Avhich betoken
increased sensorial and vascular prostration are unfavourable, as  stupor,
and  insensibility to external impressions and irritations;  on the other hand
reviving attention to these impressions—eruptions  about the  mouth, boils
on every part of the body—a fuller  and larger pulse are favourable.
   Treatment.   In  the milder cases, it will suffice to empty the stomach
with an emetic, folloAved by a purgative.  The best  is  a combination of
mere, dulcis and  pulv. rhoei—persisted in to a moderate extent  for a few
days.   Diaphoretics  may be given in the mean time, assisted  by the tepid
or vapour bath.  We may unite both  these purposes  by the exhibition
of an infus.  cinchon et serp.  Avith sulph. magnes. in small  quantity.
If the disease  is  obstinate, and the strength  of the patient  threatens to
yield, resort to calomel in proper doses as an alterative,  while  you  employ
stimulants freely internally.   Wine is  the  best of them; should be given
unmixed—Avhite preferable, as  madeira and sherry; port may be  chosen
if the bowels are loose.   Sinapisms and vesicatories may be applied, and
in such succession, that the patient must be continually under their influence.
   In the management of cases of typus gravior,  our task is a delicate and
difficult one.   Our urgent indications are to relieve morbid excitement and
undue determinations to vital organs, with the least delay,  and  the least
subtraction from the vis vita?.
   Venisection  is,  in most severe  cases,  an  indispensable measure, yet
seems so obviously forbidden by the great apparent debility, that it requires
courage to  resort to it.  The  pulse is tense, however,  and will  generally
rise during  a  moderate detraction  of blood.  The stage of excitement is,
hoAvever, short, and the  remedy cannot be repeated.
   The cold  bath  will be useful  if  the skin is hot and  dry.   If cool  and
 constricted, the hot bath should be used instead.   An emetic is next service-
 able-  if it do not move the bowels sufficiently, it may be aided by stimulat-
 ing 'cnemata;  or, if the strength alloAV it, a cathartic—the combination of
 calomel and rhubarb, above mentioned, is preferable.   The mercurial treat-
 ment should not be omitted—it affords our best hope  of safety.   In the
 mean time,  the stimulant diaphoretics  should be freely employed, as c;im- 
52             PRACTICE---CONTINUED FEVERS.

phor, the vol. alkali, aided by wine whey and infus. serpentaria.   The va-
pour bath is often very serviceable under these circumstances.
   Opium is considered as of doubtful effect.  I often employ, however,
the camphorated tincture with much advantage, and in moderate dose with-
out ill consequence.
   Sinapisms may  be applied extensively and frequently;  but  vesicatories,
although  they are  often beneficial, yet embarrass us  occasionally  by
sloughing,  especially  in  the latter  stages  of protracted cases.   Wine is
infinitely our best  and safest stimulant, and should be given unmixed—it is
important that the patient should take it with pleasure and in abundance.
   When wine seems to fail of its stimulating influence, and the patient still
sinks, we must resort to the various modes of administering ardent spirit.
Of these, milk punch seems least irritating, and deserves a preference  for
its nutritious quality.  In cases which  still seem  tending  to  a  hopeless
stage of prostration, we may resort to the tinct. cantharid—phosphorus—
and  turpentine, Avhich, though not  the  safest, are among the most active
stimulants.
   The  mineral acids constitute agreeable  drinks—quench the  patient's
thirst well—cleanse his mouth, and correct the fetor of his discharges.
   In tedious cases,  the parts prest on as the patient lies in bed,  must  be
relieved by all the arrangements employed in cases of fracture—the points
of pressure must  be changed  and gently  rubbed often.   The body and
clothes and apartment of the  sick,  must be kept scrupulously clean, and
the latter Avell ventilated. 
PRACTICE--CONTINUED FEVERS.             53
                    PNEUMONIA TYPHOIDES.

   The form of fever which  I treat  of under this appellation was  noticed
 first in Massachusetts in 1816, Avhence it spread northward into Canada, and
 southAvards until it reached the State of Georgia.  It appeared in Philadel-
 phia in 1813—in Charleston in  1815,  and undenvent in this course numer-
 ous modifications, from varying circumstances of locality and predisposition.
 Among common  people it was knoAvn as "the cold plague," "spotted fever."
 I have arranged it  as  a neAv and distinct disease; some contend, hoAvever,
 that it is a revival of the ancient "febris petechialis"—others that it is a mere
 typhoid form of influenza.
   Cause.  It Avas justly and  indeed  of necessity in its first appearance and
 early progress above alluded to, ascribed to a peculiar epidemic constitution
 of air; the modes  of excitement being precisely those which give rise to at-
 tacks of, and predisposition to typhus, as Ioav bad diet, fatigue, long expo-
 sure to cold and damp, bad air, &c.   Negroes seem to be specially predis-
 posed to it—perhaps from their constitutional inability to endure severe cold.
 The number of cases Avhich Ave meet Avith, indeed seems to be very directly
 proportioned to the severity of any given winter.
   History and symptoms.   The most common form throughout the southern
 section of our country  is thatinAvhich the tokens ofpulmonary irritation are
 prominent.   It is ushered in  by  a chill, succeeded by pains in the head and
 chest, of great severity.  The skin becomes hot and dry—the pulse frequent,
 small, irregular in force—the respiration catching, or hurried and  embar-
 rassed, Avith teasing cough—there is great muscular  prostration,  with shift-
 ing pains in the back and limbs—the tongue clean and fiery red.  A degree
 of delirium exists often from the first,  sinking soon  into a low muttering
 condition.  On the third or fourth day the tongue becomes covered with a
 dark crust and dries—the teeth and lips are covered Avith sordes—the  pulse
 groAvs weak and undulatory—from  a sleepless state the  patient falls into
 heavy slumbers, or is  comatose—the breathing is more and more difficult,
 and death follows—or about the 8th, 9th, or 10th day, his expectoration be-
 comes freer—the anxiety less—delirium subsides—the pulse rises, becom-
 ing fuller and slower—a soft warm moisture bedews the surface,  and he re-
 covers.
  The general prognosis  in this form of pheumonia typhoides is favourable.
 In individual cases the unfavorable signs are extreme  anxiety  and dejection,
 restlessness, debility—insusceptibility to external impressions, dyspnoea and
 orthopnaea with  livid  countenance,  petechia? and vibices, inattention to
 light,  the pupil being fixedly dilated or contracted; on  the other  hand
 cheerful hope, uniform warmth of surface, easy breathing with free  expec-
 toration, intelligent attention to surrounding objects, and pulse fuller and
 slower are favourable.
  Duration usually from 6 to 12 days.
  This form of  pneumonia  typhoides, is  also frequently modified in our
southern country, by combination Avith circumstances of gastric  and hepa- 
54
PRACTICE---CONTINUED  FEVERS.
tic disorder.  The first stage is characterized more distinctly by the tokens
of open  inflammatory excitement.  The pulse  is full  and frequent—the
tongue furred, Avith nausea and retching—pain in the chest and dyspnoea.
This state  does not last long, prostration soon folloAving, Avith the symp-
toms recounted above.
  The anginose cases, or those in Avhich the throat Avas  affected, Avere not
unfrequent in the middle Atlantic States.   There  Avas in these at first,
slight soreness of the throat, Avith ordinary catarrhal symptoms.  On a
sudden respiration became much impeded, and great prostration took place.
The fauces and  tonsils Avere of a dark, mahogany hue.  The proportion
of mortality Avas  very great—the patient sunk in  a  short time irrecover-
ably.
  The lethargic  cases,  described by the Massachusetts physicians, as oc-
curring chiefly among  females, deserve notice:  "There Avas universal,
deadly coldness—the skin  as white as polished marble  and smooth—
countenance  perfectly placid—pulse imperceptible at the Avrist—action of
the heart scarcely to be  felt—respiration only by gasping, and that not fre-
quent."  (Report Med.  Soc. Mass.)
  Sudden  deaths, under anomalous and inexplicable circumstances, occa-
sionally took place  during the epidemic prevalence of the  disease.  Men
died in the fields,  being seized Avhen at Avork, and sinking before they could
be carried  home.   Others again seemed to be taken off by the most iaade-
quate ailments,  "dying," as  the phrase Avas, "of a pain in  the foot, or in
the ankle, or knee, or Avrist."   Children seem to be  exempt  from its at-
tack.
  Autopsy.  The thoracic viscera bore the marks of inflammation.  Flakes
of lymph Avere sometimes found attached to the surface of the heart.  The
lungs sometimes hepatized.  The brain and its membranes showed similar
determination and  engorgement.  Effusion of serum,  of lymph,  and  of
a seropurulent fluid, found on the surface and in the ventricles.
  The abdominal  viscera presented no regular appearances.
  The blood Avas black.  The odour  of the  dead  body sometimes less
offensive than during life.
  Treatment—Should vary  with  the form and circumstances of the case;
these being much influenced  by locality, the reports of remedial  manage-
ment, accordingly differ much.   Venisection much  trusted to usually in
our southern country  in the  first stage.  I did not see it often required.
  An emetic is  often used in the first stage  Avith advantage,  or  an  emetico-
cathartic.
  The stimulating diaphoretics Avere, however, the remedies most generally
confided in—Dover's  poAvder, carb.  ammon,  camphor, &c.   Stimulants,
both external and internal, should be assiduously employed.
  In the anomalous  cases described above, opium constituted the almost
exclusive dependence of physicians, and was exhibited in very large doses,
—it deserves the  highest confidence and the most unlimited  eulogy.   The
mercurial treatment is recommended by the NeAv-England physicians.   I
have not found this resort necessary, hoAvever, in any case.
  The convalescence is sIoav, and for  a long time  imperfect.   Various
tonics have been recommended, of Avhich many practitioners have chosen
the preparations of arsenic.   I prefer, hoAvever, the cinchona—placing even
before  the sulph.  quinine, the compound infus. cinchon.  and  serpentaria,,
Avith some alkali. 
PRACTICE
55
                     SYMPTOMATIC FEVER.

  May be defined as obviously connected with local injury, derangement or
irritation—and subsequent to or consecutive upon the local disorder.
  May be distinguished into the Continued and Intermittent.   Symptoma-
tic Fever in both these types may be connected with the same local excite-
ment__the former (in such case) ahvays preceding the latter—being con-
nected Avith recent injuries and  acute inflammations; the latter taking its
origin in chronic and subacute inflammations, and supervening upon uncured
injuries of long standing.                                   .
  Continued Symptomatic is hence styled Inflammatory;  Intermittent bymp-
tomatic has received the appellation of Hectic, the fever emphatically of
irritation.                                          .
   Inflammatory Symptomatic, is the continued fever Avith Avhich every bur-
geon is familiar,  as folloAving within a short period, Avounds of soft parts,
injuries of the head, fractures and compound dislocations.  Here Ave have
all the ordinary tokens Avhich denote the presence of fever—hot, dry skin,
flushed and turgid face, red suffused eye, anxious countenance, tongue red
and foul, thirst, nausea and gastric oppression, headache, languor, muscular
pain, occasional delirium, a pulse bounding, abrupt and frequent.  It arises
also in connection with internal  local inflammations, as pleurisy, hepatitis,
sore throat.  Indeed it usually becomes of paramount importance in all these
pyrectic disorders of Avhich it forms an essential part.
   It is subject to be modified by the  seat of local  affection, and the state of
 constitution of the  patient.   In gastritis and enteritis the fever is of  Ioav
 character  or  adynamic, Avith small pulse, great muscular Aveakness and
 prominent tokens of sensorial depression—in phrenitis and rheumatism the
 strength is less impaired, the pulse full and bounding and the tokens of gen-
 eral vascular excitement are prominent. In Erysipelas we may  have either
 of those states, of high excitement,  or of typhus prostration, according as
 the patient is of robust or feeble constitution, and is situated in a crowded,
 ill ventilated hospital, or in the fresh pure  air of  the country.
    Of thet reatment of this form of Symptomatic Fever, Ave cannot speak in
 this place  without impropriety—we shall discuss it as Ave proceed, in refer-
 ence to each special case.
    Hectic—Intermittent Symptomatic Fever—is on the other hand remarka-
 ble for this trait in its character, that it preserves its regularity of history,
 and progress, without any modification of consequence from any circum-

  3 * An idiopathic hectic has been spoken of by J. Hunter, Good, and Percival,
 but (as I believe may be shown)  altogether inaccurately, and  on no good

 gf°Hectic is connected with  a vast number of external and internal sources
 of irritation.   The local disorder from which it arises, may be seated in any 
56
PRACTICE.
viscus,* or part of the body, is  usually of the inflammatory kind, and must
have been of some considerable previous duration.
   Nor is it modified by the peculiarity of function of the part thus affected
as other fevers are,  being identically the same, Avhether based upon bron.
chial irritation, lumbar abscess, phthisis tuberculosus, or cancer uteri.   The
formation and absorption of pus is not as Avas formerly  thought, necessary
to its production;  it accompanies induration and obstruction of the mesen-
teric glands, and of the pancreas—and gouty and rheumatic, and scrofulous
SAvellings  of joints without suppuration.
  The predisposition to Hectic is specially developed in connection Avith
the scrofulous diathesis, and perhaps extends throughout'the phlegmatic
temperament.
  When fully developed, Hectic presents two paroxysms in the 24 hours,
one coming on two or three hours before noon, the second about 12 hours
after.  There  is  sometimes, though perhaps not generally, a formed chill,
succeeded by hot, dry skin, Avith burning heat at the soles of the feet and
palms of the hands, pulse small, hard, tense, abrupt, and very frequent; there
is great paleness of face, Avith a small circumscribed spot of florid red on
each cheek, sparkling eyes, thirst, tongue smooth and red, as also the  lips,
and mouth, Avith sometimes light  aplhous  ulceration—the stomach retains
its tone, and the appetite and digestion are good, yet there is great muscular
debility, and great emaciation; the nails are adunque, the teeth and sclero-
tica  are of pearly whiteness.
  The patient is usually cheerful  and full of hope.  I think I have observ-
ed however, that  this is only the  fact Avhile the digesti\re system retains its
elasticity,  and Avould regard it  as diagnostic;  ahvays inferring disorder of
the chylopoietic viscera, or some  one of them, avhen the  spirits are depress-
ed.
  The emaciation of the patient, even Avhen  he eats heartily, may be ac-
counted for in two ways.   Either the digestive function is directly impaired,
which happens sometimes, with diarrhea, &c. or the respiratory function is
imperfectly performed—animalization and  assimilation of Chyle, Avhich
can be perfected only in the lungs, remain incomplete.
   The stages of the symptomatic intermittent are less regularly exhibited
than in  the idiopathic intermittent.   The  day paroxysm,  rarely  or never
sheAvs a sweatimg stage.  The night SAveats of consumptives, &c. are I
think the  termination of the  night paroxysm.
   Hectic  usually supervenes Avith the access  of  the  day paroxysm; to
Avhich is sometime after added, the evening or  night paroxysm—the first,
then, being absent for a Avhile:  it  again appears toAvards the conclusion of
the case, and both harrassthe patient.   I have, hoAvever, seen Hectic de-
velope itself Avith the double  diurnal paroxysm from the first.
   Treatment—in general terms, if the local affection Avhence hectic is de-
rived be curable, our attention should be directed to its management.   If it
cannot be cured, but can be taken aAvay, let it be removed surgically.   If it
can  neither be cured nor taken away, we must aim our efforts at the reduc
tion  of the excitability and irritability of the patient, and at the diminution

  * There is a single exception.  I have not, either in reading or observation, met  with
any one instance of thesupervention of Hectic upon any form of disease, affecting the
brain or its membranej 
                            ^PRACTICE/                         57

of the influence of the local irritation upon the system,   Narcotics and To-
nics must, with these views, be resorted to.  Of the first, opium, or some
of its preparations, morphine, acet. morphine, &c. and  denarcotized lau-
danum, will be the chief—prussic acid, spiders web and cicuta, have been
recommended.
  Of the tonics—cinchona is the best.  The sulph. quinine may be used,
or the infus. cinchona et R. serpen, cum carb potass vel sodae.
  I have succeeded in preventing the day paroxysm, not unfrequently, with
the combination  of quinine and  piperine,  formerly mentioned.  It  does
not, however,  seem to exert a similar influence over the night paroxyam.
  The metallic salts are much used, arsenic especially.
  The mineral acids—do  something in restraining  the  debilitating night
sweats and  diarrhoea.   The mur. tinct. ferri.  I  prefer, as combining the
advantages of the twe last classes of remedies.
  Sulphur has been also employed, upon the analogy of its utility in  idio-
pathic intermittents.
  Fresh air—exercise—change of place by travelling; these Avhen they can
be borne, are incomparably the best tonics. 
58
I'KACTICK.
                             SYNCOPE.

   Lkii'otiiymia.  Defined  by Cullen—"Motus Cordis imminutus vel ali-
quamdiu quiescens."—This  languor or suspension of the circulatory func-
tion, is the prominent point in its description or History.
   Causes.   Among  the predisposing we  may  rank general debility from
previous disease or  suffering—constitutional mobility of fibre, both  acci-
dental and hereditarily transmitted.  The exciting or occasional may be
arranged under three separate heads.
   The 1st.  Comprises certain structural disorders  of the Heart, or  of the
large vessels or parts in the  immediate  neighbourhood, which may me-
chanically interrupt  and disturb the regularity  of the circulation—as pas-
sive  Hypertrophy or Aneurism, Ossifications, Effusions, &c.
   2d. Such circumstances as depress the Circulatory power, whether di- >
rectly or indirectly—Hemorrhagy—Inanition  from  Avant or from pro-
tracted  disease—inordinate  discharges, Avhether natural or morbid—the
removal of the abdominal distention  in Dropsy, by allowing the blood to
rush into the vessels from which it had been for some time previously ex.
pelled by pressure of fluid.  Pregnancy presents  occasional  attacks of
Syncope, as giving rise to undue  determination of blood to the uterus leav-
ing the  Heart insufficiently excited.
   3d. Under this head, I include those agents Avhich make their primary im-
pression upon the  Sensorial system—Pain—Disagreeable impressions not
absolutely  painful, as the effect of  heat and bad air in croAvded  places, of
unpleasant  odours; or from idiosyncrasies, odours not unpleasant—the
sight of disgusting objects—most or  all of the Passions and Emotions, as
Joy, Grief, Terror, Horror,  Pity and Impatience.
   How these  latter act is  difficult to  point out Avith precision; none of
them are positively sedative in their operation.   Cullen  ingeniously attri-
butes the result to  a rapid and sudden exhaustion of the Nervous energy.
Perhaps something ought to be  ascribed  to  the very inordinate  cerebral
determination,  Avhich undoubtedly  folloAvs the application of the  above
causes—this may be so exquisite and exclusive, as  to leave the Heart so
far unsupplied, as to render its action languid or interrupt it.   That  such
Cerebral determination is a common coincident in Syncope, is evident from
the occurrence ot Convulsions from V. S., and in recovery from the faint-
ing state.
   Fainting conies  on Avith an oppressive sense  of Aveakness and languor,
with  paleness  or lividity of the  visage.   The pulse is Aveak  or ceases__
the skin is cold—the eyes are  turned upAvard and half closed.   The respi-
ration is scarcely to be perceived—or there  is  gasping and moaning__the
patient  falls insensible.   After an uncertain  duration, the surface being in
the meanwhile clammy cold and pale or livid—the circulation is gradually
restored—the  breathing  more distinct—sensibility  and  strength return.
Recovery is attended Avith Vertigo generally, and more or less Nausea__
there is sometimes Vomiting.   1 have tAvice seen  violent Convulsions__ 
PRACTICE.
59
quasi Epileptic—in patients not subject  to attacks  of Epilepsy, either pre-
viously or afterward.
  Diagnosis.   From  Apoplexy distinguished by the paleness and  coldness
of the Face and Skin—the feebleness and quickness of the Pulse, and the
languor of the Respiration.   From Asphyxia, generally, by the history  of
preceding circumstances.
  Prognosis—almost universally  favourable.  A feAV fatal cases are, Iioav-
ever, recorded.
   Treatment.   Modified by Cause and  Condition of the Patient.  If _Syn-
cope* be produced by  the first class of causes, above recited,  a cure is not
to be hoped for.   As Palliatives—physical repose must  be  enjoined and
mental tranquillity—diet unstimulating,  but moderately nutritious.   Perpe-
tual Blisters or Setons in the chest and arms are used.
   In cases  of the second order—those namely connected Avith Inanition—
the Patient  must be placed in  a recumbent position, so as to allow  of a
freer and more forcible passage  of  Blood to the Brain, now insufficiently
stimulated—dash cold water in  his  face—apply Ammonia and other pun-
gent Volatiles to his nostrils  and eyes—Avarmth to the extremities, sina-
pisms, and other irritants—Electricity and Galvanism, if at hand.  When
recovering,  give him .some Avarm nutritious fluid with Avine.
   The management of Cases arising from the third series of Causes, Avill
be more nice and  delicate.   If the patient have been excited by  the more
violent  passions,  his pathological condition presents some of the  contin-
gencies noticeable  in Apoplexy—and it will be perhaps advisable, to take
blood from  the Jugular Vein or Temporal Artery; or, at any  rate, to apply
Cups and Leeches to the Temples and Neck.   If by the less vehement
emotions, as pity or disgust—external  irritants will probably rouse him—
and Stimulants and Anti-spasmodics complete his restoration.
   To prevent recurrences of Syncope, the general health must be properly
regulated by observance of a proper regimen and diet—nutritious  but un-
stimulating  Aliment being preferable—and the use of Tonics—the Metallic
Salts and Mineral Acids being preferred—and, above all, exercise in the
open air.
   Women are much more liable than  men to attacks of Syncope—Chil-
dren are seldom  seized with it—I have, however, seen several attacks of
great violence and long duration in a child not more than seven weeks old. 
W)
PRACTICE.
                       ANGINA PECTORIS.,

  Syncope Anginosa—Sternalgia—Asthma Dolorificum. An obscure
disease—probably  an affection of the Heart.   Its nature not  well  ascer-
tained.   Spasm perhaps of the cardia\fibres or of some of them—attended
with great pain in the chest, and sense of suffocation and impending death,
—Paroxysmal—recurrent.
  Causes various.   It is connected often, but not always Avith the Pletho-
ric condition—sometimes Avith Gout—rarely appears before middle  age.
Autopsies have exhibited diversified  structural derangement of  the Heart
and large vessels—thus  the  Coronary Arteries  of the  Heart have  been
found ossified—so have  the  Cardiac Valves—Hypertrophy Concentric
and Eccentric—but none of these appearances are constant.
  The earlier Paroxysms, brought on by violent muscular exertion, as in
walking  against the wind, or ascending  a height;—after a  time, the
slightest  effort occasions a return  of the habitual paroxysm, as in cough-
ing, &c, until at last it invades, without obvious cause.
  History.  The first attacks produced by severe exercise, cease as soon
as the patient stands still—when it has become habitual, they may last an
hour, or even  more.  The pain in the chest is exceedingly intense, shoot-
ing across the sternum, and extending down one  or both arms (most com-
monly the left) to the elboAv  or Avrist.  There is Dyspnoea—the counte-
nance being pale or livid—the Pulse varies much.
  Prognosis unfavourable.  Death not unfrequently occasioned by the vio-
lence of  a Paroxysm.  The tendency to recur is obstinate, and the system
sinks under a repetition  of attacks.   I  have seen Apoplexy occur at the
termination of a Paroxysm.
   Treatment.   During the  Paroxysm—if the patient be plethoric and of  .\\j
robust habit, and the case recent, V. S.  promptly and freely—Avith revul-
sives of the  most  rapid  and  impressive power.  Cold Affusion is often
useful.   If he be,  on the other hand, feeble, or the disease chronic and
habitual,  the most vehement  stimulants  are demanded—as Ether, Lauda-  y
num, Brandy—Sinapisms to the chest.
  In the  intervals—We proceed Avith reference to the Cause and the Con-
dition of the Patient.  If there be organic affection  of the Thoracic Vis-
cera—regulated diet—rest—small  bleedings—digitalis.   If the patient be
Arthritic, the  treatment of Gout is required.^  If plethoric—endeavour  to
restore the balance of functional  poAver and action—if  debilitated, stimu-
late and revive him.  Tonics are much employed.  Exercises of gestation
are Avell borne and highly useful—the Metallic Salts—the Mineral Acids
and  Sulph. Quinine are also serviceable.  Much stress is laid upon the  x '
effect of revulsives  and  counter-irritants, as Epispastics applied  to the  *
wrists and ankles, and Setons and Issues in the arms and the thorax.   The
pustular inflammation of Tart. Antimon., exerted and kept up for a long
time, is said  to have been of great advantage. 
PRACTICE.
61
                          HEMORRHAGE.

   May be here defined, a Aoav of Blood from some part of the body, without
 Avound or external injury; usually  considered a sign of  rupture of some
 blood vessel; this is hoAvever, not often the fact.  Ulcers may corrode the
 coats of a Vein or an Artery, or they may otherAvise lose their power of
 cohesion, but usually the blood is poured out from an unbroken surface by
 a sort of diapedSesis or transudation, not Avell understood.
   Divided into Active and Passive.   Cullen has placed Hemorrhage among
 the Pyrexiae—regarding Fever as an essential part of the definition of Ac-
 tive Hemorrhage.   This is an error.  I have often met Avith Active He-
 morrhage unpreceded and unattended by Fever.  Yet it is most generally
 soon folloAved by a Febrile exacerbation—a statement Avhich is also true of
 Avhat are called Passive Hemorrhagies.  Good has substituted the preferable
 phrases Entonic and Atonic Hem:  'The first occurs Avhen  the system of
 the patient is at or above the ordinary condition of strength or tone.: Atonic
 or Passive Hermorrhage Avhen he is notably beloAv this point, and in a  weak
 and enfeebled state of general health.
   Causes of Hemorrhage.   Among the principal  of these,  Plethora is
 much dwelt on by Authors, and deserves a moment's consideration.
   Plethora was looked on by the older Avriters as of several varieties; they
 recoTw-.z d P. ad molem—ad spatium—ad volumen—ad vires. ■:>-  T<   ._  ;•
   P. ad molem contemplated the absolute superabundance  of the vital fluid
 Hyperaemia.  This I do not believe to exist in any  case; though it is a fa-
 vorite opinion of Andral and other justly celebrated moderns also.   P. ad
 spatium expressed the quantity in reference to the  contracted state of the
 vessels.  It may he questioned whether something of this nature does not
 form a part of the early history of congestive and malignant  fevers, as shewn
 by the oppressed Pulse.   P. ad volumen regards the supposed expansion of
 the Blood itself.  By some such effect on the actual mass  Avhich is subject
 to the universal law of increase of volume with  elevation of temperature
 we account for the headaches of Spring and early Summer, Apoplexy and
 Insolation, as well as the frequent Hemorrhages of that season.   The 4th,
 or Plethora ad  Vires is a condition of the system in which the mass of fluids
 and  the force of their circulation are  disproportioned to the tone of the ves-
 sels containing them or  to their powrer of resisting the impulse incessantly
 acting upon them.   If in any part the integrity of the tissues of Avhich the
 vessels are composed is impaired they must then give way—hence the He-
 morrhages in diseased lungs, and from  inflamed surfaces.  Such degenera-
tion  of tissue, is among the most  important predispositions to Hemorr-
 hage.
  Its occasional causes, are in general—such circumstances as  either ex-
 cite or increase the force of the Circulation; and such as give rise to strong
local determinations—running—leaping—violent passions, all  stimulants
under the 1st head; under the second cold, heat, their  alternations and dimin-
ution of atmospheric pressure as at great heights, external violence, impro- 
62
PRACTICE.
 per postures of the body, Ligatures, undue occupation of certain organs, as
 among Goldsmiths and Musicians.
   Hemorrhage may occur from either Arteries or Veins;  in early life, the
 Blood is usually inferred from its florid color to be arterial—in old age ven-
 ous.  Each of the individual Hemorrhages seems to be more specially inci-
 dent to a given stage of life;  Epistaxis in Childhood—Hemoptysis at Pu-
 berty—Menorrhagia, H. Proctica and H.  Cerebri in old  age; Scrofulous
 constitutions most liable to them all.
   The premonitory symptoms of Hemorrhages, those phenomena which
 immediately precede its appearance, are identical with those which denote
 the presence of Inflammation.   The part from Avhich the  Blood is to burst
 forth is affected with a sense of heat, throbs and suffers pain of some kind,
 usually sharp and  pungent—there is also a feeling as if it Avere SAvollen and
 heavy.  I do not doubt the absolute similarity of the condition of an  inflam.
 ed part, Avith that Avhich is to be the seat of Hemorrhage.
   The hereditary transmission of Hemorrhagic tendencies is not denied;
 and numerous examples are on record, in Avhich whole families are thus
 affected in successive generations.
   Hermorrhagy is  remarkably liable to  recur—and in  many  cases, ob-
 serves a regular periodicity of repetition.   This is, by many, attributed to
 Lunar Influence, and Avith much plausibility.   Hemorrhage was anciently
 regarded as a salutary effort of the  Vis  Medicatrix Naturae, to save the
 system from Avorse evils;  and this notion  is even  noAv prevalent concern-
 ing two  of its forms—Epistaxis and  Hemorrhoidal discharges of blood.
 The utmost that can be made out in favour of this  notion is, that one dis-
 ease is thus substituted for another—Hemorrhagy is no less a disease, and
requires proper management to avert serious and even fatal consequences.
  All Hemorrhagies may thus be vicarious or reATulsive,  as is often no-
ticed in cases of obstinate Amenorrhoea.   They may burst forth from any
part of the surface of the body—as from  the  mamma—the  finger, or as I
 have myself seen—from the skin of the cheek just beloAv the eye, at that
 part which is so often discoloured in sexual diseases of females.
   Particular Hemorrhagies.   Epistaxis  or bleeding  from  the Nose,
 often preceded by Headache, Vertigo, Flushing of the Face.   Cold should
 be applied to the surface, either generally or  partially—and determination
 to the head relieved by the Lancet if necessary,  and Saline Purgatives. Jf-^"
 If it is apt  to return, a Blister should  be  applied occasionally to the back - ^
 of the Neck, or a Seton introduced there.
   Bleedings from the gums and fauces, are sometimes very troublesome,    ^
 and afford  us an opportunity of remarking—1st.  That  Hemorrhage  is
sometimes a simple transudation from a surface; the blood has  been  seen
 issuing from the whole surface of the mouth, gums, tongue, &c, Avithout
 ulcer  or erosion or Avound of any kind.                                    s^
   2dly. That the unmanageableness of Hemorrhagy, Avhen it is of embar-  o :
 rassing obstinacy, or recurs  frequently, is OAving to a loss or impairment  of   ^
 the coagulating quality in the blood.   I do not  affirm this  to be always  : ' '
 true,  but I  know it to be occasionally so.   Cold and astringent washes  ~;-v
 will, generally, check the discharge.
   Haemoptysis--or Spitting of Blood.  Rarely occurs as a primary dis-
 ease;  but, for the most part, attends  upon inflammatory and scrofulous
 affections of the respiratory organs and  their tissues.   It may happen, 

                            PRACTICE.                          63

how ever, in individuals  Avhose lungs are not impaired in structure, Avhich          I
Cullen styles Hemoptysis Plethorica.  Hemoptysis generally folloAvs Pu-
berty, and takes place betAveen the 15th and 30th years of life.                    I
  Diagnosis.   The Blood is throAvn out from the mouth after coughing or          |
deep haAvkingor expectoration, frothy, and of a bright florid hue—there is
usually pain or heat  and Aveight in some part of the  thorax.
  Prognosis.   Not  usually  attended Avith great  imminent risk.   FeAv
Bleedings  from the  Lungs are so  profuse as  to kill at  once; but it may
happen.   In general, the danger arises from the previous condition of the
patient—Avhose prospect is gloomy, if he have laboured under any chro-          j
nic pulmonary disease, Avhether Bronchitis or Pneumonia proper.   There
is much less to fear—indeed, there is no great reason for  dread, if he be          j
free from previous disease of the Thoracic Viscera.
   Treatment.   If Hemoptysis be  Entonic—the pulse firm and strong, and
especially if febrile symptoms attend, V. S.  must precede other remedies.
The Lancet must however be employed Avith caution.   Much harm has
been done  by its rash and indiscriminate use.   A good domestic prescrip-          i
tion is the  administration  of Common Salt, Avhich may  be taken largely,
and  is often promptly efficient  in  checking the  Aoav  of blood,  Avhich it
does probably by stimulating the  extensive surfaces of the  Pharynx, Eso-          t
phagus  and Stomach, and thus  deriving from the neighbouring Thoracic
Vessels.   It is  also serviceable by nauseating,  Avhen  taken abundantly.
Other Nauseants are exhibited Avith benefit—Ipecac, especially,  which I
prefer—others Tart. Antimon. and the Sulphate of Zinc.                        >
   As Sedatives—the Nitrate of Potass and  Digitalis are often resorted to.
Some have ventured on cold applications; but this is attended Avith much
doubt and risk.                                                                j
   The Acetate of Lead is prescribed here as an Astringent—-and  is un-          j
doubtedly  useful in cases of a chronic character.   When  combined with
Opium, to  diminish irritation, and with Ipecac, so as to  produce  a  slight
nausea, it is among our very best formulae.
   Revulsion must be attempted vigorously.   Sinapisms and  Blisters should
be applied to the Chest and  Limbs—and the former may  be kept under
the perpetual irritation of Vesicatories, or of the Tartar Emetic Ointment.
   Cough may be allayed  by Demulcents and Opiates.    Strict silence en-          i
joined—the diet kept very Ioav—and the patient, for a time, remain per-
fectly at rest.
   In  Atonic Hemoptysis, Ave  must modify  our treatment,  by abstaining
from V. S., and allowing a freer and more nourishing diet.   Here Opium
may be given  pretty largely;  and the Muriated Tinct. of Iron, will  be
found serviceable as a Tonic and Astringent.  Absolute silence must be
advised.
   Haimatemesis—-or Vomiting of Blood.   Blood throAvn up from the sto-
mach, is  grumous, dark, clotted and mixed Avith Mucus, and other  contents
of that Viscus.  For the most  part, preceded by gastric uneasiness  and
oppression, with faintness  and nausea, and sometimes heat or a pricking
pain.  These symptoms, with  the  absence of Cough and other respira-
tory  disorder, readily distinguish the disease from Haemoptoe.
   Causes obscure.   Intemperance predisposes to it—Brought on by ex-
ternal violence, by straining to vomit—-by  obstructions  to  abdominal cir-
culation, as in  Pregnancy and in disorders of the Liver and  Spleen—and 
64
PRACTICE.
by the suppression of some  accustomed evacuation, as of the Catamenia
in women, and the Hemorrhoids in men.
  Prognosis.   Not generally attended with great danger.   is
  Treatment.  If Entonic,  with pain and heat of Epigastrum and hard
pulse—-V. S. and the Epsom Salt, should be resorted to, and  the Bowels
freely operated on.   It is more frequently Atonic however,  the pulse is
feeble, and the whole frame debilitated, and requiring a very opposite man-
agement.  Stimulants and Astringents  are required.  Small  draughts  of
Brandy  and Water may  be given—-Acet. Plumbi in moderate doses ad-
ministered with Opium—-The Tinct. Mur. Ferri is also useful—-a Vesica-
tory should be applied over the Stomach without delay to prevent a return.
The Infus. Cinchonas, with any  of the Min. Acids, may be taken, and a
generous Diet allowed.
  Hematuria, or  Discharge  of Blood  from the Urinary Organs, though
not  of frequent  occurrence, will sometimes fall under your  care.  It is
generally brought  on by accident or violeut muscular exertion.   The most
obstinate case which I have seen, was regularly produced by Coition.
  This Hemorrhage generally requires, and is readily managed, by  V. S.,
mild Cathartics, and perseverance in*a recumbent position.  If it runs on
we may use the Acet. Plumbi and the Tinct. Mur. Ferri as Astringents.
  Hemorrhagia Proctica.   Discharge of Blood from the Anus, is of very
rare occurrence,  idiopathically, being, for the most  part, an attendant
upon Hemorrhoids, Dysentery,  &c.  I have met with three or four cases
of spontaneous flow  of blood from the Anus, however,  Avhen there was
no Hemorrhoidal  tumour, and the Bowels  Avere  othenvise in a perfectly
healthy  state.
  Besides the remedies enumerated under the former heads, you will find
much advantage here in the employment of Cold and Astringent Enemata. 
PRACTICE.
65
                                  HYDROPS.

       Dropsy is generally assigned to consist in a preternatural  collection of
     serous fluid in one or more of the Cavities of the body or  in the Cellular
     Membrane.  The definition is thus taken from a single symptom—but the
     Pathology of the Disease is exceedingly obscure.
       Dropsies may be local or general.   By the first Ave mean a collection of
     fluid in some part, without disorder of the general system or farther exten-
     sion of the effusion of fluid.   General Dropsy is a phrase Avhich implies the
  _.  existence of Hydropic  Diathesis—that is the tendency to effusion of fluid
     every where—with the actual presence of some collection.   Hydrocele is
     exclusively a local  collection  of fluid—so is  Ovarian  Dropsy—so, for the
     most part Hydrocephalus.  Anasarca may be an insulated or exclusive affec-
     tion.   On the other hand Ascites  and Hydrothorax are almost invariably
     connected  with, dependent  upon,  and symptomatic of general Hydropic
     Diathesis.
       It is usual to account for the accumulation of fluid in these cases by the
     supposition that the natural and healthy correspondence between exhalation
%    and absorption is interrupted—impaired either locally or generally.   Some
     maintain an undue excitement—some a relaxation of the Exhalent vessels—
     others  suppose an imperfect action or condition of debility in the absor-
     bents—but there is an almost universal accordance in the doctrine, that the
     fluid accumulated, is the same which is thrown  out in health by the  exha-
     lents to lubricate the surfaces, as the phrase is, of the cavities.
       But it is not proved that such exhalation is  one of the natural functions.
     No fluids are found in healthy cavities.   And surely no one Avill assert that
     the Cellular tissue is the seat of a natural serous effusion.
       The causes of Hydrops are very various.   Among them are enumerated
     both Hyperemia and Anaemia—General Plethora—Debility from whatever
     source, whether Ioav innutritious diet, bad air, or previous disease, great los-
     ses of blood or other evacuations, and intemperance chiefly.   Many disea-
     ses give special predisposition to Dropsy.    This is remarkably the fact in
 <   reference to Scarlatina—It is true also of Peritonitis—Tympanitis, Hepatic
     and Splenic affections—and perhaps of Small-pox and Influenza—it fol-
     Ioavs sometimes  the abuse of powerful remedies, as Drastic Purgatives,
     Mercury, Iron, and the Vegetable Acids.
       Hydrops is connected both with the Entonic and Atonic states of consti-
     tution which, therefore, it Avouldbe well  to substitute for the old terms Acute
     and Chronic.
       Prognosis in  General Dropsy unfavorable, as would  be readily inferred
 £   from the perusal of Bills of Mortality every Avhere.  It depends upon the pre-
     vious state of the patient,  and his habits, upon the form Avhich it assumes—
     Entonic or Atonic—and upon the locality of the Effusion.
       Dropsies which are among the ultimate manifestations of a Cachectic
     condition of the body, are almost of course incurable;  such is the state of
    the Sot.  On the other hand. Ave have much  hope of removing such asoc- :
                     (} 
6b                         PRACTICE.
cur from whatever  cause in a system but lately healthy and vigorous as
Avhen Dropsy comes on from any one of the Exanthemata or other recent
malady or from a transient exposure to some morbid influences.   Entonic
Dropsy is for the most part more easily managed than its  reverse, for ob-
vious reasons.
  The locality of the Effusion seems to be of importance in reference to the
Organ, Avith the performance of avhose function it may interfere.   If such
function be important to be performed vigorously and without interruption,
the danger is of course great, as in Hydrocephalus.  Hydrothorax also pre-
sents a similar character.
  The Avorst prognosis is, however, to be draAvn from the manifestation of a
general or universal  Diathesis by the concurrence of several effusions in
different localities.  In such cases, although you may relieve the patient of
the accumulation, and in various modes procure the discharge of the fluid,
yet this is  far from a cure of the disease, which remains obstinate  and will
shew itself by the reneAved accumulation of the same effusions, until the pa-
tient can sustain it no longer.
   Treatment.   This must depend upon the condition of the patient, and the
obvious or  probable cause of the access of the  disease.  In the  Entonic
forms of Dropsy, the Lancet must often be used freely—Drastic Purgatives
are much employed—the Saline and Vegetable Diuretics—the Antimonials
and Mercury, as Diaphoretics and Alteratives, and Avhen the undue Vascular
excitement is  reduced,  various Tonics, Bark,  Iron, Wine, &c. are re-
sorted to.
   On  the other hand in Atonic cases, Tonics and  Stimulants are at once
prescribed, and every effort made to reanimate the  enfeebled functions.
   The morbid  anatomy of Dropsy deserves  attention.  If the Hydropic
affection have been general, the cavities of the body contain a Avatery se-
rous fluid—which is indeed  diffused through all the  tissues.   The very
fibres of the muscles seem  sodden in  it, and Avater will  continue to drip
from one of them for a long time, if taken out and hung up.   The Cellular
structure is  also abundantly injected with it.  I have seen the Heart itself
flabby, pale, soft as if soaked or macerated.
   In Hydrocephalus the effusion may accumulate in the Yentricles,*or
upon the surface of the Brain externally.   In the former case it will be
spread out;  and in the latter condensed and small.  Dr. Wistar saw it dis-
tended like a bag, against the Cranium, not more than 1-8 of an inch thick—
and it has been found not larger than an egg, lying on the base of the Skull.
   The fluid collects in the  Pericardium—in the Pleurce, and in  the sub-
stance of the Lung.   By its pressure, absorption of a Lung may occur—I
have met with it smaller than a man's fist.
   In Ascites the Effusion is almost always connected with obvious signs of
Hepatic disease, enlargement and obstruction.  The Spleen may be in the
same condition.  The Kidneys are  occasionally  diseased.  I have seen
them full of Hydatids, or bodies closely resembling Hydatids. 
/:  •  ;/■-,                    PR act re k.        -jf              67
 71 J
/
 rJ
'   ANASARCA,
r

   Hydrops Cellularis.  One of the  most frequent forms  of Dropsy,
 consists in a collection of serous fluid in the Cellular tissue.  Often occurs
 in a local or partial form, Avhen it is termed (Edema, as in old age—in the
 last stages  of Phthisis, and in many other diseases, and not uncommonly
 in  the debility of early convalscence from severe  maladies.
   A pale swelling of the loAver extremities, easily pitting  upon the appli-
 cation of pressure, unattended at first  with  any heat or soreness of skin
 is the first symptom of Anasarca; the intumescence becomes more general
 until the Cellular structure  every Avhere  is filled Avith fluid, giving  to the
 countenance a  heavy and flabby expression, and impeding  all the move-
 ments of the body.   If not relieved, the distention of the skin increases so
 as  to produce inflammation ulcer and  gangrene—large quantities of serum
 being thus discharged.
   These symptoms  are attended Avith  languor and general feebleness and
 inactivity—the  surface  is  harsh and  dry—the thirst considerable,  the
 tongue often foul, and the appetite and digestion impaired.
   Anasarca may be either Entonic or  Atonic.  In  the former  case  the
 pulse Avill be quick  and  hard, and the  skin above  the usual temperature.
 In the latter, which is by far most general, Ave have an opposite condition
 of the circulation, and the skin is cool or even cold.   The urine is usually
 small in quantity, and high colored.  The Bowels  are Costive.
   Causes.   Anasarca is  connected Avith a great variety of circumstances,
 Avhich are  thought to have given rise  to it.  Mere  Debility  of circula-
 tion, as  in cases alluded to  above—inflammatory affection of  the Subcu-
 taneous Cellular tissir.', as when  it follows the Exanthemata, Scarlet fever
 especially-— Visceral Obstructions.   Some of the European Avriters describe
 an acute or sudden Anasarca, connected with Pulmonary disease—diseased
 state of the  Kidneys.
  Prognosis.  If occurring alone, i;hd in constitutions previously healthy,
 Anasarca is readily  curable; under other  circumstances the prospects  of
 the patient are unfavourable.
   Treatment.   This  mus* vary obviously Avith the causes of the attack,
and the condition of  the  patient.   In the Entonic  or excited state of the
 system, the Lancet is  used freely  and with  much  advantage.  Drastic
 Purgatives  are  also employed—J dap with Super  Tart. Potass, and such
generally as procure  thin and Avatcry  evacuations, hence  called Hydra-
gogues.  Of these—Ehiteriurn, Se immony, Colocynth, and Gamboge are
recommended.   The  three first I never employ—the fourth  rarely—they
are violent and  irritating, and may, I think,  be  dispensed with froni the
Materia Medica.  The Epsom Salt is serviceable,  and may  be combined
with the other formulas prescribed.
  Emetics are often used in  Anasarca; and Avhen we have, as is very fre-
quentlv the fact  in our Black patients, a very foul tongue,  and  a stomach
much disordered by their  bad and irregular habits, Ave shall find advantage
in  vomiting, occasionally exeited.   I]>"cae. and  T;irf. Antimon. may be 
68
PRACTICE.
used separately or combined.  The Emetic is required to be frequently re-
peated in the case of those who  eat clay or dirt—a  habit  met Avith noAV
and then, and apt to be productive of Marasmus and Anasarca.
   Diaphoretics are also  employed.  The Snake Roots  are all  of them
useful.   The Antimonials have "also been highly eulogized.   Doner's Poav-
der, where no contra indication  is  presented, is among the best of this
class of remedies; and indeed I would lay much stress upon the free use
of Opium in most cases of Dropsy.  Whenever attended Avith much gen-
eral distress—irritation, restlessness and  sleeplessness, this  divine remedy
is of infinite value.
   Diuretics have been promiscuously  employed in all Dropsies, and most
unduly extolled.   The original notion of a direct dependence of the accu-
mulation  of fluid upon a diminished urinary decretion, led to  this prac-
tice, Avhich  has  seemed  to be supported by the alleged observations of
Blackall upon the changes in the urine, connected Avith the presence of
Dropsy, and  the remarks of Bright and Christison  upon the frequent co-
existence of disorganization  of  the  Kidney.  The received opinions on
this subject seem to me erroneous.  I do  not conceive any medicine to be
useful  directly in Dropsy as a Diuretic, that is,  merely by promoting uri-
nary discharges.   And further, all remedies Avhich are successful in their
application to the various cases, produce, as in the treatment of Fever, an
increase of this as of the  other excretions.   Thus the Lancet—Mercury,
—Opium—the Antimonials—all  give  rise to large discharges of urine,
Avhen used with judgment.  Digitalis  is the object of almost  unanimous
preference among the Diuretics,  specifically so  called.   Yet there  is no
satisfactory  proof of its direct Diuretic influence.   1  use it  extensively in
Pulmonary and other diseases, without  observing any  such operation.  Of
the Squill, the same may be said.
  A great number of articles are prescribed under this head.   The Ni-
trate—Acetate and Super. Tartrate of Potass—the  Vegetable Acid—the
infusions of Parsley and  Horse Radish, seem to be  among the best.  To-
bacco is sometimes,  but  rarely  exhibited.
  The several Snake Roots, of which perhaps the Eryngium Yuccifolium
or Button Snake Root is  most esteemed, and  the Cofchicum Autumnale,
deserve also to be prescribed.
  The Tonics are entitled to much confidence.
  Among our Negro population, Anasarca usually occurs of Ioav and de-
pressed character, and connected with  a very cachectic state of the body.
Here Cinchona is our best remedy, and is very often sufficient in itself for
a perfect cure.   Iron is also extensively used and much confided in. So
also the Vegetable Bitters.   The  Cold  Bath  is serviceable when it can be
borne.   To evacuate the fluid, distending and irritating the integuments.
Acupuncture is  the best  mode, and should  be  frequently repeated in all
depending parts. 
PRACTICE.
69
"f~ff
                             ASCITES.

  A collection of serous fluid  Avithin the cavity of the Abdomen.   Its
presence  is marked  by a  gradually-increasing equable SAvelling of the
Belly—attended by a sense of Aveight and usually Avith perceptible fluctua-
tion.  The general health is much disordered.   There is in  almost every
case more or less febrile excitement—thirst—diminished perspiration, with
harsh dry skin—diminished urine—droAvsiness and languor—the tongue is
foul—the appetite and digestion  disturbed—the boAvels costive—the respf-
ration impeded from the upAvard pressure of the Diaphragm—after a short
time, Anasarca ensues, and sometimes Hydrothorax.
  The Diagnosis is important,  but not  "ahvays easy.  It is to be distin-
guished from Pregnancy in women—from Tympanitis—from Physconia
or Visceral enlargements—and from Ovarian and Encysted Dropsy.   We
must consider, in relation  to the  first,  the  Signs, as they  are called, of
Pregnancy.    Where these are altogether Avanting, and the other tokens of
Hydropic Diathesis present  themselves,  the inference is clear—unfortu-
nately these tAvo states sometimes occur together and are confused.
  Tympanitis is distention Avithout Aveight—it is tense and resounding.
  Physconia is slower than Ascites, for the most part, in  its  increase, and   (
is irregular in form, and not equable in the swelling it occasions.   So also
of Encysted Dropsies, Avhich are, besides, unconnected  Avith notable dis-   '
turbance of general health.
  Causes.  Ascites is rarely Idiopathic—-generally depends  upon Vis-
ceral Disease, Hepatic Splenic, &c.   It may occur suddenly, as in a case
related by Darwall; two of a similar nature occurred to  Chapman; and I
have seen an instance  following  in a feAv hours upon Dysentery, and pre-
ceded by very transient Tympanitis.
  Prognosis generally unfavourable:  but  should refer, in  particular instan-
ces, to the cause, and  to the previous state of the patient.   If Entonic, and
unaccompanied by Anasarca or  Hydrothorax, recoveries from Ascites are
not unfrequent.
  Treatment.   Besides the  remedial  management generally instituted in
Anasarca, and equally well adapted here, we  must lay no little stress upon
the  exhibition of Mercurials, on account  of the ordinary dependence of
Ascites on Visceral obstruction.   They should be administered  slowly and
in small quantities—and in combination Avith the other remedies indicated.
Ptyalism should be avoided as irritating and injurious.
  Paracentesis has been a  matter  of much dispute.   I should not hesitate
to resort to the Trocar to relieve the patient from the distress produced by
distention.  Pressure applied carefully after the Belly is  thus emptied, has
been found useful.  The Bandage should be applied uniformly and Avith
assiduous attention.   Tonics and Exercise are indispensably necessary to   '■
a cure. 
70
PRACTICE.
                          HYDROTHORAX.

   Collection  of serous fluid within  the cavity of the Thorax; sometimes
 called  Hydropleura,  as  the  serous  collection is  usually  Avithin  the sac
 of the Pleura.
   Some vague dispute has been held, Avhether Dropsy of the Chest is  ever
 an Idiopathic affection; and a feAv writers  have unhesitatingly considered
 it as the mere result of Pleuritic Inflammation.  This I regard as an error.
 Accumulation of fluid Avithin the Thoracic  Cavities,  indeed occur from
 inflammation  of the Membrane, but are readily to be distinguished by  pre-
 vious symptoms.   Besides this, they rarely affect more than one side, and
 are not attended Avith Anasarca or Ascites.   Hydrothorax, Avhich is con-
 nected with general Hydropic Diathesis; and  Avhich exhibits,  Avithout  pre-
 vious tokens  of Pneumonia or Pleurisy, proofs  of Effusion,  I treat of as
 one of the forms of I dopathic Dropsy.
   It is the disease of advanced  life and  of  broken constitutions, for the
 most part.   There is notable paleness of the  face—Dyspnaea—inability
 to go through any muscular  exertion—Orthopnaea.  The general health
 is impaired as  in the other varieties  of Dropsy—there is  a short  dry
\ cough—great restlessness at  night, Avith occasional paroxysms of threat.
 ened suffocation.   Anasarca  is not early present;  comes on in the course
 of the malady;  and Ascites is also often added.
   The Diagnosis is difficult.   We dAvell on the Dyspnoea and Orthopncea,
 so apt to  come on Avith extreme severity in nocturnal paroxysms.  There
 is often Palpitation of the Heart,  Avith irregular and intermitting Pulse-
 great anxiety and despondency.   Exploration of the  Chest displays in-
 crease of fullness on  one  side sometimes—with loss or diminution of
 capacity for making a full  and deep inspiration.   There is loss of respi-
 ratory murmur over most  of the Chest.   Fluctuation is said to be-—but
 rarely—perceptible.   On percussion a  dull  sound is returned.   Bichat
 proposes, as a test, pressure on the Abdomen, Avhich increases  very much
 the sense of suffocation.
   Causes.  Those of Dropsy in general already enumerated.
   Treatment.   Must be guided by the principles already  laid  doAvn as ap-
 plicable to  the  other varieties of the disease.  In the Entonic form, the
 Lancet should be  used freely  to  subdue morbid excitement; but it should
 be recollected, that Ave must not make the Pulse our exclusive guide in the
 resort to V. S., as it often remains unaccountably hard and  full to  the very
 last moment of life.
   The employment  of Purgatives has been  vehemently objected to.  I
 would administer them in just such cases as require V. S., but Avith some
 caution.   Nor must Ave expect the same obvious good effects from them as
 in Ascites.
   The Diaphoretics—Antimonials, Snake Roots, &c. must  be exhibited,
 ;is has been already advised in the analogous cases.
    Diuretics are regarded as  here specially applicable: and to Digitalis  is 
PRACTICE.
71
 assigned the first place.  Squill is useful, both in this Avay, aud as an ex-
 pectorant.   The solution  of Super. Tart.  Potass, or an infusion of Com-
 mon Parsley, may be used as ordinary drink.
    Mercurials have seemed to me  almost indispensable to the cure of Hy-
^ drothorax.  They  should be administered in such small quantities, and at
 such  long intervals, as  to procure,  if possible, their alterative influences,
 Avithout the occurrence of Salivation.
    Opium,  if it  exerts  no marked effect  in  the removal of the disease,
 lends a most admirable aid in relieving or  palliating the sufferings of the
 patient.   I prescribe Anodynes freely  to  diminish the intolerable distress
 of the sick man in his nocturnal paroxysms of Dyspnoea.
    External irritants to the Thorax are of some  value here.  A succes-
 sion of Blisters will do service.   The Ungt. Tart. Antimon. has been re-
 commended.
    Paracentesis  Tltoracis is occasionally performed—oftener by the Physi-
 cians of the Continent of Europe, than by American and English practi-
 tioners.   I can see no reasonable  objection to it, Avhen  the presence of fluid
  within the cavities of the Pleurae is clearly made out. 
72/                          PRACTICE.
                        HYDROCEPHALUS.

   Collection^of Serous fluid Avithin the cavity of the Cranium.  The effu-
 sion may occupy  various localities; it is most  frequently found Avithin the
 Ventricles—occasionally as Ave  are informed by Cheyne and Golis (a Ger-
 man  writer) deposited in  the Arery parenchymatous tissue  of the brain
 itself—sometimes  poured out upon the surface of the Arachnoid —and  in
 more than one instance on record, betAveen the Dura Mater and  the bonv
 Skull.
   The nature of the Disease is obscure, and has been the subject of much
 dispute.   By many it is denied to exhibit any analogy Avith other Hydropic
 affections, and considered as a mere Phrenitis, an Inflammation of the Brain
 and its membranes, of Avhich the Effusion is an ultimate and uncertain  or
 accidental result.
   It must be acknoAvledged that such collections in the Cranium are often
 preceded by symptoms Avhich would seem  to denote Inflammation, but this
 is not always the  fact.   Congenital Hydrocephalus is  not rare, in which
 there is no proof of the  precedence of inflammation; and  most of the cases
 which develope themselves in early infancy, are free from any such indica-
 tions as are supposed to be inseparably connected Avith inflammation.  Be-
 sides this, cases are not Avanting  in Avhich the symptoms Avhich are believed
 to denote Hydrocephalus, are mingled or combined or alternate with those
 of Ascites and  Anasarca.   Tavo such have occurred to me in Black Chil-
 dren of 9 and  10 years of age, and a third  in an adult, a Physician, a friend
 and former pupil.  Blackall offers us some similar facts.  He has witness-
 ed—as in the cases just alluded to, the metastasis of disposition to serous
 effusion from other parts to the head, and  also the extension to that part of
 general Hydropic  disease.
   On these grounds I regard  Hydrocephalus and treat of it  here as one  of
 the forms of Dropsy.
   It is customary Avith Authors to follow the division of  Hydroceph. into
 Acute and Chronic.
   The former it must be acknoAvledged, Avould seem by  the very descrip-
 tion to be a mere Phrenitis, but it is after all not very definitely depicted, nor
 distinguished accurately from affections of the head, Avhich do not issue  in
 the same result—an effusion, namely of serum Avithin the Cranium.
   The precursory symptoms are  various, some of them referring to de-
 rangement of the Sensorial; others to disturbance of the Digestive system.
 The appetite is capricious or impaired—the tongue foul—the breath fetid__
the belly tumid and costive, or  irregular, with occasional  diarrhoea__the
 Urine is scanty and high colored, and there is some febrile excitement.  The
face of the child is flushed and turgid—he  is restless—sleepless__moans__
puts his hand to his head—shrinks from light—or seems to suffer from pain
in the ear.  These tokens of acute disease, having continued for a longer or
shorter time, a more characteristic series  of phenomena supervene, Avhich
are assumed to  be produced by pressure of effused fluid upon the brain,  as 
PRACTICE.
73
the former are attributed to inflammatory excitement of greater or less vio-
lence.   The pulse becomes sIoav and unequal—there  is stupor alternating
with screaming and jactitation--the vision is noAV obviously impaired—there
is strabismus with dilatation and immobility of the pupil—the child lies heav-
ily Avith the eyes half open.   It can  sometimes be roused for a moment so
as to take  food and drink, but soon  falls again into a lethargic state—the
hands are tremulous and raised frequently to the head—the loAver limbs arc
paralized or  contracted and  crossed—the  bladder and rectum pass their
contents Avithout the consciousness of the patient—great emaciation ensues
and death is often immediately preceded by violent convulsions.  The dura-
tion of this stage also  varies, but may be rated at from 12 to 15 or 16 day;;.
  The Diagnosis of this form of Hydrocephalus is not possible before it has
run into the second stage.   The symptoms of the first, are therefore, denom-
inated 'precursory' as depending  on  conditions  of disease, Avhich m;iy or
may not result in Effusion.
  Chronic Hydrocephalus it has been said, is often Congenital.  In such in-
stances the causes are of course unknoAvn; but as it occurs frequently in
several children of the same  parents and has happened very often Avhen a
Scrofulous taint is knoAvn or suspected to be present, many Physicians con-
sider Scrofula as its most probable cause.  When it occurs in early child-
hood, it may be either the result of the Acute form developed Avith less than
fatal intensity; or it may happen at once  and unpreceded by the symptoms
of inflammatory excitement, described as belonging to the  first stage.   The
parietes of the Cranium yield, and an immense distention takes place, occa-
sioned by  the  accumulation of  fluid—the head becomes thus misshapen
and  too heavy for the muscles of the patient  to support, requiring to  be
borne upon the shoulder of the nurse or laid ahvays on a pilloAV. Fluctua-
tion is distinctly perceptible.   Pressure on the  head is said  to produce in
some a complete stupor.   The senses seem to be  all lost or much impair-
ed—the powers  of voluntary motion  are  enfeebled—but Convulsions of
great violence sometimes  sheAv themselves.  When the  hands are moved
at will, there is picking of the nose—the teeth are ground together. As
the case progresses, the respiration  is affected—the legs are crossed and
draAvn up to the belly—the pulse becomes  Aveak and  intermitti■■;>-, and at
last ceases—or the patiei't dies Avorn  out Avith tedious irritative fever and
ulceration  of parts, Avhich bear  the  pressure of his Aveight.   It happens,
though rarely, that the Brain accommodates itself to this  morbid condition,
and the patient drags out a long and Avearisomc existence, attaining mature
age.
  To the  feAv such instances recorded in the books,  I add a case on the
authority of my friend Dr. W. M. Lee, who saAv the subject in Abbeville
District, S. C.   His  head was 28£ inches  horizontal  circumference—1QJ
from one  meatus  auditorius  to the other—could not Avalk, but trundled
himself on  a chair on rollers—conversed intelligently—general  health
good.
  The Prognosis—of Hydrocephalus is decidedly  unfavoui.dde.   FeAV
cases are recorded of recovery after the  unequivocal developement of the
disease  by  enlargement of the  Head and other  signs  of Effusion, had
taken place.   Previous  to this stage,  however, and during the progress of
the  precursory symptoms, or first stage,  as it has been called, we are not
without hope.
                   Hi 
74
PRACTICE.
   Morbid Anatomy.  Water is found, as has been mentioned, in the Ven-
tricles, in the substance of the Brain, between the Membranes in which it
is enveloped, and external to the  Dura  Mater.  An instance of this last
kind occurred to myself.
   The Brain  is often found presenting all  the marks of inflammation-
engorgement of its vessels—softening of its substance—adhesions of op.
posite  surfaces  of its Membranes.   Occasionally,  C. Smyth  says fre-
quently, nothing of all this is to be observed.  It  has  been  found  pressed
out, and  in thickness not more  than ■§■ of an inch—it  has been seen con-
densed and smaller than an egg.
   Treatment.   By those who Avith Rush regard this Effusion as a mere ter-
mination of Phrenitis, Venesection is placed at the head of our list of re-
medies.  The Jugular Vein  is selected  and opened repeatedly.   Others
prefer the application of Leeches.
   Purgatives  are employed  freely by almost every Practitioner;  and  in
their continued effect, Ave place, I think, our best hopes of a cure.  I pre-
fer the combination of a Resinous Drastic—Jalap or Rhubarb,  with an
Alkali—the Carb: Potass or  Soda.   To obtain the full influence of these
remedies, a judicious  perseverence is required.
   Mercury is a fashionable remedy.   It may be occasionally added  with
advantage to the Cathartics prescribed.
   I  have no confidence in  the  class of Diuretics, as applied here; but
Digitalis is  recommended by Smyth, Withering, and others.
   Antimonials have been used largely by Laennec.
   Cold Applications  to the  head are of great value,  and should  be per-
sisted in.  I prefer the frequent  pouring of a stream of  cold Avater upon
the scalp, to any other mode.
   Blistering the head is often resorted to.  Caustic Issues and Setons are
also employed—and  in the last  resort, Paracentisis Capitis has been re.
peatedly  ventured on; and  Ave have instances of restoration after  thus re.
lieving the little patient, related by Drs.  Vose and Conquest. 
PRACTICE.
7.)
                             SCROFULA.

   The various morbid affections Avhich are included under the above title,
 afford perhaps the best exemplification of the dependence of local disease
 upon morbid peculiarity of constitution or predisposition.  This predispo-
 sition or diathesis is said to be so Avell marked by characteristic appearan-
 ces of conformation and physiognomy, as  to  be recognizable before  the
 actual  occurrence  of open disease.   The skin is  fair and soft—the hair
 light and  silky—the  eye blue  and. mild, and  of  gentle expression—the
 upper lip tumid and deeply fissured in the centre.  A  child of this consti-
 tution,  often exhibits precocity  of mind, united to irritability and obvious
 debility of body.  The cheeks  flush  readily upon muscular exertion or
 mental emotion, and fatigue is promptly induced.
   Scrofulous affections are not, hoAvever, exclusively  confined to  indivi-
 duals whose aspect has been above described, but  are met Avith, and  not
 unfrequently, in persons of dark hair, coarse skin, and brown complexion.
   It prevails more in certain climates than others.  Great Britain is parti-
 cularly subject to Scrofulous disease.   Dry and  Avarm  regions are, compa-
 ratively, exempt from its presence.
   Scrofulous inflammation, Avhen it affects any other than the cutaneous sur-
 face, is apt to result in the secretion of a peculiar curdy matter, Avhich is,
 in some situations, mingled with  much serum and pus;  and in others, tends
 to  condense or concrete itself into a  solid  body, knoAvn  as a Tubercle.
 These  are  developed  in  immense numbers in  the Lungs in  Scrofulous
 Phthisis, and shall receive a particular description under that head.  The
 Children of Parents who  have laboured under any  of  the knoAvn  forms of
 Scrofula, are very liable to be attacked by similar disease, and thus here-
ditary  transmission is universally recognized as the direct  cause of Scro-
fula.
   The  predisposition is gradually  built up, in  the first  instance, under  the
influence of a number of  circumstances, Avhich  diminish the vigour of  the
system.  The cold and damp air of any particular district  of  country,
—living in close ill-ventilated apartments—being fed upon unAvholesome,
scanty, or  innutritious diet—defective clothing—sedentary or  depressing
occupations—Avant of personal  cleanliness—all these, Avhen acting upon
large masses, are known to give rise in a notable proportion among them,
and a  still larger proportion of  their children, to various maladies, Avhich
long continued observation has led us to consider as connected by a com-
mon character,  and as  depending  upon a similar morbid state of general
constitution.
   Every tissue of the body is liable to be attacked by Scrofula—the  Skin,
the Eyes, the Ha«ds? the Joints and the Bones.   Age modifies the disposi-
tion of particular structures to  be affected.   In early childhood, papular
and squamous eruptions about the head and ears,  ulceration and discolo-
ration  of the Tunica Adnata, and induration of the Mesenteric  Glands,
with tuberculous enlargement, are among its first tokens.   Next, we have


     <?/a«J7 
76
PRACTICE.
Morbus Coxarius and White SAvelling of the Knee—and at  or before the
time of Puberty,  glandular enlargements and  tumours about  the Neck—
and Pulmonary Tubercles.   The Lungs and the Bones continue to sustain
a like liability through  after life.  It is Avorthy of remark, that  not only
is  the predisposition transmitted hereditarily as above stated, but children
have actually been born, labouring under  Scrofulous  inflammation and
Pulmonary Tubercles.
  The nature of the original defect of Constitution  is  not  knoAvn.   By
some it is supposed to be seated in the Digestive  System.  I rather as-
cribe it to  improper action of the minute order of vessels, whose function
it is to separate the materials  of groAvth and nourishment, and the several
secretions.
   Scrofula also implies a contamination or deterioration of the fluids of the
body.   Sauvages  considers  the Horse  liable  to Scrofula.  The disease
Avhich, in this animal, he entitles Scrofula Farcimen, has  been propagated
by  tr.nsfusion of blood from a diseased to a healthy subject—and even
from an horse to an ass, by Professor Coleman.
   The  most common  developement of Scrofula, or, as  it Avas  formerly
called, King's Evil, consists in the  appearance and groAvth of small  hard
tumours in the course  of the Lymphatics,  and especially on the Neck.
They increase slowly, often becoming indolent and remaining long station-
ary, giving no pain, and attracting little attention.   After an indefinite time
they enlarge, and are evidently inflamed.   Matter,  at last, forms in one or
more;  not  true pus, but a  thinner fluid, containing flaky curdy  coagula.
The tumours often coalesce, and their contents are discharged by ulcera-
tion, which leaves irregular and deforming scars.
   The Treatment—is properly divided into the curative and prophylactic—
the former suited to the management of cases, in  Avhich local- inflamma-
tion, tumour and tubercle  have been developed; the latter required Avhere
Ave have reason to anticipate or dread the occurrence of such local affec-
tions, either from knoAvni descent from Scrofulous parents, or from the pre-
sence  of those physiognomical peculiarities Avhich point out the predispo-
sition.
   Mercurials have been much employed in the cure of Scrofula.   They
require to be administered in very minute doses, and Avatched Avith great
care.   If Ptyalism be alloAved  to supervene, injury is ahvays done to the
patient;  but, with the precautions suggested, Mercury Avill be found among
our best remedies.   I  prefer to exhibit the Corros: Sub:  in quantities inde-
finitely small.
   Cathartics used in mild formulae, Avith patient perseverance, are of much
benefit.   I combine them Avith some Alkali, as there  is, generally, notable
tendency to fermentation and acidity of stomach.
   Tonics are greatly confided in.  The Chalybeates  are selected by some
Physicians—Cinchona by others.
   The Baths are valuable auxiliaries—the  cold should be chosen, if it is
 pleasant to the patient; otherwise, the tepid bath.
   The most precise cleanliness  is necessary—of the person, the clothes,
 and the chamber.  Where the local excitement is high, and still more,
 when there is general sympathetic irritation, articles of stimulating quality
 must be avoided—nay, even abstinence may be, for a short time, necessarA'.
 Except at such periods a nourishing Diet should be alloAved. 
PRACTICE.
77
  Burnt Sponge has been long in use for the cnre of Scrofula.  It contains
some of the Alkalies already spoken of and the peculiar agent Iodine—
which is noAV  regarded as the chief remedy for all  Scrofulous disorders.
Some caution  is,  hoAvever necessary in its employment.   I prescribe, ex-
clusively the  Aquaeous solution, exceedingly dilute (Lugol's) and in this
form have seen it productive of extensive benefit.
  The combination of an indefinitely small proportion of Iodine Avith some
purgative Salts minutely diffused in large  quantities of Avater, as in many
Mineral Springs,  both in Europe and America, deserves to be valued as our
best remedy for all the incipient developements of  Scrofulous disease, and
perhaps for all its stages,  except  in the instance  of Pulmonary  tubercle,
Avhere the effect is thought questionable.   The Muriates or Chlorides have
been generally extolled—common  Salt—the Muriates of Lime—Barytes
and Magnesia.  It is to the mixture of some of these in Sea water, that its
acknowledged utility is to be ascribed.   It  is one of the best purgatives
Avhen recent and pure.
  The  Narcotics  deserve to be mentioned.  They are all serviceable in
relieving the symptomatic irritation, arising  from  the  local  derangement.
I confide in Opium—others, prefer Cicuta and Hyosciamus.
  Of the local treatment of Scrofulous tumour and Inflammation.  In some
of its developements it needs  active depletion by  Leeches and  Cupping.
Glandular sAvellings on the neck, &c. should at first  be soothed by soft
poultices—and may  aftenvards be  discussed by the application of Iodine
ointment—or if very hard and indolent  by Blistering and Stimulating em-
brocations.
  The Prophylaxis.   A child born of a Scrofulous mother should be placed
in the care  of a  healthy wet-nurse.  Removal from low damp  situations
must be advised.   The residence  and  especially the sleeping apartment
must be well  ventilated and kept perfectly neat.   Precise cleanliness of
person  and clothing  must be enjoined—bathing frequently practiced—exer-
cise in  the fresh air  is essential to health and vigor—the diet must be plain
and generous.  Warm clothing in Avinter must be  worn—Sedentary occu-
pations avoided. 
78
PRACTICE.
                            MARASMl S.

   I place here, because it is rare comparatively to meet Avith any other
 form of Atrophy, than that Avhich depends on Scrofulous disease.   Maras-
 mus rarely attacks adults—children are generally affected  at the time of
 Wreaning, hence the phrase Atrophia Ablactorum.   It seems reasonable to
 account for this, by the supposition that their imperfect digestive organs are
 unable to bear a change of food, yet it would rather appear to be  indepen-
 dent of the change and a mere result of their arrival at this age, for it is of
 no benefit to keep them  at the breast beyond the ordinary period.   It is
 almost exclusively confined to children of Scrofulous parents  or such as are
 subject to the causes formerly detailed Avhich tend to develope Scrofulous
 disease.
  Marasmus comes on Avith  general languor—paleness  of countenance—
Anorexia or Capricious  appetite—Bowels irregular but becoming loose,
with stools thin,  discolored, offensive and acrid.   The tongue is furred,
with occasional  vomiting—the  inside  of the mouth  and  corners of the lips
ulcerate—the gums are spongy—the belly is tumid—the flesh of the limbs
soft and flabby—the emaciation progressive, and  at last extreme.   The
duration of the case varies; but it is often exceedingly protracted.
  Autopsy.  Dissections shew the Intestines empty" and contracted, con-
taining dark ill-conditioned secretions—the Liver perhaps firmer  and hea-
vier than natural, and the Mesenteric Glands enlarged and indurated.
  The last circumstance denotes the character of the case Avith sufficient
clearness.  The  Treatment is  such as has been already indicated—with
certain modifications, hereafter to be pointed out under the head of Cholera
Infantum. 
PRACTICE.
79
DISEASES  OF TlIK ORGANS ENGAGED  IN THE PERFORMANCE OF DIGESTION.

                            DYSPEPSIA.

   This term is  expressive  of a definite  disorder  of the  Stomach—it
is not  synonymous  Avith the Avord Indigestion.   The Stomach,  under
a great variety of morbid influences, refuses to dissolve or digest food taken
into  it—in Fevers, it is common to see among the matters  vomited  in
the early stages, articles of diet swalloAved many hours previously.  Men-
tal emotion has the same effect,  and so of other circumstances; but the
transient and symptomatic derangement of the Stomach, Avhich, in these
cases, unfits it for the solution  of food, differs notably from that condition
of the organ of Avhich Ave are  to treat, and Avhich is among the most fre-
quent of the diseases  of civilized and refined life.  Dyspepsia, when it
occurs as an independent  and idiopathic affection, is the result of an im-
perfect  secretion  of the Gastric fluids, so  important to the physiological
and chemical changes of food  taken.  When this occurs as the effect of
previous disease of the Stomach, as  for example, Inflammation, it clearly
comes  under another head, Gastritis,  acute  or chronic—and  hence the
incorrectness of confounding them, as  has been done by Parry, Broussais,
and Wilson Philip.   Inflammation is a very frequent consequence of Dys-
pepsia;  and the last mentioned  Avriter has treated of it as a sort of second
stage.
   It is idle to assume hyperexcitation  as the only cause that can impair the
power of  any organ.   Even when an organ has been subjected to the ac-
tion of an  excitant, two sets of effects follow, each  of  which is equally
morbid in  its nature and ultimate results.    It is first  stimulated—its capa-
city for action is, in the second place, impaired by exhaustion—enfeebled,
relaxed.  Hence,  the direct agency of a  Sedative,  may  produce results
closely analogous to, if not  identical,  with the influence  of  a Stimulant.
We find Dyspepsia, in conformity Avith  these views, common to tAvo classes
of persons—sedentary  men, on the  one hand—literary  persons, students,
the poor who live  on  scanty inutritious diet—and  on  the other, debau-
chees, the intemperate and gluttons.  It is not probable, that  the patholo-
gical condition of the Stomach is  exactly the same in these; but the symp.
toms exhibited, are very similar and strikingly analogous.
   Dyspepsia may be  then defined as a local disorder of the  Stomach,
manifesting itself by the imperfect, slovv  and  painful  solution and diges-
tion  of food taken.   Acid eructations, Heartburn, a sense of painful ful-
ness or distention and weight, Nausea and frequent Vomiting, Gastrodynia,
Emaciation, Anorexia or  defective and irregular appetite, are among the
most general symptoms.   From the universal sympathies which connect
the diseased organ Avith the rest of the system, Ave have an infinite variety
of morbid  phenomena in the cases Avhich  present themselves.   There is
flatulence with severe colics—in many, obstinate constipation—in  some,
diarrhoea  of various character—muscular debility  and  languor—great 
80
PRACTICE.
 depression of spirits, vertigo, headache, dim, depraved and (rarely) do"ble
 vision—obstinate vigilance and  nocturnal  restlessness—vapours and hal-
 lucinations—palpitation of the heart, Avith sIoav and sometimes  intermit-
 tent pulse.
   One of the most ordinary results of a continuance of Dyspepsia, is the
 developement of a Chronic Gastro-Enterite,  which is considered  indeed
 by W. Philip, as a second stage;  and the  symptoms  of Avhich  are often,
 but improperly (as even by Parry  himself) enumerated under our present
 head.
   Dyspepsia proper is purely a functional disease.   Insufficient excitement
 of the organ  as  in persons ill  fed—and in Students, who  labour under
 undue determination to the Brain,  occasions  a defect of determination to
 the organ, imperfect innervation  and impaired or depraved secretion.   The
 same state of deranged innervation, results from irregular  and excessive
 excitement, as in  Sots and Gluttons, and in many others, Avho Avithout any
 imputation of moral impropriety, commit inadvertent  excesses in quantity
 and quality of food and drink.
   Another consequence of defective innervation—Avant of  determination to
 the Stomach, deficient  or exhausted excitability, is the impairment of the
 contractile power of the organ.  Hence its peristaltic motions upon Avhich
depend the due movement, mixture and solution of the food,  are feeble and
ineffectual.   All  these  conditions  are comprised  in the  meaning  of the
word Atony—the phrase, loss of tone of the Stomach—and constitute the
form of derangement, which Ave call Dyspepsia.
   The causes  of Dyspepsia are numerous and varied.   With Cullen I
divide them "into—1st.  Such as act directly and  immediately  upon the
 Stomach—and 2d.  Such as act upon the Avhole body or particular parts of
it; but in consequence of which,  the  Stomach is chiefly or almost only
affected."
   Under  the  1st head, I mention imperfect  mastication of food.   The
hasty eating Avhich all  foreigners regard  as  strikingly characteristic of
 Americans, helps to account for the frequency of Dyspepsia, and for the
badness of the Teeth, a cause in turn, as Avell as an effect,  of gastric de-
rangement.  Quantity of food—Excess—as Avell in eating, as in the use of
stimulating drinks.  Quality of food—as when improper and innutritious
articles  are used, or badly cooked diet.
   Under the  2d.  Modes of life and occupations may be enumerated.  In-
dolence—a sedentary habit—undue determination  to the  head, as in Stu-
dents—indulgence of the passions—labour in oppressive postures, and con-
nected Avith confinement to close and  impure air.  Exposure to striking
alternations of temperature.
   Treatment.   Most important to remove the cause—this done, the disease
disappears.   Diet should be nutritious—moderately  stimulant—plainly but
perfectly  cooked—taken at distant intervals—fluids should  be plain,  and
taken in moderate quantities.
   Studies and sedentary and  confined  occupations must be  abandoned—
 exercise taken freely  and actively in  the  open air, and  conjoined Avith
 amusement.  Medicine should  be  used sparingly, and only  for transient
 purposes.  Costiveness may require occasional and mild  Cathartics, or
 may  be obviated  by Enemata  and frictions over the Abdomen.  Acidity
 Avith Heartburn, may be relieved bv Alkalies, or the Mineral Acids in small 
PRACTICE.
81
doses.   Gastrodynia is relieved by Aromatics; or, if these fail, and the pain
is severe, by Anodynes.  Tonics are much employed—the Metallic are best,
such as  Iron and Bismuth.   It is satisfactorily ascertained by Beaumont
and others, that the Hydrochloric or Muriatic Acid, is an essential consti-
tuent of the gastric or digestive fluid—and Ave thus account for its utility in
Dyspepsia.   The same remark applies also,  but with less force, in respect
to the Acetic  Acid and the Chloride of Sodium or common Salt.   Mer-
cury has been used with advantage, when there Avas defect of secretion—
but Ptyalism does harm.
   The Mineral Springs—those which contain purging Salts, and Carbonie
Acid, and the Chalybeate are often of service.
   Prussic Acid is highly recommended by Elliotson. 
*'■-                          Pi? ACT ICE.
GASTRITIS.
  Acute Gastritis is recognized by the presence of severe pain at the Epi-
gastrium,  Avith a  sense of heat or burning—nausea—thirst—oppression—
usually repeated vomiting.   Pressure  on the  Stomach cannot be borne—
the pulse  is hard, tense, frequent, small and contracted—the skin hot and
dry—the  tongue red or covered with a thin white Coat—anxiety and de-
jection—sighing—restlessness—prostration of strength.    As  the  case
progresses, the tongue, cheeks and esophagus inflame  and ulcerate—the
pulse sinks—the eye is red and suffused—there is Ioav muttering delirium.
Black Vomit is often ejected—Respiration, as Avell as Deglutition, is diffi-
cult, and death soon folloAvs.
  Prognosis unfavourable.  Depends someAvhat upon the Cause.  Is more
likely to terminate fatally, Avhen supervening  on previous  disease.
  Causes.  The  Acrid Poisons, Avhether Mineral or Vegetable—Mechani-
cal violence externally applied—exposure to severe alternations—violent
passions—-and the  Metastasis of other inflammations, as  in Gout, &c.
Inflammation  of the  Stomach  may produce  Suppuration, it is  said, and
Gangrene.  I have seen  no instances of  the  kind.   In death, from  Gas.
tritis, the Mucous tissue is  found deeply  injected, softened as by Macera-
tion—sometimes, but rarely, eroded.
   Treatment.    The indications are obvious  and  undisputed.   If  it is
knoAvn that any poisonous or acrid matter  has been taken into the  Stomach
the organ must be  relieved by the employment of a quick Emetic, or the
Stomach-pump—and the proper Antidote," if  at hand, administered.   Be-
yond this—and from  the beginning, in spontaneous  Gastritis, the  most
prompt and energetic Depletion is called for.  Venesection  must  be car-
ried to the utmost extent that can be borne—and local abstraction of blood
by Leeches and Cups at and near the Epigastrium, assiduously resorted to.
 Warm Poultices should be applied over the belly, while Ice and cold fluids
are allowed liberally to quench the thirst  of the patient.   We may thus at
once subdue the disease  in  seme cases.  If not promptly and completely-
successful by these means, Ave must soon have recourse to the mild  and
unirritating Cathartics, such as Calomel, Sal.  Ep=om and  01 Ricini.  The
first will  often remain upon a  Stomach so irritable, as  to reject  almost
every thing else; and as  soon as it operates actively,  will be found to be
 highly beneficial.  The Cathartic action must be aided by large Enemata.
 If the patient sink rapidly, and life seem ebbing away, I Avould not hesitate
to  exhibit stimulant formulae and nutritious fluids.   Spirit:  Terebinth: has
been highly and deservedly extolled.   Camphor  suspended  in mucilage,
may be given.   Opiate  preparations are  often soothing and useful.   The
Infus. Cinchonas is unobjectionable.  In the meanwhile, we aid in sustain-
 ing the feeble powers of life with Wine Whey, Milk Punch, &c.  &c.
   During Convalescence, great  care and prudence are necessary. '  The
Diet should be fluid or semifluid, and consist chiefly of vegetable materials
 Avith the  exception of Milk, which can be taken safely bv almost any one' 
PRACTICE.
83
and of Eggs, ra\v or very slightly boiled.   Flannel should be worn next
the skin, and all exposure and excess abstained from Avith  resolution  and
perseverauce.
   Chronic Gastritis—may supervene so gradually,  and  develope itself so
obscurely, as to exist for a great length  of time  without being detected—
the sufferer being supposed  to labour under Dyspepia  or Hypochondria.
It is, as  I  have said, often a consequence of the former disease, and is
hence frequently met Avith  in the studious and sedentary, though prudent
and temperate, as Avell as in the glutton and the sot.
   Autopsy sheAvs, that  it may proceed even to the  extent  of  erosion and
ulceration of the mucous coat of the Stomach, without having been  sus-
pected.
   Symptoms.   In general, the patient complains  of a sense of distension
increased after a meal, especially if of-stimulating food—increased  also
after  long fasting.  In its farther progress there is  nausea and oppression,
—extrication of gas—thirst—a  tongue  smooth  and fiery  red, and  ulti-
mately  covered  with apthous ulcers, as on the  lips, cheeks and gums—
these latter being also swollen and spongy.   The  pulse is small and Aveak;
—a febrile exacerbation maybe observed  at night, Avith restlessness and
jactitation and hot  dry skin—there  is emaciation  and  muscular debility,
Avith  dejection and  vacillation of mind.   There  is  often, but  not always,
pain  at  the Epigastrium, augmented by pressure.  Death  is preceded by
Atrophy and Diarrhoea.
   Treatment.   If the patient's strength will admit,  we  resort to the Lan-
cet—but his debility and emaciation will often render this resource impro-
per and  unavailable.   Topical Depletion by Cups and Leeches, is always
indicated, and should be repeated as often as it can  be borne.  Abstinence
from solid and stimulating food, must be  strictly enjoined, and the diet  con-
sist exclusively of the  mildest and most unirritating articles.  The Muci-
lages are generally advised;  but, in  some cases, produce great distress, by
occasioning fermentation, flatulence,  &c.  Here, as  an alternative, I alloAv
Milk diluted—Eggs  raAV or slightly boiled, and thin gelatinous  broths.
The  BoAvels must be kept soluble, but by gentle means.  Calomel, in small
doses, will scarcely disturb the most irritable Stomaeh, and will do much
service  both  as an evacuant and an  alterative.   Ptyalism,  if sloAvly indu-
ced,  and  not carried too far,  will prove highly beneficial.   The Alkalies
are almost ahvays useful, whether by their Chemical properties alone, or
through  other influence, I will not pronounce.   The combination of Carb.
Sodaa with  Rhubarb, will  suit many patients, and seems to exert a tonic
and restorative power, in addition to  its laxative and antacid quality.  We
should not fail to advise, Avhen it is in the power of the sick, a resort to our
Chalybeate, Saline and Carbonated Mineral Springs;—but it is to be care-
fully recollected, that in  the latter stages of these  cases,  where Chronic
Diarrlnea has come on, and the Intestines have lost their tone, all laxative
Avaters will do immediate and irreparable injury.
   The Mur. Tinct. Ferri is among our best Tomes here.  Here, also, tie
Acet. Plumbi is to be used, in union with Opium in  proper dose*.   \i.<i
here  the Mist Cretacon with  Kino, will  be of service 
S4
I'KAC'I i<  r..
                            ENTERITIS.

   Inflammation  of the Intestines,  often combined Avith the subject of the
previous Lecture, forming the  Gastro-Enterite so  much talked of at  the
present day, yet not unfrequently met Avith separately.
   Symptoms.  Comes on, usually,  Avith pain about the Navel, fixed and
extending over the Avhole Abdomen, and attended w ith nausea and  a  sense
of heat and burning, Avith great dejection of mind and prostration of bodily
strength.   The  [.atient lies on his  back, with his knees draAvn up, rarely
tossing the body, and shrinks from any pressure made upon the belly.  This
test, however is not so strictly diagnostic,  as some have affirmed.  I have
seen two fatal cases, in which pressure was borne with indifference.  The
Countenance expresses great distress and anxiety.  The Pulse is frequent,
tense,  chorded, contracted.  I  have seen black  matter ejected both by
vomiting, and by stool.   Constipation is almost ahvays present at  first, but
is succeeded by an irritating Diarrhoea m bad cases, Avith varied and highly
offensive  discharges.  At last,  the strength aid pulse fail—the Abdomen
becoming distended and  sympanitic, and exquisitely tender to the touch—
the Tongue is red and smooth and dry,  or covered Avith ulcers—the breath
is fetid, and the patient sinks  with Ioav muttering delirium.
   Diagnosis.  Enteritis  may be  confounded Avith Colic and Peritonitis—
from the latter of which, indeed, it is difficult  to distinguish it; but this is a
matter of less importance,  as the indications of Cure, and even the details
of the Treatment, are so precisely  similar in the two sets of Cases.  In
Peritonit-.s, the pulse is more voluminous—there is less prostration and nau-
sea—the  abdominal tenderness is  more  urgent from the  first—and the
alvine evacuations of less morbid  character.  In Colic, the pain is less
fixed—there are  intervals of ease  more distinctly marked—the  pulse is
little, if at all atiected—and more immediate  and  greater relief is experi-
enced  from alvine evacuations and discharges of Avind.
   Autopsy.  Like Gastritis, Enteritis brings on the fatal  termination in a
majority of instances, by its oppressive  influences upon the general consti-
tution, and  the local  lesions  are not  very  remarkable.  They  consist in
engorgement  or  congestion of the vessels of the mucous intestinal mem-
brane—the duodenum among the  small, and  the colon among  the large,
being most obviously affected—the  membrane is softened usually  in pro-
portion to the discoloration.  It is sometimes, hoAvever, pale and soft, as if
macerated.  Ulceration sometimes  occurs—and the intestinal parietes are
noAV and then entirely perforated.   I have knoAvn tAvo instances of extensive
gangrene of the colon and rectum.
   Causes—the same as those which produce Gastritis.   Intestinal  inflam-
mation he*©»frequently follows exposure to cold and moisture, and  is less
likely to be brought on by acrid ingesta.
   Treatment.   V. S.  boldly resorted to, but still Avith due caution.   Topi-
cal bloodletting by Cups and  Leeches over the whole Abdomen__Ice and
4U(Th*~ 
PKACTICE.
85
cold fluids liberally alloAved internally, Avhile warm fomentations and poul-
tices are assiduously used externally.
  The  question as to  the exhibition  of Cathartics in Enteritis, has been
long and warmly contested.   I have no  hesitation in employing Purgatives,
carefully selecting such as are least likely to  irritate and annoy.  Nothing
seems to give more prompt relief to  an inflamed mucous membrane, than
abundant secretion from its own surface.  I prefer to administer the Ep-
som Salt in alternate doses Avith  Calomel—a combir.ation at once mild and
active.   When the Bowels have been Avell moved, I discontinue the Salts,
but persevere in the use of the  Mercurial, until a gentle Ptyalism is indu-
ced, Avhich  is  invariably beneficial.  Large Enemata, in the meanwhile,
will aid our purgative, and render smaller quantities more effectual.
   When topical depletion can no longer be borne, and the patient has be-
come familiar with the fomentations, Revulsion may be  farther accom-
plished by the irritation  of a Blister, Avhich  should  be large enough to
cover the Avhole Abdomen.   Others may, with the same view, be applied
to the thighs and legs, if necessary.
   As in the  latter stage of Gastritis. Stimulants may be occasionally em-
ployed  with obvious advantage.   The Spirit: Terebinth: is  chiefly prefer-
red.  Camphor aud Opium are  also of unquestionable benefit.
   Chronic Enteritis—sometimes occurs spontaneously, and often folloAvs
as  the  consequence of the Acute form.  It  is characterized  by the same
symptoms as described above, but developed  more gradually, and Avith less
intensity.
   The  Causes, results and treatment, are likeAvise similar.
   Convalescence from Intestinal Inflammation, must be Avatched Avith pe-
culiar care, as there is no disease which leaves on its subsidence a stronger
tendency to recurrence.  The  Clothing  should be  Avarm, Avith Flannel
over the Abdomen; the Diet carefully  regulated—and all  Excess strictly
avoided. 
86
PRACTICE.
                          MILK-SICKNESS.

   This is  a peculiar form of Disease,  met Avith only in the mountainous
 districts of the Southern and Southwestern States.
   The Cause is not clearly made out—but  Avhether jErial,  Mineral or
 Vegetable, seems  to be limited in  its production and influence, to a few of
 the fertile coves that run in among the Mountain ridges.   It never directly
 affects the human  subject, but attacks chiefly,  if not exclusively, the  Cow
 and the Horse.   The latter soon  dies  if not efficiently aided;—the  Cow
 may live, and is more likely to do so, if giving Milk; but the Milk, Butter
 and Flesh become poisonous, exciting in those  who make use of them as
 food, a combination  of symptoms indicative of an  inflammatory affection
 of the Stomach and Intestines—a  true  Gastro-Euterite.  The localities
 subject to the presence of this undetected agent, are Avell known and de-
 fined, and  fenced  in against the intrusion of  Cattle; it  is said, that when
 cultivated, they lose their poisonous qualities.
   Symptoms of Milk-Sickness.  Within  a short time after the patient has
 taken the deleterious milk, butter or flesh, he is oppressed Avith languor and
 lassitude—soon folloAved by  nausea  and vomiting,  with  pain, burning and
 oppression at the Stomach.   The thirst is urgent—the skin hot  and dry—
 the eyes are red and  suffused and  glassy—a peculiar  odour exhales  from
 the body.   The Bowels are  obstinately constipated.  The Pulse, at first,
 little changed, becomes frequent and contracted.  Fever, Avith Ioav mutter-
 ing delirium, supervene, and the patient sinks, Avith  symptoms closely re-
 sembling those of Typhus  Gravior.   The convalescence is  sIoav and im-
 perfect, and  apt to be followed  by long debility, by Dyspepsia, and other
 Gastric disorders.
   The Treatment does not  seem to be Avell agreed  on.  The Stomach, if
 not thoroughly cleansed by spontaneous vomiting, should be Avell emptied
 of its injurious contents by Ipecac, or other mild Emetic, Avith draughts of
 Warm Water.   If the pulse and strength admit, V.  S. must be resorted to,
 —and, at  any rate, topical depletion, by Cups  and Leeches, Avill be re-
 quired.  The Bowels must be actively  moved by  mild Purgatives.   The
 oilv are preferred;  and 1 found,  that in neighbourhoods subject to this dis-
 ease. Bears' Oil  Avas confided in as a sort of specific remedy.  01 Ricini
 and Calomel will ansAver in combination  or alternately every purpose—and
if the disease be not fully subdued, the  Mercurial should be urged to the
extent of a light Ptyalism.
  During convalescence, and indeed  for an indefinite period after it. great
care must be taken as to Diet, and all exposure and excess rigidh" abstain-
ed from. 
PRACTICE.
87
                               COLIC.

  This is one of the most frequent and painful  of human diseases;  but is,
fortunately, among the most manageable and least fatal.  It has been divi-
ded and  subdivided into a great number of species and varieties, in refer-
ence  to  the causes Avhich give rise  to the attack, and the consequences
Avhich may attend it.   I shall treat of it under three heads:—1.  Flatulent
Colic—2.  Bilious  Colic—3. Colica Pictonum.
   1. Flatulent Colic  presents  the folloAving  symptoms:—Pain  in  the
BoAvels, Avith a sense of twisting  and griping, especially about the Navel ;
Nausea, Costiveness, a feeling of Distention, which, in most cases, really
supervenes  after  a time Avith tympanitic resonance of the  Belly, giving
rise to  much general  distress, Dyspnoea, &c.  The Pulse, unaffected at
first, becomes, in a feAv hours, quick and frequent—pressure which, early
in the attack Avas sought for, cannot be borne—the vomiting is more and
more urgent—and if stools have not been procured, fecal or stercoraceous
matter is  ejected from the  mouth, forming the  Iliac passion;  nay,  this
inversion of the  intestinal peristaltic  action is occasionally so complete,
that  Glysters are vomited up;  cold  sAveats exude from the skin, and  the
patient sinks, Avorn out Avith his intolerable  sufferings.   Or the  irritation
runs on into the production of exquisite Enteritis, Avith gangrene or ulce-
 ration.
   Post Mortem examination sheAvs sometimes  little or no alteration in the
parts affected—sometimes constriction of a portion of the Intestinal tube,
 Avith distention of the part immediately above it—and sometimes  disten-
 tion  without any such constriction.   Not unfrequently there is found intus-
 susception of one portion of the tube within another, with  strangulation of
 the part received, and its consequent mortification.
    The Causes of Colic  are  numerous and much diversified.   The  pre-
 sence of crude,  acrid, indigestible food—long fasting—exposure  to  cold
 and  moisture—vegetable matters specially  liable to  fermentation.   But
 the secretion of Gaseous and ^Erial Matter, or of a fluid having  such  affi-
 nity for Caloric, as to take on the  Gaseous form instantly on its secre-
 tion from the Intestinal surface,  seems highly  probable  in Colic,  besides
 the extrication of air from fermenting Vegetables.
    While treating a patient for Scarlatina in 1831,1 saw three violent par-
 oxysms of Flatulent Colic brought  on at  intervals of 24 hours, by Ene-
 mata of thin  strained Gruel—-Nothing but Water, and that in very mode-
 rate quantity,  having  been taken in the meanAvhile by the sick man, avIio
 had been managed strictly on the expectant system.  In another, a  Dysen-
 teric subject, an  enormous and obviously tympanitic distention took place
 in the  course of a  single night-—all his former symptoms of Alvine dis-
 order suddenly leaving him.   He recovered slowly, and with Ascites.
    Pathology.   All circumstances seem to me, to establish the belief in the
 essential and  invariable presence of  spasmodic constriction of some por-
 tion of the  Intestinal  tube.  The mere loss of muscular poAver, and the
 cessation of peristaltic action, Avith  the consequent distention of a section 
        88                          PRACTICE.

        of the tube, as supposed by Abercrombie, does not account for the symp-
        toms—-the pain—the constipation—-the obstruction to the passage of air,
        the intussusception and strangulation of the  received  portion of gut.  In
        Hernia,  where the phenomena are very similar, we knoAv they depend upon
        such a stricture, and are readily relieved by its mechanical division.
          To these arguments,  a priori, Ave  add the folioAving,  a posteriori:  If
      .  Distention be the essence of the Disease, it is impossible to account for the
        undoubted  utility, nay, the immediate efficacy  of  relaxants and ariti-irri-
        tants in  its removal;  yet the Lancet  and Opium are our principal  reme-
        dies, and the Warm Bath, Tobacco, and the Antimonials, are highly recom-
        mended  by Abercrombie himself.
          Treatment.  In the early stage,  the domestic administration of Aroma-
        tics,  and so styled Antispasmodics, often succeeds completely—as Mint,
        Ether, Camphor, &c.   If the Stomach have recently received any suspici-
        ous articles of food;  or, if it be loaded Avith  a full meal, it should be emp-
        tied by an active Emetic.  The Warm Bath  and Opium are almost uni-
        versally  indicated.  Purgatives, at  this  stage,  are hurtful; but Enemata
        are highly serviceable.  If the  Pulse rise, and the Abdomen  become ten-
        der  on pressure, the Lancet must  be used freely—and Cups or Leeches
        applied to the Abdomen, Avhich should  be covered Avith Avarm fomentations
        or poultices.  Mild Laxatives are noAV proper—01  Ricini with Tincture of
        Opium, or Calomel and Opium in moderate doses, will be of evident benefit.
        By such means as these, assiduously and perseveringly employed, we may
        almost always prevent the obstinate Constipation and violent Intestinal and
        Gastric disturbance so often described, and  Avhich  most frequently appear
  .  r,v  to be consequences of harsh and ill-judged  management.   If relaxation
 ^      be aimed at, it can be most efficiently accomplished by the employment of
        Tart. Ant. and Tobacco in Enemata.   Croton Oil rubbed on the Belly, or
        on the Tongue, will,  it is said, operate actively  on  the obstructed Bowels,
r^    ,  in difficult cases.  I have succeeded,  in  De Haen's method, by the mere
        mechanical distention of the lower Intestines, by large quantities of tepid
        Avater  throAvn up steadily  from a Syringe  or  inverted  Stomach-Pump.
        The use  of mechanical  deobstruents  by the mouth—-such as  gold and
        silver Pills and crude  Mercury, I mention only to reprobate.
         2. Bilious Colic—-a. modification of Ileus, Avhich oAves its character-
        istic peculiarities to the cause producing it—-to the state of the system of
       the subject—-and to the season  of the year in Avhich it occurs.  It  is met
       Avith in Summer and Autumn—-attack persons  of "Bilious  habit;"  those,
       namely, Avho are subject to  Hepatic affections—-and  is attributed  to the
       influence of Mal'aria.   The immediate irritation of the Intestines is, pro-
       bably, excited  by the entrance  into them of a vitiated and acrid Bile---
       And in all the attendant circumstances, there is an obvious analogy Avith an
       ordinary  Autumnal Remittent.
         The access of Bilious Colic,  is often accompanied Avith a febrile chill,
       Avhich  is succeeded by flushing  of the face, heat and dryness of the skin,
       great thirst, and  a full, hard and frequent pulse.   The  vomiting, Avhich is
       urgent, brings  up Bile Avith morbid secretions—-and there  is  great heat
       and  oppression  at the  pit of the Stomach—-Avith  intense pain over the
       Avhole Abdomen.   There is obstinate Constipation.  Avith Tormina and
       Tenesmus.
         Treatment.  V. S. is obviously required, and must be promptly carried. 
PRACTICE.                          89
  to as full an extent as the strength Avill alloAV.   Opium cannot be dispensed
  Avith, and is demanded in  free  doses to relieve the sufferings of the pa-
  tient.  Cathartics may be given alternately, or in combination; but there
  is much  difficulty in procuring their operation.   1 prefer to employ large
  quantities of Calomel and  Opium together, aiding  their effect by proper
  Enemata.  In  the meanwhile, the Warm  Bath should be resorted to—the
  Abdomen cupped,  and fomentations or poultices applied.   When the Intes-
  tinal Constriction and Obstruction are overcome, the Case usually requires
  to be farther treated as a Bilious Remittent.
     3. Colica  Pictonum—Rachialgia—Painter's  Cholic.   This Gastro-
  Enteric affection, is always attributable to the poisonous influence of some  i,
  of the Salts of Lead, a metal so Avidely employed in the arts  of civilized
  life, that all are liable to be, in their turn, acted upon by its peculiar effects,
  Avhich are, in many cases, developed very gradually,  and in a chronic
  form.
    Symptoms.   Rachialgia commences Avith a dull pain at the pit of the
  Stomach, extending downwards and fixing Avith great  severity at the
  Navel.   The Abdomen becomes tender, and is  draAvn backward and flat-
 tened, with much pain in the loins and  back.   There is obstinate costive-
 ness, Avith occasional inclination to go to stool.   There is, usually, but not
 ahvays, nausea and vomiting.  The Pulse is small and tense and frequent,
 Avith headache, restlessness and dejection of mind.  The patient is emaciated
 and feeble, and prefers a bent posture, leaning fonvard.   Epilepsy super-
 venes  occasionally—but much  more frequently, a  peculiar Paralysis of
 one or both of the upper extremities, Avith flaccidity of the Avrist and hand,
 and wasting of the arm.
   Autopsy—presents  no uniform  appearances.  The Mucous  surface of
 the Intestines is generally pale.  Sometimes, but not often, the usual re-
 sults of Inflammation of this  tissue, and of the Peritoneum, are met with.
 The BoAvels are,  in some places, contracted, in others,  irregularly  dis-
 tended.
   Treatment.  Opium  is the principal remedy,  and  must be employed
 freely from the first—given in full doses by the mouth, mixed in Enemata,
 and applied  to the surface in Poultices and fomentations.   After a time,
 Cathartics must be given alternately,  or in combination Avith it—the mild-
 est being, for that  reason, the best, if at all efficient.   01 Ricini—Sal Ep-
 som—and  Calomel—are usually preferred.   If the  pulse and strength
 admit, the Lancet  may be used, and the Belly cupped or leeched,
   In protracted Cases, Alum  and poAvdered Nutmeg, haAre  been highly re-
 commended.   Epispastics are also advised to be put on the Abdomen and,
 Thighs, successively.   During Convalescence, a  Flannel fold  and  Ban-
 dage should be worn around the  trunk of the body, and the Diet carcfulh
 regulated.   The Paralysis of  the Arm and Hand,  above described, is best
 relieved by supporting the limb  in a carved Splint, Avell  fitted to it; Avhile
 Ave administer Calomel and Opium in small doses, and Avith perseverance,
 until a general Ptyalism is induced.
   In obstinate Cases,  Strychnine is said to have been exhibited  Avith a fa-
 vourable result.  The Nitrate of Silver has received similar eulogy also.
 Locally, the Cold Affusion may be of service; but more is to be hoped f<>v
from the assiduous employment of !\le,~:;vicity and Galvanism. 
90                         PRACTICE.
                             CHOLERA.

   It is  necessary to treat of this affection of the Stomach and Bowels
under the separate heads of—1.  Common or Sporadic Cholera—2. Epi-
demic  or Malignant Cholera.  The first is among the most ordinary  dis-
eases of all climates  and seasons; and though alarming by its suddenness
and violence, yet fatal in but a small  proportion of cases: the  second, ou
the other hand, though undoubtedly identical in nature and pathology, has
spread the utmost dismay throughout the civilized Avorld, by the rapidity of
its career.   Since, in the early  part  of the present  century, it attracted
attention in British India,  it has  every Avhere  exhibited a proportional
mortality almost beyond example.
   1. The  Symptoms  of Common  Cholera  are,  to  every one, familiar.
Vomiting and  purging, Avith  pain and cramp of the Stomach and  limbs,
with great  prostration of strength, cold and clammy skin, and  extreme
anxiety  and dejection of mind.  Death may sometimes  occur from the
immediate loss of strength, which follows the immediate  evacuations up.
Avards  and downAvards—it sometimes happens  too, that when  these have
subsided spontaneously, or have been  checked, a true Gastro-Enteritis su.
pervenes, with fever of Ioav irritative type.
   The  Causes of Cholera are numerous.   Crude  or indigestible food
taken into the Stomach—raAv or half-cooked or putrescent Vegetables—
Fruit in excess or unripe—and some Fruits by their acid  quality—Ices
and Confections in undue quantity—Shellfish to those unaccustomed to use
them—a Supper of mixed materials, taken just before going to  bed—Ex-
posures to alternations of temperature, and to cold with moisture.  From
its more frequent occurrence in Autumn, and in Ioav hot regions, it is usual
to speak of  Mal'aria as among its Causes, and to regard it as occasionally
the effect of the flow of a A'itiated and acrid Bile into the  Alimentary Ca-
nal;. and facts seem to me to justify the opinion.  Many of our Medicines
(as Tartarized Antimony, &c.) produce it readily; and a very severe form
of it supervenes  upon repelled eruptions, and follows sudden and careless
exposure after the subsidence of the Exanthemata—Measles  especially.
   Autopsy displays nothing uniform or explanatory.   When the Case has
oeen of brief duration, little trace of  disease is left.   If more protracted,
there are obvious marks of inflammatory irritation of the Gastro-Enteric
Mucous  surface, Avith occasional extension of Inflammation, and its results,
rjb the Peritoneum.
   The Prognosis is, for the most part, favourable, provided the patient be
of ordinary vigour, and the case be early treated Avith proper attention.   If,
on the  other hand, it  has been neglected or injudiciously managed—and
especially, if symptoms of Gastritis or Enteritis have made their appear-
ance, the danger has become serious.
   Treatment.   In a great  majority of instances, Opium is of itself suffi-
cient to calm the Gastric irritation—from Avhatever cause  arising, and to
subdue the disease.  With Sydenham, I prefer  '"liquid Laudanum" to any 
                                     8l:> 'VI  r   . ,.■

                             PRACTICE.                          $1

 other formula; it should be given in full  doses, and if not retained Avhen
 SAvallowed,  should be  throAvn up the rectum  in  a mucilaginous Enema,
 Avhile fomentations or poultices mixed Avith it,  are applied to the  belly.
 Sinapisms  should  be laid  to the wrists  and ankles; and  if the  strength
 fail, Stimulants may be required, as Ammonia, Ether, Camphor and Bran-   .
 dy.  In general, these  remedies will be found sufficient; but, if the  relief   -
 thus  procured be  imperfect, some febrile excitement, manifesting itself
 Avith menace of Gastric and Intestinal Inflammation, the treatment already
 advised  under such circumstances, must be  promptly and assiduously in-
 stituted.                              t, i v ■. . t <  ',  r
 *-2.  Malignant or Epidemic Cholera.:• To  the symptoms above recoum   ,
 ted, as belonging to Cholera generally, Ave are to add, in the  description of   ? -■;
 this terrible  pestilence, certain striking phenomena, Avhich  some consider   "^
 indeed as peculiar to, and characteristic of it.
   The Evacuations are of almost uniform appearance, consisting of a Avell
 knoAvn serous  fluid, writh  minute whitish  flakes,  and  strongly resembling
 rice Avater or thin gruel.   The Spasms are extremely violent, contracting,   '.
 with severe cramps, almost every muscle of the body.   The Blood, when
 drawn  from a vein and examined with chemical reagents, is found to be
 deprived, in great proportion, of its serum and  the salts usually contained
 in  it.  The stage  of Collapse, into Avhich patients often sink, is  remark-
 able.  It seems to me to be a state of true Capillary Paralysis.  The sur-
 face is quite blue or livid—or as I saAv it in  one  case,  of dark mahogany
 or bronze colour—the skin is as cold as after death, with a  clammy mois-
 ture,  Avhile the patient complains often  of intense heat—the hands and
 feet are  shrunken  and corrugated,  as if  sodden  a long Avhile in Avater.
 The urinary secretion  is, in bad cases, very much diminished or even to-
 tally  abolished.  The voice fails or sinks to a husky Avhisper, described as
 the Vox Cholerica.   The progress is fearfully rapid—patients often dying
 Avithin a few hours, and in some feAv of the more malignant attacks, in a
 still shorter period.
  The form assumed is somewhat modified  in the different localities i;i-
 vaded.   In some places,  we find Spasm more  prominent—in  others, the
 serous evacuations are more profuse—some are  favoured with a benign
 alarm from premonitory symptoms, as Diarrhoeas, &c.—Avhile others are
 overwhelmed Avith aAve by the fearful  promptness  Avith Avhich the sick fall
 into Collapse.  The consecutive febrile stage is, in France and England, a
 more common  Sequela—in  other countries, it is met with but  seldom.
 comparatively.
  Causes.   A  peculiar distemperature of the atmosphere, in nature and
 origin, absolutely unknoAvn, is  assumed  to be  the Generating  Cause of
 Cholera  Avhen  prevailing in this malignant and epidemic form.  I am of
 those who regard  it also as contagious, and attribute its extension, in some;
 measure, to .'his form or quality.   The  question is hotly contested, but there
 are certain facts Avhich can be explained and understood no otherwise than
 by  reference to such  a property of communicability.  We do  not, Iioav-
 ever, doubt or deny the atmospheric distemperature supposed, although the
 mode in Avhich such contamination arises, or is  effected, has not yet been
 the  subject even of a plausible conjecture.  This  pestilence is. "to a de-
gree unprecedented in the history of Epidemic diseases, independent in its
prevalence,  imon anv of the ordinary influences of place,  season  vr  v 
92
PRACTICE
mate, pursuing its ravages with equal sway  "under the burning line,"  and
amidst the Avintry snoAVs of Russia.
  Prognosis.  The  danger seems to be  proportioned  to  the Collapse—
that is, the circulatory stagnation and general loss of strength.   The inor-
dinate evacuations are sometimes Avell borne, and do not shoAV the greatest
degree of risk, unless attended by notable prostration.   The absolute non-
secretion of urine, is among the most fearful  tokens—and its resumption,
on the other  hand, sheAvs a change for  the better.   So,  also, does the re-
covery of the natural tone of  voice,  when it has been much altered.  The.
intensity of Spasm  has sometimes proved fatal; but, Ave are not to draAV
favourable inferences from its  subsidence, unless there is, at the same time,
increased fullness of pulse and warmth  of skin.   Such  vascular reaction
affords  the best hope  of recovery, but  requires to be carefully  watched,
and depletion, if necessary, to be cautiously graduated.
  The Diagnosis can only relate to  the distinction  between Ordinary and
Asiatic Cholera—for this purpose, the history of the preceding and  atten-
dant circumstances Avill usually suffice—though there are cases of the one
so mild, and of the other so severe, as to resemble very closely.
  Autopsy.   The external appearance  of the body is striking.   The  so-
lids  are shrunk—the surface  is lived, bronzed  or blue—the skin of the
hands and feet corrugated—the  fingers often rigidly contracted by Spasm,
Avhich,  indeed, in cases of short duration, may continue  to affect the vari-
ous muscles  several hours after  death.  We are Avarned  not to pronounce
hastily, in such  cases,  that death  has taken place, as several singular in-
stances of recovery have been recorded under the circumstances.  There
is, occasionally, Congestion of the vessels of the Brain, and some extrava-
sation within  the Cranium.   Magendie describes  a ghastly transparency
of the Sclerotica, as occurring even  a short time before death, or immedi-
ately after it.  wThe Lungs and Heart are usually healthy, but gorged Avith
dark  blood.   The Mucous Coat of  the Stomach and Intestines  is, for the
most part, pale"or blanched in those who die in the early stage of an at-
tack; Avhile  the other  Abdominal Viscera  shews  marks  of Congestion.
When the Case has been protracted, the  congestion of the Liver and Spleen
has disappeared, and  the  villous  Intestinal tunic exhibits traces of vari-
ous  degrees  of inflammatory irritation.  The Stomach and BoavcIs  are
found often filled wiih a serous or gelatinous  fluid, identical Avith that dis-
charged by vomiting and purging.   The  quantity thus excreted, is suffi-
cient to account for  the defect of serum and the  salts dissolved in it, in the
blood of Choleric patients—the analysis of Avhich, has been made with
great nicety by Clanny, O'Shaughnessy, and others.
   Treatment.  In mild cases, seen early—and in subjects  Avarned  by the
slighter precursory symptoms, I would promptly exhibit the Tinct. Opii in
efficient doses, putting the patient to bed, and covering the Abdomen Avith
warm Fomentations and  Poultices,  and the  extremities Avith Sinapisms.
These  means failing  to  relieve, I Avould perhaps  resort  to the Lancet,
Avatching anxiously the effect  of the  loss  of blood  on  the  pulse and
strength.   I  Avould cup the Epigastrium and Belly,  and  apply Leeches to
the back of the  Neck  and behind the Ears.   I Avould depend upon the in-
fluence of Calomel, Avhich I  Avould combine  with  Opium, proportioning
the dose to the urgency of the  Case.  If the pulse sunk,  and exhaustion
threatened to supervene. I Avould administer Capsicum and Camphor: and 
PRACTICE.
93
if the prostration increased, employ unhesitatingly, though with reluctance,
the most energetic of the diffusible Stimulants.   Ice ad  libitum should be
allowed during all the stages of the attack, if agreeable and asked for.
  The true Collapse—not a state of congestion or concentration, but a
complete Capillary Paralysis, is an  almost hopeless condition,  and fairly
beyond the resources of our  art;—but Ave must not abandon our patient;
and in our embarrassment, I Avould decidedly prefer the Stimulant, rather
than the opposite class  of measures.  A  Mustard Emetic Avith Salt—fol-
loAved  by  free doses of Turpentine, Capsicum, Laudanum and Ether—
Avith the  application of heat and irritants to the surface, seem to me the
most promising remedies.
   In the Consecutive fever—topical and sometimes general  bloodletting—
the application especially of Leeches to  the temples and occipital region.
Mild Cathartics, Avith the Mercurial treatment carried to the extent of a
light Ptyalism, are the measures most obviously indicated.
   I  scarcely  need  say, that  I have little confidence  in the exhibition of
Saline Medicines, in large quantities,  as  recommended by Stevens—or in
their introduction into  the veins, as practised by Latta and others—or in
the inhalation of Oxygen—or the deluging the Stomach Avith either Warm
or Cold Water, in the indefinite draughts  lauded by Shute and his antagon-
ists on either hand—or in the Tobacco Enema of Baird—or the frictions
with Ice, proposed by Jackson. 
94
PRACTICE.
                           DIARRHOEA.

   Inordinate frequency and fluidity of the Alvine evacuations.  Very gen-
erally, though not ahvays, there is griping pain preceding and accompany.
ing each  motion,  and relieved by it  for a time.   Anorexia attends, with
nausea sometimes, and vomiting—the tongue is furred- and whitish—fever
is rarely present.  If the  case be protracted, there is emaciation and great
debility—the lips,  cheeks,  gums, &c. become aphthous—and the patient
sinks at last, exhausted by the unceasing drain, and the Atrophy, which of
course results.
   Diarrhoea has been subdivided into  many species  in  reference to  the
alleged sources and  the morbid peculiarities presented in the stools—but
the Pathology is in  all the same.   The Mucous Membrane lining the  Di-
gestive Canal, is irritated and excited to morbid and unnatural action—its
vessels pour out an increased amount of secretion, variously changed,  ac-
cording to the circumstances, and a symptomatic or consequent urgency of
peristaltic movement ensues.
   Causes.   Indigestion, whether from excess in quantity, or any other cir-
cumstance  disordering the Stomach, is  the usual commencement of attack\
of Diarrhaea.   There are indeed many  substances, Avhich, by some pecu-
liar property, bring on transient Diarrhoea,  as the Avhole class of Laxatives
and Purgatives, several articles of food, as for example, preparations of
indian corn, many  fruits, ripe and  unripe, molasses,  confections, ices, &c.
&c.   The  Disease results  also from sudden exposures  to atmospheric
vicissitudes, and to cold and moisture.   It  arises from  impressions made
directly or indirectly upon the Liver, occasioning an undue Aoav of vitiated
Bile into the Duodenum.   It occurs from repelled Eruptions,  and at  the
subsidence of the  Exanthemata—from irregular Gout and Rheumatism—
and, in some cases of Fever, Avhen the evacuations  are spoken of as "cri-
tical."
   Prognosis.   If  early and judiciously prescribed for,  Diarrhoea is  not
generally difficult  of cure;  but if neglected or aggravated, as is often  the
fact, by the employment of inappropriate medicines, it may terminate  fa-
tally,  though this is rare;  or it may run  on  into a Chronic stage, in Avhich
it assumes a singular obstinacy, enduring for months, and even years.
   Treatment.   It has been too much a general rule, to begin the manage-
ment  of Diarrhoea,  by the exhibition of an  Emetic or Cathartic, or per-
haps both.   This  is  seldom proper.  Where foul, crude, irritating ingesta
have been recently taken into the Stomach,  a mild Emetic of Ipecac, may
be premised; and  if the stools have,  from  the first,  contained little or no
feculent matters, giving reason to suspect their retention, a gentle Cathar-
tic of 01 Ricini, Pulv. Rhoei, or  Calomel, may do service by the removal
of such oppressive accumulations.   For the most part, however,  the eva-
cuations have been sufficiently free:  and it  is best to commence at  once
Avith the administration of Opiates and  Diaphoretics.   The  Dover's Poav- 
PRACTICE.
95
der, or the Tinct. Opii Camphorata, will, with feAv exceptions, put an end
to ordinary attacks.   If soreness of the Abdomen exist, or febrile excite-
ment be present, it may be proper to Cup or Leech the belly.  Fomenta-
tions and Poultices, mingled A\rith Mustard or other stimulant, are ahvays
useful.  Alkaline and Astringent Medicines are next to be prescribed.  Of
the former, the Carb. Potass, Cret.  Ppt. and Aq. Calcis, are much relied
on.  Kino is preferred to all the Astringents, and has received high eulo-
gies from Pemberton and Bally.  The Cretaceous Julap is a familiar and
very extensively applicable  combination  of the mucilage of Gum Arabic,
Avith Cret. Ppt. and Kino and an Opiate.
  In Chronic Diarrhoea,  the Sulphate of Alumin, Zinc and Copper, have
met with zealous advocates.  The  latter is much employed by Elliotson.
The Acet. Plumbi is deserving of confidence.  The Diet should be nour-
ishing but plain, with little  fluid of any kind, and all Stimulants avoided.
The trunk of the body should be enveloped in Flannel, and a journey or
sea-voyage undertaken.
.v-
?U  iuvU'.,:.r 31"^  <A"tn*> M^
 r-
4- 
96
PRACTICE.
                           DYSENTERY.

  Pain  and disorder of the BoAvels, Avith Fever—Tormina and Tenesmus
Avith Alvine discharges of Mucous, or Muco Purulent or Muco Sanguino-
lent matter—these are  the general symptoms Avhich concur in the designa-
tion of Dysentery.
  It presents itself often Sporadically, and not unfrequently  as an Epide-
mic—is notably modified by season, climate and other circumstances, and
exhibits occasionally a contagious disposition;  nay, Cullen and others re-
gard Contagion as one of its uniform characteristics.
  Dysentery comes on with  some Gastric uneasiness, for the most part,
with griping and frequent calls to stool; the evacuations are scanty and un-
satisfactory, and give  no  relief, being attended Avith  much straining, and
consisting at first of a  mere bloody mucus, fecal matter being very seldom
discharged, and  in vfery small quantities.  Febrile excitement  runs high,
with heat and dryness of skin, and full hard  pulse—or, in other cases, par-
takes  more of the characteristics of Typhus, when Ave have sudden pros-
tration, with feeble circulation and Ioav muttering delirium;—the  belly be-
comes sore to the  touch—the tongue  is fiery red—at first  covered  with a
thick fur, but clearing  off after a time Avith a smooth epithelium-like sur-
face;—there is  great restlessness,  Avith  much anxiety and  oppression and
sighing.  The Alvine discharges are hoav very frequent and exceedingly
offensive, and much and  variously changed in appearance and  qualities.
Small, round, hardened faecal lumps (technically denoted Scybala) are oc-
casionally passed by the patient, and ahvays with notable relief^—lumps  of
sebaceous matter are also  sometimes voided.  The Stomach is now and
then, in these latter  stages, irritable—debility and emaciation rapidly in-
crease—the abdominal pains having reached an intolerable intensity, some-
times cease suddenly and  entirely, and death soon follows.
  Autopsy.   Dissections  uniformly reveal  the results of Inflammation—
often shewing Constriction of some part of the Intestinal  Canal.   These
lesions have been most frequently found in the Colon.  Ulcers are seen  of
various sizes  eroding the Mucous Coat—and gangrene is occasionally met
with of greater or  less  extent.
  Diagnosis.   Dysentery has been  confounded, on the one  hand, Avith
Diarrhoea—and on the other, Avith mere Intestinal Inflammation, Avhence it
has been styled by Ballingall and others a Colonitis.  From Diarrhaea it
is distinguished by the  essential presence of Fever and of Spasmodic Con-
striction.  Dysentery is  uniformly a  Pyrectic  affection; and  Ave cannot
doubt of the invariable constriction of some part of the tube, as in Colic,
when we reflect on the difficulty Avith Avhich foecal  evacuations are pro-
cured, and the relief Avhich always folloAVs at once Avhen they do happen.
  That the Intestine is inflamed in Dysentery is obvious and certain; but
the nature of this  Inflammation  is peculiar, and it  is uniformly combined
with circumstances and conditions Avhich do not occur in Enteritis.   In
true Enteritis Ave have no excitement  of the peristaltic movements  of the 
PRACTICE.
97
BoAvels, so urgent in Dysentery; nor is there present  the Tenesmus, nor
griping—nor the tokens of Spasmodic Constriction met Avith in the latter.
  The Pathology  of Dysentery presents several complicated conditions,
Avhich separate it—(in Practice readily enough)—from  all other disease.
Pain, Fever  and Inflammation,  Ulceration  and Hemorrhage,  large in-
crease and morbid alteration of the Intestinal Secretions, Avith urgent vehe-
mence of the  peristaltic actions, all combine in each individual case.
  Causes.   Dysentery may occur sporadically at any season  of the year,
ljke Cholera and Diarrhoea, from the irritation of the Alimentary tube, by
improper crude and  acrid ingesta—or by exposure to  cold and moisture
and sudden alternations of temperature.
  It  may arise as an Endemic, in localities subject to the influence of
Mal'aria,  and in the  Autumn especially.   This form, called by some Tro-
pical Dysentery, is  supposed to be  closely connected  Avith  Hepatic de-
rangement and effusion of vitiated Bile.
  It occurs not unfrequently as an Epidemic, spreading rapidly and exten-
sively by means of some unknoAvn  atmospheric contamination.   It as-
sumes probably  a Contagious character  under certain  circumstances,  as
when it invades a Jail, Hospital, Ship or Camp—croAvded and ill-ventila-
jted places—and Avhere the attendant Fever is of Typhus type.
  Prognosis.  The general prognosis in Vernal and Winter Dysentery and
in Sporadic attacks,  is favourable—not so much  so in  Epidemic and Au-
tumnal Dysentery—and decidedly the reverse Avhen the fever is of typhoid
character.
  In particular Cases, the danger may.be considered  as in  pretty exact
proportion Avith the urgency and frequency of the calls  to stool; and a di-
minution of this frequency is one of the most pleasing symptoms.  The
nature, too, of the discharges, is of some importance.   Hemorrhage is  a
sign  of evil, as sheAving the erosion  of some vessel, or extreme force of
vascular  determination to some part of the internal  surface; purulent
fluid, as resulting  from high inflammatory excitement, not unlikely to  be
productive of ulceration; so also fibrinous shreds or pieces of membrane,
similar to that found in the Larynx in Croup; and ichorous or sanious and
highly offensive matters,  as giving reason  to  dread the supervention of
Gangrene.   Relaxation of the Sphincter Ani is almost certainly a fatal
prognostic.
   Recovery is probably at hand Avhen the fever subsides—the tormina are
less severe—the tenesmus less  urgent—the  alvine evacuations  assume a
fecal  odour  and appearance and the tongue becomes moister and less
red.
   Treatment.  Bloodletting  is  very  generally indicated—less frequently,
I think, in the Epidemic  and Autumnal Dysenteries;—it is  of course un-
suited to cases of  feeble constitution and typhus combination.  Topical
depletion by Cupping  and  Leeching the Belly, is also generally useful;
after Avhich, fomentations and irritating poultices should be applied.  Erne-
tics  have been highly lauded; but  I have seen  little benefit  from  them.
 Cathartics are not always required; but, if properly selected, will often do
good service.   In such attacks as  occur in Winter and Spring, (Avhich
have been regarded as Catarrhal or Rheumatic) and in Epidemic Dysen-
tery, I do not think  them necessary, but would commence the treatment b\
administering  an Opiate and Diaphoretic—as  Dover's Powder or Tinct.
                          13 
98
PRACTICE.
Opii Camph: in full dose.    We may proceed to combine a feAV grains
of Calomel, if the cases threaten to protract themselves;  and under this
simple management they  will, in a vast majority of  instances, yield

'  In the other forms of the disease, those, namely, which result from acrid
ingesta, and such as depend on the impression  of Mal'ana, we must em-
ploy the class of Mild Purgatives.   In the first, it is usual to prescribe the
01 Ricini  alone, or  with a small amount of Ipecac; nor  can we advise  a
better formula.   After its  operation,  the  Belly should be well fomented,
and an Opiate exhibited.
  In Tropical,  Autumnal, Mal'aria or Bilious Dysentery, the  best of our
Cathartics is the Mercurial; and the experience of all Practitioners, in hot
climates, is in favour of its prompt and unshrinking administration.  From
one scruple upAvards of Calomel  is the dose—which should be repeated
Avith  a frequency proportioned to  the violence and danger of the attack.
I give unhesitating  testimony to the remarkable  success  of this method
of treatment.   Ptyalism need not  be aimed at, and may usually be avoid-
ed—the patient's life being secured without it.
  It would be unwise to omit  in  the meanAvhile the  use of the Lancet,
if the  inflammatory symptoms run high—the Opiate, Avhich conduces so
admirably to the relief of suffering, or the Cups and Fomentations so bene-
ficial,  locally.   Epispastics are, by some Physicians, very much trusted to
as adjuvant means  of revulsion, wrhen the  earlier stage of the case is past.
They are applied both  to the Abdomen and the Extremities—and some-
times effect striking results.
  The employment of Enemata  of various  formulas and qualities, may
tend much to the comfort and advantage of the  sick.   Cold  Water, un-
mixed, is  among the best as diminishing pain and irritation.  Mucilages,
Avith Opium, subdue the griping and tenesmus.  The Acetate of Lead has
been  administered  Avith obvious good effect, both in clysters and by the
mouth, Avhere Hemorrhage—Avhether venous or arterial—has occurred.
   The general  management of the patient is  of great importance.  He
should be kept as quiet as  possible in a recumbent posture, rising as  sel-
dom and Avith as little exposure as may be.  He should be instructed to re-
sist, with his utmost resolution, the urgent calls to stool Avhich annoy him,
and the reiteration  of Avhich is susceptible of unlimited increase by  indul-
gence. His chamber must be kept specially clean and pure, and his eva-
cuations ahvays removed on the instant.   His Diet should consist of the
lightest mucilaginous infusions, as Toast Water and thin  Gruel.  Pure
Water is  his best drink, though he may  be alloAved to acidulate it a little,
with either a Vegetable or a Mineral Acid, according to his fancy.  Every
thing he takes should be offered in small quantities at a time, as the  dispo-
sition to stool, is apt to be suddenly augmented by a large  draught.
   Chronic Dysentery sometimes comes  on slowly as a primary  affection;
but  is far more frequently a consequence or continuance of" the Acute
ifc-rm.   A similar management of the Case  is neceasary—modifying the
     ;y rf the trcafine>:t—and the doses and repetition of the remedies  em-
ployed, in  reference  to the less urgency  and violence of the symptoms,
 b ■ debility so universally present, and the tenacious obstinacy Avhich the
attack has acquired  from the influence of the habit of morbid action.   The
Diet  should  lie carefully regulated, nourishing but unirritating,  and the 
PRACTICE.                         99
Flannel Roller worn  round the trunk of the body.  The Acet. Plumbi,
Opium, Ipecac, in small doses, Kino, and the other Astringents, Mineral
and Vegetable, may be tried in succession or combination, and with perse-
verance—but our best  hope is in a long journey or sea-voyage.
i 
100
PRACTICE.
                     •  HOLERA  INFANTUM.

  Under this title, Physicians  have  treated  of every varied form of de-
rangement  of the Digestive System and  function which can affect early
childhood, including besides true Cholera,—Dyspepsia, Diarrhoea, Dysen-
tery, Scrofulous Marasmus, Atrophy from Avhatever cause, Verminous dis-
orders, and even Infantile Remittent and Hydrocephalus.  I intend by the
appellation—Cholera  Infantum—Avhen strictly applied, that modification
of BoAvel Complaint Avhich is met Avith in Spring and early Summer, and
Avhile the process  of  Dentition is going  on.   I  shall, hoAvever, follow in
some degree the general custom, and take the opportunity  to notice the
modifications Avhich the tender age  and the habits of body of our juvenile
patients may render necessary, in the treatment  of the Diseases to Avhich
in them the Alimentary Tube is liable.
  Cholera Infantum is  most frequently met Avith in cities—in  Avarm ch-!
mates and Ioav flat situations, during  the sudden heats of coming Summer.
  Its Causes are—Dentition—improper food in  all its varieties, including
the Milk of a  pregnant mother, and of an unhealthy  nurse, thick paps,
&c.—general  bad management—as want  of proper cleanliness of skin,
clothing and bed-chamber,  pure air and  sufficient exercise—Heat and
Mal'aria.
  History.  It is not my  purpose  here to  describe again the  Cholera,
Diarrhoea, Dysentery, Enteritis, 6cc. Avhich may attack Children, as Avell
as Adults,  at any  season and  under any  circumstances.  I shall merely
recount  the train  of  symptoms which occur at the age and season above
specified—in early Summer and during Dentition, as I attribute ali the pe-
culiarities  Avhich  demand  remark, Avhether in  the  course  of the attack,
the prognosis, or the treatment—to the predisposition of the  season, and to
the irritation of the Teeth in coming forward.                 ~
   The  invasion of Cholera Infantum, if it  be  not preceded by, and the
sequela  or remnant of some  of the more acute forms of  Intestinal dis-
ease, is gradual, though not sIoav.  There is fretfulness and uneasy rest-
lessness, with moaning, the  hand being often applied to  the mouth or face,
or upon the gums, Avhich are perhaps red and swollen; the lips and tongue
also  exhibit a higher than the natural colour.   The stools  are loose and
frequent, and changed from the ordinary appearance—there is thirst, and
especially  at  night, more or  less  febrile excitement.   The Stomach be-
comes disturbed, or perhaps vomiting may be one of the earliest symptoms;
and the organ  is, at last, so irritable, that  nothing can  be retained.   The
stools are attended with pain and straining—are more morbid in character
and acrid, so as to inflame  the skin about the anus.   The Abdomen is
tender on pressure and  becomes tumid, Avhile the limbs emaciate, and the
countenance groAvs haggard and ghastly—the mouth is covered with aph-
thous ulcers, and great languor and feebleness supervene. In some cases the
sufferings are unremitting, and the Child  cries incessantly, tossing its arms
about, and draAving up  its  feet.  In others, the patient lies in a  state ap- 
                                   PRACTICE.                          101

       preaching to Coma, Avith its eyes half shut, and so insensible to every thing,
       that flies  have been seen to light upon the cornea, or enter the open mouth,
       without being noticed.  In some feAV instances, death is preceded by Con-
       vulsions.   The duration of the  attack  is very  uncertain.  I have seen  a
       Child carried off by Cholera—vomiting and purging—in less than twelve
       hours; but the chronic form  I have pourtrayed, may last from 10 days to
     •  6 or 8 Aveeks.
         Autopsy.  The appearances,  after  death, vary Avith  the duration and
k*    ~S  form, and are such as have  been  described, successively,  under former   \
       heads.   g
     .<,   Progncmis.  Cholera Infantum, so called in accordance Avith the defini-
  a   * tion given above, although not mortal in any large proportion,  is a disease
  It  c  of very difficult cure—OAving to  the permanence of the Causes Avhich give
 v  -1 rise to it.  Transient relief is readily Avithin our reach;  but the symptoms
  ;  -; are  exceedingly apt  to  recur.   The chances of perfect  recovery are    .\
 \  r.i greatest—Avhere the smallest number  of Teeth remain to be "cut;" Avhen
 *;  ^^the constitution of the parents is good; and the Child has been previously
'-■$  ^< healthy.   On the  other hand, Ave dread the  result in Aveakly  Children—
  ?  ,i\ those born of Scrofulous or otherwise infirm parents—those attacked  early
  ■0     in Spring, and  having a large  proportion of Teeth  yet to cut—such as
- -i   i. live in Ioav, damp  and ill-ventilated situations—Children, Avhose mothers
     i have become pregnant, and are forced to wean them, or change their  nurses
  ^  ;^ at this unfortunate age and season.   The case has  an unfavourable aspect
  ■>   ■* Avhen the Stomach is obstinately irritable, or the BoAvels  are urged with
      n severe tenesmus, and the stools mucous or bloody or sanious; when the
  vC s>; tongue, lips and  cheeks  are fiery red or ulcerated, the belly tumid, the
       emaciation specially great, and when Coma or Convulsions occur.
          The Treatment varies with the several forms  of disorder  included under /'•/■ ■,,
     : v the present general head.   When  the  Vomiting and  Purging of ordinary/  .
    ^  Cholera  assail an infant, they must as in an Adult be  restrained by proper1/.^
     . ; doses of Anodyne, while fomentations and poultices are likewise applied  to
  '■  „:ctfhe abdomen.   I  often prescribe a combination of the Tinct: Op: Camph:
     \* Avith an Alkali—the Carb: Potass for example in small doses, repeated pro
 x. '■"} -renata.   When Diarrhoea exists, unattended with fever, I administer the
       Mist: Cretacea with or without the Tinct: Kino.   The rind of the Pome-
       granate and the root of the high blackberry are also very useful Astringents.
       When Dysentery is present, I resort to the combination of Dover's Powder
       with Calomel and Cret: ppt:  in doses,  carefully adapted to the age of the
       child, aiding the  effect with soothing, Mucilaginous, and  Anodyne  Ene-
       meta, while the Belly is well fomented or poulticed.
          In the Chronic case now under special discussion the obstinacy or  reite-
       rated occurrence of the attack will render all our resources necessary.  In
       the first place the general regimen must be carefully attended to.   The
       clothes, person, and the chamber must be kept scrupulously clean, and fresh
       air and free exercise allowed.  If the child has been weaned while teeth-
       ing at the  coming on of Summer, he must be put  back to nurse; if the
       mother be pregnant or ill, a sound breast must be procured.   If this cannot
       be done, an  exclusive diet of milk and Avater with a little  sugar must be
       enjoined.  This is the food most readily assimilated by a child unable  to
       masticate, and whose digestion is impaired.  If his residence  be in a city,
       an occasional ride into the country, or a temporary change of abode will 
102
PRACTICE.
be of service.  The gums, if SAvollen, should be scarified  freely from time
to time.   Vomiting  Avhich will  happen occasionally throughout the case,
must be checked by Anodynes and Alkalies; the latter will be very frequent.
ly called for, the prevailing acidity of the contents of the Alimentary Canal
being sheAvn both in the breath and the stools.  The Warm Bath will be
found a valuable auxiliary in procuring comfort and tranquility;—Avhen in-
convenient, fomentations, and poultices must be employed.  Constipation
Avill sometimes render  necessary a Cathartic—the most gentle of the class
should be chosen.   01 Ricini is usually and justly preferred.  Calomel is
also easy and mild in its operation, and there is little or no danger of Pyta-
lism in infants, even  when we persist in the exhibition of small doses of the
Mercurial; this is called for, Avhen the Stools are  chalky and shew deficien-
cy of the proper feculent and Bilious admixture.   Diarrhoea should be re-
strained by the Astringents mentioned above—the  Kino has Avon an exten.
sive preference, but the Acet: Plumbi: is used, and  Alum is highly extolled
by  Miller.
  The Prophylaxis or preventive management of Children is, in reference
to their liability to bowel Complaints, a matter of great importance and com-
prises a very extensive regulation of early Physical  Education.   Cleanly
ness, free ventilation, and exercise in the open air should be enjoined upon
all.  No child should be weaned in Spring or early Summer, who has not
past through the perils of Teething.   I  am disposed to think that  no child
should be taken from the breast until he has teeth  in sufficient  number to
break up and masticate his food—or, where Dentition is long delayed, has
learned to do this Avith  his gums.  Much is said of the evils  of keeping a
child too long at nurse,—the opposite evil is at least equally dangerous.—
After Aveaning, the Diet  must be plain  but abundant.  No great variety
should be allowed, and all such things as tempt to excess in quality should
be strictly prohibited. 
PRACTICE.                         103
                      INTESTINAL WORMS.

   Vermes—Helminthia.   As all plants  are  liable  to be  preyed on by
 Parasitic plants, so all animals are infested by Parasites.  Some  of these
 —probably numerous species, are of themselves and in the nature of their
 usual connection innocuous—and become hurtful if at all so, merely by their
 inordinate  increase.   Others are, either products of disease or  occasion
 disease uniformly by their presence.   Examples of each kind may be of-
 fered among the subjects of the  present discussion.   The  Avorms Avhich
 ordinarily infect the Human Intestines  are  the  Lumbricus—the Ascaris—
 and the Toenia.  The first of these Avould seem to be  always or almost al-
 ways an inhabitant of the Alimentary  tube—exciting no disturbance, and
 attracting no notice Avhatever, unless when unduly multiplied in number, or
 Avhen from some foreign cause of derangement, the body to which it has
 attached itself has lost  something of its proper tone and vigor of health.—
 The Tape Worm on the other hand is ahvays  annoying and  sometimes
 fatally irritating—While the Ascaris may be considered as in a certain de-
 gree hurtful Avherever  it exists, though its poAver to disturb greatly depends
 upon its multitude.   The other varieties of Intestinal  Avorms described in
 systematic Avorks I shall  not regard—they are very  rarely met Avith, and
 deserve to be ranked rather as objects of Scientific curiosity than of patho-
 logical  interest.
   The  Lumbricus is round, thickest in the middle, and tapering to  both ex-
 tremities, of white or slightly greenish hue, Avith a Avrinkled or annular sur-
 face, and from  5 to 12  inches long.   It enjoys distinction of sex, is of social
 habit, and chiefly infects children from two to ten years of age—being rare-
 ly found in any large number in infants while at the breast, or in adults.—
 They are so universally to be detected  in the  boAvels,  that Parr, Rush, and
 others  considered  them as regularly  belonging to  the healthy animal
 economy.
   The symptoms which are  supposed to result from their presence and in-
 jurious  agency  are in general somewhat as folloAvs:—
   The Child is languid and loses flesh,  the appetite is  irregular, sometimes
 voracious, but often deficient, the tongue is furred and the breath fetid, the
 boAvejs  are  usually loose with griping and straining and the  stools morbid
 and offensive, the abdomen is hard, and tumid, and painful, the skin of the
 face and feet puffed, the little patient  picks  his  nose and sleeps  uneasily
 with starting and sometimes  screaming, irregular irritative  fever  may su-
 pervene, there  is cough perhaps Avith Dyspnoea, and not unfrequently Con-
 vulsions quasi Epileptic.   "There is  scarcely a disease or symptom of dis-
 ease," says Rush, ''belonging to Cullen's Class of Neuroses which is not
 produced by Avorms."   I had rather  refer to them as  among the most po-
 tent exciting causes of all forms of Disease, to which the Subject may have
 become predisposed in any manner whatever.
   When the above train of phenomena, or any notable number  of them
concur  in a given case, it will be proper to manage it  by a  prompt resort 
104
PRACTICE.
to Anthelmintics or Vermifuges.  Of these, the best are the Spigeha Ma-
rilandica—Melia  Azedarach, (Camphor and Spts:  Terebinth:—and  it is
Avorthy of remark, that they often put an end to  the appearances of dis-
ease, even Avhen they fail to expel Worms as Ave had expected.  Camphor
is especially deserving of our confidence—it is distateful to all tribes of
Insects, Worms, &c.   In a dilute Aromatic infusion, it is also a good tonic,
and is  readily taken by Children.   The others are in very extensive do-
mestic  use, and very serviceable.  After a brief exhibition of any of them,
it is usual to administer a Cathartic.  I see no advantage in the  usual selec
tion of the Drastics—but prefer the mildly efficient articles—such as 01
Ricini, Avith or without Merc. Dulc.
   The Ascaris—Thread Worm—MaAV  Worm, inhabits  the Rectum
chiefly, though it is said to be found in the  Stomach.  It is small, filiform,
slender, tapering  to both ends, of Avhite colour and exceedingly vivacious.
They create an intolerable pricking and itching at the Anus, but are occa-
sionally found in  the Child's bed, having crawled from  his body in great
numbers, Avithout any notice of  their presence being previously given.  In
the Stomach they excite distress and oppression—the cause of Avhich can-
not be known, unless they are expelled by vomiting, or by stool.
  Aloes is the best Vermifuge  here—being noxious and disgustful to the
Ascaris.   It is used  both  by the Mouth and Enema.   Or a small Candle
or Bougie, smeared with Mercurial Ointment, being passed into the Rec-
tum, will dislodge them.  Castor Oil Avith Camphor, is also useful in get-
ting rid of them.
  Taenia or Tape Worm, is distinguished into three or four subspecies—is
in form flattened—separated into numerous joints, each containing an Ova-
ry—its colour is  whitish or  light yellow.  It is Hermaphrodite—attains a
great size, some  hundred  feet  having been expelled from a  patient.  I,
myself, have seen 10 yards brought away at once.  It is difficult of dislodge.
ment—the head,  which is toward the upper part of the Intestine, being
furnished Avith fangs or hooks, which it fixes into the Mucous Membrane—
it is, probably, also readily reproduced—inhabits  chiefly the smaller Intes-
tines, and is found almost  exclusively in Adults.   The other Worms die
soon after leaving the  body;  but the Tape Worm is exceedingly tenacious
of life.  Its presence  is productice of very great pain and uneasiness in
the Belly, Avith Diarrhoea and Emaciation;  but Ave have no diagnostic until
the gourdseed-like joints are detected in the  stools.   Many remedies are
offered to procure its expulsion.   I have most  confidence in the bold and
free use  of the Spts: Terebinth: either Avith or without Ol Ricini.  Calo-
mel—Filings of  Tin and of Pewter—an amalgam of Mercury and Tin—
the Male Fern—the  Dolichos  Pruriens—Pomegranate  Rind—the  Min.
Solut.  Fowleri—Camphor and  Aloes are used—and a great  many other
articles—but, I fear Ave are bound to acknoAvledge, Avith no flattering suc-
cess. 
f,
'y                               practiCf..                          10>




/*t < /



      The Liver is. apparently, the most important of the Collatitious Viscera,
    which aid in the digestion and assimilation of our food; and  although the
    special uses of its secretion, the Bile,  are not knoAvn Avith precision, yet
    the importance of the organ must be great, as it is the largest in the body,
    is one of the most  uniform of the  Animal Structure, and  its diseases
    always affect the general health in a remarkable manner.   It is subject to
    Inflammation, Acute and Chronic—and it has been much disputed, Avhether
    the  difference  announced in these  terms be merely referable to the time
    occupied  by the morbid action  and its results, or consist in some specific
    distinction of nature or locality.
      Acute Hepatitis has been attributed  by one class of Avriters, to an excite-
    ment of the ramifications of the Hepatic Artery, the Nutrient Vessel  of
    the organ; and the Chronic form to a similar condition of the minute bran-
    ches of the Vena Portae, supposed to be engaged in  the business of secre-
    tion.   Others regard the first as an Inflammation  of the investing Serous
    Membrane of the Viscus;  and the second as an  Inflammation of the Par-
    enchyma of the Liver.
      Acute Hepatitis—commences usually Avith febrile rigors, followed by
    flushing of the face,  with hard, abrupt, quick  pulse.  There is a sharp
    pungent pain in the right side under the margin of the ribs, shooting to the
    back and to the top  of the shoulder.  This pain is  permanent, but  is in-
    creased bv a deep inspiration;  it is sometimes, though not often, attended
    with  nausea.  The  iespiration  is  hurried and uneasy, and  a short dry
    cough comes on and harrasses  the  patient; there is much thirst; the skin
   is hot and dry; the tongue  is thickly furred with a yellow crust; the bow-
   els are usually costive, and difficult to be moved.
      Diagnosis—May be  confounded Avith  Pleurisy, which,  also, presents
    severe  pain  in the side, Avith  dyspnoea, cough and fever.  In Pleurisy,
    however,  the cough  is one of the earliest symptoms; Avhile it does not
    invade, until some time  after the access  of Hepatitis;—nor is there  in the
    former the pain at the top of the shoulder, so  usually attendant on Inflam-
    mation of the Liver;—the seat of pain, in the latter, is also lower doAvn the
    side, and may be traced by the  hand under the cartilages of the ribs.
      Cause.   The predisposition seems to be built up by high and long con-
   tinued Heat—the  influence of  which upon the  Liver,  is attempted  to be
   accounted for by various speculations.  The  ordinary exciting cause is
   almost always a notable alternation of temperature—exposure to damp or
    comparative coolaess.   Excesses, of all  kinds, it is said, may bring on an
   attack.
      Prognosis—generally favourable.  The principal  danger lies in the
   tendency to recurrence, succeeding attacks becoming  less and less man-
   ageable.  The  Acute is, also, very liable to run into  or produce the Chro-
   nic form of Hepatic disease.  It may,  however, terminate  the life of the
                        14.
HEPATITIS'. 
106                         PRACTICE.

patient, like other inflammatory affections, by exhausting the vital  powers;
—or it may run promptly into suppuration.  This last result is  known by
the repeated chills  or rigors Avhich supervene—there are sweats about the
face, Avith  a  pulse  small  and very  frequent—there is, also, a sense of
weight or heaviness in the right Hyp'ochoudrium.   The event is, usually,
unfavourable;  but  the abscess may  empty itself—1st.  By the Lungs; ad-
hesions connecting the inflamed Viscus with the Diaphragm,  and the por-
tion of the Lung above it, and absorption  cr ulceration making an  outlet
for the pus Avhich  is coughed up:  or 2d, by similar adhesions to the Sto-
mach or Intestines, Avhen it may be  passed by  stool or vomiting:  or 3d, it
may adhere to the  parietes of the Abdomen, and point externally, as I have
seen in tAvo attacks in the same individual,  a female.  In all these  cases,
though life may be preserved, the health of the patient is irretrievably im.
paired—Digestion and Fecification are ahvays  afterAvards imperfect.
   Treatment—Is very simple, and  consists almost  exclusively  of  active
Depletion.  V. S. should be  carried  to the  fullest extent—and Leeches or
Cups applied to the Right Hypochondriac  and Epigastric  regions.   The
Saline Purgatives are to be freely administered; and, after  their abundant
operation, the skin  is to be kept moist with  perspiration, and the  pulse low
by  the use of Antimonials.  Should the Hepatic pain continue after this
depletion, and fomentations fail to  give relief, a large Blister should be put
over the part.
   When the patient is seen early in the attack,  these measures will rarely,
if ever, fail to remove it.  But if  h.s strength  should sink,  or suppuration
supervene, we  must change our plan of management, and suppoit him  by
the cautious employment of Tonics  and Stimulants  ad a generous Diet.
until the matter be discharged in one  of the  modes above alluded  to.
   Chronic Hepatitis—is  a form of  disease of not infrequent occurrence
among us.  It  is  sometimes, as  has been said, a  s. qui la of the  Acute
Variety, but  more  commonly developes itself indepe idei.tly, gradually and
obscurely.   With much disorder of the general health, such as has been
described under the head of Dyspepsia,  there is a sc;-se of weight and full-
ness in the right side, with some  uneasiness or  pain  :r the I \, of the richt
shoulder—or, as the left  lobe of the Liver  may h •  fIVcted, these may be
felt on the left instead of the right side, though nuch  :rnn rarely.   The
complexion is salloAv, and (he tongue eucru?!■  t Avnh ; v hi.ish or broAvn
fur while the sides  and  edges  are of a dark  red -or die <  i"-an m;v
have  a contrasted, flabby and pale  :.j.pi-arav-c;. 'ookh <: soft and soudeii
and somewhat swollen.   The strength  fails. .  :d  fi  r  is  extreme■  dejec-
tion of spirits, with  ennui and  morbid vigilance.   Thr Bowels are irre-
gular, costive or loose, Avith ill-conditioned •ivacua'h.'-e?.   The Pulse  b
quick and chorded, though small.   A febrile   nx?cf rb tion, mi.re or less
marked, takes place every evening, and a dry hacki. g C ugh offer, abends.
    Cause.   Heat and Mal'aria  predi.■ pose  to  this u'd- >v>■.-'•■< of  the Liver
which, indeed,  almost exclusively belongs  to W.  rm Climates:__;' occurs
in  persons whe have been subjected  to no others: - ci ,1 or notable mode of
excitement.   It follows violent or obstinate attacks «,f Intermittent and Re-
mittent Fever.  It is, hoAvever, most  commonly met  with in the Intern-
perate.
    Prognosis—is unfavourable.  Perfect recovery of health, after a  Liver
 Complaint of any duration, is not frequent—the patient remaining Dyspep, 
PRACTICE.                        187
   tic, and liable to a recurrence of his hepatic disorder.  Among its ultimate
   consequences too, are Icterus and Dropsy.   It is more apt than the Acute
   form to run into Suppuration;  besides which, it has a peculiar termination
   in a sort of permanent enlargement with induration, technically spoken of
   as  Schirrhus.   This is readily  discoverable on examination by the hand,
   the fingers being bent and turned upAvards, Avhile the patient is  leaning
   slightly forward to render the abdominal parietes loose.
      Treatment.  If the strength admit,  Ven8esQctiou  should  be employed,
   but with some caution.  Topical Bloodletting is always advisable and may
   be repeated pro re nata.   The BoAvels should be moved from time to time
   —if constipated, by mild but efficient Cathartics.   Beyond this Ave must
   hope for permanent advantage in  an Alterative course.  The Mercurials
   are almost  universally confided in.   Th>  Blue Pill  or Calomel in small
   doses, should be administered until a moderate  Pytalism is  induced—and
   this should be kept  up for some time—during Avhich  the morbid symptoms
   Avill generally be found  to  yield.  Other alteratives have also been pro-
   posed—as Taraxacum—and the Nitrous and Muriatic Acids; the combi-
   nation of the two, the Nitro Muriatic,  has been much used in India both
   internally and as a bath.   One of the best of  our alteratives is Iodine, in
   very dilute solution.
      When the Liver is tumid and heavy Avithout pain, Epispastics  may be
/;  repeatedly applied over it, and the Galvanic and Electric Currents passed
   through the Hepatic region.
      In an obstinate case Ave should advise a visit to  some of our watering
   places.  Those fountains Avhich like Balston and Saratoga  unite a mode-
   rate purgative effect, Avith the tonic pur gene v of the Carbonic Acid Gas and
   the  mildly  alterative influences of Iodine i * minute proportions, are most
   useful in Hepatic Diseases.  There is much good  done  by the journey
   and voyage thither and homeward.   In the meanwhile the strictest Tern-
   perance must be enjoined and the patient cautioned  against indulgence in
   improper habits of  every  kind.   He must  live  on the plainest food, retire
   early to rest, abstract his mind as much  as possible  from  care, and guard
   against all  passion and emotion.   His clothing must be  warm and judi-
   ciously adapted to protect him from the vicissitudes of weather. 
- >• <•  -^vQ-
108
/    ;  /t'    -      .... '(Kfdti
PRACTICE.
l.-^-f?-. ■•'-.


ICTERUS-
JAUNDICE.
  This term is used to comprehend the  series of symptoms Avhich result
from Obstruction of the passage of  the  Bile from the Liver into the Ali-
mentary  Canal.
  The importance of this fluid in the processes of Alimentation, the perfect
Digestion and assimilation of Chyle, and the  fecification and expulsion of
the rejected portions of food taken, is Avell knowm.  The Avant or deficien.
cy of it, is productive of serious evils.   But it is supposed  that Bile is not
only a useful Secretion, but also an indispensable Excretion, containing cer-
tain essential constituents Avhich are required to be regularly and unceas-
ingly eliminated from  the  System.   Its non-secretion, or at any rate  the
re-absorption of its ingredients into the  vessels and their admixture with
the circulating mass is hence assumed to be  attended Avith injurious and
Avell ascertained consequences.
  These evil effects are still farther liable to  modification, and additional
suffering may result from the cause and nature of the Obstructions present;
all which demand in turn a careful consideration.
  1.  When the function of the Liver is thus interrupted, and Bile no longer
enters the Duodenum, the patient labors under Anorexia, Dyspepsia, Cos-
tiveness; the stools, Avhen any are passed, being unnaturally  pale or of clav-
color.   The complexion and eyes  are  velloAv.   The tongue is covered
wi*h a thick broAvnish fur, and a  bitter taste pervades the mouth.  There is
extreme mental dejection Avith physical inactivity and feebleness.   The  suf-
fusion  of the skin and eyes deepens  to an orange hue, and every solid and
fluid of the body is of the like tint—"except,"'  says Heberden, *'the  milk."
Poets aud Philosophers  have affirmed the fact, and made  it a  subject of
frequent allusion that Jaundiced persons  see all objects vcIIoav.   This is a
rare circumstance,  but (Jool affirms it to have been true in his oavii case;
here the very humours  of the eve must  have  been tinged  by the resorbed
Bile.
   There may or m.i\ not be certain local symptoms denoting Hepatic dis-
order—such as a si use  of weight and fullness in the right Fivpochondrium,
pain at tlu top of the Slamldtr, &<■..   These  though dAvclt on by authors
are not  essential, and indeed  are ioially waiting in the great  majority of
Mich cases as I have met with.
  lu^thc simple lortn of ieteius just described, I suppose the obstruction to
the flow  of Bile into the Intestinal tube,  to result from a torpor or loss of
tone and defect of  action  in the Biliaryducts,  Avhich  fail  to take  up and
transmit,  thither, ns is their office, the fluid secreted by the Sanguineous
Capillaries—she ultimate ramifications of the  Vena Porta? or of the  Hepa-
tic Arter\.   It is then  fore of necessity  reabsorbed by the radicles  of the
Hepatic  veins or lymphatics and  passes into the circulatory  current.
  The Causes of this Condition of the  Liver are very various.   It may  re-
suit from Chronic  Hepatitis—or  folloAv  the  Congestions  which form so
prominent a part of the history of MaParia Fevers.  I have seen marked 
PRACTICE.
109
   cases occur during the convalescence from  Bilious Remittent and  Inter-
   mittent, nay it may  prevail,  as if Epidemically, in certain unhealthy sea-
   sons, shewing the influence of Febrific Miasm upon the Liver and its func-
   tions.  In the autumn  of 1824 great numbers of persons—including  an
   infinite majority of the convalescents from Bilious  and Yellow  Fevers of
   that year, Avere attacked Avith Jaundice.
     Prognosis—generally favorable.  This mild grade of Icterus  is seldom
   dangerous or fatal, and for the most part easily cured.
     Treatment.   In the early stages an active Emetic -will generally procure
   entire relief.  If any thing farther be necessary, a mercurial or aloetic ca-
   thartic  Avith energetic exercise and cheerful occupation should be advised.
   Horse back riding is to be selected.  Frictions  Avith the hand, or a flesh-
   brush on the right side and over the abdomen are serviceable.  A current
   of Galvanic or Electric fluid may be directed along and through the region
   of the Liver.
     2nd. The more important modification of Icterus and one not unfrequent-
   ly met  Avith, is that characterized by the presence of Biliary Calculi.
     The  attack in cases of this kind is sudden and full of extreme suffering.—
   The  patient complains of  intense  pain,  coming on without warning, often
   after a full meal, at or near the pit of the Stomach extending across toAvard
   the right side, Avith nausea soon  increased to  violent  vomiting and accom-
   panied  by a sense of Abdominal distention.   The pulse is little affected.—
   There is extreme anxiety  and despondency.   The Epigastric pain is usu-
   ally permanent, and intolerably severe,  and pressure at that region cannot
   be borne.   It may in some instances subside or remit after a time and  re-
   turn Avith great violence—and this  may be repeated until the sensibility of
   the duct  is Avorn out—or inflammation may be excited and  transmitted
   along the Duodenum and  Intestines generally.  The BoAvels are costive
   and flatulent.  The Skin and  Eyes soon become deeply suffused.
     The  symptoms thus described are attributed to the passage, through the
   Duct leading from the Gall Bladder to the Duodenum, of Biliary Calculi
   or concretions of various  constitution, size  and form.  These bodies are
   often found in great numbers  in the Gall Bladder—and even in the bodies
   of individuals yvho have never shewn during their lives any  symptoms  of
   Jaundice.   We find them  occasionally  in the stools of our patients, Avhich
   ought with this  vieAv to  be carefully  examined.   They are divided into
/  1st.  Cholesterine Calculi—composed almost  entirely of Cholesterine,  an
   animal  substance somewhat resembling Adipocire or Spermaceti,  these are
   Avhite, lamellated, shining  and crystalized.   2nd. The  Mellitic—the most
 n common; broAvnish, composed of Cholesterine AvithPicromel and other ani-
 " mal matters, contained in Bile deposited in concentric layers.   3rd. Calculi
\  of Inspissated Bile of dark yellow color and somewhat rare.  Besides these
   I have  seen Calculi of a beautiful green so  dark  as to seem almost jetty
   black with highly polished surfaces—others still have  been described.—
   They are seldom round, but polygonal and angular.   It is not known hoAv
   they are propelled from the Gall Bladder  where they  are comparatively
   harmless, into the duct Avhich  they so vehemently irritate.
     Prognosis--doubtful.  We  cannot explain  the formation of these Con.
   cretions; but they are seldom deposited singly, and  they seem to be con-
   nected  with a condition of the Liver and certain alterations of its secre-
   tions, which, as Ave do not  clearly comprehend, we cannot readily remove- 
110
PRACTICE.
Such attacks are apt to recur in the same person.   I saAv the repetition in
one patient, productive  of Enteritis, and in this Avay indirectly fatal.
   Treatment.   It is not merely the mechanical distention of the duct to
Avhich we must  ascribe the sufferings endured by the patient—but more
probably a spasmodic  constriction  of its irritated coats, Avhich close upon
and thus detain the Gall stone.   To relax this Contriction, we use the Lan.
cet promptly and freely—administer Opium in the  largest doses, and place
the patient in the  Warm Bath.  The BoAvels are to be well moved by effi.
cient,  though  mild Cathartics and  Enemata, and  large  Fomentations or
Poultices kept to the Abdomen.   To meet the first  threatenings of Inflam-
mation, we must apply Cups or Leeches to the right side and Epigastrium,
and continue the effect  of Purgatives moderately.    This last measure must
indeed be persisted in for a few days in a majority of cases, to remove the
gastric and general uneasiness left by the attack.  To prevent a recur.
rence  of the symptoms, it is necessary to restore the  Liver to its proper
(Condition  and action, in order  that a healthy Bile may be secreted and
poured into the Intestines.   For this  purpose, no better means are in our
hands, than those recommended in the remedial management of Chronic
Hepatitis.
   In ancient times, Icterus Avas divided into species in  reference to the co-
lour of the Bile discharged, aid of the  body of the Patient.  Thus, even
Good  recognizes  Yellow, Black and Green  Jaundice; and Marcard and
Baillie sanction  this vieAv.   I have met with a case of this last named va-
riety, well-marked.  The Adnata of the Eye was  green;—the Alvine eva
cuations,  the Saliva, and the Bronchial  Mucus, were also deeply green.
My patient was a black woman, convalescent from Small-Pox.   The event
was fatal,  as it  is asserted to be—uniformly—by the Avriters above allud-
ed to. 
PRACTICE.
Ill
                            PAROTITIS.

  Cyxakche Parotidcea—Mioips.   By  this appellation, Ave  denote  a
peculiar inflammation  of the Parotid,  one of the Salivary Glands.   It  is
attended Avith fever, headache, thirst, furred  tongue,  restlessness and de-
pression of spirits.   The Parotid is swelled and painful, impeding speech,
deglutition, and mastication.  One  side only is  affected  in a majority of
cases—noAV and then both sides.   It rarely attacks the same subject more
than once, and offers a peculiar tendency to metastasis or  translation of in-
flammation from the part first affected to remote parts.   In females, the
Mamma, and the Testis in males,  are apt to be very severely attacked--in
both sexes  the Brain  also suffers occasionally.  This is  denied  by some
Avriters; but I have myself knoAvn  three instances of violent Phrenitis oc-
cur on the subsidence of the original SAvelling.
   Cause—It is contagious, and sometimes prevails epidemically.
  Prognosis—favourable.  The Inflammation usually terminates  in perfect
resolution;  suppuration of any of  the glands affected, being extremely un-
common.   In  a feAv there has remained an indurated enlargement of the
part;  and rather more frequently, a certain degree of softening of the Tes-
tis, and loss of bulk, has been observed.  The greatest danger is to be
dreaded where Phrenitis has supervened.
   Treatment.   In Children, the swelling should be rubbed gently with a
mild stimulant Embrocation, and kept  lightly  covered.   In young  and ro-
bust Adults, Venisection  and topical bloodletting by  Leeches may  be re-
quired.  This is  absolutely  necessary,  Avhtre there is metastasis   to the
more delicate and important organs above indicated.   Here, also, the free
use of the active  Cathartics  is demanded; and whe-i this has been  carried
to the  full extent, the  undue force of the circulation must be still farther re-
duced  by nauseant Diaphoretics, as Ipecuanha and Antimonials.
   The glandular indurations, when they remain, should be treated while
tender and  irritable,  by Leeching  and soft tepid Poultices—when thev
have become indolent, by Iodine Lotions and Embrocations.  Iodine should
also be exhibited internally in diffused Aqueous Solution.
   When Metastasis has occurred to the Brain,  as shewn by wild  Delirium,
&c. &c. the case must  be managed by the energetic application  of the
treatment recommended under the  head of Phrenitis. 
112
PRACTICE.
                          SORE-THROAT.

   Pharyngitis—Cynanciie—Axgi>\\.   This  malady, Avhich,  after all
the attempts to give it a name, is best designated by its ordinary" appella-
tion, is one of our most frequent  diseases.  It is essentially Pvrectic, and
is properly  divided—in reference to the  type of fever attendant upon it,
and the state of the general system in Avhich  it occurs—into Inflammatory
and Malignant.
   Inflammatory Sore-Throat is farther subdivided into Superficial—Ulcer-
ative—and Phlegmonous;  the first affecting  the lining  membrane of the
posterior fauces and isthmus, the  uvula, tonsils, pharynx and upper part of
the ^Esophagus,  without lesion  of the  surface; the second affecting the
same tissue, Avith ulcers more or  less  deep and extensive: Avhile the third,
as the  phrase imports, affects not the surface merely, but the tissues be-
neath, exhibiting  abscesses in  the tonsils, and  on the back of the pha-
rynx.
   1. Superficial Inflammation  of the Throat, is  attended Avith redness of
the diseased part, its vessels being enlarged and distended, as  in Conjunc-
tivitis.   There is a sense of dryness, Avith pain in SAvalloAving—the uvula
is relaxed, and sometimes  sedematous, occasioning a tickling and disposi-
tion to cough.  When the  Inflammation is great, there is sometimes Otitis,
with severe pain in one or both ears, attributed to its  extension along the
lining membrane of the Eustachian tube.
   It occasionally happens, Avhether from any peculiarity in the nature of
the Inflammation present, or merely from  its  intensity. I knoAv not, that a
layer of Avhitish or yelloAV lymph, is throAvn out upon some part of the sur-
face, to Avhich it adheres, but perhaps not very closely, and  is usually ta-
ken for an ulcer.  It resembles the membrane formed in Croup, in Diarr-
hcea Tubularis, &c   It seems to be connected with an obstinate and tena-
cious form of morbid action, which often runs into a chronic state.  Again,
you Avill sometimes find  a thick, condensed and highly offensive mucus,
collected in small hard lumps in the fovea? or crypts, which indent the sur-
face of the  Tonsil.  They  are apt to be  mistaken  for ulcers.  I often
press them out Avith a probe to the great relief of the patient.   If they re-
main in the Cavities in  Avhich they are formed, they occasion sAvelling and
pain, and perhaps are lgsvonwd by a slight  suppuration, and hawked out.
   2. Ulcerous  Sore-Throat—Cynanche  Ulcerosa—presents  also various
modifications, the Ulcers assuming very different aspects in different cases.
Some of these varieties, it  is well knoAvn, are peculiar and characteristic,
in accordance with the specific state  of constitution of the patient, as in
Scrofulous and Venereal  Maladies.  But of these  I  do not propose to
treat in detail.  That  which  is the subject of present discussion, and is
connected with ordiiary inflammation, under common circumstances, is at
first irritable  and very sharply painful—its surface is grey or Avhitish, Avith
red points—the edges being  savoIii,  it seems  excavated—it is disposed to
extend itself, in all directions, with a rapidity proportioned to the intensity 
                            PRACTICE.                         113

of the inflammation connected Avith it.  After a time, if the Ulcers do not
heal, they become indolent, stationary and chronic;  Avhile the sympathetic
constitutional irritation subsides Avholly or in part.  They occasionally ex-
tend sloAvly doAvn the Esophagus, healing at some points, and spreading at
others—the cicatrices Avhere they heal, contracting and rendering Degluti-
tion exceedingly difficult and painful.
  3. Phlegmonous Sore-Throat---Cynanche  Tonsillaris---Quinsy.  On
looking into the  Throat,  if Ave find one  or both of the Tonsils projecting
forward, Avith a fiery red and smooth surface, avo  have reason to fear the;
formation  of abscess within their  substance.   This is  to be dreaded as
occasioning great and protracted suffering, by the impediment thus offered
to Deglutition and Respiration—so great indeed as sometimes to threaten ,in
suffocation.  Even  when we succeed in  procuring Ilrspii:>tir>rLr there \scKJLSC
often left an enlargement and induration of the Tonsils, which affect both
the speech and hearing.   There is,  hoav and then, though rarely, abscess
formed at the back of the Pharynx; and Ave have on record, a feAV terrible
instances of Abscesses even in  the ^Esophagus.
   Causes. Sore-Throat, in its several varieties, is excited by exposures to
vicissitudes of Aveather and alternations of temperature—to currents of cool
and damp air, shoAvers, &c.   In some  individuals  and families, there is
special predisposition to it.
  Prognosis—generally favourable.   In the  Adult  of good  constitution
there is little  danger—though fatal instances are noAV and then met with.
Chronic Ulcer of the Throat, may Avear out the powers of life by the con-
stant irritation, and by its extension along the Esophagus.
  In the Child—the Infant—Sore-Throat is a more serious disease.  Even
the superficial inflammation is not Avithout some risk, being, at this age,
readily convertible into the ulcerous;  and if the  ulceration extend into the
Larynx, the case becomes almost hopeless.   I scarcely know a more for-
midable disease than  this modification of Laryngitis or  Croup, combined
with Sore-Throat.   I do not recollect to  have  met with the Phlegmnous
form—Quinsy, in a Child.
   Treatment.   In a robust Adult, it may be necessary to bleed freely from
the Arm.  Local bloodletting by Leeches, is almost ahvays useful. Cramp-
ton and others propose to carry them to the inflamed spot.  Emetics are
often given in the first stage,  and with advantage, if the Stomach is op-
pressed, the  tongue foul, and the breath fetid, without vomiting.  Cathar-
tics, especially the Saline,  are almost  universally required.   They may
be combined Avith  Diaphoretics—as at first Ipecacuanha and Antimony,
and aftenvards Avith the Infusion of Serpcntaria or Seneka.   When far-
ther depletion is unnecessary,  Ave may reduce the force of the circulation
by moderate doses of Nit. Potass, combined during the day with an Anti-
monial, and  at night Avith Dover's  PoAvder.  Various  local  applications
are recommended.   I disapprove of Gargles in  the early stage, as painful
and irritating.  The steam of  water, at a moderate heat, may be inhaled,
to relax and  sooth  the parts,  and  procure  a flow of saliva arid  mucus.
After a time,  the sedative and mildly astringent solutions, may be of some
advantage—more especially Avhere there is ulceration.  Nit. Potass. Alum.
Sulph:  Zinc:  Acet: Plumbi, and  the Mineral Acids, are much used.   In-
fus. Cinchonas and Myrrh are among the best.  This may require special
attention in the cases of Children, the foul secretions from avIioso ulrern<ed
                     10 
U4
PRACTICE.
fauces, it may be necessary to cleanse Avith a Syringe or a bit of Lint at-
tached to a probe.
   The  employment of the stimulating  Gargles,  so  much in  vogue, re-
quires a nice judgment and some experience.  It cannot be denied, that
there are cases in Avhich, even from the first, the Infusion of Cayenne is
beneficial, but it is difficult to point them out; and it is a good general rule
to abstain from the use of these washes, until the  ulcer has  become obvi-
ously indolent, and the case assumes a clearly chronic character.  In such
instances, I have done  good by the solution of the Sulph. Cupri, and even
.by touching the  ulcerated surface with the Nitrate of Silver.  These cases
farther demand the administration of Alteratives  and Tonics.  A  mild
Mercurial course, as of Blue Pill or Merc. Corros. Sub. may be alterna-
ted  or combined Avith the use of the  Bark and the Mineral Tonics, of
Avhich the best is the Tinct. Mur. Ferri.
   The Uvula, it Avas said, is sometimes permanently elongated or relaxed,
so as to fall upon the back of  the tongue, and keep up a harrassing  cough,
which, in some cases, has been the precursor of Phthisis.   To prevent this,
it should be  amputated.  When the Tonsil is so much enlarged as to im-
pede the Respiration, we must not hesitate to pass a Lancet freely into and
across it.  If an abscess has  formed, Ave evacuate the matter at once; if
not, we give relief by  diminishing the bulk of the tonsil, and reduce  its
inflammation by emptying, its  vessels.   If the  tumefaction be  so great,
that the patient is in danger  of being  suffocated, an opening should  be
made in the  Trachea, until the tumour subsides or suppurates.  The Ton-
sils remaining indurated and enlarged, they should be freely scarified in  all
directions, or completely extirpated.
   Malignant Sore-Throat.  Cyxanche  Maligna—may be described as a
combination  of Ulcerous Inflammation of the Throat with the loAvest grade
of Typhus Fever.  Sporadic cases are occasionally met with—but  it is
apt to appear as an Epidemic.   Its proportional  mortality is  frightful.   Its
subjects are  generally  young persons and children, from Infancy  to Pu-
berty.
   Symptoms.  The attack is ushered in Avith Nausea and sometimes vom-
iting; there is oppression, restlessness, anxiety, the voice is coarse or husky,
the skin dry and constricted,  there is thirst;  the pulse is  small, compressi-
ble, very frequent—there  is great  languor and  prostration.  It is not  in
every case that there is any pain or difficulty in sAvalloAving, but in exam-
ining the throat Ave find  a dusky redness overspreading the Avhole  surface
of the pharynx,  fauces, tonsil,  and uvula.   One or more ash colored ulcers
soon appear, Avhich spread rapidly but with little or no pain.   They gene-
rally, though not always throw off'sloughs, dark colored and offensive, Avith
a foul discharge from the surface.   An efflorescence  often shews itself on
the skin—but this by no means uniformly or even in the majority of cases
as affirmed  by European Avriters—avIio often confound  Scarlatina Angi-
nosa and  Maligna, with our present subject.  As the disease  progresses
the ulcers  shew a gangrenous disposition, becoming  livid or even black
 with great fetor.   Diarrhoea comes on and the patient soon sinks exhausted.
   The Cause of this malignant Pestilence is unknown.  It is usually Epi-
demic in its prevalence.   It is by many  alledged to be contagious.
   The Prognosis is highly unfavorable.   The younger the subject, in gen«
oral, th" greater the danger.  In early life there is special liability to the 
PRACTICE.
115
extension of the ulcerous action into the Larynx, a combination absolutely
hopeless and of course fatal.
   In older subjects Ave judge of the degree of risk as in Typhus Fever—Avith
less reference to the local affection.   In all, hoAvever, it is proper to exam-
ine the ulcers Avith attention.   We have every'thing to fear when they are
livid, or dark and gangrenous—on the contrary a florid aspect Avith con-
tracting granulations is favorable.
   Treatment.   The general management of the patient is similar to that
recommended under the head of Typhus Fever.  It is the general practice
to premise an Emetic.  Ipecac is perhaps the best,  but some prefer the'
Antimonial as more active, and others regard the Sulph: Cupri as exerting
a special efficacy.   I see no great objection to either.  Our permanent re-
liance is upon the class of Stimulating Diaphoretics Avhich may be employ-
ed in turn—the Infusion of Serpentaria or of Seneca—the combination of
Carb: Potass Avith the Tinct: Opii Camphorata, the Acet: and Carb of Am-
monia—the Nit: Ether and the  Infus Cinchona?, Avhile a generous and stim.
ulating diet of fluid  nourishment is alloAved  Avith Avine in proper amount if
necessary, the Bowels in  the  meantime  being gently acted  on by some
mild Cathartic;  I prefer to all others  the combination of Mer: Dulc. with
Pulv: Rhcei in small doses, and at proper intervals.
   Of local applications, I  regard the Blister and the Leech, to be alike of
equivocal effect, and prefer the mustard  poultice  to either.   The ulcers
must be kept scrupulously  clean.   The Gargles should be someAvhat stim-
ulating.  The Infus.  Cinchon. with Myrrh or Camphor or with the mineral
acids is much to be  confided in.  The Infusion of Cayenne pepper is great-
ly in vogue,  and often does good service.   It is given freely as a stimulant
besides its employment as a gargle or lotion.  I do not doubt its efficacy. 
lift
PRACTICE.
  DISEASES  OK TllH  RESPIRATORY  SYSTEM--THK .LARYNX,  TRACHEA,
                        BRONCHI,  LUNGS, &C.

                              CROUP.

  IjARYNGITIS-.CyNANCHE TRA( HEALIS— EmPRESMA BRONCHITIS--TRA-
ciiitis.  Croup is one of the most common maladies of children, in Avhom
it is  rarely met Avith, before  they have been Aveaned.  Occurs seldom in
mature life—though a feAv individuals remain subject to it.   It consists in a
well known and  peculiar  Dysonoea  attended with cough  and febrile ex-
citement.   The  voice is exceedingly  husky and the  cough is characteris-
tically harsh, stridulous and ringing.   The access is usually toAvards even-
ing, Avhen the child presents the ordinary appearances of Catarrh or com-
mon cold, with sneezing, &c.   His Breathing becomes rapidly more and
more difficult, and fever comes on Avith flushing of the face and suffused
and Avatery eyes.   He sits up in bed and his struggles for breath are fright-
ful.   If not soon relieved, his face is swollen and turgid, and  his  counte-
nance livid or  very pale,  Avhile his eyes protrude, and  his skin is bedewed
Avith SAveat.  Expectoration of a thick tenacious mucus diminishes his suf-
ferings and he sinks exhausted to sleep.  His respiration is still hurried and
croaking and a mucous rattle is soon heard over the Avhole Thorax.  Por-
tions of a flaky membrane are sometimes coughed up with great alleviation
of his Dyspnoea.   His paroxysms orrw—if art has not arrested  his dis-
ease—and he  sinks  Avorn out Avith his violent  exertions to continue  the
process of Respiration.
  Cause.  Exposure to vicissitudes of Aveather—to changes of temperature,
fo cold and  moisture—to particular Avinds as  with us the E. and N. E.
give rise  to attacks of Croup.   In some children the predisposition is so
strong that any exposure to night-air will bring it on.   It sometimes arises
from the extension of inflammation and ulceration of the  throat  into the
Larynx.   I have seen it  I think produced by Gastric  disorder and irrita-
tion.
  Pathology.   Croup  consists in an Inflammation of the lining membrane
of the Larynx and Glottis—which by its sAvelling closes the Rima—or by
the effusion of thick  tenacious mucus, endangers suffocation unless  the pa-
tient is able to expectorate—or admits the deposition of flakes of fibrhic,
the "false membrane" so often spoken of, and  incorrectly  considered by
•some Avriters as uniformly present—Avhich clogs up the passage of air into
the Lungs.  Some authors contend for the existence of a Spasmodic Croup,
in Avhich there is a spasmodic constriction and closure of  the Glottis,  but
this is not established.
  Autopsy.  The  appearances vary  Avith the duration of the  case.   If
death  occurs early,  Ave  find the lining membrane of the Larynx thick-
ened and  highly colored; if there  be greater  protraction  of the  attack,
this  state  of the  membrane  is continued doAvn  through the Trachea, and
its  ramifications  forming  true Bronchitis, and the  air tubes are clog-
ged  up Avith a thick mucus.   In such instances we find  more or  less in- 
PRACTICE.
117
flammation of the Pulmonary tissue—the Lungs being to a considerable
extent Hepatized or Solidified.  The membrane above mentioned is some-
times found in small flakes adhering to parts of the surface—or in the shape
of a complete tube—or in solid mass.  There is sometimes ulceration of
the surface in those cases connected Avith sore-throat.  I have a prepara-
tion of a Larynx Avhich exhibits at different  points of its snrface the adhe-
sion of flakes of Lymph and an extended Ulcer.
   The Prognosis is generally favourable.  Croup, though alarming in its
onset, is, if seen early, very much under Medical controul.  The danger
is in proportion to the Dyspnoea—except Avhere there is ulceration of the
Larynx.  Such cases are  insidious, but prove almost  uniformly  fatal.
Free expectoration is a good symptom—a hard, dry,  ringing cough, the
reverse.  The extension of the morbid irritation to the Bronchi and Lungs,
of course, adds to  the danger.
   Treatment.  We may  sometimes succeed in arresting  the threatened
attack  of Croup in subjects predisposed, at its commencement, or during
Avhat may be called the Catarrhal stage, by immersing  them in the Warm
Bath,  and administering  a  full dose of the Tinct. Opii  Camph.—Avhich
proves  Stimulant, Diaphoretic and Anodyne.  As soon as  the  peculiar
Cough is heard, an active Emetic should be given, Avhich  will often put an
end to all the uneasiness suffered.   I  prefer the  combination of Ipecac.
Avith Tart. Antimon.—and if there were much  Dyspnoea, Avould  adminis-
ter it Avhile  the Child Avas  seated  in the Warm Bath.   If febrile excite-
ment have had  time  to develope  itself  Avith full pulse, flushed cheek, and
sparkling eye, the Lancet should  be employed, and perhaps Leeches may
be placed about the throat.   The Emetic should be repeated, and the boAV-
els moved by uniting  with  it some  Cathartic.   Calomel may be chosen;
but I would not confide in it alone, or to the exclusion  of other remedies.
Squill and Seneka are much and justly extolled, as combining obvious  Ex-
pectorant and Diaphoretic effects Avith their Emetic property—they may,
in protracted cases, be exhibited repeatedly at  intervals Avith advantage.
As soon as the Leeches are removed from the  throat,  large  Poultices
should  be applied, at  first made irritating by the addition of a little Mus-
tard.   At  a  later  stage, they should be made to cover the  whole Thorax.
No disease is more generally  managed by  domestic means with success.
A plaster of Scotch  Snuff is mentioned by Godman, as highly efficient in
arresting it  in  the forming stage.  The Alkalies are  much employed.
 Common Ley internally, and as a bath, is serviceable.   Some parents
give the Vol. Liniment—Spt. Corn. Cervi,  with Olive or  Lamp Oil and
Molasses.  Others administer Indigo, which  operates  harshly both by
vomiting and purging.
   With regard to the operation  of Tracheotomy,  so much  discussed, I
would  offer this rule.   If a child Avere  in imminent danger.of suffocation,
in the earlier period of Croup, from sudden closure of the Glottis,  either
by swelling of the lining membrane, or by the deposition of membranous
 flakes, while yet the  air tubes beneath were permeable, as inferred from
the absence  of the mucous rale, and from the  respiratory murmur being
heard  throughout the  Lungs, I Avould  open the Avindpipe.   But it is idle
• and useless to do this when the inflammation, engorgement and effusion of
mucus have  extended into the Thorax; the  case is now Bronchitis as  Avell
as Laryngitis, and the operation can give no relief. 
118                         PRACTICE.
    Under this term is treated of the Inflammation of the Mucus Membrane
 Avhich invests the Air tubes—the Trachea  and Bronchi, and the cells of
 the Lungs.   It is divided into Acute and Chronic.
    Acute Bronchitis resembles closely, in the  first instance,  an attack of
 Catarrhal Fever, from  wrhich it  is then only distinguished by a more spe-
 cial prominence of the tokens of local and thoracic irritation and inflam-
 mation.  Its access is usually with a chill, accompanied by a sense of sore-
 ness and stricture in the Trachea, and a tickling, dry and frequent cough;
 fever soon  folloAvs, with harsh hot skin, flushed  face, thirst, pain in back
 and limbs.   In some cases, the Dyspnoea is urgent, Avith a distressing ten-
 sion across the chest, and much pain in coughing.  The patient cannot lie
 doAvn;  a crepitous rattle is heard  and  felt throughout the Thorax; but
 though oppressed with the accumulating mucus, he cannot expectorate.  If
 these symptoms be not promptly relieved he may sink exhausted by his strug-
 gles; but in general the expectoration becomes somewhat freer and fuller,
 and the disease subsides, or passes into a Chronic condition.
   Post-mortem examination shews the mucous lining membrane highly in-
 jected and thickened; the tubes and air cells being filled  with a secretion of
 varied appearance, sometimes a tenacious ropy mucus, again a thick puru-
 lent fluid, and mingled occasionally Avith a serous, ichorous or sanious effu-
 sion.  The substance of the Lung partakes of the results of the Inflamma-
 tion, and its tissue is solidified, or as the phrase is, hepatized  and incapable
 of collapse.
   Causes.  Exposures  to cold, moisture,  and alternations of  temperature
 are familiarly known to produce  Bronchitis.  It has been excited by inha-
 lation of some of the irritating Gases.  It  is more frequently  met with  a-
 mong  persons engaged in  certain occupations—Millers, Cotton-ginners,
 Needle-grinders, &c.
   The Prognosis is readily inferred from the degree of  Dyspnoea, and the
 apparent ability of the patient to struggle with the impediment to his breath.
 ing, and to bring out from the air-passages the offending  mucus.   Free ex-
 pectoration is therefore favorable, and a hard dry ringing cough  the reverse.
 Very old, and infirm persons, and young  children suffer the most serious
 risks.
   Treatment.   Venaisection  is in most cases an indispensable remedy, and
 must be promptly carried to as great an extent as can be borne Avithout inju-
 ry.  Emetics are highly serviceable, both as Expectorants and Diaphoret-
ics, and are  peremptorily demanded in the cases of  infants and  the very7
aged.   They may be repeated from time to time.   Ipecac—Squill and
Senekaare preferable; if these are not sufficiently active,  Tart: Antim. may
be added.   Cathartics are ahvays useful.   I select the  Saline, and com-
bine them Avith Diaphoretics as the Infusion  of Serpentaria  or  Seneka.
Much has been said against the employment of  Cathartics in thoracic dis-
ease, but these objections are speculative—experience shews them to be. in 
PRACTICE.                         119
the early stages not only safe, but  admirably beneficial.  In the advanced
periods of such cases they are not required, but the BoAvels should be kept
regular and soluble throughout.  Nauseating doses of  Antimony and other
Diaphoretics are much extolled.   I am not fond of the practice, but prefer
to use the same remedies  in less amount, so as  to reduce the undue force
of the circulation.
  When the febrile excitement is in some measure subdued,  Opium is an
invaluable medicine.   Dover's powder is a good combination,  to ensure its
effect as Diaphoretic and  Anodyne.
  Of Topical  applications—after  Cupping I prefer warm poultices, Avith
Avhich I envelope the throat and cover the chest.   Leeches imply too much
exposure.  To relieve  the Cough, Demulcents, are required;  Mucilaginous
mixtures Avith Opium  form  the  basis of the most valuable.   Spermaceti
formerly often prescribed; is noAV too much neglected.  In the Bronchitis
of infirm old people—the Peripneumonia Notha of writers of the last age—
Stimulating Diaphoretics and  Stimulants are demanded and must be given
freely.   Camphor and Ammonia are among the best.  Opium must be pre-
scribed with some caution.   The strength  must be supported with Avine-
whey, wine, &c.  We cannot detract Blood from such patients, but dry
 Cupping Avill often be of service—the mustard poultice should be applied—
 and here also  Blisters  will be  found Avell adapted.
   Chronic Bronchitis—is usually a consequence of the acute form; but may
 occur as a primary affection, in Avhich case it is developed sloAvly and in-
 sidiously.   There is Cough Avith  slight soreness of the Trachea and Tho-
 rax—a sense  of stricture and tightness increased on draAving a deep breath,
 the voice is somewhat hoarse, and a  crackling or rale is felt  and heard in
 breathing.  The cough becomes more harrassing and severe; the expecto-
 ration at  first scanty, increases in amount, and changes from mere  mucus
 to a mucupurulent consistence, sometimes colored with a little blood.   In a
 few cases Hemoptysis may happen, but this is not frequent.   Respiration
 is hurried, and panting attends any  muscular exertion or  the ascent of a
 stair.  The Pulse is tense and frequent, and a  febrile exacerbation  shews
 itself at first in the evening, going on to a full developement of Hectic, with
 night sAveats—emaciation and great loss of strength,  diarrhoea, &c. &c.
    Autopsy.   The Bronchial mucous membrane is high colored and thick-
 ened, and in many places eroded Avith ulcers.   The Lungs are found Hep-
 atized or solidified—the air cells  and tubes filled Avith mucupurulent mat-
 ter mingled with a frothy and bloody serum.
    Prognosis.  The unfavorable indications are chiefly draAvn from  the
 degree of Dyspnoea in the early stages, and at a late period from the atro-
 phy and emaciation which  waste the patient.  An extreme  frequency of
  Pulse is unfavorable—so is the absence of the respiratory murmur in  any
  considerable  portion of the Lungs, Avith a loss of the proper degree of reso-
  nance on percussion.
    Diagnosis.  The distinction betAveen Chronic Bronchitis and Tubercu-
  lar Phthisis is often difficult.   In the latter there is less Crepitus or rale-
  less soreness of the  Trachea and Thorax—more tendency  generally to
  Hemoptysis—and less expectoration in the early stages.   In their latter
  progress we can draAV no line between  them, except from  their previous
  history.                                       .
     Treatment.  The Lancet is in most cases required but must be employ- 
120
PR AC TICK.
cd with caution.  We derive most advantage from small bleedings repeat.
ed.  Leeches may be applied  to the throat, and Cups to the  chest with
benefit.  Even after we can no longer detract blood, dry Cupping the Tho-
rax is useful.  Emetics—are much confided in  and great stress laid on the
preference  due to particular articles.  Ipecac  is generally  chosen—some
combine it Avith Tart: Antimon:  and others  with the Sulph: Cupri.  The
utility  of Emetics is unquestionable—they  are expectorant, Diaphoretic
and in most instances move the BoAvels sufficiently.  To soothe Pulmonary
irritation and keep up a  constant determination  to the skin, Ave may ex-
hibit a combination of the Nitrat. Potass. Avith  Dover's Powder—allowing
a full dose of Anodyne  nightly at bed time.   A choice  of the numerous
preparations from Opium may  be made to suit  each particular case.  I do
not think any other of the  Narcotics as the Lactucarium—Hyoscia-
mus, &c, entitled to our confidence.  The Digitalis may do service Avhen
the pulse is  particularly  frequent.   Squill is highly prized by some as an
expectorant.
   The Infusions of Serpentaria and Seneka, afford good basis for  the Mu-
cilaginous, Demulcent and Anodyne Solutions, administered to relie\7e the
troublesome Cough.  In  threatening cases, I would  advise an unhesitating
resort  to an alterative Mercurial course.  Calomel, in small doses, or the
Blue Pill, may  be  so given, as to produce highly beneficial results—Avhile
it  should not interfere Avith  the proper employment  of  such other remedies
as may be demanded.  Inhalation of various airs and  gases has been pro-
posed;  but,  after a  fair  trial, I have abandoned  them.  The Vapour of
Ether, in which Cicuta  has been macerated—that of burning Tar and of
Resin—Iodine and Chlorine, have been extolled.
   The several  Balsamics Avere formerly much in ATogue.  Myrrh,  Tolu
and Copaiva are the best  of them.   "Pine-gum  Pills" and "Lightwood-
Rum,"  are common domestic prescriptions in  the south and south-Avestern
States.
   Tonics may be made of great benefit, by a proper selection of the period
for their exhibition, and the cases to Avhich they are adapted.  I Avould use
them when  the tokens  of muscular debility and general relaxation wrere
more prominent than those of local irritation  or febrile excitement.  The
Infusion of Cinchona Avith Mucilage, is lauded by  Broussais and Hast-
ings.   The Elixir Vitriol and  Tinct. Mur.  Ferri, are also useful.  They
aid in restraining nocturnal SAveafs.
   The persevering application of counter irritants to  the chest and arms,
has often been of great  advantage.  I  prefer to blister successively one
and another portion of  the surface.   The  Tartar Emetic is a ftwourite
irritant with many Physicians, Avhile others still prefer Setons and Caustic
Issues.
   The Convalescent must take as much exercise in the open air as he can
undergo, without fatigue.  A  long journey or  a sea-voyage should be  ad-
vised,  and an equable climate  chosen.   Flannel should be Avorn next  the
skin, and all undue exposure nA'oidcd. 
LMtACTK.'E.
1^1
                           PLFFR1TIS

   Pleuro Pneumonia—Pleuro  Pneumonitis.   Pleurisy.   Under this
head I propose to treat of Acute Pneumonia, as Avell as of Inflammation of
the Pleura, in all its extent, and its various local connectious and subdivi-
sions.  In their access and early stages, it is not possible to distinguish in-
flammation of the Pulmonary tissue from  that of its investing membrane.
although in their results and consequences, there  may  be some ultimate
difference.   Besides this, they never occur separately or entirely indepen-
dent of each  other; and in a practical point of vieAv, the Diagnosis is  as.
unimportant as it is confessedly difficult—the indications of cure, and the
details of Treatment, being precisely the same in both.
  Pleurisy is a common and  Avell-known disease;  usually met  Avith  in
Winter and Spring, and frequent in occurrence in proportion to the degree
and suddenness of the changes of these unsettled  seasons.   It comes on
Avith  pain  in the Thorax—most often perhaps the right side—fixed and
circumscribed, and much increased by a deep full inspiration; the breathing
is therefore  hurried, short, and catching and the patient assumes a bent
posture leaning to the affected  side.  Fever soon  supervenes with  sharps ...<  -'
and rapid pulse^a skin hot and dry, and a harsh,cough which aggravates
intolerably the Thoracic pain.                <- ^
   The results or  "terminations" of this  Inflammation, if it progress un-     '
checked, are someAvhat various, but from  the importance of the organs at*'
tacked are full of suffering and danger.  The most common is the effusion^ ,,',
of fibrine or Lymph, in layers upon the serous membrane,  which becomes ■■'•.. ..#■-<
organized and causes adhesion between the opposite surfaces of the Pleura,
Costalis and Pleura Pulmonalis, impeding someAvhat the movements  of
respiration and occasionally giving pain.   Upon this false membrane are /
occasionally seen streaks of purulent matter.  The Pulmonary tissue not
unfrequently becomes solidified, losing its light cellular texture; this change
is spoken  of as Hepatization of the Lung, w hich becomes  granulated and
assumes a livid brownish  color.   Allied to this condition  is the establish-
ment of Chronic inflammation of a portion of this tissue, tending to the for-
mation of Abscess and perhaps the  developement of Tubercle—Chronic
Pneumonia—one of the recognized forms of Phthisis Pulmonalis.  Cullen
speaks of a sanguineous infiltration into the cellular structure of the Lungs
as a common termination of Pneumonia when it proves fatal; I have not
seen it.
   Chronic Pleurisy, with effusion of seropurulent fluid is spoken of by LaAV
and other English writers as an ordinary  result or sequela of the acute
form.   I have never met with it.   It is knoAvn by the continuance of Dys-
pnoea, after the earlier acute symptoms have subsided—by fullness  of the
affectf d side of the Thorax, perceptible to the eye and ascertained by meas-
urement__by Avant of resonance on percussion, and of the natural vibration
of the chest, felt by the hand applied, while the patient  breathes or speaks,
and by the absence or dul ness of the respiratory murmur.
»* 
122
FEAGTIKB.
   Hydrothorax—Hydropleura is regarded by some as a termination  of
Pleuritis, Acute and Chronic.   I have discussed the  subject elsewhere  in
speaking of Hydropic Affections.
   The Causes of Pleuritic and Pulmonic Inflammation have been already
pointed out—as exposure to cold and moisture,  and to sudden  changes of
temperature.   External violence may give rise  to it;—the puncture from
Spiculae of a fractured Rib occasion it, and a fatal case is on record Avhere
the Pleura was injured by a needle  employed in passing a  ligature round
the Subclavian Artery.
   Prognosis.   In our Avarm climate, Pleurisy may be regarded as a highly
manageable disease, and attended with  little  danger if the patient is seen
early.  In the first stage, the degree of danger may be inferred  from the
extent of the inflamed portion of surface, the violence of access, and the
capacity of the patient to bear the necessary  remedial measures.  As the
case  progresses, the increase  or obstinacy of the Dyspnoea is unfavour-
able.   By exploring the Thorax, Ave derive definite information of the con-
dition of the Thoracic Viscera.  All tokens of effusion or deterioration  of
structure, are of course to be  dreaded.
   Autopsy.   In speaking of the results or terminations of Pleuritis, we
have  anticipated a description of the changes found post mortem.
   Treatment.   The Lancet used promptly and boldly, at the onset of the
disease, will often put an end to it  at once.  It is to be resorted  to at  all
stages Avhile the  breathing is  painful, unless the pulse is specially feeble,
and the strength  of the patient has notably failed.   Topical depletion by
Cups, which should be applied on and near the seat  of pain, is next pro-
per; after which, large Avarm Poultices should be laid over the Thorax.
   Cathartics are highly useful; and  in severe cases,  those which are
somewhat drastic and irritating, should be chosen.   No prejudices have
less foundation, than those which exist against the use of Purgatives in Pul-
monary Inflammation.   They  are among  our best  revulsives; but their
employment should be confined to the early periods of acute cases.  It  is
advantageous  to  combine an  Antimonial or other  Diaphoretic, as in  the
common formula? of Jalap  with Pulv. Antimon., or of the Nit. Potass,
with Jalap and Antimon. Tart.  I  have seen  little or no benefit from the
exhibition of Emetics,  so strongly  recommended  by some.  Among the
Vegetable Diaphoretics,  the Infusions of Seneka and Serpentaria and the
Asclepias Recumbens, are deservedly  extolled.  The  combination of Ipe-
cac. Avith Opium in Dover's PoAvder,  is an invaluable remedy; a full dose
of it should be given nightly, and it may  often be added at regular intervals
to such other Medicines as may be prescribed through the day.   The De-
mulcent  Drinks, formerly spoken  of, may be  taken to relieve Cou<di.
Where some pain remains after the febrile symptoms have been subdued,
and the Pulse has lost its force and tension, the part  should be repeatedly
Blistered—a measure Avhich I have  found singularly impressive and effica-
cious.   Where Effusion is ascertained to have taken place in the cavity of
the Pleura,  the urgency of the Dyspnoea may demand the  operation of
Paracentesis.
  Bilious Pleurisy.  The Thoracic Inflammations which occur early in
Winter and  late in  Spring, in our  low miasmatic regions, are apt to be
combined with notable symptoms  of Gastric and Hepatic disor 'er.   I
have been disposed to attribute the modification to the impression of Mai'- 
PRACTICE.
123
aria;  an English writer of some authority, speaks of it as owing to an
atmospheric and epidemic influence.  In this form less vigorous depletion
by the Lancet is required or admitted of, than in Simple Pleurisy.   Emetics
are useful—Cathartics are prescribed more freely, and the Mercurials se-
lected.   Blistering is earlier resorted to.   The  Bark is said to be service-
able in protracted cases.
  Convalescence from Pulmonary Inflammation, requires great care and
prudence.  The clothing should  be Avarm,  and all exposure cautiously
guarded against. 
11\
PKACTICK.
                     PHTHISIS PULMONALIS.

   Fnderthis head I include Chronic Pneumonia, and Tubercular Inflain-
mationof the Lungs.   Dr. Duncan  divided Consumption into  three kinds
1. Catarrhal Consumption, identical  with Chronic  Bronchitis,  already
treated  of.   2. Apostematous Consumption,  our present subject—and 3.
Tubercular Consumption Avhich shall be considered next in order.
   Chronic Pneumonia with abscess is not so rare a disease as it is repre-
sented to be by Laennec and some  others.   It has been alluded to as a-
mong the Sequelae of Pleuro-Pneumonia, and may  perhaps folloAV Catarr.
hal Fever,  and Bronchitis.  I  have seen it  tAvice occur from  gun-shot
wound of the Lung; in one case it Avas fatal, the other recovered after long
protracted illness.   Wounds of the Lungs, hoAvever, often heal kindly.   It
may supervene upon Asthma—and results from tenacious  Gastric and He-
patic derangements, constituting the  Dyspeptic Phthisis  of W. Philip.
Hemoptysis is said to produce it—but is in general only a coincident effect
from the same cause.  Some of the Exanthemata as Measles and Small-
pox render the patient exceedingly liable to it.   It has been brought on by
the suppression of Itch and other cutaneous eruptions.
   An obvions predisposition is found in a flat or narroAv  or otherwise  ill
constructed  Thorax.—Sedentary occupations Avhich  exclude  from fresh
air and free exercise predispose to it—so  do all  such  trades as subject  the
Respiratory organs to mechanical irritation, as Avith Millers, Needle-grind-
ers, Cotton-ginners, &c.
   The formation of pulmonary Abscess is attended by a fixed heaA-y pain
in the Thorax, pulsatory, or at  intervals sharp and lancinating.  There is
Dyspnoea Avhich does not admit of muscular exertion,  and is increased also
on lying down, especially if the patient  attempts to rest  on the sound side;
but this  rule is not Avithout exceptions.  The  cough is severe,  but at first
Avithout  expectoration.   The  Abscess sometimes empties itself through
small openings and gradually, but in general bursts and discharges its con-
tents freely  and suddenly—Pus  being  coughed up in quantities, varying
from ounces to  pounds.  There is great relief at the time, and the expecto-
ration continues abicdant for a Avhile after, consisting of pus mixed Avith
mucus and sanious scum.   Recovery sometimes happens from this state
—but more  commonly Hectic  supervenes, in place of the inflammatory
type of fever which  had attended the formation of the Abscess__there is
great emaciation and muscular debility—the voice is weak and hoarse, and
colliquative sweats and Diarrhoea terminateljhe  tedious train of suffering.
The Pulse is at first tense and quick and in some  cases full__after the ab-
scess is matured it becomes very frequent  and  more contracted.   The  di-
gestive system in many instances remains  unimpaired until the last stages
—Diarrhoea then coming on Avith redness and ulceration  of the lips, cheeks.
gums, and tongue.
   The Prognosis is unfavourable, holding perhaps a middle rank between
Uroi ehi:;s and Tubercular Phthisis.  When a case occurs in a person  of 
PRACTICE.
125
Aveli-formed chest,  previously healthy,  and from a transient and^notable
cause, there  is good hope of his  restoration.  The Avorst symptoms are
great emaciation  and debility.   By careful  exploration of the Chest, Ave
can ascertain the extent of the Pulmonary disorganization—to  Avhich the
danger is pretty regularly proportioned.
  The duration of Apostematous Consumption is  very various—from a
feAv Aveeks to many months.
  Autopsy.   Laennec and Andral declare it to be quite  uncommon to find
Pus in a circumscribed cavity in the Lung in this form  of Pulmonary dis-
ease—the  frequent mention of Abscesses  by  other  Pathologists,  being
attributed  to their  having mistaken  tubercular vomicae (to be hereafter
spoken of) for Abscesses.   They describe  purulent infiltration as super-
vening upon hepatization—the colour being changed from red to grey, and
the matter being diffused through the  Lungs—the te/ture of Avhich is bro-
ken doyvn and softened.   There  is, hoAvever, good proof that encysted  or
circumscribed Abscess does occur.  A large one is described by Laennec
himself.   Nor can Ave otherAvise account for the fact of large and  sudden
evacuation of Pus after  Pulmonic Inflammation, Cough, &c. have existed
for some time.   Such cavities are lined by  a false membrane, or layer of
organized fibrine.
  Diagnosis.   Apostematous Phthisis is attended  Avith more pain and
dyspnoea,  than Chronic Bronchitis or Tubercular Phthisis,  and Avith less
expectoration than the former, for some time from the commencement.   If
a considerable amount of purulent matter be suddenly discharged, we infer
that it must have collected in an  abscess.  The physical signs of this state
of the Lungs, are the lessening  of the capacity of the Thorax—the dull
sound upon percussion over the  pained part, and the  loss of respiratory
murmur there,  and after the Abscess is empty—Pectoriloquism.
   Treatment.  While pain urges, and until the failure of pulse and strength
absolutely prohibit, Venisection  to small amount should be repeated occa-
sionally.   Cupping the  affected  side of the Chest,  at first Avith, and then
Avithout, the Scarificator, Avill be of much service.   Large  Warm Poulti-
ces are also useful.  Blisters applied in  long succession, are  among our
best remedies.   When in anyway un suited, the  Ung.  ex Tart. Antimon.
may be substituted.
   Emetics  have been much employed by different Physicians, and Avith
very different views.  Some suppose them specially adapted  to procure
resolution and absorption of any deposit—others exhibit them  to  rupture
the Abscess—others still use them perseveringly as the most efficient re-
vulsive.   Some prefer  Ipecac,  alone—others  prescribe it in combination
with the Sulphates of Zinc and  of Copper.
   The Antimonials have been highly eulogized—by some as  the best Eme-
tics—by others, for  the  property of reducing the pulse and exciting pro-
tracted nausea—while  Laennec  and many continental Physicians, look
upon the  Tart. Antimon.  as gifted Avith a specific remedial  influence, and
give it in large and increasing doses as a contra-stimulant.   These consi-
der it as most beneficial when alone and uncombined.   In this country, it is
often exhibited  in combination with Nitrate Potass to reduce vascular  ex-
citement and determine to the surface—or with  the Infusion of Seneka and
Serpcntaria.  With similar  vieAvs,  and  as exciting a tranquillizing  influ-
<micc of great advantage. I  employ the Dover's  PoAvder, both before and 
126
PRACTICE.
 after purulent expectoration  has appeared.  Mercury, in small  doses, is
 occasionally administered with much benefit—but it is not adapted to all
 cases, nor should it be carried to the extent of an irritating Ptyalism.  In
 the first stages, it is useful in moving the boAvels gently, and subduing any
 gastric or hepatic disorder that may be present.
   Digitalis has been the subject of extravagant eulogy;  but I do not consi-
 der its remedial influence as well-marked or striking.  It is best adapted to
 cases where great frequency of pulse exists, and  the tokens of inflamma-
 tory excitement are not particularly high.  The Prussic Acid  has been in
 like manner extolled, and some authentic reports made in its favour—but it
 has  not retained the confidence of the profession.   After the Abscess has
 been ruptured, as will be known by the sputse and pectoriloquism, if the
 expectoration  be free  and Avithout pain, we may derive advantage from the
 Infusion of Cinchon^ with  which Mucilage and Anodyne may be united.
 The Mineral  Acids are also serviceable as Tonics here.  On  the  other
 hand, if there still  remain tension across the chest, with a harsh cough, it
 may be necessary  to take blood from the  arm, or  apply the Cups and  the
 Poultices or  Vesicatories, and even to administer an Emetic, which will
 often give great relief.   If Diarrhoea should come on, it must be restrained
 by the Acet:  Plumbi,  Kino,  or such  other  astringent as is best adapted—
.wJiieh1 we indulge the patient, Avith free doses of Opium, which will aid in
 checking the Alvine disturbance, while it subdues, in an unequalled degree,
 the Pulmonary irritation and Cough.  Among the numerous formulae pre-
 pared by modern Chemists  from its constituent principles, some  one will
 surely be found without objection.   The other  Anodynes may be tried—
 Thrid ace—Lupuline—Hyosciamus—Cicuta—but I have no confidence in
 any of them.  With the view to promote the healing of the Abscess or
 Ulcer, inhalations of Gases,  and even of finely-pulverized Bark, and other
 remedies, have been advised.   Iodine has been tried—Chlorine—the Va-
 pour of  Tar,  of R^jsin—several of the Gases less stimulating than com-
 mon air, as mixtures  of Hydrogen—Nitrogen—Carbonic Oxyde, &c.  I
 cannot express any confidence  in these measures, f The Balsamics are
 also in ancient repute for the same purposes.  If any good be done by
 such prescriptions, it must be in an indirect way.  Our best hope  is, in
 keeping the constitution at its highest point of tone and \agour.  As soon
 as the patient can bear it, exercise in the open air must be advised.   He
 should take a jeurney  or sea-voyage.  Flannel should be worn next  the
 skin, and a diet chosen for him, nourishing but unstimulating. 
PRACTICE.                         127
                    TUBERCULAR PHTHISIS.

  This insidious and fatal form of Pulmonary Inflammation derives its name
as Avell  as its other characteristic peculiarities from the  presence of Tu-
bercles in the Lungs.   It is therefore proper here to enter into  the consid-
eration of their nature and origin.
  Tubercleis variously described by authors.  In the condition most com-
monly met with, it is a pale  yellow or yellowish grey, opaque, inorganic
substance, someAvhat resembling cheese  in  appearance,  soft and friable.
CarsAvell regards the  mucous and serous surfaces  and the  blood "as the
exclusive seats of tuberculous matter"—it is principally found, deposited in
the  first of these positions.   It is composed of Albumen  Gelatine and Fi-
brine Avith a very small proportion of  muriate  of Soda and Phosphate and
Carbonate of Lime.  The majority  of Pathologists suppose it to be deposi-
ted  in this solid form—Cruvelhier asserts it to be at first fluid.  Laennec
contends that a Tubercle grows by  intussusception, but the opinion of An-
dral prevails, that it increases by the successive deposit of molecules around
the  primary  granule.   When deposited "each granule," says Morton, "re-
tains its appropriate tunic of cellular tissue."  The deposition may go on
until the mass shall occupy an entire lobe of the Lung.   The softening of
a Tubercle is not well explained.   Laennec  and  others contend that it
always commences in the centre—a view hardly  consistent with the ac-
knowledged inorganic state of the mass.   It seems more probable that it
results from inflammation of the JalesSsSi cellular  tunic  above spoken of, t
upon whose  surfaces pus is effused, mingles with and macerates the tuber-
culous matter.  Tubercles are not constant in their form.   They are often
rounded and cor tained  in a sort of circumscribed  cavity in a cyst, the inner
surface of which secretes purulent fluid.
  But Tubercle it  is well knoAvn is  not confined to  the Lung—it is met
with, as mentioned in the Lecture on Scrofula in many and  various loca-
tions, and is so  often connected with the other  Phenomena of strumous dis-
order, that it is by many supposed to be exclusively the product of Scrofu-
lous constitutions.   Whether this be absolutely true or not, it  is certain that
Scrofula constitutes an obvious and strong predisposition to the formation of
Tubercle; and that  Tubercular Phthisis  is  hereditary and of lamentably
common occurrence in strumous families.
  Another question of  great  importance is, whether  Tubercle is ever the
result  of  common  inflammation in  a  constitution previously sound.  The
alarming opinion that it can be thus developed is held  by  Andral and others
—but I am inclined to believe that Inflammation  is only to be  regarded as
the exciting cause  of  the series of symptoms which  constitute Phthisis.
The deposition of Tubercle I  believe,  to be independent of, and often unat-
tended by inflammation in any form or degree.  When this  deposition has
taken place, it may go on, and by its bulk excite inflammation round it and
thus develope Phthisis—or it may remain in minute mass and indolent, until
inflammation of the surrounding parts shall be excited by some extraneous 
%fcl£fa&PRACTICE-
 cause, Avhen its iaJfistHHrl* cellular investment shall secrete pus, and by this
 process  soften the tubercular  mass—Pleuritis Pneumonia and Bronchitis
 being thus converted into Tubercular Phthisis.  Phthisis by a large pro-
 portion of writers of a past age, and in many countries hoav,  Avas and is
 considered as  communicable or contagious; and  Avithin my own observa-
 tion so many  circumstances have  occurred Avhich seem to  confirm the
 doctrine, that with Cullen "I dare not assert that Consumption is not con-
 tagious."
   Symptoms.  The access  of this fatal malady is often extremely gradual
 and obscure.  The patient is  scarcely disposed to complain, though har-
 rassed by a dry hacking cough Avith occasional pain in the chest heavy and
 deep-seated.  There is languor and debility, and after a time notable ema-
 ciation, though the  appetite is unimpaired and the digestion good.  He-
 moptysis may now  and then folloAV a fit of coughing, though the hemorr-
 hage is not apt to be very large.  As the  case progresses, the respiration
 becomes hurried, Avith frequent pulse, and on ascending a stair the patient
 pants, and his countenance  is  pale  or livid, he cannot lie doAvn at night
 Avithout uneasiness, or is confined to one side or to his back—there is op-
 pression or tension of the Thorax Avith a disposition to stoop or lean for-
 Avard—Hectic ensues Avith its  long train of derangement  and  suffering—
 Colliquative SAveats and Diarrhoea—the tongue and mouth being covered
 with apthous ulcers, though the inclination for sapid  food may hold out  to
 the last—and the patient ultimately  sinks after an indefinite protraction  of
 his tedious disease inabsolute Atrophy or Marasmus.
   Prognosis very unfavorable—recovery scarcely to be hoped for.   It can
 hardly be possible that a single tubercle or even one mass of tubercles ex-
 ists alone;--if so there might be a softening and expectoration of them and
 the patient would be in the state described under the head of Apostematous
 Phthisis after the rupture  of the abscess.   It might heal.   But the  forma-
 tion of Tubercle in  the Lung  is generally a mere portion of the  general
 diathesis or  constitutional derangement, and similar deposition goes on or is
 repeated from time to time.  It is consoling hoAvever, to know that in many
 instances, an indefinite protraction of life is attainable by judicious and pro-
 per management.
   Diagnosis.  The unfavorable prognosis which a melancholy experience
 enforces from us, requires from us  great care in distinguishing this, from
 more hopeful forms of disease.  The Pathognomonic signs  are not  very
 clear.   The slowly progressive, gradual  increase of the symptoms  will
 attract our notice.  We will inquire if the patient be of strumous family or
 have exhibited in early life any Scrofulous developements-—or if his parents
 or ancestry have died of Consumption.   His expectoration will  not be
 abundant, and mixed with much mucus from the first, as in Bronchitis; nor
 suddenly augmented Avith pus as in the bursting  of a vomica.  The  pain
 will not be at  any time as acute in any part as it is from the commence-
 ment of Pleuro Pneumonia although it will in its progress be actually com-
 plicated with this affection—nor will there ever be so general a  soreness  of
 the respiratory tubes, as in the former.
   There is  in these cases too, a tenacious cheerfulness and resolution and
 hope of recovery, proverbially  noticeable.   It lasts until the impairment  of
 the Digestive function which is often delayed to the very last moment of life.
 The physical signs are rather negative than positive in the  first stages—the 
A
./., c,
x  &„.. ■:■'. ■  <"->  ^/fL^l*- ykifttui/i.  /:'.         .!..%xi
flCS^aW               PRACTICE.                          1J9

    absence of respiratory murmur may be remarked in more than one spot ot
    the Thorax, and after a time Pectoriloquy will be distinctly observable.
       We should be aAvare  that Tubercular  Phthisis may go on to a fatal ter-
    mination Avithout pain  in the Thorax or Dyspnoea in notable degree,  or
    Cough.   I once sayv a patient die,  the  nature of Avhose case—from the
    absence of these symptoms—Avas not detected, the right lobe  of whose
    Lung was found, after death, a mere mass of Tuberculous matter.  I atten-
    ded in the last Aveeks of his life, an eminent literary gentleman Avhose Phy-
    sicians had  treated him  for  Chronic  Hepatitis and Diarrhoea.   He  was
    surprised at learning that his Lungs  were at all diseased, as he had labored
    under no  difficulty of  Respiration and almost no cough, but desired  that.
    his body should be examined.   In complying  with his request I found his
    Liver little, if at all affected, and his  lungs full of Tubercles.
       The relations of Phthisis with other Diseases should be noticed here,    hs
    connection Avith other and more obvious forms of Scrofula has been men-
    tioned.   Children  who have been specially subject to Epistaxis, are apt to
    fall into Phthisis after Puberty.   Hemoptysis is also  a coincident effect of
    the same malformation and defect of organization which predisposes to
    Phthisis.
       Fistula in Ano is very often observed in subjects predisposed to Phthisis.
    and even after Phthisis has commenced: in this case it may suspend or pro-
    tract the progress of the latter indefinitely.  There is said by authors to be
    a similar connection or alternation betyveen Mania and Phthisis,  but I have
    had no occasion to remark any thing of the kind.   Intermittent Fever has
    also been supposed to exert a suspensive or protracting poAver over Phthisis.
    I doubt this—nay, I have seen our ordinary Mal'aria Fevers repeatedly de-
    velope Phthisis and excite it in  subjects predisposed.   It is  well   known
    that the  condition of Pregnancy will almost  invariably suspend—even in
    its advanced stages—the further progress of Phthisis, and that the  feeblest
    patient will almost certainly live  until she  is delivered.  Lactation does
    not, however, continue the privilege, and such  a patient Avill sink sooner if
    permitted to nurse her child.
       Treatment.   Little remains to be added to Avhat  was  said  under  the
    last head on this subject.  A Tubercle is an inorganic substance, and so far
    as can be positively stated, is not injurious, otherwise than as a mechanical
    irritant—whose presence produces Chronic Pneumonia with abscess, and
    sometimes excites perhaps, an attack of Acute Pleuro Pneumonia.   As Ave
    are not able to  remove the  cause—our principal indication  is  to palliate
    the effects; and this is best done as has been already shewn—By Bloodlet.
    ting—Antimonials—Digitalis—Opiates, &c.   From the analogy of its use-
    fulness in other forms of Scrofula with Tuberculous  deposite, Iodine is the
    subject still, of hopeful experiment.  I have been pleased Avith the apparent
    benefit derived in two or thiee well marked cases from  the Deut-Iodide c*.
    Mercury and Potassium.
       In no disease can the general subject of Prophylaxis be of greater conrr
    quence.   Children of Scrofulous or Consumptive  parents or  Avho  h <ve
    suffered much from Epistaxis—or avIio exhibit notable malformation o: the
    Thorax, should have selected for their future occupations through life  such
    employments or situations as shall admit of, or require  the  full develope-
    ment  of muscular power by Active Exercise in the fresh air.   Phthisis can
    neither be prevented nor cured,  nor even long protracted, otherwise  than
    bv exercise constantly and habituallv taken under the open sky.
    ■ ■•  . ,                 17 
130
PRACTICE,
                             ASTHMA.

  Defined to be—a species of Dyspnoea,  paroxysmal, spontaneously re-
mitting and recurrent.   Divided  by writers generally into tAvo forms—the
Dry, Nervous or Spasmodic—and  Humid or  Humoral Asthma—the dis-
tinction referring to the presence or absence of mucous rale and expecto-
ration.
  A paroxysm of Asthma usually comes on at night—is often preceded by
flatulence, a loose griping stool, heartburn  and other symptoms of Indiges-
tion.  The patient aAvakes  from his first sleep, Avith a sense of uneasiness
and constriction  of the  Chest, difficulty of breathing, and cough.   He is
forced to sit up, nor can  he  bear the Aveight or  pressure of any clothing or
fastenings about  his neck or body.  Respiration is effected Avith Avheezing
and panting and great muscular effort.  At first, the cough  is  dry—but
after a time, a frothy mucus is brought up, occasionally tinged Avith blood,
—this is attended Avith relief.   In the Avorst cases, there is neither cough
nor expectoration.  These  symptoms, depending  on the affection  of the
respiratory organs, are uniform;  those Avhich arise from the sympathic dis-
turbance of the general  functions, vary with the condition  of the patient.
In the robust and plethoric, and in recent cases, the pulse is full, hard and
frequent—the countenance flushed and turgid—the eyes suffused and pro-
minent,  Avith much tension and pain  of the chest.   On the  other hand,
Avhen the disease has become habitual, and the  patient is feeble, the face is
pale or livid, the surface cold and moist, and the pulse small and weak, and
the  tokens of gastric derangement more marked and prominent.  The du-
ration of a paroxysm is uncertain; it remits  usually  at the  approach of
morning, the Dyspnoea  continuing,  hoAvever,  in some degree  through the
day, Avith more or less cough, and the exacerbation  again recurring at night;
these  changes go on for a  feAv days before the entire subsidence of the
attack;—it has been endured for Aveeks.
  The general Prognosis  is favourable as regards the danger of a fatal
issue—feAv die; it is unfavourable as regards the hope of a  cure—feAv re-
cover.  Besides  the impairment of the constitution universally, which
must folloAv the repetition of paroxysms of Asthma, it sometimes developes
Hydrothorax, Chronic Bronchitis, and Phthisis Pulmonalis.
  Autopsy.   Asthma  is found accidentally connected  Avith a great many
lesions of the viscera of the  Thorax—hut is clearly proved  to be essen-
tially independent of any of them.  The most  frequent organic change in
the  asthmatic, is Emphysema of the Lung—the cells being found distend.
ed, two or more  of  them dilated  into one cavity, and incapable of collapse.
Even  this, however, is  far from beieg constant; and numerous cases are
recorded, in which  there Avas no notable deviation from the natural state
of the Lung.
  The Pathology of Asthma is  difficult and  obscure.   The  difficulty of
breathing is two-fold, and urges both during expiration and inspiration.  It
is hence plausibly suggested, either that the muscular fibres of the bronchi 
PRACTICE.
131
are every where rigid, refusing both to contract  and to dilate; or, that in
some portions of the air tubes,  these  fibres are spasmodically contracted,
resisting both the entrance and exit of air.
   Causes.   A  predisposition is obviously derived from vicious conforma-
tion  of the Thorax, or of some of the organs contained in it, either acci-
dental or hereditary.  A first attack generates a strong tendency to recur-
rence.  Paroxysms are excited by exposures to change of temperature, or
to cold and moisture—to the bad air of croAvded apartments—to certain ot
the gases and to some odours.  They come on after full meals, late sup-
pers especially—violent muscular exertion—loud singing and speaking, and]
supervene on repelled eruptions.   It seldom appears early in life—I havcy
hoAvever, seen a Avell-marked case in childhood.
   Treatment.,  During the Paroxysm, it may be necessary to  employ the
Lancet if the pulse be full and hard, and the patient robust.  It is especially-
called for in the early stages of cases Avhich present marks  of thoracic
engorgement or inflammation.   Cupping  the Chest is  also a useful mea-
sure, under these circumstances.   But Ave must be cautious not to detract
blood in the  opposite conditions—when th   patient is  feeble, and  the
Asthma habitual.  Emetics are  highly beneficial in many cases,—given at/
the beginning of the attack, they often cut it short; and if this fail, may bo
repeated after a time;—they are among our best  expectorants—and  arey
indispensably necessary, Avhen the patient has indulged in a full meal just
before going to bed.   It is Avell, too, to have the BoAvels opened by a pur-
gative Enema.   Many of the Narcotics enjoy great repute for the relief
of Asthmatic Dyspnoea.   Tobacco—Stramomium—Lobelia  Inflata—the
Spider's Web—Coffee and Opium  have their eulogists.  I prefer the last
mentioned, and in combination Avith Camphor,  Ether or Ipecac, have seen
it  of  immediate and  striking advantage.   Inhalations of various Gases
have been tried, but Avith no very obvious good results.  Galvanism de-
serves more general employment and confidence.   My experiments Avith
it have been successful and gratifying.  ^-^
   In the prophylactic management of the asthmatic, Ave must depend more
upon regimen than Medicine.   If any disorder of  the digestive system, or
any chronic pulmonary disease exist,  Ave  must endeavour to remove it.
We must aim to restore the patient to full and perfect vigour  of constitu-
tion by air and exercise.  We  must attend to the place of his abode, for
there  are particular localities in Avhich asthmatics suffer much, though in
regard to  the situation best fitted for each, no general  rule can be  laid
doAvn.  The matter must, therefore, be decided by  experiment. 
I. .32
PRACTICE,
                           PERTUSSIS.

  Tussis Convuxsivtjs—Bex Convulsiva, Kink-Cough, Chin-Cough, Hoop*
ing Cough—these are all significant  appellations for  the well-known dis-
ease now to be spoken of.   It is one of the specific Contagions—often be-
comes Epidemic—does not attack usually more than  once the  same indi-
vidual, although this rule is liable to many exceptions.  Hence, it is most
frequently met with in young children.  It invades for the  most part as a
common cold or mild Catarrhal fever.  After a certain  duration the par-
oxysms of coughing become  more and more violent, and  protracted,  and
convulsive.   Rapid and repeated expirations  are  made with  vehemence
and then a sonorous inspiration, whence the common name Hooping Cough.
These paroxysms terminate  Avith large expectoration or vomiting.  The
intervals between them, are shorter or longer and  more or less perfect and
free from uneasiness in proportion to the violence of the attack.  There is
generally a considerable secretion of mucus in the air passages with a loud
rale.  Pulmonary inflammation sometimes arises Avith fever and great Dys-
pncea.  In  other cases  there is notable and prominent disorder of the Di-
gestive system, with Diarrhoea, &c.   Not unfrequently too, there is much
determination to the head with Convulsions.
  The Causes which occasion or render more violent a paroxysm, are a
full or indigestible meal—any forcible muscular exertion—mental emotion
—exposure to cold and moisture, &c.  The average duration of Hooping.
cough may be calculated at from 6 to 8 weeks; it  may be prolonged indefi-
nitely by a renewal of Catarrhal affections, Avith Avhich it readily associates
itself.  It is said also to assume sometimes a periodical character Avhich
gives it a tedious protraction.
  Prognosis generally favorable.  The greatest proportion of  deaths hap-
pens among very young infants, Avho may die suffocated by engorgement of
the air cells and tubes with mucus that they are unable to expectorate,  and
children Avho are teething—a complication Avhich often gives  rise to con-
vulsions.  The supervention of any of the  more  ordinary forms of Pul-
monic Iaflammation, is attended with danger;—the  Diarrhoea, Avhich is
sometimes present, may become unmanageable and fatal.
  Autopsy.   The traces found  in post mortem examinations  of this  dis-
ease, are not regular or  uniform.   It sometimes happens, that no lesions or
morbid changes can be  pointed out.   Most generally, hoAvever, the Bron-
chial Mucous Membrane is irregularly reddened and injected in patches;
Avhile, at the same time, there are marks of determination to the head and
engorgement of the brain.
  The Pathology of Hooping Cough is not  clearly made  out.   Many
deny the existence of inflammation as an essential condition; the majority,
however, believe it to be an inflammatory affection of  the Bronchial Mem-
brane.  Some very respectable authorities  refer  all the phenomena to
cerebral and nervous disorder.   Others still regard both cerebral and pul-
monary inflammation as necessarily present, and in some  manner connec- 
PRACTICE.
133
ted.   Desruelles calls it a "Broncho-Cephalite."   It cannot be a simple
Bronchitis, as we infer from the spasmodic or convulsive character of the
cough Avhich attends, and the peculiar manner of coughing.
   Treatment.   It is made a question, Avhether we  harve the poAver to cure
an  attack of this singular malady; and Avhile some denying this power,
use their efforts merely to palliate the symptoms,  others are engaged in the
search after specific remedies,  of Avhich a large number is already accu-
mulated.  I would advise, as  the great majority of cases are, in the first
instance, attended Avith pulmonary disorder and inflammation, that they be
treated as Catarrhal Fever or Acute Bronchitis, by  general  and  local
Bloodletting, if severe; by  Emetics, Purgatives  and Expectorants.  The
Sulph.  Zinc,  has been supposed to  deserve a special  preference among
Emetics—and of the Expectorants, Squill and Ipecac.  The Narcotics
and Antispasmodics are  much  used Avhen the first stage has passed.  I
am much in the habit of combining Avith the Camphorated Tinct. Opii,
the Tinct. Mosch Fact., Avhich I mix in a solution of  the Carb. Potassae.
The Warm Bath should be employed at night, and counter irritation by
Mustard Poultices  frequently  resorted to.  Assafoetida is much extolled
among the  Antispasmodics.   Prussic Acid  is  supposed by some to be
almost antidotal; and in the same way the Acet. Plumbi. Nit. Argenti and
 Cochineal,  are prescribed, without any definite idea  of the modus ope-
 randi.  Of the Tonics, Cinchona and Arsenic are  justly preferred, and are
 well adapted to the relief of protracted attacks,  y '       /     ,   t  "



    ,X  ^ <J.        <,;■■'■-             ■■ ' •' .'■   '   ' 
134                        PRACTICE.
       EXAMINATION OR  EXPLORATION  OF THE THORAX.

      The knowledge  of the Phenomena from which we deduce the condition
    of the  Thoracic Viscera, is highly important to the Practitioner.  These
    physical signs are various in their character, and are to be ascertained by
    the modes of investigation of which I proceed to speak.
      I.  Inspection  of the outline and  the  surface of the Chest.  One side
    may  be flattened—may be enlarged—the intercostal spaces may be pro-
    truded—it may remain still  and passive,  unaffected by the motions of res-
    piration.   The subject may  be more  or less malformed—chicken breasted,
    &c.
      II. Investigation of the capacity  of the Thorax.  This may be ascer-
    tained in several ways.   A.  By Mensuration.  One  side may  be contrac-
    ted or  unequal to the other in circumference.   B.  By expiration into a
    gasholder  or bellglass  turned upside down  over Avater.   This is a good
    comparative test of the capacity of the Lungs at different periods during a
    chronic pulmonary disease.   C. By  counting seconds during inspiration or
    expiration or retention of breath.
      Ill*  Hyppocratic succussion—or  brisk agitation  of the trunk by the
    shoulders—for the  purpose of detecting "fluctuation in the Chest.
      IV.  Percussion—performed by striking the Chest with the finger, or the
;    points of them, or four together smartly.  A notable reverberation or hol-
    low sound is returned, on striking a thorax Avhich is healthy  and full of
    air.  If the reverberation does not occur, or if the resonance is impaired
    in any part of the Chest, we infer the presence of some impediment to the
    entrance of air into the portion of Lung  immediately beneath—either by
    effusion of fluid, or by the solidification of the Lung  itself.  Percussion is
    sometimes  performed mediately, a "pleximeter" being interposed betAveen
    the finger  and the chest.  A flat piece of Ivory is used for the  purpose—a
    bit of leather—of caoutchone—or a finger of the other hand.   The latter
    I prefer, and usually employ.
      V. The hand laid upon the several portions  of the Thorax, gives very
    distinctly the perception  of vibrations occasioned in breathing, speaking,
    coughing,  &c.—and any  impairment or increase of  the natural and  heal-
    thy degree of vibration is  readily recognized.   Thus, also, Ave examine
    the impulse of the heart, and determine  upon  its enlargement or hyper-
    trophy, and its situation or displacement.
      VI.  Auscultation.  This  is immediate, as Avhen Ave lay the  ear to the
    several regions of the Thorax, and listen  to the sounds Avithin.  It is me-
    diate AvheB' we employ  the Stethoscope.   This instrument sheAvn and de-
    scribed in  its several  varieties of form and  composition.  I prefer a tube
    made of Avood not  dense or  heavy and in one piece.   I dislike its division
    into more  than one piece to be sereAvcd or jointed together.  If the bore is
    sufficiently large. I do not think it of great  consequence.  Avhether it be of
    paper, ivory [or caoutchouc,  but prefer wood. 
PRACTICE.
135
  Respiratory sounds described. 1. Healthy sound or respiratory murmur.
A. Vesicular.   B.  Bronchial.   C. Tracheal.   D. Puerile respiration.
2. Morbid  sounds.  A.  Crepitous  rale.  B. Mucous  rale.  C. Metallic
tinkling.   D.  Gurgling or bubbling.  E.  Cooing or  purring.  F.  Sibi-
lant or Avhistling sound.
'Vocal  sounds described.   1. Healthy sound.  A. Bronchophony.   B.
Diffused thrill or vibrating murmur.   2. Diseased sounds.   A. iEgopho-
ny.  B.  Pectoriloquy.
  Sounds occasioned by the motions of the Heart, described. 1.  Healthy.
A. Auricular.  B. Ventricular.   2. Morbid.  A. BelloAvs  sound (bruit de
soufflet.)   B. SaAv sound (bruit de scie.)   C.  Rasp sound  (bruit de rape.)
A solid  stethoscope is said  to convey to the  ear, most distinctly, these
sounds produced by the action of the heart.
  VII. Insertion  of flat  Trocar—a means of exploration proposed  by
Marshall Hall, to be used in doubtful cases to ascertain the presence of air,
serum, or pus  in  the sac of the Pleura.   Not to be lightly employed, if
ever—and  suited only to cases in Avhich Paracentesis is contemplated and
proper to be resorted to.                 ..''-" 
136
PRACTICE.
                 UISEASES OF THE SENSORIAL SYSTEM.

  The functions of this important system are performed by the Brain; the
Spinal Cord; and the  Nerves—the diseases of Avhich organs must be con-
sidered in succession.
                            PHRENITIS.

  Inflammation  of the  Brain and its  investing  membranes, is  divided
into Acute and Chronic.   The latter is plausibly alledged to be the prox-
imate  cause of most of the diversified forms of  Mental  Alienation or
Insanity—Avhich varies in its history and symptoms  in relation to the vary-
ing seat and nature of the Cerebral Affection.   Of Chronic Phrenitis, I
do not now propose to treat.
  Acute Phrenitis is not often met with  as occurring Idiopathically or
independently, but  many of its phenomena arise sympathetically, in the
course of other diseases;  and in the class of Fevers, this is so generally the
fact, that Clutterbuck and others, have  maintained Cerebral inflammation
to be the primary  location and essential  condition of Fever  properly so
called.
  Acute Inflammation of any portion  of  the  Brain and  its Membranes,
commences with  pain in the head, Avith  a sense of fullness, heat,  and
throbbing;  the eyes are red  and  suffused, and intolerant  of light;  the
face is flushed and turgid; there is a pain in the back of the neck and down
the  spine—the stomach is in some cases oppressed, with retching and vomit-
ing; the pulse is full, hard and bounding; there is great anxiety and mental
dejection, or even from the first wild delirium, which at at any rate,  sel-
dom fails to supervene early in the progress of the attack; the hearing is
acute, and ordinary sounds occasion distress; there is Perviligium, sometimes
tenderness of the scalp—the tongue is whitish and lightly furred, the skin
hot and dry.   If the disease advance unchecked, the patient sinks into a
soporose state, the eyes groAv less and less sensible to light; there is perhaps
strabismus or a fixed state of the pupil, at first contracted closely and after-
Avards Avidely dilated—the hearing is impaired, there is  sighing, grinding
of the teeth; tremulous debility; Respiration and Deglutition become diffi-
cult, and coma or convulsions precede death.
  The Predisposition is said to be  sometimes hereditarily  transmitted. It
is found to exist in men of irritable and violent temper and morbid suscep-
tibility to mental emotion; in persons of sanguinous temperament; those ac
customed to free and luxurious living, and in profound students and literary
men of excitable character.
  The Exciting  Causes are insolation,  blows on the head, gusts of vehe-
ment or prolonged passion and intemperance.
  Autopsy.  The  appearances after death vary Avith  the duration of the
case.   The vessels of the Brain and its Membranes are turgid—lymph is 
PRACTICE.
137
found adhering to the surfaces of the latter and connecting them by adhe-
sions—serum is often effused over the surfaces  and in the ventricles and
Pus not unfrequently found mingled with it in considerable quantity.  Gan-
grene is affirmed to have occurred.
  Prognosis—Generally unfavourable.  We draAv the most gloomy infer-
ences from the supervention of great debility, Avhile the local excitement is
unabated—and from  the  tokens of effusion and  mechanical pressure—-as
Paralysis, Strabismus,  Deafness, Stupor, Coma, Convulsions.
  Treatment.   Bloodletting is universally acknowledged to be  indispensa-
ble.   Some open the temporal artery—some the jugular vein.   That ves-
sel is to be selected from Avhich Ave can obtain the fullest and freest flow of
blood.   The head should be elevated, and persevering affusions  of cold Ava-
ter thrown on it from some height.  The scalp should be shaved—cups  or
leeches may be applied to the scull and behind the  ears,  but  our best reli-
ance is on the lancet and cold affusion, Avhich I prefer to pounded ice, &c.
The most active purgative doses should  be given—a combination of the
Resinous and  Saline, I think should be preferred, and used freely and  as
long as the strength  will bear.   In the meantime the chamber should  be
kept cool and  dark, and absolute  silence  enjoined.  The  head of the pa-
tient should be elevated and abundant cold drinks alloAved him.   He must
be perfectly controled, and by  such means as admit of  no struggle or re-
sistance.
  The convalescence must be for some time guarded most carefully.  The
diet should be low—the mind kept free from care and anxiety, laxatives
administered occasionally, and a total abandonment of such habits as may
have predisposed to  or excited the attack, strictly enjoined. 
138
1'ltACTlCK.
                         MANIA A POTU.

  Delirium  Tremens—Brain Fever of Drunkards—La Folie des Ivrog-
ues, SfC JSfC.   Among the numerous appellations of this remarkable ma-
lady, I prefer to retain the first of those above set down, as strikingly sig-
nificant of the cause to which it is  attributable.  Until  we have clearly
designated its true Pathology, Ave shall not be able to give it a title abso-
lutely correct and entirely  unobjectionable.   It is not  properly  a Fever.
The line between  Delirium and Mania is not distinctly drawn—and there
can be no special impropriety  in using the latter phrase, where there is so
much mental derangement,  with constant hallucination.  Besides this,  it
runs so readily into  Phrenitis,  acute and chronic, as to give good ground
for this selection.  Indeed, although I  confess its Pathology to be extremely
obscure and ill-defined,  yet  I am rather disposed to regard it as a  peculiar
form of Phrenitis, modified  1st. By the cause Avhich produces it;  and 2d.
By the morbid condition of other organs, Avilh Avhich it is universally cor-
nected.
   The Cause to which it is exclusively  ascribed, is Intemperance in the
use of Ardent Spirits—distilled Alcoholic  Liquors. The influence of these
agents is slowly developed in  the  production  of Mania a Potu, which re-
quires time, and which  ultimately sheAvs itself in various forms, according
to the several diseases of other organs  which may  exist in each case.
Some have maintained  the  necessity  of a transient discontinuance of the
use of Ardent  Spirit, and a consequent exhaustion or prostration of nerv-
ous energy from the substraction of accustomed stimuli.  The fact, hoAv-
ever, is not so.  I have repeatedly seen  attacks of the several modifica-
tions of Mania a Potu,  supervening during the  actual progress of a frolic,
or while the sot was living in his usual maimer.
   Symptoms.   In a  majority of instances, the Stomach has yielded  long
previously to the morbid effects of stimulating potation, and the Liver and
all the other chylopoietic viscera have suffered.  There  is total loss of
appetite, Avith occasional retching and vomiting especially in the mornings;
the bowels are irregular, usually  loose Avith  acrid bilious discharges; the
hand and tongue are tremulous, the latter thickly furred, with fetid breath,
or smooth and fiery red.   The mind  is deeply depressed, and the state of
intoxication into which the  patient plunges for relief from this dejection, is
often more gloomy and remorseful.  At last the patient Avanders__he mut-
ters incoherently and Avith incessant restlessness;  or if he sinks exhausted
into a brief and unquiet slumber,  starts from  it in terror which cannot be
soothed.  The pulse is Aveak and very frequent, his skin cool and clammy,
his eye red and suffused.   Convulsions may occur, but  are  not usually
met with when the stomach is still disturbed with  the frequent retching, so
prominent a symptom of this form of the malady.
   In  some patients, the brain  suffers  more immediately, and  with much
less gastric disturbance previously, or at the  time.  Some fit  of intoxica-
tion deeper and more prolonged than ordinary, terminates in a horrid con- 
PRACTICE.
139
 vulsion, followed by another and another.  The unhappy subject may thus
 die at once,  or he sinks from  convulsion into a state  of exhaustion, with
 cold skin,  pulse  indescribably rapid,  and so feeble as scarcely to be felt,
 Avith  countenance haggard and eyes half shut.  After lying thus for some
 time, his muscular strength suddenly returns, and he  becomes capable of
 prodigious exertions;  he is haunted by some frightful  hallucination, and
 becomes extremely dangerous to  those  about  him,  whom, in his frenzied
 anxiety to escape, he Avill assault and  pursue with vehement malignity.
 This  condition often runs into acute Phrenitis, and  sometimes terminates in
 permanent insanity.
   Others again,  with less  obvious affection of the digestive system, and no
 acute cerebral disorder, sink into absolute imbecility, both mental and phy-
 sical, mingled with  a peculiar shade of gloom and despondency.   The
 skin, is  such cases, is  hot and dry—the pulse  is small, corded and frequent;
 —the patient takes almost no food, and scarcely sleeps—seems always
 restless and uneasy; he affects solitude,  often mutters  to himself, and ap-
 pears alarmed causelessly.   In almost all these there  is  a notable predis-
 position to suicide.
   The Autopsy of Mania a Potu, developes nothing  uniform or character-
 istic.   A  variety  of lesions have been  noted, but  are not regular.   The
 "Anatomy of Drunkenness" sheAVs marks of extensive disease of the Sto-
 mach, the Liver,  and the Brain;—the progress of the several changes or
 steps  of disorganization, is proportioned to the duration  of sottish habits.
 But all these changes may  have taken place, Avithout the  production of this
 particular form of disease.
   The Prognosis is generally favourable.  Few die in Mania a Potu, and
 those few rather  of the derangements of the  constitution, which are the
 coincident effects  of the cause which has produced the  attack.   The to-
 kens of a specially unfavourable case are—obstinate  pervigilium, Avhich
 always  threatens convulsions—a repetition of the convulsions, with brief
 interval—or the occurrence of  Coma.   It is also unfavourable to find the
 pulse  rising and becoming fuller and slower, while the mind continues per-
 turbed.   We have here to  dread permanent insanity.
   The Treatment must be modified to suit the condition  of the patient.
 Venisection is seldom necessary or justifiable.   It may be required to ob-
 tain a respite from Convulsions.   When a transitus has t.ken place to the
 symptoms of Acute Phrenitis, the Lancet must be freely employed—this is
 marked by fullness and hardness  and comparative slowness of pulse—by
 the cessation of trembling of the limbs and tongue, and by a change in the
 manner of the -patient, which is now fierce and resolute, and no longer full
 of tremor  and vacillation.   If  there be no doubt on this point, the hair may
 be cut close and Leeches and Cups applied to the temples and back of the
 neck.   But such  cases, it  should  be kept in  mind, are not common, and
 this mode of depletion is riot to be often resorted  to.  Cold affusion may
 be of  advantage Avhen the face is flushed and the skin hot and dry—under
 opposite circumstances I Avould not advise it.   Emetics have been highly
 eulogized,  bnt they are of doubtful  effect.   When the stomach is  nau-
 seated Avith retching and ineffectual vomiting, with foul  tongue  and^ fetid
 breath, they may  do service.   They may also be occasionally employed to
arouse the susceptibility to the action of other remedies, w hen we have foun<J
ordinary doses incapable  of affecting  the patient.   Cathartics are  onen 
140                        PRACTICE.
 beneficial.  Calomel,  in large doses,  is the best.   The Saline may  be
 added, if the patient be strong and robust.   In general, hoAvever, it is not
 advisable to employ  Cathartics freely.  Opium  is, unquestionably,  our
 most important  remedy.  It is applicable to all cases of Mania a Potu—
 and has  only been subjected  to doubt, by  having been erroneously pre-
 scribed,  Avhen the  case has run into Phrenitis of ordinary  character.  I
 prefer the Tincture, and prescribe it with unyielding perseverance in large
^doses until the patient  sleeps.  I do  not like to combine Avith it any other
 stimulant.  Camphor  and Ether  are the least objectionable, if an addition
 be necessary.  Nor can I assent to the propriety of exhibiting large masses
 of solid  Opium, which may not dissolve at all when  most needed, and may
 lie inactive in the stomach, until a period when its solution and consequent
 absorption and active  influence may be productive  or injury  rather  than
 benefit.
   The management of the patient is a matter of much  importance.   He
 should be kept under the most perfect controul by a sufficient number of
 resolute  attendants—or, Avhich is  often better—by solitary confinement.
 His diet, if he will take any, may be nourishing and Avell seasoned.   His
 convalescence must be carefully guarded.   His mind must not be disturb-
 ed with  care or business.   Tonics  may be  of use to him—but all stimu-
 lants (except those already mentioned)  must be positively refused.
    The Prophylaxis of Mania a Potu—the reformation of the drunkard is
 a  topic  of infinite  interest.  The peculiar craving or longing after ardent
 spirit is, in the sot, the consequence of a morbid condition of the stomach
 chiefly.   To remedy  this,  it is  proposed  to  combine the Sulphuric Acid
 with the accustomed drink—and the effect  is said, in some cases at least,
 to be strikingly advantageous.   By  others, it  is suggested to combine Avith
 the several  forms of  distilled  liquors,  the Tart: Antimon.  or Ipecac, or
 other emetic, in  such  amount as  to nauseate long and vomit severely.
 These attemnts  may sometimes succeed; but, in general, they either totally
 fail or produce  only a transient influence.   Nothing is to be hoped from
 any  measure short of perfect abstinence;  nor is any thing to be feared
 from the abrupt enforcement of the injunction.   I  would scarcely alloAv,
 in any case, the use of a substituted stimulant; but if such  an indulgence
 seemed  necessary in a given instance,  Opium and Camphor would suffice
 abundantly,  and the dose being rapidly diminished, might  soon be safely
 withheld. 
PRACTICE.                         141
APOPLEXY.
  Apoplexy may be defined to consist in a loss or remarkable impairment
of the poAver of motion, with insensibility and stupor.  The patient cannot
be roused and gives little or no token of consciousness.  The action of the
heart is usually little disturbed at first, but soon becomes feeble, and after a
time ceases.  Respiration is performed Avith some labour and effort, and
with  stertor generally—the difficulty  increasing as the circulation is more
impeded.
   Causes.  A  predisposition to Apoplexy is found in a full plethoric con-
dition of body—habits of undue indulgence  in  the pleasures of the table
and venereal gratification—in mental excitability, liability to  gusts  of an-
ger and other violent emotions.  Yet it is not only  the luxurious  who are
thus predisposed, similar  tendencies  are  often  found in the ill-fed, badly
nourished poor.  As age advances, the predisposition  seems to  increase.
It is  commonly believed to be connected  too with a particular form,  of
Avhich "rotundity, corpulence, Avith thickness and shortness of the neck," is
the description.
   The Exciting Causes Avhich affect the  predisposed are numerous:  all
stimulants, a full meal, especially if  the subject place himself soon after in
the recumbent  posture; insolation,  vehement muscular exertions, ligatures
round the neck, fits of passion, stoopmg down for any length of time—all
circumstances  in short, Avhich either render  active the cerebral circulation,
determining  to the brain, as the phrase is,  or Avhich impede the return of
blood from the head.  Apoplexy is said to be often connected with Hyper-
trophy of the heart, and to follow the sudden disappearance of regular Gout
and the suppression of accustomed evacuations.
   Diagnosis.  Apoplexy resembles profound sleep, but the sleeper may be
aroused;  it is distinguished from Syncope hi doubtful cases, by the respira-
tion, Avhich is almost always noisy and laborious—generally by the pulse
also, Avhich is  full and slow, and the countenance,  Avhich is in the majority
of instances, flushed—from Epilepsy by the absence of distortion or con-
 vulsions—from Asphyxia by the previous history of the case,  and  in the
 same manner from the torpor of extreme cold, which closely resembles it.
 It is very difficult to distinguish it from intoxication,  and it is often most per-
 fectly simulated by the Hysteric Paroxysm.    There is also a sympathetic
 loss of sense and motion from Gastric disorder, not easily separated from it.
    The Prognosis is generally unfavorable—perfect recovery from it is not
 frequent;  hemiplegia is a very common result of  the attack; a  strong ten-
 dency to recurrence of the paroxysm remains.   Ihe best hope of restora-
 tion is in the young and temperate, subjects  marked by no special bad habit,
 or other token of predisposition, and attacked under circumstances of tran-
 sient influence, as from Insolation.   In the old, and infirm,  and intemper-
 ate,  the prospect is gloomy.
    When one side is in any degree agitated, and the other remains  motion-
less, we predict Paralysis of the latter.   If the pulse sink, the  respiration 
142
PRACTICE.
become louder, with puffiag of the cheeks, and relaxation of the sphincters
occur, we expect a promptly fatal termination.
  Autopsy.   The appearances  vary somewhat, but in a  vast majority of
cases betoken impediment to the performance of the functions of the brain
or actual lesion of cerebral structure.   1.  Hemorrhage is of frequent oc-
currence.  Blood may be poured out upon the surface of the membranes,
or within the ventricles, or in the very substance of the brain with laceration.
2. Serum or Seropurulent fluid may be found in the ventricles or upon the
membranes.   3. Turgescence of the Cerebral vessels is rarely Avanting in
greater or less degree.   Exceptions are however recorded on good author-
ity in which none of the  above marks of disease Avithin the head were dis-
covered.
  Pathology.  Apoplexy is properly the abolition  or  suspension of the
sensorial functions, occasioned by pressure on the brain.   Mechanical pres-
sure, as  by fracture and  depression of the skull,  gives rise to a train of
symptoms precisely the same.  This pressure maybe 1. Extravascular, i.e.
from fluids poured out, blood, serum, &c.—or it may be 2. Intra-vascular,
from mere fulness or  turgid state of the cerebral vessels—which latter con-
dition may disappear at the time of death, leaving no trace.
   Treatment.  This must vary with the condition and circumstances of the
patient, Avhich in different cases will be strongly contrasted.   Apoplexy has
in relation to these diversities, been  divided into two forms,  Sanguineous
and Serous—Meningeal and Cerebral—Entonic and Atonic—phrases sig-
nificant,  and applied  with some foundation in propriety.  These modifica-
tions are explained by the constitutional peculiarities of the subject, by the
nature of the cause which has affected  him, by the degree of lesion of the
brain and the particular locality of the  lesion.
  1.  A majority of the cases present the following symptoms.  The pulse
is full and strong, though sloAver than natural,  the face is flushed or turgid,
the eyes prominent, the pupils someAvhat dilated, though not  altogether in-
sensible to the influence of light, the respiration stertorous—the surface is
of natural temperature—the features flabby and  the jaAv somewhat fallen.
There have been, for the most part, certain premonitory indications before
the fit, such as flashing of light before  the  eyes, tinnitus and other noises
Avithin the ears, fullness or throbbing, or pain in  the head  or vertigo, with
somnolency;  and sometimes a failure of strength of the arm and leg of one
side, or a sense of numbness in them or iu the tongue—for Paralysis  may
precede as well as folloAv Apoplexy.
  In  this state of things, the Lancet must be promptly used and fearlessly—
and blood drawn from a large vein or veins, to an amount sufficient to make
a definite impression upon the force  of the circulation.   Cold Affusion on
the head is useful—the hair being cut close  or shaved.   Active Cathartics
and Enemata must be employed for their revulsive effect—the Drastics will
be chosen  on account of the impaired susceptibility.  Counter Irritation by
Sinapisms to the extremities and Epispastics, will be of service.   Emetics
are equivocal remedies, and should not be  administered, unless when the
patient has been attacked immediately after a full meal.   The best means of
promoting the certain recovery of the  patient,  and of  confirming a cure
thus begun, is to keep up a regular and free  determination to the boAvels, by
the use of efficient purgatives in  repeated doses. 
PRACTICE.
143
  2. The patient is sometimes pale or livid,  Avith a  cold moist skin, and a
pulse feeble and intermittent.   Here the Lancet is forbidden.   Cold Avater
must be applied over the head, by affusion  or with  a  sponge,  and cups to
the back of the neck and betAveen the shoulders, or leeches behind the ears
or around the arms.    Volatiles may be held occasionally to the nostrils,
and mustard laid upon the extremities and epigastrium.  Stimulating Ene-
mata may be given Avithout delay, and  Epispastics laid upon the spine and
other parts of the surface.   If the pulse rise under this treatment, Ave may
bleed and administer' purgatives. 
144
PRACTICE.
                            PARALYSIS.

   Under this head, 1 shall notice several diseases usually recognized as dis-
tinct.   1. Hemiplegia, or Palsy of one side of the body, closely connected
with our last subject, as being an affection of the Brain primarily, and al-
ways the result of pressure on some part of that organ.  2. Paraplegia—
Palsy of the lower half of the body,  transversely divided;  the result in a
vast majority of cases, of lesion in the Spinal cord, though it has occurred
independently of it.   3. Paralysis Agitans—and 4. Paralysis  Vacillans or
Chorea Sancti Viti.   Apoplexy in its wrorst grade,  may  be considered a
complete and total Paralysis, but  there  are degrees even  in  Apoplectic
seizure, and the various divisions above stated, are obviously, forms of par-
tial Paralysis.    We may  have Palsy of a single limb—nay, of a single
muscle, or of a feAv muscles.  In Colica Pictonum,  there is Palsy of  one
or both hands.   The arm has been palsied, Avhile the  hand,  if supported,
Avas capable of Avriting.  A Palsy of one side of the face is not very rare.
The tongue is sometimes palsied.  In Avhat I have called P.  Agitans, there
may be a constant trembling of the hand, or  more frequently, an incessant
shaking of the head.   This is common with the aged,  but I  have met with
it also, in the young and robust.   In Apoplexy and Hemiplegia,  the Brain
is evidently the seat of injury.   The mind is disturbed  more  or less,  and
both sensation and motion are impaired.  In the three latter forms of Para-
lysis, the mind usually remains unaffected and the sensibility  of the parts
is not changed, the nerves of motion having suffered exclushrely.  This
may either result  from  some cause acting upon the  nervous ramifications
which supply the parts, or may depend upon lesion of the portion of spinal
or cerebral substance from  which these spring.  Paraplegia, Avhich in a
great majority of instances, arises from obvious injury or  disease of the
Spine, has been ascribed in a feAv, to cerebral derangement, and has occur-
red as a sympathetic effect  of Gastric and Intestinal disorder, Avithout any
perceptible change in the condition, either of the  brain or spinal  cord.   In
Chorea Sancti Viti—Paralysis Vacillans—styled by some of the English,
P. Agitans, incorrectly—the tremor or agitation is not constant, but exhib-
its itself only at  the moment Avhen an effort is made at voluntary motion.
The volition fails  in part, and the muscles called upon, act Avith vacillation
and irregularity,  but not at all feebly.   There can  be little doubt,  I think,
that the Cerebellum—the organ of association of action, is here affected as
well as the nerves, and Avhen the case is severe  and protracted, the Avhole
brain may become disordered, the patient becomes fatuous, and there is ten-
dency to convulsions.
  1. Hemiplegia is nearly allied to Apoplexy Avhich it may either precede
or folloAV.  As the consequence of the  Apoplectic seizure, it has  already
been spoken of.    Its approach may often be observed and foretold.  I  have
more than once, marked in  the Apoplectic, the exact  moment of its occur-
rence,  denoted by a slight quivering of the muscles  of the face,  trunk  ami
limbs, Avhich in an instant relax and subside into a passive condition. 
PRACTICE.
145
   It often invades gradually.  The patient first complains  of a numbness
i~nd tingling of one arm and leg—is apt to trip or stumble,  and to let fall
Avhat he attempts to hold;  there is noise is the ears, and the  eye of one side
cannot be closely shut; there is some distortion of the mouth, and  articula-
tion is impeded.   The mind is usually  someAvhat disturbed;  the  memory
generally fails, though not  invariably, and some terror attends the feeling
of so great a calamity.  When fully developed, Hemiplegia implies an in-
capacity to stand or walk, or close or raise the hand; but the poAver of sensa-
tion and voluntary motion in the side affected, though  greatly impaired,  is
seldom, if ever, totally lost, and in numerous cases,  the sensibility has  re-
mained, or been morbidly enhanced, Avhile motion Avas impossible,  and vice
versa; in  one  remarkable  instance, there  Avas loss of power on  one side
Avhile the feeling of that side continued, and loss of sensibility on the other,
the voluntary movements of Avhich Avere impaired.  These facts are easily
explained, since the discovery made by Sir C. Bell, of the independent ori-
gin of the tAvo sets of nerves.
   Sometimes the case runs rapidly on into Apoplexy, occupying from a few
hours to a feAv days—the  prostration of muscular poAver increasing, and
the mind becoming more and more disturbed, until insensibility  and coma
supervene.
   Manyr patients hoAvever,  drag out a miserable, protracted existence of
months and years, of unabating suffering.    The nutritive actions of the
vessels of the affected  limbs, are impaired—they shrink and are emaciated,
their  natural heat being lessened—harshness and dryness  of the surface
ensues, the ordinary transpiration ceasing—the fingers are pale and Avaxen,
and sometimes  contracted; the countenance  is distorted by the traction of
the mouth to the sound side, the saliva escapes over the chin, the tongue is
thick, and when protruded turns to the paralytic side, and the speech is con-
fused and imperfect.  There is sometimes severe pain, and sometimes spas.
modic muscular contractions on the affected side.   Amnesia is usually pre-
sent in various degrees.  The  memory of Avords is oftener lost than the  re-
membrance of things or facts.  The names of familiar  objects are sought
for in vain, or incorrect names obstinately applied—and Avords pronounced
by the tongue, Avhich the will had not contemplated.   The emaciation and
debility increase, until the patient sinks, Avorn out and  exhausted by a long
train of evils—in Avhich every function has successively suffered.
   In a feAv cases, a gradual improvement takes place, and  a restoration of
some of the capacities for action and enjoyment,  but  such  recoveries are
rare.   They are attended Avith formication  and  tingling of the  limb and
sometimes painful swelling, Avhile the poAver of  motion increases sloAvly
and the mind gains strength.
   The Causes of Hemiplegia are those of Apoplexy already enumerated—
Plethora and the reverse condition arising from imperfect supply of food in
the poor—Insolation and Intemperance.
   The Prognosis is unfavourable.   It is proved that absorption of extrava-
sated blood, which by  its presence in the Brain has produced Hemiplegia,
may take place—but"the  process is sIoav and uncertain, and the constitution
in the meanAvhile sinks under the general impairment of function.^  Lacer-
ation  and disorganization of the Cerebral tissue  hardly admit of restora-
tion.                                             .          .   .    i
   Autopsy.   The most common circunr-tancc uoted in the  examination of
                     1<> 
146
PRACTICE.
Hemiplegics is the presence of a clot of blood in some part  of the brain.
It is usually, perhaps always, enveloped in a cyst, and has undergone more
or less change from absorption.  The process is slow;  the  clot has been
found undminished in size, and filling the cyst two  years after the attack.
Sometimes the cyst is found empty, with its sides collapsed—at others, it
contains  serum.    Tokens  of inflammation  of a  portion  of Brain  are
found—there  is induration of substance—RamoUissement or  softening,  a
change supposed by some to be analogous to Gangrene of other  tissues.—
Abscess  or effusion of Pus—of Serum, and  tumours connected with  the
membrane.
   The Pathology of Hemiplegia is readily deducible from Avhat has been
stated above.   It is the result  of  pressure upon some part  of the Brain,
and the degree and kind of effect are in relation to the locality  and  extent
of the lesion  Avhich interrupts the sensorial function.   The pressure on
Avhich it depends, may be, though rarely, intravascular.
   The Treatment must be varied, as in Apoplexy, to suit the condition of
the patient.   If he  be  young and robust—the  pulse full and strong—the
face flushed, with pain  and throbbing of the head, he must be bled iargely,
and cold Avater poured upon the head from a height.  Purgatives of active
and  irritating  character,  must be  promptly administered, and  their effect
hastened by the aid of  Enemata.
   In  the opposite state  of  the system, when  the countenance is pale, the
pulse feeble, the skin cold and moist, Volatiles must be applied to the nos-
trils, Sinapisms and Epispastics to the limbs and trunk, and the head spun-
ged with Vinegar and  Water.  Enemata  may be given, and Leeches or
Cups put to  the  temples and  back of the neck.   If reaction ensues, Ave
should deplete, but with caution.
   In  the protracted state of Hemiplegia,  the  persevering employment of
Purgatives has done service—and some of the Cathartic Mineral Springs
are celebrated for cures effected.  Determination to the head must be com-
bated by keeping the head shaved, and occasionally applying a feAv Lee.
ches behind the ears, or blistering the back of the neck or betAveen the
shoulders, or  inserting an issue or a seton in the neighbourhood.  Farther
revulsion is attempted  by frictions Avith Turpentine, Mustard, &c, Avhich
are supposed to excite locally the enfeebled muscle's  and nerves.   With the
same vieAV, the skin of the limbs affected is irritated with Tartar Emetic—
rubbed with rough  tow and hard brushes—stung  Avith nettles and burnt
with moxa.   Both the cold and hot baths are much eulogized.  But the
most useful means, in my hands, have  been Galvanism and Electricity;
and under the employment of these, I  have seen some remarkable cures.
The Tonics are much  employed,  especially the Metallic—the Nitrate of
Silver—Bismuth—Zinc—Arsenic.  Strychnine has been of late  highly
recommended, and  is supposed to possess some specific and peculiar pro-
perties, which adapt iMo the relief of  the Hemiplegic.
   2.  Paraplegia  is one of the most obstinate and hopeless of human mala-
dies.   The spine should  be  carefully  examined, and at any  point exhibit-
ing fulness or tenderness on pressure, Leeches or Cups should be repeat-
edly applied.   The use of Purgatives,  and the employment of Electricity
and Galvanism, furnish perhaps our most reasonable hope of improvement.
   3.  Paralysis Agitans—if in the old, is  incurable.  In the young, it is
connected with various other derangements of health, and AA'ill require the 
PRACTICE.
147
treatment to be accordingly modified.  In females, it seems dependent upon
habitual constipation,  and sometimes upon irregularity of the Catamenia.
Under both circumstances, I have succeeded in removing it by employing
a combination of some resinous purgative with the rust of Iron.
  4.  Paralysis Vacillans—Chorea  Sancti Viti belongs generally to child-
hood and early life.   It is  produced  sometimes by the irritai.on of Worms.
I have seen it during convalescence from  other maladies, as Scarlatina,
Catarrhal Fever, &c.   I kneAV it supervene upon the introduction of a Nee-
dle into a  part of the body; and after a duration  of some months, cease
suddenly on the Needle finding its way ou* of a distant part.  It often in-
vades, however, without obvious cause.   I have seldom failed to relieve it
by the exhibition of Iron Avith an occasional purgative.  Other Tonics are
used, as Bark, Sulph. Quinine, and the Cold Bath.   I  have used Camphor
and Opium in minute doses, Avith great advantage.   In obstinate cases, I
have  seen  the best effects folloAv from Galvanism and Electricity. 
14'8
PRACTICE.
                                       EPILEPSY.

             This terrible disease is of paroxysmal or recurrent character—the pa*
          hent  usually enjoying good health in the interval,  but liable to an occa-
          sional attack upon the application of exciting causes of great number and
          variety—and in bad cases spontaneously, or without the influence of any
          obvious cause.  The paroxysm consists in a sudden loss of consciousness
          and sensibility, attended Avhen fully developed,  by convulsive agitation of
it-.-—-^ / the body and  limbs.   Convulsion  described as an wltiroistoiand rapid con-
'^Tc^tSraction and relaxation  of the muscles of voluntary motion.  There is
          much irregularity both as to the muscles affected, and the force and quick-
          ness of their contraction.
             In  a fit or paroxysm of Epilepsy as ordinarily  occurring, the  patient
          falls and is agitated Avith convulsions.  The countenance is flushed or livid
          and horribly distorted, the head draAvn forcibly backward, the eyes turned
          upAvard and  inward, and  the lids  incessantly in motion.   The mouth is
          rapidly opened and shut, Avith inarticulate sounds and moaning expressive
          of great suffering, the  tongue is mangled by the  gnashing of the teeth,
          and the lips are covered with foam.  The limbs are tossed violently or
          drawn together, Avith the hands tightly  closed—the trunk is tAvisted to and
          fro, and the resistance of the sphincters being overcome by the contraction
          of the  abdominal muscles, the contents of the Bladder and Rectum are
          evacuated.   After a time these  convulsions subside, and the  patient lies
          passive, languid and soporose—his intelligence  gradually returns, or is at
          once  recovered, after Avaking from this slumber,  but there is no memory
          or consciousness of what has happened; great debility, and usually some
          headache, remain for a few hours.
             Epileptics often receive a species  of Avarning, which admonishes them
          of the approach  of a fit.  In some,  this consists in  the throbbing of the
          head, tinnitus, &c, Avhich precede Apoplexy.   In others, there  is an inde-
          scribable affection of one or more of the organs of sense—either of smell,
          taste, or sight;—to perceive a particular odour is  not uncommon; and a
          patient of my own was ahvays aware of Avhat she  denoted "a green taste"
          just before an attack.   Others still feel  in some  part of the body,  a sensa-
          tion  usually spoken of, as  "a cold creeping vapour," Avhich  originating
          these, moves upwards towards the head.  This  is knoAvn as "the Epilep-
          tic Aura;" but the accounts given of it by different patients, are  dissimi-
          lar.  Some speak of it as a titillation—others as severely painful—others
          as indifferent or but slightly uncomfortable.
             The Paroxysm  of Epilepsy is not ahvays fully developed, as above de-
          scribed, the sensorial and muscular system being affected in  various modes
          and degrees.  There may be for  a moment, or  a very few moments, total
          unconsciousness—a mist, as it Avere, coming over the mind, while the mus-
          cles remain undisturbed.   On the other hand, the intellect may  be clear,
           while the aura is felt, and the muscles, if not agitated, refuse to obey the
           will.   <>ne class  of muscles may be exclusively and strongly contracted. 
PRACTICE.
149
which is spoken of as the tetanoid form of Epilepsy;  or the Avhole mus-
cular system may become at once rigid and  fixed in the mode and degree
or state of action existing at the precise moment of seizure—a state Avell
known as Catalepsy, and  of Avhich I have met Avith tAvo Avell marked in-
stances.  And all  these  varieties may, at different  periods, exhibit them-
selves in the same  individual case.
   The Autopsy of  Epileptics, discloses no uniform lesion or derangement.
Many  affections of the Encephalon and  Spinal Cord,  have been noted—
but they are found in comparatively feAv  subjects; and  on the other hand,
are often observed uncoimected Avith Epilepsy.  Among them may be
mentioned, Ossific and other tumours attached to the  inner  table of the
skull, and to the membranes of the brain,  and purulent and other effusions,
upon the surface of these membranes; and in the Vertebral Canal.
   The Pathology of Epilepsy is  extremely  obscure  and ill-understood.
The  nature of the intermittent disturbance  of the sensorial system  and
function upon Avhich it depends, is absolutely unknown.
   The Causes  of  Epilepsy are varied and numerous.   The predisposition
is transmitted  hereditarily; and in  certain families,  many of the members
become its subjects.   In persons thus predisposed, almost every derange-
ment of any organ or function may become an efficient exciting cause.  I
would distinguish  Epilepsy in reference to the first notable link in the chain
of circumstances Avhich give  rise to it, into Idiopathic and Sympathic.
   It is Idiopathic Avhen  it occurs  Avithout  obvious derangement of  any
other function than the sensorial, and Avhen Ave can reasonably refer it to
some knoAvn agent, capable of directly impressing the sensorial system—
as for example, mental emotion of many kinds, and  the strong principle of
imitation.
   It is Sympathic—Avhen on the other hand Ave trace the sensorial disorder
 to an indirect or secondary influence exerted upon the brain and  nerves,
 through the diseased condition of some of the other organs or systems.
   1. The  Digestive.  Dentition and Worms produce, by their irritation,
 many attacks  of  Epileptic Convulsion in young children.  Intemperance
 is a frequent cause among adults;  though  it  may be questioned Avhether,
 in this example, the primary impression be made upon  the stomach or the
 brain.   Hepatic disorder has  been accused of bringing on Epilepsy.
   2. The Genital.  In Avomen, Epilepsy is often connected Avith derange-
 ment of sexual health.  Masturbation will give rise to  it in both males and
 females.   Venereal excesses have  proved fatal by inducing Epilepsy.
   3. Metastatic Epilepsies.   Under this head, I Avould  include such as
 precede and folloAv the Exanthemata—such as supervene upon the sudden
 disappearance of  inflammations and the removal of tumours.  I have more
 than once seen such convulsions folloAv the sudden  disappearance of drop-
 sical sAvellings.
   4.  Epilepsies  connected Avith "the Aura."  This strange  sensation has
 sometimes an  obvious cause in the  condition of the  part where it commen-
 ces.  The part is sometimes tender on pressure, and sometimes it  invites
 pressure.   Where no disease can  be  traced on examination, I am still dis-
 posed to believe  there is a morbid local affection of the nerve distributed
 there.
   The Prognosis—in the first species or Idiopathic Epilepsy is unfavour-
 able except Avhere it is clearly  owing to some transient excitement of the 
150                         PRACTICE.
feelings or Avhen it is founded on the instinct of imitation.   In the Sympa-
thic, we distinguish the several forms.  Attacks occasioned by the irritation
of worms or dentition, or even by intemperance, are, for the most part, rea-
dily curable, upon the removal of these transient causes.  So also of those
which I  have termed  Metastatic, which are not usually obstinate.  But
Epilepsies, arising from genital derangements,  take promptly a tenacious
character, and are difficult to expel; and in the modification  specified un-
der the 4th head, we have little room for hope, unless Ave can appreciate
and remedy the disorder of the part primarily  affected with  the Aura, or
can detect and remove Avith the knife, the diseased portion  of the nerve—
means of relief very rarely Avithin our reach.   In general, all the forms of
Epilepsy  are  difficult  of cure, in proportion to their duration.  Sponta-
neous  cures of Epilepsy occur now and then, but are not Avell understood.
In almost all cases, it is in our poAver to render the paroxysms less fre-
quent,  and perhaps to diminish their violence.  But feAv die in the parox-
ysm.   It is affirmed to have brought on Hemiplegia and Apoplexy, and by
repetition, to tend to reduce the patient into a state of idiocy and fatuity.
Many Epileptics, hoAvever, live long and enjoy unabated vigour and clear-
ness of intellect.
   Treatment.  During a fit, loosen all clothing about the neck and body—
elevate the head, and sponge or Avash it with cold  water—place a soft bit
of stick, or roll  of cotton, betAveen the teeth, to preserve the tongue from
injury—and give the patient fresh air.   The Lancet may be  of use, but is
not often required.  I Avould bleed if the patient was  young and robust, of
apoplectic make, Avith  face  flushed and turgid—and labouring under some
strong  excitement of transient nature.
   Owing to the  extreme obscurity  of the Pathology of Epilepsy, and our
total ignorance of the conditions  upon Avhich it immediately depends, our
efforts  for its removal, it must be confessed, are  rather tentative than direc-
ted by  scientific or definite indications.   The  practice  in the case may,
therefore.be considered Avithout impropriety, under the heads of the Pallia-
tive and Empirical.
   The Palliative management  of the  Epileptic, is sometimes successful
beyond our hopes;  not only lessening the number of the attacks of Con-
vulsion, and subduing its violence, but even in some happy instances arrest-
ing the disease altogether.   The Diet should  be strictly regulated; tempe-
rate though  not abstemious,  nourishing but not  stimulating.  The  hair
should be cut  close, or even shaved off.  If at  any time the head throb or
ache, or the face be flushed, V. S. should be resorted to, or Cups or Lee-
ches applied.   Vigorous and constant exercise should  be enjoined—stu-
dious and sedentary habits abandoned.  The administration of Cathartics
is often beneficial;  the most remarkable cure Avhich 1 have ever seen, Avas
effected  by  perseverance for years in the habitual  employment of gentle
purgatives.    In  Sympathic Epilepsies,  besides  this general  palliative
course, avc must endeavour to eradicate or remove the primary affection
wherever seated.  A careful examination of the source of the Aura should
be instituted, Avith  the view to the  counteraction of its influence, in Avhat-
ever method might be practicable.
   The Empirical Treatment of this justly dreaded malady, consists in the
administration of certain remedies, Avhose modus operandi in the case is to-
tally unknown; but Avhose reputation is the result  of tradition and. experi- 
PRACTICE.
151
ence simply.  I have  not succeeded  Avith any  of these Anti-Epileptics,
though some  of them are in high repute, and have been favourably repor-
ted of by Physicians of name and authority.  They are the Nitrate of Sil-
ver—the Salts of Zinc, of  Copper, and of Arsenic,  and  the Misletoe of
the Oak.  Successful experiments  have been also made Avith Galvanism
and Electricity.   These powerful  agents,  especially the former, would
seem capable of advantageous application here,  and deserve repeated trial
from the profession. 
152
I'RACTICK.
DISKVSKS OK  THE  JKITORY SYSTKJI.
                                GOUT.

    Podagra---Akthkixis.   We  have to consider Gout  like Scrofula,
 in  a two fold  point of vieAV.   It constitutes or depends upon a peculiar
 Diathesis, of Avhich its several local developements, are the results or exter-
 nal manifestations.  Regular attacks of Gout hoAvever,  affect the joints
 exclusively, whence the propriety of the term Arthritis and  the arrange-
 ment of it here.
   The Gouty Diathesis or Constitution, may be transmitted hereditarily,
 determining a predisposition  to its local manifestations so  strong, that  they
 cannot be escaped, the subject being attacked in childhood or early youth.
 In the  generation of the Diathesis, full or luxurious living is the most influ-
 ential  agent; this  is much aided by habits  of  indolence  and refinement.
 Climate has probably an effect in inducing this state of the  system, as in
 Great  Britain, where Gout prevails as extensively among the upper classes
 of  society, as Scrofula among the loAver.
   The nature of this predisposition is not at all understood.   It is  usually
 connected with a state  of  Plethora, and attended by a proverbial exemption
 from other forms of disease.
   The Exciting Causes Avhich tend to develope it and give rise to an Ac-
 thritic  Paroxysm,  are numerous  and diversified.   Intemperance—nay, a
 temperate use of stimulants,  even a single glass  of Avine, will occasion it in
 the predisposed—so Avill any  indigestible or stimulating food—fatigue,  loss
 of sleep.   Local  injury  of  a joint,  as a tAvist or strain  of the ankle, is
 sometimes folloAved by a fit of Gout.
  Gout is divided into  Entonic and Atonic—into  Regular,  Misplaced,  and
 Retrocedent.   ItisEntonic, Avhen the local inflammation is  attended Avith
 febrile excitement and  increased force of vascular action.   It is  Atonic
 Avhen the pulse and strength  are beloAv the  usual standard—Avhen instead of
 febrile  excitement  and  local pain, Ave have general uneasiness and  distur-
 bance, Avith little inflammation of a joint or limb.  Regidar Gout attacks a
joint and is there fixed, the constitutional disorder being proportioned to  the
 locaraffection,  and disappearing as it abates.  Retrocedent Gout, consists
 in a Metastasis  of  such local affection from the joint first  attacked to some
 one of the internal organs.   Misplaced Gout occurs Avhere, at or about the
 usual period of the recurrence of a Paroxysm,  or under the  influence of
 the causes which tend  to produce it, an arthritic subject becomes  affected
 Avith much internal disorder.
  The Pathology of gout is confessedly  obscure  and uncertain.  The pre-
vailing opinion of (he day, refers the symptoms in all their variety, to disor-
der of the Digestive system.   In this vieyv I do not concur.   The nature
of the Diathesis—especially Avhen hereditarily derived, is utterly unknown.
The local Inflammation is of peculiar character—and terminates only, in 
PRACTICE.
153
resolution or deposition of earthy matter, never in effusion of pus, or serum
or in gangrene.
  The Diagnosis of Gout is eas}' in cases of long standing.  A first fit may
be mistaken for Rheumatism.   It is  distinguished by its  intensity, and its
exclusive invasion of the smaller joints—very generally  the ball of the great
toe.
  The Prognosis in  regular Entonic Gout is decidedly favorable.  In A-
tonic irregular attacks it is the reverse; these are often suddenly fatal, wheth-
er the stomach, the heart or the brain be the part affected.
  A Paroxysm of  regular Gout begins Avith swelling of the ball of the great
toe, Avhich is extremely tender to the  touch, Avith great tension and redness
of the skin, the veins being full and the arteries throbbing.   The pain which
is insupportably severe,  extends upwards towards the ankle and calf of the
leg, and is much increased on letting the foot hang.   Motion is impossible.
There is fever, Avith headache and uneasiness of  stomach—the pain is de-
scribed as very distinct and peculiar,  and attended Avith a sense of numbness
and paralysis  of the part.   The  inflammation occasionally changes from
one foot  to the other, or extends to  the knee.  After a duration of a feAv
days, these symptoms subside, leaving the patient in good health.   At first
the intervals are long, and the paroxysms do not recur for  a  year  or six
months, but by repetition their duration is lengthened and their frequency
increased, until the local  inflammation  becomes  almost permanent, when
Ave may have the deposition of urate and phosphate of lime, so characteristic
of Gout.
   The symptoms  of Retrocedent  and  Misplaced Gout depend  upon the
organ attacked.   When the Viscera of the Thorax and Abdomen are affec-
ted, there appear the usual signs of  Gastritis,  Enteritis, Pneumonia,  &c.
When the Brain is the seat of the evil, it assumes rather the form of  Apo-
plexy than Phrenitis—and Avhen the heart is assailed, the case is one of An-
gina Pectoris.
   When with  these Arthritic affections there co-exists an infirm, debilitated
condition  of the patient—it is termed Atonic Gout.  The  pulse is feeble
and Avavering—the skin, cold and clammy—the pain intolerably oppressive
and  described as Spasmodic  with constriction of the  chest  or  stomach.
When these pains are transitory though severe, and shift from place to
place, now assailing the trurrk and noAV the limbs, now one organ or part,
and now another, it is the "flying Gout" of the books.
   Treatment.   During the Paroxysm.  In young and robust subjects, and
in the earlier attacks, it will be proper  to resort  to V.  S.—but not in the
opposite class of cases.   Purgatives are almost always useful and necessa-
ry.  I prefer the combination of a  resinous  with a saline, adding some
aromatic.  Emetics are very seldom indicated—I Avould employ them when
the stomach was loaded with a recent full meal, at the commencement of a
fit.  Opiates are much objected to, by some, but in all  prolonged paroxysms
I am in the  habit of prescribing the   Dover's powder freely at night, and
with excellent benefit.                                .  .   ,
   The Tincture of Colchicum and Eau Medicinale, maintained by many
to be the same—are on the one hand highly eulogized, as not only safe, but
admirably successful; while on the other, they are accused of fatal tendency.
I have seen them both employed—there was some advantage gained, yet not
much; and no  evil resulted. Local management. Leeches are generally spi-
              20 
154
PRACTICE.
viceable—they diminish the pain, if they do not  shorten the paroxysm.—
Some patients are relieved by a soft tepid poultice—while others derive com-
fort from cold astringent applications, as the solutions of Acetate of Lead
Sulph: Zinci:, &c.  I have not seen the good effects promised from Opiate
frictions and blistering.  Percussion and bandaging are recommended by
Balfour and others, but my  patients cannot bear  the  part thus handled.
With regard to the cold bath so much a subject  of  dispute, I Avould resort
to it if in a young and robust  patient, after proper  depletion, the pain and
inflammation Avere obstinately  prolonged.  Under other circumstances I
Avould consider it unsafe, and dread its giving rise to Retrocedent or Metas-
tatic Gout.  During the interval.   Temperance and  exercise are the best
Prophylactics.  The diet should be nourishing but unstimulating. A threat-
ened attack should be opposed  by the  use of Laxatives and tonics.   The
Tinct: Guiac: combines these properties—I think I have seen it servicea-
ble.  The Alkalies and Bitters have enjoyed a high repute—but since the
Portland powder lost its reputation, are  not so much used as formerly.
  The  irregular forms of Gout—the  misplaced and retrocedent  must be
treated on general principles.   If Entonic—the local affections  will be
highly inflammatory and will require the prompt and  free employment of
the Lancet, Leeches or Cups, Purgatives, and Blisters to or near the part
assailed.   If Atonic, on the other hand, an immediate resort  to  Opium, and
Stimulants is necessary.  The  Tinct. Opii must be given in large doses,
with Ether and other diffusible  stimuli, w hile we apply the quickest revul-
sives to relieve the affected organ—Mustard—hot Turpentine—Moxa, &c. 
PRACTICE.
155
                          RHEUMATISM.

  This disease is specially interesting to the Physician, from the frequency
of its occurrence—the intensity of suffering Avhich it often causes, and the
readiness with which, in the majority of cases, these sufferings  are reliev-
ed by proper management.
  The division of Rheumatism  into Acute and Chronic, is familiarly and
universally recognized; yet it is not easy  to describe clearly the distinc-
tions Avhich separate these varieties, nor even the points of similarity which
connect them.  In the first,  the local  affection is always  painful and in-
flammatory, and is attended, for  the most part, Avith fever of high excite-
ment.  In the second, the local affection is, generally, less intensely pain-
ful,  and  sometimes  productive  of no  pain—the  derangement  consisting
merely in the impairment of the capacity of moving or being moved—and
the part thus affected, often exhibits no  external  mark of inflammation, ex-
cept a degree of swelling and consequent deformity.   If Fever be present,
Avhich is not usually  the  case in any obvious degree, it is of Ioav irritative
type.  There are, hoAvever, cases of Chronic Rheumatism, in which great
pain is suffered by the patient,  especially on  motion of the diseased part;
and others in which Fever, although not constantly present, comes on with
much general and vascular disturbance from time to time.   Rheumatic In-
flammation chiefly attacks the  larger joints—but may affect the smaller
articulations also,' and the fibrous tissue every where, and perhaps the cel-
lular.
  The  Predisposing Causes are not well  knoAvn, although it is evident that
certain persons are much more  susceptible of seizure than others.  One
attack renders the subject more liable to a second.
  The  Exciting or Occasional  Causes are more obvious; sudden alterna.
tions of temperature and exposure fctcold and moisture, are the chief.  So
clear is this connection, that a partial exposure will produce a local Rheu-
matism, as in the familiar instance of stiff-neck, from sitting near  a partially
opened AvindoAV or door.
  The  Diagnosis  of Rheumatism is usually  easy.  It  is not liable to be
mistaken for any other disease  than Gout—the characteristics of which
are  Avell  marked.
  The  Prognosis  in  Acute Rheumatism is favourable; very few die of it,
although fatal terminations have been met with, where the attack Avas spe-
cially violent in a feeble constitution, or the febrile excitement was protrae.
ted into the Typhous state.   The principal danger perhaps is found in the
tendency to  Metastasis—the inflammation leaving  the joint or other exter-
nal  part, and invading some of the internal organs, as the Heart, the Lungs,
the  Diaphragm, &c.    The symptoms thus  arising are urgent; and the pa-
tient, if not promptly relieved, sinks under his severe sufferings.
  In Chronic Rheumatism, the prospects are more gloomy.   It if art after-: 
150
PRACTICE.
tion of proverbial obstinacy, and in a large proportion of instances, adheres
tenaciously.
  Symptoms.  Acute Rheumatism comes on with stiffness and pain in some
one or more of the joints, or in some muscular part, soon attended with
fever.   The pain  is severe, especially on motion,  and the part becomes
swollen and red, and  tender on pressure—the pulse is full, hard and  fre-
quent—the skin harsh, hot and dry—the tongue lightly furred.   A noctur-
nal exacerbation of pain and general disorder occurs regularly, and in the
morning an uncertain  degree of remission.   After a duration of 10 or 12
days, the pain and inflammation subside, and the fever disappears—the part
affected remaining for some time after weak and easily hurt.   Rheumatic
inflammation seldom  runs into suppuration; in the joints  it produces  an
effusion of synovia, which is afterwards absorbed readily.  It is much dis-
posed to shift its place—changing from one joint or muscle to another, and
sometimes assailing the internal organs.  I have seen it twice attack the
Heart.  In one instance, an Acute Carditis was excited, which proved ra-
pidly fatal—in the other, it gave rise to palpitations, dyspnoea  and hyper-
trophy of the ventricles, under Avhich the patient finally sunk.   The symp-
toms which are exhibited in these metastases, are usually such as appear in
other acute inflammations of the organs invaded.   Acute Rheumatism
chiefly affects young adults and middle aged persons.   I have seen it, how-
ever, exquisitely developed  in  a child  of three years, and in old people.
Both sexes seem equally liable to it.
  Treatment.  In  the robust  and strong it is  Avell to employ the Lancet—
but this instrument has been used Avith great  imprudence by many, in the
hope to extinguish the disease at once.  A  certain  degree of caution is
required,  or injury will ensue—and although it is undoubtedly proper to
relieve Hyperaemia (if it exist) in the plethoric, and to reduce the vascular
excitement Avhich prevails by bloodletting; yet it should be remembered,
that  there is something peculiar in  the nature of the inflammatory affec
tion, Avhich refuses to yield to mere  abstraction of blood; and that this re-
medial measure, Avhen carried too far, has changed a transient  or acute,
into an obstinate chronic or passive Rheumatism. Purgatives are undoubt-
edly useful.  I employ the  Saline—in  the  first stages alone; as the case
progresses in combination with Diaphoretics.
  Diaphoretics, indeed,  have been regarded as specifically adapted to the
management of Rheumatism.    The Antimonials  are much prescribed.
The Colchicum  is  highly recommended  here  as  in Gout.  It  is said to
combine, when  given in proper dose, a  purgative Avith a diaphoretic effect,
and is much depended on by many practitioners.  I make much use of
Serpentaria—at first, with enough of the  Epsom Salt in solution, to ope-
rate freely upon the bowels—aftenvards Avith  some form of Opiate.  The
Dover's  Powder is invaluably beneficial Avhen the earlier violence of excite-
ment has been subdued by the Lancet and Cathartics; and in large doses,
will often  remove promptly all traces of the disease.   In protracted cases,
the  Acetate of Ammonia, with Camphor and  Opium, is highh efficacious;
—Sulphur is also Avell adapted to relieve.    U  combination with these. Ave
may frequently administer Infus. Cinchona? with striking advantage.  The
Mercurials so warmly  eulogized by some  late writers, do not seem to be
required in simple Rheumatism; but become  necessary Avhen there is any
complication Avith Visceral disorders, or Avith  Syphilis. 
PRACTICE.
157
  The local management of Rheumatism deserves attention.  Leeches or
Cups should be applied, and the flow of blood kept up by warm fomenta-
tions or soft poultices, which will relax and relieve irritation and tension;
—at a late stage of the attack, Sinapisms may  be applied, and embroca-
tions of a volatile or stimulating nature made use of.  The Vapour Bath
is serviceable.  I mention only to disapprove of cold applications.
  Chronic Rheumatism  is a state  of disease difficult  to describe.   It may
be the result of an intractable attack of the acute  variety.   There is  a
subsidence of Fever, and of general excitement—the appetite and strength
of the patient  are in great measure restored—and the appearances of local
inflammation diminish or disappear, Avith the  exception  of the swelling,
Avhich continues or may increase, the joint being incapable of motion.   In
general, there is no acuteness of pain;  but the part is ill at ease, and some
cases  are  attended Avith excruciating sufferings,  Avhich no lapse of time
subdues; and in others, fever persists of the low irritative type.   The mus-
cles which move  the  affected limbs emaciate—the joints become large,
hard, stiff and misshapen, Avith a pale and Avaxen  hue of the skin covering
them.   Chronic Rheumatism, Avhen not the  consequence of the Acute
form,  is said  to select usually Avomen and  feeble men; but the most re-
markable instance of it Avhich I have ever met Avith, was  in  a stout and
robust man—a Physician—iu the prime of life—healthy and athletic.
The case is Avorthy of description, as exhibiting very strongly  the charac-
teristic peculiarities of Chronic Rheumatism.   The  subject of it was sent
for on a warm night in autumn, to see a patient some miles from home; he
rode hastily thither, prescribed, and then, bathed in perspiration, lay down
to sleep  under a window  in  a strong  current of air.  On awaking, he
found himself incapable of moving Jiimsok" without severe distress—every
limb and  joint being stiff and sore.   A brother practitioner being called,
bled him  40 ounces, from which time he had no pain.  He Avas still unable
to  move, and in a few hours  after  Avas bled 20 ounces more.  He never
 recovered the use of his hands, but was able to walk sloAvly  and  feebly.
 His joints Avere swoln, pale and stiff—he  emaciated  gradually—his fingers
 were slightly  bent, and had the appearance of waxen preparations.  His
 appetite and digestion were good, and he had no  obvious febrile exacerba-
 tions, though  his  nights were often  restless and uncomfortable.   In this
 state'of helplessness he remained some years, Avith a clear intellect and
 cheerful spirit.   Having removed to a distance, 1 know not the manner of
 his death.                                        .
   Lumbago  and  Sciatica are tAvo forms of Chronic  Rheumatism,  well
 kuown and of frequent occurrence in trie aged.  In these affections of the
 Hip and Loins, there is usually much pain  and incapacity for motion, but
 with  little fever or general disorder.  Some have doubted whether  they
 are correctly to be considered as  Rheumatic, and have regarded them as
 affections of the large nervous trunks—but it  is  difficult, if not impossible,
 to draw such lines of distinction as are here aimed  at; for many cases of
 painful  affection of distant  joints with  swelling,  readily recognized  as
 Chronic Rheumatism of ordinary  character, seem connected  with, or de-
 pendent on, affections of the nervous trunks, and are relieved by cupping
 or leeching the part of the spine whence they arise.
    Treatment.  In Chronic Rheumatism, I  would advise a total abstinence
from the  Lancet.  The stimulating Diaphoretics arc our best  remedies— 
158
PRACTICE.
Guiac—Camphor—Ammonia and Opium.   Stimulants alone are  much
employed,  and sometimes Avith  good effect.   The Tinct:  Cantharid:—
Turpentine—Savin—and Balsam Copaiba, are strongly eulogized.   Sul-
phur is often beneficial, and in feeble subjects, may be well combined with
Infus: Cinchon: and Serpentaria.  The Colchicum  Autumnale is supposed
to be Avell adapted here also.   The Phytolacca Decandra is thought to be
similarly useful.  The Lisbon  Diet Drink is a formula much employed,
and combines  some  of our best Diaphoretics.  Experiments  have been
successfully made  Avith the Prussic Acid in very obstinate cases.   Ender-
mic Medication by  Vapour Bath—Fumigations  of Sulphurous  Acid—
Chlorine—Phosphorus—Ether has  been  much  in vogue.  The  natural
Hot Baths have effected numerous cures in our oAvn country—the springs
of mountainous Virginia and of  Buncombe,  are much  resorted to—and
hot and sulphurous Waters are drank with remarkable benefit.
  Local applications have not been neglected, and the number and variety
of those recommended at different times, and by different persons, for the
cure of this very obstinate disease, are great.   Leeches and Cups are used
occasionally Avith advantage.   To Dr. Mitchell of Philadelphia, Ave OAve
the suggestion  of the preference due to the Spine as the place of applica-
tion—at the part  Avhence arise  the nerves  supplying the joint affected.
Epispastics, the pustular irritation of Tart:  Antimon:—Moxibustion—the
persevering employment of strong friction over, and forcible motion of the
stiff articulation, have all restored patients.   Acupuncture has often  given
striking relief, and so have Electricity and Galvanism.
  The Diet during the protracted  existeuce of Chronic Rheumatism, should
be nourishing and generous.   Motion of the  stiffened limb should be reso-
lutely and frequently attempted*—-1-f.J.here be any obvious susceptibility to
cold, it will be a useful precaution to envelope the trunk and limbs  in flan-
nel, or even to  apply to the latter the  flannel roller-bandage. 
PRACTICE.
159
                UISKASES OF THE  EXOERXEXT  SYSTEM.

  Of all the classes of the Physiological Nosologists, this  has been found
most difficult to deliueate and circumscribe.  The business of Excretion
seems to be divided among many of the organs, Avhich assist incidentally in
its performance while engaged iu their peculiar function.   Thus the Lungs,
the Liver, and the Intestines throAv off much effete matter, Avhile busied in
digestion, absorption, and assimilation.   The Kidneys  are,  perhaps,  the
only organs  exclusively  excretory—Ave  know  of no  other function  in
which they are employed than mere elimination.   Next to  them, the  skin
perhaps, deserves  to be considered in this point of vieAv.  Excretion is the
most important office of the Cutaneous  Integument, although  by no means
the only one.
   The diseases Avhich affect  this extended surface are numerous,  diversi-
fied, and often highly severe;—they are of frequent occurrence and in eve-
ry respect deserve our particular attention.
   Among the chief of the maladies in Avhich the skin is especially implica-
ted, are, the Exanthemata or Eruptive Fevers—a group of diseases so cal-
led. from the fact, that, a  cutaneous eruption, preceded or attended by Fe-
ver, forms the prominent  point in their  history.   Under this  head are in-
cluded Variola—Rubeola—Scarlatina—Dengue—Varicella and Vaccine.
   The four first combine many circumstances of close analogy.  A certain
febrile disorder Avith notable gastric derangement precedes, by a pretty reg-
ular interval, a specific cutaneous eruption of definite character.  The pe-
riod at Avhich this characteristic eruption makes its appearance, though
subject to occasional and slight modifications is well knoAvn;  it is transient
in its duration, running a limited course, and then declining and passing
aAvav.   The Small-pox throws  forth its eruption on the 3d  day from the
invasion of the disease—arrives at its height on the 10th, and then declines.
The Rubeolous eruption  appears on the  4th, and declines after the 7th.
 Scarlatina she avs itself on the surface on the 2d—and fades from the 5th.
 Dengue produces its eruption  on the 3d, and  disappears after the 6th.
 They are contagious always, and often become epidemic also.  They  af-
 fect the human constitution but once—a rule, which, hoAvever, is proved to
 be subject to occasional exceptions.
   In the instances of Small-pox—Measles and Dengue the  gastric  disor-
 der is notably diminished as  soon as the eruption has  appeared upon the
 skin; in Scarlatina this relief is  less immediately observable.
   The Pathology of the Exanthemata, is specially obscure, although  there
 is no want of Theory or Hypothesis on the subject.   The  nature of the
 connection, so uniform and essential, between irritation of the  mucous mem-
 brane of the Respiratory and Digestive apparatus,  and  inflammation of the
 Skin of varied appearance and character, is entirely unknown.  It is very
 common to  represent the Cutaneous affection as a metastasis of  diseased
 action from the mucous tissue, which is assumed to be  the seat of primary
 irritation, and first assailed—but this is incorrect.   The mucous surface is 
160
PRACTICE.
not ahvays—if ever restored to a healthy condition at the time of the erup-
tion; but the nature of the  diseased action is altered.   It is  noAV affected
similarly with the skin, and continues to be so until the latter  is restored to
health.   In Small-pox—pustules form upon it; in Measles—the red patch-
es are first seen on the palate; in Scarlatina—the tongue, throat and gas.
trie surface, are last to lose their extreme susceptibility to painful impres-
sions; their heightened color and obvious inflammatory condition.
   The whole mass  of fluids seems to be, in some manner vitiated in these
Eruptive Fevers; of Avhich  the best proof is found in the fact  that they are
conveyed to the  foetus in  utero when  the pregnant  mother is  attacked.
Such instances happen not  unfrequently in Variola, and although more rare-
ly in Measles also. 
PRACTICE.
161
                             VARIOLA.

  Small Pox—a Avell knoAvn Contagious, Eruptive, Inflammatory Disease.
It has been supposed to  be  indistinctly mentioned in ancient writings, as
prevailing among the Easterns, but we have  no definite description of it
until the 6th century-
  Small-Pox is universally treated of.under.the separate heads of Distinct
and Conflaent;  Avhich terms however, refer not to any  specific difference,
but merely to the degree of violence of the attack, Avith-the amount andjex-
tent of the attendant eruption.
  Variola commences like the inflammatory fevers, Avith a rigor or .shiver-
ing, followed by heat, pains in the head, back and limbs, gastric oppression,
nausea and  often vomiting, restlessness,  anxiety and  muscular  debility*
Sometimes there is-soreness of the throat, with pain in the side and chest,
cough and dyspnoea.  In young children, the  invasion  is not unfrequently
marked by convulsions.   These symptoms continue for three  days; on, the
fourth usually4tJnay be twenty-four hours sooner or later^-the skin ofthe
face and breast, exhibitfan eruption, consisting of small papulae, slightly
projecting and of red colour, which aftenvards spreads over the arms and
the restof the surface.  From the time of its appearance, the febrile symp-
toms decline, and in a great measure subside.   These pimples or papulae,
assume in a day or two the vesicular form, becoming distended with a thin
serous fluid;—they increase in number and size, and on or about the 7th and-
8th, are of a circular shape, with a depression in the centre of the greater
portion.  On the 9th and 10th, the contained fluid is  turbid and purulent.
In proportion as these pustules  abound,  the  case is  Distinct or Confluent.
In the latter form of Small-Pox, they  often run together  so as to make a
complete mask for the face, and on certain parts of the body,  those for. in-
stance Avhich lie always in contact with  the bed, run into large patches and
crusts.   Where they are not in contact, the ski i between and around them
is inflamed,  red, and elevated.   There is Ophthalmia and the face and eye-
lids are swollen, the mouth and. throat are sore, and the patient spits large-
ly a tenacious saliva.   About the 11th day, there is  an abatement of the
Liflammatio i, both Pustular and Cutaneous.   The  Pustules, or  many  of
them crack, and the contained fluid oozes out, they flatten and by the 14th,
have begun to dry and condense into a hard crust.   From the  20th,  these
crusts fall off, leaving in a great majority of cases, a permanent depression
or pit in the skin.
  The case may thus terminate without further  danger or inconvenience,
and such is the history of a mild or Distinct attack, but when the Pustules
are very numerous or confluent, we may  have them  spreading  over and
destroying the eye—extending into the throat and trachea, occasioning suf-
focation or severe pulmonary inflammation, and in such  instances a secon-
dary Fever arises, depending,  probably,  on the great degree of constitu- 
162                         PKACT1CE.

tional irritation, occasioned by so extensive and violent an inflammation  of
the Mucous and Cutaneous  surfaces.  This  secondary fever invades  at
variable periods, from the 8th to the 11th day.  The tongue and mouth be-
come dry—the pulse is very  frequent and  rather tense, but  often feeble;
the breathing is difficult—droAvsiness comes on, increasing into Coma, and
the patient sinks exhausted with intolerable sufferings.
   The Prognosis is favourable in Distinct Small-Pox—in the Confluent form
it is the reverse.   Bad cases may be knoAvn from the first, by an imperfect
eruption, the Vesicles rising very little, being  rather  livid than florid and
filling, or as the phrase is, maturating badly.  If at any time the Pustules
flatten and the skin becomes pale or livid, the danger is great, especially if
the pulse and strength fail, and the mind is observed to wander.    The oc
currence of any urgent internal determination is to be dreaded, whether to
the Brain—as shewn by delirium, coma, &c.  or to the Respiratory Organs,
Avith pain  in the side or chest, Cough and Dyspnoea.
   The Sequelae of Small-Pox,  are often  very  serious.    Deformity and
blindness,  Avith sometimes a permanent Ophthalmia, a Chronic Diarrhoea—
Anasarca, occasionally follow it.  The voice is in some persons permanent-
ly changed and  rendered disagreeable by  injury done to the soft palate.
Scrofula is said to  be excited to severe and rapid developement, and the pre-
disposition to pulmonary disease generally, but more especially Tubercular
or Scrofulous  Phthisis.
   Autopsy.  The Variolous  eruption is found  not only on the skin, the vas-
cular network or Rete mucosum, being the seat of tjie pustules, but extends
to the mucous tissue lining the  mouth, fauces, pharynx,  trachaea, larynx,
and rectum, and upon the conjunctiva.   The  structure and formation of
the pustule in these positions, is not well made out.  In the Cutaneons in-
tegument  it is multo cellular.   The pit is occasioned by the sloughing of a
circular portion of the Cutis  Vera.
   In many subjects the Brain and its  membranes are found dark with vas-
cular congestion.  In others the Lungs are  engorged and hepatized and the
Pleura inflamed.
   Treatment.   During the Eruptive Fever  of Small-pox, if Ave are aware
of th i nature of the case, there is little temptation to interfere,  when  the
attack is mild.  1  k:tcw  not that there is  any risk or evil, in the ordinary
management of Fever of equal intei sity, applied here.   If at the time of ac-
cess,  there are exhibited determi; ations to the head, lungs, stomach, &c,
violent  and severe, the La-cet  mav be used—and its effect aided by mild
Purgatives.  The  Mercurials are supposed to exert here a peculiar efficacy,
but of this I am not satisfied.  Great  gastric  oppression Avith foul tongue,
and fetid breath, require an  Emetic—especially if the retching be insuffi-
cient, and fail  to empty the stomach of its  crude contents, and morbid secre-
tions.   Mild Emesis can scarcely do harm and  is serviceable besides, by
favoring a centrifugal determi ation of the fluids.   It often relieves the in-
fantile convulsions Avhich precede the eruption.
   The Purgatives Avhich I have advised to be  used with moderation, during
the eruptive fever, must be abstained from, when the papula? are forming up-
on the skin; after this, the boAvels should be kept free by Laxative Enemata.
   The use of the Avarm bath, should be one of our earliest measures in the
management of negroes and  of Avhites of the  loAver class.  It is beneficial 
PRACTICE.
163
to children attacked with convulsions; who may be relieved with the Lan~
cet cautiously employed, if the pulse be full and hard and the face flushed—
and on the other hand if pale and  feeble, may be tranquilized Avith small
doses of the Tinct: Op: Camph.   The apartment of the sick, should be Avell
aired, and kept perfectly clean.   He should lie on a firm mattrass, and if
able  sit up occasionally.   The  cool regimen,  so  vastly preferable  to  the
heating system, anciently in vogue, must not, however, be carried to an ex-
treme.  It will, if  urged, do harm, when the Pulmonary symptoms  arc
prominent.  Nor do  our negroes, in general, bear it well,  unless much
modified.
   Light mucilaginous drinks should form the only nourishment.   The sore-
throat should be gargled often Avith tepid water, and the inflamed eyes Avash-
ed from time to time with milk and other mild Collyria, and carefully pro-
tected from light  and other irritants.
   To prevent the pitting, so much feared,  many expedients are  proposed.
I have not confidence in any one of them.  The resort to them in  Confluent
and really severe cases is trifling, and in Distinct  Small-pox, there  is little
deformity left.
   In the Secondary Fever, most advantage is derived from the mildly stim-
ulating Diaphoretics, as the Infus: R: Serp: with slight addictions  of JEther,
Camphor, or Ammonia.  I employ Opium unhesitatingly and freely, Avhen
it is  required to relieve the Cough, Dyspnoea, restlessness  and other suffer-
ings of the patient.   It does not seem contraiudicated by any circumstances
but those Avhich shew a tendency to  Coma.   I prescribe the Dover's poAV-
der or the Camphorated Tincture.
   In protracted cases Avhen the strength yields. Cinchona is  of much ser-
vice.  The infusion  maybe combined Avith other remedies.  Extensive
crusts are rubbed off occasionally by  the motions of the patient  in  bed,
leaving painful sores.  These must be dusted with Cinchona or finely poAv-
dered chalk, the pressure of the body frequently changed by the attendants,
and extreme cleanliness inculcated.
   If the "striking in" of the eruption—as the phrase is—occur, the Pus-
tules flatten and become indistinct, Avith failing pulse, and cold  and livid sur-
face, it is necessary to stimulate promptly and  energetically, both by inter-
nal and external means.                                          .
   The treatment of the convalescent requires much attention. He is cov-
ered Avith a neAv and highly susceptible integument, and is specially liable
to the ill effects  of exposure  and  alternations—from which he must be
guarded strictly by proper clothing.  His  diet should, for  a long time, be
plain and unstimulating, though nutritious.
   Variolous Contagion is both palpable a.;d impalpable.   It  may be com-
municated palpably bv contact with  the diseased  person or  with  fomites,
and  by inoculation,  or the direct  insertion of SmdI-Pox Matter into a
wound.   It is also  capable of diffusing itself palpnbh  thro the atmosphere.
At what stage of the case  a sick bodv becomes thus a  focus  of contagion,
is not clearly known—perhaps from the 7th day, when a peculiar odour
or effluvium begins to be given off.                    ■,-••,
   The latent period—the interval  between infectioi and  invasion,  is also
doubtful—it is usually rated at from nine to fourteen days. The effects of
inoculation shew  themselves earlier—about the fourth day.
   Small-Pox attacks the same persons but once—a rule clenr and positive. 
164
PRACTICE.
though not Avithout exceptions.  This exemption gave great importance  to
the practice of Inoculation, which enabled  the subject  to select his own
time and circumstances for suffering the disease.  It is difficult  to account
for the immense difference in violence and mortality" between the casual and
inoculated Small-Pox.
   Variola is liable to many modifications in  history and character,  some
of which have been pointed out and separated in common language by spe-
cial denominations, while the strong similarity which they present to each
other and to the common stock' of all, is  indicated in the use of a Avord now
become familiar every where, Varioloid.
  'All the older Avriters speak  of irregular  forms of Small-Pox.   Syden.
ham is particular in detailing the varieties which the disease  offered in the
several years of its epidemic  occurrence under his own  notice.   Lieutaud
speaks of a "spurious Small-Pox," occasionally taken for the  legitimate.
Parr tells us that  "the varieties of Small-Pox are numerous."   Others tell
us  of Avater-pock, of wind-pock, stone-pock, &c.  in  almost unnumbered
diversity.  It Avas only among the English, and not by them, until the time
of Heberden, that Varicella (Chickei-Pox) was distinguished from Small-
Pox.*   Morton, of the time of Sydenham, speaks of it as mild Small-Pox.
His contemporary must so-have regarded it, if he met Avith itat all.  And
though Heberden, Willis, Rayer and M'lntosh  talk very positively of the
distinctions between the two, yet other writers have not  been able to  mark
them  so clearly.   Thomso.i,  for  instance,  maintains Varicella  in  all  its
varieties, to be a modified Small-Pox.   And  Avhile Willan  recognizes it
only as  presented in the serous or vesiculous  form, Rayer acknowledges,
that it occasionally assumes  a pustulous condition.  With  regard to the
grade, Avhich is made the source of distinction between Distinct and Conflu-
ent Small-Pox, it  should be remembered, that Riiig has given us a case of
confluent Chicken-Pox, and that M'lntosh has recorded two fatal cases, one
in a child, the other in an adult.   Heberden speaks of a malignant sort of
Chicken-Pox,  in  Avhich "the  cowtinuance of the  pain and fever, after the
eruption, and the  degree of both  these,  though there be not  above tvventy
pustules, are, as far as I have seen, Avhat never happens in the Sinall-Pox."
Chicken-Pox has  been known to pit the  skin, and Distinct Small-Pox often
fails to do this.  If we receive the diagnosis of M'lntosh, and others, who
discern  Chicken-Pox by the succession of crops of pustules, Avhat shall Ave
say to Heberden's acknowledgment of his having seen  four cases  of its
unequivocal occurrence in Small-Pox?   These are "the only instances," he
says, and his language  is  striking, "Avhich have happened to me something
like what is often talked of—a second crop."
   If seems to me, that the above observations, in making which, I have re-
ferred  in preference  to the older Avriters, exhibit plainly enough the diffi-
culty of distinguishing Small-Pox from its kindred affections, if their actual
identity be not established.  The term,  Varioloid,  is a new one, first used
by Thomson,  in  his "Account of the  Varioloid  epidemic," Avhich pre-
vailed at Edinburgh, in 1*!8   Cross  gives an excellent history of a simi-
lar epid mic (which, however, he terms Small-Pox) as occurring at Nor-
Avich.   The same pestilence, it is asserted, raged about  the  same time in

  * That is, by the profession; nurses and common people, had noted and named these
wirietics-11 IfiasT half a century before. 
PRACTICE.
165
a' ranee, Italy and Germany,  from which last source it was brought into
America in 1818,  making its  first invasion in  Baltimore, (Md.) and Lan-
caster, (Peon.)   It was first noticed in Charleston in January, 1824.
  Varioloid has been assumed to differ  essentially from  Variola,  Small-
Pox, because, first,  it affects  persons  known to have previously passed
through  attacks  of regular Small-Pox;  secondly, it  affects persons pre-
viously vaccinated; and thirdly, it presents certain peculiarities  of  history
and character, which serve as distinguishing marks.
  The  first of these alleged  reasons  is  obviously of no force.   It was
long since observed, that Small-Pox sometimes  failed to destroy  the lia-
bility to its own recurrence, and  instances of its  repetition are to be found
in all the old writers.   "Petrus  Borellus," says  Heberden, "records the
case  of a woman Avho had  this distemper seven times, and catching it
again, died of the eighth attack."  Dr. Oppert, of .Berlin, relates the case
of a girl, who, at six  years of age, had Confluent SmalhPox.   Seventeen
years after, she was  again attacked, and died  of the  disease.  A similar
case is authentically stated to have occurred in this city.   If it  is  replied,
that these cases are too feAv  in  number, to affect the general  rule,  that
Small-Pox invades the constitution but once, Ave readily  acknoAvledge the
correctness of the assertion, and  proceed to apply the inference to the case
before us.  Duri.ig  the prevalence of the epidemic of 1823-24, in Phila-
delphia, (call it  Varioloid or Small-Pox,) but sixteen  persons are reported,
by  Drs. Bell and Mitchell,  as attacked with it, Avho had previously Small-
Pox.  A similar list may be made out of cases  -of the  same kind occur-
ring  here, while the pestilence prevailed among us, so limited).in,number,
however, as  to prove most conclusively, that Variola'protects at least  in a
certain degree, from Varioloid disease.
   With regard to the second point mentioned above, it is only necessary to
 observe,  that no Avell informed  physician of the present day, retains any
 confidence in the absolute preventive power of  Vaccine against the invasion
 of Small-Pox, however much he may be disposed to confide in.its unfailing
 modifying influence.  But of this, more h -reafter.
   Thirdly, the  principal peculiarities which are  supposed to characterize
 the Varioloid, and to offer specific marks by Avhich we may discern it, are,
 so far as we have been able to collect, the following:
   First, the eruption comes forth in successive crops.
   Secondly, the pocks or pustules, Avhen formed, are conoidal, without a
 central depression.
   Thirdly, they are vesicular and not multicellular as in Small-Pox.
   Fourthly, they are smaller  than the variolous.
   Fifthly, they contain lymph and not purulent matter.
   Sixthly, they dry and fall off  without pitting.
   Seventhly, th -ir progress and  maturation are unattended Avith secondary
 fever.
   To all these Ave would rejoin, that  the circumstances • above described,
 are by no means regular or connected in their occurrence; and that if they
 Avere, they Avould not imply  sufficient  distinctness  to constitute a  separate
 form of  disease.  For,
    First, in the Small-Pox, the eruption issometiraes incomplete at-first, the
 pustules appearing  to thicken  as-the;disease  .progresses; and it is well
 known to all nurses, to be easy to increase, locally, the number of pocks bv 
166
PRACTICE.
 exposure of part  of the body to long continued heat, as by lying on it,
 wrapping it, or exposing it to the heat of a fire.
   Secondly, thirdly and fourthly, the size  and configuration of the pustules,
 vary much in the most clearly defined cases of Small-Pox.  Upon the same
 individual, some will be seen large, and  others small, some conoidal, and
 others depressed in  the centre.   The internal construction of the pustules,
 Avill be found to differ in a corresponding  manner; the conoidal are vesicu-
 lar—those which  present the depression in the centre are,  like  the Vac-
 cine, multicellular, that is, divided into many separate cells or spaces.   If
 we have not grossly deceived ourselves on many occasions, we have fur-
 ther noted that the pock  changed its appearance in this regard  during its
 progress; at first vesicular and  conoidal, it exhibited aftenvards a depres-
 sion at the apex, becoming flattened and  multicellular.   But upon this, as
 it is by no means important to the argument, Ave shall lay no  further stress,
 content, if we can draw the attention of the profession to it by our remark.
   Fifthly, as  to the assertion, so often  repeated, that it is characteristic of
 the Varioloid  vesicle to contain lymph or serum, and not pus or matter, as
 the common phrase is, I affirm, on the other hand, that the Small-Pox virus
 is limpid and colourless.   The most experienced inoculators, as for exam-
 ple Parr and the tAvo Suttons, ahvays  preferred clear transparent lymph.
 It is in the latter stages of the pock, after common inflammation has super-
 vened  upon that Avhich is specific and peculiar,  that Ave find  purulent mat-
ter;  and the few cases of Varioloid  or  modified Small-Pox,  which run on
 into this stage, exhibit just as distinctly the formation of pus.  If the inflam-
 mation of the skin be stopped at an early stage, Ave prevent this: and  such,
 as I shall hereafter show, is  the most important of the train of effects attri-
 buted to the Vaccine.
   Sixthly, John Hunter has someAvhere declared, that in each pock of the
 variolous eruption, a slough of the cutis vera  (the true skin) takes  place,
 answering in dimensions to the size and  form of the pustules.   This slough-
 ing forms the pit  or depression left by Small-Pox, and the circumstance is
 assumed by him and others, Ring, for example, and Dr. Adams, to be pecu-
 liar to, and diagnostic of Small-Pox, and to depend,  not upon the intensity
 of the inflammation, but on its specific  nature.  Thus they propose to  se-
 parate Varicella,  or Chicken-Pox from Variola, or Small-Pox.  It is easy,
 however, to demonstrate the fallaciousness of this test, supported as it is by
 the authority of such high names.   A pit is not made by every Small-Pox
 pustule.*   In distinct Small-Pox,  and in  inoculated persons, there is fre-
 quently left no mark  or  trace of the  location of a pock.  Nor can it be
 doubted, that  the  Chicken-Pox and the (so called) Varioloid, occasionally,
 though seldom, produce similar sloughs or depressions, and so leave  marks
 on the  faces of those who have gone through an attack.
   Seventhly,  Secondary fever is often Avanting in the mild cases of Distinct
 Small-Pox, and very rarely occurs in the inoculated.  Dr. Parr indeed men-
 tions the absence of it as a peculiar character of inoculated Small-Pox. It


  •Goethe—When a child, at Frankfort, was attacked by Small-Pox there—long ill—
 but had the good fortune to escape without being disfigured.
  Mary, Queen of Scots, so remarkable for her exquisitely fascinating  beauty, bad the
 Small-Pox in her early childhood—but, says Bell, "It must  have been of a partirnlnr
 gentle kind, having left behind no visible trace?."—Brit, p. f>4 
PRACTICE.
167
is clear, then, that no inference can be drawn from its absence, of a nature
favourable to our opponents.  It arises like the secretion of pus  from the
irritation of the cutaneous surface, and is proportioned in degree to that irri.
tion.   It is, therefore, met with noAV and then both in Varicella and Vario-
loid.
  I believe Varioloid to be identical in nature  Avith Small-Pox, because
they are promiscuously capable of producing each other.  The modifica-
tions Avhich have been noted and discussed, I attribute in a vast majority
of the instances presenting themselves at the present day, to the influence
of  Vaccine, of which  I shall speak presently.  In others,  for  they are
confessedly irregular, to certain indefinable and varied peculiarities of con-
stitution, or habit or condition of body in the affected subject.
   Under this head of Varioloid, I unhesitatingly coincide with Dr. Thorn-
son in comprising Varicella, Chicken-pox.   This gentleman entered upon
the course of observations, upon the Edinburgh epidemic, made by him with
so much care and nicety, a thorough believer iu the opinions of Heberden
and Williams Avith regard to the separate and independent nature of Chick-
en-pox.   His candor, hoAvever, did not long permit him to remain the ad-
vocate of this vieAv of the matter.  "During  the epidemic, I had occasion,"
he says, "to observe natural Small-pox, modified Small-pox, and the disease
which I had been accustomed to regard as Chicken-pox, co-existing  in the
same  situations,  and appearing in their progress, to produce one another.
In three families in  particular, situated at a  considerable distance from one
another, and between Avhich, except through their medical  attendants, no
sort of intercourse had  existed, my attention was strongly excited by ob-
serving Chicken-pox arise  in unvaccinated children, from the contagion of
malignant Small-pox.  The  occurrence of this event, in  circumstances
which left no room for doubt, because there  appeared to be no possible
source of fallacy in the observation, led me to conceive that all the various
appearances of the epidemic, in the different classes of persons whom it
attacked, might be produced by the operation of one and the same  conta-
gion."
   Phenomena precisely similar, have occurred under my oAvn observation,
in the several invasions of  this eruptive disease, call  it what you Avill.—
Such of mv patients as had not been previously vaccinated, or had not had
the Small-pox, exhibited, for the most part, the regular symptoms of Vario-
 la as it is found described in the books and recognized by the  best authori-
ties.   Those, on the other  hand, who had been protected by  either  of the
 above means, had the disease modified variously, and in different degrees of
 mildness, some of them scarcely, others not at  all  distinguishable from
 Varicella.   That the same contagion is capable of producing these several
 forms of variolous disease, whether regular or in any manner modified, is
 not only proved by their occurring thus together spontaneously,  or  in the
 natural way, but has been definitely established by repeated inoculation
 with the matter of the modified  vesicle Varioloid or Varicelloid, in which,
 regular Avell marked Small-pox was the result of the insertion of the virus.
 Among such  examples the case of Dr. Hennen's son, of  Edinburgh, is
 most Avorthy of being detailed.   This boy, from  whatever  source infected,
 was  seized with  an eruptive  disease, concerning  which,  Dr. Thomson
 thus explicitly expresses himself:—
   "If I had been requested to  point out the case,  which seemed to  me, to 
168                        PRACTICE.
correspond must accurately Avith the descriptions of Chicken-pox, I should
certainly, have fixed upon the eruption of Dr. Hennen's boy."  It Avas the
circumstance of Dr. Hennen's vieAving the  disease in his son,  as a Avell
marked example of Chicken-pox, that led him to think  of instituting the
experiments Avhich produced such interesting results.   These results, may
be stated briefly, as follows:  In four children inoculated from the  above
case, the disease Avas mild, and of short duration—Varioloid or  Varied-
loid; in tAvo, it exhibited the appearance of Small-pox.  In three men, who
caught the infection from sleeping in the same rooms Avith these inoculated
children, the disease Avas "uncommonly severe"—not to be distinguished
from Small-pox; and, in a fourth, under the  same circumstances, "the mild-
est variety ever'described ot' Chicken-pox."
   Upon these grounds, then^ I cannot help reprobating the introduction of
a new term,  the application of Avhich is not only unnecessary, but calcula.
ted to confuse and  lead  into  error.  The modifications,  which have been
assumed,' to -constitute a separate disease, dignified with the specific appel-
lation of Varioloid  are each,  and all of them, to  be found described by the
old writers, under various  names.  Thus we have from  Dr. Huxham "an
Account of an anomolous form of Smalhpox  at Plymouth,  in 1741."
Th'uswe meet, amougthe older writers, with the phrases, horn-pock, stone-
pock, water-pock,  Avind-pock,  crystaline-pock, SAvine-pock,  sheep-pock,
chicken-pock, and  numerous others, by Avhich,  they intended to point out
the undefined, but not  uncommon  varieties,  Avhich the variolous eruption
occasionally assumed.   I  have  already remarked that Chicken-pox Avas
familiarly recognized  as one of these varieties until the time of Heberden,
who separated it under the name of Varicella or  Variola pusilla,  in Avhich
he was followed  by Willan.  I  noAV add, that Dr.  Bateman,  closely as he
was attached to Dr. Willan's views in  general; found reason to doubt their
correctness  in this particular,  as appears from  an extract from a  letter,
written by him to Dr. Howitz  of Copenhagen,  in Avhich he  says,  "fam
much inclined to concur Avith you in the supposition,  that  Chicken-pox is,
in fact, modified Small-pox."
   These varieties  and irregularities formerly noted  of  variolous disease.
arose from peculiarities  of constitution probably, in  some  instances;  in
others,  from local  or general condition of  atmosphere,   habits,  manners,
&c. and perhaps; in most, from causes  entirely unknoAvn  and unassignable.
   To all these, is now added, a more general and an uniform disturbing
cause.  The influence, namely of the Vaccine;  and hence,  at the present
day, these variations and modifications are more regular,  and better defined
than they were of  old, as well as infinitely more  frequent.
   Vaccinia—the Vaccine—derives its origin  from the  coav (Vacca.)  It
was first made known to the medical profession in  1798, by the justly cele.
bratedDr. Jenner,  Avhom we rank, unhesitatingly, among the greatest bene-
factors of the human race.  The history of Vaccine  is an exemplification
of the acuteness of the remark of Southey,  in  his Omniana, "that most
things are known  before they are discovered."  Prela, physician to the
Pope in 1825, contends, plausibly, from passages in Pliny and Celsus, that
the Vaccine was known to the ancients, under the name  of Boa.    It had
been long observed, in Gloucestershire and Dorsetshire,  two of the dairy
counties of England, that their cows Avere  occasionally  affected Avith a
species of ulceration about the udder, which communicated to the hands of 
PRACTICE.
169
the milkers a pustular eruption.*  The occurrence of this eruption Avas no.
ticed to have conferred upon such persons, a security against the casual in-
fection of Small-pox,  and such Avas the "general opinion," says Parr, "that
the inoculator, who attempted to convey  the Small-pox to one Avho had
been thus previously affected Avith vaccine, was ridiculed."  There was no
difficulty in following  up so plain a hint,  and the  artificial  communication
of this disease as a preventive of Variola Avas tried first by a farmer  of that
country, and aftenvards by Dr.  Jenner Avith the most satisfactory results.
The early writings of the latter on this subject, Avere received  with  scorn,
and his papers refused publication among the Philosophical Transactions.
It,  hoAvever,  forced its  way into notice; the value of the  discovery Avas,
after very vehement and angry  debate,  established  on the  most authentic
basis, and the zeal of its promulgator amply rewarded  by the  British  Par-
liament.   Since that  time, the Vaccine has been  extended  all over the
globe, and all nations of mankind have exulted in the benefits thus bestoAved
upon them.  It Avas first introduced into this city by  our  highly esteemed
historian and practitioner, Dr. David Ramsay.  To the present time it has
enjoyed the  undoubting confidence  of the profession, Avith scarcely a soli-
tary exception, and at once superseded, and almost entirely suppressed, the
practice of Inoculation.   Vaccination is performed by introducing, under
the cuticle, a small portion of lymph, taken from a vesicle about the  eighth,
ninth or tenth day—while yet  the fluid distending the vesicle is transparent
and colourless.  The puncture remains unchanged until the third or fourth
day, Avhen slight elevation  and  inflammation are percepitible, which in-
crease sloAvly.  About the sixth it assumes a regular circular  form,  with
a depression in the centre.   The vesicle is completely developed  on the
eighth or ninth day, and attains the average diameter of one-third of an inch.
 An areola noAV surrounds it, of an intensely florid red  colour,  and some fe-
 brile excitement of the system is perceptible, with stiffness, pain and slight
 SAvelling under the arm—if the vaccination be performed  about  the usual
 spot, above the elboAv.   The  diameter of the areola differs   from one to
 two inches.  It is attended with a degree of roughness, hardness and intu-
 mescence of the skin over which it spreads, circumstances Avhich  denote
 its existence and extent in the black.   The vesicle is multicellular,  that is,
 composed internally of numerous spaces or little cells which  communicate
 freely with each other.   The fluid  within these  cells begins to dry away
 on the eleventh or twelfth day, having previously  lost its transparency, and
 become milk or straw coloured—the areola at the same time,  declines and
 gradullv disappears.  About the twenty-sixth day, a hard round  scab of
 mahogany colour, smooth on the outside and  remarkably  hollowed in the
 centre, falls off, leaving a permanent cicatrix or scar of peculiar and char-
 acteristic aspect-its  surface being marked with minute pits or depressions

   *It has been attempted to ^J*^^ £^^£*»52



 tact w**™^™™^0"^™^^ adduced on this head.   I also  regard
 however either with the facts or^he reason  g          concerm  the conversion
 asunworthyofnot.ee.the^^X °JmUp^ixture with milk from the cow.  Bull
 °l 7, be dadI have made ^'ou^wTcountry, some decisive experiments in respect
 ,MfftSi^nofsSSl-io« through the cow, by inoculation of the odder. 
170
PRACTICE.
 similar to those on the head of a  thimble, "denoting,"  says Willan "the
 number of cells of Avhich the vesicle had been composed."  It has been
 observed, that, as in variolous inoculation, the vesicle forming at the point
 of insertion has been attended by the eruption of others in different parts of
 the body—but this, as respects Vaccine, is a fact of very rare occurrence.
 Two such instances, however, have been communicated to me authentically.
    I shall not attempt to describe any, ot the numerous deviations from the
 above history, Avhich are to be met Avith, in the irregularly diversified forms
 of Avhat are called "spurious vesicles."  Suffice it to say, that any striking
 or obvious departure from the ordinary phenomena, in the progress of a vac
 cine pustule, should  make us cautious of  confiding a patient to  its  protec
 tive influence.    Vaccine, like  every other disease,  may undergo  certain
 modifications from the condition of the recipient, an infinite majority of
 Avhich, are slight and unessential, not affecting its character and influence,
 nor impairing its genuineness.   Others there  are, however, though few in
 number, which change the nature  of the specific action, either  locally, or
 in its effect upon the system, and thus render it "spurious."  Of the local
 modifying causes, the principal and most common, is the  mechanical irrita-
 tion of the vaccinated spot, (as by rubbing,) by which a common inflamma-
 tion is substituted, for the specific, and a common sore produced.  Erysi-
 pelatous inflammation may also supervene, and interfere Avith the formation
 of a regular vaccine pustule.  Vaccine, may, perhaps,  be  affected by, or
  combine  Avith some  forms of constitutional disease,  and  thus take on a hy-
  brid state.   All  cutaneous affections disturb the regularity of its progress,
  if they do not hinder the success of the operation, and no  physician  vaccin-
  ates as Avillingly from a pustule on the arm of a patient knoAvn to labor un-
  der Scrofula,  Herpes or Lues  Venerea, &c. as from  a healthy  subject.
  There is a lurking doubt, in the mind of every one, hoAvever scornfully he
  may regard  the humoral pathology, Avhether he may not,  by vaccinating
  from such a  case, communicate a mongrel disease.
     I am disposed to lay some stress upon  the progress of maturation of the
  vesicle,  although this may be slightly hastened or impeded, Avithout detract-
  ing from the value of the pustule.   Thus  the temperature of the season, if
  high, may occasion  it to anticipate tAvei-ty.four or thirty-six hours perhaps,
  and severe  cold, on the contrary, by checking the  cutaneous  circulation,
  may retard it in an  equal degree.   The  debility or robustness  of the sub-
  ject, may give rise to like results.
     The pustule should be prominent and clearly defined, and the  areola dis-
  tinct and vivid.   There should attend, some febrile disturbance of the gen-
  eral system.   The appearance of the scar, as above described, 1 consider
  as  of much  importance.  We should  revaccinate when this peculiar ap-
  pearance is  Avanting, and Avhen the scar is smooth and resembles that of a
  burn.
     I do not find  the  observation made  by any Avriter, but I have certainly
  noticed the  occurrence of a doubtful or  spurious vesicle,  to cause much
  difficulty in procuring, subsequently, the satisfactory  results of vaccination
  in the production of a regular or genuine pustule.
     Vaccination is of course  best, and most successfully performed Avith fluid
  lymph, taken immediately from the vesicle, but this  simple mode of com-
  munication is not always possible.  When required to be transported to a
* distance, or  kept for any length of time,  it may  be preserved  by  various 
PRACTICE.
*m
methods.   The fluid is  caught on a small plate of glass, Avhich is pressed
closely against another of similar size and shape,  and the edges Avaxed, to
prevent the access of air.   We receive it on the  points of quills, likewise
protected from the air by envelopes.   Cotton thread is dipped in it and laid
aside Avith  equal care.   But in the scab Ave have the most convenient means
of preserving and transporting this invaluable agent.  It has been kept for
years  and  found capable  of communicating the genuine disease, just as
Avhen recent.   It may be protected from the contact of air  and  moisture,
by immersion  in softened Avax or spermacetti.   It is scarcely necessary to
remark, that the first scab alone possesses the specific vaccine character; if
this falls off, or is rubbed off too early, another may succeed it, but posses-
ses none of its useful properties.*
  Some have strenuously argued the propriety of recurring occasionally to
the udder of the coav,  the  original source of Vaccine, to ensure  its genu-
ineness, and  renew it from  time to  time,  but it may now be looked on as
settled, that its primary and essential characteristics are unchanged and un-
impaired by any imaginable number of transmissions.   Nay more, it is ob-
viously improved by thus passing through the human system; it is so modi-
fied as to  have become a milder malady, though not less effectual in its
influence on the constitution.   A person inoculated directly from the  coav,
ahvays suffers more, much more, than one Avho receives the infection from
a human vesicle, and, as far as has been ascertained, Avith no  correspond-
ing advantage to compensate.
   Among  the animals Avhich have been found capable of receiving and com-
municating the Vaccine, are the horse, the ass, the camel, the buffalo, the
 goat, the sheep, and the baboon.
   It has been doubted,  Avhether Variola does not exert a reciprocal influ-
 ence upon the Vaccine, Avhether it tends to prevent its introduction into the
 system, or in any manner or degree modifies it, and disturbs its regularity
 when  so received.   But the most  positive proof  has been obtained,  of the
 transmission of perfect vaccine, through constitutions previously subjected
 to the  variolous impression.   It has  been in this Avay  brought across the
 Atlantic, by the successive vaccination of individuals, among the passengers
 and crew  of the vessel, many of whom Avere knoAvn to have had the Small.
 pox.                                                        ..
   Much has been  said of the difficulty of communicating the disease more
 than once to the same constitution.  Gregory, of the Small-pox Hospital,
 declares that  "it is impossible, or nearly so, to reproduce the vaccine in any-
 thing  like its genuine form, where the cicatrix left by a preceding pustule
 is perfect, and the result of a perfect  vesicle."   Dr. Darrach,  of Philadel-
 phia,  in experimenting on  this subject, found that the repeated insertion of
 the matter in the  arms of vaccinated children, occasioned a local disease,
 exactly similar to that produced by the first operation,  with the exception,
 that the pustule and scab were much diminished in size.  In none of these

   * It is difficult, in this latitude, to preserve any form of vaccine matter,  (even the scab
 not excepted,)  through one of our summers.  The heat and moisture of our climate, |in
 the warm months, occasion it to undergo a deterioration, or decomposition, wh.ch ren-
 ders it unfit for use—at least, such has been the uniform result of numerous experiments,
 made with  the greatest nicety and care.   If we fail in transmitting the Vaccine from one
 subiect to another, in continuous succession, through the  summer and autumn, we find
 ourselves under the necessity of obtaining a new supply from our more fortunate brethren
 elsewhere. 
172-                        PRACTICE.

cases couid fever, or any other constitutional effect be discovered.   Unpro-
tected children Avere, Avith complete success, vaccinated from one of these
scabs not larger than aline (one tAvelfth of an inch) in diameter, Avhich was
the result of a fourth insertion of the virus.
  The duration of the influence of  the Vaccine, the permanency  rather of
the effect Avhich it has Avrought upon the system, has  been denied by some
Avho are staunch believers in its temporary  power to destroy the  suscepti-
bility of the body to the invasion of Small-pox.   But the mass of facts col-
lected under this head, certainly go to prove, that Avhatever may be the re-
sult of the vaccine inoculation—whatever the impressions made by it upon
the organism—this result—these impressions  are not likely to be impair-
ed or obliterated by any process of time or any  changes in the state of the
system from any cause.  Of tAvo  hundred and fifty cases collected by Dr.
Gibson, "in which Small-pox is said to have occurred  after  vaccination, it
appears that by far the greater number  had been vaccinated less  than two
years."  In Dr. Thomson's account of similar eruptions, they occurred at
various intervals after vaccination, from a few days to fifteen years, not
Avarranting, in any degree, the suspicion that the power of the Vaccine is
weakened or exhausted by time.
  To ascertain the true influence  of Vaccine upon Small-pox, is an object
of the utmost importance.  I will, therefore, briefly and formally  recapitu-
late the points fairly established, by  a due  consideration of the facts col-
lected on every side.
  First—Vaccination is no longer to be regarded as exhibiting the absolute
power of preventing the access of Small-pox.   In  some persons, it does
seem completely to destroy the susceptibility to variolous contagion—in all
it diminishes  notably,  though  in different degrees, the liability to be  infected.
   Secondly—The introduction of the Vaccine virus into the system in its
genuine form, and in the proper manner, never fails to produce  there such
changes as to modify certainly the future influence of the variolous poison,
if, under any circumstances, it should affect the constitution.
   Thirdly—The modification thus asserted, does not appear  to consist es-
sentially in a diminution of the violence  or duration of the first stage—the
eruptive fever.  This, though it is in general very slight, may be as severe
as in casual Small-pox.
   Fourthly—Nor does it  appear to imply  essentially a diminution of the
quantity of eruption upon the skin;  although the number of pustules is usu-
ally very limited in Small-pox after vaccination.
   Fifthly—The great poAver of the Vaccine  unquestionably  consists in
modifying the progress in of fiammation in thevariolous eruption.  Hence, the
slighter degree of cutaneous irritation Avhich terminates  in numerous in-
stances Avithout secretion of either lymph or pus—the less amount of mat-
ter formed in the pustules  (Avhen effusion does occur)—the  sudden  check
given in a majority of cases, to the  suppurative process, after it has com-
menced—the early disposition to rapid  drying.  Hence, the absence  or
transient duration of ophthalmia,  Avhich, Avith ulceration of the  cornea and
destruction of the eye, constitutes the Avorst and most  unmanageable se-
quela of unmodified Small-pox.   Hence, the rare occurrence of sloughing
of the cutis, and consequent  pitting, seaming and scarring of the skin.  It
has noAV become, happily, as unusual as it once Avas common, to see  a per-
son deformed with these marks of Small-pox.  Hence, lastly—the  infre- 
PRACTICE.
173
quency of what is termed secondary fever, and  its mildness, Avhen it does
shoAV itself.  This is Avell knoAvn  to be the most  dangerous of the several
stages of unmitigated Small-pox; it is tedious in duration, and leaves scarce
one constitution in ten thousand, Avithout  inflicting severe injury  and  per-
manent deterioration.   The convalescence from Small-pox  is, on this  ac-
count, in the unprotected, notoriously sIoav.  On the other hand, there is no
convalescence more rapid or more perfect than that  of a patient who  has
been assailed after vaccination.  He recovers both perfectly and promptly.
   "Observe," says Dr. Gregory,  "hoAv strikingly opposed to (contrasted
with) each other in this respect, are the influences of inoculation and vac-
cination.    Inoculation lessens the quantity  of  eruption, but does not alter,
in the slightest  degree, the progress of inflammation inthatAvhich is throAvn
out.  Vaccination, on the other hand, Avhile it  does not  (necessarily) af-
fect the quantity of eruption, ahvays influences  more or less, the progress
of inflammation in it."
   Sixthly—Nor can it be  denied,  that as far  as Ave  have a right to draw
our conclusions from the tables of mortality, published in  reference to this
question, vaccination tends much more surely and effectually to the preven-
tion of fatal results, than inoculation.  Thus among the cases stated to us
 by Doctors Bell and Mitchell, as occurring in Philadelphia, in 1823—24.

      Out of 248, 64 had been  previously  vaccinated  1 only died.
                  7 had natural Small-pox previously 3 of these died.
                  9 had been inoculated             3 of these  died.
                 13 unknown                          no deaths.
 Of those entire- > lg5 in numb   there died        85> more than one half;
 ly unprotected. ^
      a dreadful mortality.

   It is surely impossible to set in a stronger light, the advantages of  vac-
 cination, than is done in the above  paragraph.  Results  similar to these,
 are given in the annual reports of the National Institution of Great Britain,
 and in every other authentic document, Avithout exception, to which we have
 access.                                                              s
   In our own community, Variolous and Varioloid diseases have prevailed
 repeatedly.  I give you a list of the deaths, extracted from our annual bills
 of mortality, as follows:
               1824    1  Small-pox     1 SAvine-pox—
               1825   49     „   „
               1826   29     „   „
                1827                     1 SAvine-pox—

                1829 \  N° deaths recorded*
                1830   17  Small-pox.   4 Varioloid.      Total, 102.*

    Of whom, as far as I could ascertain,  on the most diligent inquiry, but
 one was known to have been  previously  vaccinated.

   *The neatest number of cases occurred in  1829-30  Vaccination had then been
 „„Jl P*Lsivelv.  The city and suburbs contain a population of 40,343.   During the
 whole of the above period, casee of Small-pox were occasionally brought  into the har-
 bour, by vessels from infected ports. 
174
PRACTICE.
  If we ask, Iioav has this ancient and justly dreaded pestilence  been thus
deprived of its terrors, and shorn of its fatal energies,  Avhat shall be the im-
partial answrer?  Not by any change in the nature of the case—not by any
loss of its inherent poAver over  the  human constitution—for the mortality
among the unprotected is most  appalling, greater than that of yellow-fever,
or, perhaps, even the plague; amounting every  Avhere, it  Avould seem, to
fully one half.  Nor is it OAving to such protection as inoculation  affords—
for that practice has been obsolete among us for the last quarter of a centu-
ry.   But it is clearly attributable, and we do not hesitate to ascribe it to the
kindly influence of the Vaccine—the most  valuable among the  generous
benefits conferred upon their fellow men, by the cultivators of the divine
art of healing.
«r* 
PRACTICE.
175
                             MEASLES.

  Morbilli. Rubeola.—A specific form of Fever, Eruptive, Contagious,
Inflammatory.  It is often Epidemic as Avell as Contagious.  It is difficult
to communicate by Inoculation, but Home  and Speranza affirm their sue-
cess—employing blood taken from vivid patches of eruption.
  Symptoms.   Rubeola makes its appearance Avith the  ordinary  tokens of
Catarrh.  There is rigor often, folloAved by heat of skin,  headache,  hard
and frequent pulse, soreness of throat, Avatery redness of the eyes,  sneezing,
a hard and dry cough, nausea and retching.  In children, convulsions oc-
casionally attend.  This state of things  may continue for many  days, but
usually, on the fourth, the eruption breaks  forth, at first visible on the pal-
ate, then on  the face and arms, gradually spreading over the body.  It is in
patches of small red spots, rough and a little  elevated.   The fever gener-
ally abates, but not ahvays  on its coming out.   The eyes suffer much from
it, the adnata being covered and the lids SAvollen.   It begins to fade on the
seventh, and soon dies aAvay, the cuticle desquamating .n minute  bra^my
scales.   In  the progress of Measles or at the  subsidence of the  Eruption,
Pneumonia is very apt to develope itself.   At this latter period Diarrhoea
of very obstinate  character often  arises.   Rubeolous Ophthalmia is sin-
gularly persistent.
  The Prognosis  in  Measles is generally favourable—and the  danger is
fairly proportioned to the attendant maladies above mentioned, the Pulmo-
nary Inflammation especially.   In children, the convulsions are  occasion-
ally, though not often, fatal.   It sometimes happens that  the Fever  is of
low  typhous type—Avhich is unfavourable.   The "striking in,"  or sudden
disappearance of the Eruption, is also unpropitious, and excites Avell groun-
ded  alarm.
  The Diagnosis does not  seem to me difficult; yet it Avas not until nearly
the end of the  17th century, that Measles Avere separated from Small-pox,
a confusion  Avhich we should noAV regard  as impossible.
  It may be confounded Avith Scarlatina,  Avhich  has  indeed been  called
Confluent Measles.  This  very phrase suggests a distinction, for  the patch-
es of Rubeolous Eruption,  are usually separated by notable intervals.   In
1829, hoAvever, I saw some cases in Avhich they  were nearly Confluent.
In Scarlatina the deep diffused redness  of the tongue and  mouth is  diag.
nostic.   The Catarrhal affections are prominent in Measles—the sneezing,
coughing, &c.—and the Ophthalmia, Avhichis often absent and very seldom
at all severe in Scarlatina.
  Pathology.   One  might  almost venture to declare that Rubeola consists
in the combination of some peculiar Exanthema with  Catarrhal  Fever.—
This affects the human constitution but once—a rule presenting  very feAv
exceptions.   The Eruption may occur  alone, a  circumstance   not unfre-
quently met with in Rubeolous Epidemics—the Rubeola Inco^ta of Good—
R. sine Catarrho  of Willan—the Bastard Measles of the common people*,
Noav by this form the susceptibility to a second attack is; not destroyed, not 
176
PRACTICE.
even impaired.  Other varieties of Measles are  noticed  by  Avriters.  R.
Nigra—R. Maligna—R. Variolosa.  I have met Avith none of these.   The
concurrence of Measles Avith Typhus Fever,  presents a livid eruption Avith
great danger, a compound of Nigra and Maligna.
   Treatment.  It often happens that the Catarrhal symptoms Avhich pre-
cede the eruption, are not sufficiently severe, to call for any remedial man-
agement, and the nature of the case is first sheAvn by the appearance of the
red patches on the surface.   Under  such circumstances, it is best not  to
interfere farther, than to keep the patient at rest, in bed,  and on Ioav diet—
regulating properly the temperature of his apartment, Avhich should be mod-
erately but not unpleasantly  Avarm.   But  in  the majority of  cases, some-
thing more will be required.   If there are tokens of Pulmonary inflamma-
mation and the pulse will  bear it, V. S. should be  freely  resorted to—and
the use of the  Lancet followed by the administration of Cathartics, combin-
ed with Diaphoretics—as the solution of Sal: Epsom in the Infus: R: Serp.
The Vascular  excitement being thus  reduced—the  Diaphoretics should be
continued with some Demulcent and Anodyne preparation to relieve cough
and procure rest.   Cups  or  Leeches to the chest may be  demanded—and
the Thorax enveloped in Avarm poultices, if the Dyspnoea be severe.  In
children affected Avith much  Gastric disorder and Convulsions, the Emetic
is useful—given, perhaps Avhile the subject is in the Avarm bath and follow-
edHby a Mercurial Cathartic.  The eyes  should  be kept clean,  Avith  tepid
Avater at first, and  afterAvards Avashed Avith mild astringent  Collynia.   If
Diarrhoea come on upon the subsidence of the eruption, small doses of O-
pium Avill restrain it—aided  by the Cretaceous mixture Avith Kino—or by
small doses of Acet: Plumbi.
  The Pectoral  uneasiness  remaining  after  Measles is  best remoAred by
the persevering application of successive blisters to the chest, or the irrita-
tion of the Tartar Emetic Ointment—Avhile Ave administer full doses of Do-
ver's PoAvder nightly.
  The sudden  disappearance—"striking in" of the Eruption is ahvays alar-
ming—and apt to be attended Avith Convulsions in children; and in adults
Avith Dyspnoea and Abdominal distress.   If the pulse be  full and hard, we
must bleed freely—but if on  the other hand, as is more common, the patient
has sunk into a sort of collapse, Ave must resort to the highest order of Stim-
ulants.   The  hot bath of 100 Fahr. at least, must be made  ready, while
we apply Sinapisms to the cold and  pale, or livid surface—the Camphora-
ted Tinct: of Opium, Avith the Vol: Alkali, and hot  Avine or brandy must be
given boldly and in abundance, until the skin becomes Avarm  and the pulse
rises.
  When Rubeola is accompanied Avith Fever of Typhous character, it is
proper to premise a mild Emetic,  after Avhich, a Mercurial Cathartic Avill
be of service—folloAved  promptly by the  stimulating Diaphoretics, Avhich
should be persevered in—adapting the doses to the condition of the patient
and the  effect produced.
  The Convalescent from Measles requires to be treated Avith caution.   His
diet must be mild and unstimulating, though nutritious, and he  must be clad.
warmly and guarded  from all exposure. 
PRACTICE.                         177
                           SCARLATINA.

   Scarlet Fever.   A  Contagious,  Eruptive, Pyrectic  disease, charac-
 terized by a peculiar efflorescence  of a very florid red hue, whence the
 name designating it.   First described, about the middle of the 17th Century*
 It is often Epidemic as well as contagious.   It has been communicated by
 Inoculation, and as has been asserted, with the same effect as in Small-pox,
 of procuring a milder disease.  As a general rule,  it attacks but once the
 same subject.
   Scarlatina is divided by writers, commonly into three varieties—S.  Sim-
 plex, S. A-igioosaand S.  Maligna.   I regard these, as mere differences in
 degree of violence and intensity.  The attack is ushered in with irregular
 shiverings attended by oppression at stomach, and nausea, Avith occasional
 vomiting—then succeed heat of skin,  thirst, frequent pulse, and headache,
 with sometimes delirium.   The eruption appears generally, on the second
 day, but may  postpone until  the 3d or 4th, shewing itself first on the face
 and neck, gradually spreading  over the trunk  and limbs, until  it almost
 covers their surfice.  On the succeeding day, the  lining membrane of the
 mouth, fauces and pharynx becomes inflamed, with ulceration of the tonsils
 and uvula in the Anginose form.   The tongue  throws off its fur and  as-
 sumes a deeply red color, the surface being at first smooth, but  soon  shin-
 ing Avith elevated and projecting papilla?—it is acutely  sensible to the touch
 or to the application  of temperature either above, or beloAv its own.  The
 efflorescence which in many cases is almost confluent,  is bright red,—hot—
 dry—little elevated or rough—indistinctly papular.   The skin seems thick-
 ened.  On the 5th and 6th days it begins to fade—and desquamates gradu-
 ally in minute  branny flakes.  At this time the hands and feet are  SAvollen,
 and for some short period  the new surface remains morbidly sensible, espe-
 cially that of the mouth.   The inflammation in  the  Anginose form, is not
 always attended with ulceration, but sometimes the Tonsils, dec. are cover-
 ed with flakes of Lymph or  false membrane.
   In bad cases the eruption comes out irregularly  and is  ready to recede.
 When this  occurs, Congestion or  Inflammation of some  internal organ is
 prompt to follow—and we  have either Dyspnoea with thoracic pain,  or
 vomiting and purging, or convulsions.  If the patient be not quickly reliev-
 ed, the pulse sinks, the countenance  becomes ghastly, the complexion palo
 or livid, the skin cold, and  death rapidly hastens on.
   By the term Srarlatina  Maligna, I would designate those cases in which
 the Fever assumes the Typhous  type,  This is  common in some localities
 where, of course the Epidemic visitations of Scarlet fever are highly dreaded.
 The Eruption in these attacks may  be early or otherwise.  The throat is
 affected with ulceration, which has a tendency to slough—is of ash color,
 and gives out a fetid odour, and an acrid discharge,  excoriating the nostrils,
 and the corn?rs of the mouth, and if swallowed, offending :he stomach and
intestines, and  producing  vomiting and purging.  The internal  organs are
often attacked at the onset—there may be delirium,  often quiet and playful;
              23 
178
PRACTICE.
Dyspnoea  with mucous rale—and intestinal or peritoneal  inflammation.
The termination of this variety is often fearfully hurried, taking place from
the 3d to the 5th day.   Recovery is very sIoav and for a long while  doubt-
ful.
  The Convalescence from Scarlatina is attended in many cases with An-
asarca,  and in some with general Dropsy.   It is not so apt as Measles, or
Small-pox, to leave permanent sequela;, affecting the Thoracic or Abdom-
inal Viscera.
  Autopsy.  The appearances on examination after death, vary. In some,
there  is engorgement of the brain  and vascularity of the  membranes with
effusions.   In others, the Lungs are congested  and  hepatized;—in others
still, there is injection of the mucous surface of the stomach and intestines.
I haye had no opportunities of  personal observation, never  having lost a
case of Scarlatina.
   Diagnosis.   I have  not found  it difficult  to  distinguish Scarlet Fever
from Measles which it most resembles—by the want of Catarrhal symptoms
in the Fever of Incubation, by  the confluent  extension and peculiar appear-
ance of the Eruption,  which in  Measles is in patches, more distinctly papu-
lar and more prominent.  The  Scarlet tongue with elevated and  swollen
papillae is also characteristic.  They differ much in the Sequelae to which
they subject the patient.  The books make a confusion betAveen Scarlatina
Maligna and Cynanche Maligna.  In the instances of the  latter formidable
pestilence which I have met with, the Eruption was not general or much
diffused, and the tongue continued furred thickly to the  end.
   Prognosis.  Scarlet Fever, as it prevails in this city, (and it is of frequent
occurrence) assumes usually a mild form,  and the  proportion of deaths  is
small.  The type of Fever in the first place, and in the second, the degree
in which the internal organs suffer, would  indicate the force of the attack.
Thus if there Avere delirium orconvulsions—or the ulcers of the throat as-
sumed a gangrenous aspect—or Dyspnoea supervened; and especially if with
any or all these, there Avas combined a disappearance of the rash or  efflo-
rescence, we should know the  patient to be in serious danger.
   Treatment.  In general it will be sufficient to commence the management
of the case with a mild Cathartic.  If the vascular excitement be specially
 high, it may be reduced by the  Lancet.  The throat being  much inflamed,
we may apply Leeches at the angle of the jaAV or on the neck. An EmeU
ic will relieve occasionally the oppressed stomach,  if it be not emptied by
spontaneous vomiting.  After   the  Eruption is  fairly  out,  the  Cathartic
 should be abandoned and the case trusted  to the Diaphoretics.
   Currie, Gregory, and other high authorities, advise strongly the  Cold af-
fusion in Scarlet Fever, and attribute to it the best results—while on the
 other hand, those who consider the Cutaneous Eruption in the Exanthemata
 as a Metastasis from the Mucous Membranes Avhich they regard as  the seat
 of primary irritation,  deprecate the application of cold water, as extremely
 dangerous.  Truth lies between them—but in general we may decide that
 the remedy, though safe, is not  necessary,  nor capable of the striking good
 effects Avhich some Avould teach us to expect from it.  Should any form of
 Visceral inflammation arise in the progress of the case, it must be  combat-
 ted Avith the usual remedial measures.  I am  not  aware that the  connec-
 tion  Avith  Scarlatina modifies the necessary treatment.
    In Scarlatina Maligna, it is prudent to  begin  Avith a prompt Emetic,  fol- 
PRACTICE.                        179
loAved by a mild dose of Calomel.  The Cordial Diaphoreties are early re-
quired and may be combined  with other stimulants in requisite amount.
Cinchona—the Vol: Alkali—and the Tinct: Op: Camph:  are among our
best remedies. The hot bath should be used if  the surface is cold and pale
or livid, and Sinapisms extensively applied.   If the bowels are  not moved
by the Mercurial, Enemata should be  administered.   The throat  should
be Avashed with tepid Avater and steamed—and if there be from the ulcers
much fetid discharge, Avhich may  irritate the stomach, the Emetic may re-
quire to be repeated.
  Great confidence is placed by many Practitioners, in the exhibition of the
Infusion of Cayenne Pepper, both as a local  corrector of the morbid con-
dition of the gangrenous Ulcer, and as the stimulant best adapted to the ex-
igencies of the case.
   The Dropsical Affections which supervene so often during convalescence
from Scarlatina, must be treated as formerly advised,  under the head  of
Hydrops—with this modification, that they allow and require an early and
free use of tonic and aromatic formula?—as the Infus: Cinchon with Rad:
Serp: and Camphor, in small doses, with Nitrat: Potass: and Nitrous Ether.
   I ought not perhaps to omit that the German  Homoiopathists propose the
use  of Belladonna as a  preventive of  Scarlatina  in all its forms.   They
imagine it to excite a state of disease similar to, or identical with Scarlati-
na.  The speculation is ingenious, but is not sufficiently  confirmed.  My
own experiments with the Belladonna have been altogether unsatisfactory. 

 
 
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