NATIONAL LIBRARY OF MEDICINE Washington Founded 1836 U. S. Department of Health, Education, and Welfare Public Health Serrke THE AMERICAN ECLECTIC PRACTICE OF MEDICINE: BY I. G. JONES, M.D., LATI PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE, IN THE ECLECTIC MEDICAL INSTITUTE OF CINCINNATI, ETC., ETC. TO WHICH ARE APPENDED THE POSTHUMOUS WRITINGS Ob' T. Y. MORROW, M.D., ALSO LATE PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE Uf»HE SA^JfiJiSSWllTK, ETC. ■» VOLT.MK T. „V'<.-'&- ft 4s* CINCINNATI: MOORE, ANDERSON & CO. 18 5 3. 1854- Entered according to Act of Congress in the year 1853, BY DR. I. G. JONES, In the Clerk's office of the District Court of the United States for the District of Ohio. CHARLES SCOTT, PRINTER AND BINDER, COLUMBUS, OHIO. TO ALL MEMBERS OP THE MEDICAL PROFESSION, WHO, CHASTENED BY EXPERIENCE AND OBSERVATION, AND RISING ABOVE THE TRAMMELS OF PARTY FEELING, ARE READY TO RECOGNIZE VALUABLE CONTRIBUTIONS TO MEDICAL SCIENCE, AND TO ADOPT MEASURES PROVED SUCCESSFUL IN RELIEVING HUMAN SUFFERING: TO ALL WITH WHOM THE LOVE OF TRUTH AND ITS DISSEMINATION ARE PARAMOUNT TO PROFESSIONAL PRIDE OR INDIVIDUAL OPINION: TO ALL WHO ARE FREE TO CHOOSE AND FREE TO ACT: IN FINE, ®o all ©rauhw Ssckcticg, WHO HAVE CHOSEN MEDICINE FOR THEIR FIELD OF LABOR, THESE LECTURES ARE MOST RESPECTFULLY INSCRIBED, BY THEIR FRIEND AND CO-LABORER, THE AUTHOR PREFACE. The object of the present publication is to supply, in a measure, the increasing demand for a Text Book for students, and a work of reference for practitioners of the Eclectic School of Medicine. A work embodying at once the general principles, and the modern im- provements in practice, advocated by that school, adapted equally to the wants of Western physicians, students, and professors, and calculated to correct and remove erroneous impressions too generally prevalent in regard to the Eclectic system, is, and long has been, greatly needed. It was to answer these several demands, and promulgate more liberal medical sentiments, that the late lamented Prof. Morrow commenced preparing for the press a work on the Theory and Practice of Medicine. He had made some considerable progress in the dis- cussion of a number of the diseases usually treated of in such a work; but, aside from the incidental mention of principles growing out of the consideration of the treatment of diseases, and before arriving at the formal discussion of the important and distinctive general principles connected with medical improvement, which he had for many years been teaching with eminent ability, he was cut off by the hand of death. Remote from the field of labor in which Prof. Morrow was engaged, the present writer had no opportunity to consult or arrange with him, or even to ascertain the extent of the matter he had prepared before VI PREFACE. his decease. But having been his associate in the Eclectic school when first established in Worthington, and his partner in the practice of our profession for many years, it was, perhaps, not unreasonably supposed that I fully understood and appreciated the views and the- ories of our late friend; and hence, doubtless, it was, that I was immediately called upon, both by Ms friends and the friends of the institution, of which he was the moving spirit up to the time of his death, to take his place in the school, and complete the work which he had begun. However reluctant I might have been to suddenly exchange my own active business, at no small personal sacrifice, for the more quiet, perhaps, but more exhausting labors of a professorship, yet I did not feel at liberty to resist the urgent personal solicitations of too partial friends, nor to decline the appointment, by the trustees of the Eclectic Medical Institute of Cincinnati, to the chair of " Theory and Practice of Medicine." With health not the most firm, and accustomed to active outrdoor exercise, I feared the result of the confinement necessary to the com- plete preparation of a course of lectures, and the continuation of Dr. Morrow's work. I therefore resorted to the expedient of procuring a phonetic reporter, to take down and transcribe my lectures, and thereby accomplish, to a great extent, the two-fold purpose of completing the work referred to, and imparting a more thorough course of instruction than I should otherwise be likely to do. On examining the matter left by Dr. Morrow, it was found much less extensive and more unfinished than was expected; and what he had written was mainly confined, as before stated, to the consideration of the symptoms and treatment of some of the most common diseases, without any separate discussion of the pathological phenomena, or general principles, always important, but indispensably necessary in a work proposing great changes in the Theory and Practice of Medicine. I also found, on reflection, that it was not convenient, in deliverinc a PREFACE. Vll course of lectures, to continue the plan adopted by Dr. Morrow, nor could I appropriate and embody his matter, without considerable modification. I therefore prepared my lectures independently of his writings, and have concluded to present his matter in this volume, separately, and exactly as it was left by his hand, not feeling authorized either to withhold its publication, or to introduce any other changes than were required by evident verbal omissions or mistakes. This much was, perhaps, due to the memory of the late Professor, and will be gratifying to his numerous friends, who had been apprised of his intention to prepare a work for the press. And this will account for the appearance of the present volume, which, I trust, will meet the expectations of the profession, and supply, at the same time, the pres- ent necessities of our schools. It will be seen that there is some difference between the course of treatment of malarial diseases recommended by Dr. Morrow and that advocated in these lectures. The views which I have set forth of ma- larial influences, and the treatment of all diseases arising therefrom, had been gradually ripening into settled convictions for the last eighteen years, and are the result of personal observation and experience. They had not till recently been communicated to Dr. Morrow or the profes- sion, and not till after he had mainly written what appears in this book. But I have reason to believe, from several interviews with him, that, after fully testing the theories and measures which I suggested to him, he would, had he lived to complete his work, have modified his previously prepared manuscript so as to correspond and harmonize with the views set forth in these lectures. In every other respect, it will be observed that our views of treatment are essentially the same. On reviewing the manuscript furnished by my reporter, many de- fects and mistakes were found, partly referable to the difficulty of reporting extemporaneous lectures, but mainly owing to the imperfec- tions of the phonetic system, or the want of experience in writing on viil PREFACE. medical subjects on the part of the reporter. They have, however, been corrected, so far as the circumstances connected with an extensive daily practice would permit. And although I make no claim to exemption from errors and mistakes, I nevertheless believe this work will be found, on the whole, as perfect in these respects as most other similar productions. In a future edition, should any be demanded, no pains will be spared to correct any errors of omission or commission which may be discovered on a more careful review. My first design contemplated but one volume; but it was found that the proper discussion of all the subjects legitimately embraced in the terms " Theory and Practice," would swell a single volume, however condensed, to a size inconvenient both to students and practitioners. I have, therefore, hastened to issue the present volume in time to furnish a text-book to be used during the ensuing course of lectures in our institutions, and hope to have the second volume ready by the time the subjects treated upon in this volume shall have been gone over in those institutions. As to the character of the work, it does not become me to speak. I may say, however, that it contains a faithful record of the results of an experience extending through a quarter of a century—a daily expe- rience in the treatment of nearly every variety of disease incident to the human family, in the valley of a western river, midway between a northern and a southern climate, where the diseases of both are often seen, and both occasionally in the most malignant types. Such a record, it seems to me, is worthy a candid consideration. Although the work has been produced more especially at the instance of those favoring the claims of the Eclectic branch of the medical fraternity, I nevertheless invite an examination by the profession at large. I cannot expect those who differ widely from me to adopt my views at once, nor do I desire to impose the results of my own expe- rience upon any member of the profession, without a patient analysis PREFACE. IX and careful examination; that, however, I have a right to expect, in this age of progress and improvement, from all who are able to rise above the influence of professional pride and sectarian bigotry, and with whom the real advancement of the science, and the well-being of the race, are more than paramount to considerations of interest and arbitrary professional ethics. If the principles herein taught, and the practice herein claimed to be successful, after being faithfully and impartially tested by the lights of science and at the bed-side of the sick, shall prove to be erroneous and deceptive, then this work would deserve to be denounced, and its errors published to the world. But should the success of its teachings prove equal to its claims—should the work itself be found to contribute anything of value to the stock of medical science and practice—I ask, in all candor, if it should not be acknowledged? Even if the individual rights of the author are neglected—if his reputation as a benefactor of the race is not to be considered—yet, do not the great and paramount claims of diseased and suffering humanity, require as well the practical test as the open admission of the merits of the work ? If the practice recommended in this work were the result of mere theory, or the suggestion of a "closet practitioner," its claims would rest upon a very different foundation. But since it is supported by the authority of a long and arduous experience, in an unceasing prac- tice, tested in thousands of cases, and rigorously compared with a different course of medication, more particularly in the treatment of malarial diseases, it presents a claim for an impartial trial not always found. My conclusions were not wholesale original assumptions, fol- lowed by tests which it was guessed or hoped would produce the preconceived effects; they were rather the result of careful experiment and close observation, made, in the first place, by slight variations from routine practice, and repeated in many subsequent cases, with increas- ing boldness, and in a less limited and restricted application, until, step X PREFACE. by step, the principles of the new mode of treatment, in malarial diseases, at least, were clearly established and triumphantly demon- strated ; and this, too, in thousands of cases of almost every conceiv- able grade, from the slightest intermittent to the most malignant congestive and bilious fevers. No further apology or explanation, I think, is needed for the appear- ance of this work. And I now submit it to the public, trusting to the candor of those who have repeatedly called for its publication, and to the high toned moral integrity of a large majority of the profession, to do it justice; remarking, however, that, if in this I am destined to be disappointed, I believe, with an undoubting faith, that a generation is yet to come, of loftier and more liberal sentiments, of deeper sympa- thies with the whole human race, and freer from the trammels of sec- tarian pride, which shall be ready to award to truth its full demands. It remains only to acknowledge my obligations to various medical authors and publications, used and referred to in the preparation of these lectures. I especially acknowledge my indebtedness to the lectures of Doctors Armstrong, Watson, and Stokes & Bell, on the practice of medicine; to several medical journals and retrospects for isolated facts—such as the Boston Medical and Surgical Journal, &c.; to the works of Magendie, Vogel, Schomel, Gross, John Hunter, and others, on pathological phenomena; to the voluminous works of Dr. Tweedie; to the extensive Modern Practice of Prof. Wood, of the University of Pennsylvania; and to Doctors Meigs, Condie, and Chapman. I am also under great obligations to Prof. W. Sherwood, of the Eclectic School at Cincinnati, for his valuable assistance in copying and preparing the work for the press. CONTENTS. LECTURE I. Introductory,.....................1—20 LECTURE II. FEVER. Importance—Definition—General Descriptive Remarks—Stages: 1st, Forming; 2d, Cold; 3d, Hot; 4th, Sweating.............21—29 LECTURE III. FEVER—CONTINOED. General Remarks continued—Crisis—Two General Classes, Symptomatic and Idiopathic—Their Difference—Brousais' Doctrine of Fever—Local Diseases only secondary—Seat of Fever—Nervous System—Organs—Secretions and Circulation affected secondarily—Typhoid Differs—Secondary Disease may become Paramount—Violence of Fever—How Modified—Causes of Fever- Miasmata—What is it?—How Produced—Where it Prevails—In what Sea- sons .......................30—38 LECTURE IV. FEVER—INTERMITTENT. Miasmata continued — Koino — Idio—Suggested Classification of Fevers—Old Names Retained—Intermittent Fever—Types—Varieties—Stages: 1st, Form- ing; 2d, Cold; 3d, Hot; 4th, Sweating—Modifications—Neuralgic Affections— Sun Pain, &c.—General Remarks—Paroxysms may occur Day or Night- Wearing out Ague—" Ague Cake"—Tendency to Relapse - - - - 39—49 LECTURE V. INTERMITTENT FEVER—CONTINUED. Periodicity — Diversity of Opinion — Bailey's Opinion—Cullen's—Explanation Suggested—Complications—Gastro-Intestinal Inflammation—Congestion of Liver, Spleen, and Brain—General Remarks—Differences of Susceptibility— Post Mortem—Causes, Predisposing and Exciting—Prognosis—Diagnosis— Treatment, Palliative and Radical.............50—59 LECTURE VI. INTERMITTENT FEVER—CONTINUED. Treatment continued—Palliatives—How Varied—Restlessness—Case Cited—De- termination to Head—Doubtful Cases—Case Cited—Radical Treatment- General Directions—Remedies—Former Practice—Evacuants—Dr. Morrow's Practice—Reasons for Differing—Popular Remedies—Case Cited—Treatment for Vomiting and Purging—For Nervous Irritation—Protracted Cases—Ad- ditional Means—Tonics—Cinchona—Iron—Remarks on Various Remedies— Quotation from Dr. Bell—Old School Doctrines—Differences between Au- Xll CONTENTS. thors—Quotations from Dr. Bell—Remarks—Quotation from Dr. Wood- Remarks......................60~78 LECTURE VII. INTERMITTENT FEVER—CONTINUED. Treatment continued—Neuralgic Cases—Sun Pain—Local Inflammations—Re- marks on Treatment—Doctrine of Books set aside—Periodic Symptoms in other diseases—Scarlatina. Croup, &c—Prophylactic Treatment—Bone's Bit- ters : Recipe—Substitute: Recipe—Cholagogue Pill: Recipe—General Direc- tions—Concluding Remarks. Remittent Fever —Synonyms —Localities, Seasons, Periodicity—Differs from Intermittent—Differences of Suscepti- bility—Forming Stage—Chill, Fever, Remission—Modifications—Complica- tions—Congestion of Liver—Biliary Derangement—Gastric Disorders—Vari- ations of Pulse...................79—93 LECTURE VIII. REMITTENT FEVER—CONTINUED. Complications continued—Inflammation of the Lungs—Any Organ liable—Symp- toms of Complication peculiar—Opinions of Authors—Local Disease second- ary—Cause of Bilious Fever—Endemic Character explained—Influence of Age, Sex, Habit, &c—Latent Period—Diagnosis—Prognosis—Duration—Post Mortem—Treatment—Old School Doctrines—Quotations—Remarks on Calo- mel—Bleeding—Dr. Wood on Mercury and Quinine—Reply - - - 94—112 LECTURE IX. REMITTENT FEVER—CONTINUED. Remittent Fever continued—Treatment when first called—How to proceed—Pal- liate till Fever begins to Decline—Antiperiodics—Recipe—If not arrested the first day, repeat—Emetics considered—Cathartics considered—Treatment has reference to Paroxysm—Tonics, when necessary—Complications—Different Complications—Gastro-Intcstinal Symptoms, Treatment for.—Congestive Va- riety—Symptoms—Treatment.—Over-action of Liver, Remedy for.—Deter- mination to the Brain—Symptoms—Treatment.—General Remarks.—Typhus Symptoms—Management of such cases—Diet and Exercise - - 113—129 LECTURE X. CONGESTIVE FEVER. Preliminary Remarks—Dr. Armstrong's Views—Synonymous with Typhus- Malarial Origin—Not Contagious—Mere modification of Bilious Fever- Symptoms—Treatment, Palliative and Radical—Complications—Gastroin- testinal Disorder—Hepatic Disorder—Treatment—General Remarks and Directions -...................130—148 LECTURE XI. PERNICIOUS FEVER. Modifications of Bilious Fever continued—Pernicious Fever—More at the South- Symptoms—Character—Symptoms continued—Condition of the Bowels; Blood—Diagnosis—Prognosis—Prof. Wood's opinons—Treatment—Two in- dications, produce reaction and prevent subsequent Paroxysm—Treatment continued—Wood's Treatment—Concluding Remarks—Professor Bell's Cases and Treatment—Remarks........-......^49__ig2 LECTURE XII. YELLOW FEVER. When and where it prevails—Endemic and Epidemic—Symptoms and peculiari- ties—Course—Three Stages—Symptoms of each—Extract from Wood— CONTENTS. xiii Symptoms continued—Black Vomit: its occurrence in Charleston—Con- tinued—Its prevalence in Natchez : Description of the town and surrounding country—Description of the Epidemic—Symptoms—General Remarks—An- atomical Character.................163__iso LECTURE XIII. YELLOW FEVER—CONTINUED. Cause—Vegetable and Animal Malaria—Reasons given—Additional Facts—Ex- tracts from Dr. Perlee—Yellow Fever in Natchez in 1817; in 1819—Dr. Dixon on Yellow Fever in Charleston, 1817—Reference to other cases—Circum- stances necessary to produce Yellow Fever—Contagiousness disproved— Diagnosis—Prognosis—Treatment—Quinine and Iron—Other Remedies- Remarks on Cathartics, Mercury, and Lancet—Convalescence—Means of Prevention....................181—199 LECTURE XIV. TYPHOID FEVER, OR CONTINUED FEVER. Preliminary Remarks—Synonyms—Mode of Invasion—Febrile Symptoms—Dif- ferent Periods of Progress described—Sometimes Periodic—Tympanitis- Peculiar Discharges—Petechia?—Sudamina—Subsultus Tendinum—Posture of Patient—Fatal Case—Mode of Death—Duration—Favorable Result—Con- valescence—Sequelae—Anatomical Phenomena.......2C0—216 LECTURE XV. TYPHOID FEVER—CONTINUED. Cause—Doctrine of Contagion considered—It is Infectious—Difference between Infection and Contagion—Influence of Acclimation, Age, and Sex—Nature of Typhoid —Diagnosis —Prognosis —Treatment—General Remarks —Dr. Jackson's Method—Chomel's—Louis's—Statistics......217—234 LECTURJH XVI. • TYPHOID FEVER—CONTINUED. Discussion of Treatment continued—Dr. N. Smith's Method—Review of the Au- thors cited—Proper Treatment—Remedies Recommended—Cases cited— Typhoid may be cut short—Further Measures for Protracted Cases—Man- agement of Convalescence..............235—247 LECTURE XVII. INFLAMMATION. Definition—Symptoms—Changes produced—Functional, Structural—Causes- Nature—Results or Terminations—Resolution—Effusion—Induration and Adhesion —Hemorrhage —Suppuration —Quotation from Dr. Wood on Pus—Softening—Ulceration—Gangrene—Granulation—Cicatrization—Sum- mary ......................248—269 LECTURE XVIII. INFLAMMATION—CONTINUED. Chronic Inflammation—General Effects of Inflammation on the Blood—Hunter's Opinion—Gendrin's—Buffy Coat—Nervous Influence—Fibrin—Serum—Ma- gendie on Bleeding—Effects of Inflammation beyond its Seat—Sympathetic Fever—Microscopic Changes in Inflammation—Contraction of Capillaries— Relaxation—Engorgement—Effusion of Lymph—Quotation from Tweedie— From Hunter—From Magendie, on Capillary Circulation - - - 270—293 XIV CONTENTS. LECTURE XIX. INFLAMMATION—CONTINUED. Effects of Blood-letting—Magendie's Character and Researches—Quotations from him—Bleeding increases Serum—Various Experiments—Excess of Serum embarrasses Capillary Circulation—Promotes Inflammation—Quotation from Magendie—His change of Views—Bleeding predisposes to Inflammation- Quotation from Hunter—Tweedie—Review of his Doctrines—Results of Bloodless Practice.................294—315 LECTURE XX. INFLAMMATION—CONTINUED. Treatment—Indications—Remove Cause—Equalize Circulation—Attention to Skin—Objection answered—Hsemastasis—Adjustment of Ligatures—Other Measures—Phrenitis—Inflammation of the Brain—Definition—Synonyms— General Remarks—Symptoms—Premonitory—Early Stage—More advanced Stage—Fatal Termination—Diagnosis—Prognosis—Anatomical Characters- Reference to Phrenology—Further Research urged—Causes—Treatment— Obscure Chronic Diseases—Neuralgic Affection.......310—338 LECTURE XXI. OTITIS: INFLAMMATION OF THE EAR, ETC. Preliminary Remarks—Peculiarities of Otitis—Predispositions—Brain sometimes Involved—Causes—Treatment—Local Measures—Constitutional Remedies— Recipes—"Alteratives"—Associated with Malarial Fever—Case of Neuralgia. Stomatitis : Inflammation of the Mouth—Never Idiopathic—Symp- toms—Causes—Treatment. Thrush: Treatment—Condition of Mother— Idiosyncrasies—Nurse's Prescriptions. Cancrum Orris : Nurse's Sore Mouth.....................339—355 LECTURE XXII. GLOSSITIS: INFLAMMATION OF THE TONGUE, ETC. Description—Treatment. Angina: Inflammation of the Fauces—Variety of Symptoms —Peculiarities—Causes—Treatment—Chronic form—Treat- ment. Tonsillitis : Inflammation of the Tonsils—Symptoms—Lo- cal — General — Terminations — Chronic — Prognosis — Cause — Epidemic- Treatment—Strictures on Calomel and Lancet. CEsophagitis : Inflamma- tion of the (Esophagus—Symptoms—Treatment.....356—372 LECTURE XXIII. GASTRITIS: INFLAMMATION OF THE STOMACH. Subject defined—Division—Acute Gastritis—Generally secondary—Symptoms- Local—General—Favorable and Unfavorable—Of Disorganization—Dura- tion—Modification—Pathological relations—Redness of Mucous Membrane- Legal investigations—Causes—Treatment .........373—383 LECTURE XXIV. CHRONIC GASTRITIS—CHRONIC INFLAMMATION OF THE STOMACH. Preliminary Remarks-Distinguished from Dyspepsia-Symptoms-Duration- Causes—Treatment-lf caused by Over-eating, &c.-lf caused by Spirituous Liquors—Active Purgatives to be Avoided. Dyspepsia or Indigestion— Digestive Function considered-Effects of Fluids-Symptoms of Hepatic Disorder—Influence of Irregular Habits—Want of Exercise, &c. - 3S4-395 CONTENTS. XV LECTURE XXV. INDIGESTION—CONTINUED. Treatment. Hygienic Treatment—Food, proper and improper—Fluids not advisable—Exercise—Summary. Medical Treatment—Neuralgic cases- Spasm of Stomach.................396—406 LECTURE XXVI. ENTERITIS : INFLAMMATION OF THE SMALL INTESTINES. Synonyms—Parts Involved—Symptoms—Diarrhcea—Character of Stools—Fe- brile Symptoms—Prognosis—Post Mortem—Causes—Diagnosis—Treatment for various Causes—Cold—Acid Accumulations—Excessive Bile—Malarial Fever—Diet. Chronic Enteritis: Symptoms—Treatment. Diarrhcea: Symptoms—Causes, &c.—Treatment for over-loaded Bowels—Treatment for Atony......................407—421 LECTURE XXVII. DYSENTERY: INFLAMMATION OF THE LARGE INTESTINES. Synonyms—Acute Dysentery—General View—Modifications and Varieties- Symptoms—Local—General—Caused by Worms in Children—Adynamic Form—Associated with Periodic Fever—Prognosis—Causes reviewed—Post Mortem—Treatment—Where caused by Cold—By Irritating Substances—For Derangement of Stomach—Emetic Recipe—Injections—Treatment in late Stage—Where caused by Worms—Epidemic Form—Antiperiodic Medicine- Obstinate Cases..................422—437 LECTURE XXVIII. CHRONIC DYSENTERY, ETC. Symptoms—Constitutional Derangement—Post Mortem—Cause—Treatment- Mild Cases—Ulceration—Diarrhcea—Varying Remedies—Prolapsus Ani— Diet. Peritonitis : Inflammation of the Peritoneum—Preliminary Remarks—Varieties—Acute—Symptoms—Puerperal—Tympanitis—Periodi- city—Post Mortem—Cause — Diagnosis — Prognosis—Treatment—Chronic Form—General Remarks—Symptoms—Treatment—Clinical Case of low Fever......................438—158 LECTURE XXIX. DISEASES OF THE RECTUM. Stricture of the Rectum. Preliminary Remarks—Two Forms—Spasmodic Stricture—Symptoms and Causes—Treatment—Organic Stricture—Two Va- rieties — Non-Malignant— Symptoms and Causes—Treatment—Cancerous Formation—Symptoms—Treatment: Radical, Palliative. Hemorrhoids or Piles. Frequency and Importance—Definition—Varieties—Constitutional Condition—Local Development—Primitive Type—Positions of Tumors— Bleeding Piles—Wart-like Excrescences—Diagnosis—Causes—Treatment— Constitutional—Local—Removal by Ligatures—Precautionary Measures 459—478 LECTURE XXX. FISSURE OF THE RECTUM. Introductory Remarks — Description—Appearances—Causes—Treatment—Gen- eral—Local. Fistula in Ano : Remarks—Causes—Character—Treatment— Local and General. Prolapsus Ani : Character—Symptoms-^Cfcuse—Treat- ment ......................479-49 XVI CONTENTS. LECTURE XXXI. COLIC. Varieties. Spasmodic or Wind—Bilious—Painters'. Wind Colic : Symp- toms—Cause—Treatment. Bilious Colic: Symptoms—Nature—Cause- Fatality—Anatomical Character—Treatment—Particular Remedy—Diosco- rea—Remarks—Other Treatment. Painters'or Lead Colic: Distinction- Symptoms—Paralysis—Chronic—Cause—Remarks—Diagnosis—Prognosis- Anatomical Character—Treatment—Prevention .......493—508 LECTURE XXXII. OBSTRUCTION OF THE BOWELS, ETC. Obstruction of the Bowels. General Remarks—Symptoms—Causes—Treat- ment—Concluding Remarks. Constipation: General Remarks—Symp- toms—Causes—Treatment—Case stated—Diet—Treatment of Obstinate Cases......................509—522 LECTURE XXXIII. CHOLERA MORBUS, OR SPORADIC CHOLERA. Introductory Remarks — Character — Symptoms—Cause—Predisposition—Ana- tomical Character—Diagnosis—Treatment.........523—530 LECTURE XXXIV. EPIDEMIC CHOLERA—ASIATIC CHOLERA—MALIGNANT CHOLERA—SPASMODIC CHOLERA—CHOLERA ASPHYXIA. Introductory Remarks—History—Progress—Appearance in United States—Symp- toms—Stages—First, Chlorine Stage—Second, Positive Invasion—Third, Col- lapse—Symptoms of each Stage—Reaction—Convalescence—Variations- Anomalies—Blood in Cholera—Rice-water Discharges—Anatomical Charac- ter—Causes—Predisposing—Exciting ...........531—548 LECTURE XXXV. EPIDEMIC CHOLERA—CONTINUED. Nature of Cholera—Primary Seat—Prognosis—Treatment of different Stages- Treatment of first Stage—Treatment of Second Stage—Treatment of Third Stage—Dr. Morrow's Treatment—Dr. Jordan's Report—Concluding Re- marks ......................549—566 LECTURE XXXVI. MILK SICKNESS—SICK STOMACH. Introductory Remarks—Symptoms—Case of Milk Sickness—Treatment—Char- acter—Cause—Nature—Treatment—Note—Other Cases—Quotation from Dr. Haynes—Dr. McCall's Views—Cause—Treatment......567—583 LECTURE XXXVII. WORMS. Remarks—Varieties—First Variety—Character—Appearance—Situation. Second Variety—Character—Appearance—Situation. Third Variety—Character- Appearance—Situation. Fourth Variety—Character—Appearance — Situa- tion. Fifth Variety—Character—Appearance—Situation. General Symp- toms—Origin-Spontaneous—Propagation — Remarks—Anatomical Charac- ter—Treatment for Lumbrici and others—Treatment for Tenia—New Rem- edy......................584—600 POSTHUMOUS WRITINGS OF PROF. T. V. MORROW - - - - 601-779 LECTURES ON THB THEORY AND PRACTICE OF MEDICINE. LECTURE I. INTRODUCTORY. Gentlemen— Your attention is invited this morning to a general view of the extensive and important subjects pertaining to this chair. The Theory and Practice of Medicine is a title defined to some extent by its own terms; yet, neither the mere enunciation of the phrase, nor attention to the literal signification of the words composing it, will convey an adequate idea of the subject which it comprehends. The Lectures to which you will listen as delivered from this chair, will have for their object your instruction in correct Theory, or those doctrines which, appearing to coincide with philosophical truth, are sustained and confirmed by experiment and observation, in health, in disease, and post mortem research; and the eluci- dation and illustration of a system of practice believed to be rational in its basis, truly scientific in its measures, and which has proven eminently successful in its results. And, rest assured, Gentlemen, I feel most sensibly the responsibility of my position. The duties of a Professor, occupying this chair, are laborious and 1 2 INTRODUCTORY. extensive, and must tax, to their utmost capacity, the abilities of even the most giant intellect, however qualified for the task, by study and experience. But were labor, physical and mental, all that is involved in the assumption of such a position, it were, com- paratively, a matter of minor importance; the professor might perform his task with fidelity, and having accomplished " a' the hireling his day," feel no further concern. But when I reflect upon the consequences which will flow from my labors in this capacity; on the result for good or evil which will follow every Lecture; when I realize that by assuming the position of a teacher, whatever of error may still attach to my Theory and Practice will be multiplied by the number of my pupils, that by misunderstanding or misapplying the facts taught by philosophy and by experience, I may mislead you, and send you forth among my fellow-men, under the guidance of false doc- trine, and armed with the means of death to curse my fellow-men by magnifying their sufferings, and shortening their days, I cer- tainly tremble under the weight of my moral responsibility. But when, on the other hand, I recur to the Past, and recall the tedious months and years through which, as an individual, I strug- gled on under doubts and perplexities; when I remember cases in which it is highly probable life was lost through my early errors, derived though they were from the highest professional authority; when I call to mind the satisfactory results which have attended my professional labors, since the adoption of my present views in regard both to theoretical and practical medicine, I cannot, as I do not desire to repress a feeling of confidence that my labors in this chair will not be in vain, if they enable you to commence your medical career free from many of the errors which embar- rassed my early practice; and while they will save you the per- plexity and mortification, with much of the labor, which truths gained by experience so often cost, they will shield your patrons from the dangers to which they would have been exposed had you been left to discover, as my colleagues and myself have done, the fatal errors which, under the semblance of science, and associated with truth, are inculcated by medical authorities. I would not be understood as claiming for the system of medi- cine which will be set forth in these Lectures, that it embraces INTRODUCTORY. 3 all that can or should be known in Pathology and Therapeutics. I do not even claim that the doctrines taught will be entirely free from error; but I do honestly believe that the experience of my fellow- laborers and myself in the department of Medical Reform, for the last thirty years, has resulted in the discovery and addition to the common stock of scientific truth, of a large amount of facts and improvements, and in detecting and exposing a great number of errors in Theory, and abuses in Practice, which, associated as they were with, and disguised under the semblance of truth and science, had escaped detection by our predecessors. I may, with safety, add, also, that while the improvements thus made in scientific medicine are radical and obvious to the unprejudiced observer, they are of a character which would have been forever overlooked by self-inflated professional pride, and could never have been developed by the modes and means of research which the spirit and authority of assuming and illiberal conservatism would have been competent or willing to suggest. But though our modes of research have been, by self-constituted censors, declared to be erratic and "irregular," and though the field of nature, by us explored, had been almost forsaken by them and their followers, and its resources treated with contempt, yet the revolution which is now in irresistible progress throughout the profession, is so unequivocally distinguished by the improvements introduced, and the spirit of independence and liberality propagated by the reform- atory rebels against the conservative hierarchy, that very soon we may expect to see a republic in medicine, established upon the broad basis of experimental science, laid by liberal minded and earnest philanthropists, and appreciated and admired by an intel- ligent and enlightened community. Would we run over the pages of medical history, we should find that nearly all we know of any practical utility in the treat- ment of disease has been developed by experiment, and introduced in opposition to prevailing prejudices. We should be impressed, also, with the tardy progress which this department of human knowledge has exhibited, especially in modern times, as compared with that of almost every other. I speak now of the special department of practical medicine. This branch of medical science probably preceded every other 4 INTRODUCTORY. in point of time; that is, before any researches had been made in Anatomy, Physiology, Chemistry, or the like, man had been led by observation and experience to adopt certain measures to relieve pain and obviate disease; so that without doubt, practi- cal medicine had its origin in experiments, prompted by necessity, and grew into the character of a science under the culture of ob- servation and experience. Although on this subject we have no resource but rational conjecture; yet from the manifest circumstan- ces of the case, there can be little doubt that such were the begin- nings and early characteristics of the healing art. The first annotations of our science found on the page of history are very obscure, but enough can be made out to denote that the practice of medicine was at a very early period in the hands of the priests, who were also the chief repositories of every other depart- ment of learning. The Egyptian priests associated the healing art with the mysteries of mythological religion, and while they probably employed very simple medicinal agents, their use was accompanied by various magical incantations, by which the imagin- ations of their patients were impressed, and to which were attributed, with some measure of truth, the cures which were effected. The same appears to be true of the early history of medicine in Assyria. This monopoly of learning by a particular class, and that class receiving their office by inheritance, was not favorable to the rapid development of truth, and of course the progress of medical science under such circumstances was extremely slow. According to Grecian history, iEsculapius appears to have been the first to devote himself to the pursuit of medical science as a profession, but so closely were the ideas of medicine and religion associated in the minds of his countrymen, that the record of his life and discoveries is almost inseparably interwoven with the mythological fables of early Grecian story. He was deified after his death, and temples erected to his service. The priests of these temples succeeded to the titular honors of the profession, and perpetuated the prejudices which connected the treatment of disease with religious rites and ceremonies, and thereby retained the influence which mystery and superstition places in the hands of those who happen to be regarded as superiors. But these temples of ^sculapius became the means of promoting the pro- INTRODUCTORY. 5 gress of medicine by affording their priests ample opportunity to observe and make experiments on disease in its various forms, as presented by the vast numbers which their reputation attracted to their altars ; and when subsequently the records of these temples became accessible to the votaries of science, they proved a source of much valuable information. After the lapse of ages, in which the healing art was thus ap- propriated by an idolatrous priesthood, to increase their influence and sustain their authority over the minds and bodies of mankind, a new order of things began to be introduced. Reforms began to make their impression on the various departments of human affairs, as a spirit of general inquiry seemed to gain influence among mankind. The dawning of that comparatively bright period, in which the republic of Greece flourished, was also a new era in the history of medicine. Individuals of energy, industry and learning, began to devote themselves exclusively to researches into the laws of health and of disease, and to the discovery of remedial agents. Hippocrates was so truly the first medical reformer, and the revolution he wrought in isolating the practice of medicine, and transmitting it to his successors in the form of a distinct science, was so great, that he has been universally awarded the appellation of Father of Medicine. He was a descendant of iEsculapius, but had imbibed the sentiments of Pythagoras, and especially of the sect of Heraclite, and thus combined the advantage of a practical medical education in an ./Esculapian temple, with the indepen- dent, free and vigorous character of a liberal minded philosopher. And, although we find his theories partake of the errors and cru- dities of that early day, it is remarkable that he had always the sagacity to perceive where clinical observations contradicted his philosophy, and to follow experiment rather than hypothesis. Hence, he was a true Eclectic, a rational Empiric, if you please, and the head of the long list of public benefactors who have suc- cessfully labored to wrest practical medicine from the hands of mystical usurpers, and, pruning it from error and false theory, place its study upon the only correct basis, that of patient experi- mental research, and clinical observation. He was a careful observer of all the circumstances connected with human diseases. 6 INTRODUCTORY. The influences of atmospheric changes, of season, and of climate, in the production and modification of disease, attracted his atten- tion, and his observations thereon have come down to our day. His general descriptions of diseases are still recognized in many instances as remarkably correct; and his views have always been treated with respect, and some of them are regarded as true expo- sitions of medical philosophy at the present day. It would be interesting and instructive to follow down the histo- ry of medicine, and observe the changes which were wrought in its doctrines and practice by the numerous individuals who have been prominent in the profession, and by the various sects or schools into which that profession has been successively divided. But the points to be presented in this Lecture, according to the plan I had marked out for myself, will not allow time for even an enumeration of the names of persons and of parties which illus- trate the historic pages of medical science. I have merely adverted to the subject for the purpose of showing that medicine, as a science, had its birth in a revolution against exclusivism, assumption and blind superstition. And should you hereafter, as I strongly hope you will, make yourselves familiar with medical history, you will discover that during every period of the world, from the days of Hippocrates to the present time, and in every country where science has been at all cultivated, the medical pro- fession has been continually agitated by discussions, not only as to philosophical doctrines and practical measures, but also as to the claims of certain sects to the exclusive honors of the profes- sion, which claims you will generally find to have been based upon their adherence to the teachings of Hippocrates, or of some other celebrated reformer, whose particular star happened at the time to be in the ascendant. In prosecuting your historical researches, you will find, for instance, that through a lapse of centuries the profession was divided about equally among the Dogmatists, who made Theory the only basis of legitimate Practice; and the Empirics, who pro- fessed to discard Theory, and be governed by experience alone. And you will observe, also, that both these sects claimed, and that with truth, to have derived their doctrines from Hippocrates him- self. The Father of Medicine did reduce medicine, in some degree INTRODUCTORY. 7 to the character of a theoretical system, but his Theory was based upon observation, and he spent his life in correcting it by expe- rience, so that while these two sects were about equally descended from the great founder, neither one nor the other was entitled to set up the claim of exclusive legitimacy. And as they, in the heat of controversy, drove each other to opposite extremes, and were both entrenched midway between error and truth, you will observe that the middle ground of Theory and Experiment com- bined, remained unclaimed by either, although in practice occu- pied by both. And you will find that as science and the arts were cultivated, and the human mind expanded, this great dis- crepancy, in the doctrines of the contending parties, became so manifest as to invite a third party into the field. This was the party of the Methodics, who, by selecting in a truly Eclectic spirit, the truth from both extremes, and leaving them to cherish and sus- tain their errors, became really the representatives of Hippocrates, or, in other words, of reformatory and rational medical science. When, in your review of medical history, you shall have passed the dark ages, you will find medicine, with other departments of human knowledge, presenting a scholastic aspect, and mere theo- rists assuming the titles, the dignities, and the honors of the medical profession, in contradistinction to all who ventured to cleave to nature and be governed by personal observation and practical experience. And here you will discover a reproduction of the old parties—the Dogmatists and the Empirics—in spirit and in fact, though not in name ; and here again you will observe the necessity of an Eclectic reform to concentrate the truth and separate it from error. As is always the case the vacuum was at once filled. Boerhaave, with his sound judgment, his cultivated intellect and weight of moral character was the man for the occa- sion ; and he in the spirit of a true Eclectic attempted to bring order out of chaos, and give the world a system of rational and practical medicine. He was not, however, sufficiently divested of reverence for antique theories; he took more upon credit or the endorsement of authority than he should have done. Hence, you will not fail to observe, that although he exerted a controlling and highly beneficent influence over the profession, which is felt even in our own times, yet he failed to settle certain important 8 INTRODUCTORY. points of controversy which, with others that have incidentally risen, have kept the ranks of medicine in a state of constant agitation. The controversies of different authors and of rival medical institutions, form indeed a large portion of medical history since the revival of letters ; and while, in the true spirit of European aristocracy and pedantry, the highest claims to the homage of mankind have been set up by those who assumed the title of professors, as if their theories were all oracular, and never to be called in question; the grossest contradictions and the most hu- miliating inconsistencies have been published as incontrovertible truth, and defended respectively by their friends, all equally claiming exclusive legitimacy, with a zeal and rancor only equaled by the malignity with which they have resisted the claims of the laity to examine these questions for themselves. The temples of JEsculapius have in fact been rebuilt in these latter days of reform, and their priests, assuming to possess and retain all medical knowledge, which they offer to reveal to novitiates, upon consid- eration of exorbitant fees, have, nevertheless, lacked the uniting spirit of the God of Physic: and while each temple has been occupied, as a kind of Babel, to exclude the rising tide of en- lightened and reformatory public sentiment, they have all been used, at the same time, as forts and batteries for the prosecution and maintenance of hostilities between the authors or adherents of different medical tenets. How much respect is due to a claim of exclusive professional legitimacy, when the claimants can at no time agree among themselves ? And who can feel safe in acknowledging allegiance to an assuming hierarchy, or rely with unquestioning trust on its doctrines, when those doctrines have no more stability than the sand on the ocean beach ? To show that this is not an unfounded insinuation, I read an extract from unquestioned history (BostocTc): "At the termination of the last century, while the doctrine of Cullen was generally embraced, typhus fever was called a disease of debility, and was of course to be cured by tonics and stimulants. No sooner was it ascertained to exist, than bark and wine were administered in as large doses as the patient could be induced, or was found able to take. No doubt was entertained of their power INTRODUCTORY. 9 over the disease; the only question that caused any doubt in the mind of the practitioner was, whether the patient could bear the quantity that would be necessary for the cure. " To this treatment succeeded that of cold affusion. The high character and literary reputation of the individual who proposed this remedy, its simplicity and easy application, the candid spirit which was manifested, and the strong testimonials which were adduced by his contemporaries, bore down all opposition, and we flattered ourselves that we had at length subdued the formidable monster. But we were doomed to experience the ordinary process of disappointment; the practice, as usual, was found inefficient or injurious, and it was, after a short time, supplanted by the use of the lancet. But this practice was even more short-lived than either of its predecessors; and thus, in a space of less than .forty years, we have gone through three revolutions of opinion with respect to our treatment of a disease of very frequent occurrence, and of the most decisive and urgent symptoms." But while thus mutation and revolution stand forth so con- spicuous in the history of the science, we have the most clear and conclusive evidence of the empirical and routine practice, con- nected with the reign of each, that can possibly be desired; thus showing the more than autocratic influence the leaders have upon the throng. In what system of medical practice, or in what newspaper puff or empirical advertisement, can we find greater uniformity of remedy or sameness of practice, as far as what is considered the essential remedy is concerned in the treatment of disease, than is to be found in the leading and standard works of the now waning system of practical medicine—a system which, though it be recited in classic style, mixed up with the varied learning of its authors, and beclouded with all the qualifications of supposed conditions and attendant symptoms, yet, when stripped of its gaudy plumage, and shown in its nakedness and truth, will exhibit a more universal application of a single remedy for all the " ills that flesh is heir to," than can be found in any system considered of an irregular character. Look through the long catalogue of diseases, and you will find one remedy prescribed for nearly all of them, especially for diseases of children. If it is the jaundice, as a matter of course, a small portion of calomel must be taken ; 10 INTRODUCTORY. if your child has irritation of the bowels, from teething, no remedy can as speedily divert it, by setting up a similar action in the liver, as calomel; if costiveness is found to exist, it is dependent on biliary derangement, and no other remedy will reach that organ but calomel. In remittent fever, the universal teaching is, that the patient is bilious and mercury is the specific. If congestive fever, nothing will unlock the portal circulation equal to calomel, and your case is fatal without it. If it be catarrhal fever, a more searching remedy for diseases of mucous membranes cannot be found, and calomel must be given. In nearly the entire range of eruptive fevers, without any attempt at explanation, we are advised to administer calomel. In typhoid fever, its substituting influence must be brought to bear on the case, by way of slight salivation, or the patient is in danger. Whooping cough can be greatly modified by repeated small doses of calomel. In short, if it is not recommended, it is the exception to the rule ; while the principle that runs through the whole is to admin- ister calomel. Where, I ask, can be found a more systematic routine, or in what a more empirical practice ? Fidelity to a single empirical remedy is the unbending rule, while the purity of faith is belief in its use. It has, in short, become the only test of respectability and standing, that you are constantly in the habit of administering calomel. By it, you are adjudged worthy or otherwise of pro- fessional courtesy, and by it, alone, will you be admitted or re- jected from social communion with the members of the profession. Professional or scientific attainments are not made the subject of inquiry, nor the moral character of the individual taken into the account, in the consideration of credentials for membership in the medical conventions ; while the profoundly ignorant of real science, the clod-hopper of yesterday, and the dregs of immorality and crime, are admitted to full communion, if they but acknow- ledge their fidelity to the one empirical remedy. It matters not that they have never seen the inside of an insti- tution of learning, or have never witnessed an anatomical demon- INTRODUCTORY. 11 stration, or heard from the lips of their high priests a single lecture; if they are not suspected of infidelity on the subject of calomel, they are offered, at once, the right hand of fellowship. While on the contrary, though a man's acquirements are of the first order, literary and medical; bearing his credentials from the best institutions of our country of their own faith even, and possessed of all the moral qualities of a gentleman and a Christian; if he is not true to the faith, he can have no admittance. He is branded with " quack" by the fraternity, and thrust from among them. Are these things right ? Are they befitting a liberal and hon- orable profession ? The good sense of every intelligent mind will answer in the negative. The progress of medical science is retarded and the lives of community are sacrificed on the altar of professional ethics, enacted for personal considerations and pecun- iary interests. "All men are created free and equal" is a declaration worthy of universal remembrance, and shall we be told that this physician or that one shall dictate whom we shall employ when sick ? Or that if we see fit to send for another, without his approbation, he will withdraw from the case and refuse to have anything to do with it—and forever thereafter exhibit the scorn and neglect of one whom otherwise we might have regarded as a friend and companion ? Such being the high claims of *' regular " medicine, and such the unstable character of its most prominent doctrines and measures, is it at all surprising that suspicions, and distrust, and a desire to investigate these claims, should be manifested in an enlightened community ? It could not be otherwise ; more espe- cially when the spirit of European professional arrogance and assumption was imported to this country, with all its selfish rancor and venom, as the iEsculapian deity was carried from Greece to Rome in the form of a viper. And when it was attempted to erect the temples of medical idolatry and set up the doctrine of the divine right to legitimacy, on this soil consecrated to freedom and equality, it could not be otherwise than that an American people should not only resist the assumptions, but pry into and expose the fallacies and inconsistencies of the despotic system of 12 INTRODUCTORY. medicine. And it was a necessary consequence that the attempt to exact homage for theories wearing the guise of learning, and to enforce obedience to formula? dressed in the costume of antiquity, should have produced a reaction which tended to inspire contempt for scholastic science, and to the rejection of the entire system of " old physic." All who have been observers of the position of medical parties in this country during the last forty years, must be struck with the fact that the results just now hastily sketched have actually occurred. Never in the history of medicine have contending parties occupied such extremes, as have the adherents of "regular" medicine and the ultra reformers, the " Botanies," during the half century just closed. On the one side it was claimed, not only that learning is requisite to the medical practitioner, but that this learning must be gained in a particular way, and under the auspi- ces of certain legitimate institutions. On the other, all scientific education was discarded as unnecessary, and the right of every individual to practice medicine was claimed to be as unrestricted as his privilege to cultivate the soil. One party made certain irritating and poisonous minerals the leading articles of the materia medica, almost to the practical exclusion of vegetable agents, and contended for the lancet with a zeal which nearly cut off ordinary hygienic measures; the other rejected all minerals, insisted that the vegetable kingdom supplied us with all needed medicines, and that with these, the bath tub, and steaming appa- ratus, any intelligent and energetic person might assume to grapple with disease in all its forms; deprecating and discarding the extraction of blood either generally or topically. Here again is presented the middle ground of truth between the two extremes, and here, once more, has the spirit of Eclecti- cism, of rational reform, summoned her votaries and displayed her ensign. And, as Hippocrates opened out the records of the yEscu- lapian temple to the inspection of the world; as the Methodics in their day, and Boerhaave in his, culled truth from both extremes ; so now does the Eclectic branch of the medical profession seek to gather truth from every source, from the aristocratic and the peasant practitioner, from their predecessors and contemporaries • and to enrich their store of remedies with valuable agents from INTRODUCTORY. 13 every kingdom of nature; rejecting only such agents and condemn- ing only such measures as sound philosophy and practical experi- ence have demonstrated to be both hazardous and unnecessary. We claim the confidence of community for an enlightened selec- tion from all available sources, of every measure, which observa- tion and experience shall prove safe and efficient in the cure of disease. This we profess to do without prejudice, and without fear or favor, with an open and frank avowal that we spare no pains or expense within our reach to secure the object sought. Whatever humiliating associations may be connected with the achievement of the measure to be accomplished, or whatever of contumely may be cast upon us by " Old Physic " or its support- ers, we have steadily persevered in this course, and the result is known to those who have sought to be informed. We claim safer and more efficient substitutes for that " Samp- son of the materia medica," that panacea of human maladies— Mercury, in its different preparations. We claim, also, to have made large contributions to the materia medica, of new and impor- tant agents not before known, and to have essentially modified the application of many old ones to subserve more valuable and im- portant purposes in the treatment of disease. We claim to demonstrate, beyond a chance for cavil, a more successful result in those inflammatory diseases for which the lan- cet is unsheathed, and the loss of the vital fluid is considered the sine qua non. "We affirm that bleeding is a barbarous and unscientific remedy, and deny that it is ever necessary. In this matter we take our stand upon the facts recognized by the highest authori- ties in medical literature. We refer to the most recent and accurate researches in Chemistry and Pathology—to the experi- mental investigations of Andral, Magendie, Louis, Simon and many others, which have settled, beyond all doubt, and placed among the permanent facts of medical science, to be received by all medi- cal schools of whatever Therapeutic faith, the phenomena of the blood, when its composition has been affected by hemorrhage, by bleeding and by various other agencies. " It is indisputably established that bleeding produces a special 14 INTRODUCTORY. change in the composition of the blood. The change which it produces is not a removal of any effete or morbid material—not a removal of any element which tends to create or aggravate dis- ease, but a removal of the most necessary and healthy portion, upon the presence of which we depend for the maintenance of health and vigor. Bleeding inevitably reduces the red or globu- lous portion of the blood, because it removes or destroys a certain amount of the red globules, and the loss which it produces is readi- ly supplied by absorption of water and of comparatively crude materials, while the highly organized globules are regenerated with great slowness and difficulty. " It is a well established fact that the red globules of the blood are essential to life, and that their abundance or scarcity is a cri- terion of the vital force and activity of the constitution. As the proportion of the red globules increases, the general vital power rises, and the activity or energy of all the organs increases; while a diminution of their ratio enfeebles or disorders the various organs, and predisposes to nervous and tuberculous disorders, and to the whole range of adynamic and cachectic diseases. If the ratio is diminished as much as one-seventh, general debility is the conse- quence, predisposing to disease, and diminishing the power of recovery; if as much as one-fourth or more, this reduction of vital power is incompatible with health, and inevitably results in some form of disorder. " Is it not, then, exquisitely absurd to adopt, as a remedy in disease, a measure which, even in the most vigorous health tends directly, with rigorous precision, to destroy the vital powers, and bring on disease ? Yet this measure has been, and still is sus- tained by many medical men, although clinical experience, as well as chemical science, has shown its injurious effects, and thousands in America and Europe have been, and are now demonstrating, that all forms of disease may be better treated without blood- letting than with it."* We claim to have discovered important truths in the treatment of many diseases not taught in the books, nor disseminated from the college halls. We claim to have made distinctions in the character of a num- * Buchanan's Introductory Lecture. INTRODUCTORY. 15 ber of diseases of the most vital importance, and adapted remedies to meet the character of each. We claim also to have made important discoveries in surgical practice, by which many diseases heretofore considered incurable without a formidable operation, and oftentimes incurable with it, are readily cured ; thus saving to the patient great sufferino1 and distress, at the same time perhaps an important member. And we claim the confidence of community for as thorough and scientific acquirements in our graduates as in those of any other college in the country. In short, we claim as high respectability of character, and as thorough scientific acquirements in our profession; far safer remedial appliances, and many new agencies in disease; a more successful result in practice; new views of Therapeutic medicine and important improvements connected therewith, to so great an extent, that if the old and new system of medical practice were placed in juxtaposition, a striking contrast would be observed in all their leading features. Such, gentlemen, is the position of parties in the medical world at the present time, and it is doubtless because you have surveyed the ground and appreciated the advantages presented by the position and resources, and approved the doctrines and liberal spirit of the American Eclectic branch of practical medicine, that you have entered the halls of an institution which proposes to teach those doctrines and inculcate that spirit. You come, I trust, impelled by an ardent desire for truth, and imbued at the same time with the indomitable spirit of American freemen, ready to hear and examine for yourselves, and having found the truth, to appropriate and disseminate it, fearless alike of the scorn or wrath of arrogant pedantry or self-conceited and assuming igno- rance. You will commence your medical career early in the progress of American Eclecticism, and when, like the lamented Morrow,—whose decease has created the vacancy which I, his former partner and colaborer, have been called to fill,—the pioneers of this revolution shall all have passed to that -----"country from whose bourne No traveler returns," it will devolve upon you to occupy their places, to sustain the cause 16 INTRODUCTORY. of liberal, scientific and rational medicine, and to illustrate, by your learning, your wisdom and your virtues, that freedom of thought and liberality of spirit are perfectly consonant with the utmost scientific, intellectual and moral development. In attempting to shadow forth an outline of the course of lectures I propose to deliver, I must of necessity be very brief. To narrow down the scope of a course of lectures on the Theory and Practice of Medicine to the strict limits of these subjects, is perhaps impracticable. So essential is an acquaintance with Anatomy and Physiology, to an understanding of the nature and indications of disease, that constant reference to the subjects embraced by those departments is unavoidable. I would therefore urge it upon you to devote especial attention to those two branches. Therapeutics and the Materia Medica are also intimately connec- ted with the subject of this, and even a knowledge of Chemistry is indispensable to him who desires to master the subject of prac- tical medicine. Surgery and Physic have long been separated in the old world, and the distinction is in some measure obtaining in the new. This, however, ought not to be, for the surgeon should unquestionably possess a general familiarity with every form of disease, and with all the resources requisite to their treatment, while the treatment of surgical diseases, beyond the mechanical manipulations of surgery proper, falls within the purview of the general principles, without a knowledge of which no man can safely undertake the treatment of disease. In this country, both branches are generally united in practice, although the subjects are consigned to different chairs in the course of collegiate instruc- tion. To my colleagues I must therefore refer you for information in all these departments of our profession, and shall, as far as possible in referring to them, avoid stopping to explain the facts involved, taking it for granted that you have been or will be thoroughly instructed therein. With a view to facilitate the acquisition of any branch of knowledge it is important that a judicious classification of the subjects embraced should be made. Hence, writers on the various sciences and departments of human knowledge have devoted much attention to the systematic arrangement of the topics upon which they have been employed. Efforts of this kind have not INTRODUCTORY. 17 been wanting in medicine. Cullen made the first attempt at the classification of diseases, and his Nosology, like the other produc- tions of that practical man, did much to simplify the subject of medicine. Good's Nosology followed that of Cullen. He arranged diseases into 6 classes, 22 orders, 121 genera, and 464 species. His classification is too ideal, and impracticable, requiring months of study to enable the student to remember it, and a much longer time to comprehend the fancied similarities upon which the grouping of diseases is made to depend. The only object of classification is the more easy elucidation of diseases and to aid the memory by association, but that of Good really obscures the subject and unnecessarily burdens the memory. Dr. Chapman's classification has reference to the different systems of the body, and he treats of disease under the heads of Diseases of the Circulatory System, Alimentary System, &c. This is a great improvement on the former system, yet it does not appear to me adapted to the elucidation of the subject in the form of oral lectures. I shall not attempt a systematic classification of diseases, but leave myself at liberty to vary my course as circumstances may seem to suggest; in which way I shall be able to give my lectures, in some measure, the character of a clinical course. I shall however observe a general arrangement, as far as convenient, in view of the above suggestion, by which diseases will in the first place be grouped together in obedience to certain general and manifest outlines, as Idiopathic Fevers, Inflammation and Inflam- matory diseases, Exanthematous diseases, &c. In treating of diseases, a general distinction will be made be- tween their acute and chronic form; and in discussing diseases of a local character they will be taken in the order indicated by proximity or relation of the parts involved. Thus: in treating of local inflammation, that of the head will be first discussed, then that of the ear, mouth, tongue, throat, oesophagus, stomach, &c. In the consideration of each group of diseases I shall endeavor to present and elucidate such general principles as are dependent upon the course of symptoms which characterizes it, and the principal indications to be fulfilled, together with the complications and anomalous phenomena which have been occasionally encoun- o 18 INTRODUCTORY. tered; and in considering individual diseases those' general prin- ciples will be reduced to practical application; the most approved remedies for each indication will be given, and such recipes and formulae announced as have been found by experience of benefit under the circumstances. I shall close the present lecture with some brief suggestions in regard to some of the circumstances which it is necessary to con- sider in the investigation of disease generally. The first thing in point of importance for a physician to ascer- tain, when called upon to prescribe, is the nature of the difficulty; in other words, what disease he has to treat. The old adage will apply here: " Find before bind." By this I do not mean that he must of necessity be able to give a specific name to the affection, but that the true nature of the morbid condition should be com- prehended. The second important consideration is in regard to the origin or producing cause of the disease. As tending to cast light upon the subject of disease, its cause and appropriate management, it is important also to inquire into the history of the case, how long since he was attacked; the character of the early symptoms; what were his previous habits, &c. The age of the patient is often an important point to be consid- ered in the investigation. Some diseases are almost peculiar to certain ages. Hence, where you find the symptoms of a disease not generally occurring in persons of the age of your patient, the opinion, which would otherwise have been formed from the symptoms, will be at least weakened, if not precluded. You would at least be led to look farther and ascertain whether the symptoms observed may not belong also to some other disease. The sex of your patient will very frequently modify your opin- ions and your treatment. Any hereditary tendency, which may be derived from the family history, in connection with present developments, such as enlarged or indurated glands, &c, and any acquired predisposition of the individual, as indicated by his habits of life, place of residence, former diseases, &c, are subjects of very great interest to the practical and scrutinizing physician, and will by such never be overlooked. Temperament, also, will aid in forming correct opinions in regard to disease and its INTRODUCTORY. 19 symptoms. Cheerfulness, for instance, is generally a favorable symptom, but the sudden exhibition of vivacity, by a person of habitual melancholy, might, under certain circumstances, be a very unfavorable omen. Idiosyncrasy, and other peculiarities of constitution, should be known to the physician, where the patient has any, as a knowledge of such characteristics will not only affect his diagnosis, but very often materially vary his treatment. A red or a furred tongue may be habitual with an individual in health; hence you would not, if aware of this fact, decide that he had irritation of the stomach when his tongue was red, nor that his stomach was deranged by accumulation, when his tongue was furred; these symptoms, generally reliable, would need confirma- tion by other phenomena, in such a case. Some individuals cannot safely take an emetic; others will not bear opium in any form, and so on, and the physician who prescribes without learning whether such peculiarities have been observed in his patient, runs the risk of being disappointed in the operations of his medicine, at least, and serious consequences might be the result. Where doubt exists in the mind of the physician in regard to the nature or extent of morbid conditions, he should resort to the various methods of investigation which will hereafter be explained, and examine separately every organ in the body: as, the stomach, and the tongue as an index to the stomach; the liver, by means of the evacuations, the skin, the eyes, and by pressure upon it; the bowels, by pressure upon them, and by the discharges from them; the lungs, by percussion and auscultation; the heart, by listening to its sounds, and observing the pulse, whether regular or irregular, full or small, frequent or slow, &c. As my hour is almost expired, I shall not attempt to proceed further in these general remarks. What I have said, and what I should further say in this relation, will be clearly stated, and perhaps frequently repeated, in the progress of our course, and it is not deemed necessary to detain you with lengthy preliminary remarks, nor with an abstract discussion of general principles. Not that the general principles of medicine are undervalued, or are by any means to be lost sight of in these lectures, but it is believed they can be more clearly elucidated, and more forcibly presented, as they shall be found involved in the consideration of 20 INTRODUCTORY. the various forms of disease. The short time necessarily allotted me for the presentation of the subject in hand, in its various aspects, requires that our time should be husbanded with economy, and that such subjects only as are indispensable to our final object, should be introduced, or at least discussed at any length. The object at which I shall aim, during my occupancy of this chair, will be to present to the class all the important and indis- pensable information in my possession, in relation to the true nature and proper treatment of disease, and especially such facts as have come under my personal observation, and such principles as have been developed or confirmed by my own experience. I say that it will be my object to be full and explicit on these most important subjects, many of which you can learn from the living teacher only; but I shall crowd into the course also as much general information, and as many minor topics, as can be done consistently with my leading object. I shall, in the main, speak from experience, and when I derive my information entirely from others, in speaking of subjects in which I have had no experience, I shall give them due credit for, while I pass over to them the responsibility of, the instructions thus given. LECTURE II. FEVER. Importance—Definition—General Descriptive Remarks—Stages: 1st, Forming; 2d, Cold; 3d, Hot; 4th, Sweating. As Fever is admitted to hold the first rank in point of impor- tance in the history of medical science, as well as in a practical point of view, it is of right the first topic in a course of lectures on the Theory and Practice of Medicine. Before considering the particular forms of Fever, our attention should be directed to the subject as a whole. With this, there- fore, we shall be occupied this morning, reserving the details for subsequent lectures. According to the most modern and popular authorities, Fever is a disease in which all the'functions of the system are more or less deranged, and of which the most striking phenomenon is a palpa- ble disturbance in the sensorial functions. Along with the irreg- ularity of these functions we usually find increased heat, frequent pulse, disinclination for food, and a general dullness of the patient. It will be observed that these symptoms imply, in essence, a uni- versal derangement of the organism. All the organs of the body are out of tune, and cease to perform their functions with the regularity and system essential to health, and the proper distri- bution of the vital energy. And these evidences of universal derangement, it will be also observed, do not imply particular local determination. We start, then, with the proposition, that increased heat, fre- quent pulse, and disinclination for food, are the leading symptoms characteristic of the great class of febrile diseases. It should be 22 FEVER. remembered, however, that these symptoms, although generally present, are not universally so. Excited pulse and hot skin are the most invariable symptoms in febrile cases; nevertheless, we have seen cases where both these symptoms were absent. Hence, we see the fallacy of relying solely on any special phenomena, as invariable and certain diagnostic symptoms. Many excep- tional cases occur under circumstances which will be noticed in the discussion of particular forms of disease. Even in the cold stage of Fever, these two symptoms are often absent; and perhaps in a majority of instances they would not be recognized in the forming stage. As a general thing, however, on a careful examina- tion, the skin on the body is found to be pungent and hot in the cold stage; while on the extremities it is sensibly below the healthy temperature. I shall now, with a view to more particular illustration, resort, as far as practicable, to a general classification. The object of such classification and division of diseases is to make a more dis- tinct impression upon the mind of the learner, and by the frequent repetition of the important principles connected therewith, more indelibly to engrave them there. Four stages may be enumerated as comprehended by the general outlines of Fever: 1st, the forming stage; 2d, the cold stage ; 3d, the hot stage ; and 4th, the sweating or declining stage. By separately considering these several stages, you will the better retain all the phenomena of this group of diseases, and also per- ceive the great importance of the division. For were I to enume- rate all the general symptoms of Fever, without regard to the difference of stages, I could not, without confusion, say where the characteristic symptoms may be considered diagnostic, and where they may be overlooked. But by making this division, we can clearly ascertain the particular symptoms, peculiar to each stage, separately; and these, taken together, will give you all the characteristics and phenomena of what is understood to be Fever. 1. Forming Stage. This stage rarely commences suddenly. It creeps slowly, insidiously, and almost imperceptibly upon its victim, while he is almost unconscious of being indisposed. Per- sons under the influence of the forming stage feel a languor and FEVER. 23 listlessness, and an indisposition to make any mental or bodily effort. This gradually increases, until they are finally admonished that they are " not very well." This stage continues for a longer or shorter period, depending on the natural resisting force of the system, and the concentrated influence of the cause that produced the attack. On the duration of this preliminary stage will greatly depend the intensity and obstinacy of the disease after it is formed; for when it has been thus insidious in its approach, making grad- ual inroads upon the functions of the economy, and gradually incorporating its causes with the elements of the system, its removal will, of course, be proportionately slow and tedious. But if the system yield readily to the influence, and the disease be developed at once, unless it entirely overpower and soon forcibly destroy the animal functions, you will find but little difficulty in throwing it off. This is a matter of observation and experience at the bed- side of the patient, which is probably not altogether compatible with the theory of the times. The foregoing are not the only symptoms accompanying this stage of Fever. A general soreness and lameness over the whole system, an " aching of the bones " throughout the body, as the patient will express it, is strikingly characteristic. Especially is this the case in our malarial fevers. At length a slight pain is experienced in the back, which, in some instances, extends through the whole vertebral column. Finally, an occasional chilly sensation, and an inclination to draw up more closely to the fire will be manifested, in addition to the other symp- toms, even before the patient is fully conscious of being sick. When this symptom begins to develop itself, and the individual does get close to the fire, there is almost always a palpable increase of the same phenomena, and shortly the character of the disease is fully developed. In some instances, but not invariably, head- ache accompanies the preliminary symptoms. As I have already remarked, many of these symptoms may be entirely absent; never- theless, I am giving you, gentlemen, the symptoms that, accord- ing to my observation, are very characteristic of the general group of diseases called Fevers. Accompanying this stage, there is usually considerable restlessness at night; the sleep is unsound, and the patient is disturbed more or less by disagreeable dreams; producing debility on rising in the morning. Lowness of spirits 24 FEVER. is a very common symptom. Persons who, in health, scarcely know what it is to be gloomy, find themselves depressed and low spirited, while wholly unable to assign any cause. These symptoms, characterizing the incipient stage of Fever, continue through an indefinite and varying period, usually, however, quite a number of days previous to the second stage, which we shall next consider. 2. Cold Stage. This we understand to be the positive devel- opment of the disease. It is the first decided step which con- vinces the patient that he is positively sick; especially if he has not been much accustomed to disease. He may, during several days, have experienced the symptoms of the incipient stage with- out apprehending danger, and even refusing to regard himself as indisposed; and not till the rigors of the cold stage have com- menced, it may be, will he acknowledge himself to be sick, and employ the means of cure. The symptoms of this stage vary much in different forms of Fever, and in different individuals. In ordinary Chills and Fever, the sensation is that of coldness, accompanied by slight rigors; in Typhus, slight chills, with occasional flashes of heat over the body, characterize this stage; while in Ague, it is distinguished by an uncontrollable shaking, the motion of which is distinctly communicated to the bed. In many cases the chill is but slight and almost imperceptible ; still by close observation it may be recognized. If there be no other manifestation, a careful exami- nation of the fingers, will establish the presence of this stage, by the blueness of the nails and the shriveled appearance of the capil- laries. In other cases it is palpable to the most careless observer. The sunken appearance of the eyes, and blueness of the lips will, unequivocally, tell the real condition of the patient. The slight uneasiness in the back and limbs, which commences in the form- ing stage, is now developed into positive pain and distress, so much so, in many cases, that the suffering in the cold stage is decidedly more severe than in any other. So excessively severe, sometimes, is the pain in the back, that the patient complains of it alone, and applications are necessary to give him relief. The suffering, indeed, is so powerful in some cases, that the patient sinks into collapse, and dies in the first chill. At the South, the FEVER. 25 second or third chill is often fatal; in the North, this is less fre- quently the case, though it has occurred here also. Hence, you see the importance, gentlemen, of understanding these different stages, so as to have a proper appreciation of the disease in all its modifications, and to know what remedies are applicable under the various phases which may be presented. In this stage the pulse is frequent, but small and depressed; in some cases hard, in others weak and compressible under the finger. In very severe chills it is scarcely perceptible. In a majority of cases it is tense, small, and thread-like, and very frequent, more frequent in fact than in the hot stage; for, as will be shown here- after, it then generally becomes more full and bounding, but less frequent. Exceptions to these rules will, however, occasionally be found. The capillary circulation, during the cold stage, is diminished. This is decidedly the case on the extremities, and more or less so on the entire surface, although the skin on the body may present a pungent feeling. The face is pale, and, as I have before remarked, the toe and finger nails are blue. A return of the paroxysm, in some cases, can only be recognized by reference to the fingers and toes. In all cases you will find the respiratory system involved. The respiration is difficult and hurried, and the patient will request the doors and windows to be opened, even when suffering sensa- tions of extreme cold. Nausea and vomiting are, also, very common symptoms of this stage, both in intermittent and remittent bilious fevers. We often find these the only symptoms accom- panying the cold stage, except the appearance of the extremities before described. You will often find this nausea, vomiting, and even purging, very much resembling cholera morbus, attending this stage of intermittent fever. This should admonish you to be on the alert, for these symptoms may tend to mislead you. If you are called to see a patient who thus seems to be suffering with cholera morbus, it is important that you be able to distinguish between this disease and the similar symptoms attending the cold stage of fever. Your reputation rests upon your decision, and this you must arrive at by careful inquiry into the history of the case. Without a correctly detailed statement of the facts and 26 FEVER. symptoms which may have been gradually developed, you will be liable to run into the error of treating it as a case of cholera morbus. But if you learn and carefully consider the history of the case, you will most certainly hit upon distinguishing phenom- ena, which will enable you to recognize the nature of the disease. Otherwise your patient may slip through your hands, and you be left to the unfortunate reflection that you have neglected to apply the means that might have saved the life of a fellow being. If any of you have already assumed the responsibility of practition- ers, you will, I doubt not, recognize a coincidence between the symptoms and circumstances I have given, and those which have occurred under your own observation. Thirst is another striking symptom in the cold stage of fever. You might suppose that the hot stage would be marked by a greater demand for water than the cold, but the opposite is the case. There is, of course, thirst during the hot stage ; but it is not so intense or importunate as during the cold stage. The mouth is not as dry in the cold, as it is in the hot stage, but it is clammy, and the patient experiences a constant desire for cold drinks. There is also a general diminution of vital sensibility in the various organs of the body. The continuance of these symptoms in different individuals is quite variable. In some cases they will continue only a few minutes; in others they will last for hours. In intermittent fevers, the urinary secretion is increased in quantity, and almost destitute of color, in the cold stage, while in the hot stage it is high colored and has a very peculiar odor; the quality and quantity bothbeinc essentially changed in a very short time. Such, in general terms, is the cold stage of fever. One after another, the symptoms gradually pass away, until the patient, as it were unconsciously, throws off the bed clothes, and the hot stage is gradually developed. The recurrence of the chill during the progress of intermittent fever, as a general rule, is as re> * * ****** emissions. " The salubrity promised by the natural topography of Natchez, has been evidently impaired by the means used to improve the site of the town. The earth of which the hills that have been dug down were formed, contains numerous particles of partially de- cayed vegetable and animal substances, which, when exposed to heat, air, and moisture, quickly undergo the putrefactive process. The earth itself being loosened, absorbs large quantities of water, which retained, assists the operations of this laboratory of pesti- lential exhalations. The natural water courses being obstructed, ponds are formed, which soon stagnate—and at every fall of rain receive copious additions of filth. The cellars in many parts of the city, particularly those situated in the loose new-made earth, are liable by every copious rain to become partly filled with water— and frequently containing quantities of putrescent matter, form another very obvious cause of disease. In consequence of the filling up the streets and alleys, the back yards of many houses are lower than the adjacent ground—and having no drain, admit of large accumulations of kitchen offal and other offensive matter. The streets not being paved, are by every considerable rain cov- ered with mud several inches in depth, which, being mixed with the excrements of the herds of horses and cattle with which they are crowded, emit a most offensive effluvium, in warm, moist weather. The privies are also very much neglected, and being frequently so situated as to have their sinks receive water, are abominably foetid. The burying ground is another nuisance of a moist, noxious character. Located almost in the compact part of the city, and the earth being of the lightest texture, very par- tially prevents exhalation from the dead bodies deposited there, many of which were buried during the prevalence of the epidemic, * "A provincial appellation given to gullies or ravines that occasionally carry off water." YELLOW FEVER. 185 in very open or carelessly made coffins, in shallow graves. The effluvia hence arising was exceedingly offensive in the warm, still mornings and evenings of the latter part of 1819." " In addition to all these causes, which wrould make a Montpe- lier sickly, there is a general neglect among the inhabitants in their cellars, yards, outhouses, &c. Can it be doubted that such causes are not amply sufficient to produce malignant fever in a climate where the temperature, for at least five months in the year, is as high as eighty of Fahrenheit—the average temperature of the whole year not below sixty-five—and the quantity of rain as much as fifty-five inches ? " Speaking of the year 1819, Dr. Perlee says: " The winter and succeeding spring were mild, and no partic- ular disease prevailed. The summer set in very warm. The month of June, though warm and rainy, still continued healthy. July was attended with an increase of temperature, and an extra- ordinary quantity of rain,—greater than had fallen in any one month for nine preceding years. During the last four days of the former and first three of the ensuing month, there were tre- mendous torrents, occasioning extensive and destructive inunda- tions of all the low grounds adjacent to the water courses. At the subsidence of this flood, hundreds of acres along St. Catha- rine's creek were covered with sediment, from a few inches to several feet in depth, which, after it had been exposed to the sun, and the surface become dry, cracked open, and emitted most offensive exhalations from the putrefying substances beneath. Great numbers of cattle, sheep and hogs were drowned, and afterwards lay putrefying upon the surface. The sickness and mortality prevailing along the whole course of this creek evidently resulted from this inundation. The streets of Natchez were com- pletely deluged, and became a bed of mortar. All the low places that had their drains obstructed were filled, and also most of the cellars, in a greater or less degree. This rain was followed by extremely hot weather, with a very bright sun. The months of September and October were very warm and dry. " About the middle of July many cases of intermittents were observed, mostly attended with copious excretions of bile. The negroes upon the plantations suffered severely. Not a few who 186 YELLOW FEVER. recovered from the first attack of fever, were carried off by vio- lent diarrhoeas. The type of the fever progressively assumed a more serious character. About the beginning of August, remit- tents or double tertians greatly prevailed, and several persons died. The increased number of cases that occurred in the be- ginning of September, excited considerable alarm, and induced the board of health to request the physicians to report the first cases they might observe indicative of malignity. On the first of the month I was directed to visit four men lying sick at the upper end of Main street, who were said, by the neighbors, to have the yellow fever. After a careful examination of them, I reported their disease to be a severe bilious remittent, unattended with symptoms of malignancy, but that I apprehended, if the severe warm weather continued a few days longer, such symp- toms would probably appear. I suggested that the large pond of stagnant water very near the house was the cause of this sickness, and advised it to be drained, the bottom scraped and covered with lime. This was not done till the sixth day, and then very imper- fectly. On the third day one of these men died, and it was as- serted by the good woman of the house, of the black vomit. The attending physician did not report it as a case of yellow fever, the existence of which in Natchez he obstinately denied. He fell a victim to it himself. On the second day of the month I was called to visit three men in the same neighborhood, who had been employed in a work-shop very near the before mentioned pond. At the same time another man, who belonged and worked in the same shop, was taken sick and removed further down the street, where he died on the fourth, and was formally reported by his physician to have died of yellow fever. On the evening of the third one of my patients was removed to the lower part of town, where I found him next morning with every pathognomonic symp- tom of the epidemic. On the same day a man died at the Natchez Coffee-IIouse, with black vomit, sallow skin, and such other symp- toms as left no doubt on the minds of the medical men who saw him, of his disease being yellow fever. The three cases being reported to the board of health, they immediately published a handbill, announcing the existence of the disease, and advising the inhabitants to remove into the country without delay. These YELLOW FEVER. 187 facts coming under my own observation, I can attest the truth of them, and have no doubt that the fever originated from local causes exclusively." Here, you observe, the rain, the heat, the local circumstances, the vegetable and animal putrefactions, all favor the production of the compound or idio-koino-miasmata, and the gradual progress of the disease from intermittent to remittent, and this increasing in malignancy until yellow fever is finally developed, exhibiting, " in some measure," as the author elsewhere remarks, " the char- acter of typhus gravior," with " a disposition in the intestinal canal to diarrhoea," " eruptions of petechias resembling fleabites," &c, all incontestably sustain the doctrine I have advanced. To show that this is not an isolated case, I produce the state- ments of Dr. Dixon, from his description of the yellow fever of Charleston, S. C, in 1817, before quoted.—" Philadelphia Jour- nal of the Medical and Physical Sciences," Vol. III., page 250. He says: " The spring of this year was distinguished, in our city, by the frequency and violence of the common diseases of children. Great numbers were carried off by cholera and atrophy, and the process of dentition was unusually dangerous. The summer set in with such floods of rain as had seldom or never before happened within the memory of the oldest inhabitants. But these seemed to fail of their usual effect in producing coolness of the earth and air, for the weather was steadily warm, though perhaps not so hot as the average of our summers. The range of the thermometer was generally between 82° and 88° of Fahrenheit. Thunder storms, which in ordinary seasons are of frequent occurrence in our climate, were observed to be extremely rare, as well as slight. " The country fever, a form of bilious remittent which has ob- tained this name among us, as chiefly seizing those who have exposed themselves by sleeping among the marshes of our low country, after the coming on of warm weather, made its appear- ance this year earlier than usual, and attacked many who con- sidered themselves perfectly safe, as having removed to the city at the usual period, about the end of May. Its attacks were also 188 YELLOW FEVER. peculiarly violent and fatal, the number of deaths from it being greater than had ever been known before. " The common bilious fever of our climate was also more than usually severe, and numerous cases of it were recorded in our bills of mortality. This concurrence of circumstances, however, did not seem previously to create any dread, though it is evident from them that our atmosphere was infected with some principle unfriendly to fife and health. " It was not until the 23d of July that the yellow fever ap- peared among us, and, spreading with considerable rapidity, soon excited universal alarm. " The first case which I have been able to ascertain, was that of a Mr. McCoy, who lived in a low and dirty part of the town, on East Bay street, between the Market and Exchange." Here, then, we have a similar state of things preceding and accompanying this disease in a locality where it is endemic, and where, as the same author conclusively shows, it originates in local causes and not by importation. In a subsequent part of the same paper, Dr. Dixon says: " That the yellow fever is an endemic of our climate can scarcely be doubted. The facts which go to prove this point are so numer- ous and clear, that the contrary opinion is not held by any physi- cian of this city with whom I am acquainted. I have been informed by Dr. G. P. Prioleau, whose statement on this, as on all other subjects, is entitled to the highest consideration, that during his long and extensive practice, no single summer has passed, in which he has not met with some case or cases of yellow fever. " It is impossible to account for the appearance of the disease among us every year, on the plan of importation. If such were the fact, it is evident that seafaring men, and that class by busi- ness connected with them, would be the most liable to be attacked. During several seasons, however, not a single case was brought into our marine hospital—so that sailors often escaped entirely while others were seized—notwithstanding the fatigues and expos- ures which, in all southern ports, mark them as peculiarly the victims of fever. " McCoy, the first case in 1817, clearly appeared to have had YELLOW FEVER. 189 no connection with any shipping, and was in no way exposed to contagion or fomites before he was taken ill. Can these facts be made to agree with the supposition that the disease was imported into our city ?" To the historical facts thus adduced others might be added, derived from the visitations of yellow fever at other places, as New York, Philadelphia, &c. But the foregoing is deemed suffi- cient to sustain the doctrine of the compound malarial origin of the disease. I must refer such as desire further historical in- formation on this point, to the various works containing accounts of the prevalence of this disorder in different places. My limits will not admit of further extracts. This subtle compound miasm, then, is necessary to the produc- tion of yellow fever; yet the disease is not always developed even where the miasmatic cause prevails. This cause must exist in a very high degree of intensity, and meet with a constitution predisposed, by habits of life, much exposure, or other depressing influences, to insure the production of disease in its full malig- nancy. Hence, most of the community escape, especially accli- mated persons, even where the disease prevails with the power of an epidemic. Under such circumstances all, perhaps, will be sensible of a depressing influence operating on their constitutions. Some will have a very mild attack, and cases will occur with every grade of character, from a slight indisposition up to the stroke which lays the walker prostrate in the street. So that, having satisfactorily ascertained the specific cause of the malady, all its various phases, phenomena, anomalies, degrees of virulence, and other peculiarities, are to be explained, as in the case of other fevers, on the ground of differences of constitution, combinations of local circumstances, complication with other affections, &c. It will be recollected that these peculiarities were extensively dis- cussed under the head of intermittent fever. It will also be recollected that it was there shown, that the mild intermittent of the North was only a different grade of the same disease which is often so malignant in southern climates. Now, to the malarial influence which produces malignant intermittent or remittent fever, let there be superadded a miasm capable of developing a 190 YELLOW FEVER. low grade of typhoid, and you will, where other circumstances favor it, have genuine yellow fever. Much space is allotted, in the books, to a discussion of the question whether yellow fever is or is not a contagious disease. From what has been said of the' cause, character and history of the disease, it is unnecessary, I apprehend, for me to say that I do not regard it as a contagious malady. As an endemic, origi- nating annually in its accustomed localities, and whether prevail- ing as an endemic or epidemic, confining its ravages to certain circumscribed limits, and disappearing on the occurrence of frost, it certainly exhibits none of the marks of contagion. True, a constitution which has once suffered from the disease, appears to be in a measure protected from a second attack, and this has been thought to bring it within the class of contagious diseases which exhibit that peculiarity. But it is not, as I believe, clearly established, that persons who have had yellow fever are exempt from future attacks. Numerous instances are on record of fatal cases, where the victims of the disease had the second or third attack. Such instances are comparatively frequent among those who do not reside permanently in the regions where the disease is endemic ; and it is very questionable whether one who has had yellow fever, is fortified against it, any further than accli- mation protects him who lives through the epidemic season, with- out taking the disease. Dr. Wood says, " hundreds of instances occur, in extensive epidemics, in which patients originally seized in cities are scat- tered through places in the country ; and yet the instances are exceedingly rare, in which it is even pretended that the disease is thus communicated." Finally, I remark on this point, that fevers resulting from marsh miasmata, such as ague and fever, bilious fever, &c, are not even suspected of being contagious; that typhoid fever, which is produced by animal miasm, is not propagated by contagion, as will be shown hereafter ; and we would scarcely expect to find the contagious character attach to a disorder resulting from a combination of these two non-contagious causes. This considera- tion alone, in the absence of well-attested facts to the contrary, YELLOW FEVER. 191 must lead us to conclude that yellow fever is not communicable by contact or fomites. The diagnosis of this disease in the first stage, is attended with difficulty. It presents the usual symptoms of fevers in their incipient stage, with no symptoms to distinguish the disease, or, if any, they are very obscure. There is sometimes, it is true, an early development of diagnostic symptoms, upon which an opinion may be based with some degree of certainty. These are those severe pains in the back and loins which have heretofore been mentioned, the injected conjunctiva, and the flush of red on the forehead and face. Where these occur under extraneous circum- stances, calculated to suggest the probability of an attack of yellow fever, little doubt would remain. But suppose the disease had not prevailed in the community, and was not anticipated, what peculiarities would mark the first case in the first stage, so as to enable even an experienced practitioner to decide that the case is an invasion of yellow fever ? My answer is, I know of none. I well recollect a case illustrative of the liability of physicians to fall into error in forming a diagnosis in the early stage of aggra- vated forms of bilious fever. A gentleman visited Boston with a view of purchasing a stock of hides. He suffered considerably, during his absence from home, from fatigue and mental anxiety. On his return he at once exposed himself, for some time, to a cold, damp atmosphere, in repairing a water wheel in a mill race. The result was, an arrest of all cutaneous secretions and exhala- tions, followed by the symptoms of a violent attack of congestive fever. The attendant physician pronounced it a case of yellow fever. Physicians were attracted from all parts of the country to examine the case; ropes were extended across the street lead- ing to the house, and the citizens of the village forbidden to pass. The most active measures were employed, according to the usual method, for the cure of yellow fever. But the patient died, with- out a development of any other pathognomonic symptoms than those which mark an aggravated case of congestive fever. His death, in all probability, is attributable more to the harsh deple- tory treatment than to the disease. When the primary stage has passed, and especially at about the commencement of the third stage, the diagnostic symptoms are gen- 192 YELLOW FEVER. erally well presented. The primary fever has subsided ; the eyes and skin are tinged with yellow; there is great prostration, when the third stage sets in, unless a secondary fever should occur. These, with the great gastric disturbance, and especially the black vomit, are the chief phenomena that distinguish this from other forms of malignant fever. The prognosis has always been regarded as unfavorable ; and the term is perhaps correct in a general sense. The disease has generally been characterized by great mortality. Its character in this respect has, however, been much modified by the reform introduced in treatment by Broussais, of Paris. Whenever and wherever the lancet and calomel have been the chief reliance for its arrest, its fatality has been very great; but under a different mode of medication it has proved much more manageable ; and, as in other grave disorders, the remark is true, that the results of the disease depend much upon the treatment which is to be pur- sued. Different visitations of the malady vary in respect to their mortality. Sometimes it is very malignant, and nearly all who take it die; in other seasons its grade is in the general mild, and few fatal cases occur. Its fatality varies also in different periods of the same season; being generally more virulent when it first breaks out as an epidemic, and becoming more mild as the season advances. It differs also in its malignancy in different districts of the same city, according as the cause is more or less concen- trated. All these general views it will be necessary to take, in forming an intelligent estimate of the character of this disease during its prevalence in a community. Your prognosis in individual cases will, to some extent, regard the general character and tendency of the disorder in the neigh- borhood. Your opinion of the result of a given case will, how- ever, finally depend upon the favorable or unfavorable character of the symptoms presented. The unfavorable symptoms are, " excruciating pains in the forehead, back and limbs; great fre- quency and feebleness of the pulse — a gaseous state of it, or its entire absence at the wrist; a blood-shot appearance of the con- junctiva, and a bronze or mahogany color of the skin ; a short and violent febrile stage ; coma or convulsions; a slow respiration, with deep sighs ; hickup; excessive restlessness, and a disposition YELLOW FEVER. 193 to get out of bed and walk; an unnatural apathy, or an expres- sion of dogged indifference; in the advanced stages, a voracious appetite ; suppression of urine; a universal hemorrhagic ten- dency, with petechias; and finally, the occurrence of black vomit. This last symptom is regarded as almost necessarily fatial; but occasional recoveries are mentioned by authors as having taken place after its appearance. A total suppression of urine may be regarded as a certainly fatal symptom in adults. "The absence of the above symptoms must of course be regarded as favorable. A prolongation of the primary fever beyond the accustomed period, the occurrence of a moderate secondary fever, and the appearance of a gentle diaphoresis at any period from the fourth to the seventh day, are also favorable signs." ( Wood's Practice, p. 301-2.) In short, any symptoms indicating energy of the nervous system, and a tendency to respond promptly to appropriate remedies, and especially evidences of convalescence, " the gradual cleaning of the tongue from the edges, along with a subsidence of vomiting, and a diminution of the epigastric ten- derness," are certainly favorable. Treatment. While yellow fever was considered an inflamma- tory, hepatic affection, the lancet was early brought into requisition in every case ; rivers of blood were shed with a view of allaying inflammation, and pounds of calomel were employed, as combining all the qualities of an antiphlogistic, cholagogue, cathartic and health-insuring alterative. For the philosophy of this system of practice, I must refer you to those who still adhere to the same measures under the circumstances which were formerly supposed to attend this disorder ; for the success of such treatment, I refer to the statistics of yellow fever as recorded in the books. If a different mode of practice had not exhibited more encouraging results, I should feel that very little hope or reliance can be placed on medical experience, in a disease of such fearful mortality. But different and more favorable results have been attained. Just in proportion as old school practitioners have modified or abandoned their depletory, paralyzing efforts, have they presented less horrible bills of mortality ; and wherever a rational mode of medication, similar to that which I am about to detail, has been employed, the results, I am assured, have been highly satisfactory. 13, 194 YELLOW FEVER. I have already told you that I never saw this disease, where it prevailed either as an epidemic or endemic ; but I have met with isolated cases of what I called congestive fever, which exhibited the prominent symptoms of genuine yellow fever, even to the yellow skin and dark ejection from the stomach, answering well to the descriptions of black vomit. And I have found cases of this gravity yield under the treatment I shall describe. In the early stage of an attack, while the symptoms are still so indefinite as to prevent the formation of a satisfactory diagnosis, though yellow fever may be suspected, the case should be treated in all respects, as regards medicines, as an attack of malarial or bilious fever. If there is derangement of the stomach, a gentle emetic will be proper. This will remove any irritating substances from the stomach, and prepare for the more efficient exhibition of other medicines ; it will rouse the nervous system from the leth- argy into which it sinks in this form of disease ; promote, me- chanically at least, the action of the liver; and have a potent influence in determining the blood to the surface, and thus re- storing the capillary circulation. I should even be more certain to give an emetic in such a case, than if yellow fever were not apprehended; for, bear in mind, that should it prove to be this disease, a very brief time may be allowed in which medicines can be of any avail; and where time is so important, an emetic is peculiarly adapted to our purpose, from the little time required for its operation. Half an hour is generally ample time for accomplishing all that can be done with an emetic. The choice of an agent to be employed for this purpose is important. It should be prompt and thorough in its action, and at the same time mild and easy in its operation ; unirritating to the mucous mem- brane. These properties are combined in the Lobelia inflata; and the calm, quiet condition of the stomach, which uniformly follows its operation, renders it, in my judgment, the very best article we possess for a case of this kind. The action of the lobelia is very much improved by combining it with Eupatorium perfoliatum. A saturated infusion of equal parts of these two herbs may be given, in doses of two table-spoonsfull every ten minutes, until a sufficient emesis is effected. The febrile stage requires thorough bathing with broke water YELLOW FEVER. 195 and whisky over the entire surface, with friction by rubbing with a towel or the hand. Extensive sinapisms should at the same time be applied along the spine, and to the epigastrium. These tend to divert irritation from the nervous system, and stomach. Warm teas, such as catnip and balm, are highly useful, as they tend to encourage perspiration, and thus diminish febrile action. In short, pursue in this stage a soothing mode of treatment, cal- culated to allay febrile excitement, equalize the circulation, and relieve any local congestion which may exist. And let it be always borne in mind, that what is done must be done with des- patch, and efficiently. The physician should, if possible, see his prescriptions administered, and witness their effect. Do not, if you can avoid it, leave your patient in these malignant cases, and trust to an ignorant nurse to carry out your orders. Immediately upon the decline of fever, or before, if the symptoms denote urgency, administer the medicines which I have denominated antiperiodic. For here you have a malarial fever, depending principally upon the same cause which produces periodic fevers', modified, it is true, by combination with a depressing influence, which prevents, it may be, any tendency to remission; but which must certainly be amenable, to a great extent, to the same reme- dies as are intermittent and remittent fevers. And here I do not rely on theory alone in recommending this antiperiodic treatment. For it has been tested with the most gratifying results by those who have had the opportunity. In New Orleans, it was first introduced in the epidemic of 1841, by assistant surgeon Charles McCormick, and Dr. A. J. Wedderburn, and has been since extensively employed. " The practice of giving large doses of quinia very early in the disease, is asserted by some to have been attended with great success," says Dr. Wood in his Practice, Vol. I., page 308. Other authorities might be quoted to the same effect, but this is sufficient to show that the treatment called for by my views of the cause and nature of this disease, proves efficient in actual practice, whatever may be considered the par- ticular ground for its exhibition. The remedy does not fail when administered in a proper manner, even though the practitioner's theory may be erroneous. Quinine has done much good in thou- sands of cases when given under the name of a tonic, though its 196 YELLOW FEVER. real pathogenetic action is certainly that of a sedative. Having, therefore, my own experience in the use of the antiperiodic medicine, in cases which seem to approximate very nearly the character of yellow fever, and finding it successful in the treat- ment of that very disease in the hands of others, I do, with the utmost confidence, advise you all to employ it when opportunity shall offer. The sulphate of quinia should be given in doses of six or eight grains, with equal quantity of prussiate of iron; or if the latter disagree with the stomach, it may be omitted. I have recently found much advantage in inflammatory diseases by combining tannic acid with the quinine. The constringent property of the tannin has, I believe, a beneficial effect in repressing inflammatory action in the mucous membrane. Another advantage of the combination consists in the fact that the tannin renders the quinine almost tasteless. The bitterness of the quinine seems to be removed, either by a chemical combination, or by the constringent effect of the tannin rendering the surface of the tongue in a measure insensible. The latter, I am inclined to believe, is the true explanation. The quinine thus combined, or alone, as suits the views of the physician at the time, should be repeated at suit- able intervals, until its full effect upon the system is realized; and you need apprehend no injury from its administration, in view of any symptoms the case may present. These, with the various accessory measures which I have so often recommended in other grave forms of fever, would be the means I should adopt, if called upon to treat the disease. I have said nothing, as yet, of cathartics in this affection. I believe they have been far too frequently employed, under the erroneous notions which have been entertained of the cause and nature of yellow fever. Why should we give a cathartic ? Does the diseased action indicate such a measure ? If there were evidently accumulations in the bowels, I should favor their expul- sion by a mild cathartic. But upon general principles, I see no call for catharticism in this disease. If the bowels are irritated, why increase the difficulty ? If the bowels are healthy, why originate mucous irritation by purgative medicines ? It is in this very way, I am confident, that untold mischief is done in this and YELLOW FEVER. 197 other disorders, by mercurial preparations. The liver in the beginning of the attack is generally active. But the disease indicates a cathartic, say the books, and the best cathartic is calomel. This is accordingly given liberally, and followed in three or four hours by a saline cathartic. The mucous membrane of the stomach and intestines, especially the duodenum, has now suffered violence, which results in irritation,— perhaps inflamma- tion. The difficulty is extended by sympathy to the liver, and that organ is locked up, and then follows all the train of symp- toms incident to hepatic disease. But, gentlemen, the reign of mercury as the sovereign remedy is waning, and indications at present point to its ultimate banish- ment from the commonwealth of physic. Even the old school authorities of recent date manifest distrust of this most potent drug, which a short time ago seemed to be the one thing needful, not only in yellow fever, but in almost all diseases. It was the catholicon, the panacea, the physician's staff in all his difficulties, the patient's hope in the valley of despair; the means first tried as disease approached, in hope by potent doses to frighten it away; and then, when strength was gone and aggravated complications had been induced, the last resort and only hope consisted in the possibility of substituting mercurial for other disease, so that if the patient must be lost, his death might be accomplished by sci- entific means. But such times, I trust, are nearly past, and a brighter day has dawned upon us. True, mercury still has apol- ogists, but their tone is much modified, and where the agent is directed it is apt to be coupled with a contingency, such as, " if calomel is employed," or " it will be necessary that the practi- tioner should decide, at a very early period, whether he will have recourse to mercury in the treatment of this disease." Men cling with great tenacity to old favorites, and often expressed opinions are seldom unequivocally renounced; but it is encouraging to know that prejudices sometimes die with the men who cherish them, and much is to be hoped from the next generation of med- ical men. The lancet, too, is losing its hold on the confidence of the profession, not only in yellow fever, but in various other affections, for the arrest of which it was formerly deemed indispensable. 198 YELLOW FEVER. Recommendations of its use are now associated with solemn warn- in os of danger, and with intimations that little is to be expected from blood-letting as a means of cure. " The question,"^ says Prof. Wood, " must be decided at an early period, whether it will be requisite to use the lancet." " It is generally considered a hazardous remedy after the lapse of one or two days. Bleeding will not cure the disease, nor should it be vaguely employed with this view." Subsequently, speaking of prevention, he says, " attempts to guard against the disease by low diet, bleeding and purging, or the use of mercury, are futile, and even worse than futile. The feebler the system, the less is it able to resist the entrance of the poison or its influence when absorbed." Please observe these quotations, gentlemen: "bleeding will not cure"— it will not prevent. In all sobriety I would then ask, for what purpose we should resort to so hazardous and so useless a remedy. But such is the truth, and such is the doctrine for which, as a medical school, we have so long contended. " The feebler the system, the less is it able to resist the entrance of the poison, or its influence when absorbed." This doctrine, gentlemen, is un- mitigated Eclecticism—which, when applied to other measures and diseases, is as certainly true as when advanced in relation to the lancet in yellow fever, and a consistent adherence to it will terminate the blood-letting epoch, and will introduce fully the reform for which we are struggling, and for which the world is well nigh prepared. Should you first see a patient in the period of prostration, the quinine must not be delayed a moment. Its introduction should be prompt, in full doses, and its retention by the stomach favored by anodynes, carminatives, or stimulants, as the case may require. Oil of turpentine and capsicum combined with quinine has been recommended, and the prescription strikes me as one well adapted to the case. Let the strength of the patient be sustained by every means that can be employed. Mild and bland nutriment, such as gruel and weak animal "broths, bread-water, or milk and water, as the stomach can be induced to retain them, are import- ant means for this object. Sinapisms, as recommended in the former stages, are equally important now, and even a blister over the stomach might be of much service, by its prompt revulsive YELLOW FEVER. 199 influence. The circulation should be invited to the extremities by drafts on the wrists and ankles, and stimulating frictions should be used over the whole surface. Should you be so fortunate as to induce a reaction, and get your patient into a convalescent condition,— and I confidently believe you will do so in a majority of cases where you are called at an early period of the attack,— you will then have the general principles for your rule, which govern in the management of con- valescence from all depressing fevers. Husband carefully the remaining strength, employ proper tonics, and allow wholesome, digestible food, increasing the quantity gradually as the patient gains strength. Let moderate exercise be taken within doors, or in the open air, where there is no exposure to infection. And here I will say, what I might have said before, that wherever it is practicable, I should be in favor of removing every patient at once to a healthy location, as the chances of recovery are thereby greatly increased. There is one more point in connection with this pestilence, upon which I desire to make a remark or two, and that is, the means of prevention; for in this case the old adage is emphatically true,— " an ounce of prevention is worth a pound of cure." Public authorities should see that general cleanliness is observed by the whole community. All ponds should be drained, where deposits of vegetable or animal matter are liable to collect and be left to decompose. Sewers should be provided to carry off the filth of the city, and the back yards and cellars should be duly inspected, together with every other place where miasm is likely to be gen- erated. During the prevalence of the disease, all who can should leave and avoid the infected district. Those who cannot avoid exposure to the cause by removal, should avoid the night air, and sudden changes of temperature ; they should sleep in the highest part of the house; be moderate in taking exercise, avoiding fatigue and mental excitement; their food should be generous and nutritious, though not stimulating, and they should never expose themselves to infected air with the stomach empty, or when the system is exhausted by labor or loss of sleep. LECTURE XIY. TYPHOID FEVER, OR CONTINUED FEVER. Preliminary Remarks — Synonyms—Mode of Invasion — Febrile Symptoms—Different Periods of Progress described—Sometimes Periodic—Tympanites —Peculiar Discharges —Petechice—Suda- mina—Subsultus Tendinum—Posture of Patient—Fatal Case— Mode of Death—Duration—Favorable Result—Convalescence— Sequelce—Anatomical Phenomena. We come now to speak of a variety of fever having distinct and well-defined characteristics, differing, in many respects, from any of the forms we have hitherto considered, and worthy of de- liberate attention and thorough investigation. I mean typhoid fever. This fever has, perhaps, been the subject of as much careful and calm discussion and recondite investigation, and has been ob- served with as close scrutiny in its entire train of phenomena, as any other disease to which the profession has given attention; yet there are many things connected with it still veiled in obscu- rity, and requiring further research and observation. In regard to the name of the disease, I remark, that I use the term typhoid fever for want of a better. It is the title by which the disease is described in most of the recent authorities, but it is not descriptive of the nature of the disease, nor expressive of its cause. In fact, there is some objection to the term typhoid as applied to this particular disease, from the tendency which exists to refer to the original word typhus, as denoting the same disease. Now, although typhoid is an adjective, derived from the noun typhus, and, when applied to a low condition, such as sometimes TYPHOID FEVER. 201 attends protracted fevers, expresses the idea that the symptoms are similar to those of typhus fever—they are " typhoid symp- toms"—that is, symptoms resembling those of typhus—yet the term, when employed as the name of the specific disease now under consideration, loses, in a degree, its descriptive character, and becomes an arbitrary name. You will please, therefore, re- member the distinction between typhis and typhoid. By typhis fever, I mean that modification of bilious which I have elsewhere denominated congestive fever ; by typhoid fever, I refer to a dis- tinct and very different disorder, originating in a different cause, and presenting, for the most part, symptoms of a different charac- ter. The name typhus has, I believe, been applied to this disease in New England, where the true typhus does not prevail; but those who have had experience in both fevers, will have little difficulty in distinguishing between them. The researches of M. Louis and other European writers, have very satisfactorily deter- mined the character of this disease; and the term typhoid is preferred by them, and adopted by most American authors; while Ware, Jackson, Hale, Gerhard and others, have, in vari- ous observations, made at different times and in different parts of the Eastern States, fully shown the identity of the typhus of those sections and the typhoid of Louis and others. The disease under consideration has been called nervous fever by some authors, from the symptoms of nervous disorder which attend it; some French writers call it entero-mesenteric because the intestines are always found diseased in fatal cases; and Breton- neau calls it dothin-enteritis (from (Jodnjv, pustule, evre^ov, intestine), to denote the character of the intestinal affection; follicular en- teritis has been applied to it for the same reason; Prof. Wood proposes the term enteric fever, but this might cause it to be con- founded with other forms of gastro-intestinal inflammation; some still adhere to the old name of continued fever. These numerous efforts to furnish a suitable name, while they are somewhat inter- esting, as they indicate, in some measure, the character of the fever in question, have certainly resulted in considerable confu- sion ; to avoid which, and to avoid, also, the fault of authors in furnishing a name of my own devising, I shall designate the dis- ease by the term first mentioned, with the express understanding 202 TYPHOID FEVER. that I use it rather as an arbitrary cognomen, than as a descrip- tive appellation, although this disease is attended with many symp- toms similar to those of typhus or low congestive fever. The invasion of the system by typhoid fever is remarkably in- sidious. Few diseases are as slow in their approach as this, its inroads being at first almost imperceptible. So gradually does the morbific influence develop itself, that patients are frequently unable to say when they first began to be unwell. The period of invasion varies in duration from a day or two to as many weeks. Perhaps the average length of time occupied by what may be called the premonitory symptoms, is about six days. It is said by some authors that the disease sometimes comes on suddenly, with a chill followed by fever. Of this I have doubts, for I am inclined to believe that practitioners have been accustomed to mistake low forms of bilious fever, coming on with a chill and finally developing typhoid symptoms, for this disease. I myself have seen cases which might easily have misled one who was not on the alert. The question with me formerly was, indeed, whether typhoid fever itself might not be regarded as a peculiar modifica- tion of one of the ordinary forms of fever, owing to enteric dis- ease ; though more recent observations have satisfied me that we have a form of disease requiring an independent and distinct po- sition in the catalogue of fevers, and this is the one to which I apply the term typhoid fever ; but I repeat, that it is very doubt- ful whether it is ever introduced suddenly, by chill and fever. Its mode of approach does, however, vary in different cases. In some, the symptoms are palpable and characteristic, almost from the first, while in others they are indefinite and inapprecia- ble for some time, the patient feeling weary, listless, and dull, with an indistinct soreness in the limbs; finally he begins to " feel unwell," a headache comes on, the skin becomes hot by spells, with alternate chilly sensations. Where the disease comes on more rapidly, these same sensations are experienced earlier, and, instead of an undefined listlessness, there will be a feeling of fatigue and even debility; there is a disinclination to walk, or take other exercise ; the limbs feel sore, and often there is actual lameness. The appetite fails, partially or altogether, so that if food is taken, it is not relished as usual. Sometimes the appear- TYPHOID FEVER. 203 ance of food of the best quality will produce nausea. The bowels are perhaps slightly constipated, or there may be a tendency to diarrhoea, not sufficient, however, to be recognized as disease. The skin becomes dry, and flashes of heat are experienced, while the pulse is accelerated, the head aches, and a creeping, chilly sensation is occasionally felt along the back, passing off in a mo- ment, and followed by a glow of heat. In a short time another chilly sensation will be felt, followed by heat, as before. While these symptoms are progressing, the patient feels very restless and irritable, perhaps, though this feeling is not so prominent here as in bilious fever. The tongue is but slightly coated, if at all, while in bilious fever there is usually a heavy coat upon it. The disease is now fairly commenced. The febrile symptoms continue; the pulse becomes more excited and frequent—not full and bounding, as in bilious fever, but hard, wiry, quick, and fre- quent. The bowels will not yet, perhaps, manifest positive dis- ease ; there will probably be loose discharges—not watery, nor very frequent, but two or three motions of the bowels during the day. The urine will not be found, generally, so scanty nor so high colored as in most other fevers, though it will become more so as the disease progresses. The bowels will be found peculiarly sensitive to the action of medicines, requiring, perhaps, less than an ordinary dose to produce hypercatharsis—and this is an im- portant fact to be borne in mind during the treatment. The skin, at this stage of the disease, becomes sensibly more dry and harsh. There is not a decided pungency on application of the hand, as in congestive fever, though there is a palpable increase of tem- perature on the body. Headache is still a prominent symptom in most cases, and sometimes is the principal subject of complaint. This symptom differs much in different persons, but it is very sel- dom entirely absent. Thirst is an early symptom, and is frequently extremely urgent, especially under mercurial treatment. This circumstance was the occasion of dreadful suffering, in early times, yet within my recollection, when the use of water was forbidden as incompatible with that of mercury ; but fortunately this bar- barous practice has been suspended ; not, I apprehend, from con- siderations of science, but of expediency. The face of the patient is usually flushed and shining, though 204 TYPHOID FEVER. less so than in congestive fever. The skin assumes a dusky hue, and there is a dull or obtuse expression of the countenance, in- creasing as the disease advances. The tongue is not yet much coated, though a fur may make its appearance, with perhaps red- ness of the tip and edges of the organ. The stomach sometimes becomes irritable, if it has not been so before, and the tendency to disturbance of the bowels will probably be increased. Pains may be felt in the bowels, which will be increased by pressure on the lower portion of the bowels, especially on the right side, and generally a tympanitic condition of the abdomen is perceived on percussion. The irritated condition of the skin and mucous mem- branes is often extended to the bronchia, and a cough, either dry and hacking or attended with mucous expectoration, will set in. This may, indeed, become a very urgent symptom, and require special attention. In such cases physical exploration will detect a dry, sonorous rale, extending sometimes over the whole chest. The progress of the disease, as thus marked, generally reaches the seventh, eighth, or ninth day from its development. If it occur in an atmosphere where vegetable malaria exists, there is very apt to be, during the early stage, a tendency to remission daily, or every alternate day. This it is important to bear in mind, as it will exert a practical influence on your mode of treat- ment. By remissions here I do not refer to temporary seasons of apparent relief from fever, during which perspiration may per- haps break out upon the forehead, face, and neck. These gen- erally occur frequently every day, at irregular intervals. But I speak now of regular quotidian or tertian revolutions, generally the former, which are denoted by a regular and gradual decline of the febrile symptoms, until a remission, more or less perfect, is perceived. The remission generally occurs in the morning, the fever rising again towards evening, increasing, it may be, till midnight, and then again gradually diminishing—marked all the time, however, in most cases, by the irregular alternations of which I have spoken. Although the progress of this fever is so very slow that its vic- tims do not generally regard themselves as much sick for several days after the attack, yet the practiced eye and hand of the phy- sician will soon detect evidences of serious disorder. The peculiar TYPHOID FEVER. 205 febrile action, the hard, wiry, frequent pulse, the sensitive mucous surfaces, especially of the bowels, all point to serious lesion, not to be hastily removed by remedies now within our knowledge. These symptoms continue, increased probably in intensity, and others are superadded. The tongue becomes more dry, and per- haps somewhat darkened in color in the middle, while the edges and tip continue red; the saliva will have a cottony appearance and the tongue, when protruded, will seem inclined to curl up at the sides and extremity. The throat will be dry, feel sore, and deglutition will be painful and difficult in many cases. You will now find the abdomen much extended, and percussion will pro- duce the hollow or tympanitic sound. The looseness of the bowels will, probably, be increased, and a slight purge would now pro- duce a hypercathartic action, which would continue for several days. Hence, it is evident that such medicines will merely aggravate the difficulty. The evacuations are now watery in their character in most cases, whether they are the spontaneous production of the diseased bowels, or are induced by the inju- dicious administration of a cathartic. They are of a dirty yellow color, resembling a thin watery gruel in appearance, and the smell is Exceedingly offensive. There is one phenomenon often observable in the alvine discharges in typhoid fever, which I have never seen in any other disease, and that is, the existence of small red specks on the surface of the evacuations, having the appear- ance of little particles of bloody mucus. And now, by examining the surface, you will be pretty certain to find a particular diag- nostic symptom, to which I call special attention, for it is peculiar to this fever. I refer to the appearance of small red or purple spots or eruptions, resembling flea bites. They may be found first, perhaps, on the abdomen, but extend over the whole body, and especially to the extremities. These eruptive spots are called petechia}, and they are to be recognized by the appearance of circumscribed prominences on the skin, obliterated by pressure, but reappearing shortly after the finger is removed. Accompany- ing this symptom is often observed another eruption, differing from it essentially in.character, though scarcely less diagnostic of the disease. This is the sudamina, consisting of minute vesicles, filled with lymph. The vesicles vary from the size of a millet 206 TYPHOID FEVER. seed to that of half a buckshot, and are found principally on the neck and upper part of the chest, sometimes extending to the abdomen, but seldom, if ever, to the limbs. This eruption may be easily overlooked, owing to the colorless transparency of the vesicles ; but upon applying the hand to the skin, they are easily recognized, being more prominent than the petechiae, and impart- ing a peculiar sensation of roughness to the touch, unlike any thing else. At this stage of the disease, the nervous disorder begins to present more decided symptoms. There will be slight delirium, or it may be a tendency to stupor, with tremors and twitchings of the muscles, when the patient reaches out his hand. The first indication of delirium which is observed, may probably be an increased brightness of the eyes, which might lead a casual ob- server to suppose the patient is much improved ; but very soon signs of mental hallucination will be evinced by his motions or language. I have said that there may be a tendency to stupor, but generally the opposite is the case ; the patient is wakeful and very restless. There is a buzzing sound in the ears, which may be compared to the rushing of a current of water; similar, in fact, to the sensation produced by full doses of quinine. The eyes become injected and somewhat red in appearance, with a vacant stare, and the patient will seem to have an imperfect per- ception of objects, though, on first looking at him, you Avould suppose his eyes were unusually clear and bright. The tongue can with difficulty be put out of the mouth, and it may be ob- served to have a trembling motion. This difficulty of motion is not owing, as in typhus or congestive fever, to a swelled and cracked condition of the tongue, but to an inability to direct or control the muscular actions by the will. This inability, in fact, extends in some measure to every other muscle, as is manifest when the patient attempts to change his position, or use his limbs. The symptoms just described continue through several days, in some cases increasing more rapidly than in others, but generally with a steady advance in the morbid manifestations, until the typhoid condition is fully presented. Now the patient lies, per- haps, in a partially comatose condition, if undisturbed; though he TYPHOID FEVER. 207 may be aroused without much difficulty. His mouth is kept open, and his breathing is heavy and laborious. A peculiar, dark deposit, called sordes, appears upon the teeth, and sometimes on the lips, and by breathing constantly through the mouth, the moisture is carried off, and the tongue left in a dry, parched con- dition, somewhat resembling its appearance in congestive fever • but close inspection will enable you to perceive that this dry state of the tongue is not owing to an irritated, inflamed condition of the organ, but merely to the evaporation caused by the breath passing over it. The pulse is generally very frequent at this stage of the disease, though there is much variety in this respect in different cases. It may be as low as 85 per minute, or it may reach 150; and the gravity of the disorder may, perhaps, be re- garded as being more or less serious, in proportion to the fre- quency of the pulse. It is generally not only frequent, but very feeble ; though it may still retain a hard, corded character. There is still a hot skin, though this may not be uniform ; some portions of the surface may be hot, and others cool. The heat here is somewhat pungent, but less so than in congestive fever • and there is a peculiar odor arising from the body, and perceived in the breath, which is very unpleasant, and difficult of descrip- tion, though it is readily recognized by one who is accustomed to the disease. It is not so offensive and nauseating as the odor which characterizes the last stage of congestive fever but it is very disagreeable and sickening. Subsultus tendinum will gen- erally be witnessed in connection with the symptoms now de- scribed. This is the trembling of the muscles, of which some mention has already been made, and which sometimes is increased to such a degree that the patient is unable to hold a glass of water in his hand. This inability to control the muscles increases until there are finally established constant successions of involun- tary motions. There is an indefinite reaching or grasping with the hand, or a constant picking at the bed clothes. This cannot be regarded as specially diagnostic of this disease, as it generally appears in other forms of low, nervous disorder, but it is always a very formidable symptom; though I have known recoveries after its appearance. There is another fact worthy of notice though not confined to this disease, but observable in most low 208 TYPHOID FEVER. fevers, especially where there is intestinal disease. It is the position of the patient. He lies on his back, with his knees drawn up, and with a constant tendency to slip down towards, the foot of the bed. Another circumstance may be observed in this, as well as other low forms of fever. There will probably be fre- quent involuntary discharges, from the bowels and bladder. 'This may arise from unconsciousness of what is being done, or the patient, in his confused, dreamy state of mind, may conceive him- self to be in the proper position for voiding these accumulations. Sometimes there is almost entire retention of urine. Hemorrhage from the bowels often occurs in the advanced stage of typhoid fever. This occasionally is seen in congestive, and perhaps in yellow fever. I saw a case of congestive fever but a few days ago, in which there was a copious discharge of bloody matter from the bowels ; but this is more common in typhoid than in other forms of fever. Epistaxis, or bleeding from the nose, is not an unfrequent occurrence, and in some cases it proceeds to an alarming extent. The petechiae are increased on the skin; and here I desire to point out a difference between this and an eruption frequently seen in the last stage of congestive fever. In the latter disease, you will not see the small rose colored spots scattered over the surface, especially on the hands and wrists, but a more irregular and extended eruption, of a reddish hue,—the spots being more numerous, of a higher color, and appearing like an effusion of blood in the cellular structure ; the color not receding on pres- sure, as in typhoid. Sometimes vibices, or large purple spots, make their appearance on different parts of the body, owing to the devitalized condition of the skin. Owing to the same cause, too, eschars will be produced in parts subject to pressure from long confinement of the body in one position, as on the hips or sacrum. There will first be produced a small blister at the point where pressure is long continued ; this will be extended, the sur- face will become raw, and, owing to the want of vital force, there is a tendency to gangrene, and the skin may entirely slough away, leaving the process of bone exposed. I have seen a case where a slough came off as large as my hand, and so deep as to TYPHOID FEVER. 209 expose the vertebral spinous processes, and yet the patient re- covered. J£ the disease progress, with an increase of these symptoms, the case must soon become very formidable. The pulse loses its remaining force, becomes hurried, perhaps fluttering ; or it may become very slow and weak, and disappear from the wrist occa- sionally. A clammy sweat will cover the skin, the extremities become cold, and death steals upon his victim as slyly and insen- sibly as did the disease in its first approach. Sometimes, how- ever, the vital forces give way more suddenly, and the patient dies with agonizing struggles. Such is the usual course of a fatal case of typhoid fever. As has been remarked, the course frequently varies, the symptoms do not appear in the same order, nor with the same relative de- gree of malignancy in some cases as in others. The duration, too, is quite variable; for though the disease is usually slow in running its course, yet cases are spoken of in the books, where death occurred as early as the sixth or seventh day. It generally occurs, however, during the second and third week, though it may be deferred much longer. Where a case is to terminate favorably, a moderation of some of the symptoms will be observed, generally, during the second or third week. The tongue will appear more moist, and the coat upon it will be gradually removed ; the pulse will improve, be- coming less frequent, and acquiring more volume ; the skin will assume a more natural appearance, and cooler temperature ; the nervous symptoms are diminished; the mind of the patient be- comes clearer, and he manifests greater interest in his own case, and observes more intelligently what is transacted about him ; the tension of the abdomen becomes gradually lessened ; the dejections assume a more healthy appearance, and less offensive smell; the thirst is less urgent, and some desire for food may be expressed,— or a willingness, at least, may be manifested to take it when offered. In short, there is a general but very gradual resolution of all the morbid conditions, and the restoration, by degrees, of the various organs involved, to their healthy functions. But these recuperative changes progress slowly, and convalescence is usually tedious ; requiring from five or six days, in a very mild 14 210 TYPHOID FEVER. case, to as many weeks, where the attack has been very severe, and the organic lesions extensive. The beginning of convalescence is, however, generally more tedious than its subsequent progress. Indeed, it often happens that after the patient becomes able to take nutriment, and the processes of digestion and assimilation are commenced, and he begins to use his limbs in moving about, his recovery will be remarkably rapid. Sometimes, however, there is an acquisition of flesh beyond that of strength, and the patient will feel a con- siderable degree of debility, while his appearance indicates full flesh, or perhaps a bloated condition. The appetite is sometimes insatiable, and its indulgence may lead to a fatal relapse. Where the course of the disease has been very severe or protracted, or where injudicious treatment, such as bleeding or mercurial ptya- lism, has produced great prostration of the powers of life, and an impoverished condition, both of the blood and solid tissues, a long train of unhappy and discouraging symptoms may haunt the unfor- tunate patient for weeks or even months. Symptoms similar to hectic fever: night sweats; depressing nervous disturbance ; anasarca, or at least an edematous condition of the legs and feet; annoying and tedious abscesses; loss of the hair; and other un- pleasant sequellae, may follow. The anatomical phenomena developed by post mortem exami- nations, next claim our attention. Chomel divides the morbid appearances into constant or characteristic, and occasional or accidental. Perhaps no other disease has given rise to as many post mortem explorations as typhoid fever. Having prevailed in some places to a great extent, and in some localities and espe- cially under certain modes of treatment, proved very fatal, the profession have not been at a loss for opportunities to make autop- sic researches as to its morbid phenomena. It has formed a subject of careful and critical investigation, by the most intellect- ual and learned men in our profession. While local phenomena were supposed to demand paramount consideration in determining the nature of any disease, and consequently the minutest changes in any of the organs were matters of very great interest, obser- vations of this kind were prosecuted with commendable zeal; and volumes have been written, article after article published, medical TYPHOID FEVER. 211 minds and hands and eyes have been actively engaged through- out the world, or at least wherever this disease has made its appearance, for the purpose of developing its character, and learning from its footprints something of its origin and course; and one would suppose the subject must now be perfectly elucidated. But such is not the fact; many points still remain in obscurity, and the main object of research,—the cause of the disorder,—is still a subject of doubt and controversy. It is said by Louis, whose labors have thrown more light upon the subject than those of any other man, that in half the cases of death from typhoid fever examined by him, the heart was softened and diminished in volume ; but this I do not regard as a peculiar mark of this disease, but a condition common to low and protracted forms of fever. Another circumstance not peculiar to typhoid, but frequently observed in connection with it, is a fibrinous struc- ture in the heart and aorta. I referred to this in a former lecture, and only mention it here in passing. I will add, however, that I have seen this structure three or four inches long, and entirely closing up the aorta. It is said that blood drawn from the arm during life does not present the buffy coat and cupped appearance considered pathognomonic of inflammation, unless there be a com- plication of some inflammatory affection with the main disease. Its autopsic and chemical examination after death has furnished little or no information of value. It is said to be deficient in fibrin, and it is thought that this diminution is in proportion to the severity of the symptoms. While speaking of the blood, I will take occasion to remark, that there are some important and stubborn facts which go to show that the buffy coat does not necessarily indicate inflammation. Hamilton says the blood from a patient under the influence of mercury has the buffy coat; and yet who ever ascribed inflammation to mercurial action ? Is it not declared to be peculiarly antiphlogistic ? Until the relation of the peculiarities of the blood to morbid action during life shall be a little more definitely ascertained, little reliance can be placed upon its post mortem condition. The lungs have often been found diseased, but there are few if any members of the profession who believe that disease of these organs bears any special relation to typhoid fever. The most 212 TYPHOID FEVER. frequent morbid condition of the lungs, following this fever, is that which has been described by Louis, as resembhng, in color and appearance, the natural condition of the spleen, and named by him splenization. The propriety of this description is, how- ever, disputed, as the color of the lungs is not like that of the spleen, but is a " bluish red," and when cut there is an effusion of a thick, red fluid, and the affected portion of the lungs has a specific gravity greater than water. The lower and posterior portions of the lungs are most frequently involved,—owing, prob- ably, in some measure, to the influence of position. The mucous membrane of the air passages is also occasionally found in a diseased condition, exhibiting considerable traces of vascular engorgement, and in some instances there is disorganization, extending even to adjacent structures. Lesions of the brain, or of its membranes, from the severity of the symptoms referable to this organ, might readily be supposed U: exist. But in this, as in other diseases, we frequently fail of detecting physical changes in this organ, bearing any reasonable proportion to the symptoms observed in the progress of the fever. This, however, need not produce much surprise, since observation has satisfactorily determined the fact, that extensive functional disturbances do frequently exist for a long time, without any traceable organic change being produced. The knowledge hitherto obtained from post mortem examinations of the brain, in relation to its diseases, is not in fact as satisfactory as that furnished by similar researches in most other organs of the human system. Future observations, with the advantages of the microscope and of chemical analysis, which modern science enables us to bring to our aid, will, it is hoped, result in the explanation of many symp- toms pertaining to this and kindred diseases. Suffice it to say, that where organic changes are observed at all, the one most common, perhaps, is an effusion of serum between the arachnoid and pia mater, with traces of sanguineous engorgement of the latter membrane, and of the medullary substance; while, in rare instances, there may be observed either " an increase or diminu- tion in the consistency of the brain." Let us now examine the alimentary track. In the pharynx and esophagus, but especially in the former, traces of organic change TYPHOID FEVER. 213 are occasionally exhibited: such as cankered or ulcerated points, or sanguineous engorgements. The stomach still more frequently presents evidences of morbid action. But these differ greatly in extent in different cases,—from a slight appearance of inflamma- tion, to a general softening of all the organic tissues; from small apthous points in the mucous surface, to extensive ulceration, involving, in some instances, all the coats of the stomach. And it is perhaps worthy of remark, that the structural lesions of this organ often exceed, in extent, the changes we might reasonably anticipate by observing the symptoms of gastric disorder during life. This, however, is not always the fact, for we often meet with cases where there is great irritability of the stomach, espe- cially in the early stages. In some instances there is even protracted vomiting of bilious matter. But of all the lesions which post mortem examinations have revealed, as connected with typhoid fever, none are so uniformly present, or so peculiar in character, as those found to exist in the small intestines. Not only are they constant, but strikingly simi- lar in different cases—varying merely in extent, or by complica- tion ; but almost always presenting characteristic peculiarities, believed to have been observed in no other disease. The contents of the small intestines are somewhat peculiar, though they are not considered pathognomonic. As might have been anticipated from the tympanitic state of the abdomen, during the progress and especially towards the termination of the case, the small intestines are found more or less filled with flatus; while the fluid contents are usually quite thin, mixed with mucus, and of a dirty yellow color; though sometimes the color is more bright, and the appearance is more bilious; and in those cases in which hemorrhage from the bowels had occurred, the color was red, as if stained with blood. Sometimes there is a considerable amount of dark grumous, or coagulated blood. Independent of the specific local lesion which I shall presently describe, the mucous membrane, throughout a large portion of its extent, is sometimes found more or less injected, or otherwise changed from its healthy state ; this injected condition is however more frequently found to exist in separate zones or distinct patches. The morbid action indicated by this red color and altered appear- 214 TYPHOID FEVER. ance, has sometimes been so intense and protracted that an extensive softening of the mucous membrane is found to exist. In some protracted cases, the color, instead of being red, has a grayish cast. Sometimes there is a thickened condition of the mucous membrane, with or without a darkened appearance; while in other instances it seems somewhat diminished, and changed in consistence, so as to have the character of, or to " resemble, an unorganized pulp, spread like a layer of paste over the subjacent tissue." But the lesion to which reference has already been made, and which is believed to be characteristic of this disease alone, con- sists in the altered condition of those elliptical plates found prin- cipally on the surface of the ileum, and denominated Peyer's glands. The abnormal condition of these glandular patches varies in different cases, according to the violence and continuation of the diseased action, and the peculiar constitutions or susceptibility of the patients. In some cases there is merely a thickened con- dition of the elliptical patches, their edges being raised above the surface of the surrounding mucous membrane, with an engorge- ment of their subjacent cellular tissue. The surface of the raised plates may be smooth, or it may present a granular appearance. In others the morbid action has proceeded in such a manner as to produce redness and softening of the mucous membrane and cellular tissue; this is more commonly the condition of those cases which have an early termination. But in a vast majority of cases, in addition to a hypertrophied state of these glandular plates, they are found to be ulcerated to a greater or less extent. The ulcer may be a mere point on the surface of the plate, or it may occu- py the fourth, half, or whole of its surface; for in some cases the whole patch is destroyed, and its place occupied by an ulcerated surface, surrounded by a raised edge. All these different condi- tions may, indeed, be found in the same intestine; the glands in the upper portion of the tube being least affected, and the lesion being found more and more deeply marked as we pass down towards the ileo-caecal valve, in the vicinity of which the most numerous and extensive ulcerations are generally found, which sometimes involve the muscular and even the peritoneal coat, re- sulting in perforation of the bowel and the escape of its contents TYPHOID FEVER. 215 into the peritoneal cavity. The number of patches in which these pathological changes occur is quite variable, ranging, according to M. Louis and others, from twelve or less to about forty. But the ulcerations are not always confined to the aggregated glands, but those denominated solitary glands are often, I might say, more or less affected, especially in the lower portion of the ileum. These, by Bartlett and others, are called Bruner's glands, but this is erroneous, Bruner's glands being found in or near the duodenum only, while the solitary glands proper are spread over the whole surface of the small intestine. Changes of the mucous membrane, and occasional ulceration of the caecum and colon, have been observed, in protracted cases. That persons frequently recover from this disease, after ulcera- tion of the intestine has occurred, there can be no doubt; and it is believed that the lesion in such cases is so completely restored that not even a visible cicatrix remains, as no such appearance has been detected in the intestines of persons dead from other diseases, and known to have recovered from typhoid fever. As might be expected, the mesenteric glands always exhibit more or less pathological change from typhoid fever. Where death occurs before the end of the third week, the principal pe- culiarities will generally be found to consist in a rosy color, increased size, and softened consistence. In more protracted cases, the volume may be diminished, the consistence less soft, and the color will be changed to a gray, perhaps violet shade, and in some cases there are found purulent points containing a yellow deposit. The extent of the affection of these glands cor- responds very nearly, both in extent and degree, with the dis- eased condition of Peyer's glands. The glands of the meso-colon ., are generally more or less affected, and so, too, are the lymphatic glands throughout the system; and, since the mesenteric and lymphatic glands generally are not often changed from their nor- mal appearance by other acute diseases, their diseased condition may be regarded as, in some measure at least, pathognomonic of typhoid fever. The spleen is nearly always found enlarged, generally softened more or less, and darkened in color. The liver is less frequently affected, the most common change being that of softening, with 216 TYPHOID FEVER. some loss of color. Most generally, however, there is little evi- dence of disease, either in the liver or gallbladder. The pan- creas, salivary glands, and urinary and sexual organs are not affected by this disease, except incidentally, as in other fevers. The more minute and complex phenomena which have been the subject of observation by pathological anatomists, I deem it un- necessary here to detail. I will merely refer you to such writers as Louis, Chomel, Bartlett, Gerhard, and others, for further in- ^ formation on this subject. LECTURE XV. TYPHOID FEVER—Continued. Cause—Doctrine of Contagion considered—It is Infectious—Differ- ence between Infection and Contagion—Influence of Acclimation, Age, and Sex—Nature of Typhoid—Diagnosis—Prognosis— Treatment— General Remarks—Dr. Jackson's Method—Chomel's— Louis'—Statistics. In regard to the cause of typhoid fever, a great diversity of opinion is entertained, among the most learned of the profession. Some contend, with great earnestness, that it is specifically contagious, and cite instances that may seem difficult to explain, to sustain the contagious character of the disease. Others again, equally entitled to confidence, from extensive observations, express themselves without any doubt in regard to its non-contagious char- acter. It has always been a difficult matter to reconcile these apparently conflicting facts, and, in view of the fidelity of the statements, made by individuals standing before the world and the profession both unimpeached and unimpeachable, on both sides of the proposition, it may be thought impossible to do it. But in reviewing the whole subject, and examining the arguments and facts adduced by the partizans of both doctrines, I have at length, I think, discovered a satisfactory solution of the difficulty, by which the facts claimed by both are readily explained and recon- ciled. From its most general prevalence " where human beings are crowded together with insufficient or unwholesome food, in con- fined and vitiated air"—such as hospitals and ill ventilated prisons; the densely populated, crowded, and filthy portions of 218 TYPHOID FEVER. cities ; among the soldiers of large armies, in camps; and in the close and crowded holds of emigrant ships—the generally accred- ited opinion is, at the present time, with most members of the profession, both among contagionists and non-contagionists, that it is caused, in some way, by the effluvia arising from the decom- position of animal matter; or, in other words, that it results from a poisonous animal malaria. This conceded, it does not matter in what this effluvia consists; whether it be in the form of animalculae, mephitic gas, or animal fungi—either of which will equally explain the facts. But from this statement it will be seen that it may be either a contagious or infectious disease, and the difficulty is not thereby removed. Let us see, however, if it can not be reconciled better with one than the other. The laws of contagion are peculiar, and subject to few excep- tions. All those diseases admitted to be contagious have their uniform periods of incubation, or latent periods; their regular rise, progress, and decline, without any considerable variation, unless by some accidental occurrence they are made otherwise; and they are uniformly propagated by exposure. Such, it may be said, is the case with all those contagious diseases of which we have any knowledge, and we conclude, therefore, these are the laws of contagion. In this definition we include that class of contagious diseases known to be propagated without the necessity of actual contact; making a distinction between those thus com- municated and those requiring immediate proximity to the poison to be taken—such as venereal, gonorrhea, itch, &c, which clearly are not subject to the same laws, and I apprehend should not be comprehended in the term contagion, in its ordinary acceptation. These latter diseases, though they may be communicated directly from one person to another, are not governed by those general laws peculiar to the class of contagious diseases of which I am speaking; and I think, therefore, should be regarded as propa- gated by what may be styled limited contagion, or perhaps with greater propriety, local contagion. How is it with typhoid fever ? Its latent period is irregular and uncertain, varying from twenty-four hours to nearly as many days; and its rise, progress, and decline are little more regular TYPHOID FEVER. 219 or determined than its period of incubation—in some instances continuing from four to six weeks, in others terminating in a few days; and exposure to the disease is not necessary to its propa- gation, for it often has a spontaneous origin. We conclude, there- fore, it is incompatible with the known laws of contagion, and hence cannot be contagious. How, then, it may be asked, can we explain those instances cited by Nathan Smith, M. Gendron, and others—and no doubt similar instances have been observed by most physicians of any considerable experience and observation—where patients having the disease in full force, have been taken into a healthy atmos- phere, where it had not previously prevailed, and from which other cases have arisen. This, then, is the question, and the only one that can present any difficulty in the way of reconciling its character with the ordinary principles of infection. Let it be remembered that contagion is capable of being communicated di- rectly from one person to another—in other words, some recon- dite influence is thrown off from the system, in a certain stage of contagious disease, which, coming in contact with a system not previously protected, produces a disease of like character. Not so with infection. This, though governed by certain laws pecu- liar to itself, is caused or developed by an influence generated out of the system, and a person exposed to it, and susceptible to its influence, will have a disease similar, in all its essential charac- ters, to the diseases of others, exposed in like manner. This in- fectious matter may be furnished by the human system, in health or disease, or by other animal matter, or by vegetable substances undergoing a change by decomposition, and producing an agent capable of developing a disease of a peculiar and specific charac- ter, each in its own way, and of its own kind. It has already been said that the weight of testimony concedes to typhoid fever an origin from the decomposition of animal matter or idio-mias- mata. Thus a case of typhoid fever, originating from any of those circumstances capable of producing it, and leaving behind all those materials to which vomica can adhere, taken into an at- mosphere pure and healthy, may, during the continuance of the disease, eliminate from the system animal matter, or some of its elements, in sufficient amount, which, when favorably circum- 220 TYPHOID FEVER. stanced, will undergo further change by decomposition, and thus produce or generate a poison of a similar character to that which infected the system first diseased, and in that way propagate the disorder to those about it. Now here is the distinction. The poison generated at certain periods of contagious affections produces, as eliminated, or formed, without any subsequent change of the poison, a similar disease in those exposed to it. The infectious poison, on the other hand, requires a combina- tion of circumstances extrinsic to, and in no wise necessarily connected with the system thus disordered, for its production; but animal matter, in some way, must be furnished, either after it is thrown off from the system in its diseased condition, or from others in a healthy state—or it may be furnished from some other source—though most probably it is eliminated during the existence of organic or functional derangement. In either case, however, a subsequent change or decomposition in the matter thus furnished, is necessary to its infectious properties. In this view, typhoid fever is infectious to the same extent that intermittent or remittent fever is, and requires an exposure in a similar way, with this difference only—one is produced by vegetable and the other by animal malaria, the two poisons being, no doubt, gov- erned, in some respects, by different laws. In regard to the supposition that the insusceptibility to £ sec- ond attack affords an objection to its infectious character, I will barely remark, that many other propositions are better determined than the immunity thus claimed. In New England, where I was raised, and where typhoid fever may be almost regarded as en- demic, second and third attacks were too frequently witnessed to constitute mere exceptions to a general rule ; and I am acquaint- ed with no facts which, in my judgment, show an immunity from second attacks of this disorder, beyond the acknowledged ten- dency of infections generally to fortify the system, which has sus- tained an attack, against future invasions. The power of differ- ent infections probably differs in this respect, but in no case are the exemptions so constant as to establish a law. In fact the ap- parent prophylactic influence of this class of diseases seems to rest upon the principle of acclimation—a principle so universally recognized that no argument is necessary for its support. TYPHOID FEVER. 221 The human system in some cases adapts itself to surrounding circumstances with great facility, but in others with greater tar- diness, and more difficulty ; and, though a thorough acclimation does afford protection, more or less reliable, still it cannot be pre- sumed to afford sufficient immunity to be considered a law. This protective or prophylactic influence may, no doubt, as has been already observed, operate in different degrees in different infec- tious disorders, and probably varies, also, in its operation upon individuals of various constitutions and idiosyncrasies ; and the very irregular and uncertain protection which appears to follow attacks of typhoid fever, may evidently be attributed to the same principle — the fortifying influence of acclimation. The period of life at which this disease generally occurs, though in no wise affecting the question in regard to contagion, is, never- theless, a subject of much interest; and affords, as I think, much strength to the views heretofore explained in regard to the cause of the disease. It cannot be questioned, as the statistics of the disease amply show, that its most frequent and general occur- rence is at a period of life, when exposures to the cause supposed to produce it, are more general and complete. Children, it is said, under ten or fifteen years of age, rarely have typhoid fever, and persons over the age of thirty-five or forty years, are not often known to be attacked. This accords with what we would reasonably suppose, in view of the idio-miasmatic origin of the disease; for before the first period above mentioned, children are rarely found under those circumstances necessary to the produc- tion of the malarial cause. But where they are so exposed, they are not exempt. This accords with my own observation, especially during the past season ; for among the children of our common schools, where some hundreds are congregated in one building, and fifty or sixty in a single room, of various ages, from four to sixteen, I have seen a number of cases, having well defined symp- toms of typhoid fever, blended with more or less symptoms of a remittent character ; thus showing that childhood is not exempt from mere considerations of age, where surrounding circumstances favor its production. So, also, it may be said of individuals past the middle age of life, in whom the statistics show a comparative immunity; the cause is not to be found in a positive exemption 222 TYPHOID FEVER. after that period, but in the fact that persons beyond the age of life referred to, are rarely found in our armies, on board ships, or peopling the hospitals of our maritime marts. These exemptions, it will be found by reference to the statistics on this subject, be- come more general as age advances, and in this they evidently correspond with the usual exemptions of aged persons from expo- sure to the cause of the disease. It is said that the influence of sex has to do in the production of typhoid fever. This, however, is variously estimated by dif- ferent writers ; some representing females, and others males, as more frequently subjects of the disease. We may, however, reasonably infer that this difference is owing mainly to the pecu- liar circumstances connected with these observations, and that little, if any, difference exists in the liability of the two sexes. Thus, where the disease was observed in private families, in which females were more exposed by nursing and attendance on those diseased, and in certain factories where females were the prin- cipal operatives, physicians have reported its occurrence as more frequent among females; but where the observers were situated in hospitals, and other places in which males bore a more con- spicuous part, during the prevalence of the disease, they have furnished us with statistics showing its greater prevalence among males. In regard to the nature of typhoid fever, but little need be said,— in fact, but little of a very satisfactory character can with truth be said, in relation to it. From the enteric phenomena, so uniformly presented in fatal cases, it has been supposed by some that these local lesions constituted the essential disease. But its early symptoms clearly imply embarrassment of function, else- where located, and in no wise connected with these enteric lesions, manifested at a much later period; and though the local difficulty may be so constant in its connection with the essential and prim- itive disorder, as to constitute one of its characteristic phenomena, yet the real disease may be looked for elsewhere. Thus, the morbid impression may first be made on the great nervous centers, presiding over all the functions of organic life, and be thence re- flected upon the particular parts finally involved by reason of a peculiar affinity existing between the specific cause or poison that TYPHOID FEVER. 223 produced it, and those particular glands. Or, more probably, the first morbid influence may be exerted on the blood, through the medium of the lungs, and perhaps other organs, and thus con- taminate the whole circulating fluid ; and the specific affinity of the poisonous elements, as above suggested, might tend to pro- duce this definite local determination. This latter supposition is strongly corroborated, when we consider that the special function of Peyer's glands appears to be the elimination of effete, putres- cent or poisonous matters from the blood. The uniform and peculiar local lesions found in typhoid fever, differing in so many respects from the usual appearances attendant upon the ordinary enteric or gastro-enteric affections, leave no doubt that its cause is equally peculiar and specific, and since we know of no direct way in which the original morbid impression is likely to be made upon the parts found involved, it does not conflict with well estab- lished physiological and pathological rules, to suppose the local phenomena may result from a secondary impression. This view accords with what is well ascertained to be the case in many other diseases, and some, too, of an infectious character. This disease cannot be regarded as inflammatory in its char- acter ; for inflammatory action is always attended by an unusual quantity of fibrin in the blood; while in typhoid fever that ele- ment is generally below the proportionate amount found in healthy blood. Besides, the disease does not exhibit that high grade of symptoms which characterizes inflammation. If it were a disease of a specifically inflammatory character, as supposed by some, it would never be relieved until the specific influence was exhausted, or, in other words, until the specific inflammation had run its course ; which does not accord with experience. In its early stage, before the local phenomena are developed, it is not an unusual occurrence, by a protracted course of free perspiration, to arrest the disease. This I have witnessed in numerous cases, and it has much influence on my mind in determining the nature of the disease. The diagnosis of typhoid fever is a subject of much import- ance. Although I have already specified the principal diagnostic characteristics, while speaking of the general course and symp- toms of the disease; yet I will here recapitulate, for the purpose 224 TYPHOID FEVER. of impressing them more deeply on your minds, by presenting them in a distinct group, separated from those symptoms which belong in common to this and other diseases. The initiatory stage presents some peculiarities, which "should receive attention, with a view to diagnosis. While this stage is quite uniformly more slow in its developments, and more pro- tracted than in other forms of fever, its symptoms indicate an involvement of the nervous system from the very first, to an ex- tent peculiar to this disease ; and these two circumstances, taken in connection with the appearance of the tongue, which is gen- erally clear from fur, and healthy in appearance, or at least not so much affected as in the commencement of fevers generally, afford good grounds to anticipate the development of typhoid fever. The peculiar character of the diarrhoea, is a symptom of some consequence in this relation. While diarrhoea often accompanies attacks of other forms of fever, it is seldom so persistent and unyielding as in this disease ; nor is there in other disorders that peculiar dirty yellow color and offensive smell, which characterize the evacuations in typhoid fever. The frequency of the pulse, together with its hard, wiry, yet feeble character, is characteristic of this disease. True, we often have a rapid pulse in congestive fever, but it does not seem to combine the qualities of irritation and debility in the degree gen- erally observed in typhoid; and in other diseases, an acceleration of the pulse is generally attended with an increase of volume and force. In typhoid, the pulse is seldom less thau one hundred per minute ; but whether more or less frequent, it is found to be small, wiry and feeble. There is a peculiarity of countenance presented by most pa- tients in this disease, which it is more easy to recognize than to describe. It is a kind of indefinite, vague expression; partaking, as it were, in many cases, of sprightliness and obtuseness; for, while the eye will appear to be unusually bright, especially in the early period of the disease, the features generally will present a dusky, unmeaning appearance,— showing that the lustre of the eye is not a reflection from the mind. Finally, the petechiae, which I have before so carefully and TYPHOID FEVER. 225 minutely described, when they make their appearance will leave you no longer in doubt. But you must learn to distinguish be- tween the rose-colored, lenticular elevations, the color of which recedes on pressure, and which are scattered over the surface, peculiar to typhoid, and the red, irregular, more numerous spots, which maintain their color under pressure, sometimes attendant on low cases of congestive fever. The prognosis of typhoid fever, under proper treatment, I regard as generally favorable. It is true, that the statistical reports of the disease denote that it has, under certain circum- stances, proved exceedingly fatal; while at other times, and in other places, it has appeared remarkably mild. These differ- ences, no doubt, result, in part, from variations in the intensity of the cause; but more, I apprehend, is to be attributed to differences in the modes of treatment. According to my own observation and experience, a harsh, debilitating mode of practice, in typhoid fever, always aggravates the symptoms, and tends to produce fatal results; while under a mild, sustaining, yet soothing course, few diseases of any gravity will so generally terminate in health. The unfavorable symptoms in a given case, may be thus enu- merated : Delirium, or great mental depression; coma ; great subsultus tendinum; spasmodic action, or rigidity of the muscles ; excessive diarrhoea; involuntary discharges ; hemorrhage, espe- cially from the bowels ; an extremely frequent pulse, say 130 or more, with great feebleness; coldness of the skin, attended with a clammy sweat; profuse perspiration, with great prostration; and very great abdominal distension. The favorable symptoms are, of course, the opposite of those just mentioned; but I may remark, that, however grave the symptoms may have been, a tendency in a part or all of them to yield under treatment, or the spontaneous resolution of any of them, as evincing the renewal of vital energy, will be regarded as favorable. The treatment of typhoid fever has been, and still is, a subject of much interest and investigation. Many methods of treatment have been employed by different members of the profession, who have, of course, been governed by the theory they have enter- tained as to the nature of the disease. Experiments have been 15 226 TYPHOID FEVER. made, both in private practice and hospitals, for the purpose of determining, if practicable, which of the many methods proposed would lead to the most favorable results. But all these experi- ments have seemed to fail in the establishment of a mode of treatment, satisfactory to the mass of the profession. Experi- ments, made under circumstances highly favorable for arriving at the truth, have, under different practitioners, resulted in unsettling the therapeutics of the disease, by the introduction of new methods of management, which, while they supplanted existing methods, were at diametrical variance with each other. The consequence is, that the student cannot possibly derive from the books such a system of medication for typhoid fever as will be satisfactory to him, or command his confidence. To verify this assertion, I shall now give you a synopsis of some of the various methods which, under endorsement of influential practitioners, are placed in competition for professional favor. Dr. Jackson, of Boston, after many observations and experi- ments, both in private practice and in the Massachusetts General Hospital, recommends the following course: First. Cessation from labor ; abstinence from food, except of the simplest, liquid kind; and a state of repose. Second. Free evacuations as soon as possible; " it is especially important they should be made as early as the third day." First, " an emetic of tartarized antimony," " then an active cathartic, or the two combined." If there is constipation, an active enema at first, to " facilitate the action of the cathartic." " If vomiting and purging are not followed by great relief," venesection should be practiced on the following day, unless the constitution should be feeble, or the case very mild. Third. If the disease has not subsided give tartarized anti- mony every two hours, in increasing doses; keep the bowels open, and for two or three days "calomel should enter into the medicine used for this purpose; not, however, more than one moderate dose in a day." " It should be noted, however, that, usually, after the antimony has been given for forty-eight hours, this will act sufficiently on the bowels, and that sometimes it must be restrained by opium." TYPHOID FEVER. 227 And yet a scientific practitioner advises its employment, even in typhoid fever. Fourth. " When the disease subsides early under any active treatment," "the patient should be restrained from solid food for two or three days, at least, after he has appetite for it;" and " then use vegetable food in small quantities, for two or three days more." Should be confined to his room, but not wholly to bed, and not talk on business or any interesting subject, until convalescence is fully established. Fifth. " Evacuations, vomiting and purging, at least may be resorted to with advantage in the second week;" and " perhaps some benefit may be obtained from antimony, in small doses, when commenced in that week." But " after that period no active treatment should be employed, or none that will cause any serious inconvenience to the patient." Sixth. The usual admonitions as to diet, and the obvious duty of watching the progress of convalescence, and so guiding the patient and guarding him from the dangers of indigestion. Seventh. The use of cordials to be regulated by the peculiari- ties of the case. Seldom do hurt at a late stage of disease, where patient is enfeebled, and no more is used than is grateful to the patient. " When he spontaneously demands them, as late as the third week, they will almost always be found useful. By cordials are meant vinous liquors. Cider has been commonly found grate- ful, beginning with an ounce, two or three times a day, and in- creasing according to the effects. Sound beer or ale is more rare- ly, but sometimes grateful. In patients much exhausted, how- ever, the strong foreign wines, Sherry, Port and Madeira, are found most useful. The articles may be diluted, or may be em- ployed to season articles of diet, or may be given alone, accord- ing to the taste of the patient." " Dr. Jackson's faith in the usefulness of calomel was shaken a few years after the commencement of his practice; when the Massachusetts General Hospital was opened, he still resorted to it occasionally during the first few days of the disease, and par- ticularly when any secondary inflammation supervened; but confi- dence in the specific power of the medicine grew less and less, 228 TYPHOID FEVER. and since 1830, its use in the hospital has been nearly abandoned." Bartlett on Typh. §c. page 148 et seg. The following synopsis of " ChomeVs Method" I condense from Bartlett on Typhoid, &c, page 158 etseq. " The treatment of typhoid fever has been, especially for the last fifteen years, a subject of great interest amongst the physi- cians of the large hospitals of Paris. It was in these institutions, that the symptomology, diagnosis, and pathology of the disease were first thoroughly studied ; the opportunities which they offer for a careful trial and comparison of different modes of manage- ment are unequaled; and these opportunities have been very faith- fully made use of by a considerable number of cautious, accurate and philosophical observers. Amongst them may be mentioned, particularly, and this without any invidious distinction, Chomel and Louis. Chomel has been for many years attached either to La Charite* or to the Hotel Dieu; he has grown old in the constant and conscientious study of disease; and, now, in the ripe maturity of age and experience, is unsurpassed in the capital of France as a man of practical sagacity and skill. I shall first give a summary of his practice in this disease." * His treatment is, for the most part, what is called rational or symptomatic. Simple and benign cases maybe very safely trust- ed, he says, to refreshing drinks, such as lemonade, currant water, orange water, or pure water taken at short intervals and in such quantities as the patient may desire; emollient fomentations or poultices to the abdomen, when this is painful; sponging the sur- face of the body, if the skin is hot; cold applications to the head, if painful; and hot poultices and sinapisms in case of drowsiness and disturbed sleep. He is inclined to think that a single moder- ate bleeding at the commencement of the fever may be of some advantage in modifying present symptoms, preventing ulterior complications, and influencing favorably the march and termina- tion of the disease. If the headache or pains in the abdomen are severe, leeches may be applied below the mastoid processes, for the former, and near the arms for the latter. For constipation, a gentle laxative ; for troublesome diarrhoea, rice water, injections of starch and water, &c. **'Lecons de Clinique Medicale. Par A. F. Chomel, p. 449, et seq." TYPHOID FEVER. 229 Strike out the recommendation for bleeding, and this is a truly rational, and I doubt not a successful mode of treating these mild forms of typhoid fever. Bleeding would I apprehend very often rob them of their mildness. Chomel " is inclined " to think favor- ably of it; I am not only "inclined," but constrained by reason and observation, to think otherwise. In what he calls the inflammatory form of the disease, Chomel adopts a more decided antiphhogistic course, such as bleedings, leeches, entire abstinence from food, &c. For bilious symptoms, as a yellow fur on the tongue, a bitter taste, nausea, vomiting bile, and constipation, he relies on the same treatment as for the sim- ple form. Seldom gives even an emetic, finding it unnecessary; though where the attack is sudden and the stomach oppressed by its contents, an early emetic would, he thinks, be useful. In the adynamic form he adopts a decided tonic and stimulant treatment, adapted to the degree of prostration and debility. Where the failure of muscular strength is extreme he gives tonics, aromatics and cordials, as cinchona, wine, camphor, ether, &c. He prefers cinchona in the form of an extract, administered in an aromatic potion to the amount of one or two ounces in twenty- four hours. He also employs it in decoction as a drink and at the same time gives either the decoction or extract in the form of enema. While the adynamic phenomena are moderate, and before the free use of cinchona is deemed necessary, he uses light wines, as Bordeaux and Burgundy; when these phenomena are more strong- ly marked, he resorts to the stronger wines, such as Madeira, Sherry and Port. Ether is to be used when there is an urgent necessity for rapid and immediate stimulation, and with this he combines the extract of cinchona. Camphor he rarely uses ex- cept as an ingredient in tonic injections. He speaks more deci- dedly of the evils attending the application of blisters, than of any benefits to be derived from them. For hemorrhage he recommends the usual means. A cold astringent solution for epistaxis, or if necessary plugging the nos- tril. For hemorrhage from the bowels, iced water for drink, in injections, and applied upon the abdomen; lemonade, and extract of rhatany. Local inflammations he meets by local and general 230 TYPHOID FEVER. bleeding, adapted to the circumstances of the case. "If the pa- tient is in a condition not likely to tolerate these measures, dry cupping and sinapisms in the neighborhood of the inflammation, which is most commonly a pneumonia, may be substituted. Gentlemen, I have never seen, nor do I expect ever to see a case of genuine typhoid fever, in a condition to "tolerate" gen- eral bleeding to the extent of controlling pneumonia, or any other local inflammation. The idea appears to me to be utterly pre- posterous. But mark what follows: "When these complications take place, during the adynamic period, or in the adynamic form of the disease, they do not con- tramdicate stimulants and tonics. The local inflammation, un- der these circumstances, will be more surely relieved, or enabled to relieve itself, by a removal of the extreme general debility, through the agency of a tonic medication, than by the abstraction of blood." How ingeniously men of science can frame language into senten- ces, which may serve as light craft to enable them to navigate the shallow waters of inconsistency, into which they are often carried by the current of false theories. I suppose the learned author almost imagined he heard some inquisitive student inquire, Would you seek to check epistaxis or hemorrhage from the bowels, if a pa- tient had local inflammation ? or, suppose that while you were giving cinchona and stimulants, to keep a patient from sinking, you should discover symptoms of pneumonia, would you suspend them, and open a vein ? And, gentlemen, if this be sound old school authority ; if tonics and even stimulants are not contramdicated, in certain condi- tions of typhoid, by pneumonia, and other inflammatory compli- cations ; let me once more inquire, what becomes of the long and strenuous contentions, maintained by the advocates of the doc- trine, that sulphate of quinia is incompatible with inflammation, or even fever, in intermittent and remittent fevers ? Surely, the same rule should apply in all these cases. In 1831, Chomel commenced the trial of chloride of soda, in typhoid fever, in connection with the system of management of which an outline has just been given. He administered it in a sweetened solution of gum arabic, containing from one grain to TYPHOID FEVER. 231 one grain and a half to the ounce. Of this solution, his patients generally took from fifty to ninety ounces in the twenty-four hours. Injections of the same solution were given morning and night; the body of the patient was freely washed, several times a day, with a solution of the chloride in water ; poultices moist- ened with it, were applied to the abdomen ; the bed clothing was sprinkled with it, and vessels containing it were placed under the bed. After employing this additional treatment from 1831 to 1834, he says : " Finally, although the results of this treatment have been very different in different years, it has still been attended with more success than any other. Several distinguished prac- titioners have informed us that they have arrived at the same conclusion. We shall continue, then, our trials with a mode of treatment, which, combined with the rational method, has thus far given us, notwithstanding its failures, more satisfactory re- sults than any other." " Subsequent to this, however,in 1835," remarks Professor Bartlett, " with a frankness, a conscientious- ness, a single-minded regard for the truth, which it is beautiful to witness, he says : ' The hopes, which our first trials with the chloride had permitted us to conceive, have not been realized. The results which have thus far been obtained, are not sufficiently encouraging to justify us in the expectation of continuing our trials with much chance of success.'" This confession of the failure of chloride of soda, which at first gave such hopes of success, when we remember that it was only employed in addition to Chomel's ordinary course, certainly does not indicate that the results of his method without the chloride, could have been very satisfactory. And should not the same honest regard for truth, which led him to record its failure, have called forth an expression of distrust in regard to some of those more heroic measures which he employed, ana evidently with as little advantage ? Why did not he, and why do not the profes- sion generally, honestly confess that the lancet, antimony, and mercury have failed, as they evidently have, to justify the reli- ance which has been placed in them ? Prof. Bartlett well re- marks that such frankness " is beautiful to witness;" and its rare occurrence contributes much to increase its beauty. How easily 232 TYPHOID FEVER. might the temple of medical science be festooned with such orna- ments, should her votaries generally follow the example set by the venerable Chomel in this instance. Louis' method of treatment in typhoid fever, may be very briefly stated. He commences with blood-letting, proportioned in extent and repetition to the strength and vigor of the patient, and the severity of the disease. This, he thinks, should be done within the first ten or twelve days. Thinks it generally shortens the duration of the disease a few days ; diminishes its gravity, and lessens its mortality. Has not, however, found its immediate effects very obvious. It appears, sometimes, to meliorate urgent symptoms ; at other times, to aggravate them. This measure may be aided by suitable mucilaginous drinks, emollient enemata, and cool, fresh air. If diarrhoea be persist- ent, a small injection, containing a few drops of laudanum, should be used. Tonics are considered very useful and necessary, when the general febrile excitement has subsided ; where there is extreme prostration; when the pulse is only moderately accelerated, or not at all; and when there is slight diarrhoea, and little or no tympanites. Prefers sulphate of quinine to any thing else, in doses of eight to twenty grains, given in mucilage. Gives cin- chona, in infusion, for drink; and in diarrhoea, administers tome and astringent injections. He condemns and rejects blisters in this disease. He thinks opium of use in allaying nervous symptoms, when the febrile ex- citement is not high. He has seen little or no benefit from leech- es, or the application of ice to the head, in violent delirium; but, if the face is flushed, advises another moderate bleeding, even as late as the fifteenth day; although the patient may, already, have been twice bled. The following are his concluding words on this subject, as quoted by Bartlett, from whose work the summary just read is an abridgment. " It results from all that precedes, upon the effects of the prin- cipal therapeutic agents at present employed in the treatment of typhoid fever, that these agents possess a favorable, though limited influence, upon the march and termination of the disease; and TYPHOID FEVER. 233 that an impartial examination of facts points out, with a good degree of precision, the best method of employing the three prin- cipal means which experience has placed in our hands, to wit: bloodletting, evacuants and tonics. Furthermore, the limited degree of success which has thus far been obtained, ought not to discourage the friends of science, nor prevent them from hoping, that a more appropriate and successful treatment of this disease will yet be discovered. Who would have foreseen the effects of opium, of cinchona, or the preservative power of the vaccine virus ? What accident and observation have hitherto done, they are still able to do; without doubt they will do ; and therapeutics, like the other parts of science, ought to hope and to expect every thing from observation." Here, you perceive, we have a confession, also, of the failure to a considerable extent, of the mode of treatment pursued; but it is not coupled with a conviction that the active, I might say heroic, measures employed, are of doubtful propriety. No ! bloodletting, evacuants and tonics, have been placed in our hands by experience ; and though experience has not demonstrated their efficiency, especially as regards the depletive measures; nay, though suspicions are raised that they sometimes, at least, aggravate urgent symptoms,— still, until accident or observation shall give us some better mode, we must continue to use these active meas- ures. Why not trust to the efforts of nature, where it is doubtful whether your measures will assist, and where it is probable they will embarrass those efforts? If you must give something in these cases, let it rather be an agent which will have no effect at all, than one of positive power, which may be exerted against the health of your patient. When we turn to the statistics of the disease, under the meth- ods of management just described, and others of a similar char- acter which might be noticed, we certainly find but little encour- agement to follow any of these plans of treatment. The bills of mortality, wherever the disease has prevailed in a severe form, present melancholy evidence of the failure, indeed, I should say, the injurious consequences, of such medical interference. Making all proper allowance for the difference in favor of private over hospital practice generally, I solemnly aver, that I have never 234 TYPHOID FEVER. witnessed the prevalence of typhoid fever in a form that would justify one-fourth the average fatality recorded in the books; and I have been an attentive observer of the disease in New England and in Ohio, for about twenty-five years. Just listen to the authorities. During fourteen years, from 1822 to 1835 inclusive, the average ratio of deaths to the cases treated, in the Massachu- setts General Hospital, was as one to seven, or more than fourteen per cent. During one year of this time, the mortality was one in three and a half cases, or more than twenty-eight and a half per cent. The reports of Louis show a mortality of over thirty-seven per cent., and in Chomel's wards, in the Hotel Dieu, about one- seventh of the cases, or over fourteen per cent., terminated fatally. I trust, gentlemen, your practice will never exhibit results like these. LECTURE XVI. TYPHOID FEVER—Continued. Discussion of Treatment continued—Dr. N. Smith's Method—Re- view of the Authors cited—Proper Treatment—Remedies Recom- mended— Cases cited"—Typhoid may be cut short—Further Measures for Protracted Cases—Management of Convalescence. In my last lecture I gave you summaries of three modes of treatment, in illustration of the great diversity of methods adopted by the profession, and of the unsettled state of the medical mind in regard to the therapeutics of typhoid fever. Two of the meth- ods referred to—those of Jackson and Louis—are, you have ob- served, decidedly active and depletory, while that of Chomel is more moderate and expectant, mixed, however, with a little hero- ism, and experiments with suggested means. I will give a synopsis of Dr. Smith's mode of treatment be- fore I present my own, merely introducing it with the remark that, though I differ from him as to our ability to cut short the disease, in its early stage, in many cases, I regard his method as much more philosophical than that of any other author whose treatment I have read, and that, with a few modifications, my own experience justifies me in speaking of it in a highly favorable manner. I therefore call your special attention to the method of Dr. Nathan Smith, as found in Professor Bartlett's work on Typhoid, &c, pages 154 et seq. He first remarks, that he had never seen a single case in which he was satisfied he had been able to cut short and arrest its pro- gress ; and that, where the disease is going on regularly in its course, without any symptom denoting danger, and without any 236 TYPHOID FEVER. local distress, active interference will be likely to do more harm than good. Under such circumstances, he thinks, no medicine should be given. He is convinced that all powerful remedies or measures, in the early stage, do harm, and that patients treated with them in the beginning, do not hold out so well in the latter stages of the disease. He has seen many cases in which persons in the early stages of this disease were moping about, not very sick, but far from well, and who, upon taking a dose of tartrate of antimony, have been immediately confined to their beds. He thinks that in simple, mild forms of the disorder, " we had better leave the disease to cure itself, as remedies, especially powerful ones, are likely to do more harm than good." He advises simple diluent drinks, a very little farinaceous food, and the avoidance of all causes of irritation. He opposed the plan of general bloodletting at the commence- ment of the disease ; would bleed only when there was " uncom- mon pain in the head, accompanied with great heat in that part, a sense of fullness, and a throbbing of the temporal arteries, or marks of congestion in the viscera of the thorax." Here he thinks that the loss of twelve to sixteen ounces of blood will often mitigate the severity of the disease. The immediate effects of bleeding have not, however, appeared to him very obvious, and he says that where the pulse is very frequent, the operation is seldom or never attended with any advantage. Emetics are recommended by Dr. Smith, only where there are nausea and oppression, either at the commencement, or during the progress of the disease. His favorite articles are ipecacuan- ha, eupatorium, or sulphate of zinc, given either singly or com- bined. Tartrate of antimony he looks upon as an inappropriate and unsafe remedy. The bowels should be kept open by gentle laxatives, but active and indiscriminate purging he considers hurt- ful. Blisters, he thinks, may as well be generally dispensed with; they may relieve local pain, but are sometimes injurious. Stim- ulating remedies internally, with external heat, to excite active perspiration, are attended, he thinks, with bad consequences, at all periods of the disease. Opium, he says, may be used with advantage, for the purpose of procuring rest and quietness during the night, when it is not contraindicated by high febrile excite- TYPHOID FEVER. 237 ment and pain in the head, and, in combination with ipecacuanha and camphor, to restrain immoderate diarrhoea. He has seen, in many instances, very serious evils from the specific action of mer- cury, but no benefit. Cinchona he has found to produce a good effect in some cases, where the surface was cold, and also where there was hemorrhage. The mineral and vegetable acids, the alkalies—refrigerants, as they are called—such as sulphate of magnesia, super-tartrate, and nitrate of potash, he regards as un- important or questionable remedies. The most effectual refrigerant and febrifuge, in the hands of Dr. Smith, consisted in the free use of cold water externally. He very strongly commends this measure. He directs the pa- tient to be uncovered, and then sprinkled or dashed repeatedly, with pure cold water. He allows cold water as a drink, as freely as the patient may desire, during the whole course of the disease. As to the general care of a patient in typhoid, or, as he calls it, typhous fever, he says: " He should be kept in a spacious room, the larger the better. His bed should be of straw or husks, espe- cially if it is the warm season; and it should not be placed in the corner, but brought out into the room. We should contrive to have a current of air pass over the bed, by means of doors and windows. * * * In the warm season of the year, the win- dows should be kept open night and day. All the furniture should be removed, except such articles as are required for the patient's use. The windows should be darkened, or something opposed to the light in such a way as to still admit the air. The room should be kept as quiet as possible, since noise is injurious, and no more persons should be admitted than are necessary to take care of the patient, which will, if he is very sick, require the labor of more than one. " The room should not be carpeted, and the floor should be often washed with pure water, or soap and water, and in the hot season, it, as well as the walls, may be kept wet with water during the heat of the day. " Cleanliness is absolutely essential to the patient's comfort, and no dirty dishes, or useless medicines or food, should be suf- fered to remain in the room. All excrementitious matter should be removed immediately. In the warm season of the year, the 238 TYPHOID FEVER. bed and body linen should be changed every day, and in the cold, every other day, at farthest. " The patient's body and limbs should be cleansed every day with a piece of sponge and warm water, or soap and water. If a male, he should be shaved every day, or every alternate day; and if a female, with long, thick hair, it should be cut off, or thinned, so as to leave but little of it the full length."* Having now put you in possession of the views of treatment of four eminent practitioners, of about equal respectability and au- thority in the profession, I might raise the question, which should we follow ? And I frankly confess that, in the absence of expe- rience to aid me in the solution of the question, I should not be able to make a satisfactory selection. I should doubtless hesitate to adopt the apparently inefficient placebo method of Dr. Smith, unless, like him, I believed it impracticable to arrest the disease, even in its early stage; I should fear to employ the lancet, and tartar emetic, and purgatives, with Jackson, Chomel, and Louis, for they do not agree with each other in regard to some of these; they evidently are not satisfied with their own practice, and the published statistics demonstrate its failure, if not its inju- rious effects. And thus, in the present state of medical know- ledge in regard to this and other diseases, the inexperienced prac- titioner is compelled to choose between variant plans of treatment, and probably sacrifice valuable human life in experiments to de^ termine what mode of management is best adapted to cure. Having myself experienced the embarrassment resulting from this confusion and clashing of theories, I feel anxious to define a mode of treatment which, after years of observation and expe- rience, I have adopted; which, by the institution of efficient means, shall cut short such attacks as are susceptible of being arrested; and which, at the same time, by the avoidance of all harsh, irritating, and debilitating measures, will leave the patient all his constitutional vigor with which to bear up under the dis- ease, if it must run its course. If I shall succeed in so present- ing such a course of management as to gain your confidence, and induce you to give it a fair and impartial trial in future practice, * Smith's Medical and Surgical Memoirs, pp. 95, 96. TYPHOID FEVER. 239 I shall feel that I have not only rendered you a service, but have subserved the cause of humanity. In the treatment of typoid fever we should aim to eliminate from the system the malarial poison, by such means as shall not diminish the vital forces, nor hasten the development of the spe- cific intestinal disorder; and we should relieve the case from the depressing influence of periodic or marsh malarial fever, which, in this western country, very often complicates the attack at its very commencement. Having treated the case with reference to these two indications, should it not then be arrested, a third gen- eral indication will remain to be fulfilled, and that is, to foster the strength and vigor of the patient, and thus enable his system to endure the force of the disease, or possibly throw it off. I need not speak of the two indications first named separately, because, fortunately, they do not contrai'ndicate each other, but the remedies adapted to fulfill one, are at least corroborative of the treatment called for by the other. Where there is reason to suspect the influence of marsh malaria, even though the periodic tendency were so obscure as to be scarcely recognized, I should at once exhibit the antiperiodic agents. I would give the quinine and iron, mixed in equal quantities, in doses of three grains each, every two hours, until cinchonism was produced, unless the fever should evidently rise; in that case, I might suspend the antiperi- odics until evidence of a remission, more or less perfect, in the fever, had made its appearance, employing, in the meantime, such palliative measures,—as the alkaline and whisky sponge bath, gent- ly fanning the head, if it were hot, and diluent teas,— as would tend to lessen febrile excitement. But generally you will find the fever mitigated by the direct influence of the quinine and iron. Their administration will generally produce a gentle dia- phoresis, and a remission, if not an intermission, will follow, which in some instances will be an end of the disease, the patient being entirely relieved from the morbific influence. This is the very result at which I should aim at this stage of the case, and, to make its attainment the more probable, I would advise the use of mild, unirritating diaphoretic and diuretic medicmes, to be used in alternation with the quinine and iron. For this purpose, make a solution of acetate of potassa, ten grains to an ounce of water, 240 TYPHOID FEVER. and give one teaspoonful every two hours, alternating, as before remarked, with the quinine and iron. This may be continued, even though it should appear proper to suspend the antiperiodics. As adjuvant to these remedies, let the patient drink freely, as he may be willing, of an infusion of mullein, which is an unirritating yet efficient diuretic ; or, if the stomach shows signs of irritation, indicated by a red tongue, the marsh mallows (Althaea officina- lis') may be substituted. By such a course of treatment you will seldom fail of making a manifest impression, even if you do not completely arrest the fever the first day. If, however, the anti- periodics are suspended because of the rise of the fever, or should fever rise the second day, in all such cases, calm down the fever by the soothing diaphoretic and diuretic agents, and by bathing and fanning the surface, and again administer your quinine and iron as the fever subsides. The second day's treatment will, almost without fail, arrest the periodic complication, and, if the typhoid disease do not disap- pear under the reactive energy of the system, it will not be in the least degree aggravated by the measures I have recommended; but very often both morbific influences will be eliminated or dis- missed together, and the patient recover, after only two or three days' confinement. Upon this subject, Gentlemen, I am not talking at random;— and although I cannot claim to " speak by the book," I can do what is better, I can speak from experience. I have seen scores of cases resolved at once by the simple measures I have mention- ed, which I am confident would have developed the grave symp- toms of typhoid fever, and in some instances would probably have proved fatal, under another plan of treatment. I will mention a case in point. Not long ago I was called to a family, three of whom were down with unmistakable signs of typhoid fever. One of them was exceedingly sick, and died in a few days. The other two lingered a week or two longer, and recovered. They were all under the management of another physician previous to my being called. The two cases which recovered were too far ad- vanced to be relieved at once, yet the antiperiodics exerted a beneficial influence on the symptoms of both, and probably short- ened the duration of the disease. Two other members of the TYPHOID FEVER. 241 family were taken with the same symptoms as the first three, and were tending evidently to follow the same course. These were both relieved at once by the treatment just before described, without an emetic or cathartic or the loss of a drop of blood. Where I had no reason to suspect the presence of marsh malarial influence, I should not deem it necessary to employ the quinine and iron, though even then they would do no harm. I might give them with a view to their febrifuge effect, but not to the same ex- tent as when I desired their antiperiodic influence. But whether the quinine and iron were or were not deemed advisable, in a case of uncomplicated typhoid fever, I should still resort to the other measures named. I should bathe the surface as in other fevers, to allay the febrile excitement, and I should, by the use of the acetate of potassa, the infusion of mullein, our sudorific tincture, and other unirritating measures, endeavor to produce free per- spiration and diuresis, which when induced, I would maintain ten or twelve hours, with a view of eliminating from the system, by means of the renal secretion and cutaneous exhalation, the pois- onous element which was overwhelming the nervous forces, and vitiating the vital functions. And here, too, I should expect to succeed, as I have succeeded, in a large number of cases, in cut- ting short the disease, and restoring the patient to complete health in a very few days. I say, I should thus expect to cut short the disease in the com- mencement of its march, and I hold that such an expectation is not unreasonable, even if it had not been justified by experience. Why not arrest the morbific power of animal as Well as that of vegetable malaria before structural lesion has been produced ? Why not enable one individual to throw off a depressing influence which hundreds of others equally exposed are able to withstand without assistance ? But I would not expect to throw it off by bleeding or purging, pr even vomiting my patient. Bleeding will exhaust the system of the healthy as well as the unhealthy constituents of the blood, and is a measure directly calculated to depress, irritate, and prostrate the patient. Active purgation must unquestionably tend to produce intestinal irritation, and hasten the development of those enteric symptoms, which charac- 16 242 TYPHOID FEVER. terize the disease when fully established ; and thus add to the gravity of the most serious feature of the disorder. If there were evident accumulations in the bowels, I should re- move them by a mild enema, or if this did not succeed, I should administer an aperient, such as olive oil, or, if there were a manifest acid condition of the alimentary canal, our neutral- izing mixture* might be given, to the extent of gently moving the bowels. But beyond this I would not go in the use of purga- tives ; I would rather let the bowels alone, and even risk the evil effects of accumulations, than produce active catharsis. If there were nausea or vomiting caused by the presence of irritating substances in the stomach, their ejection should be fa- vored with a gentle emetic ; but no tartarized antimony, nor even ipecacuanha or other impalpable powder should be given, which, by adhering to the mucous membrane, may produce and keep up very serious irritation. If emesis is to be produced, let it be ef- fected by means of the infusion of Lobelia inflata and Eupatorium perfoliatum. This will accomplish the object with more prompt- itude, and less permanent prostration or irritation than any other. I have tried it too often to be mistaken; having never been disappointed by it, nor seen the least unpleasant result grow out of its use. If by the measures I have described, the disease be not arrested, you have a case on your hands which demands your most careful and prudent attention; and though you should not despair even yet of seeing the system rise superior to, and throw off the malady, still you should be prepared to see the fever pursue its wonted march, and develop the train of phenomena in greater or less se- verity, which ordinarily attend upon it. And again I warn you against an active, harsh interference, with a view to arrest the disease; for you will, by adopting such a course, aggravate the severity of the case, and diminish the chances of recovery. You had far better abandon your patient to the resources and energies of his own constitution, than attempt to bleed, vomit, purge, or mercurialize the disease from his system. On the contrary, let all your efforts be directed to calm nervous irritation, allay febrile * Best Turkey Rhubarb, Sup. Carb. Potass, Peppermint leaves and Pulv. Cin- namon, of each two drachms, to half pint hot water. Dose—tablespoonuil every hour. TYPHOID FEVER. 243 excitement, counteract and arrest local inflammation or conges- tion, and husband and sustain the vigor of the system. One of the most important measures, now within your control, is the bath. This may be pure, cold water, or broke water, ap- plied with a sponge to the whole surface, or broke water and whiskey, applied warm in the same way, and allowed to evapor- ate, where there is much heat; otherwise it should be followed by friction with a dry towel. The warm sponge bath followed, as it always is, by a more rapid evaporation than the cold bath, is a genial, yet efficient mode of reducing febrile heat, and when the heat in the head is great, the evaporation may be greatly favored by a gentle motion of the air produced with a fan. The bathing should be repeated every one or two hours, and in the manner most agreeable to the patient. The importance of this constant attention to the surface is self-evident to any one who duly appre- ciates the sympathy which exists between the cutaneous and mu- cous surfaces, and the influence which may, by this means, be exerted upon the capillary circulation and the nervous system. By this measure both sensible and insensible cutaneous transpira- tion is promoted, and the elimination of poisonous effete matters of the system is greatly favored. It equalizes the circulation, and tends to maintain its equilibrium, and it calms nervous excitement, allays irritation and mitigates very much the suffering of the sick. I have often seen my patients restless, wakeful, and irritated by the distressing heat and nervous disorder, calmed down to a con- dition of comfort and repose, by the application of this invaluable measure. Let it never be forgotten or neglected throughout the entire course of typhoid fever. Instead of the blister recommended by some authors, and which I formerly employed over localities where inflammation is present, as the thorax or abdomen, I now apply the scarificator and cups, and follow these with a hot fomentation, of hops put into a bag, and wrung out of hot water ; or the hops may be mixed with bread and milk, forming a poultice, and laid upon the surface after the cups are removed. A fresh poultice should be applied every ten or twelve hours. Or when there is great heat and tension of the abdomen, a folded linen of-four or five thicknesses, wrung out of cold water, may be placed over the entire abdomen, and changed 244 TYPHOID FEVER. once in two or three hours, so as to keep up a constant moisture and evaporation. I have derived the most decided advantage from this expedient, in a great many instances. It may be con- tinued, by repeating as directed, for a number of days, and will rarely fail in manifesting its salutary influence, not only in reliev- ing the abdominal tension and heat, but also in its quieting and sedative effect on the febrile symptoms and general nervous dis- turbances. If the bowels are irritated, soothing injections, such as a solu- tion of starch with a little laudanum, will be of much service, and may be administered without apprehension of aggravating any symptoms of the case. It is a point of considerable importance to restrain the tendency to constant discharges from the bowels. Though it is generally desirable to have the bowels sufficiently open to prevent the accumulation of morbid secretions, yet I have often allowed patients to go a number of days without a passage from the bowels, when great irritability had previously existed. It is better to have the bowels entirely quiet under such circum- stances, as the inflammation will be more likely to subside. In those cases of inactivity of the bowels which sometimes occur, connected, generally, with torpor of the liver, it will proba- bly be necessary to resort to some gentle means to correct the difficulty. For this purpose the compound taraxacum pill, here- tofore often recommended, may be given, with a view of producing a very mild aperient action; though when there is mere torpidity of the bowels, an injection of cold water, or, if that is insufficient, one of oil, molasses, and water, will very generally produce a sufficient alvine movement. The patient, or his friends, might not be satisfied by these gentle means, but I should not proceed farther in the use of cathartics, even though urged to do so by the patient himself. In cases of a low grade of fever, with a tendency to coldness of the extremities, carbonate of ammonia, ten grains to an ounce of water, given in drachm doses, every second hour, will have the effect of increasing the capillary circulation ; it will also serve to correct acidity of the stomach, and it will at least satisfy the de- sire of the patient and his friends to be doing something for his relief. When given, however, as a mere placebo, it may be given TYPHOID FEVER. 245 in solution just strong enough to satisfy the patient that it is not water. It will often be found that cold water does not have the effect of relieving the thirst, so urgent in many cases, in which case warm diluent drinks may be substituted. I find such drinks much more satisfying, in some cases, than cold water. Balm tea is one of my favorite remedies, being simple in its nature, with a very slight, yet pleasant, aromatic taste, and admirably efficient in allaying thirst. I have not found much benefit from the use of those effervescing draughts so much recommended in the books, but, on the contrary, they seem to aggravate the irri- tation of the mucous membrane ; consequently I would not recom- mend their use. A far more suitable and equally effective means for relieving the dryness of the mouth, and diminishing the sensa- tion of heat both in the mouth and stomach, will be found in a cold infusion of the root of marsh mallows, or Althaea officinalis. It should be prepared fresh every day, and used in such quanti- ties as may be desired by the patient. This will act also as a diuretic, which will be an additional reason for its use, where it is desirable to increase the renal secretion. After the principal symptoms of typhoid fever have been de- veloped, including the characteristic eruption, great irritation of the bowels will constitute a troublesome and important symptom, not to be neglected. Where the diarrhoea exhibits the mucous or hemorrhagic appearances, I am in the habit of giving nitrate argenti, one-eighth to one-twelfth of a grain, mixed with finely pulverized gum Arabic, made into a pill, repeated every three hours, but not to be continued longer than twenty-four hours. The effect of this prescription will be, to favor the action of the liver, by allaying irritation of the bowels; to excite healthy ac- tion in the diseased intestinal glands, and thus change the charac- ter of the discharges to a mushy and bilious appearance, which will be followed by a fine capillary circulation, and a return of warmth in the extremities. When the diarrhoea is not attended with hemorrhage or mucous discharges, I have found a remedy of great value, perhaps as much so as any other, in the spirits of turpentine, given in doses of five, six, or eight drops, repeated every two hours. It will not, however, be likely to act favorably 246 TYPHOID FEVER. in those cases where the tongue is red and smooth; and in any case, if a beneficial effect is not manifest in twenty-four hours, it should be discontinued, and ammonia, in weak solution, given in its place. You will meet with some cases of extreme irritability of the nervous system, which it will be necessary to quiet. The admin- istration of a few doses of valerian, or of lupulin or hop tea, will usually have the desired effect. Where these remedies fail, and there is danger that your patient will rapidly sink for want of sleep, our diaphoretic powder, given in an eight or ten grain dose, and repeated in two hours, will rarely fail of producing a highly favor- able impression, even if the entire effect desired be not produced by it. But-1 recommend these medicines with much hesitation, lest I may be misapprehended; for I hold that opiates are, in most cases, objectionable, and should only be administered when other means fail. In this light, I felt it my duty to call your attention to them. In some very severe cases, characterized by great restlessness and subsultus tendinum, especially if the heat of the skin had mainly disappeared, I have obtained favorable effects from the administration of ale. I prefer Scotch ale, diluted with water, sweetened with loaf sugar, and given in wine glassfull doses every hour or two, according to the urgency of the symptoms and the influence of the remedy. I look upon this as the best stimulant and tonic, in these low grades of fever, which we possess; and I confidently recommend its use, not as a curative agent, but as an aid to nature in sustaining and restoring the energy of the system. In some cases of extreme danger, where the patient seemed to be rapidly sinking, in spite of the means already mentioned, I have administered large doses of brandy toddy, and sometimes, apparently, with admirable success. Whether the brandy did really deserve credit for the reaction, or whether the case would have taken a favorable turn without it, as is sometimes seen, I cannot say; but where a patient was sinking under the use of our ordinary measures, the surface cold, pulse rapid and small, with an apparent giving way of the powers of life, I should not hesitate to recommend large doses of brandy toddy to be given, as warm as the patient could take it. In a few instances I have TYPHOID FEVER. 247 administered the brandy in incredibly large quantities, without producing any symptoms of intoxication, but acting, in a remark- able degree, as a sedative to arterial excitement. Convalescence must be managed with much prudence. It may be expected to advance slowly, especially at first, until food be- gins to be appropriated, and little can be done or should be attempted, to hasten its progress. But little tonic treatment will be borne, at first, and but very few agents of this class seem at all adapted to the peculiar condition in which the system is left. The Staphylea trifolia, however, seems, when given in infusion, to produce a very mild and genial tonic impression, without irrita- ting, but rather soothing the irritated mucous membrane. It promotes appetite, enables the stomach to endure suitable nour- ishment, and favors the early reestablishment of the digestive process; and it will be tolerated when every other tonic, with which I am acquainted, is rejected. The diet must, of course, be very simple and nutritious. It must be regulated, in both quantity and quality, with judgment, having reference to the effects experienced and the demands of the appetite. Generally, the spontaneous suggestions of the patient's own mind will be safely followed in regard to the kind of food; but it should be taken in small quantities, at first, and increased gradually, as strength is regained. It sometimes happens that, upon the decline of the more grave symptoms, well marked periodical fever will intervene. This may, in fact, occur at any time during the course of the disease, or during the progress of convalescence. Whenever I observe it, I do not hesitate, in any case, and under all circumstances, to exhibit the proper remedies for its arrest; and I repeat, in this relation, what I have so often said before, that the antiperiodic treatment should by no means be withheld, through fear of aggra- vating the disease, or any complication associated with it. This is a matter of no small experience. LECTURE XYII. INFLAMMATION. Definition—Symptoms — Changes produced—Functional, Structu- ral— Causes—Nature—Results or Terminations—Resolution—Ef- fusion—Induration and Adhesion—Hemorrhage—Suppuration— Quotation from Dr. Wood on pus—Softening—Ulceration—Gan- grene—Granulation— Cicatrization—Summary. In pursuing the plan adopted in the commencement of these lectures, of grouping together diseases in accordance with their analogies, and then considering those first, which are supposed to have the greatest importance in a practical point of view, I shall next take up the subject of inflammation. The term inflammation comes from the Latin word inflammo, to burn; and this was used by the ancients as expressive of the supposed character of this form of diseased action. The literal meaning of the word is, perhaps, calculated to mislead the learn- er, to some extent; since there are modifications of imflammato- ry action, which present nothing that will harmonize with the rad- ical signification of the term. It had its origin unquestionably in the appearance of the disease in its most common, and obvious forms; but since we see so many modifications of it so destitute of any symptoms to sustain the idea on which the term, in its orig- inal sense, might be predicated, its employment may be regarded as objectionable. Since, however, terms are often conventionally used without reference to the primitive import, and since in the present case the word is generally employed and understood in an accommodated sense, it is probably better to retain it. I shall not, in the consideration of inflammation, discuss INFLAMMATION. 249 to their full extent, all the points connected with it. This is a subject bearing upon two departments of the profession, surgery and the practice of medicine; and since many of the diseases, with which inflammatory action is connected, belong to the class of surgical diseases, and exhibit fully all the results of inflamma- tion, I shall refer you to that department for much that might otherwise be deemed proper to be said in this place. The usual phenomena of inflammation are " increased redness, increased heat, pain, and swelling." I say these are the usual characteristics of this species of diseased action; but as there are exceptions, in which one or more of these symptoms are not mani- fested, you see the importance of investigating the subject so far as to recognize and appreciate inflammatory action, where the or- dinary verbal definition is not fulfilled by its phenomena. If, for instance, you suppose that inflammation must necessarily be ac- companied by all the symptoms just named, and you meet with a case in which one or more of these symptoms cannot be discov- ered, you will not recognize the existence of inflammatory action. But with a clear understanding of the nature of this morbid action, and aware that although, as a general rule, the four peculiar symptoms attend upon it, yet it is liable to many exceptions, you will be able to discriminate between the different aspects in which it will be occasionally presented. Sometimes the symptoms of inflammation are very obscure, and require close attention in order to their recognition. Thus in some low forms of inflammatory action pain appears to be entirely absent—the patient being unconscious of its presence, but upon a careful examination by pressure over the part affected, a degree of tenderness at least, will usually be perceived. These varia- tions in the manifestations of inflammatory action depend, to a considerable extent, on the kind of structure involved. Redness is usually the earliest symptom of inflammation, and is more uniformly observable than perhaps any other. It will be seen in every shade, from a deep crimson to a slight flush, the in- tensity depending upon the degree of inflammation, its stage, the part involved, the condition of the system, and perhaps the nature of the cause. It is, however, sometimes wanting, as in white swelling, where, although there is heat, pain and swelling, there 250 INFLAMMATION. is no redness of the surface. There is evidently engorgement of the part, as shown by the tumefaction, but it is probably of a se- rous character principally, though it is possible that the vessels of the deep structures immediately involved, might, upon inspection, be found to be injected with red blood. The surface in this af- fection is in fact paler than natural, hence the name " white swelling." The increase of temperature is likewise variable in its inten- sity, though it is said never to exceed the temperature of the blood in the heart. The heat in an inflamed structure, is probably ow- ing partly to the presence of more blood in the capillaries of the part, and partly to an increase of vital action. But inflammatory action may exist without any appreciable increase of heat; and we often meet with cases where, although the inflammation is ev- idently of a high grade, yet the manifestation of heat is very slight, far less than the palpable condition of the case might lead you to expect. Pain is a symptom of inflammation which is perhaps more va- riable in its manifestation than any other. It usually is an early symptom, sometimes the very first, and it occurs with every de- gree of intensity. It varies also in character, being sometimes sharp and lancinating, at other times dull and obscure; it may be throbbing, or it may have a pungent, or a burning character. Sometimes the pain is intermittent or remittent. Occasionally there is a mere soreness, perhaps unnoticed by the patient except when moved, or when pressure is made upon the part. Often- times the sensation of pain far exceeds what the amount of lesion would appear likely to produce, and it perhaps as often falls be- low what would be expected. The degree of pain depends much upon the structure involved, as well as the stage and degree of the inflammatory action; and it is a remarkable fact that tissues which possess little or no sensibility in health, often become in- tensely sensitive and painful when inflamed; as the bones, tend- ons, ligaments and serous membranes. Another fact is worthy of remembrance, and that is, that the pain is often felt in a part distant from the seat of inflammation; as in the glans penis from inflammation of the bladder, and in the knee from inflammation of the hip. INFLAMMATION. 251 The swelling generally attendant on inflammatory action also presents great diversity in its extent,—sometimes amounting to a mere thickening of a mucous membrane, at other times, pre- senting the most enormous distension, as in inflammation of some of the glands. In some of the structures, swelling cannot be regarded as an attendant of inflammatory action, as in the serous membranes, and scarcely in the alimentary canal. It is in those soft structures which abound in areolar tissue that this symptom is more fully developed. It is caused by an engorgement of the vessels belonging to the part, by effusion into the structures, and finally by the production of additional capillaries and the growth of new structures. I have thus given you a brief description of these four symp- toms of inflammation, and you perceive that constancy in their development is by no means to be looked for: on the contrary, they may exist all together, in similar, or extremely dispropor- tionate intensity; or any of them may be absent, or at least not observable, in cases where those present indicate a high degree of inflammatory action. These are facts which it is important for you to remember, as without a knowledge of them you will be constantly liable to be misled in practice. If the inflammation continue for a considerable length of time, additional phenomena will be produced. These will consist in functional changes of the part or organ involved, and finally of structural alterations. The functional changes may be briefly stated to consist of—First, during the initial or forming stage, an increased natural secretion of the part; secondly, on the establishment of active inflammation, a diminution or total cessa- tion of the secretory function, as indicated by the dryness of the skin, if that organ is involved, or the dry, hacking cough, when the mucous membrane of the air passages is inflamed. This is followed by, thirdly, a morbid secretion,—being an effort of nature to.arrest or terminate the inflammatory action. Hence, we have the copious expectoration in the advanced stage of inflammation of the bronchial mucous membrane, and the peculiar mucus-like discharges in dysentery. Sometimes the fluids thus formed are very copious, as seen in dropsies, and the effusion tending to diminish inflammatory action has been classed among 252 INFLAMMATION. the terminations, so called, of inflammation. The effusion of serum of which I have just spoken, must not be confounded with that of coagulable lymph, which, escaping from the vessels of an inflamed structure in the fluid form, soon coagulates, forming a substance capable of being organized and vitalized, if kept in contact with the living tissues. From this effusion and organiza- tion of coagulable lymph result those adhesions which take place between opposing surfaces,—as between the Pleura costalis and Pleura pulmonalis, &c, and also between the surfaces of a heal- ing wound. True, the lymph and serum may be effused together, but the lymph, by its tendency to coagulate, becomes separated from the serum, just as the clot is separated from the serum of blood when drawn from the body. The tendency of lymph to become organized demonstrates its fibrinous character, and clearly distinguishes it from the albuminous exudation which sometimes takes place from irritated surfaces, and which, by evaporation, becomes consolidated, but never receives nerves, or blood vessels, and consequently does not become a living structure. A striking example of this kind is seen in membranous croup, of which I shall speak in a future lecture. The phenomena resulting from inflammatory action will be fur- ther considered, but before doing so, I deem it best, in order to a full comprehension of this branch of the subject, to speak of the causes of this form of morbid excitement. The causes of inflammation are of two kinds, local and general. Local influences, or local irritation, will produce inflammation, and the degree of the inflammatory action will depend much on the nature and amount of local irritation, — or, in other words, on the character of the local cause,— but more on the constitu- tional condition of the individual at the time. If the system were in perfect health at the time the local cause of inflammation occurred, the resulting morbid action might be expected to be proportionate to the character of the cause that produced it, but very often the inflammation, following a given local irritation, will differ in degree from what would be anticipated in a perfectly healthy system,—its nature and extent being dependent upon the general derangement of the system, but especially on the condi- tion of the blood. Hence it is of the first importance, in observ- INFLAMMATION. 253 ing the train of morbid phenomena connected with inflammatory action, to look to the general system, not only in regard to the condition of the blood, but to the character of the secretions and the constitutional predisposition to this form of disease. Proper attention, in these respects, will often enable you to anticipate and prevent inflammation, or at least to meet it successfully, when from the nature of the exciting cause alone you would not appre- hend its production. The importance of this suggestion is exem- plified in the predisposition to disease of particular organs of the body, as found in some persons, producing great tendency to the development of inflammation under the influence of causes which would not, under ordinary circumstances, produce such an effect. Thus, there is no necessary connection between inflammation of the lungs and of the bowels, yet where there is a strong predis- position to intestinal disease, whether hereditary or acquired, it is very likely to be developed during an attack of pneumonia. Again, it is no uncommon occurrence to find local inflammation supervene upon febrile action of a specific character, and readily subside upon the removal of the general febrile disease. This is often observed in our malarial fever, where no local disorder is necessarily connected with the febrile disease; but where, from predisposition to local determination, inflammatory action is exci- ted in some organ of the body. That the local inflammation in such a case is secondary, is proved by the fact, that an early arrest of the fever will cause the local inflammation to subside. Hence, in speaking of the treatment of fevers attended by the local inflammatory complications, I recommended the removal of the fever first, by appropriate remedies, — that being the cause, and the local disease merely an effect. But if, after the fever is arrested, the inflammation do not subside, having been kept up by the exciting febrile cause until it has become an independent disease ; in that case additional treatment will be required for the local disorder. And I again repeat, that the proper treatment to arrest the fever, in such cases, will not aggravate the local diffi- culty ; for, bear in mind, that in removing the febrile affection, you remove the cause of the local inflammation. It may be asked why it is, that, in some constitutions, there exist these predispositions to local disease. I reply, that it is 254 INFLAMMATION. owing to some peculiar conformation or structure of the organs, over which it may not be in your power to exercise any control. And this fact will be important in your prognosis of the case, as well as in the selection of remedies. If you find an individual, for instance, with a strong hereditary predisposition to disease of the lungs, laboring under a present attack of pulmonary inflam- tion, your prognosis would not be so favorable as in a different case. So in some families we meet with hereditary predisposition to disease of some particular organ—as the bowels, lungs or brain; and where such is the fact, it is an important guide in treatment. Where, for instance, there is a natural tendency to inflammation of the bowels, our treatment for such an attack should certainly be quite different from that which would be proper in case of accidental inflammation of that part of the body. While in the latter case you might use very prompt and efficient measures to remove the local irritating cause, in the former you should pursue a more mild and soothing mode of treatment. Where there is constitutional predisposition to inflammation of the brain, it is a matter of great importance, which should by all means be known, and constantly borne in mind, in treatment. In some diseases, it might be advisable to administer a narcotic, but if you find a hereditary disease of the brain, or a hereditary tendency to cere- bral inflammation, great caution would of course be requisite in the use of such remedies, while other, more active and efficient measures, would be indicated. To conclude my remarks on the causes of inflammation, I ask you to note, that, in view of what has been said, a local cause trivial in itself may excite morbid action, which, from constitu- tional predisposition, may result in extensive and indeed general inflammatory disease; and that general influences,—such as feb- rile action, or the constitutional effects of medicines,—may tend to develop local inflammation where there is either hereditary or acquired predisposition to such local affection; and finally, that the constitutional condition and natural predisposition of the patient should receive special attention, where inflammation is present or to be apprehended. Inflammation appears to be a peculiar effort of the system to repair injuries resulting from violence or morbific influences, and INFLAMMATION. 255 to rid itself of disease. Even where local inflammation super- venes upon a general disease, as malarial fever, I regard it in this very light; and I hope to be able, in the progress of our discussion of this subject, to prove to your satisfaction, that the legitimate tendency of inflammation is the repair of structures, and the restitution of the system to health. I hope to prove this from the well known condition of the organs under its influence, as well as from the best authorities; and although inflammation may result in the destruction of an organ, and even in the termination of life itself, it is only an instance in which the method of nature has been incompetent to, or has been prevented from, the accomplishment of its end. The results of inflammation are various and peculiar, yet capa- ble of being classified in a manner which has great utility, in enabling us to comprehend the nature and tendency of this form of disease. The variety in the results of inflammatory action, is caused, no doubt, by differences in different cases in regard to the condition of the system at the period of the disease, and the character and morbific force of the cause that produced it. This is remarkably exemplified in the great facility and rapidity with which some individuals recover from the most extensive and serious accidents, while in other cases the most trifling injuries are followed by serious, and often fatal results. The condition of the blood has the most important influence upon both the char- acter of inflammatory action during its progress, and the results which may be produced by it. Magendie has fully demonstrated this fact by his experiments. " I am anxious," says he, " to recall your attention to the experiments we made, last session, on the blood. You learned, through them, the influence that fluid exercises on our organs. You saw me produce, at will, in ani- mals, the majority of the striking phenomena determined by the most terrible diseases, for the relief of which, science is power- less. You saw me give rise, at pleasure, to pneumonia, scurvy, yellow fever, typhoid fever, &c." " These positions acquire new importance, from my having been enabled, since last session, to make some very curious applications of them. Take, as an ex- ample, malignant pustule. That frightful disease, in which inflammation is said to play so important a part, coincided in the 256 INFLAMMATION. case of a subject, who died a short while past of it, at the Hotel Dieu, with non-coagulability of the blood." The results of inflammatory action, denominated by some of the modern authorities its terminations, are numerous ; and though differing very widely in different cases, they all tend in a greater or less degree to impair the organized tissues, or destroy their healthy action. Each, however, is attended by its own peculiar symptoms and train of phenomena, and each is characterized by its own specific changes in the vessels and structures involved, differing essentially from those pertaining to any of the others. Resolution. The most simple, and, where circumstances are all favorable, the most natural, result of inflammatory action, is a gradual decline of all the abnormal appearances, with a restora- tion to healthy action. In this case, the pain diminishes, the swelling subsides, the general fever declines, and all the other symptoms gradually disappear; and the part affected being wholly restored, regains its natural color, form and functions. This is termed by authors, Resolution, in which there is no for- mation of pus, and no permanent injury to the structure of the part. Effusion. Another result of inflammation, is, where some of the elements of the blood are discharged from the vessels into the surrounding cellular tissue, or from the surfaces of serous mem- branes into the cavities lined by them. In some cases, this effu- sion consists really of blood, either in a state of decomposition, or deprived of its plastic qualities, so as to be rendered unfit for circulation in the minute capillary vessels,— as the black vomit in yellow fever, and the bloody evacuations in dysentery; though in the latter case, it is accompanied by a mucous secretion. Wheth- er this effusion of blood is accomplished by a sort of secretory process, or by exudation through the relaxed tissues of the mucous surface, it is not necessary to discuss at this time. Induration and Adhesion. Inflammatory action, occurring in the cellular structure, will be accompanied by more or less swell- ing ; and not terminating in resolution, there will be an effusion of serum and lymph, not unfrequently increasing the tumefaction by the organization of new living tissue. Where this is the case, and the cellular structure is very loose, the inflammation has a INFLAMMATION. 257 tendency to become chronic, and result in induration. But, by the same process precisely, where the effusion occurs between the serous surfaces of membranes, such as the pleura, peritoneum, synovial capsules, &c, or between artificial surfaces, as of wounds, the coagulating lymph becoming organized, interposes a new living structure, which forms a bond of union between the opposing surfaces. This effect is called adhesion. By this mode, nature repairs those injuries which result from a destruction of continuity of structures ; and by this same mode, she surrounds inflamma- tory action with a barrier to limit its extent, in many cases ; and it is an interesting fact, that, generally, in the cases last men- tioned, the newly organized structure is removed by absorption, after the disappearance of the morbid action, which both rendered it necessary, and effected its production. Sometimes, however, the new growth remains as a permanent structure, after all other traces of inflammation have disappeared ; especially in adhesions between serous membranes. Where the effusion following inflammatory action is but slight, the restorative powers of the system are usually sufficient to dis- pose of it, without any serious lesion ; perfect and complete re- covery follows, and few, if any, traces of previous morbid action can long be seen. This, however, is not the case in all inflam- matory diseases. In acute rheumatism, for instance, where a high degree of inflammation is supposed to exist in structures of a low grade of organization, the decline of inflammatory action is frequently followed by effusion within the capsular ligaments ; and although such effusion is generally inconsiderable as to quan- tity, yet the difficulty with which it is absorbed, often renders recovery very slow and tedious. Hemorrhage. The effusion of blood, or hemorrhage, generally takes place from the mucous surfaces. In bronchitis and inflam- mation of the lungs, one of the most common symptoms is a bloody sputa, or expectoration. These effusions or secretions, should not be considered healthy or normal productions, but are the results of morbid processes, manifesting an effort at restora- tion. We never see an effusion of a healthy, natural fluid, from any structures in a diseased condition. In pleuritic inflamma- tion, the effusion does not accompany the more active stage of 17 258 INFLAMMATION. inflammatory action, but occurs on its decline; and is a summary method of nature to relieve the engorged vessels, and restore a state of health. Such, also, is the case with peritoneal inflam- mation. Another benefit arising from effusion in serous cavities, is, that the fluid thrown out exerts a protective influence, by keep- ing the diseased surfaces separate, while its discharge relieves the morbid action, and thus in many cases adhesion is obviated, which, from the difficulties it may occasion, and the permanency of its duration, is more to be dreaded than even dropsy itself. Effusion cannot, therefore, be said ever to accompany active inflammation, but it follows it. The natural secretion is arrested, and the inflamed part becomes dry ; and where the morbid action is very intense, it even becomes both rough and dry. But, more commonly, there is some effusion upon the borders of the inflamed part or structure. Even that discharge which accompanies dys- entery, coming as it does, from a mucous surface, is altogether different from healthy mucous, in most instances ; and in those cases where the discharges do contain mucous closely resembling the normal secretion, it does not emanate from vessels involved in active inflammation, but from the adjacent parts in a state of irritation ; while from the relaxed vessels immediately implicated in active disease, a peculiar effusion or exudation of a sero-sanguineous character, takes place. In the severe and malignant forms of dysentery, this last mentioned discharge often resembles water in which bloody meat has been washed ; but in the milder forms of the disease, the discharges consist of a mucous secretion, with blood entangled in it. I have already stated that induration often follows effusion, and perhaps this cannot be more aptly illustrated, than in those cases of chronic inflammation of the liver and spleen, so often found in this western country. Enlargement of these organs is not the result of a mere accumulation of blood, but an effusion of serum in the cellular structure. We find the same thing to occur very frequently in the skin, where inflammation is followed by induration of the dermoid tissues; and the same result is often produced by inflammation of the lymphatic glands. Protracted venereal disease, will generally produce induration of lymphatic glands of the groin, and other parts of the system. INFLAMMATION. 259 Suppuration, or the formation of pus, is another result of inflammatory action. A great difference is found to exist in dif- ferent tissues, as to their tendency to the formation of pus. The loose structures, and those less highly organized, are more liable, as a general rule, to form pus under the inflammatory pro- cess, than those tissues which are more dense, and which have a higher grade of organization. This production of inflammation is very different in character, also, in the different tissues and organs ; each of these has a tendency to yield a peculiar kind of pus. In the cellular structure, this matter is yellow or greenish yellow, and somewhat consistent, having the thickness of cream; and when it occurs in a healthy or sound state of the constitu- tion, it is called "healthy, or laudable pus," tending to the resto- ration of the part to a healthy condition. In the serous tissues, the matter is more thin and watery. In the parenchymatous structure of the liver and spleen, the pus produced bears some resemblance in color to-the organs or parts in which it is formed. The serous membranes are not very liable to suppurative action, while nothing is more common in the loose structures of the mu- cous membranes, and in the subcutaneous areolar tissue. When this result has occurred, it may generally be known by the rounded, tumefied, smooth and shining appearance of the part; by its becoming less painful, with a decline in the general febrile excitement, which may have existed ; and by a distinct sensation of fluctuation, upon proper examination. To determine the exist- ence of matter, is often a subject of some embarrassment to the young physician ; but by placing the palmar surface of the fingers on one side of the part supposed to contain pus, and with the fingers of the other hand applying a gentle tap to the opposite side, or, what is a better method, making gentle pressure with the fingers a few times alternately on opposite sides of the tumor, the wave or fluctuation may be distinctly felt, if pus be present. " Authors are not agreed as to the precise mode in which pus is produced. By many it is believed to be the product of a se- cretory process. Gendrin, however, maintains that it results from some change in the blood independently of any action of the ca- pillaries ; and that this change may be effected, either after the blood has been effused, or while it still remains in the vessels ; the 260 INFLAMMATION. pus, in the latter case, being allowed to pass out through the coats of the vessels unaltered. According to that author, when blood is effused in inflammation, it first coagulates ; if suppuration do not take place, the serum is then absorbed, the red globules lose their color, and the clot becomes organized ; but if the disorder advance to suppuration, the blood gradually loses its color, and is changed into pus. Gendrin also believes that the fibrinous fluids, effused in the course of inflammation, are often converted into pus. They who consider pus to be the product of secretion, ascribe these apparent results to the gradual absorption of the effused blood and fibrin, and the deposition of pus in their place. Ger- ber believes that the pus corpuscles are produced by the degen- eration of the exudation corpuscles, which form in fibrin after its exudation. It is certainly not impossible, that blood or fibrin may be changed into pus after extravasation ; but when it is consid- ered that pus, ready formed, is often thrown out abundantly from the inflamed tissues, without any previous effusion of blood or fibrin, the inference appears necessary, that it is the direct pro- duct of a secretory action, performed upon the blood of the capil- laries, either by these vessels themselves, or by the ultimate cells. " It is doubtful whether pus is at all times the product of in- flammation. It is occasionally found disseminated in tissues, or collected together in masses, in the lungs, liver, and other parts of the body, without any evidence of inflammation in those organs during life, and without any other ordinary appearances which that affection leaves behind it after death. The pus appears to have been merely deposited by the vessels, without any coexist- ent derangement of the tissue. Such phenomena are not unfre- quently observed in the cases of individuals who have recently suffered amputation or other operation,' by which a suppurative disease of longer or shorter continuance has been removed. But they are also said to be presented in some rare instances, in which no inflammatory source of pus, existing at the time, or within a short period previously, could be discovered. In the former case, the collection of pus may be ascribed to the previous absorption of that liquid from the suppurative source ; and it is known that pus occasionally enters the circulation by absorption ; as it has been found, both in veins and absorbents, proceeding from the INFLAMMATION. 261 neighborhood of purulent deposits. But no such explanation can be given in the latter case. It has been suggested by Andral and Tessier, that there may exist a purulent diathesis, which may dispose to the formation and deposition of pus, as the tuberculous diathesis does to that of tuberculous matter, without any essentia] complication with inflammatory action. Some suppose that pus, in these cases, is formed in the blood out of its healthy constitu- ents ; and, where any suppurative focus exists, the change may be ascribed to the absorption of a portion of the pus, and the ex- citement, by its presence in the blood, of a sort of purulent fermen- tation. Others, again, believe that it is the result of inflammation in the lining membrane of the veins, or blood-vessels in general. " When suppuration is established, the violence of the inflam- mation abates; and hence its occurrence has been erroneously considered as one of the terminations of inflammation. The pus may appear upon the free surface of membranes, or diffused in the interstices of the tissues, or collected together within the sub- stance of the different structures, forming abscesses."—Wood. While speaking of the effusion of coagulating lymph, I had oc- casion to describe, with perhaps sufficient minuteness, those struc- tural changes which result in an increase in the quantity or dens- ity of the living tissues, called adhesion and induration. Other structural changes also result from inflammatory action, differing very widely from those just mentioned; being characterized by diminution of vitality and consequent approximation of the' tissues to the character of inorganic foreign matter. These results of inflammatory action are expressed by the terms softening, ulcera- tion and gangrene. Softening, to a certain degree, may be said to be almost a ne- cessary consequence of a high grade of inflammatory action ; the engorgement of the vessels and interstitial effusion which produce tumefaction, tend necessarily to diminish the natural cohesion of the tissues, and render them more easily separable than in health. As inflammation progresses, this change of structure increases, until sometimes the tenacity of the textures becomes so much di- minished that they will break down under the application of slight mechanical force. Indeed it occasionally results in the total dis- organization of a portion of the structure, which is either removed 262 INFLAMMATION. by absorption, or is discharged with the purulent secretion. Where softening proceeds to the degree just described, a suppur- ating surface is generally left entirely similar to that produced by the removal of a gangrenous slough, or the discharge of an abscess. Ulceration depends upon the process of what is denominated interstitial absorption, by which such portions of a structure are re- moved, as have been so far deprived of their vitality, as to be inca- pable of resisting the power of the absorbent vessels. Where this occurs at the surface of an inflamed part, free or open ulcers are produced; but when it takes place in the interior of an organ, it produces an excavation, which may serve as a receptacle for pus; and the process of ulcerative absorption, as it is termed, being continued, generally in the direction of the surface of the body, a way is thus provided for the discharge of purulent matter. In this case we have what is called an abscess, which differs from a superficial ulcer, only in having a deeper origin,—being produced by the same process. There can, I think, be no doubt that ulceration results, as has been said, from the destruction of vitality in the tissues, to a cer- tain extent, by the inflammatory process, which renders them in- capable of resisting the action of the absorbents, and they are con- sequently dissolved and carried into the circulation. Such portions of the devitalized matter as are not thus taken up, are discharged in the form of unhealthy pus. Gangrene implies the death of a part, to a greater or less extent. This is the most formidable result of inflammatory action, but for- tunately it is the least frequent in occurrence. Some authors make a distinction between the terms gangrene and mortification; using the former to denote the condition of a part immediately pre- ceding its actual death; and the latter to express the state of a structure after its vitality has become entirely extinct. I adopt the definition of Prof. Wood, who says: " In the course of an attack of inflammation, a portion of the diseased structure sometimes loses its vitality, and passes from under the influence of physiological to that of chemical laws. This loss of life in a part is denominated mortification, the resulting condition, gangrene or sphacelus. Many writers, however, fol- lowing Galen, make a distinction between gangrene and sphacelus, INFLAMMATION. 263 applying the former term to the state which immediately precedes the absolute death of a part, the latter, to that which exists after its death. There is some convenience in this division ; as we frequently have occasion to refer to that condition, in which mor- tification, though strongly threatened, or inevitable, is not com- pletely accomplished ; but this condition is, in fact, nothing more than one of the phases of inflammation, and can scarcely receive a distinct name without some confusion. In using the term gan- grene, therefore, I«shall consider it as applicable to parts already dead; though the epithet gangrenous may sometimes be employed as expressive of a state allied, or approaching to gangrene. " The immediate cause of gangrene, in inflammation, is proba- bably a disproportion between the excitement of a part and its powers of vitality, the latter being entirely exhausted by a great excess of the former. If the life of a part is feeble, a compara- tively slight elevation of its action may produce its death ; if vigorous, a great excess of excitement is requisite to this result. Whatever, therefore, weakens a part, or excessively excites it, may dispose to gangrene ; and those parts are more liable to this condition, which are naturally the weakest. There are certain states of the system, and certain diseases, which are characterized by a universal reduction of vital power, and in which inflammation is very apt to run into mortification; and there appear to exist certain specific inflammations, which are much more liable to this result than inflammation of the ordinary character. The blood also is sometimes in a condition which strongly predisposes to gan- grene, probably because it is unable to afford those supplies, and that healthy stimulus, which are requisite to vigorous health. Gangrene, moreover, may occur from obstruction to the circula- tion in the capillaries of the inflamed part." The symptoms denoting an approach to gangrene are, a change of color to a purplish or livid hue, owing to the languor of the capillary circulation; reduction of sensibility in the part imme- diately threatened, though very intense pain may be experienced, with a sense of burning in the associated structures; a diminu- tion of temperature; loss of tension and elasticity in the part. giving it a sort of doughy feel; and a clammy moisture, gen- erally, upon the surface, caused by the effusion of serum from 264 INFLAMMATION. the vessels. The circulation finally ceases altogether in the part, its sensibility is entirely lost, the color becomes more dark and livid, and a red line is formed, indicating the extent to which death has extended. Chemical changes now commence in the sphacelated portion, fetid gases are emitted, with other evidences of spontaneous decomposition. This is termed putrefaction, and whatever doubts may have existed as to the occurrence of morti- fication, they will be completely removed upon the appearance of the putrefactive phenomena. # Gangrene, with the exception of resolution, may with more propriety, perhaps, than any of the results of inflammation, be denominated its termination, as the inflammatory action does, of course, cease in the dead structure; but this is not the case in adjacent tissues. As has been said, a red line, defining the bound- ary of the mortification, is seen, ulceration occurs, and the gangren- ous portion is thrown off in the form of a slough, leaving a surface in which the inflammation may progress, resulting in successive sloughings, and finally in death; or granulations may be formed and the part be restored to health. Besides, inflammation is not a necessary forerunner of this condition; for, by what is termed dry mortification, the death of structures may occur, without the appearance of any inflammatory excitement. So that, in neither point of view, can we with propriety designate gangrene, or mor- tification, as a termination of inflammation. The fact is, that the usual mode of expression among authors, by which inflammation is represented as having a certain number of terminations, from three up to ten or eleven, according to the fancy of the writer, has produced much confusion, and rendered the subject very difficult of comprehension to students. The phenomena which have been thus designated are truly results of inflammatory action, but their occurrence does not, by any means, imply a termination or cessation of the morbid action. Neither can the term be properly employed as indicating a special ten- dency of particular forms or grades of inflammatory action to re- sult in this, that, or the other termination.' Gangrene itself, we have seen, is usually accompanied by ulcer- ation ; and suppuration may follow, granulations be formed, and the lesion be healed by cicatrization. Yet each one of these is INFLAMMATION. 265 laid down in the books as a termination of inflammation, acute or chronic. Granulation is a process of repair, by which the loss of struc- ture is partly or wholly supplied, and a healthy condition restored, in parts which have suffered from the effects of ulceration, sup- puration, or mortification. It is effected by the effusion of coagu- lable lymph upon the diseased surface, which becoming organized, forms a new surface, composed of small, red, vascular, and coni- cal elevations. Upon this surface a new effusion and organiza- tion takes place, and so on, until the process of repair is completed. This process, when proceeding kindly, is attended by the secretion of healthy pus, which lubricates and protects the delicate and tender granulations; and there is a slight elevation of tempera- ture, indicating that the process now going forward is truly an inflammatory one, though tending to restore the injuries resulting from the previous march of inflammatory action. There is a tendency in granules, in contact, to unite and form a continuous structure. Thus it is that the surface of a part will be finally rendered smooth, by the union of adjacent granules and their final coalescence; and by the same means two granulating surfaces, when in apposition, unite by what surgeons call the second intention. The only difference between this mode of union and that by first intention, is that in the latter case the coagu- lating lymph forms a bond of union which cements the incised surfaces together, so to speak, without the formation of pus, or granules, while in the latter these processes are necessary to fill up the space between the two surfaces. But both are effected through the interposition of coagulating lymph, under the power of the vitalizing principle. This mode of repair, by which a part is restored to a more or less perfect form and structure, is termed cicatrization, and the remaining scar or trace indicating the existence and location of previous lesion, is denominated a cicatrix. I have now given you an account of the various recognized re- sults of inflammatory action. They may be thus recapitulated: 1. resolution; 2. effusion of serum; 3. deposition of lymph; 4. suppuration ; 5. adhesion; 6. induration; 7. softening; 8. ulce- ration ; 9. gangrene; 10. granulation; 11. cicatrization. An 266 INFLAMMATION. example of all these results of inflammation may be seen in a severe boil, and more particularly in the carbuncle. In the cen- tre, or core, we have a slough, or gangrene; this is separated from the walls of the cavity by ulceration; this is followed by suppuration. Farther from the centre there is effusion; still farther, organized lymph, or adhesion. The structures of the tumor are more or less softened, while a degree of induration will remain often for a long time after the inflammatory excite- ment has passed away. The centre of the boil or carbuncle will heal by granulation and cicatrization, while the inflammation in its border will subside by resolution. I will now briefly notice the peculiarities observed in the in- flammatory process, according to the tissue in which it occurs. It is true that the general outlines of inflammation are similar in all parts of the system, sufficiently so at least to enable us to re- cognize the affection wherever observed as belonging to this ge- nus. Still there are peculiarities in the phenomena developed by this sort of morbid action, in different tissues of the body, which have led to an arrangement of inflammatory disease into what might, perhaps with some propriety, be termed species; and it is important to give some attention to this view of the subject. In the cellular or areolar tissue, inflammatory action exhibits more uniformly than in any other, all the symptoms and results characteristic of this form of disease ; and consequently its course and phenomena in this tissue have been taken as the type of in- flammation. When it occurs near the surface in this tissue it produces a tumor or boil, technically called a phlegmon, from its color and heat; and from this the term phlegmonous has come to be applied to ordinary inflammation in all parts of the body. The disease in this tissue is apt to surround itself with a bar- rier by adhesive inflammation, and thus produce a circumscribed abscess; but occasionally it diffuses itself very widely, producing wide spread havoc in the cellular tissue by a sort of softening, or gangrenous suppuration. When the shin is involved in this form of diffused inflammation, it is called Erysipelas phlegmonodes. Common inflammation in this tissue is attended usually by an aching pain which becomes throbbing when suppuration is about to occur; there is apt to be much swelling and local heat, though INFLAMMATION. 267 but little general febrile excitement. Hence, when some vital or- gan is suffering from inflammation of its areolar tissue, the danger is often far greater than outward or general symptoms indicate, while in some other tissues very slight and in itself unimportant inflammation, may produce very marked general febrile symp- toms. As was shown, in the case of a boil, this species of inflamma- tion may be characterized by all the results of inflammation in a single case ; or it may eventuate in resolution without progressing so far as to destroy the continuity of any structure. Effusion of serum and deposition of lymph are seldom wanting in areolar inflammation. In the serous tissue, inflammation is characterized by an acute, severe pain, generally; and by an inflammatory or sympathetic fever, upon the peculiar symptoms of which it is not necessary now to dwell. Effusion is its most usual result, though most or all of the effects of inflammation may be produced in this tissue. Adhesion of opposing serous surfaces is not an unfrequent event, as was stated while speaking of coagulable lymph. In the dermoid tissue, inflammatory action assumes a great variety of forms, and from its exposed position, it is peculiarly liable to such irritating causes as are likely to result in morbid excitement. It is subject, also, to many specific inflammatory affections, symptomatic of general disease,—as the exanthemata of certain fevers, and to erysipelas, in its several forms. Inflammation of the shin, as resulting from the effect of a local irritant, is distinguished by a peculiar, burning pain, by a bright red flush, some swelling generally, and a sensible increase of heat. It may subside speedily, by resolution, but if continued, serum is effused beneath the cuticle, producing what is called a blister; the inflammation may progress from step to step, and exhibit all the results before described. Gangrene is as frequent an event in cutaneous inflammation as in the disease of any other tissue. The mucous tissue is, in reality, only a continuation, with some modification, of the external integument, and like it posses- ses sympathies with the entire system to an extent which renders it peculiarly liable to be implicated in the affections of other 268 INFLAMMATION. tissues. It is, furthermore, exposed to the irritating action, both mechanical and chemical, of all uncongenial substances which may be swallowed, or formed within the hollow viscera. The pain experienced in an inflamed mucous membrane is of a smart- ing or stinging character, as in the eye in opthalmia, inflammation of the urethra, &c. But little pain is experienced in the mucous coat, itself, of the stomach and bowels — the gripings in dysen- tery, and spasmodic pains which sometimes occur in gastritis, being the result of irritated and spasmodic contractions of the muscular coat. Hence, between the muscular efforts, as between the discharges in dysentery, the patient is generally exempt from pain. An inflamed mucous surface may exhibit any shade of floridity, from a slight flush to a dark red or reddish brown, owing to the intensity and duration of the morbid action ; and it is generally more or less thickened. The inflammation may ter- minate by resolution, or it may eventuate in softening, ulceration, suppuration or gangrene. It is generally characterized at first by increased mucous discharges; the inflamed surface then becomes dry, or at least is not moistened by any secretion of its own; afterwards, fluids, as vitiated mucous, with serum or blood, or both, are discharged; and finally, if the disease progress, pus will be thrown out from the inflamed part. These peculiarities, marking the different stages of the affection, are usually clearly observed in the expectoration during bronchitis, and in dysenteric evacuations. The cartilaginous and fibrous tissues, under which terms I intend to embrace all the forms of cartilage, and of tendinous, ligamentous, and fibrous structures—such as the dura mater, peri- osteum, and animal substance of bones—are liable to inflammation, but less so than the other tissues. The affection in most instances, when occurring in these structures, presents the symptoms of rheumatism or gout. Although these tissues possess little or no sensibility during health, in disease they may become exquisitely sensitive, and the inflammatory action is generally characterized by a continued gnawing pain. The affection may assume the highest grade of morbid excitement, exhibit all the phenom- ena of inflammation, and result in death of the part, or gangrene. The march of the disease is generally slower than in other struc- INFLAMMATION. 269 tures, but it may be none the less destructive. It is true, as stated by authors, that tendons, &c, resist to a considerable extent the process of gangrene, even when it occurs in structures in immediate contact with them, but it is not true that either or any of these tissues is exempt from gangrene. I have seen an entire limb, tendons, ligaments, bone and all, come off in a slough. Necrosis is a result of inflammation in the bone, where the whole bone, and exfoliation where its surface only, is involved, which I cannot distinguish from mortification. The rheumatic variety of inflammation rarely produces de- struction of structure in any manner; its most common result is effusion. LECTURE XYIII. INFLAMMATION—Continued. Chronic Inflammation—General effects of Inflammation on the Blood—Hunter's Opinion—Gendrin's—Buffy Coat—Nervous In- fluence—Fibrin—Serum—Magendie on Bleeding—Effects of In- flammation beyond its Seat — Sympathetic Fever — Microscopic changes in Inflammation—Contraction of Capillaries—Relaxation— Engorgement—Effusion of Lymph— Quotation from Tweedie— From Hunter—From Magendie, on Capillary Circulation. Having defined the term, inflammation; described its general symptoms and results as developed in the parts immediately in- volved ; and noticed the peculiarities which characterize it in different tissues; we will, on the present occasion, inquire more particularly into its influence on the blood; its relation to the general system; and the minute changes which occur, during its progress, in the capillary system, as discovered by microscopic observations. You observe, Gentlemen, that I have laid out pretty broad grounds for consideration this morning; grounds embracing mat- ters of great practical importance, and principles which involve the philosophy of a vast range of human diseases. But before proceeding to the discussion of the subject in this light, I will make a collateral remark or two, upon the division of inflammation into the acute and chronic varieties, as recognized by the author- ities. In chronic inflammation the same phenomena may be said to occur, with all the changes, and most of the modifications which characterize the acute form, as presented in the lecture of yes- terday ; the main difference consisting in the slower march, and INFLAMMATION. 271 more protracted duration of the former ; owing to difference in the intensity or continuance of the exciting cause, and perhaps to the influence of peculiar states of the general system. Every con- ceivable grade of violence is observed in the inflammatory process, as we examine different cases, according as the cause and consti- tutional condition, seem to favor a slower or more rapid progress; so that authors have even introduced another term indicating an intermediate grade—the Subacute ; but the distinctions thus at- tempted to be made, are not based upon real physiological or pathological differences, and are consequently of very little prac- tical importance. We have heretofore considered inflammation mainly as a mere local affection ; but although its observable phenomena are local in their character, yet the disease generally exerts important in- fluences upon the blood, and upon organs remote from the imme- diate seat of the morbid action, and not directly connected with it; so important indeed as to demand more attention and create more concern than the primary disorder. As to the character of those sensible and apparent changes in the blood, which are observed to be the usual attendants on in- flammation, there is no room for difference of opinion; but the cause of those changes has given rise to no little discussion. For instance, all agree that inflammation, under most circumstan- ces, is associated with a condition of the blood, which is indicated by a peculiar appearance on the surface of that fluid, when drawn from the system and permitted to coagulate, called the " buffy coat." This is a whitish or yellowish-white, and sometimes greenish stratum, which is formed upon the upper surface of the blood, during coagulation, which all authors recognize as consisting principally of fibrin; but in regard to the cause of its appearance under such circumstances, much difference of opinion has been ex- pressed. Hunter attributes it to the slower coagulation of inflamma- tory blood, allowing the red corpuscles to subside by force of gravity before the clot is formed. Gendrin, on the other hand, asserts that the coagulation of blood affected by inflammation, commences sooner, and is sooner completed than that of ordinary or healthy blood. Here, then, we have two opinions, founded, as they both remark, upon their own observations, which are in direct conflict 272 INFLAMMATION. as to a fact, in relation to which there ought to be no great diffi- culty, certainly, in arriving at the truth. It is not, therefore, sur- prising that authors should differ in regard to the cause of the change in the nature and constituency of the blood, by which it is disposed to coagulate in this peculiar manner. The influence of inflammation in effecting the alteration of the blood throughout the system, is by no means uniform. The buffy coat will not always appear on the blood of inflammation ; and it does undoubtedly sometimes occur in blood drawn from systems in which no inflammation existed. Hence, although this peculiar condition of the blood generally makes its appearance under the influence of inflammatory action, it is a question whether the change is effected by the direct agency of the local disease, ex- erted upon the blood as it passes through the capillaries of the in- flamed part, or whether it is a secondary result dependent upon a peculiar condition of the nervous system, which, although gener- ally brought about by the inflammatory process, may exist inde- pendently of it. This last view of the subject is rendered very plausible by the fact, that although the system may be enduring the most intense inflammatory action, the blood first drawn will not present the peculiarity referred to ; but if sufficient blood be abstracted to re- lieve the patient from the oppressive excitement, the buffy coat and " cupped" appearance will characterize it upon coagulation. It would also appear to be more constantly manifested in those inflammatory conditions connected with disease of synovial mem- branes, where the inflammation itself depends on constitutional dis- turbance and a vitiated condition of the blood. This view of the case is greatly strengthened from the undis- puted influence of the nervous system in producing serious altera- tions in the circulating fluid, as evinced in those destructive epi- demics of the south and west, such as congestive, pernicious and yellow fever; in which the blood is often found in a decomposed condition, evidently referable to the enervating influence of the poison upon the nervous system. From all that has been said we may, I think, reasonably infer, that the condition of the blood which causes it to exhibit the buffy coat and cupped appearance, is the result of defective innervation, INFLAMMATION. 273 and that it is merely a step in the progress of morbid action towards the decomposition of the vital fluid, the healthy condition of which can only be maintained by the faithful performance of the functions of the nervous system. Or, in other words, that this condition of the blood is not produced by the direct influence of inflammation on that fluid, but is a secondary consequence of the inflammatory action. This discussion, however, is one of very little practical impor- tance, except in so far as this state of the blood has been made an indication for bleeding in the treatment of inflammation; but this doctrine is now well nigh abandoned. The most sensible influence which inflammation exerts upon the blood, as determined by analysis, is manifested in the increase of its fibrin. This, it is said, is uniformly augmented in quantity during the progress of inflammation, commencing from the first establishment of this abnormal excitement, and diminishing as it declines. The elements furnishing the materials for this sudden increase of fibrin are supposed to be derived from the albumen of the blood, as that particular constituent is said to be sensibly diminished. This increase of fibrin in the vital fluid illustrates the wonderful resources of nature for accomplishing the purposes of the animal economy. The best experiments have shown that a due propor- tion of fibrin is indispensable to the free circulation of the blood in the capillaries, and that a deficiency of this element is attended by obstructed circulation in some of the vessels, even in ordinary health, while in inflammation we have positive obstruction in the vessels of the inflamed part, as shown by very careful microscopic observations. Admonished of this fact, nature, with her wonder- ful resources and skill, sets about the work of removing the ob- struction, and repairing the injury. As the best means for the accomplishment of these purposes, an immediate supply is afforded of that element which is best adapted to promote freedom of cir- culation in the obstructed vessels, and furnish the materials necessary for repair; and this supply is continued until the inflam- matory process subsides, when this particular element is gradually reduced to its normal proportion. The well known impediment to free capillary circulation, pro- 18 274 INFLAMMATION. duced by the presence of serum in the blood beyond its ordinary and healthy proportion, taken in connection with the equally well settled facts, that fibrin facilitates the movement of the blood in the capillary vessels, and that bloodletting diminishes the relative amount of fibrin, and increases that of serum, appears to me to afford one of the most conclusive arguments against the abstraction of blood in inflammatory disease that can be adduced upon any proposition. These facts also conclusively demonstrate the prop- osition, that the general symptoms of inflammation result from the efforts of the system to remove disease. The facts I have stated, to wit: the increase of fibrin in the blood, during the progress of active inflammation, and its decrease on the decline of the inflammatory phenomena, are established by the very best authorities ; while the influence of the loss of blood in diminishing the due proportion of fibrin in the circulating fluid, and thereby materially increasing the obstruction in the capillary vessels, is shown by recorded experiments and demonstrations, equally reliable and authoritative. Some of the testimony to which I refer, it may not be improper to read in this connection. Says Magendie, in addressing his class: " You are already acquainted with a great number of causes that modify the blood, and induce disease ; but you are scarcely, perhaps, prepared for the announcement, that by means of a therapeutical agent, holding the first rank amongst the fashionable remedies of the day, I produce the very same alterations in the blood, and, as their result, the very same disorders in the econo- my. This may, perhaps, strike you as a random assertion; but my words are not lightly spoken. I have within my reach the guaranty of their veracity,— experiment shall confirm them. I assert, then, loudly, and fear not to affirm it, that bloodletting induces, both in the blood itself, and in our tissues, certain modi- fications and pathological phenomena, which resemble, to a certain extent, those we have seen developed in animals deprived of atmos- pheric oxygen, of drink, and of solid food. You shall have the material proof of the fact. Here are three glasses, containing blood drawn from a dog on three different occasions, at intervals of two days. The animal was in good health, and I took care to supply him abundantly with nourishment. In the first glass, you INFLAMMATION. 275 see that the serum and clot are in just proportion to each other ; the latter, which is perfectly coagulated, forms about four-fifths of the entire mass. This specimen of blood, consequently, ap- pears to possess the desirable qualities. - Now turn your atten- tion to the second glass. The animal was still well fed when its contents were drawn, and yet you perceive an evident increase in the quantity of serum ; the clot forms, at the most, only two- thirds of the whole. But here, in the product of the third vene- section, although the animal's diet remained unchanged, we find a still greater difference. Not only is the proportion of serum more considerable, but its color is changed. It has acquired a reddish-yellow tinge, owing to the commencing solution of the globular substance." * * * " I will continue to bleed this animal from time to time; but I can tell you beforehand, from the result of similar experiments, that the alteration in the properties of its blood, will entail that of its organs, and finally death. The lung, for example, will become affected with engorgement, oedema, pneumonia, and the entire train of what people are pleased to call inflammatory phenomena ; and, mark the extraordinary fact, that this inflammation will have been produced by the very agent which is daily used to combat it." Magendie on the Blood, page 19. In regard to the elements of the blood, and the necessity of their due proportion to healthy circulation in the capillary ves- sels, the same author remarks: " The absence of one of its normal constituents, is not percep- tible by any untoward sign; the sample before you appears per- fectly identical with the blood that circulates in the living animal. Yet, notwithstanding this apparent similarity, its properties are different; for, if I reintroduce it by a vein, it will at first pass through the large vessels, but on reaching the capillary system, its progress will be arrested ; the series of phenomena I have so often described will succeed, and the animal soon perish of the disorders induced by the stoppage of the capillary circulation. Now, nothing has been added to this blood; I have simply re- moved from it one of its elements,— an element, too, that at the utmost, forms no more than from ToVo *° t/o? °f ^s volume. That element is fibrin, which, while in the vessels is liquid, but 276 INFLAMMATION. when removed from them, becomes solid ; and hence, it is to its fibrin the blood owes the extraordinary property it possesses, of passing through the capillary system. " But this is not the-only important fact affecting the fibrin ; indeed, were we to take this alone into account, we should fall into a very serious error. Let us suppose an animal whose blood contains fibrin, as well as all its other constituent parts, in the normal proportions. If I inject into the veins of such an animal any substance possessing the property of combining chemically, of forming salts with the fibrin, such as fibrinate of soda, potassa, or ammonia, that fibrin will lose its coagulability. The change in the character of the fibrin affects the blood generally; it ceases to be coagulable, and the usual consequence ensues. You per- ceive, therefore, that the blood may contain its just proportion of fibrin, and yet be unfit for circulation. " Observe, I beg you, gentlemen, the fundamental point in the theory of the blood, deducible from the facts just described,— it is, that in order to support life it must be coagulable ; if it loses that property, existence is threatened, and ceases within a short while ; and this is precisely what occurs in the greater number of destructive epidemics. They are specially connected with cer- tain modified conditions of the blood, that cause it to stagnate in the pulmonary vessels. Such was the state of things in the epi- demic— the l grippe'— by which we were lately visited." In addition to the effect that inflammation has been shown to produce on the blood, it may be remarked, that its influence is no less manifest on organs remotely situated, and having no direct relation to the primary seat of the difficulty. Thus, gastro-intes- tinal disorders in children, have a remarkable tendency to de- velop inflammation of the brain, and all the serious consequences attendant upon it in such cases. Also, inflammation of the kid- neys is usually followed by more or less disturbance of the stomach, and so on. I might enumerate a great variety of instances in which organs of the body, having apparently very little connection with each other in health, have an intimate rela- tion developed during disease, through the influence of what is termed sympathy. This is an influence of very great importance, and not to be lost sight of, in the treatment of any disease ; for INFLAMMATION. 277 it is to this influence we are often to look for the beneficial effects derived from therapeutic agents, and to it, also, we must refer many important symptoms in the progress of disease. So important is the influence of sympathy, and so potent in the propagation of disease, that in overlooking it, we would often fail to perceive the only hope that could possibly attach to a case. Instances of the kind are of almost every day occurrence. A very marked case of this kind occurred not long since in my own practice ; in which all the general symptoms of rapid consump- tion followed what was thought to be a cold, after confinement. Hectic fever; night sweats; rapid emaciation; an uncontrollable cough, with an expectoration that had all the general appearances of pus; oppressed respiration; frequent pulse ; and burning in the feet and hands, were the manifestations. The physical phe- nomena, however, showed at once that these general symptoms bore no proper relation to serious pulmonary disease ; and upon further examination, an extensive irritation in the roots of the spinal nerves was found to exist, and believed to be sufficient to account for the train of morbid phenomena just described. It should be remarked, also, that before the physical exploration was made, the symptoms were so remarkably persistent and obstinate, as not to be amenable to medication. But when the source of the difficulty was discovered, and appliances adapted to the re- moval of the real disorder were employed, the symptoms yielded with great promptness, and perfect relief followed. The influence of local inflammation in the production of general febrile action, is so well known, and will be so often a subject of consideration, when we shall speak of particular affections, that it is unnecessary to dwell upon it at this time. A few words, how- ever, in relation to the immediate cause of this sympathetic fever, may not be out of place in this connection. In using the term sympathetic fever, I do not now include those febrile phenomena which result from malarial and other similar causes ; although, in one sense, all febrile action might be con- sidered sympathetic ; but I apply the term only to such general febrile symptoms as result from some appreciable local lesion. Whether the immediate causes of those febrile symptoms asso- ciated with the local phenomena of inflammation, are referable to 278 INFLAMMATION. derangement of the blood, resulting from preexisting irregulari- ties, hereditary tendencies, or accidental and unavoidable circum- stances; or, whether it is at first produced by derangement of the nervous functions, from causes not apparent; are questions which cannot be very readily nor satisfactorily determined, in the present state of our knowledge. The controlling influence of the nervous system in the phenomena of animal life, and also in the production of morbid action, is fully recognized, and seems to distinguish it as the guardian of the citadel, and subject, almost necessarily, to receive the first morbid impressions. But since the very first sensible manifestions of sympathetic fever are ob- served in the secretions, denoting an effort of nature to throw morbid elements out of the system ; and since the source of such unhealthy materials can be the blood alone; it seems equally evident, that derangement of this fluid, if not the primary diffi- culty, is at least an early associate of the first phenomena of sympathetic disease. The progress and complications of these febrile symptoms will depend, as a matter of course, on the character, extent and state of the local disease; developing different combinations at differ- ent stages of the primary affection ; which will be discussed, when we come to speak of disease of the particular organs. I will, in the next place, call your attention to the minute changes which characterize inflammatory action, as ascertained by the microscope. Many careful observations, and critical and extensive experiments, have been made in this department of pathological research, with a view of detecting the changes which occur, and the peculiarities of condition which exist in the minute vessels and tissues, during the inflammatory process. To this subject I bespeak your most careful attention, for upon the nature of inflammation as thus determined, and upon the effects which the loss of blood produces on the circulation of that fluid in the vessels, we predicate the philosophy of correct treatment in active inflammatory disease. These changes and peculiarities, too minute to be detected by unassisted vision, have been brought to view by the powers of the microscope; and the observations made with this instrument are so various and extensive, and have been so often reiterated, under a great variety of circumstances, INFLAMMATION. 279 both upon the lower animals, and upon the human system, that there appears to be here no longer any room for doubt or uncer- tainty in regard to the truth. I shall not, however, attempt to give you in detail all the experiments, observations and minute facts, which have been recorded by those who have been prose- cuting such researches, but in a summary manner state those results in regard to which there is a general coincidence in the experiments made by different individuals. First, then, all experiments prove that the earliest observable changes which take place in parts exposed to a cause of inflam- mation, are always essentially the same, whether that cause be local or general; whether it be from constitutional influences, or extraneous irritants; and whether the irritation be produced by mechanical violence or chemical action. The first observable change in a part thus exposed, is a contraction of the capillary vessels, or a diminution of their calibre, which must of course be attended by increased activity of the circulation in them; for the channels being made smaller, the current must be more rapid. This, it may be observed, is the mere initiatory stage, and does not denote the actual existence of inflammation, but as it were, a process preparatory to the development of positive inflammatory action. Should the morbid excitement be arrested without pro- gressing further, the affection could not be called inflammation, but merely irritation,— although this stage is an indispensable step in the inflammatory process. This constricted state of the vessels is followed by a relaxed condition. They now begin to enlarge and become extended in a sensible degree, while the movement of the blood in them becomes slower. These phenomena denote the development of positive inflammation, and in exact ratio with the increase and intensity of the inflammatory symptoms are the relaxation of the vessels and retardation of the circulation, even to the effect of entire stagna- tion. At the very centre of the inflammatory action, a complete cessation of the circulation occurs, which causes the part to assume the pointed or conical form. Often during this stage there is ob- served a retrograde motion in the circulating current. Whether this results from the obstruction at a certain point, damming up the vessels ; or whether it is caused by effusion from the vessels, 280 INFLAMMATION. tending to produce a vacuum, and thus inducing a backward flow of the blood to refill the vessels ; or whether it results from chem- ical changes in the blood, producing such new affinities as to cause the blood to flow back under the influence of attraction upon its particles, is not fully determined ; but such are the perceptible facts ; there is a manifest oscillatory motion in the capillary circu- lation of the part involved, during this stage of inflammatory ac- tion. Nor are these peculiarities of movement the only changes observed in the blood. The red globules which hold so important a relation in all healthy action, lose _ some of their peculiarities of form, and exhibit a tendency to coalesce, often as it were running together, forming masses of globules, which evidently tend to in- terrupt the circulation. This is, no doubt, attended by great modification in the vitality of this important element of the blood. If, however, the inflammatory process be here arrested, either by efforts of nature alone, or assisted by proper treatment, so that this condition is not permitted to continue long, the globules seem to possess the capacity of resuming their vitality and individual identity, even where the latter appeared to be entirely lost. It has been supposed by some that they possess a kind of individual life, and that each little molecule has a kind of repelling force with which to resist morbific influences, and that when, in their in- dividual capacity, this power is insufficient for the purpose, they arrange themselves in platoons or armies for the purpose of in- creasing their resisting force; and that when the invasion is end- ed, their alliance is dissolved, and a disbanding of forces takes place. This may be called the refinement of theory, yet it is worthy of serious consideration. Simultaneously with the occurrence of the changes just de- scribed, there occurs an effusion of lymph from the vessels into the cellular structure of the affected part. This exudes or passes out through the pores of the vessels, in a fluid condition, and af- terwards becomes solidified by coagulation, and the absorption, probably, of the fluid portions. In this new substance, which has the organic structure characteristic of coagulated fibrin, there is soon observed a transmission of colored fluid, probably pure blood ; which, by virtue of its vitality, (a very unmeaning term, however, as I have before remarked,) or by the power of the blood-vessels, INFLAMMATION. 281 or by the action of the heart, (which is felt throughout the sys- tem,) is forced into this coagulated matter, the particles of which, by some vital instinct, as I may call it, are attracted around the blood corpuscles and thus form an entirely new set of vessels. This extra accumulation of blood gives to the surrounding parts the great increase of redness so common in inflammation; and this color and the tumefaction produced by the formation of the structure, may remain long after the disappearance of active in- flammatory symptoms, constituting a chronic inflammation, which may yield only to a long course of medication and the slow ab- sorption of the superabundant organic structure. The process by which coagulating lymph is thus converted into organized living tissue, is what we mean by the term adhesive inflammation. It, of course, cements the structures where vitality remains, and, around the centre where the circulation has ceased and vitality is lost, it builds a barrier or wall, as if to resist the extension of death, while the increased vascularity of the part determines the circulation towards this devitalized centre, which at last is separ- ated from the living structure, as a slough, or is dissolved in the serous effusion and purulent secretion, and thus prepared to be discharged. Such, gentlemen, are the microscopic phenomena of inflamma- tory action. They are striking and peculiar as characteristic of this form of morbid action, and they are remarkable for their uni- formity. True, the same effects are not always observed to follow the application of a stimulus, and the inflammatory action may be more promptly set up and more speedily terminated in one case than another; yet the minute changes which occur in the structures and circulation, are substantially the same in every tissue and under all circumstances, so far as the microscope can reveal them, whether they are observed in the web of a frog's foot, in the per- itoneum of a dog, or in the lungs of a human being. The pecu- liarities of each inflammatory stage are always essentially the same in kind, however they may differ in extent or intensity. As confirmatory of what I have said upon this subject, and as affording a more minute exposition of some of the microscopic phenomena than I can give you in any other form, I will here 282 INFLAMMATION. read you a few extracts from eminent authors. The first is from Tweedie : " Immediately after the application of a stimulus which is capable of exciting inflammation—especially if it be one which acts on a large surface, as alcohol applied to a membrane—a con- stricted state of the small vessels of the part, and an accelerated flow of blood through them has been distinctly seen by various ob- servers ; but this state is of short duration, and during it the char- acteristic marks of inflammation are not perceived. After a time, varying from a few minutes to some hours from the first applica- tion of the exciting cause, the opposite change in the condition of the small blood vessels is observed; they become enlarged and distended; the movement in those most affected is slower than before ; there is often absolute stagnation for a time, and often oscillation, in different portions of them, and the globules of the blood which they contain are found to coalesce into irregular masses, in which their individual forms are no longer recognized. This is the condition of those parts in which the redness and swelling are the most intense. In the neighborhood the vessels are likewise enlarged, while the flow through them is more rapid than natural. Over the whole surface, and es- pecially where the movement of the blood is retarded, many small vessels become obvious, which were not previously seen. This is, no doubt, chiefly owing to the reception of the globules of the blood into vessels previously admitting only its clear and colorless liquid; but Kaltenbrunner and others have distinctly observed the formation of new vessels, by globules escaping from the vessels and making tracks for themselves in the sur- rounding textures. It does not appear that either acceleration or retardation of the flow of blood is essential to the state of inflammation ; and although the latter state is always predominant in the parts most severely affected, yet, partly in consequence of the accelerated flow in the neighboring vessels, and partly of the increased quantity of blood received, more than compensating for its slower progress through the most diseased parts, the whole quantity of blood returned by the veins from an inflamed part (as in the case of the hand) is found to be greater, and, when the inflammation is severe, to be three or four times greater than that INFLAMMATION. 283 returned, within the same time, by the veins of the opposite sound organ. " Within a time, which is likewise various, but often very short, from the beginning of these changes, the characteristic effusions of inflammation begin to show themselves, chiefly, perhaps solely, in those parts where the flow of blood is retarded: first, the sur- rounding textures are loaded with a serous fluid; but, gradually, changes take place in this fluid, which indicate that other constitu- ents of the blood have exuded from the vessels; or part of the fluid effused assumes a gelatinous consistence, and forms flakes or layers, which gradually become solid. In the semi-fluid matter first effused, according to Gendrin and others, decolorizing globules of the blood may often be perceived; and in many cases globules of pus—known by their larger size and freer motion on one another, and, when observed in mass, by their yellow color, soon appear in this effused matter; and it assumes, more or less rapidly, and more or less generally, the form of purulent matter. " When the inflammation occurs in serous or mucous mem- branes, the first effusions from the blood vessels go only to increase, and probably attenuate, the natural exudations from these surfa- ces; but as the inflammation advances, the fluid thrown out becomes always, as in other parts, of thicker consistence, as well as more copious than natural, and often more or less distinctly purulent. "Along with the semi-fluid lymph effused in the earlier stage of inflammation, there is often extravasation of the coloring mat- ter of the blood, and sometimes of entire blood; but most of the inflammatory exudation, in the cases to which we give the name of simple or healthy inflammation, soon acquires in most textures the appearance of the coagulable lymph or fibrin, such as constitutes the buffy coat of inflamed blood. In this effused coagulable lymph it is very generally observed that canals are gradually formed, into which some of the capillaries of the inflamed texture soon effuse blood; these canals are, in the first instance, of larger calibre than the vessels which supply them, but soon contract and assume the appearance of vessels (chiefly of veins, when the inflammation is of healthy character), in which the motion of the blood goes on as in the vessels of other 284 INFLAMMATION. parts of the body, and by means of which this new texture of the body becomes liable to nutrition and absorption, like any of the preexisting textures. It is thus that the permanent adhesion of inflamed surfaces, and the closing of wounds, whether by the first intention (as it is called) or by granulation, is effected; and that inflammation within due limits, becomes the grand agent in repair- ing injuries attended with loss of substance. " On the other hand, the inflammatory effusions are always liable, in a greater or less degree, to the vital action of absorp- tion ; which, although very beneficial, and indeed essential to the final disappearance of the disease, very often, in the more advan- ced stages, extends irregularly to the surrounding textures, and goes on to an extent which is not required for any useful purpose; and it is in this way, chiefly, that inflammation becomes a cause of that irregular breach of substance in the solids of the body to which we give the name of ulceration. " Lastly, when the inflammation and consequent effusion have lasted some time in any texture, it often happens that the parts chiefly affected gradually lose their sensibility, change their color to gray, purple or black, become soft and flaccid, and ultimately putrid — their circulation gradually ceasing, and all their vital properties being extinguished. This is the termination in gangrene or mortification, often attended by suppuration and ulceration along the edges of the mortified part, which effects its separation from the living by the process called sloughing; while in other cases (as in what has been called traumeter gangrene), no such process is established to Umit the extension of the gangrene, and it is arrested only by the death of the patient. " These obvious changes are attended with less striking, but equally characteristic alterations, in the blood which passes through the inflamed parts. Not only do the globules coalesce into irregular masses, but much of their coloring matter separates from them (Gendrin) ; not only does the liquor sanguinis, or clear fluid of the blood, exude from the vessels, but it comes forth more loaded with fibrin than natural, so as to deposit much of it in the solid form, when at rest; and this effused fibrin appears to have a peculiar firmness of aggregation, for when it exudes on the inner surface of blood vessels, where a current is going on, INFLAMMATION. 285 although fluid in the first instance, it is not carried off by the stream, but " concretes upon, and furs over, the inside of the vessel." (Hunter.') And not only does much of the effused fluid often gradually take the form of purulent matter, but the same change has been distinctly observed to take place on por- tions of the blood contained in the inflamed vessels themselves. ( Gendrin.) " These local changes are always observed to extend, more or less, from the point where they commence, before subsiding there. This extension takes place in a much greater degree in some varieties of inflammation (to be afterwards mentioned) than in others; but in all cases, two important observations may be made on the extension of inflammation: first, that it is more apt to take place along the texture where it originates, than to cross from one texture to another; and, second, that it usually takes place from the original point, as from a centre, in all directions, not following the course either of vessels or nerves, and often passing from one portion of a membrane (as the pleura or peritoneum) to another portion lying contiguous to it, although the vessels and nerves of this portion may arise from a distinct source." * * * The same author, after presenting his reasons for rejecting the theory that inflammation is the result of mere mechanical obstruc- tion of the capillaries, remarks: " It will be observed that these considerations are well founded, not on speculation, but on observed facts, at least equally well- ascertained, and equally guarded from fallacies, as any that can be observed in experiments on animals. To leave them out of view, in forming an opinion of the nature of inflammation, is to reject, not the aid of hypothesis, but the evidence of facts. We do not say that we explain these facts by saying that inflammation is a vital phenomenon,- of which the explanation must be sought only in the laws of life ; but we make the first step to the proper explanation, when we place the phenomenon in its proper class among the sub- jects of human knowledge; and from the facts now stated we infer, with perfect confidence that any mechanical explanation of the kind in question can only reach a part, and not the most charac- teristic part, of the phenomena of inflammation; and that, in this as in other instances, all attempts to resolve the most essential 286 INFLAMMATION. changes which go on in the living body, into the laws of dead matter, can only tend to perpetuate false views in physiology, and to draw us off from the proper point of view, in which the actions of living bodies should be regarded." In one of Palmer's notes to Hunter on the Blood, it is said: " When the web of a frog's foot, or the transparent mesentery of a warm blooded animal, is viewed in the field of a good mi- croscope, and at the same time irritated, effects very different are observed to ensue in different cases; but in all instances where inflammation is well established the vessels are observed to be increased in number as well as size, and the course of the blood to be much retarded. The evidence upon this point is so univer- sal, precise, and satisfactory, as to render any detail on the sub- ject quite unnecessary. * * * It would appear, however, that there is a great difference between actual inflammation and that precedent state of erubescence which is excited by slight stimulants, or which bounds the outer circumference of an in- flamed part, a difference which has not always been attended to, and which in many instances has led to mistakes on this subject. At first the effect of stimulation is generally to contract the small vessels and to accelerate the circulation; but as soon as inflam- mation is unequivocally established, the circulation is invariably retarded. In severe cases, indeed, the retardation amounts to a complete stasis, although in the surrounding parts the blood is ob- served to flow with more rapidity than usual." That you may the more clearly perceive the difference between these abnormal peculiarities, and those which characterize the healthy capillary circulation, I will now quote from Magendie on this latter subject. He says: " We will now leave the subject of the venous circulation, and pass to that of the capillary system; and the change is a satis- factory one; for our existing knowledge of the capillary circulation is much more complete and accurate than our acquaintance with the general circulation. In the large vessels, we can only judge of the state of the internal currents of blood by the appearance of their walls; according as the latter dilate, contract, become curv- ed, straight, or elongated, we perceive that the former move with such and such velocity and energy; in fact it is by induction only INFLAMMATION. 287 that we are enabled to analyze its phenomena of progression. The thickness of the vascular tunics prevents us from directly in- specting the globules of the blood,—an obstacle which does not interfere with their examination in the capillary vessels, as, by the help of the miscroscope, we are enabled to follow perfectly well the displacements and oscillations of the colored corpuscule floating in the serosity. The sole difficulty in this branch of the system consists in devising rational explanations for the phenomena observed. I constantly, as you are aware, brought the laws of hydrodynamics to bear, in explaining the circulation in the large trunks ; to the same laws I shall refer in our new investigation. " The tenuity of the capillaries is, therefore, favorable, instead of being an obstacle to the examination of the course of the blood in their interior. Injection lends very feeble assistance in the study of the capillary circulation: it can, at the most, do no more than give some anatomical notion of the material arrangements of the vessels themselves. The blood is not the only fluid that moves in the beautiful rete formed by their interlacement; there are certain organs and tissues into the capillary system of which that fluid does not appear to enter at all in the normal state; but if you push an injection into the vessels, it will penetrate into the canals wherein fluids of another description usually circulate, quite as well as into those in which blood is ordinarily found. Thus, when the material injected is well fitted for the purpose, and cautiously introduced, the serous membranes will become covered with vascular arborisations. Now the vessels you descry on its surface, when thus injected, were not during life traversed by blood ; white fluids only were contained in them; but as these hold no opaque granules in suspension, their mode of circulation cannot be accurately followed during life. The lymphatic capilla- ries have as transparent walls as the sanguineous, and yet what we know of the phenomena occurring in them is exceedingly limited. If you lay bare and examine a serous membrane, you can discover no circulation in the interstices of its tissue; nevertheless, that tissue is principally formed of infinitely minute tubes. You can- not allege that there are no liquid currents in movement; the rapidity with which substances deposited on its surface are ab- sorbed, gives you the proof of the contrary. When this system 288 INFLAMMATION. of white canals, in consequence of some morbid condition, comes into relation with the blood, a fluid hitherto unconnected with them, you may perceive myriads of vessels in the substance of the membrane. It is this change in the color of the circulating fluid that betrays its presence; so long as it remains diaphanous we are unable to study its course. " I have already adverted slightly to the researches of M. Poiseuiile respecting the capillary circulation. I have told you how that observer ascertained that the blood moves in the capil- lary vessels in the same manner as a liquid in an inert tube ; in both cases a motionless stratum adheres to the inner surface by a sort of affinity. Its existence in vegetable tubes, also, has been established by the same experimentalist. Examine the course of the blood in a vessel spacious enough to allow of the passage of several globules abreast, and you will perceive that their velocity of movement is very great in the centre, and less so in the neigh- borhood of its walls, while in the stratum of serum they are nearly motionless. In the axis of the vessels the globules are only subjected to a movement of translation ; in the neighborhood of the stratum, to one of translation and rotation. The latter is more and more marked, the nearer they are to the stratum of serum. The globules that happen to be dashed into it become motionless; those which merely touch it undergo a movement of rotation, as if they had jostled, against an undulating surface. This stratum protects the vessels by means, of its immobility, as it prevents the friction of the globules against their walls. It is only where it is in contact with the periphery of the vessel that it is perfectly at rest; the globules move with a progressively increasing velocity in proportion as they are close to the axis of the vessel. This difference of velocity and movement in the globules placed in the centre, or near the periphery of the vessel, does not exist in its lateral direction only. Those occupying its inferior part are slower in their progress than those situate at its upper end, as may be easily ascertained by examining compara- tively those two parts. " The irregularities occurring in the movements of the globules, are, therefore, to be ascribed to their relative position to the adhering layer. Thus let us suppose two globules advancing to- INFLAMMATION. 289 gether with equal rapidity; one of them, jostled by its companion, is driven towards the periphery, its movement slackens, and it remains behind; the other continues on its way. Another jolt, from some other globule, restores the one remaining behind, to its former place, in the centre, and the moment this occurs it is borne away by the current and regains its previous velocity. In other cases a globule gets placed crosswise, so that both its extremities are immersed in the motionless stratum; its movement is thus slackened; others overtake it, press upon, and accumulate behind it; the passage is intercepted, and a sort of dyke opposes the further advance of the globules. Shortly after the globule which has caused all this disorder moves from its anormal position, be- comes longitudinal, resumes its motion, and at the same instant all .the others reacquire theirs. These agglomerations of globules very rarely occur in cases where the heart retains its full force, and the animal continues strong; they are consequently, in general, observed only towards the close of an experiment. The existence of a motionless stratum, being a continually present and powerful cause of slackened movement in the globules, it is indispensably necessary for the force that moves the blood to have a certain degree of power in order to carry on the capillary circulation. By means of anastomotic communication all these minute canals are made vicarious of each other. When a mechanical obstacle is created in any point, the globules stagnate; the resistance is out of proportion with the motor power, and the liquid remains at rest in its tubes. The central globules are not in the least influ- enced by the motionless peripheric stratum in the large vessels, in consequence of the distance separating them from it. In the capillary vessels, on the contrary, they are obliged to traverse a mass of serum, of which the central filament alone, if I may so speak, possesses any rapidity of motion. Haller, Spalanzani, and other physiologists, saw the globules advance, retreat and move in a variety of directions; but these are not, as has been maintained, vital phenomena. The arrangement of the globules among each other, their relation to the motionless stratum of serosity, and other circumstances, give us the key to the comprehension of all those ...,.„.*** * * * * peculiarities. " In investigating the capillary circulation in animals, the 19 290 INFLAMMATION. microscope is always employed, and the animals on whom such examinations may be most effectually made, are frogs and .sala- manders, among batrachians; mice and small rats, among mam- malia. The tail of some fishes, too, is, from the transparence of the integuments, well adapted for inspections of this kind. I shall extract the greater part of the facts I am about to lay before you from M. Poiseuille's ' Essay on the Capillary Circulation.' As this essay has not yet been printed, I shall quote some passages verbatim, commencing with the simplest phenomena. "'The experimentalist separates the femoral artery and vein from their connections with the surrounding tissues by delicate dis- section, and then passes a ligature round the thigh, taking care to tighten it forcibly; the circulation of the part is now carried on solely by the twro vessels named. The animal is pinned down to a plate of cork, so as to make the inter-digital spaces correspond to the object-glass of the microscope. When he has ascertained the degree of velocity of the globules, he intercepts the course of the blood in the artery, leaving the vein free. The globules still continue to move, but do so more slowly, and their movement gradu- ally grows slower and slower, until at the end of two or three minutes, it ceases completely. When the compression is taken off, each globule which was in a complete state of rest, instantly starts off with the rapidity of an arrow, and recovers its normal velocity. Some physiologists on observing the persistence of the movement of the globules after the impulsion of the heart had been prevent- ed from acting on them, were very naturally perhaps induced to recognize a sort of inherent progressive force in those bodies, which, they further supposed, directed them from the arteries towards the veins. Others conceived that the latter vessels exer- cised a kind of aspiration on the globules; both these notions are erroneous. The same phenomena to which I have already drawn your attention, as existing in the vascular trunks, occurs in the capillary vessels. The facts with which you are already well ac- quainted, show that the movement of the globules is to be explained by the elastic retraction of the arterial walls below the ligature. When the passage of the blood is intercepted in a large artery the vessel retracts abruptly—the diminution of its diameter takes place suddenly. In the capillary system, on the contrary, re- INFLAMMATION. 291 traction is a slower process, and this difference in point of elasticity in the small and large tubes, explains why, in the experiment I have just described, the globules continue to move for several minutes after the application of the ligature. "' The mesentery of a frog is next separated from the animal and spread out on a piece of glass. A certain quantity of blood escapes from the opened vessels, and as those are no longer dila- ted by the column of blood impelled forward by the heart, they retract, and their retraction is so considerable, that the diameter of some veins and arteries decreases to half its original amount.' " The flow of blood only ceases when the vessels have reached the utmost limit of elastic retraction; and the greater number do not undergo retraction throughout their entire extent; there are swollen points observed here and there. Now this irregularity in the retraction of the capillary walls depends on the manner in which the small quantity of blood remaining in each tube is distributed, and undergoes coagulation. Masses of globules accumulate in several points, and to each of these accumulations corresponds a swelling of the vessel: for the coats being arrested in their retraction by a physical obstacle, are unable to retract so fully as if the cavity were empty. The notion of the existence of different degrees in the retractile force of the capillaries is, there- fore, an incorrect one ; remove any clots they may contain from their interior, and the diminution in their calibre will be the same through their entire extent. " One of the chief proofs adduced in support of the opinion that the globules are endowed with a faculty of spontaneous movement, is derived from the following experiment. It has been said that if, while you examine the circulation in a capillary vessel, you make a small hole in any point of its walls, the direction of the current within it is instantly modified. The whole column of blood, which a moment before obeyed one and the same impelling power, separates into two distinct columns; these, moving in con- trary directions, rush towards the little orifice you have made and effect their escape through it. The action of the heart has ceased to be felt beyond the accidental opening,—the movement of the globules there situated cannot, therefore, be explained by that action; besides, their movement is a retrogade one. What other 292 INFLAMMATION. cause, it is asked, but an act of their will, can cause these intelligent corpuscula to move in this novel direction ? The fact, gentlemen, is unquestionably correct, and the inference drawn from it is, no doubt, specious enough; but a little reflection clearly shows it to be faulty. We know that the pressure exercised by the blood in the normal state on the walls of the arteries and veins, is superior to that of the atmosphere. Now this pressure is suddenly dimin- ished at the point of section; to this point, consequently, a rush of blood must, in pursuance of the laws of the equilibrium of bodies, take place. Whatever be the existing direction of their course, it will now become that of the artificial opening; this movement of the globules is also promoted by the elastic retrac- tion of the walls of the vessels, which press circularly on the blood, and, in the absence of the impelling influence of the ven- trical, communicate a retrogade motion to it. I see no necessity for imagining hypotheses, when the physical explanation of the phenomenon is so easy and natural. But, further, if you distend a caoutchouc tube with an injection, and then make an opening in its central part, the contained liquid will rush thither from both ■ends of the tube. The case is the same as with the living vessel. * ****** " Hear another experiment, which proves in the clearest manner that the movement of the blood in the capillary vessels depends on the impulsion of the heart and the elastic retraction of the walls of the vessels. I extract it verbatim from M. Poiseuille's manuscript: ' The femoral vein, artery and nerve of a frog are accurately separated to the extent of two centimetres, at the least, from the surrounding tissues, and a ligature then passed round the thigh, excluding the vessels and nerve ; a loose ligature, ready to be tightened at will, is thrown round the vein. A thread is next fixed to the extremity of each digit of the same limb, to facilitate the examination of the circulation in the interdigital spaces without modifying it by pricking the tissues. The frog being pinned down to a flat piece of cork, and the web laid under the object-glass of the microscope, the ligature embracing the bone and muscles of the thigh is forcibly tightened. The experi- menter is then certain that the circulation in the lower part of the .limb is carried on by the dissected vessels alone. The circulation INFLAMMATION. 293 in the arteries,veins and capillaries, goes forward in the same man- ner as before the performance of the operation described ; jerking movements sometimes take place. The globules move more rapidly in the arteries than in the veins; and in the capillaries their velo- city is less than in the other two orders of vessels ; in some, how ever, it is greater than others, for reasons to which we need not at present direct our attention. The observer now watches with espe- cial care an artery and vein of the interdigital space submitted to investigation: he then interrupts the course of the blood in the femoral vein ; the moment he does so the progression of the globules in the vessels of the digital interspace under examination becomes jerking, and this jerking mode of progression lasts a few seconds only, being followed by an oscillatory movement. The span of these oscillations at first equals the length of five globules, and soon decreases to that of two; the rhythm is identi- cally the same in the artery and capillaries of the interdigital space, and they continue, to the number of forty-six in a minute, so long as the compression of the vein is kept up. While the femoral vein still undergoes compression, the experiment is varied by interrupting the course of the blood in the artery also ; the oscillatory motion ceases at the same instant. The globules become quiescent in the artery, the capillaries, and vein of the extremity. If the femoral artery be then freed from constriction, oscillations of equal length, in the three orders of vessels, recom- mence. These experiments concluded, the heart of the animal is laid bare, and the number of contractions of the ventricles counted; these are found to be one hundred and eighty-six in four minutes, or forty-six in a minute.' " LECTURE XIX. INFLAMMATION —Continued. Effects of Blood-letting—Magendie's Character and Researches— Quotations from him—Bleeding increases Serum— Various Ex- periments—Excess of Serum embarrasses Capillary Circulation— Promotes Inflammation—Quotation from Magendie—His change of views—Bleeding predisposes to Inflammation—Quotation from Hunter—Tweedie—Review of his Doctrines—Results of Blood- less Practice. Having presented you with a general description of inflamma- tion, as developed in its sensible phenomena; and having fur- nished you with the very best and most reliable information of which our profession is in possession, in regard to the minute changes which occur in the capillary vessels and in the blood, during the inflammatory process ; and having produced, also, in this relation, such experiments as seem best adapted, from the authority of the experimenters, and from the simplicity and con- clusiveness of the experiments themselves, to give you a correct idea of the mechanism and movements of the capillary system in a state of health, I believe vou are fully prepared to pass with me to an examination of the effects of blood-letting on the con- stituency of the blood, and on its circulation in the capillary sys- tem. As we are now ready to enter into an inquiry as to the most philosophical and truly scientific mode of treating inflamma- tion, it seems unavoidable that we first dispose of that thera- peutic agent upon which so much reliance has been placed for years, by prominent men in the profession. And I hope to be able, before the close of the present lecture, to convince you that, in INFLAMMATION. 295 rejecting the lancet as a means of treating inflammatory disease, we are sustained both by physiological facts and practical expe- rience. In pursuing our inquiries on this subject, your attention will be directed to the laws which appear to govern the constituent elements of the blood, and its circulation, as influenced by the abstraction of blood ; as well as to the special effects of venesec- tion upon parts involved in the inflammatory process. And as I do not desire to deal in mere denunciations, nor yet set up my own ipse dixit as authority in this connection, I shall, as here- tofore, make free use of such authors as are recognized by the whole profession, and whose interesting researches have been placed upon record, as a general fund upon which all inquirers after truth may draw, to sustain their investigations; and although a vast amount of hypothetical reasoning, and professional abstrac- tions, clothed in imposing verbiage, have almost converted our medical libraries into heaps of rubbish, with only an occasional truth to repay our labors,— yet it is our privilege to isolate those facts which constitute the real essence of medical knowledge, and bring them to bear upon the subject before us. Perhaps no man ever lived that manifested a more disinterested, deliberate, yet earnest desire to arrive at truth in his investiga- tions and experiments, than Magendie ; and certainly no man stands more deservedly prominent in the ranks of medical author- ity, as a bold, successful and accurate experimentalist in physi- ological and pathological science. Occupying important positions, first, as physician to an important institution in France, and, secondly, as teacher of the principles and science of medicine to a large number of pupils, it behooved him to be exceedingly care- ful in regard to the principles which governed his practice, and the doctrines he taught: and you will find in all his writings, those disinterested, cool, careful and deliberative characteristics, found in but few authors. You will find him most remarkable in one thing, especially; that is, where he has expressed an opinion which he subsequently perceives to be wrong, he yields at once, acknowledges his error in the most frank and candid manner, and makes the most of the truth by which his former views have been subverted. Unfortunately for the good of humanity, and the 296 INFLAMMATION. advancement of medical science, this virtue has been too deficient in most of the profession. The extracts which I shall now read, from Magendie in par- ticular, are intended to demonstrate the influence of venesection on the constituent elements of the blood. And first, let me recall your attention to some of the extracts I read to you yesterday, establishing the fact that the due proportion of all the elements of the blood is indispensable to free and healthy circulation in the capillaries ; and especially, that to the presence of " fibrin, the blood owes the extraordinary property it possesses, of passing through the capillary system." You will remember, also, the exper- iment of the same author, in which, by three successive bleedings, he modified the blood of a dog to such an extent, that the clot was reduced from four-fifths to less than two-thirds the entire mass of the blood; and that the fluid portion was changed to reddish- yellow, " owing to the commencing solution of the globular sub- stance." And you will please remember the assertion of this candid and earnest experimentalist, in view of these results, " that blood-letting induces,both in the blood itself, and in our tissues, certain modifications and pathological phenomena, which resemble, to a certain extent, those developed in animals deprived of atmos- pheric oxygen, of drink and solid food." There are other passages, by the same author, which might have been quoted with propriety under another head, but as this was not done I introduce them here. They throw still additional light upon the topics we have been discussing, while they illumi- nate the ground we are about to explore. " There is a fact in physics, remarkable for the excellent term of comparison which it serves to establish between the phe- nomena of the movement of the blood in our organs and the cir- culation of liquids in inert tubes. I allude to the enormous, pres- sure which is required in order to make water pass through a tube of very small diameter, while the blood traverses with ease the infinitely more minute tubes that abound in our tissues. There must be some particular conditions to facilitate its passage. What proves their existence is, that if certain alterations are effected in the composition of the blood, it stops, undergoes morbid changes, becomes extravasated and decomposed, and produces the various INFLAMMATION. 297 disorders which pathologists have vainly attempted to explain by the words inflammation and irritation. What sense, in truth, is there in applying the words inflammation to our organs ? Do our tissues really take fire ? I confess I know of no example of such a phenomenon. When the blood rushes to a part in abund- ance, a certain rise of temperature, no doubt, occasionally follows; but it only reaches a few degrees above the normal standard of the organ, and never exceeds that of the blood in the left ventri- cle. To cause a real inflammation, the elevation of heat should be carried infinitely higher; besides, in many cases also called inflammatory, there is a notable fall of temperature." Further on he says : " But to return. We ascertained that the first condition for the accomplishment of the circulation, was that the blood should have the property of forming into a mass when removed from its vessels and left to itself. This is the fundamental fact to which the majority of those we shall subsequently become acquainted with will be found referable. Meanwhile we will endeavor to discover the physiological or chemical circumstances, and the par- ticular substances that influence that phenomenon." He then relates an experiment made by him, by the injection of a drachm of oenanthic aether mixed with an equal quantity of dis- tilled water into the veins of a dog, producing death in three quar- ters of an hour, evidently from liquefaction of the blood,yet attended with the autopsic appearances of gastro-enteritis; and adds: " As the sudden introduction of a little oenanthic aether into the veins of an animal destroys the coagulability of its blood, it is by no means impossible but that the prolonged abuse of wine may, in the end, entail similar modifications in the physical properties of that fluid. Much has been written on drunkenness, its effects, and the disorders it induces in the organic functions. The patho- logical anatomist has examined every organ in its turn, in search of the peccant principle, but in vain; in spite of all that has been done, conjectures are all that we have got. Delirium tremens has been attributed to inflammation of the brain, of the cerebellum, of the meninges; but not a word has been said of the condition of the fluids. It will be my aim to investigate these different points thoroughly; they are of the last importance, for it is by examin- 298 INFLAMMATION. ing the condition of the blood that we have learned the mechan- ism of the production of several of those terrible diseases that de- cimate the human species. Thus we have been enabled to explain the black vomiting of the yellow fever that devastates the shores of America." * " Continuing our scrutiny into the properties of the blood, we soon discover another of its special characters. This is a pe- culiar viscousness. Now on first thought, this would seem an ob- stacle to its passage through the ultimate tubes, but it is in reality an indispensable condition to its free circulation ; to such a degree indeed is this true, that viscousness and the normal state of the blood are two inseparable ideas. This property, again, is illustrated by experiments made on inorganic tubes. If we en- deavor to introduce water into a tube of extremely small diameter, that liquid, as I have already mentioned, will not enter it, no matter what force be employed; but if a certain quantity of any mu- cilaginous substance, such as gum, gelatin, or albumen, be added to it, the attempt at injection becomes successful immediately. " * * " Now here is the blood of an individual who had an attack of hemoptysis, and was bled freely for it. You know well what I think of that remedy,—worse, perhaps, than the disease. Be that as it will, you may perceive that this blood'is very slightly vis- cous ; I, in consequence, presume that further mischief will occur. We shall see if my presumptions are realized. We have no instruments to measure the viscidity of fluids; we are, there- fore, instead of having an accurate and rigorous estimate of that of the blood, reduced to simple conjectures. I consider that the discovery of any method of measuring it with exactness would be a most valuable acquisition. Meantime we will do what we can to determine it with the areometer. There is further proof that a certain share of viscidity is an essential requisite for the healthy circulation of the blood. If you bleed an animal several times, and replace the blood withdrawn with water, exhalation and effu- sion into the cavity of the pleura will follow, and subsequently into the peritoneum. Now you have done no more than diminish the viscidity of the blood, by adding a little water to it. But on the other hand, if you try the converse experiment, and augment its viscidity beyond its natural term, the circulation ceases altogether, INFLAMMATION. 299 in consequence of the affinity between the molecules of the blood being rendered too great. The molecules adhere to the walls of the vessels, and impede the circulation, just as blocks of ice, stuck to the banks of canals, or rivers, interrupt the course of their streams. Hence, there must be diseases originating in excessive viscousness of the blood." * " But there are important facts of another order, totally, to be learned respecting the blood. When we examine that fluid while yet circulating in the living animal, we are immediately struck with its heterogeneous appearance. It is seen to hold myriads of little particles in suspension, rolling on each other, and interming- ling in a multitude of ways. These particles, called globules, are known to have determinate dimensions, and to affect particular forms, according to the class of animals in which they are ob- served. They are elliptical in fishes, reptiles and birds; in mam- malia they have the appearance of a circular lens. These glob- ules deserve our close attention; for, when they undergo certain changes, they are unfitted for circulation in their tubes. However, it must be remarked, that, of all the elements of the blood, they undergo the fewest modifications in disease." * " Their mean ordinary diameter varies from the eightieth to the one hundred and twentieth part of a millemetre. There are some considerably smaller, but in all probability they are of a different species from those of which we have been speaking; to ascertain this for certain, however, would be a very interesting as well as novel topic for inquiry. " If we turn from these purely physiological questions to the chemical history of the blood, we shall find in it many points quite as interesting as those we have rapidly reviewed. The difficulties encountered in the prosecution of that branch of inquiry, are not less serious than those met with in investigating its physical prop- erties. However, it is easy to establish one important fact, namely, that every anormal chemical modification of the blood is followed by morbid phenomena, of just as great gravity as those which have already afforded us subject for discussion." " Among other practical points of importance to which these general views have led us, we have ascertained that venesection modifies the relative proportion of the serum and clot. Here is 300 INFLAMMATION. the product of the fourth and fifth bleedings which were practiced on the animal I showed you the other day. In the fourth, the serum is to the clot as 55:45 ; in the fifth, as 65:35. Now this is surely a very great difference; yet in this case the various ab- stractions of blood took place at intervals of two days, and the animal was fed well all the while, which prevents any very rapid alteration of the blood; and not only is the clot modified, but the serum also becomes whitish, and is pretty often found covered with a layer of opaline matter. " In fine, the nature of the blood, and of its different elements, is an important question in a therapeutical point of view. We can now maintain, with confidence, that it is not a matter of in- difference whether we bleed little or much ; whether we draw a small or large quantity of blood, in a very short space of time, or at distant intervals ; whether we push the abstraction to syncope, as has been advised by many writers, or repeat it to a smaller extent, at several different times, with a variable interval of time between them, as learned practitioners of the present day recom- mend. We are also justified in proclaiming, that men who bleed without giving themselves the least uneasiness about the disorders that follow the removal of blood, both in that fluid itself, and as their consequence, in the various organs ; who look on these dis- orders as curable by blood-letting, while they are, in reality, pro- duced by it, act with most reprehensible blindness. In simple language, they do mischief where they imagine they are doing good ; and in many an instance, on their doing that mischief or that good, the death or recovery of their patient depends." Having introduced the foregoing quotations from Magendie, in addition to those read in the last lecture, for the purpose of es- tablishing in your mind clear ideas of the properties in the blood indispensable to its free circulation in the capillaries, the quota- tions which follow will tend mainly to exhibit the tendency of venesection to change the character and destroy the equilibrium of the blood, so as to render it unfit for capillary circulation. In fact, the quotations already made do not leave this point doubtful, but, as more direct testimony is at hand, I will introduce a portion of it, before stating my own views in regard to the proper treat- ment of inflammation. INFLAMMATION. 301 Speaking of the results of bleeding an animal which he exhibited to his class, Magendie says : " His blood contains as much serum as clot. Here is the product of the seventh venesection practised on the animal, about which I have already more than once spoken. Although he eats and drinks as much as he likes, his health is materially affected, a notable change has taken place in his gait, habitudes and temper. The mucous membranes have grown sin- gularly pale — a peculiarity which has been long noted by veteri- nary practitioners in appreciating morbid symptoms. When he is bled now, syncope follows. I have no doubt but that an affection of the lungs will soon come on, and speedily put an end to his ex- istence." Again, the same author, in a subsequent lecture, says : "I stated to you that repeated blood-letting caused a variation in the proportions of serum and clot; but I have ascertained a still more important fact. It is this : in every case of serious disease I have met with since commencing the researches with which we are at present engaged, those two elements have invariably presented some anomaly, in respect of their relative volume." He then introduces cases in illustration and confirmation of this point, and adds: " A medical practitioner gave me some of the blood, drawn on three successive occasions from a patient affected with pneumo- nia. Each of the bleedings was abundant. The two first were practised on the day of the patient's admission; the last on the fourth day of his sojourn at the hospital. " In the first there are 11 grammes of serosity and 50 of clot, which gives about 22 parts of serosity in 100. In the second, there are 24 grammes of serum to the same proportion of coagu- lum ; the relative quantity of serosity was, therefore, more than doubled. Finally, the third gives 34 of serum to 35 of clot; that is, 50 per cent, of the former. These augmentations of serum, induced by bleeding, ought surely to have struck practitioners. I have full room for astonishment at their having excited so little attention, for it is a regular practice to have the blood of patients set aside for examination. At the end of twenty-four hours, usually, this examination is made. The clot is felt, turned up and down, and fingered in every direction ; and all with a view to the 302 INFLAMMATION. discovery of an appearance of buff. If this buff cannot be found, the conclusion is, that the disease is not inflammatory, a conclusion well wTorthy of the process by which it is obtained. But if you intimate to the physician that the serum has, at the second bleeding, acquired double its previous proportional quantity, and that it has lost its normal transparence, and that the clot is soft and diffluent, he will answer, that such things are not of the most trifling consequence. No, the really important point is, to detect the inflammatory element, were it only the veriest morsel of it, and then to annihilate it by the antiphlogistic treatment. Such is the manner in which medicine is generally practised. When we consider, gentlemen, that in spite of the plainest and most forci- ble facts, the majority of medical men persist in blindly following a regular routine that brings discredit on the art, we are surely justified in applying to them these words, which, in more than one view, recapitulate the history of men,—they have eyes, that they may not see." " A superabundance of serum in the blood is, in my mind, a positive contraindication to blood-letting ; and I conceive that this fact will sooner or later be admitted as a fundamental position in the treatment of disease. It is fully established, that inopportune bleeding may singularly aggravate the condition of a patient, and even render his restoration to health a positive impossibility." And yet a superabundance of serum is by no means inconsistent with the existence of the most aggravated forms of inflammation— may, indeed, be the cause of such inflammation. How then shall inflammation be arrested by the lancet, which uniformly increases the serosity of the blood ? In a single instance Magendie found himself mistaken in anticipating the effect of veterinary depletion. He attempted to ascertain what proportion of serum to the clot is essential to vitality. To hasten the experiment, he drew blood from an animal, and replaced it by injecting into the vein an equal quantity of distilled water at the temperature of the blood. The result was a dimunition of serum. Speaking of this circumstance, after remarking that one well observed fact cannot overturn another, he says: " Under circumstances like these, we should confine ourselves to registering the seemingly contradictory facts, and waiting INFLAMMATION. 303 patiently until further observation enabled us to get rid of the dif- ficulty. This is what we will now do; we will note down, that repeated venesection increased the quantity of serum in a patient, while the same agency appears to have had the contrary effect on this dog. However, it is right to mention, that the circumstances are not precisely the same in both cases. In the instance of the animal, there is, in the first place, a certain amount of forces in the organism, which tend to keep the blood within certain limits of composition. There is also a direct and most efficient cause why the introduction of water into the veins should not contribute to increase the quantity of serum in the blood; it is that, as my assistant this moment informs me, the animal has an abundant miction after each injection. " You are aware, gentlemen, with what rapidity fluids, ingested into the stomach, are carried by the veins of that organ into the general circulation, and thence to the kidneys, which they stimu- late to secretion. Thus, when we drink beer, seltzer water, or champagne, we are almost immediately seized with a desire to void our urine. There can be no doubt, that, if we could retain these liquids longer in the circulation, a bleeding practiced before this expulsion, would discover evidence of their presence in the blood ; but as they give an extraordinary degree of activity to the urinary secretion, they are quickly removed from the body. To continue our parallel: when a patient is bled, he is put on a very low diet; the animal on which our experiment was made, has, on the contrary, been given abundance of nutritious food, and, therefore, provided with the means of repairing the losses of his blood. A patient treated on the antiphlogistic plan, is placed in a diametrically opposite condition; his blood is taken from him, and he is, at the same time, deprived of all nourish- ment ; he has nothing wherewith to make up for the lost blood but ptisans, of which, to speak a truth, he is allowed no nig- gard supply. But as the restoration of the mass of the blood is indispensable, the lost elements must be got, as best they can, from these same ptisans ; hence, without doubt, comes the in- crease of serosity. Still it would be an interesting point, to learn the means and mechanism by which an animal is, in a case like the present, enabled to maintain the component parts a£ his blood in their normal proportions. 304 INFLAMMATION. " In spite of anything that may seem to indicate the contrary, it is perfectly true that any signal disproportion between the se- rum and clot, renders the blood unfit for the performance of its functions. A very curious case, supporting this doctrine, has been recently observed in my wards, in the Hotel Dieu. A female was, some time past, admitted under my care, with most violent uterine hemorrhage, which had existed for two days at the time of her admission. This was the consequence of an artificial miscarriage, induced by the use of those powerful drugs which certain women, whose moral turpitude is even greater than that of the unfortunate beings employing them, make a trade of vending. As I have since learned, it was not her first attempt in this way ; she had already succeeded twice or thrice in producing abortion. Such practices would be less frequently had recourse to, if their terrible consequences were better known. I may here say, that death is often the most desirable issue in such cases, for it puts an end to most atrocious suffering. In other instances, incurable mental alienation, or abdominal neuralgia, that no remedy can soothe, follows. Various cases of this kind have lately come be- fore me, and I distinctly ascertained that serious disorders of the brain were the occasional consequences of these criminal practices. " In the example to which I more particularly advert, there was, as I said, hemorrhage from the uterus. The general pallor of the subject was very remarkable, as well as the state of pros- tration and stupor under which she labored. Her blood trickled away in diffluent clots of a peculiar odor; it was this indeed which turned my thoughts to the probability of a premature delivery having taken place ; this, however, the patient employed all her remaining strength in pertinaciously denying. I had two ounces of blood taken from her ; not on homoeopathic principles, but to enable me to prognosticate the probable issue of the affection. Here is the blood, the disproportion of its elements is frightful; there is only 15 per cent, of coagulum. I affirm, that with such a quantity of serum in the blood, the capillary circulation cannot be regularly accomplished." * * * * "At the end of forty-eight hours, during which every drug supposed to possess antihemorrha- gic virtues was employed, among the rest secale cornutum, peri- tonitis supervened. You know that by this term is understood a INFLAMMATION. 305 disordered state of the secretion and exhalation of the serous membrane of the abdominal cavity. You find, after death, a viscous liquid, in the midst of which flocculi of albumen are seen to float, &c." " Now, can you fancy that the attack of peritonitis was the result of excitation, or irritation, suffered by the patient ? She was, on the contrary, perfectly anemic, and in the most marked state of weakness, and peritonitis is so acute a disease, that it carried her off in less than four and twenty hours. Is no relation to be recognized between the liquidity and slight coagulability of the blood and the affection of the peritoneum ? But this is not all ; if we turn from the abdomen to the lung, there, too, we find a state of engorgement, in other words, serosity effused ; in short, lesions perfectly analogous to those detected in the lung of the animal submitted to repeated blood-letting. I may, therefore, legitimately conjecture, that these diseases are to be referred to particular conditions of the blood. In peritonitis I find an effu- sion of serosity, and I know that there is serosity in the blood also. I also discover a substance solidified in the form of very thin lamellae ; may I not suppose that this is the fibrin of the blood escaped from its vessels and become organized?" In a subsequent lecture, Magendie further discourses on this subject as follows: " The point in the history of the blood about which we are at present more immediately interested, is the effects induced in the economy by variations in the relative quantity of the serum. If we could succeed in determining, even in an approximate manner, the influence of those changes on disease, and on tem- perament, we might assuredly lay claim to the honor of having done some service to pathology. But, gentlemen, this question is not one of those that may be solved in a single lecture, nor in two, nor in three; it requires to be examined in various points of view, and calls for the evidence of facts of an accuracy that none can gainsay. When we shall have studied this branch of our subject, we will turn to the chemical composition of the serum and clot, which, it cannot be denied, still requires minute investi- gation, although it has already been laboriously studied. We have hitherto done no more than receive specimens of blood 20 306 INFLAMMATION. into vases, examine them and the changes they undergo therein, compare as well as we could the proportions of their liquid and solid constituents, and inquire if the phenomena of life can con- tinue to be accomplished with such and such quantities of serum and clot. You have already seen, by the serious modifications induced in the state of the economy by certain diversities in their proportions, that we are not without plausible motives for invest- ing this question with the importance we have done. Let me recall to your minds the case of uterine hemorrhage of which I spoke to you in my last lecture, following abortion produced by criminal practices. You cannot have forgotten the consecutive symptoms, such as the intense peritonitis which supervened at the end of two days, accompanied with most violent pains and em- barrassment of the respiratory system, and which terminated by death in less than twenty-four hours. This case is worthy of close consideration; for, setting aside the signs proper to that fatal affection, we may ask, what is peritonitis? what are its mode of origin and first cause ? In general, the answer is, that it is an inflammation of the peritoneum: that the mode of vitality of that membrane is changed by irritation; that this irritation accumulates the blood in the capillary vessels, which were pre- viously impermeable by it, and that both an increase and a modification of the materials of exhalation are consequently pro- duced. When these different suppositions, and a variety of others, have been more or less carefully enumerated, it is pre- sumed that all has been said; nevertheless, the real question has not been so much as glanced at. For my own part, though I admire the ingenuity of those pathologists who have made peri- tonitis one of the inflammations per eminentiam, I cannot quite accede to the correctness of their opinion. We found in the blood of the woman to whose case I now especially refer, a most remarkable proportion between the serum and clot; there were 85 parts of serosity to 15 of coagulum. This single fact was in itself enough to suggest to our minds a very different explanation of the disorders under which she succumbed, from that afforded by the doctrine of inflammation; and we had no difficulty in estab- lishing the existence of certain relations between this occurrence and the phenomena daily observed in our experiments. Among INFLAMMATION. 307 other things, you saw that there was a most striking resemblance between the lesions of the lungs in our patient, and those occur- ring in the pulmonary organs of the animal submitted to a series of successive bleedings. But I must avail myself of the present opportunity to point you out a physical phenomenon long mistaken by medical men for a pathological change. In consequence of the greater or less liquidity and diminished consistence of the blood in certain cases, it becomes infiltrated from the capillary vessels in the pulmonary cells, accumulates therein, and consti- tutes the effusions known under the name of hypostatic pneumonia, which is in truth a simple effect of gravitation." From what has now been quoted no room is left for doubt, that fibrin is an element, the presence of which facilitates the capillary circulation, and that its appearance in inflammatory affections is merely evidence that the system is employing the proper means to overcome obstruction and repair injury. It is equally well established by the quotations read, that an undue amount of serum in the blood is inconsistent with free circulation, and tends to pro- duce or at least aggravate inflammatory action. The authorities quoted also show, what all the profession admit, that the loss of blood diminishes the relative amount of fibrin. Indeed, under the idea that fibrin is the inflammatory element, the practice of blood-letting finds almost its only justification. But the readings to which you have just listened establish still another fact, which, too, cannot be questioned by any advocate of the lancet, and that is, that the use of that instrument tends directly to increase the serum at the expense of the clot; or, in other words, to pro- duce such a disproportion between these two elements as to most surely embarrass the circulation ; and when carried to a certain extent, to render the blood incapable of forming a consistent co- agulum. From all the evidence before us our only decision must be, that blood-letting is not only incapable of arresting inflammation, but that it tends to promote it by embarrassing the circulation. As a still further confirmation of this opinion, and as bearing especially on the practice, wThich has been extensively prevalent in the pro- fession, of providing against apprehended inflammation, in cases 308 INFLAMMATION. of injury, or where capital operations are necessary, I shall read one more passage from Magendie. He says: " These reflections on the serum remind me that when I com- menced my medical career, imbued with the prejudices of the schools, and just such a novice as men usually are when they give up attending lectures; when, too, like my brethren, I paid my tribute to scholastic dogmatism ; that is, I believed in inflamma- tion, irritation, and the rest of it, as in so many articles of faith ; they remind me, I say, that even at that early period, these ques- tions excited my attention. You shall hear how I was led to their consideration. It was, at the time I allude to, an acknowledged point of doctrine that the abundance of serosity acted on the blood by modifying its tendency to inflammation, in somewhat the same manner as water added to alcohol prevents it from inflaming. Here, gentlemen, the word is used in its true signification. I had, as it happened, set about repeating the experiments of Sir Benjamin Brodie, now one of the first surgeons in England, on the ligature of the ductus choledochus. The animals on whom I practiced the operation, died without exception, of peritonitis. With a view of preventing this disagreeable result, I practiced a copious bleeding before the experiment, fancying, in conformity with the notions then prevalent, that I should thereby infallibly put a stop to the development of inflammation,—the inflammation nevertheless appeared with even still greater intensity than before. Subsequently I injected water in the room of the blood withdrawn, but in every instance peritonitis supervened with greater violence than before, and proved rapidly fatal. At the present time, when more correct notions on pathology have replaced those of former days, it appears to me that the more the blood abounds in seros- ity, the more probable it becomes that the consecutive exhalations of the serous membranes will be abundant; and hence, that, to use the orthodox language, inflammation will be more violently developed. Now, this fact alone shows what fatal consequences may be the result of a fallacious theory founded on an imperfect conception of the morbid phenomena occurring in the body. I do not hesitate to assert that the anti-inflammatory bleeding ordinarily practiced before capital operations, may frequently, according to the constitntion of the individual undergoing them, help to deter- INFLAMMATION. 309 mine the serious accidents observed to follow those operations. I recommend you strongly to take a note of this proposition, and to watch with attention the issue of cases in which such prophy- laxis has been adopted. You will, no doubt, find exceptional cases, but in the majority I make no question you will have reason to admit the justness of this view. The whole forms a subject for inquiry, which, though of great interest, has not yet been exam- ined by any one. I myself long upheld contrary opinions to those I now maintain, but I willingly sacrifice my vanity and acknowl- edge my error; if all were as ready to do so, the progress of our science would be much more rapid." What experiment and sound reason so clearly indicate to be truth, gentlemen, we shall generally find confirmed in practice ; and such I know to be the case in respect to the proposition now under consideration. Let a healthy person receive an injury suf- ficient to justify the apprehension of inflammatory action ; and let the lancet abstract blood freely from his system, changing the constituency of the blood, diminishing its fibrin and increasing its serum. If inflammation was to be apprehended before, it has now become unavoidable ; and instead of the reparative, I might say healthy character of the excitement which would have ensued, you will now have an intensity of morbid action, in exact propor- tion to the changes you have effected in the blood by your vene- section. And, indeed, it may be laid down as an established rule, that inflammatory action is least to be deprecated, and is always most manageable, when the constitution is most strong, and the blood in a normal condition. But for the correctness of this doctrine we need not depend on the authority of Magendie alone, however unimpeachable. The same view is in fact sustained by Hunter, Tweedie and others. " In inflammation," says Hunter, " when the constitution is strong, then it will be commonly the most manageable, for strength lessens irritability. But in every kind of constitution inflamma- tion will be the most manageable where the power and the action are pretty well proportioned." Again: " A wound, for instance, made upon a person of a healthy constitution and sound parts, will unite almost at once; it admits readily of a union by the first intention. A greater 310 INFLAMMATION. strength of constitution and of parts admits of resolution, while in the adhesive state of inflammation, very readily, and therefore tends to prevent the suppurative inflammation from taking place, for it gives a better disposition to heal by the adhesive; so that the union of parts by the first intention, the inflammation and res- olution, as well as the readiness to change from one to the other, according as the preceding is prevented, depends equally upon the strength and health of the constitution and parts inflamed. We may also observe that a greater strength and soundness of the constitution or parts inflamed, when the inflammation has got be- yond the stage of resolution, and has assumed the disposition for suppuration, hastens on inflammation and suppuration, and also brings it soon to a termination, while at the same time the matter is brought more quickly to the skin by ulceration. Whatever therefore, is the step which nature is to take, whenever an injury is done or a necessity for inflammation has taken place, it is per- formed with readiness and facility in strong constitutions and parts. " Weakness of constitution and weakness of parts are supposed to be the immediate cause of most tedious or chronic diseases." In regard to this last proposition Mr. Hunter says: " Where there is a strong susceptibility for any one disease, in which weakness might also become a predisposing cause, I can believe that in such cases weakness, especially if suddenly brought on, may be- come an immediate cause of that disease: as for instance, a man may, from a wound or any other cause, have a tendency to a locked jaw. If you bleed that man freely it is a thousand to one that a locked jaw comes on; weakness produces a consciousness of its own want of powers, or incapacity, which produces increas- ed action, that even proceeds the length of unnatural actions called nervous." * * * " When a wound is made in a person of a weak habit there is a great backwardness in the two cut surfaces to unite by the first intention, therefore inflammation takes place if there be strength of constitution to produce it, which is not always the case, so that in such habits inflammation is more likely to be a consequence; but this does not arise from a greater readiness to inflammation in the habit, but from a want of power and disposition to heal, INFLAMMATION. 311 which renders inflammation necessary. However, in this case, the want of powers or disposition to unite may partly depend on a different principle from that of weak parts or solids: it is prob- able that the blood of people of weak habits, is weak in its living principle, which it therefore very soon loses upon extravasation, so as to become unfit for a bond of union, by which it degener- ates into an extraneous body, and therefore the suppurative in- flammation must take place if there be strength to produce it. " In weak habits and diseased parts inflammation is slow in any of its salutary effects, and is hardly capable of either producing the adhesive or suppurative inflammation." This same doctrine of the necessity of vigor in the constitution, to sustain necessary inflammatory action, is clearly taught also by Tweedie, in his voluminous Library of Practical Medicine ; and he also fully recognizes the tendency of blood-letting to deterio- rate the blood, and enfeeble the constitution, and acknowledges its injurious influence ont he termination of inflammation in many cases; yet he is one of the most strenuous advocates of its general employment in inflammatory affections. It is strange, passing strange, that with all the acknowledged facts before his eyes; with the revelation by the microscope of the uniform condition of the parts involved in inflammatory action; and the well known influence of general bleeding upon the constitution of the blood, and upon its circulation in the capillaries; and with a personal experience and observation which compel him to acknowledge that " it is in a few cases only that blood-letting can be said to cut short inflammation; " and that " the more usual effect to be hoped for, is more correctly expressed by saying, that it disposes it to a more favorable termination;" it is I say, passing strange, that with such facts and experience staring him in the face, this author has never conceived or at least expressed the suspicion that this unnatural and hazardous agency should be entirely dispensed with, and such means employed for the treatment of inflammation as will more generally tend to cut it short. I will give you one or two remarks of this author, which, although they may look strange in the new relation which I com- pel them to assume, yet they will I think serve a much more val- 312 INFLAMMATION. uable purpose in an argument against the sanguinary mode of treatment than they can ever do on the other side of the question. " In judging of the effects of blood-letting on inflammation," says Tweedie, " it is important to observe, that the remedy may be highly beneficial, even in cases where the inflammation may extend, or the effusions consequent on it increase, after its use. It may often be observed, as in cases of pneumonia, that after full bleeding, the fever subsides, and the breathing is considerably re- lieved ; but, nevertheless, the indications by auscultation and per- cussion, of the extension of the effusion in the lungs and pleura continue for some days. But if the febrile symptoms do not re- turn, and the breathing continues easy, it may nevertheless be confidently predicted that, under proper management, in a sound constitution the case will terminate favorably, and the effusions gradually disappear by absorption and by expectoration." * * * " It is in few cases only that blood-letting can be said to cut short inflammation; the more usual effect to be hoped for, is more cor- rectly expressed by saying, that it disposes it to a favorable ter- mination. " While such benefits are to be derived from the prudent use of blood-letting in the strictly inflammatory diseases, and in their early stage, it is equally certain that in diseases not strictly of that type, and in the advanced stages even of the best marked inflammations, it may either aggravate and prolong the disease, or even rapidly and considerably determine its fatal event." Now, with so little hope of " cutting short" the inflammation, with the bare possibility that fever may not return after bleeding, and that the case may terminate favorably under "proper manage- ment ;" and in view of the nice distinctions as to constitutional condition, stage of the attack, type of the disease, &c, thus shown to be indispensable to its safe exhibition, how in reason can a sane man contend for the practice of general blood-letting ? But perhaps the cases in which its use is advisable are so clearly defined that there is no danger of mistake, and the few cases in which the measure is admissible may be readily determined. Let us see what our author says on this point: " The symptoms by which such distinctions are to be established belong, of course, to individual diseases, and cannot be advanta- INFLAMMATION. 313 geously stated here ; but there are two symptoms common to all inflammatory complaints, and often guiding in a degree the use of blood-letting"—" these are the state of the pulse, and the state of the blood in inflammatory diseases." He then gives the peculiar- ities of pulse,—such as the more frequent, the fuller, the firmer or stronger, and the sharper pulse, compared with the natural pulse, as indicating the inflammatory condition. " But," he says, " there are many cases of active inflammation, admitting of the most essential benefit from blood-letting, in which one or more of the peculiarities here stated are absent." And again: " Of the possibility of this fallacious fullness and even sharp- ness of the pulse "—" some of the experiments of Dr. Parry on animals, killed by repeated bleedings, and in which the pulse was lfull and bounding' almost to the moment of death, afford une- quivocal proof. And it were easy to quote practical observations by Rush, Armstrong, Marshall Hall, Travers, and others, illus- trating this 'reaction after the loss of blood,' which may, per- haps, be most correctly described as a modification of the inflammatory fever, produced in a great measure by the loss of blood, and persisting after the local inflammation has subsided or passed into a state no longer demanding evacuation." The pulse, then, is no safe guide ; for, according to this most orthodox theory, we should often bleed when the pulse forbids ; that is, when " one or more of the peculiarities" denoting inflammation "are absent; " and it may be " fallacious," and seem to indicate the lancet, when the " inflammation has subsided or passed into a state no longer demanding evacuation." But the blood,—we may surely rely upon its appearance and state to guide us in " the use of blood-letting." Let us see) First, you must abstract, and let it stand and coagulate, before you can ascertain whether its abstraction is proper or not. You must also be very expeditious in your experiments and examina- tions of the clot, serum, buffy coat, &c.; the time consumed may carry you beyond that " early stage " in which the measure will be proper. Well, having satisfied yourself as to the state of the blood, are you now prepared to act ? Suppose you find the buffy coat, will you proceed to take more blood ? Be cautious; for, says Dr. Tweedie, " In regard to the buffy coat there are 314 INFLAMMATION. occasional anomalies not yet understood." And again: " If, how- ever, as is most probable, the blood acquires this property by passing through the vessels of the inflamed part, it is easy to understand that, for some time after even intense inflammation has set in, the buffy coat will be slight, or even imperceptible ; and again, that when inflammation of some standing is declining, or still more, when it has passed into the stage of suppuration or ulceration, the buffy coat will still be found in perfection: and, therefore, that its absence or slight degree in the early stage of inflammation is no reasonable objection to blood-letting ; and that its presence in the advanced stage (especially if suppuration is going on) is no indication for the remedy." Thus, then, our second guide in the use of blood-letting utterly fails of affording any reliable assistance, and we are left to the uncertainty of chance in the exhibition of an agent, which, if we would be orthodox, must be employed in a case of active inflam- mation. The pulse is indefinite; the blood may be without the buffy coat; if we wait long the first stage may be past, and we cannot bleed at all: if we only knew the case required bleeding, or would " bear " it, and that this is the proper time, we might possibly "cut short" the inflammation, or at least " dispose it to a favorable termination ; " but then to take blood wrongfully may do much harm; there may be " reaction after the loss of blood;" or one of the chief evils which Dr. Tweedie says, further on, "is always to be apprehended " from large and repeated bleeding, may arise,—namely, " that it always increases the facility with which the surface of the body may be chilled, and, therefore, the liability to relapse, or to the excitement of fresh inflammatory disease, perhaps of worse character, on any subsequent exposure to cold;" or we may "aggravate and prolong the disease, or even rapidly and considerably determine its fatal event." What say philosophy and true science, under such circumstances, should be our course ? Most emphatically, " bleed not at all," is the response heard by every unprejudiced mind. Thus, gentlemen, I have given you a summary of the experi- ments which have been made with the blood, for the purpose of determining its normal composition, the influence that any deviation from the due proportion of its elements has upon its circulation INFLAMMATION. 315 in the minute tubes of the capillary system which have to be traversed by it, and the effects of blood-letting on its constituency and on its capillary circulation. I have, as I think, fairly exam- ined, by the light of science, the claims of the blood-letting theory; and now, in view of all that has been said, and in view of one other fact: that thousands are dying annually of inflammation, under orthodox practice; I ask in all candor whether we have not sufficient reason for rejecting the blood-letting treatment, and seeking a better mode of practice ? That better mode it will be my pleasure now to describe. Truth is what we all desire, and after men have theorized, and speculated, and dogmatized, to the full extent of their mental and physical powers, we are not satisfied with their conclusions, unless they bear the impress of her signet, and that endorsement is only to be obtained in the department of practical experiment. But when the results of our practice verify the correctness of the conclusions we have drawn from natural phenomena, as observed in health and in disease, we feel that we are standing on tenable ground; and when I assert, as I do, without fear of contradiction, that, within the last fifteen years, I have treated nearly every form of inflammatory disease, without resorting to general blood- letting in a single case, and with uniform success,—I merely state the simple truth. And such being my experience, it is vain for any one to tell me that this class of disease cannot be successfully treated without the lancet.* And now, when I compare the results of my practice in these latter years with those which attended my early experience, it is with the most triumphant satisfaction that I declare to you, that the anti-blood-letting treat- ment, which I am about to describe, has not only been attended by little fatality, but that it has proved more promptly curative, and has been very rarely followed by any of those consequences of effusion which so frequently follow the treatment of inflamma- tion by general blood-letting. But my hour has expired, and I must defer what I have further to say on this subject, until our next meeting. * In my early practice I frequently resorted to blood-letting, though not as frequently as most other practitioners of that time. LECTURE XX. INFLAMMATION—Continued. Treatment—In dications—Remove cause—Equalize Circulation—At- tention to Skin—Objection answered—Hoemastasis—Adjustment of Ligatures—Other Measures—Phrenitis—Inflammation of the Brain — Definition — Synonyms — General Remarks—Symp- toms—Premonitory—Early Stage—More advanced Stage—Fatal Termination— Diagnosis—Prognosis—Anatomical characters— Reference to Phrenology—Further Research urged—Causes— Treament— Obscure Chronic Diseases—Neuralgic Affection. Having occupied so much time yesterday, in discussing the subject of blood-letting, I was unable to give you any information in reference to the general mode of treatment which the eclectic school of medicine regards as appropriate in inflammation. This I propose to do in the present lecture. From what was shown to be the condition of the parts involved in inflammatory action, and the effects of general blood-letting on the circulating fluid, you would not now need to be told, even though you had never heard it stated, that we reject the lancet as a means of treating inflammation. And yet so universal has been the resort to this mode of treatment, that when we speak of any other method, it seems almost necessary to regard it as a substi- tute for venesection. Should not the very opposite of this be regarded as the true state of the case—namely, that general blood- letting has been substituted for the rational and philosophical management of inflammation, and that our object and duty are not to find a substitute for bleeding, but, having demonstrated its in- appropriateness, lay it aside, and adhere to measures truly scien- ific and curative ? INFLAMMATION. 317 The first indication to be fulfilled in the treatment of inflam- mation, is, if practicable, to remove the cause of the difficulty. It will be of little avail to give medicines, or employ means to arrest, modify or palliate inflammatory action, while the irrita- ting cause, whether local or constitutional, remains. So that the very first subject of inquiry, when a case of inflammation is brought under your notice, should be, what is the cause of the morbid con- dition? This principle should not be lost sight of in any case, for without reference to it, you must in a measure operate in the dark; having no plainly defined indication to fulfill, you are com- pelled, where the cause is unknown, and cannot be ascertained, to act upon supposition or assumption, which may or may not be cor- rect ; but when you know the origin of the difficulty, you will feel far less embarrassment in determining what treatment is requi- red. Of course I can only speak now in general terms of the prin- ciples to be observed. Special means and instrumentalities must for the most part be deferred until I take up the special diseases. Having ascertained the cause, then, your remedies must be adap- ted to the peculiarities of the case. It is true, the present diffi- culty may be no longer dependent on the cause that originated it, as the inflammation produced by a scald ; but if so, you should know that fact certainly. There are many cases, however, where the inflammation is not only originated, but sustained and increased by the constant operation of the exciting cause, as where gastritis has been produced by alcholic liquors, and the individual still keeps up the habit of dram drinking. Sometimes the inflammatory action is merely the reflection of some prior disease, general or local, and it may progress until the reflection will become the paramount difficulty, obscuring, perhaps entirely eclipsing, the primitive affection; which may still remain, however, exerting its injurious influence on the case, and rendering futile all efforts to remove the inflammatory disease. This fact should by all means be detected, wherever it exists, and the proper treatment instituted for the removal of the primary cause. When this is accomplished, you are prepared to manage the inflammatory affection with more prospect of success. You then have to con- 318 INFLAMMATION. tend with the reflected affection alone, whereas, before, you had the original difficulty, also, on your hands. Having removed the cause, or ascertained its absence, the next most important indication is that of equalizing the circulation. When this shall have been accomplished, and an equilibrium of the circulating fluid is established throughout all the minute ram- ifications of the capillary bloodvessels, you will of course have obviated the difficulty and accomplished your work. But you must be careful to attain this end by such means as shall not in- flict violence on the constitution, or impair the vital functions; hence general blood-letting is out of the question. The indication next in importance, and one indeed to which your attention should be directed simultaneously with the fulfill- ment of the last, is the removal of offensive and vitiated materi- als from the system. The measures employed to effect this object will also be among the most effectual to equalize the circulation. Hence I say the two indications should receive simultaneous attention. A thorough evacuation of the stomach and bowels is, generally, the most appropriate measure which can be directed for these purposes. It accomplishes a threefold object, first, the removal of accumulations, whether of undigested food, vitiated secretions or fecal matter, from the ahmentary canal, which if allowed to remain must be a source of disturbance to the entire system ; secondly, the stimulation of the secretory organs to in- creased action; and thirdly, the equalization to a greater or less degree, of the general circulation. In addition to these manifest and immediate results of gastro-intestinal evacuation, it is a fact that you will remove from the circulating fluid of the body, by the operation of one thorough cathartic, a greater amount of matter, than you would dare to abstract by venesection, and that too, the very matter which it is best to have withdrawn ; and the loss of which will not destroy the equilibrium of the normal constituents of the blood. You draw off, through the eliminating functions of the intestinal surfaces and glands, the effete, irritating matters which are embarassing the vital functions, and you leave behind the healthful elements of the blood, so essential to life, and to the re- pair and replenishment of the different organs ; and you do it without injury to any of those organs. Besides, it has already INFLAMMATION. 319 been shown, beyond all question, that the loss of blood does not tend to produce permanent reduction of inflammatory action. The vacuum, so to speak, produced by the sudden abstraction of blood, is filled at the expense of the capillary circulation, and thus a temporary mitigation of the inflammatory engorgement is effected, but this is immediately followed by a returning tide, im- poverished by venesection, and unfitted, as Magendie has demon- strated, for free capillary circulation. Hence blood-letting, so far from curing, must necessarily aggravate the inflammatory condi- tion. No such result will follow the operation of an appropriate cathartic. There is another indication analogous to the preceding, and scarcely less important; and that is, to promote a healthy condi- tion and increased action, of the skin. The last mentioned meas- ures had in view the removal of obstructions from the internal surface, and the establishment of laudable secretions from the mucous membranes and glands ; but the external surface is greater in extent, equally liable to derangement of function, and is a me- dium through which very powerful sanative impressions may be made upon the nervous and circulatory systems. The skin is not a mere covering for the body, but it is a vast emunctory, for the elimination of useless or hurtful matters from the system, per- forming more in this way than any other organ in the animal economy, almost as much, indeed, as all the others taken together. Hence you see the importance of giving attention to the skin in all diseases, especially in those of an acute form, and still more especially in inflammatory conditions of the system. Not only does philosophy point to the skin as an organ upon which remedial measures may be employed with great propriety and benefit, but practical experiments and observation have demonstrated the effi- ciency of such practice. Such treatment, then, should be insti- tuted in the management of inflammatory disease, as shall first effectually cleanse the surface from all filthy, unctuous, or other matter which clogs the pores, and otherwise impairs the cutaneous functions ; and secondly, promote the activity of those functions until copious perspiration is established. And, gentlemen, you cannot too highly appreciate this indica- tion. When you remember that the skin in health, without any 320 INFLAMMATION. sensible evidence of moisture, does, by what is denominated the insensible perspiration, throw off from the system several pounds of matter daily, you will be prepared to anticipate highly impor- tant depurative results from such copious perspiration as may be induced with entire safety, by means familiar to any respectable practitioner. It is, however, objected to the course of treatment I have just prescribed for the arrest of inflammatory action, that circumstan- ces are presented occasionally, where no time is allowed for the action of a cathartic, nor the establishment of perspiration. And we are asked, with perhaps an air of triumph, whether we would not then resort to the lancet ? Certainly not. We have another mode of meeting such emergencies, more prompt, more efficient, more philosophical, and incomparably more safe. What! you ex- claim, is there any measure upon which we may rely for imme- diate relief, as in case of severe congestion of the brain, or rapid hemorrhage from the uterus or lungs, tending to a speedy destruc- tion of life ? I assure you, gentlemen, that we have a resort much more reliable in all such cases, than venesection is even claimed to be by its most tenacious adherents. The measure to which I refer is hcemastasis, or the controlling of the circulation by means of ligatures around the extremities. By this means you can withhold a very large amount of blood from the general cir- culation, without robbing the system of any portion of that impor- tant element, or in any degree impairing its quality. I have seen rapid and copious hemorrhage from the lungs promptly and effec- tually arrested by this means. In fact, the first case in which I applied the ligatures was one of this character; the hemorrhage ceased in a very few moments, notwithstanding the case was one of very formidable symptoms; and the patient's system suffered none of the injurious effects which must have followed the abstrac- tion of a sufficient amount of blood from the arm to have arrested the pulmonary hemorrhage. The proper adjustment of the ligatures is a matter of much im- portance. They should be passed around the limbs near the body, and drawn so tightly as to arrest the circulation in the veins, but not in the arteries. Should you compress the arteries so as to prevent the flow of blood into the limb, your ligature would of PHRENITIS. 321 course do no good and might increase the difficulty. Where the effect is desired to be suddenly produced, and the symptoms re- quire a very great impression to be made, all the limbs may be ligatured at once, and to the effect of retaining a large amount of the venous blood in them. When a less impression is required, part only of the limbs may be ligatured, or if all are tied, the effect maybe regulated by making the bandage more or less tight. In this way you may produce any desired effect, even to syncope. In removing the ligatures, remember to do so gradually, so as to allow the blood to return by degrees, into the general circulation. The length of time that the ligatures shall be kept on, will depend of course upon the circumstances of the case. As this measure is only employed for present effect, and to gain time for the employment of other remedies, as is venesection by its prac- titioners, it is seldom necessary to be continued long, though when necessary it may be repeated at pleasure. And herein is one great advantage of hemastasis over venesection, that it may be employed on all constitutions, and repeated as often as necessity may require, whereas the abstraction of blood is entirely inad- missible in many cases, and in all it becomes more and more so by repeated bleedings. Another important consideration grows out of the fact that we are all liable to error in the exhibition of remedies, but if upon applying the ligatures you find the measure will not be borne, to the extent you have carried it, you may cor- rect your mistake, and all is right; but who shall return to the exhausted vessels life's vital current, where the too officious lan- cet has compelled its escape ? Instances are not wanting where practitioners would have given liberal premiums, to have had blunders of this kind corrected. Various other measures are employed, having for their object the protection or mollification of inflamed surfaces, such as local depletion, counter-irritation, revulsion, and so on, all of which will be more appropriately presented in connection with partic- ular forms of disease. Let what has been said suffice, as a general outline of treatment of inflammation. PHRENITIS—INFLAMMATION OF THE BRAIN. Having considered the subject of inflammation in its general 21 322 PHRENITIS. outlines, we will now pass to the individual diseases which belong to the inflammatory group. In treating of the subject according to this arrangement, I am aware that I depart from the classifi- cation generally adopted in the books; but I do so, not with a view to be captious or eccentric, but because it appears to me more consistent with science and true philosophy, to associate diseases, in some measure according to their manifest analogies, rather than to group them as they may be developed in the same organ. Hence I shall now treat of inflammation in the various structures of the body, pursuing the subject from organ to organ, as may seem most in accordance with a natural arrangement. I shall commence with Inflammation of the Brain. Quite a number of terms have been employed by different writers to designate this affection. It has been called Phrenitis, from the mental derangement which attends it; Encephalitis, and Meningoencephalitis, from the structures involved, and Arach- nitis, from its supposed origin or seat in the arachnoid membrane. The term Phrenitis, is perhaps more arbitrary than any other, but it seems less liable to misapprehension than any other, and I shall generally employ it as synonymous with inflammation of the brain and its membranes, having no reference to any particular locality. There is so little difference, if indeed there is any at all, between the symptoms manifested during life, whether the brain itself, its membranes merely, or both, are inflamed, that no advan- tage can result from a separate consideration of inflammatory action in these different structures, at least so far as pertains to diagnosis ; and as the -affection, in each and all of these portions of the encephalon, indicates precisely the same treatment, such a distinction is divested of all practical importance. Post mortem researches may enable us to ascertain, in a given case, what par- ticular structure or location within the cranium was the special seat of lesion, but we shall seldom find either the brain or its membranes extensively inflamed without the other being also involved. When we wish to designate inflammation of the me- ninges alone we use the term Meningitis, and when we speak of inflammation of the substance of the brain alone, we call it Cepha- litis. Where we desire to refer to inflammation of the serous PHRENrTIS. 323 covering of the cerebral mass we use the term Arachnitis. This last named affection will require special notice when we come to speak of Cholera infantum, as it possesses special importance in relation to that disease ; but with this exception we shall treat of inflammation of the brain and its appendages under the compre- hensive term of Phrenitis. Symptoms.—An attack of inflammation of the brain may occur very suddenly, or it may come on slowly and gradually. It is sometimes produced by exposure of the head to the direct rays of the sun in very hot weather. Persons under such circumstances may be suddenly attacked with such violence as to be unable to get home. But the affection generally commences by a more gradual progression of symptoms, constituting a kind of forming stage, as observed in other diseases. The early symptoms com- mence with a vague uneasiness in the mind, lowness of spirits, defective appetite, general debility and weakness, in some cases vertigo and dizziness ; unpleasant sensations on changing posi- tion, as blindness and giddiness, with a tendency to stagger on rising from a stooping posture, and uneasiness in the head with confusion of ideas on lying down. Another early symptom, often, is a ringing in the ears, called tennitus aurium. These premon- itory symptoms do not continue as long as the forming stage of fever, but usually long enough to admonish the individual of the approach of serious disease. In this stage of the attack the pulse is slow and full, but upon the first development of inflammatory action it will become rapid and small, with a hot skin and much thirst. These symptoms are usually preceded by a chill, which sometimes amounts to a " shake." This will be accompanied by a severe headache, with more intense suffering than will be expe- rienced after the disease shall have considerably progressed, and the inflammatory process shall have blunted the sensibility. As the disease becomes fully developed, the face appears flushed and swelled, indicating great determination of blood to the head. The pulsations of the carotid arteries are rapid and forcible, often impart- ing a perceptible motion to the pillow upon which the head rests. The eyes have a very striking and peculiar appearance; in some cases they are bright and suffused with water; in others there is a wild, anxious expression, as if evil were foreboded; or the patient 324 PHRENITIS. looks earnestly about him as if apprehensive that some one intends to do him injury, while his language will not express any such impression. The tennitus aurium will be increased perhaps until the sound will resemble the buzzing of bees, or the roaring of a distant waterfall. The eyes are painfully sensitive to light, and when it is allowed to fall upon the face suddenly, as by the open- ing of a door or window, the head will be suddenly turned from it, and the eyes forcibly closed. This symptom may, indeed, be the first to fix the suspicion that inflammation of the brain has occurred; for all the other symptoms I have described may occur in an attack of fever, with much nervous irritation and deter- mination to the head, without the cerebral lesion reaching the point of inflammation; but in such cases you will not find this exquisite sensibility of the eyes to light. Upon examining the pupil it will be found contracted, sometimes almost entirely closed, which is a very characteristic symptom, though in making the examination at different times, you should remember that the degree of contraction will depend, in a great measure, on the intensity of the light. As in many other diseases, constant restlessness is an early symptom, which in phrenitis becomes increased by the intolerance of light, and the progress of the inflammatory action, and is soon associated with convulsive muscular movements, and with eviden- ces of delirium, an invariable attendant on active inflammation of the brain. The pulse is hard, frequent, quick, and occasionally irregular. The respiration is peculiarly affected, not hurried as in most febrile diseases, but sighing and irregular; and this is an important guide in distinguishing between inflammation of the brain and mere congestion of that organ in fevers. The skin upon the body is usually hot, while upon the extremities it is inclined to be cold, the capillary circulation is decidedly diminished, and the cutaneous functions partially or wholly arrested. Generally, the stomach sympathizes with the brain more than any other or- gan, in this as well as other diseases; consequently, nausea and vomiting are frequent symptoms of phrenitis. Constipation, often very obstinate, is a frequent occurrence, owing to the diversion of sensibility from the organs under control of the nerves of organic life, during active inflammation in the cerebral centre. Hence, PHRENITIS. 325 also we find the urinary secretion greatly diminished, if not entirely suspended. As the morbid action progresses, a very great change of symp- toms occurs. The delirium of the earlier stage subsides into a state of drowsiness or stupor, sometimes complete coma. There will be great difficulty in arousing the patient; the pupils, instead of being spasmodically closed by the action of light, now become permanently dilated, and there is comparative insensibility to light. The hearing becomes very much impaired, and in fact all the sen- sibilities become blunted, if not entirely suspended. The convul- sive muscular movements are often modified into subsultus tendi- num ; and the patient picks at the bed-clothes, or reaches about as if trying to grasp something in the air, in the manner described while treating of typhoid fever. Sometimes there is rigidity of the muscles, with perhaps contraction of the fingers or toes, or a whole limb. This indicates very severe cerebral lesion. The pulse changes from frequent and small, to the slow, sluggish and full pulse common to apoplectic and comatose conditions. If it is intermittent, this may be regarded as an unfavorable symptom, indicative of extreme cerebral oppression. The urine is generally very nearly suppressed, but if the secre- tion go on, it is apt to be retained, and greatly distend the bladder. At last, the vital powers are overwhelmed by the progressive march of the inflammation, and begin to give way. Another change now occurs in the symptoms. The pulse, which in the beginning of the inflammatory action was rapid and quick, and became slow and depressed in the second stage, now becomes very rapid and small,—not so hard as in the first stage, but hurried and irregular. The surface appears sunken and collapsed, and the capillary circulation is entirely arrested, the countenance looks haggard and cadaverous, a cold, clammy perspiration appears upon the skin? and the patient insensibly sinks into the arms of death. Such, gentlemen, is an outline of the usual course of a fatal case of inflammation of the brain. The symptoms, it may be re- marked, vary in different cases, in accordance with constitutional peculiarities of the patient, the violence of the attack, and the complications attending it. It is probable also that the violence 326 PHRENITIS. of the symptoms, such as rigidity of the muscles, drowsiness and insensibility, depends in some measure upon the involvement of the deeper cerebral substance, and that where the case falls short of these manifestations, we may suppose the inflammation to be principally confined to the membranes and periphery of the brain. The diagnosis of phrenitis may be more difficult than you would, at first thought, suppose. The phenomena presented by many febrile attacks are very similar to those which generally mark the commencement of encephalic inflammation. Generally, however, there will be something in the history of the case, or some additional symptoms or circumstances which will enable you to distinguish phrenitis from such diseases as bilious fever, typhoid fever and small pox. If not at first, diagnostic symptoms charac- teristic of these individual diseases will soon make their appear- ance, and demonstrate the character of the attack. Simple inflammation of the brain will lack those general and peculiar symptoms which have been described in speaking of fevers— especially in the second stage, and the distinction will be more and more easy as the case progresses. Delirium Tremens is, perhaps, more liable than any other af- fection, to be mistaken for inflammation of the brain ; and scarcely any other mistake is more likely to be attended with unfortunate consequences. The active treatment, requisite in acute phrenitis, would generally sink a patient laboring under delirium tremens beyond recovery, the opposite course of treatment being the only hope in the latter disease. Here again the history of the case is important. If the individual have been addicted to intemperate habits, or should the smell of alchoholic liquors be detected in his breath, suspicion might be entertained that the difficulty was mania a potu. But if so, it will be characterized by peculiarities differing from those of inflammation; such as horripilation, and fearful foreboding of evil, or a sense of alarm and terror, at some imminent danger actually present. Enemies pre- sent themselves in a thousand different fantastic forms; myriads of bugs, reptiles, and snakes are seen crawling about and upon his person ; perhaps an infuriated clan of demoniac forms, armed to the teeth with dirks, bowie knives, bludgeons and firearms are seen skulking in the corners of his room, meditating blood and PHRENITIS. 327 murder on the helpless victim of their malice ; or perhaps your patient assumes the office of mediator between contending duel- ists, and seeks to reconicle those who appear to him intent on de- stroying each other's life. These peculiarities in most cases will clearly signalize cases of delirium tremens. The symptoms already described will be sufficient, in fact, in most cases to form the basis of a correct diagnosis, namely, the pain in the head, the gastric disturbance without evidence of disease in the stomach; the delirium; convulsions; affections of the hearing, and especially of the sight, the sensitiveness to light, and permanent contraction of the pupil; and in the later stage, the permanent dilatation of the pupil, the stupor, or coma, rigidity of muscles, &c, leave no room for reasonable doubt. The prognosis depends much upon the condition of the general system, the cause and nature of the attack, and the stage at which treatment is commenced. It is always a grave affection; yet where the necessary treatment can be borne by the constitution of the patient, and where the case has not progressed so far as to produce serious disorganization, recovery may generally be anticipated. Where it is the result of some known accident or temporary circumstance, the chances are more favorable than where it arises spontaneously from some constitutional cause, which may sustain the difficulty in spite of our remedial meas- sures ; yet even the most discouraging cases should not be aban- doned as hopeless, for recovery sometimes occurs in cases which had seemed to be b eyond the reach of remedies. We will next give some attention to the anatomical characters of phrenitis. And now we shall be able to discover, what the symptoms during life have not revealed, the precise seat and ex- tent of the inflammatory process. The contiguity of the dura mater to the other membranes and to the brain itself, would lead us to expect to find it generally involved in the inflammatory ac- tion. This, however, is not generally the case, unless where the disease is the result of injury in which the dura mater has partici- pated. Like the periosteum, and other structures of low vitality, it appears less liable to the encroachments of inflammation than those more vascular membranes, the pia mater and arachnoid. But these latter tunics of the brain are not always involved where the 328 PHRENITIS. substance of the brain itself has undergone serious organic chan- ges. The stomach may have been much affected, and the gene- ral muscular system convulsed or paralyzed, with even apparent sympathetic affection of the membranes enveloping the brain itself; an instance showing that organs remotely situated often have more direct and intimate sympathy than those lying in actual contact. In case of a blow or other external violence the dura mater is quite as liable to inflammation as the other structures, and in that case is frequently found separated from the bony structure, and the surface of the skull is left in a smooth, slippery condition, and whiter than natural, while the membrane itself maybe merely injected so as to appear reddened and thickened, or it may be in an ulcerated or even gangrenous state. Occasionally, it i3 covered by a layer of lymph or pus. The arachnoid more rarely escapes being involved to some extent in cerebral inflammation, yet it seems to be remarkably exempt from structural changes or disorganization. It is sometimes found perfectly sound, transpa- rent and glossy, with both its surfaces covered with pus. It is often, however, injected, and somewhat opaque, and covered by a deposition of lymph. The effusion of lymph may be found between the dura mater and arachnoid, in the cavity of this mem- brane, or between it and the pia mater. Sometimes the arachnoid is found dotted with little particles of red matter, and occasionally it has a rough feel under the finger. This dotted appearance is usually found to accompany the active stage of inflammation of the brain, and it will be observed generally, where copious effusion has taken place into the subarachnoid space and cellular tissue. In such cases the fluid effused will escape when the serous mem- brane is punctured. This effusion is in the folds of the pia mater, between the convolutions; and when the fluid portion is thus allow- ed to escape, by puncture of the arachnoid, such portions of lymph or pus as may have become concrete, remain involved in the cel- lular tissue of the pia mater and have the appearance of yellowish patches. Sometimes a layer of concrete pus or lymph may be found between the two surfaces of the arachnoid, resulting without doubt from an altered condition of the fluid usually secreted by this membrane. The function of the arachnoid is evidently to secrete a serous fluid to lubricate its smooth opposing surfaces, PHRENITIS. 329 and thus prevent friction and adhesion, while freedom is allowed for all the changes of position in the brain, required by the mo- tions incident to the circulation of the blood, and mental exer- cise. That motions of both these descriptions occur in the brain, cannot be doubted with reason. I myself have had an opportunity, on one occasion, of observing such motions to occur, in a remarkable degree. Sometimes a considerable quantity of serous fluid, generally rendered turbid by lymph, pus, and perhaps blood, is found in this cavity, and also in the subarachnoidean space, and in the ventricles. This is more likely to be the case where the inflammation has approximated the chronic character. The pia mater is reddened, and often adheres with so much tenacity to the surface of the brain, that the latter will be torn, in an attempt to separate them. The surface of the brain is al- most always in an altered condition. Sometimes it is softened where the inflammation of the meninges has been protracted, but generally it is hardened where the membranes have been the prin- cipal seat of inflammation. Upon cutting across the fibres in the substance of the convolutions,many bloody specks or points will be observed, but where the incision is made parallel with the fibres, there will be a streaked appearance, indicating in either case the engorged condition of the minute blood vessels, which ramify through the medullary substance. Scarcely ever are the ventricles of the brain found free from accumulations of serum. The amount, however, varies greatly in different cases. The medullary substance of the brain frequently undergoes material changes. It is sometimes so softened as to be easily scraped up with the handle of the scalpel, presenting the appear- ance of lard. It requires much experience, however, to be able to detect the evidences of disease in the substance of the brain. Indeed, notwithstanding the many minute post mortem examina- tions of this organ which have been made by skillful pathologists, comparatively little is known which throws light upon the nature of phrenitis, or by which we may be guided in diagnosis. Even the most formidable, raving insanity, may leave not a trace of disease in the brain or its meninges, which shows that the condi- tion of this organ in disease is very obscure. It is supposed by 330 PHRENITIS. some that insanity may be simply a functional disturbance, with- out any physical disorganization or structural disease. But this seems to me to be improbable; I cannot suppose so palpable a disease as insanity to occur without some physical change in the cerebral organs, but in what that change consists we are often unable to determine, from our want of knowledge of the minute structure of the cerebral substance. Many efforts have been made to discover some constant relation between the external manifestations of disease and the different localities of diseased action in the brain, and thus enable the practitioner to form accurate opinions, in the various cases which may be presented to him, as to the precise location, extent and degree of inflammation. Very little reliable information, how- ever, has been gained by these efforts. The researches of Gall and Spurzheim, and their successors in the department of phre- nological science, seemed to justify the hope that something might be gained for practical medicine in this way, and it is very prob- able that such may yet be the case. Phrenology has demonstrated the fact that the brain consists of a plurality of organs, adapted to the exercise of a like plurality of faculties of the human mind ; and, if each mental power has its appropriate cerebral organ, it seems not at all improbable that each corporeal function and action is under the control of some special organ also. Many experiments have been instituted to establish the doctrine that different portions of the brain influence or preside over different parts of the body. Some have attempted to show that the per- iphery of the brain presides over the mind, and the deep struc- tures over the body. My friend, W. Byrd Powell, M. D., of Covington, Ky., believes he has discovered that the motive power of the muscular system resides in the cerebellum, and he sustains his proposition by very plausible arguments and experiments. The decussation of the fibres of the medullary substance in the medulla oblongata, has led many to believe that the functions of each side of the body may be governed by the opposite side of the brain, and experiments and observations seem to justify the idea. So that muscular rigidity, spasm, or paralysis on one side, is thought to refer with some certainty to lesion of the opposite side of the brain. Some experiments of physiologists seem to PHRENITIS. 331 establish a sympathetic relation between the cerebellum and the genital organs, as determined by contractions of the spermatic cord when the cerebellum is mechanically irritated, by priapism when that organ is in a state of inflammation, and by the tendency of undue sensual indulgence to produce cerebellar inflammation. But the observations of others seem to discredit these suggestions and deductions, by showing that affections of a local or general character, — such as " softening of one of the corpora striata, one of the optic thalami, the anterior lobe, the middle lobe, a deep point in the white substance, a cerebral convolution," and even " a whole hemisphere,"— have occurred, where there was " nothing in the pronunciation, in the derangement of movement in the arm or the leg; nothing in the state of the intellectual functions," which seemed to permit a suspicion as to the limits of the part affected. Some have even tried in this way to cast discredit upon the whole science of phrenology. In opposition to the doctrines of phrenology it has been alleged that portions of the brain, repre- sented to be the seat of certain mental faculties, have been destroyed, without in the least affecting those faculties. But since the brain is a double organ, and, consequently, each faculty has two organs, located in corresponding positions, one on each side of the mesial line, it is very easy to understand how the function in any case might be carried on by one organ after the other had been destroyed, just as one eye can see after the other has become blind. But even should both the organs assigned to a particular faculty be obliterated, and the mental manifestation of that faculty appear unaffected, the fact would not necessarily disprove the correctness of the phrenological hypothesis : for we may readily suppose that some kindred organs might assume and perform vicariously the function of the one which had been destroyed. Such substitution is not unfrequent in other parts of the system. The biliary, the renal, and other secretions, have been vicariously carried on after the proper organs have been destroyed, or rendered useless. The substitution in the brain of one organ for another, where the faculties concerned were very nearly alike, would present even less difficulty to our minds, than some of those adaptations of secretory organs to new functions. 332 PHRENITIS. Yet I do not believe there is any well attested case of a complete destruction of the same organ in both hemispheres, without dis- turbance of the mental faculties. Phrenologists have challenged the world to produce cases of the kind; and, although examples of extensive injuries have been brought forward with an air of exultation for this purpose, yet in every instance, so far as I have been able to learn, the results have, to some extent at least, sus- tained phrenology. But to return from this digression, I will remark that this whole subject of the effects of inflammation upon different portions of the brain, and the relation, not only of different localities but of different degrees of inflammatory action, and of different ana- tomical characters,— such as softening, induration, &c,— to the external symptoms, lies open for research and investigation. Very little of practical value has yet been determined,— hence, I will not detain you with the results of hitherto unsuccessful efforts, but would urge you to give your attention to this subject in the spirit of true friends of science and votaries of truth, bearing in mind that the most formidable mountain which presents a barrier to your progress, may yet offer you a " pass " through some hitherto undiscovered ravine; or at least that you may construct instrumentalities with which to scale its summit or tunnel its base, and explore the land of promise beyond. The causes of inflammation of the brain are various. They are spoken of by authors under the ordinary divisions of predisposing and exciting causes. The predisposing causes are somewhat in- definite and unreliable. Age is found to have much to do with the predisposition to phrenitis,—children under two years of age, and persons between the periods of puberty and the decline of life appearing to be most liable to this affection. The liability diminishes after the second year until puberty, and again dimin- ishes after about the forty-fifth year. A sanguine temperament, plethora, intemperance in eating and drinking, and excessive mental exertion, have a predisposing tendency to cerebral inflam- mation. It is most frequent in hot climates, also, and it some- times prevails epidemically. It very rarely, however, occurs as a spontaneous or independent affection, but is not at all unfrequent PHRENITIS. 333 as the result of accident, or the attendant of general or local disease. It is scarcely necessary to attempt a statement of the exciting causes of this affection, and yet a few remarks under this head may not be out of place. It is said that a sudden exposure to a draft of air will sometimes produce inflammation of the brain where there is a hereditary tendency or predisposition from other causes to this disease. I have seen cases caused by exposure to heat, and it is not improbable that cold may have a similar effect. Blows, concussions of the head, &c, are frequent causes of cerebral inflammation. But it more frequently occurs as the sequel or metastasis of some general or local disease, such as rheumatism, gout, erysipelas when located on the scalp, &c. A case of ery- sipelas recently occurred under my observation where there was a determination to the brain, which, had it not been promptly arrested, would most certainly have resulted in active inflammation of that organ. I need not repeat that some parts of the body remotely situated from each other, are more nearly related in nervous sympathy than others lying in contact or close proximity. Hence, as we might expect, the brain is often found to suffer from affections of the skin, stomach, bowels, &c. The tendency of cholera infantum to result in cerebral inflammation is a striking instance of this kind. We come now to speak of the Treatment. In this, as in other grave forms of disease, the paramount question is in regard to the cause; for to attempt the treatment of a case without any knowledge of the cause, is like attempting navigation without chart, compass or landmark. Better leave the case to the pow- ers of nature, unless you can gain such a clue to the cause and character of the difficulty as to avoid the risk of inflicting injury by inappropriate medication. This remark, however, applies with equal force to all forms of disease. Though emetics are generally contraindicated in this affection, from their tendency to determine the blood to the capillaries of the brain, as well as other portions of the system, yet, were I certain that the affection were connected with, or depended up- on accumulations in the stomach, I should promptly evacuate that organ by an emetic; and in some instances this is about all that 334 PHRENITIS. is required. In the selection of an emetic to be employed under such circumstances, it is important to choose one that will operate quickly, thoroughly, and without prolonged or continuous, retch- ing after the stomach has been emptied. I object, as a general rule, to impalpable powders, which are apt to become attached to the villous coat of the stomach, and keep up a state of irrita- tion, which may be difficult of removal. I much prefer to give an emetic in the form of an infusion, and I know of no better for- mula than the one I have already mentioned on several occasions, embracing a combination of Lobelia and Eupatorium. As was re- marked, emesis in this affection is generally regarded as inappro- priate, and unless palpably required by the necessity of the case, it should not perhaps be employed. I think, however, that the objection to this measure, as generally urged, is rather assumed than real: at least, when I estimate the influence of an emetic on the brain and general system, I am unable to feel the force of the objection. In fact, the relaxing and sedative influence of an emetic is often very desirable in just such a case as the one under con- sideration. There is a temporary forcing of the blood into the whole capillary system, but the effect appears to me to be an equal- ization of the circulation rather than a special determination to the brain. The next important indication is to evacuate the bowels, pro- vided the cause and nature of the disease permit this measure. Cathartics exert a powerful influence in attracting the circulation from the brain by their derivative effect. Nor should we depend on mild cathartics; they should be of the active and thorough character. I have found our antibilious physic, not in sufficient doses to produce vomiting, to answer an excellent purpose. It should be repeated to the extent of producing thorough evacua- tion. You can in this way detract from the circulating mass, more than could be done by a full bleeding. The only argument in favor of bleeding is its immediate effect, but this is more than counterbalanced by the injurious consequences which follow the measure. You know that I have already abundantly shown that depletion by the lancet takes from the blood its vital element, fibrin, in a very large proportion, and produces an increase in the PHRENITIS. 335 serum, and thus renders it unfit for circulation in the minute capil- laries. And you recollect that bleeding is not claimed to be gen- erally a curative measure; it is a mere temporary expedient, which I have sufficiently proved should never be employed. Topical bleeding, by cupping the temples and nape of the neck, is not objectionable, but is often of great utility, affording relief by local depletion, while the quantity abstracted can inflict no serious injury on the circulating fluid. This measure may be re- peated two or three times daily until the active symptoms are subdued. Simultaneous with the means I have mentioned, you may, if deemed necessary, resort to the application of ligatures on the limbs in the manner described under the head of general treat- ment of inflammation. By this means you give much more prompt • and certain relief to the engorged parts than could be effected with the lancet, and that without the loss of a drop of blood. Another important means is that of cooling applications to the head. You will find in almost all your books the use of ice and ice-water recommended to be employed for this purpose; but I much prefer a very different mode of management, and one based upon strict principles of philosophy. Cold applications serve to give momentary relief by benumbing the sensibility for the time, to be followed by a more severe reaction. But the application of warm water, has a calming, soothing influence upon the nervous system, and, from its more rapid evaporation, is far more effectual in reducing the temperature of the parts. I have seen that rest- lessness, so characteristic of inflammation of the brain, completely overcome, and the patient calmed down into a quiet sleep, from the application of warm water to the head, followed by a very gentle fanning to promote its evaporation. I was formerly in the habit of applying ice, cold water, cloths wrung out of cold water, &c, to the heads of my patients, but I find far better effects fol- low my present method. Another potent and effectual means of diverting the circulation from the head is counter-irritation, by applying sinapisms to the extremities and spine. But this measure, to prove effectual, will generally need to be persevered in for some time. A single 336 PHRENITIS. application will frequently fail to do much good, but it should be repeated and thoroughly followed up until an effect is produced. You may find it necessary to repeat the cathartic daily, for some days, or until the disease is relieved. Where inflammation of the brain supervenes upon a general debilitated condition of the constitution, resulting from protracted febrile or other disease, where depletion in every form is precluded, cathartics will, of course, be inadmissible. The bowels in such cases should be soothed by cholagogue aperients and enemata, the circulation equalized by the usual derivative applications, and the heat of the head kept down by the warm bathing already recommended. Such is the course of treatment I would recommend in inflam- mation of the brain, and I have reason to believe that it will be found as successful as any other; much more so than the notorious and once popular remedy, blood-letting. The measure I have recom- mended for controlling the circulation is far more than a substitute for the lancet:—it is a more safe, prompt, and thorough means of relieving the engorged vessels of the brain, by locking up in the extremities the large mass of blood which they will contain, and holding it in reserve for the use of the system, when the pre- sent danger shall have been averted. The use of ligatures is by no means a far-fetched measure, the phlebotomist himself employs it to arrest the blood in the veins until he can let it out; and it is a measure which commends itself at once to the comprehension and apprehension of every intelligent and unprejudiced mind, as being, without doubt, more efficient than blood-letting. The diet should of course be of the simplest kind. Indeed no other will be borne by the patient. Digestion being arrested, the appetite will not demand much food. The patient may take a little rice gruel or corn meal gruel, or similar light food, but pro- bably nothing at all will be required during the active stages of inflammatory disease. During convalescence, the usual precau- tions and care will be requisite in order to conduct the case to a perfect recovery. It is said in some of the books that this disease sometimes becomes chronic. Such may be the case when a disorganized portion has become isolated, as it were, by being surrounded by a cyst, where adhesions have formed between the layers of the PHRENITIS. 337 arachnoid, and where considerable effusion has occurred in the cavity of the latter membrane or in the ventricles, &c. If acute phrenitis degenerate into the chronic form, it generally presents a case of more or less stubborn insanity, which is to be managed according to the mode to be prescribed for that affection. Chronic disease of the substance of the brain may however exist with symptoms of a very obscure character. I once saw a case of this description. The individual was an active business man, and extensively engaged in heavy pecuniary transactions, requiring protracted mental labor and much bodily exposure and fatigue. These circumstances predisposed him to cerebral dis- ease, and under the force of malarial influence he became very much indisposed. The case was investigated by a number of physicians, all of whom, except myself, referred the disease to hepatic disorder. It was argued that the location of the patient in a malarious neighborhood, with some evidences of periodicity presented in the case, justified the diagnosis which regarded it as a clear malarial affection, having its seat in the liver. But while I readily admitted the presence of malarial influence, yet the fixed pain in the head, the peculiar restlessness of the patient, the imperfect capillary circulation in the extremities, and other symp- toms not now remembered, convinced me that the principal dis- ease was seated in the head. The individual would not be con- fined to the bed, nor even to his residence, but went to New York on a business trip, and on his return placed himself under my care ; but he gradually sank and died. A post mortem inves- tigation revealed the seat of disease to be in that portion of the brain to which phrenologists assign the organ of acquisitiveness. A large abscess had formed in the substance of the brain at that point. During the progress of the disease, though his intellect did not seem to be seriously involved, yet the acquisitive faculty was certainly for a time morbidly active, as shown in various ways, but more especially in the disposition of his estate. I deem it proper to add, in this connection, that we occasion- ally meet with cases of neuralgic affections of the head very much simulating, in outward manifestations, the inflammatory affection of which I have been speaking. It will sometimes oo 338 PHRENITIS. require very close discrimination to distinguish these neuralgic attacks from phrenitis. They are however marked by symptoms of periodicity, which call for the appropriate remedy for periodic disease, so fully presented heretofore ; which should at once be administered without apprehending any injurious consequences from its use. LECTUEE XXI. OTITIS: INFLAMMATION OF THE EAR, ETC. Preliminary Remarks — Peculiarities of Otitis — Predispositions —Brain sometimes Involved—Causes—Treatment—Local Meas- ures— Constitutional Remedies — Recipes —'' Alteratives''—Asso- ciated with Malarial Fever — Case of Neuralgia. Stomatitis : Inflammation of the Mouth — Never Idiopathic—Symptoms — Causes—Treatment. Thrush: Treatment—Condition of Mother— Idiosyncrasies—Nurse's Prescriptions. Cancrum Orris : Nurse's Sore Mouth. There is another form of disease which might be denominated inflammation of the brain, and to which I have before referred. But as it is generally associated with another affection, and per- tains especially to infancy, it will be described under the title of cholera infantum. We shall therefore pass to the consideration of inflammation in other organs. The next disease to which we will turn our attention, is Otitis, or inflammation of the ear. This you may perhaps regard as an unimportant affection, and so it is, as compared with many others, but it is one which often causes very intense suffering; and the reputation of a physician often depends much upon his knowledge of trivial matters, and his ability to afford relief from pain, even where there is comparatively little danger. Yet even this affec- tion, if neglected, or improperly treated, may result in serious injury. This is a very common disease among children, though not confined to them, for it also occurs in adults; but it is important to be able to distinguish it from neuralgia, which is likewise very 340 OTITIS. common. If you make a mistake in this respect you will subject your patient to much unnecessary suffering and inconvenience. Inflammation may be distinguished from mere neuralgic irritation of the ear by the swelling which attends the former affection, and which may generally be discovered upon careful examination. The pain in inflammation is constant, while there is generally some tendency to periodicity in neuralgia, though this peculiarity is not always preceptible. But by using the speculum and inspect- ing the meatus auditorius, and membrana tympani, evidences of inflammation, if present, will generally be detected. The inflam- mation may be deep seated, involving the tympanum, or it may be confined to the meatus, and even to the outer portion of that, causing the orifice to be nearly or quite closed. Some constitutions appear to be strongly predisposed to the disease, especially those of a scrofulous diathesis. It is also very frequently a sequel of other diseases, though it may occur without any evident connection with other affections. It is usually accompanied with more or less constitutional disturbance, which may hold the relation of either cause or effect to the local difficulty. I have known inflammation of the ear to follow expo- sure to cold sufficient to disturb the general system, and I have seen it occur without any general disturbance of the health. I have, however, seldom met with a case where the tongue was not slightly coated, indicating derangement of the stomach. In case of gen- eral constitutional disturbance, the pulse will be excited, and the skin hot; and I have seen well defined cases of intermittent fever with which inflammation of the ear was connected. In such cases as these, where the local difficulty is caused by the general disease, it will usually subside if the fever be promptly arrested. On the other hand, where the febrile reaction is a result of the local inflammation, your remedies must of course be directed more especially to the latter. Whether the inflammation is primarily dependent on derangement of the stomach, or results from sudden exposure to cold, checking the cutaneous transpiration, and destroying the equilibrium of the circulation, you will in most cases, as before intimated, find a furred tongue ; the bowels are usually torpid; and the secretions generally more or less deranged. In some instances the inflammatory action becomes so aggra- OTITIS. 341 vated and extended as to involve the brain, producing delirium, which it is important to bear in mind. When properly treated, otitis often terminates in resolution; but the most usual result is the formation of an abscess; and this often degenerates into a chronic affection to be hereafter considered. Local injuries are very frequent causes of inflammation in this organ. Prompted by curiosity or some other unassignable motive, some children are strangely disposed to fill their ears and noses with foreign substances, such as pieces of paper, rags, peas, beans, and other seeds, which remaining some time produce inflammation. I have frequently been called to treat cases of this kind. This penchant it is sometimes difficult to overcome in a child. I was once called to a child that had the second time rolled up little pieces of cloth and forced them into its ear, notwithstanding it had, on the first occasion, experienced much pain from the local irri- tation and the operation of removing the pieces, and had withal been pretty severely chastised. But there are similar causes over which neither the child nor adult can always have control. I refer to the fact that bugs, flies, and other small insects occasion- ally creep into the ears, causing a great deal of annoyance to the patient and sometimes producing severe inflammation. Another very common cause is an undue or morbid secretion of the cerumen aurium or earwax. I have seen this the case a number of times, and to a very great extent. I recollect the case of an old man who gradually become deaf, but as it was not at first accompanied with much pain, he supposed his deafness to be the natural result of age. But finally it became really painful, and he came to me for an examination. I discovered by means of the speculum, that the ear was filled with this morbid secretion, in an inspissated con- dition, and succeeded in removing a plug of it, as large in circum- ference as my little finger. Scarlet fever is a very common cause of otitis, and as a sequel to that disease it is often very troublesome. The communication between the tympanum and the pharynx, through the eustachian tube, will readily account for the phenomenon. The inflammation extends from the tonsils by continuous sympathy on the mucous membrane lining that tube, and thus reaches the drum of the ear. 342 OTITIS. In the treatment of this disorder, as in that of all other dis- eases, the first object to be accomplished is the removal of the cause that produces it. If it is occasioned by the presence of a foreign body in the ear, remove it. This, however, is sometimes difficult to accomplish, and your utmost ingenuity may be taxed to devise a successful method. The first case which ever gave me much trouble, was that of a child that had introduced a pea into its ear. The pea had become swelled very much, and the ear was so sensitive, that the slightest touch produced pain. I had recourse to all the measures which I remembered to have seen recommended in the books, without success. Among the numerous expedients recommended is that of introducing a probe tipped with stiff honey to which the object may adhere with sufficient tenacity to enable you to extract it. But it failed in this case, as the pea was so much enlarged, and the parts so much swelled, as to require more force for its removal than could be exerted in this way. It then occurred to me that water thrown forcibly against the tympanum, would, by its momentum, expel the pea. I tried the experiment and it succeeded at once. I have used the same means with invariable success in removing substances which had got into the ear, 'and also the inspissated secretion of the lining membrane of the meatus. Sometimes the substance is expelled with sufficient force to carry it some dis- tance. The water should be thrown in by means of a small syringe, and should be repeated until the object is accomplished, though very often the first impulse will be sufficient. The syringe should have a slender pipe, and be so introduced as not to obstruct the passage. The water may be thrown in with considerable force. Having removed the exciting cause the inflammtaory symptoms will indicate such further treatment as may be required. In an ordinary case of otitis, resulting from cold, a thorough sweat, with warm applications to the ear, such as the steam of a decoction of hops, will usually give relief, unless the inflammatory action has gone too far. If there be general derangement, a moderate cathartic is indicated. For this purpose the seidlitz powders repeated every two or three hours will do very well; continuing in the meantime hot fomentations to the ear. Where there is much pain I have found tobacco smoke to afford OTITIS. 343 very prompt relief. It may be blown into the ear through the stem of a common tobacco pipe. The bowl of the pipe may be filled half full of dry tobacco; which should then be ignited, and a silk handkerchief placed over it. By applying the mouth to this a stream of smoke may be blown into the ear of the patient with facility. This will generally afford temporary relief, but you must continue your efforts to reduce the inflammation and thus prevent a recurrence of the pain. A cup applied under the ear is very beneficial. A roasted onion put into and upon the ear is an excellent application. For the purpose of immediate relief from suffering, I have often dropped into the ear a small portion of the sudorific tincture mixed with sweet oil. In cases where there is palpable derangement of the stomach, it is sometimes necessary to give an emetic ; and you may do more by this means, perhaps, in an hour, than would be effected by cathartics in a day. You will often find that the stomach has ceased its functions, is overloaded with irritating substances, and from its influence upon the whole system, certainly requires attention. A thorough emetic will relieve the stomach, equalize the circulation, and induce a free perspiration. Inflammation of the ear often results in an abscess, and becomes chronic; and, in this case, it may be very troublesome. You will meet with such cases, which are of long standing, and have been treated and given up by physicians, and success in treating them will often do much to establish your reputation as a practi- tioner. In these cases it will not do to depend upon either local or constitutional treatment alone, but both must be employed at the same time. The first local indication is to keep the part clean by daily washing; and if the abscess be deep a syringe should be used for this purpose. Among the remedies I have used as a wash is an infusion of hydrastis canadensis, with a little myrrh to correct the offensive fetor. This wash excites the parts to healthy action, and it may be used every day, after cleansing the abscess with soapsuds. Sometimes it is necessary to open the ear with the speculum and touch the ulcer with nitrate of silver, or a solu- tion of the sesquicarbonate of potash may be injected into the ear with a syringe. I have found this to be a very valuable adju- vant measure in the treatment of this form of the disorder. In 344 OTITIS. addition to the local measures just mentioned, I have been in the habit of making an issue at the back of the neck, which seems to substitute the long continued drain of the abscess upon the sys- tem. The constitutional remedies will depend in some measure upon the idiosyncrasy of the patient. Where there is a scrofulous dia- thesis, indicated by a pale skin, an ansemic condition of the circu- lation, glandular enlargements, and perhaps chronic opthalmia, it will be necessary to restore the general system to a healthy condition, before the local disorder can be removed. I have been in the habit of administering in such cases the following pill: #. Sulph. ferri, Carb. potassa, da 3ij Extr. taraxacum, q. s. F. pilulae xx. Sig. 1 to 3 daily, according to age. This pill supplies the deficiency of alkaline elements in the blood always existing in the strumous habit; supplies, also, the material for enriching the blood in those elements requisite for active and healthy circulation in the capillary system, while it at the same time promotes healthy secretions in the liver, kidneys and other glands, and thus tends to eliminate noxious matter from the system. In other cases, I have used with decided advantage our altera- tive syrup: fy. Sarsaparilla, Yellow Parilla........> __ Burdock, Guaiacum Rasp.........\ ^ Sassafras Bark, Elder Flowers.....) _ _ „. Blue Flag.....................} aa %iy Make into a gallon of syrup. See Eclectic Dispensatory, or Beach's American Practice. The term " alterative," as applied to a medicine, may sound to you like a vague term,—and so, in one sense, it is; for the pro- fession are accustomed to employ it as expressive of therapeutic action which they are unable satisfactorily to explain ; yet it is by no means an unmeaning epithet, even when used in this way. It signifies a remedy that effects an alteration in the condition of the system. As just intimated, the mode of its operation may not be easily or entirely comprehended, though the beneficial results may be manifest. The most probable action of these med- OTITIS. 345 icines is to promote the ehmination of unhealthy materials from the system through the secretions. They may, I believe, be strictly termed, stimulants of the 'secretions, and the alterative syrup possesses this property in an eminent degree. I have used, also, in lieu of the last article, the Compound Syrup of Stillingea, and am favorably impressed by it, though my experience with it has been too limited to enable me to speak very confidently of it. If inflammation of the ear be associated with malarial fever, your first object will be, of course, to arrest the fever ; and when this is done the inflammation will subside without further attention, in almost every case where disorganization has not been produced. Or if it possess the neuralgic character, the treatment must be adapted to such an affection. You remember what was said on a former occasion, on the subject of neuralgia, and every form of masked ague. Although your remedies will be similar to those adapted to malarial fever, it is necessary to administer them in a very prompt and efficient manner, to overcome the neuralgic difficulty. Speaking of neuralgia reminds me of a very interesting case which lately came under my notice. It is the case of a young man from Indiana, who during the fall was attacked with a pain in one of his eyes, accompanied by severe fever. His physicians called it congestive fever, and gave him calomel several times, bled him, cupped him, and applied blisters; but in spite of all these, the eye began to swell, the lid was turned outward, until finally it attained an enormous size; the ball became prominent and finally burst, and discharged its contents. The inflammation then disappeared from that eye. He soon, however, began to have pain in the other eye, and that too began to swell as the other had done. He was brought to the city, and placed under the care of a celebrated occulist. There he was salivated, and received other treatment, but with no advantage. Prof. Newton was then called, and he requested me to see the case with him. The lower lid wras entirely everted, looking like a fungus growth upon the cheek, as large as a filbert. The eye was projected almost beyond the external boundaries of the socket, though the ball itself was not much inflamed. The pupil was permanently 346 STOMATITIS. dilated to nearly the size of the cornea, and the power of vision was gone. He could barely recognize slightly the impression of light on turning his face to the bright glare of a window. The pulse was small and frequent ; the pain in the eye was severe all the time, but more particularly so in the after part of the day. I became satisfied that it was a case of neuralgia, and advised the use of quinine and iron, as I have heretofore recommended for that affection in my lectures from this chair. I also advised the bathing of the eye with warm water, followed by a gentle motion of a fan. Under this treatment alone the swelling dimin- ished, the eye sank back into the socket, and the lid returned to its natural position. The inflammation disappeared, and the function of the eye was gradually restored. STOMATITIS —INFLAMMATION OF THE MOUTH. I propose to occupy your time still further in the consideration of what may be regarded as minor diseases: I refer to the differ- ent forms of sore mouth. We sometimes meet with affections of the mouth which may not be properly regarded as inflammatory diseases, but which have a highly irritative character that assim- ilates them very nearly to this class of diseases; and there is, perhaps, no position in the arrangement we are observing, where they may be introduced with more propriety than under the head of inflammation. The same remark will apply to disorders of a similar character in other regions of the body, which will receive such attention when we come to treat of inflammation in those parts, as their importance may seem to demand. I shall first speak, then, of Inflammation of the Mouth, or Stomatitis. You may, perhaps, think that I am going to consume time now with an unimportant disease, but your experience will be different from mine, if you do not find your patience, skill and ingenuity, as often and as greatly taxed by what may be regarded as trifling affections, as with those of a more formidable character. According to my experience, inflammation of the mouth is never an idiopathic disease, for where it has not been caused by local injury, — as scalding, corrosion of the mucous membrane, or something of that nature,—I have always been able to refer it to some other affection of the system, of which the inflammation STOMATITIS. 347 was either a symptom or a result. It is very frequently a sequel of measles, or scarlet fever, or some other protracted disease of a febrile character, in which gastro-intestinal irritation is a promi- nent feature. Symptoms.—The tongue in many cases has a speckled or striped appearance; some portions of the surface being covered with a white substance resembling curdled milk, while in spots or streaks the surface will be bare, and of a fiery red color. The white coat just mentioned does not lie loosely upon the tongue, but adheres closely, and is probably the epithelium in a deadened condition. In other cases the whole tongue will be red, smooth and glossy as a varnished surface, and almost destitute of moisture ; while in others it will be equally red and smooth, but quite moist. Indeed, these appearances are not confined to the tongue, but may extend to the whole mucous covering of the mouth. In some instances, instead of the smooth surface, the papillae will be so engorged as to produce prominences, giving the mucous surface a rough appearance. These differences of appearance and condition of the mouth when inflamed, have always appeared to me to depend very much upon the state of the stomach and general system, as affected by other diseases, so that, as before remarked, I never regard it as an independent or idiopathic disease. In some cases, the inflam- mation not only occupies the whole surface of the mouth, but extends throughout the entire mucous membrane of the alimen- tary canal. As a general rule, indeed, you will find the tongue a pretty sure index to the condition of the stomach, and a diag- nosis based upon its appearance is not very likely to mislead you. Thus, where the tongue presents a heavy coat, we are generally safe in concluding that there are accumulations producing gastric derangement; but if the tongue is red and clean, or nearly so, we may usually be sure that there is a similar irritated condition in the stomach, and you will find such an inference confirmed by tenderness in the epigastrium, upon pressure being made. But there is one condition of the tongue which may mislead you ; and that is, where a heavy coat exists upon it while the membrane beneath is inflamed; its condition being hidden by the fur on the surface. This may be the case when there are no accumulations in the stomach or bowels, but it will gradually come off, leaving 348 STOMATITIS. the mucous membrane of the tongue, and perhaps other parts of the mouth, red and inflamed. I always suspect irritation when the coat has an unusually thick and scaly appearance. Causes.—Inflammation of the mouth to a greater or less extent may result from local irritation, as where a scalding drink, or a strong acid or alkali has been taken into the mouth through care- lessness or mistake. It may also be produced by carious teeth, which always throw out unhealthy and irritating secretions. Where the inflammation results from a local cause, it is seldom so severe as to produce much general febrile excitement; and will be amenable, generally, to appropriate local applications. As to treatment, it is obvious that much will depend on the origin of the affection. If it be the sequel of scarletina or measles, very little need be done. Constitutional remedies will, mostly, be out of place ; and your reliance must be upon a plain diet, and soothing applications to the mouth, and stimulating fomentations over the stomach. A decoction of Hydrastis canadensis will be found an excellent remedy in such cases, for, though it does not possess astringent properties, it seems to exert a peculiar, I might say specific influence in allaying inflammation in mucous surfaces. Let a portion of the decoction be taken cold, into the mouth, and retained until a copious flow of saliva and a slightly stinging sen- sation is produced. In general terms it will be sufficient to say, that where the sore mouth is dependent upon constitutional derangement, such general treatment must be instituted as is appropriate to the condition of the system, and local applications should at the same time be employed calculated to give comfort to the patient, and allay local excitement. If the affection is caused by a local irritant of any kind, little or no general treatment will be necessary, except such as was before referred to ; a simple diet and attention to the condition of the stomach and bowels, so as to prevent accumulations. Time will, generally, effect a cure in these cases, after the irritating cause is removed. Carious and snagged teeth should be removed, where these cause the diffi- culty, and the sound teeth cleansed from all accumulations of tartar. The solution of hydrastis or other soothing wash may aid in the cure. There is another remedy which I have employed more than THRUSH. 349 any other in this and other forms of irritation of the mucous sur- faces, especially where a tonic seemed to be indicated, as is usually the case, if the disease is a sequel to some form of fever. I now refer to the staphylea, of which I have spoken before. It acts as a pure tonic without producing the least irritation, even where the mouth and stomach are in a stage of inflammation. The infusion should be given three or four times daily in table- spoonful doses. You need not look for any palpable and imme- diate demonstration of its action, for its impression is so gentle and gradual that you may be led to question whether it is really entitled to any consideration ; but I have seen cases treated with and without it, and have clearly observed decided advantage in the cases where it was used. THRUSH, OR INFANTILE SORE MOUTH. There is another variety, so to speak, of inflammation of the mouth, resembling that just considered in some measure, but pe- culiar to infants. It is usually called " Thrush," and occurs in children from a few days to three or more months old. At the beginning of the affection, small white specks are first seen, not much larger than the point of a pin. It most frequently com- mences in little clusters of these points on the inner side of the under lip or cheeks, but it may begin at other places. These little clusters gradually spread until the entire surface of the mouth is involved ; the small points being magnified to the size of a pea in circumference. You will most generally find spaces throughout the mouth which are bare and red; but I have seen cases where the whole surface was covered with the white coat, very much resembling milk curd. This I regard as deadened epithelium, and this conclusion is justified by the fact that you cannot wash it off; but when it has remained long enough for another epithelial layer to be formed it will come off itself. But no attempt should be made to wash it off, as by doing so you will aaa 3ss * # Rhubarb pulv.(Turk.)" Bi-Carb. potass. Fol. Mentha pip Cassia Cinnaui. pulv. Water, boiling, Oij Infuse, strain, and add sugar q. s DYSPEPSIA OR INDIGESTION. 391 either of the muscular coat, mucous membrane, or gastric follicles. When the mucous coat is torpid it may fail to secrete the proper amount of gastric fluid, so essential to digestion, and slow or imperfect digestion will be the result. This constitutes one form of indigestion; so when there is positive debility of the muscular coat, that contraction of the stomach so important in every stage of digestion is wanting, and dyspepsia or indigestion is the inevitable consequence. For the purpose of better appreciating the phenomena of indi- gestion, it will be profitable for us to inquire into, or understand in what the process of digestion consists, and what are the well defined attendant phenomena that follow after mastication, and after the food is taken into the stomach. If liquids are taken with the food, it will remainu nchanged until the fluid portion is absorbed. We find a peculiar set of vessels in the stomach, which are found in the system no where else, consisting of open mouthed veins, which, by a kind of suction, or to speak more scientifically, by absorption, take up the fluid. When the fluid is all absorbed by these vessels, the muscular coat of the stomach contracts upon its solid contents, and digestion may then be said to be properly commenced. I do not use the word solid in its usual signification, that is, I do not mean that the food becomes as solid as a piece of marble, but that it acquires a considerable decree of consistency before the muscular action of the stomach is exerted upon it. After the muscular coat contracts, and the mucous and villous coat touches the mass of food and presses upon it at every point, the gastric juice is given out, and then the pro- cess of digestion is fully under way. The gastric juice spreads over the solid contents of the stomach and softens the surface of the whole mass. The surface is then rubbed off by attrition of the villi of the mucous membrane, produced by the constantly recurring contraction of the variously arranged fibres of the muscular coat of the stomach, and when thus rubbed off is passed onward to the pylorus. From thence it is taken into the duode- num and mixed with the secretion from the liver. Another portion of gastric juice is then secreted and performs its work of softening as before, and another portion of the food is 392 DYSPEPSIA OR INDIGESTION. rubbed off by the villous surface and passes into the duodenum ; and thus the process goes on until the contents are digested. Fluids, taken into the stomach, during the process of diges- tion, suspend this process, until the fluid is absorbed. This should be borne in mind in the treatment of dyspeptics. They should have their regular drinks as well as regular meals, and take neither out of the proper time. You can readily see how debility of any of the coats of the stomach may be connected with indi- gestion, and you can also appreciate the modifying influence of both the quantity and the quality of food. It follows conclusively from these considerations that the sus- pension of action either in the muscular coat, or the mucous membrane and gastric follicles, must of necessity interrupt more or less the process of digestion, and should be avoided. Indigestion may also be dependent upon torpor of the liver or excessive action of that organ. In that case the stomach is not usually or necessarily involved to any great extent. Where it depends on the liver the character of the evacuations will be the main circumstance that will enable you to recognize it. The liver may however perform its functions naturally and properly, while indigestion may exist, dependent on mere atony of the organs concerned in the first process of digestion. This condition of the stomach will be accompanied by some symptoms of a peculiar character. I may remark here, however, that the absence of those symptoms common to inflammation of the stomach will be your main guide in determining the proposition. In other words, if you find a patient laboring under indigestion, a ' ose fool produces distress a few hours after it has been taken, who regurgitates his food with or without nausea—whether he had an appetite before eating or not—whose food passes off undigested, and who does not exhibit those symptoms of excitement described as characterizing chronic inflammation, you may look upon it as a case of dyspepsia depending on debility of the stomach and not on irritation. Per- sons with this form of indigestion are apt to have restless nights and unpleasant dreams. Another peculiar symptom in this form of indigestion will be the entire relief from all uneasiness imme- diately after eating. Eating seems to satisfy the demand for food, and is not immediately followed by those distressing symp- DYSPEPSIA OR INDIGESTION. 393 toms which invariably accompany the early stage of the digestive process, when there is an irritable condition of the stomach. This fact is peculiarly diagnostic. A great variety of sympathetic symptoms will be found to accompany this form of disease, upon which it is unnecessary to dwell at length. Palpitation of the heart is often an attendant symptom, and subsides when the tone of the digestive organs is restored. The tongue in most cases is furred, especially in the morning, and the coat will sometimes pass off toward evening, and leave the tongue clean and without any unusual redness. More or less debility too is a general attendant upon indigestion. The capillary circulation is gener- ally imperfect, and the extremities usually cold upon the least exposure. In some cases the individual seems to retain his ordi- nary amount of flesh, but in most cases the disease is attended by emaciation. The most common cause of this form of indigestion is irregularity of habits associated with want of exercise. Individuals of seden- tary habits are most liable to it. The stomach seems to regulate its action by the activity of the other organs of the body. When the individual is confined and takes little exercise, the muscles being but slightly employed, nutrition is imperfectly accom- plished, and the stomach will also assume an inactive character. Exercise is almost as necessary to good health as the food we take, and it is the only method in fact by which the old, effete matter can be eliminated from the system, and new materials taken in its place. As a general rule the muscular vigor and power will be in proportion to the exercise taken. This is true of the muscular system in general and of each individual muscle separately. No muscle can continue habitually inactive without becoming more or less debilitated, and without in a degree impairing the tone of the stomach. In other words, the full energy of the diges- tive functions cannot be sustained without such exercise as shall require moderate action in all the muscles of the body. Hence, the muscular coat of the stomach is usually, in persons of sedentary habits, debilitated. This fact should by all means be taken into account, in regulating the dietetic habits of individuals. There should in all cases be observed a proportion between the receipts 394 DYSPEPSIA OR INDIGESTION. and expenditures of the system. Persons with but little exercise should take but little food, while the active out-door laborer requires an abundance of stimulating and nutritious aliment. Excessive mental labor also diverts from the stomach those ner- vous energies so essential to digestion; hence you will find that among the literary portion of community this is a very common disease. Another very prolific cause of this form of indigestion in this country, may be found in the practice of eating too fast, so very common among a large portion of our population in this land of hurry, and b ustle, and free institutions, where every man is dependent upon the energy and rapidity of his movements for his advancement or success in any department of business. Hence we find among the boarders of our large hotels, who always eat in a hurry, a great amount of indigestion. This is brought about in two ways ; first, an individual who eats very fast is sure to swal- low a much larger amount of food than his system demands. The rapidity with which it is forced into the stomach prevents that organ from recognizing and indicating when the requisite quantity has been received. Hence the rapid feeder always eats too much. Not only so, but this habit involves, necessarily, less perfect mas- tication than where sufficient time is spent in eating. In this condition the gastric juice acts less readily upon the food, and the mucous surface is less efficient in reducing it to the consistency of chyme. In this way the stomach is overburdened and oppressed, and this form of indigestion is rapidly produced. It is also a fre- quent attendant of chronic disease of the liver, in which case the stomach is very liable to become sympathetically affected. But even before this is the case, the usual general symptoms of dys- pepsia may occur. The process of chymification may be properly accomplished in the stomach, but owing to a deficiency of healthy bile the further progress of digestion may be very imperfectly performed. This form of indigestion, in addition to the debility, emaciation and other symptoms of dyspepsia, is attended with alternations of costiveness and diarrhoea and clay-colored evacua- tions, and very generally a jaundice-like hue of the eyes and skin. You will find it to be a common practice among nurses where infants have to be fed, to dilute their milk. This is a great error and scarcely ever fails to produce its bad effects. The functions DYSPEPSIA OR INDIGESTION. 395 of digestion need only be understood to satisfy any man of this matter. The milk when taken into the stomach must become curdled and the water absorbed before it will digest; and when digestion is delayed beyond a certain length of time, the substance in the stomach has a strong tendency to ferment, and this is a very common cause of indigestion. Almost every article is more or less liable to fermentation, especially vegetables. The symp- tom of fermentation is eructation of wind from the stomach, and when this is the case it will be well for the patient to change his diet and use a small quantity. LECTURE XXY. INDIGESTION —Continued. Treatment. Htgienic Treatment. Food, proper and improper— Fluids not advisable—Exercise—Summary—Medicinal Treatment —Neuralgic cases—Spasm of Stomach. In the Treatment of Indigestion, paramount, in importance, to every other consideration, is attention to diet and exercise. With- out reference to these two important matters, you need not expect to meet with success, from any course of medication that you may adopt; but by properly regulating the habits of your patient in these respects you may often be entirely successful in relieving him, without administering a portion of medicine of any kind; though generally the symptoms can be favorably modified and the cure hastened by judicious medical treatment. Although there are certain general principles by which we should be governed in the main, both in regulating the diet and exercise of the patient, and in prescribing remedial agents, yet each and every case must, to a certain extent, be managed accord- ing to its own peculiarities, and the idiosyncrasies of the patient. Hence, notwithstanding my directions as to regimen and medi- cine, as well as the treatment recommended in the books, must necessarily be of a general character, it will be requisite for you to exercise a judicious discretion in each individual case. I shall speak for instance of those articles of diet which are gen- erally admissible in cases of this kind, and of such as are objec- tionable ; but from the experience of the patient, and your obser- vation of his symptoms, you will determine what quantity and quality of food are adapted to his case ; and so also in regard to exercise and medicine. INDIGESTION. 397 Hygienic Treatment. It will be borne in mind that we have now under consideration a case of indigestion depending upon debility of the digestive apparatus, and almost always connected with general debility. The food allowed the patient should, therefore, be easily digested, so that it may not oppress and over- power the stomach; and it should be at the same time nutritious, and adapted to sustain and invigorate the general system. Hence, all fat and greasy food of every description should be avoided. Salt meats too are generably objectionable, mainly because they are more difficult of digestion than those that are fresh. Pork of every kind, and however prepared, should be proscribed, unless under some peculiarities of constitution which rarely occur. Occasional instances may be found where pork appears to agree with the stomach better than any other kind of animal food, and where such is clearly the case it should be allowed once a day. Veal also is an article that should be generally forbidden. It is a fact, which would probably be strongly doubted, had not expe- rience established it beyond question, that young animal flesh is generally harder of digestion than that of older animals, though extremes either way are objectionable—both old beef and young veal are digested with difficulty, and so of other animals. The flesh of some kinds of fowls, too, is hard to digest, owing chiefly perhaps-to the oil usually contained in it. Geese and ducks, however young and tender, will generally be found inadmissible in cases of dyspepsia. The same may be said of most kinds offish, whether fresh or salted ; yet there is one kind of fish, which I have found by experience to be not only easy of digestion, but very acceptable to many debilitated stomachs, and it is highly nutritious; I refer to codfish. This is one of my favorite articles of diet in dyspepsia where the patient has been accustomed to its use, or is fond of it. Almost every variety of green vegetables is objectionable, not only because they are indigestible, but also from their tendency to fermentation and decomposition. Cabbage, lettuce, radishes, onions, and the like, should in all cases of indiges- tion be strictly avoided; while ripe vegetables, such as mealy potatoes, ripe peaches, ripe apples—cooked, &c, being articles of rather easy digestion, may be allowed, where there is no consti- tutional peculiarity barring their use. Pastries of every descrip- 398 INDIGESTION. tion are so imperfectly acted upon by the gastric fluid, and so tardy of digestion, as to exhaust the powers of the stomach and produce debility of the organ, where freely used, even in health, and they are of course highly improper in the condition now under consideration. Hot bread and hot biscuit, are liable to the same objection, as they form a pastelike mass in the stomach, almost impervious to the gastric fluid and consequently digested with much greater difficulty than cold bread, which is dissolved with facility ; hence, according both to experience and sound philoso- phy, hot bread is incompatible with the state of the stomach of which I am now speaking, if indeed it should be tolerated under any circumstances. Highly seasoned dishes, containing condi- ments of an irritating or stimulating quality, that tend to retard digestion by interfering with the proper secretion of the gastric fluid, and by their debilitating influence on the muscular coat of the stomach, are very improper articles of food. Puddings of almost every description, combining the qualities of pastries, hot bread, high seasoned food, and frequently abundance of saccharine matter, are not only difficult of digestion, but they are apt to pro- duce acidity and fermentation, and are in all respects inadmis- sible in this disease. Hard boiled eggs should not be allowed, and in fact I have some doubts whether eggs in any form are suitable as food for dyspeptic persons; at least I should not recommend them. Soups of every kind are objectionable, not because the articles of which they are composed are necessarily indigestible, but because of the large proportion of fluid they con- tain, which must be absorbed previous to the commencement of digestion ; and before this is effected, fermentation is apt to com- mence and thus prevent the process of chymification from being accomplished. Instances may occasionally be found where this form of food will seem to be suited to the peculiar character of the case, but generally, soups and indeed all liquid forms of food are unfavorable. Sugar and articles containing it arc hard to digest, and tend to promote fermentation and the formation of acid. So also of butter, which, strange as it may appear, is demonstrated by Liebig's analysis to have the same chemical com- position as sugar, and consequently the same combining affinities; the only difference being, as is supposed, in the different physical INDIGESTION. 399 arrangement of their elementary constituents. They both con- sist principally of carbon, which is also the principal constituent of the adipose matter accumulated in the systems of corpulent persons. This accumulation results from an excess of carbon- aceous materials, which, as they are not largely employed in the organic structures of the body, are deposited as a reserve store, to be consumed, if need be, in the combustion of respiration and calorification, but contribute very little to the nutritive process. It is true, you will find in the older physiological works, that butter and sugar are set down as highly nutritious. The fact that the negroes generally grow fat, during the sugar making season in the South, has been adduced as evidence of the nutritious character of the saccharine substance. I do not deny that butter and sugar will produce fat; but this is far from being muscle, or tendon, or ligament, or any structure essential to vigor, strength, and energy. Perhaps you are now ready to inquire, since so many articles are proscribed, " where shall we find diet suitable for the dys- peptic patient ?" I answer, it is abundant. Bread at least a day old ;—not short biscuit but light yeast bread ;—and ripe, mealy potatoes,—roasted, baked or boiled,—are two articles, that furnish a large amount of nutriment, and are easily digested; and which, fortunately, are very generally acceptable to the stomach, where food can be tolerated at all. Unripe potatoes are hard to digest and should not be allowed, but ripe ones, well cooked, can generally be digested with facility if taken in moderate quantities. I have already said that ripe peaches, cooked or raw, and ripe apples, stewed, are generally acceptable even to debilitated stomachs; and they serve to give a zest to the plain, simple food to which the patient is necessarily restricted. Milk is in some cases accepta- ble, and easily digested, and where this is found to be the case it is an excellent article of diet, but there are cases in which it will not be borne at all. I will here remark, also, that I have found cream more generally acceptable, and more easy of diges- tion than milk, and have often met with cases where small quan- tities of it, taken with other light food, were appropriated with facility to the nutrition of the system. Ice cream has often been prescribed in this affection, but according to my own personal 400 INDIGESTION. experience, and my observation of its use by others, I regard it as of doubtful propriety, to say the least. If used at' all, it should be in small quantities, and not too rapidly taken. Cheese is too hard to digest, to be admissible generally in this disease. In my remarks concerning butter, a few minutes ago, I did not intend to be understood as proscribing the article entirely. On the con- trary, I generally allow a small quantity of fresh, sweet butter to be taken with the bread or potatoes. I do not deem it necessary to confine the patient to an offensive or unpalatable diet, but, while I would insist on its being light and simple, I would willingly render it as pleasant to the palate as practicable under the cir- cumstances. Hence I should not forbid the prudent use of good butter; but the rancid article, too frequently met with, should not be allowed at all. I have been in the habit of allowing certain kinds of fresh meat also, and experience seems to justify the course. Tender beef, rarely cooked, being easily digested and with facility assimilated to the tissues of the system, may be used in such moderate quantity as not to oppress or overstimulate the organs of digestion. The same may be said of mutton, well cooked, but not crisped, of venison fresh or dried, of the white flesh of chickens and turkeys, of birds, such as quails, partridges, &c, all of which being principally devoid of oil or fat may be safely allowed in reasonable quantities. Oysters, either cooked or raw, as the patient may prefer, are tolerably easy of digestion, and may be occasionally allowed; but they should not be cooked with milk and condiments, as you sometimes find them in the restaurant, as such cookery renders them difficult of digestion and totally inad- missible in this condition of the stomach. As regards the use of fluids I have perhaps already said enough to enable you to anticipate my views. But little liquids of any kind should be taken either during meals, or during the process of digestion, for the reasons which have been already stated. If taken with the food, the liquid must be absorbed before digestion can commence, and if swallowed during its progress, the process is arrested until absorption shall have removed the fluid taken; and in either case it tends to encourage fermentation, or at least afford time'for that process, by delaying the digestive function. But between the periods of digestion, innocent drinks are not INDIGESTION. 401 objectionable. Coffee, however, should not be used at any time, by the dyspeptic, for it seems to produce debility of the stomach, probably by its primary stimulating effect, followed by a local nar- cotic or sedative influence on the gastric nerves; and its use is probably a prolific source of dyspepsia. Black tea or cold water is the best drink in such cases, either between meals, or where the patient must use a liquid while eating. While speaking of bread, I omitted to mention an article of this kind which is often employed with advantage in this affection. I refer to brown bread or bread made of unbolted flour. This, while it is sufficiently nutritious, and as acceptable to the stomach and as easily digested as common white bread, has an aperient effect upon the bowels, and tends to keep them in a soluble con- dition. As it is not convenient to procure it from the bakery in many places, it may be well to state here, that it should be made of the flour of common wheat without bolting. The flour should, however, be passed through a sieve, to remove any extraneous substances, and the coarsest of the bran. The bread is raised with yeast as other bread, but should be baked without being kneaded a second time. I will now close my remarks on diet by adding, that patients in this disease should not partake of many varieties of even admis- sible articles at the same meal, as the practice generally leads to over-eating; and mixing several kinds of food together both favors fermentation, and increases the difficulty of digestion. We come now to another important item in the treatment of dyspepsia ; I mean exercise. As a means of restoring healthy action in the digestive apparatus, exercise judiciously taken is of scarcely less importance than the regulation of the diet. Per- haps the want of proper and regular exercise may have been the principal cause of gastric debility in a case for which you are called to prescribe ; and, if so, attention to this matter will of course be indispensable. In fact there is no condition in which persons can be placed in life, where daily and regular exercise may be safely neglected. Where physical effort is not necessary for obtaining the means of sustenance, it should be performed as requisite to health and vigor. The extent of the physiological influence of bodily exercise is not, I believe, half appreciated by 26 402 INDIGESTION. the medical profession, much less by mankind at large. I have heretofore dwelt at some length on the effects of exercise in changing the habit of the human system; and the influence of muscular inactivity in producing atony of the digestive organs, so that it is perhaps unnecessary to detain you with remarks on this subject at this time ; I will, however, merely repeat in another form, one or two ideas heretofore presented. Without proper exercise neither the function of absorption, nor that of nutrition, can be efficiently performed, so that an inactive, sedentary life tends to deteriorate the animal tissues, by leaving the old, stale or effete materials uneliminated, long after they should be removed from the system, and their place supplied by new and healthy products of nutrition; whereas regular and judicious muscular activity has a constant rejuvenating influence, making us healthy, vigorous and fresh as the plant in spring. Even young persons, and more especially those who are old, experience the vitiating influence of inactivity, and the habitual neglect of proper exercise does much, not only to promote disease, but to bring on premature decline. In the absence of exercise the stomach is not called into action, there is no relish for food, stimulants are employed to pro- mote appetite and force digestion, where there is no natural demand for aliment, and in this way the nervous sensibihty of the stomach is impaired, its muscular energy weakened, and its secretions are vitiated and all the horrors of indigestion are experienced. No wonder this has been called a " fashionable disease," since habits of indolence and irregularity, the common traits of fashion- able life, are so well calculated to produce it. The mode of exercising the body as a means of cure, is a mat- ter of some importance ; for while muscular effort performed in any manner is of more or less advantage, the greatest benefit can be realized from such modes only as bring into play all the mus- cles of the body. As to the amount of exercise necessary to be taken, much will depend on the previous habits of the patient. Thus, a person whose system has been accustomed to laborious efforts, would derive but little benefit from a daily walk or a short ride on horseback, while a person who had been raised in a count- ing room, or whose life had been spent in a study, would at first neither require nor bear any greater exercise. So that the pre- INDIGESTION. 403 vious habits as well as the present condition of the patient, should be taken into consideration in prescribing this hygienic measure. Horseback riding is a very good exercise, as it in some mea- sure brings into action the muscles of every part of the body, and the amount can easily be regulated by extending or shortening the ride. But there is one mode of exercising the muscular sys- tem, where patients can be induced to adopt it, which I have found to be preferable to most others, not only because it requires action in all the muscles, but because it associates the idea of usefulness with that of exercise, and enables the patient to feel an interest in what he is doing. I refer to the labor of sawing wood. I have often directed persons to saw their own wood instead of hiring a sawyer, and whenever my direction has been followed, the dyspeptic has realized much benefit from the exercise. I have even had females exercise in this way when it was inconve- nient for them to do so by other means. Females, however, who have the care of a household, will seldom lack occasion for ample exercise by attending to their domestic affairs, an employment of which no lady should be ashamed. Riding in a buggy is pretty good exercise on some of our Western roads, but where the road is smooth it has but little advantage, except that it affords oppor- tunity for breathing fresh and pure air; which is indeed an important consideration. In whatever way the patient may exer- cise, he should do so regularly, and never to the extent of pro- ducing exhaustion or much fatigue. Exercise should not be taken just before nor immediately after meals, as it diverts the nervous forces from the stomach to the muscles brought into action, and thus interferes with digestion; and the same remark is true of mental effort under such circumstances. When it is necessary for the stomach to perform its function, the patient should desist from much physical or mental exercise, and thus avoid this per- turbation, which is inconsistent with the concentration of the ener- gies of the system requisite to digestion. To sum up the indications in this affection as regards the habits of the patient, I will say, let his food be plain, simple, and nutritious; let him observe constant regularity in his meals and hours of exercise and rest. About three meals a day at regular hours, exercise between the meals, going to bed early, 404 INDIGESTION. and rising early in the morning, and partaking freely of pure air, will comprise the outlines of the hygienic prescription to be made for indigestion, dependent on gastric debility. The medicinal treatment must necessarily be of a very simple character, and may be comprehended in two general expressions; mild aperients, if the system requires them, and gentle tonics. These are the principal means, in a medicinal point of view, upon which you will rely in the treatment of that form of dyspepsia, which we are now considering; but you must bear in mind the essential difference between this form of indigestion and that which is associated with irritation of the stomach. But enough wras perhaps said on this subject, while speaking of the latter form, and I merely refer to it here, to rei'mpress your minds with the importance of due discrimination between the affections. As a means of preparing the way for a more speedy cure, it may be necessary, if the bowels are torpid or sluggish, to pre- mise your tonic remedies with a free evacuation of the alimentary canal; but in this you should be governed by circumstances. If the stomach is healthy, with the exception of debihty, and if there are no morbid secretions or indigestible ingesta, it will not be necessary to subject the patient to the operation of an emetic ; yet I can scarcely conceive a case where it would do much injury. It would certainly arouse the stomach to greater activ- ity ; still, unless pretty clearly indicated, I should not generally employ this measure in these cases ; and never where there are constitutional peculiarities rendering emetics objectionable. A thorough cathartic will generally be sufficient, and can scarcely be amiss in any case of the kind now under consideration. Having removed accumulations, and to some degree aroused the stomach and bowels to increased activity, you should follow up the impression thus made, by the use of such medicmes as will give tone to the digestive organs, and secure and sustain a proper degree of activity in the whole alimentary canal, and organs connected with it. To meet these indications, I am in the habit of prescribing a preparation of which I have frequently spoken before, and which may be properly called empirical, if that term be used in its true sense as descriptive of a remedy tested by experiment; for by long experience I have demon- INDIGESTION. 405 strated its efficiency, having scarcely ever found anything else necessary. I refer to the Restorative Gin Bitters (Bone's Bit- ters) of our Eclectic Dispensatory. It is the recipe which has been heretofore given, to be administered in doses varied to suit the age, constitution and condition of the patient. If there is a torpor of the liver, or a tendency to costiveness, add a small quantity of podophyllum to the bitters, just sufficient to produce one free movement of the bowels every day, and this will be about all the medicine you will find it necessary to employ. It is scarcely necessary to dwell here on the combined properties of this preparation, or to explain in what manner it fulfills the va- rious important indications which it does. It certainly possesses very excellent tonic properties, arousing the stomach from the inactivity into which it has sunk from exhaustion and debility, and giving it tone and sustaining it in the efforts requisite to digestion. It also acts on the liver, and where the biliary secre- tion is impaired, as is usually the case, is a sufficient corrective. It is an efficient diuretic and will soon manifest a beneficial influ- ence on the renal secretions. It is a diaphoretic, producing gentle perspiration, and it also possesses expectorant properties, and is therefore useful where there is torpor of the bronchial mucous membrane. It therefore fulfills more indications than any ordinary preparation, and, although not concocted according to any preconceived theoretical dogma, it is commended to your consideration by a much more valuable indorsement, the prac- tical, daily experience of those who have tested its virtues. Sometimes cases occur in which other simple means become necessary, which I will mention. If the patient has a tendency to diarrhoea and acidity of the alimentary canal, I would admin- ister instead of the bitters, our compound neutralizing medicine combined with the bark of wild cherry, (Prunus Virg.) Sometimes there will be connected with this form of indiges- tion, a number of anomalous symptoms, which may prove embar- rassing to the young practitioner. I have already referred to the extensive sympathetic relations of the stomach with the other organs of the body. Owing to these sympathies the stomach is liable to be affected by causes remote from it. Hence it is not at all uncommon for a dyspeptic condition of the stom- 406 INDIGESTION. ach to be connected with uterine difficulties. Where this is the case your attention must of course be directed to both of the affected organs, but your remedies should have special reference to the primary difficulty. If the uterine derangement be merely secondary to the gastric and general debility, the ordinary treat- ment for dyspepsia, with judicious correlative measures directed to the uterine system, will be sufficient. On the other hand, where the difficulty originates in uterine disease, the cure of this will be a prerequisite to the removal of gastric disorder. The stomach also sympathizes very strongly with the brain, and over-taxing the latter organ is often the cause of gastric debility and consequent indigestion. In such cases it will be necessary to proscribe mental labor and study, and have the patient engage in moderate physical exercise. Indigestion is sometimes dependent, also, on disease of the spinal cord, and this fact should never be overlooked. I shall hereafter have occasion to speak at large of spinal disease, but I refer to it here as occasionally associated with gastric debility. Where such is found to be the case, it will be necessary to cure the spinal dis- ease before you can remove that of the stomach. A form of indigestion is sometimes encountered which will not yield to the means to which the affection is usually amenable, but which will be overcome very promptly by the administration of quinine and morphine in efficient doses. This is where the dyspeptic symptoms depend on neuralgia, which will usually be recognized without difficulty. The quinine and morphine should be given for a day or two and then suspended, to be repeated if necessary. There is a symptom which I believe I have not mentioned, which occasionally attends this form of disease, especially during the efforts of the stomach to perform the function of digestion, and that is, spasm of the muscular coat of the organ; and I think I have seen patients suffer as severely from this symptom as from any other cause of pain. I have known the most lion-hearted persons utter groans under the agony of these spasms. In such cases I have always found our sudorific tincture to afford prompt relief. LECTURE XXVI. ENTERITIS: INFLAMMATION OF THE SMALL INTES- TINES. Synonyms —Parts Involved—Symptoms — Diarrhoea— Charac- ter of Stools — Febrile Symptoms — Prognosis — Post Mortem — Causes — Diagnosis — Treatment for various Causes — Cold — Acid Accumulations — Excessive Bile — Malarial Fever — Diet. Chkonic Enteritis : Symptoms — Treatment. Diarrhcea : Symp- toms — Causes, fyc. — Treatment for over-loaded bowels — Treat- ment for Atony. The subject for consideration this morning is Inflammation of the Small Intestines. The term Enteritis is perhaps the best name we can employ to designate this disease, but as the word literally signifies inflammation of the bowels generally, it may be well in the outset to restrict it to the signification with which it will be employed in this lecture. Modern writers have divided the alimentary canal below the stomach into three sections in relation to inflammation, and designate that affection as it occurs in these different sections by the following terms, namely: Duo- denitis, for inflammation of the duodenum, Enteritis, for inflam- mation of the jejunum and ileum, and Colitis or Dysentery, for inflammation of the large intestines. The first of these I shall not discuss separately, as the duodenum is very seldom if ever diseased alone, and if it is, there is no satisfactory diagnosis of the fact, and no indications of treatment, differing essentially from those pertaining to the affection where the stomach or intes- tines generally are involved. With this exception, therefore, I shall pursue the arrangement just mentioned, and shall apply the term Enteritis to inflammation of any portion of the mucous 408 ENTERITIS. membrane of the small intestines. Peritoneal inflammation was formerly embraced under this title, but as we shall consider that as a distinct affection under the name of peritonitis, it is not com- prehended within the signification of Enteritis as now employed. From the fact that the inflammation of which I am about to speak is most frequently located in the ileum, it has by some authors been denominated ileitis, and by others ileo-colitis, from the fact that the colon is apt to be more or less involved when the ileum is inflamed. Let us not, however, be confused by a multitude of names. I repeat, then, that the subject of the present lecture is Enter- itis, or inflammation of the mucous membrane of the small intes- tines. It is somewhat difficult, however, to conceive of inflam- mation as existing for any length of time in any portion of the alimentary track, without being extended by continuous sym- pathy to other portions of the mucous surface of the tube. Hence it is, that inflammation of the small intestines, and espe- cially of the ileum, is almost always extended in protracted cases to the colon, with the diagnostic symptoms to be mentioned presently. The two extremities of the small intestines, or the duodenum and ileum, are more liable to inflammation than the jejunum. The last mentioned portion appears to be very seldom the seat of disease, although it would appear at first thought to be as much exposed to irritating influences as either of the others. But the duodenum is in more direct association with the stomach and liver, and consequently more liable to be sympathetically affected when they are diseased. The ileum too is situated in a position which will readily account for its liability to irritation and inflammation. The constriction of this portion of the tube at the lower part, and especially at its entrance into the coecum through the ileo-coecal valve, is certainly calculated to retard the progress of the intestinal contents, and hold them longer in contact with the mucous surface, and thus subject it more fully to the action of any irritating substance which may be present, than in the upper portion of the tube. Symptoms. Inflammation of the mucous membrane of the small intestines usually commences with uneasiness, often ob- ENTERITIS. 409 scure in the commencement, but gradually increasing until positive pain of a griping character, and more or less constant, is felt about the centre of the abdomen. The most severe pains will be felt, generally in paroxysms, with a constant sensation of distress between them. The griping is sometimes so severe in children as to cause convulsions, and in adults the suffering is often very great. In other cases, however, there is but little pain. Sometimes the pain, instead of commencing gradually, is violent from the first. The uneasiness, I have said, is usually felt about the centre of the abdomen, or umbil- ical region; this, however, depends in some measure on the locality of the attack; if the inflammation is in the duodenum or first portion of the jejunum, the distress will be felt higher, more deep seated, or possibly referred to the back; whereas, in case the ileum is the part affected, and especially the lowest portion of it, the pain will be in the hypogastric, extending also into the right iliac region. There is usually more or less tenderness under pressure, corresponding in some measure to the amount of pain experienced; and this symptom serves per- haps better than any other in fixing the location of the inflam- matory lesion. Diarrhoea is a very common symptom of enteritis; being rarely absent, unless in cases where the disease arises from obstruction. If, however, this symptom has not appeared, it may at any time be easily produced by the mildest purgatives, which is a circumstance calling for great care in respect to their use. The evacuations are somewhat peculiar, and their character should receive attention. If the disease is confined to the small intestines, they will be watery, generally of a dirty yellow color, and containing but little mucus, comparatively; but when the colon is likewise involved, there will be more mucus, and that often mixed with blood, in the discharges. Such an extension of the inflammation into the colon will also be marked by tenes- mus and by the more severe bearing down pain of dysentery, in addition to the griping, twisting, or cutting pains of enteritis. Of course, the evacuations will at first be mixed with foecal matter, but when this shall have passed off, they will assume the sero-mucous character of which I have spoken. 410 ENTERITIS. In some instances the stools are decidedly bilious during the whole progress of the disease, indicating that the liver has taken on a sympathetic action. This is more apt to be the case where the duodenum is involved in the inflammation, or becomes highly irritated. More commonly, however, there is a deficiency of bile in the evacuations. When bile is present it is apt to be changed, so as to impart a greenish color to the dejections. It is, there- fore, important that you give special attention to the character of the evacuations, so much is to be learned therefrom respecting the real condition of your patient; and as I said on a former occa- sion, I now repeat, that you should not trust others to examine the matters discharged and rely upon their reports, but see and examine for yourself. I have rarely found even a physician who observed with the scrutiny necessary to the formation of a correct judgment, as to the amount of bile, its character, and the other peculiarities of evacuations in diseases of the bowels, which serve as the basis of true diagnosis. The bowels are not usually bloated or distended with gas, to the extent of producing tympanitic symptoms, but occasionally, and especially in children, and in very protracted cases of adults, this symptom is present. Generally, the abdomen is in a collapsed or sunken condition. Febrile symptoms are usual accompaniments of enteritis, but they are not generally as intense as in many other cases of inflammatory disease. We usually find the pulse somewhat accelerated, but open and full; very unlike the rapid quick pulse characteristic of peritoneal inflammation. The skin will be more or less hot and dry, the tongue moist, and slightly coated, and the urine scanty and highly colored. The febrile symptoms sometimes precede those of local disease, in which cases they are usually more prominent, as the reaction is apt to be much greater; and it is very common under such circumstances to find the fever exhibiting the remittent character ; coming on with the initiatory symptoms of bilious fever and pre- senting more or less marked remissions. This complication of enteritis with periodic fever, is especially frequent during the prevalence of the autumnal fevers in this western country, as will be verified by every intelligent and experienced practitioner in ENTERITIS. 411 this region. Where this is the state of the case, there should be no hesitancy, I think, as to the course to be pursued, after what I have so frequently reiterated in similar relations. Arrest the periodic fever before you advance another step, and in nineteen cases out of twenty the inflammation will yield at once. On the contrary, if you undertake to treat the inflammatory disease first, you will soon, in all probability, have a troublesome case on your hands; and if you do not lose your patient you may deem your- self fortunate. The general character of this disease is mild and its prognosis favorable. Where there is but little pain, diarrhoea, or fever, it usually terminates in health in a short time, even without treat- ment. Where the symptoms are more severe, it generally yields with readiness to simple, but appropriate treatment, whether the inflammation is a primary affection or a secondary one, resulting from fever. Though some cases, of the latter description especi- ally, and under improper management in the beginning, assume a very grave character. Where this is the case, and indeed where, from any cause, the disease assumes an unfavorable aspect, the symptoms I have de- scribed become aggravated. The pain increases as the inflamma- tion extends; the discharges become more offensive; the colon per- haps becomes involved, with all the symptoms of dysentery; or the stomach becomes implicated, as demonstrated by nausea, vom- iting, pain and tenderness in the epigastrium; the skin and eyes become yellow, indicating involvement of the liver, or at least closure of the bile duct; the tongue becomes red and dry; the brain and nervous system are affected; delirium perhaps appears; the pulse is frequent and feeble, and the patient gradually sinks, from prostration, or suddenly dies, owing, it may be, to perforation of the intestine, or to mortification. If the case does not prove fatal it may run into the chronic form of inflammation, or the patient may recover after a tedious and prudently managed con- valescence. The post mortem developments you can perhaps readily anti- cipate. They do not materially differ from those following inflam- mation of the mucous membrane of the stomach. Generally, the appearances will differ in different localities, presenting, it may be, 412 ENTERITIS. the evidences of every degree of inflammation, from redness and thickening of the mucous membrane, or enlargement and injection of the follicles, to extensive and deep ulceration, or, occasionally, gangrene and sloughing. Generally speaking, the depth of the ulcers will depend on the violence and duration of the inflamma- tion. In some instances they barely involve the mucous mem- branes; in others they pass through the submucous tissue, the muscular, and occasionally the peritoneal coat, producing perfor- ation of the intestine, which, if it does not produce sudden death, will result in peritoneal inflammation, and finally in death, with scarcely any exception. Sloughing or gangrene is sometimes found, though rarely, perhaps because the disease wears out the powers of life before the point of disorganization is reached. The causes of this disease are numerous and various. A very common cause is exposure to cold. I am familiar with a number of individuals who have apparently no other predisposition except to disease of the bowels, but in whom the slightest exposure will frequently develop this affection, with more or less violence. There is perhaps in a majority of individuals some predisposition to morbid affection in some organ of the system. The weak point may be the lungs, the brain, the liver, the stomach, or some por- tion of the intestines, or indeed any organ of the body, and where- ever the predisposition to disease exists in an organ, slight causes may suffice to develop it. Some persons think they never " take cold" because they never are troubled with a cough, but perhaps these very persons will take inflammation of the bowels upon sud- den exposure to cold or by getting wet in a shower. And in order to " take cold," a very vague expression, by the way, it is not necessary that the individual shall be exposed to a low degree of temperature. I need not make the remark that there is no such thing in existence as " cold," but that the word simply indi- cates the absence of heat, and has merely a relative signification. If you pass from a room heated to 100 degrees Fahr. into one in which the thermometer stands at 70°, you are exposed to a greater transition, than by passing from an atmosphere at 50° into one where the mercury stands at the freezing point. It is the sudden vicissitude of temperature which destroys the equilibrium of the the system, and develops disease at the weak point. ENTERITIS. 413 A very common cause of enteritis is the sudden recession of eruptions from the surface. This is especially frequent with children that have any of the exanthematous diseases ; or the eruption commonly called " rash," which is itself dependent on gastric and intestinal derangement. It is also said to result from metastasis of gout and rheumatism ; which is not at all improbable ; and cases believed to be of this nature are generally attended with very distressing symptoms. It may result also from the suppression of accustomed discharges. Another frequent cause of enteric inflammation is the presence of irritating substances, such as indigestible articles of food, which, having resisted the action of the stomach, have passed in a crude or slightly altered form into the small intestines, where they irri- tate the mucous membrane until inflammation is developed. Acrid or morbid secretions, especially vitiated bile, are doubtless often the cause of inflammation of the bowels. I have seen many cases where I was confident the whole difficulty resulted from acridity in the biliary secretion, and which would not be relieved until this secretion had been corrected. Accumulations and induration of the ordinary contents may occur from inactivity of the bowels and produce inflammation. Relaxation resulting in intussusception or invagination, and strangulation from hernia, &c, are also causes of inflammation of the small intestines. I need scarcely add that enteritis is a frequent attendant on other affections, general or local, as fevers, whether malarial or contagious ; consumption, gastritis, hepatisis, &c. The diagnosis of enteritis is not very difficult. The two prin- cipal affections with which it is liable to be confounded are peri- tonitis and colic. From peritoneal inflammation it may be dis- tinguished by the fact that diarrhoea, a very usual symptom in enteritis, is seldom present in peritonitis ; on the contrary, consti- pation generally attends the latter disease. In peritonitis there is almost invariably tumefaction or a tympanitic condition of the bowels, with tenderness over the whole abdomen; while in enteritis there is seldom much tympanitis, and the tenderness is generally circumscribed, or at least most severe in a limited space. Nausea and vomiting are usual in peritonitis, but not in enteritis, unless gastritis exist at the same time. The pulse affords a very marked 414 ENTERITIS. distinction between these two affections ; in enteritis it is not very frequent and is open and full, while in peritonitis it is small, rapid and hard. By attention to these various peculiarities you will have little difficulty in distinguishing between inflammation of the mucous and serous surfaces of the intestines. From colic this disease is distinguished also by very clearly marked symptoms. The absence of diarrhoea and of febrile symp- toms in colic, and the fact that pressure on the abdomen rather relieves than increases the pain, are sufficiently diagnostic circum- stances upon which to base a satisfactory opinion. The treatment of enteritis will of course depend very much on the producing cause, and I will give the leading indications pre- sented by the disease under different origins. If you have a case which is produced by exposure or " cold," without evidence of accumulation or other causes of obstruction to be removed ; with no invagination of the intestines to relieve, and no recession of eruptions, nor translation of gout or rheumatism to be diverted, but a plain, simple case of inflammation arising from cold, is it not perfectly clear that such treatment as shall establish the cutaneous transpiration and equalize the circulation, will be likely to remove the disease ? Secure a general and copious perspiration, and employ revellants to attract the circulation to the surface, and you will in most cases relieve your patient imme- diately. I have seen cases relieved in one or two hours by the administration of our sudorific tincture. This preparation allays the irritability of the bowels, and powerfully determines to the surface, thereby equalizing the circulation. Let a sinapism be applied over the bowels as long as it will be borne, and followed by hot fomentations after its removal; and let hot bricks be applied to the feet. Let the sudorific tincture be given in drachm doses once in two or three hours with warm tea, as balm, catnip or the like, and let this be continued until a copious perspiration is brought about over the whole surface, and kept up for an hour or two. This will generally be all the treatment required to arrest this form of enteritis. Where the disease is produced by acrid accumulations in the intestinal canal, the first indication is the removal of such accumu- lations. In the selection of an article to fulfill this indication, it ENTERITIS. 415 is important that you exercise discretion; for while it is necessary to have an agent that will certainly accomplish the object, it is equally important to avoid any thing like a drastic or irritating purgative. I know of nothing better adapted to this state of things than our neutralizing physic ; for while it operates mildly in the removal of accumulations, it effectually neutralizes all acidity and thus diminishes materially the irritating tendency of the intestinal contents. It should be given in sufficient doses to act effectually, and repeated until the bowels have been freely evacu- ated ; which will generally be effected by about two drachms of the powder, digested in a pint of water, strained and sweetened with loaf sugar, and given in four doses with an interval of an hour and a half between. Frequently, sufficient action will be produced by the first or second dose. Meantime, other means, adjuvant to this, may be employed with benefit, such as counter-irritation and fomentations as just recommended under the other cause. After the removal of all irritating substances from the bowels, you have a case of simple inflammation of the mucous membrane of the bowels, which is to be managed by means of the most soothing treatment adapted to allay irritation. Mucilaginous drinks, with small doses of morphine ; injections of starch with small portions of laudanum, especially where there is diarrhoea, and dysenteric symptoms; perfect repose and very light diet, are about all that will be necessary. If you have a case of retrocession of an eruption from the sur- face, your treatment will be counter-irritation and gentle dia- phoresis. Hence a large sinapism over the abdomen, followed as before mentioned by hot fomentations, is indicated, with such other revulsive measures as are familiar to every practitioner; and internally, moderate doses of the diaphoretic tincture. If it is from translated rheumatism or gout, let counter-irritation be applied to the whole length of the spine, and if the particular location of spinal irritation can be detected—as it often may be by pressing upon the roots of the spinal nerves successively, until a tender point is discovered—let a dry cup be applied to that point and then apply a sinapism to the same part. If the disease is produced by an excessive secretion of bile, you should administer small doses of podophyllin and leptandrin 416 ENTERITIS. combined with diaphoretic powder. In this prescription you secure the stimulating influence of the podophyllin and leptan- drin in exciting healthy action of the liver, combined with the ano- dyne influence of the diaphoretic powTder. If diarrhoea be an urgent symptom, you may, instead of the diaphoretic powder, give the tincture of catechu and paregoric, combined in equal quanti- ties, in drachm doses as often as necessary. If it is dependent on intussusception or invagination of the intestine, your success must of course depend on your ability to relieve this condition. This is a difficult case, and I shall speak of it more fully hereafter. I will remark, however, that I have relieved this difficulty by introducing as far into the rectum as practicable, the tube of a stomach pump, and filling the intestines with water. If the invagination is at or below the illio-ccecal valve, this is pretty certain to reduce it; and if it is above that point, although your injection may not reach it, yet by the disten- sion of the colon and the movement in the intestinal convolutions thereby produced, you may cause a reduction of it. Another means which has been employed is the applications upon the abdomen, of a vessel, as a large tumbler, in which a partial vacuum is produced by burning a pledget of cotton within it. Or, in an extreme case, the receiver of an air pump might be employed. Such means are said to have produced successful results. But where the cause of inflammation of the bowels is malarial fever, the case is a plain one. Before you proceed a single step in the treatment of the local inflammation, arrest the periodic fever and in nineteen cases out of twenty the inflammation will yield at once. On the contrary, if you undertake to treat the inflammatory disease first, you will soon, in all probability, have a troublesome case on your hands ; and if you do not lose your patient you may deem yourself fortunate. The remedies for the arrest of the fever have been already fully set forth, and should the inflammation have proceeded too far to terminate spontaneously, such treatment as has been directed for simple enteritis will of course be indicated. The diet in this disease, under all circumstances, must be rigidly simple and bland, and the patient must be kept still; this, how- CHRONIC ENTERITIS. 417 ever, is not generally a difficult matter, for with symptoms at all severe, he will be disposed to take and keep to his bed. CHRONIC ENTERITIS. Enteritis often assumes a chronic character, and then the mucous surface of the whole intestinal track is very apt to be involved. This chronic form of enteritis was quite prevalent among the soldiers who returned from the recent campaigns in Mexico. I have seen a number of these cases, and a brief descrip- tion of them may not be out of place here, as they will serve as marked instances of that form of disease of which I am now speaking. The symptoms in all these cases were as follows: a red tongue, and the color was not confined to the edges and tip, as in ordinary cases, but the whole tongue and mouth was as red as raw beef; a tympanitic condition of the abdomen with soreness under pres- sure ; there was generally extreme emaciation, with a small and frequent pulse, and everything to be observed indicated, very con- clusively, marks of extensive and protracted disease ; the skin was dry and parched, the extremities cold, the appetite in most instances entirely gone ; the thirst urgent, the urine scanty and high-colored, and there was generally more or less irritation of the lungs, causing a troublesome cough. The discharges were of a dirty watery character, with which matter of a slimy appear- ance was mixed ; showing plainly that ulceration of the mucous follicles existed. These cases were produced by protracted attacks of bilious fever with bad treatment; and it often follows cases of this kind, where active, drastic purgatives have been resorted to in the early stage of the disease ; but wherever the febrile symptoms are promptly removed, you will rarely find any such effects following malarial fever. The treatment of this form of inflammation, is unquestionably of more importance to you than anything else I can further say in regard to it; for you will seldom have any difficulty in forming a correct diagnosis in these cases. I have had occasion to treat a number of the cases from Mexico, and though some of them were tedious, recovering very slowly ; yet every case to 27 418 CHRONIC ENTERITIS. which I have been called has got well. One case of the kind, I will particularly mention, which had been treated during two years by a number of physicians, and given up as hopeless. He was extremely emaciated, with an almost black appearance of the skin: there being large dark spots over the whole body, while the intervening surface presented by no means a healthy appear- ance. The tongue, evacuations, and symptoms generally, were very much as I have just described them in my general remarks. I put this patient upon a very simple, mild course of diet, such as rice, and stale bread, with no animal food, and administered our neutralizing cordial, to which was added a small portion of wild cherry bark to be taken in doses three times a day.* I had him bathed regularly in whisky and broke water; and in addition applied one of our irritating plasters to the whole abdo- men. This irritating plaster differs materially in its effect from other irritating applications; for while it makes a sufficient impression upon the surface, equal to that of any other, it may be borne with impunity, as it does not produce debility, nor consti- tutional disturbance. Tartar emetic exhausts the patient, without producing nearly so beneficial a local effect. In connection with these means the compound tincture of catechu and paregoric in equal parts was administered once or twice a day, not to arrest but to restrain the looseness of the bowels; for in all these cases the more frequent are the evacuations, the more will the patient be reduced, and the longer will the disease continue. If the liver is torpid it usually returns to its proper function when the local difficulty is removed; but if it should not, it may be excited to healthy action by a small dose of podophyllin, lep- tandrin and ext. taraxacum combined in the form of a pill, taken daily on going to bed. With this course of treatment, varied of course to meet peculiarities, I have usually been suc- cessful. * Ifc Rhubarb, pulv. Mentha pip. pulv. I---?- Wild Cherry Bark, pulv. f'"3j Bi-Carb Potass. J Digest in boiling water Oj. Add loaf sugar 3j- Brandy half a gill. Dose fl 3j. DIARRHG3A. 419 I cannot avoid adverting, in this relation, to the treatment pursued in similar cases in the Commercial Hospital of this City under the medical oversight of the faculty of the Medical College of Ohio. I had an opportunity last winter of seeing a well defined case of this description under their management in that hospital, and I would appeal to every honest man of common sense, whose natural judgment is not swayed by professional prejudice or false teaching, and who will examine the records of that hospital, to say whether the treatment there employed is not opposed to sound philosophy; especially when taken in connec- tion with the bills of mortality following it. Very few of the unfortunate individuals who entered that institution with this dis- ease ever left it, except to be carried to the grave. DIARRHCEA. This term signifies literally " pouring through," and is applied to purging in general. Consequently we have, as has been shown, diarrhoea dependent on inflammation or irritation of the small intestines; diarrhoea connected with typhoid fever, &c, and we shall hereafter have occasion to speak of diarrhoea con- nected with and dependent upon chronic colitis or dysentery, hepatic disease, epidemic cholera, cholera morbus, cholera infan- tum, &c. In this place I only propose to call attention to a form of diarrhoea which does not depend on local inflammation or irritation, nor active constitutional disease. The affection of which I now speak appears to be dependent on mere debility of the bowels, either habitual or temporary. Debility or atony of the bowels may in one sense be merely relative, that is, there may be sufficient tone or energy in the organs to enable them to perform their functions in a healthy manner under ordinary circumstances; but when an extra duty is imposed or a slight perturbing influence brought to bear upon them, their weakness will be manifested. Thus among persons accustomed to overload their stomachs with food, you will occa- sionally find one whose meals are habitually followed by semi- fluid alvine discharges. This has been denominated crapulous diarrhosa. Again you will meet with many persons who cannot hear sudden intelligence, whether joyous or sorrowful, nor experi- 420 DIARRHffiA. ence alarm, anger, nor any other strong mental agitation without an attack of diarrhoea. The vessels of the mucous membrane appear to be suddenly relaxed in both these forms and an extra quantity of serum thrown into the bowels, while the peristaltic motion is increased by the presence of the food in the one case, and by nervous excitement in the other, and a diarrhoea is the consequence. The same consideration will account for the diar- rhoea sometimes occurring in hysterics. The treatment for this affection is very simple. Where the bowels are overloaded they should of course be relieved by a cathartic, for which purpose the compound neutralizing physic is very appropriate. A dose of castor oil would also answer the same end. Beyond this, a prevention of the cause, whether that be improper eating or nervous excitement, will of course be necessary; which, together with some gentle tonic, combined, if need be, with an astringent, at first, will be all-sufficient. The infusion of staphylea in table-spoonful doses four or five times a day will be all the tonic necessary, and where an astringent is found necessary, an infusion of marsh rosemary, of Geranium maculatum, or of blackberry root may be employed. But there may exist a state of positive atony or debility, in which there will be habitual diarrhoea without pain, fever, excite- ment of the pulse, redness of, or fur on the tongue, or any other symptom indicative of inflammation or irritation. This condition is often found to remain, following febrile and inflammatory diseases, long after all symptoms of such disease have disappeared. But it occasionally occurs without any previous irritating cause of which you can become aware. The nature of this difficulty appears to be a relaxed condition of the secreting vessels of the mucous membrane, so that they are unable to retain the fluids forced into them by the circulating current, and hence, instead of the moderate amount of moisture necessary to mollify the food and lubricate the tube, there is discharged into the alimentary canal a large amount of serum, with portions, it may be, of fibrin, or even the red globules, which, imparting a watery if not a bloody character to the contents, is passed off, constituting a diarrhoea of pure debility. This tendency is much heightened by an anaemic condition of the DIARRHOEA. 421 circulating fluid, and where it becomes much increased a passive hemorrhage may be the result. The appearance of the dis- charges is, of course, variable. Their color may be light, yellow or green, according to the quantity and quality of the biliary secretion. The treatment in these cases will depend very much upon the circumstances in each case. If the liver is torpid, a very small pill, say £gr. podoph.,^ gr. leptand., andq. s. ext. tarax., should be taken once or twice a day. The bowels may be held in check and their motions properly regulated by our compound neutralizing cordial, aided if need be by some efficient astrin- gent, such as tannin, infusion of marsh rosemary, Geranium mac. or blackberry. In connection with these remedies the infusion of staphylea may be relied upon as a tonic, or in its absence, the quassia, columbo or gentian may be employed. In some cases an infusion of cinchona may be of much advantage. The diet must be light and easily digested, but nourishing and taken regularly. The daily use of the cold or tepid bath, followed by brisk friction over the whole surface, and moderate daily exercise in the open air, will also be very important in restoring general tone to the system. When there is an impoverished condition of the blood, one of the preparations of iron, in connec- tion with the other remedies named, will be highly proper. I have brought in this subject, in this place, not because it belongs in reality to the class of diseases we are considering, but because the diarrhcea may mislead you into a mode of interference which would be highly injurious, unless you were warned of the fact that this symptom does not necessarily imply inflammation or irritation. LECTURE XXVII. DYSENTERY: INFLAMMATION OF THE LARGE INTES- TINES. Synonyms—Acute Dysentery—General View—Modifications and Varieties—Symptoms—Local— General— Caused by Worms in Children—Adynamic Form—Associated with periodic Fever- Prognosis— Causes reviewed—Post Mortem—Treatment—Where caused by cold—By irritating substances—For Derangement of Stomach—Emetic Recipe—Injections—Treatment in late stage- Where caused by Worms—Epidemic Form—Antiperiodic Medi- cine— Obstinate Cases. We come now to the consideration of Dysentery. This dis- ease has received various names among medical writers, such as Colitis, Colo-rectitis, &c, and it is known in various parts of the country, as flux, bloody-flux, &c. It is, however, more generally described under the term dysentery than any other, and as this is a convenient name, I shall employ it. It is necessary, however, to be aware that many persons are entirely ignorant of the dis- tinction between diarrhoea and dysentery; for if you rely on the term as employed by patients or their friends you will often be misled. The inflammation in this disease may be located in the rectum alone, but most generally the colon is also involved to a greater or less extent. It is characterized by mucous and bloody dis- charges, accompanied by severe tormina, or pains in the lowrer part of the bowels and tenesmus, and generally with constitutional disturbance. It is with great propriety divided into the two forms, acute and chronic dysentery, the former of which will first occupy our attention. ACUTE DYSENTERY. 423 ACUTE DYSENTERY. This disease may commence without premonitory symptoms, but it is generally preceded by more or less constitutional dis- turbance, indicated by general lassitude and uneasiness, with pains in the abdomen, either sharp and transient, or dull and per- sistent, and by constipation or diarrhoea. There is always con- siderable febrile reaction, if the case is at all severe, but this may not appear until the local inflammation has become established. But the circumstance under which the Western physician is most frequently required to manage dysentery, is where it is associated with malarial fever, in which case it is often, though not always, preceded by the development of the periodic fever. I say it is not always preceded by the fever, even where the latter presents very clearly the periodic character; for the inflammation maybe the primary disease, and the secondary fever be rendered periodic by the prevalent malarial influence. But the association of the two diseases is remarkably common, according to my observation, and that of others with wThom I have conversed. I have, this morning, learned from members of this class, who have been prac- titioners in different parts of the country, that this complication is very prevalent in their respective localities. Such, indeed, is the testimony of all who have any experience in the diseases of mias- matic districts, and when dysentery occurs in this form it is generally regarded as most difficult to manage. When the disease is thus associated with malarial fever, there will, generally, be a slight chill and febrile reaction, preceded by the incipient symptoms of remittent fever, such as debility, lassi- tude, disinclination to exercise, uneasiness in the head, back and limbs, and general derangements of the various functions. The dysenteric symptoms, as before remarked, may precede the febrile, or they may occur at any period of the progress of the fever. Dysentery often occurs as a sequel of other diseases, especially of badly managed fevers, such as bilious, congestive and typhoid, where the bowels have been irritated by drastic medicines. The disease occurs with every grade of severity, from a slight irritation to the most extensive and active inflammation of the mucous surface of the large intestines, and is accompanied by an 424 ACUTE DYSENTERY. equal diversity of symptoms, from those of a mere local character, tending to subside without medicine, to those of the most violent constitutional disturbance, or of a low grade of adynamic disease, as presented in typhoid fever. The violence or malignancy of the disease will depend upon the constitutional peculiarities of the patient, and also on the nature of the producing cause. Hence you will find a great difference in the grade of the disease in different patients, even during its prevalence as an epidemic. Those of robust constitutions and general health, if they take it at all, will usually have a light attack, while debilitated persons are not only more likely to take it but to have it severely. Symptoms. An early and very common symptom of dysentery, before the disease is fully developed, is a vague uneasiness in the lower part of the abdomen, generally accompanied by diarrhoea. In fact there is no mode of introduction of dysentery more com- mon than by diarrhoea, more or less profuse and protracted. This is very generally one of the earliest symptoms where the disease is prevailing epidemically; but the diarrhoea is under such cir- cumstances accompanied by soreness and a sense of weight and pressure in the lower part of the bowels, by which it is clearly distinguished from the diarrhoea of mere debihty. This last men- tioned symptom increases as the disease becomes developed, and in severe cases produces the most intolerable distress. It occa- sions a constant desire to go to stool even after the bowels have been completely evacuated, and the effort to have a passage gives partial temporary relief, although nothing at all, or only a little bloody mucus may be discharged. The frequency of these efforts at evacuation will vary, with the severity of the case, from one in two or three hours to one every five minutes. The tenes- mus, as this symptom is called, is sometimes attended by such spasmodic efforts of the muscular coat of the rectum that prolapsus ani is produced, especially in children, which is a very distressing and troublesome occurrence. Every evacuation, although it appears to give present relief, tends to increase the irritation, and consequently the desire to go to stool, and the pain and spasm attending the discharges; and the patient should, as far as prac- ticable be induced and assisted in resisting the desire to get up. The character of the evacuations varies greatly in different ACUTE DYSENTERY. 425 cases. In some they consist of pure mucus, in others of pure blood, and in others still, of mucus mixed with blood, which last is their most usual appearance. Sometimes the dis- charges seem to be a kind of blood-stained serum, resembling, as I have heretofore described it, water in which fresh meat has been washed. This is a grave symptom, and most common in epidemic dysentery. It indicates a low condition of the vital forces, and a tendency to decomposition in the mucous tissue. The pain and tenesmus are perhaps most severe in cases where the discharges are principally mucus ; for where they consist of pure blood the local depletion affords more relief; while the sero- sanguineous evacuations are attended with general debility and severe griping pains throughout the abdomen, but not so much irritation of the rectum. Occasionally, small lumps of hardened foecal matter will be passed, causing much pain, but followed by great relief. But in any case and under all circumstances, this disease, when fully developed, is attended with much distress, more, perhaps, on an average, than any other to be met with in practice. Connected with the local symptoms I have described, are usu- ally others of a more general character. Unless it be a very mild case there will be pyrexia, whether the affection occur under malarial influence or not. Hence, you will generally find an excited pulse and hot skin, and general derangement of the secretions. The liver is apt to be torpid or else over-excited, and its secretion vitiated; the stomach in severe cases is often affected, causing vomiting. The urine is generally scanty and high-colored, and as the bladder and urethra, sympathize by proximity with the inflamed bowels, much pain is experienced in micturition, often, indeed, amounting to strangury. In females, the vaginal mucous surface often becomes affected, producing more or less leucor- rheal discharge. The pulse of course varies in this as in other disease. It has not generally however the irritated character common to many other inflammatory affections. It is usually somewhat accelerated, but open and full, but differs greatly in accordance with the sever- ity of the local inflammation, and the condition of the general system. You will sometimes find a hard, rapid pulse, with a cool, 426 ACUTE DYSENTERY. clammy skin, which, let me remark, are grave and very alarming symptoms. The extent of the inflammation may generally be determined by the pain felt under pressure, when made along the course of the colon. If there is soreness in the upper portion of the abdo- men it indicates that the transverse colon is involved, and in this case the stomach is very likely to participate in the disease and nausea and vomiting follow. The right or ascending colon may also be inflamed, in which case pressure on the right side of the abdomen will produce pain. Sometimes the ascending, or even the whole colon is affected in the commencement, which is most usually the case where the disease commences with diarrhoea. In other cases the inflammation commencing in the rectum or lower part of the colon is propagated upwards by continuous sym- pathy until the whole colon, the ccecum, and even the small intes- tines are involved. In the case last mentioned there will of course be general tenderness of the abdomen, and the usual symp- toms of enteritis will be superadded to those of dysentery. The tongue, in simple cases of dysentery, is generally moist and slightly covered with a whitish fur. But where the liver is much deranged it will be loaded with a yellowish coat; and where the stomach becomes involved the edges and tip will be red, and per- haps the surface gashed. Sometimes the coat will come off, leaving the whole surface fiery-red as described in gastritis, especially in the last stage of the disorder. I have already remarked that the liver is generally torpid, but that occasionally there is an excessive discharge of bile. This is indeed the first symptom in some cases, where the diarrhoea is of a bilious nature, and the acrid character of the secretion acts as an irritant upon the mucous surface, and thus produces inflamma- tion. Cases of this kind are usually denominated bilious dysentery. Dysentery in children is sometimes caused by worms, in which case the attack is preceded and attended by the usual symptoms denoting the presence of worms in the alimentary canal. There is another form of the disease to which I may as well refer in this place as any other. It is the adynamic dysentery of the books, being thus named from the deficiency of vital energy in patients affected by it. It is usually found in armies, hospitals, ACUTE DYSENTERY. 427 and densely populated cities, where disease is produced by the decomposition of animal matter and the absence of a free circula- tion of fresh, pure air. It is characterized by a small, frequent pulse, and usually preceded by diarrhoea. The skin is cool in some cases, in others there is a pungent heat, but always a mani- festly low condition of the capillary circulation. Dark livid spots are often seen on the surface, and sometimes elevations resembling the petechia? of typhoid make their appearance. The disorder, very often partakes evidently of the character of dysentery proper and typhoid fever, and is without doubt the result of causes, cal- culated to produce the one, acting on the system conjointly with those tending to develop the other. Dysentery in this adynamic form is not an uncommon sequel of typhoid and congestive fever, and it is always to be regarded as a very grave form of disease. I have already spoken of this affection as associated both pri- marily and secondarily with periodic fever. I will take occasion here to add that where the disease occurs in such a location and at such a season as to suggest the probability of malarial influence, it is perfectly safe to treat it as resulting from that cause, even where no distinct periodic features are presented. I have adopted the plan of treating the disease under such circumstances with a distinct reference to the malarial origin, without even waiting to discover a periodic tendency, and I have abundant reason to be gratified with the results. Another form of dysentery, said to occur occasionally, is where the disease results from a translation of rheumatism. Those of you who were in attendance last winter saw a pretty well marked case of this kind in the Commercial Hospital. This form may be known, generally, by its being preceded by a rheumatic condition of the system, perhaps seated in some organ or location, and by a sudden metastasis of the reflected irritation from its former seat to the large intestines. The prognosis in dysentery will of course depend on the vio- lence of the symptoms, and its complication with other affections. Occurring alone, and in the usual form, especially where there is no epidemic influence, the prognosis may be regarded as decidedly favorable; it is not under such circumstances difficult of removal. 428 ACUTE DYSENTERY. But where it is associated with certain other diseases, or follows typhoid or congestive fever, it may be regarded as a very dan- gerous disorder, though not necessarily fatal, as prompt and judi- cious treatment will generally prove successful even in these grave forms. I think, indeed, that we should set down the general prognosis of dysentery as favorable, for I am confident that not more than two per cent, of all the cases of it should be lost. You may per- haps suspect this to be a hasty estimate, but I assure you I speak advisedly ; being sustained not only by the results of my own practice, but also by those of others who have pursued what I regard as a proper course of treatment. The causes of dysentery have been already mentioned in speak- ing of it in its various forms; still it may not be amiss briefly to recapitulate them here. So far as regards sporadic dysentery, cold may be stated as a frequent cause. Persons naturally pre- disposed to irritation of the bowels, or in whom such a predisposi- tion may temporarily exist from any cause, may, by sitting in a draft of air, or on the damp ground, bring on an attack of dysen- tery. Another frequent cause of the disease is the presence of acrid and indigestible substances in the alimentary canal. These may consist of articles swallowed as food, but which, not being digested, have passed into the intestines and produce irrita- tion, especially if detained in their progress, as they are likely to be, in the pouches of the colon. Or the irritating materials may be the production of vitiated secretions of the liver, pancreas, mucous follicles, and intestinal glands. The great prevalence of intestinal diseases generally in the summer season, and especially among children is, I am confident, owing mainly to the habit of eating indigestible vegetables so common at that season. The summer complaint, as it is familiarly called, among children, is very commonly due to this cause, and it is often kept up and aggravated by the continuance of the cause until cure is beyond hope. The effect is nearly as bad for the mother who is nursing to eat such food, as to feed it directly to the child. But the most serious and important cause of dysentery is the epidemic influence, associated as it generally is in this country, with malarial poison, and it is in this form of disease that, not ACUTE DYSENTERY. 429 only the reputation of the practitioner, but also the lives of his patients, depends to a very great extent on a correct mode of treatment. Sporadic dysentery will generally get well if left to the unassisted efforts of nature, though judicious treatment will diminish suffering and hasten the recovery; but in epidemic dysen- tery, where the nervous system is brought under the depressing influence of atmospheric poison, and the blood and all the secretions are thereby vitiated, the tendency is very often from bad to worse until the patient is relieved by the hand of death, made welcome through intensity of suffering. It is in this disease, and especially in this form of it, that the prompt and well directed prescriptions of the physician will be more fully appreciated, perhaps, than in any other condition of the human system. Upon post mortem examination, signs of inflammation are always found in the rectum and lower portion of the colon. The appearances are not uniform in all cases, but vary from mere redness and thickening of the mucous membrane to ulceration, or even gangrene, which may involve the submucous and muscular tissue of the tube. The surface of the bowel is sometimes covered by a coat of coagulated lymph, while in other cases the mucous membrane itself has been removed in patches, probably by exten- sive ulceration, and the discharge of a slough. As would be inferred from the symptoms described, cases occur in which the mucous membrane of the whole colon, or patches in every portion of it, evince similar signs of disease. The bowels and stomach will also be found in some instances to have been more or less affected by inflammatory action. The mesenteric glands are generally enlarged and softened, where the case has been pro- tracted, and the liver often presents evidence of engorgement and sometimes of inflammation. Occasionally, hepatic abscess may be found, especially in the dysentery of southern countries. In the adynamic form of the disease, the mucous membrane is generally very much changed, and, if not actually in a disor- ganized condition, verging closely upon it. In speaking of the treatment to be employed in dysentery, I must repeat what has been said in reference to every variety of inflam- mation. The cause is the most important subject of inquiry. I cannot, certainly, too often reiterate this principle, nor too deeply 430 ACUTE DYSENTERY. impress it on your memory. It is more than folly, it is madness, to attempt the treatment of any disease without reference to the cause that has produced it, where such cause can possibly be ascertained. Nothing shows such want of science, in a practi- tioner, as does inattention to the origin of disorders for which he prescribes. To be always ready to give a prescription for inflam- mation, or fever, or headache, or any other affection, without inquiry into such symptoms and facts as may tend to refer the disease to the exciting and even the predisposing cause, is downright quackery. An individual has dysentery, we will suppose, as indicated by frequent bloody discharges, tenesmus and fever. Is it a matter of no consequence whether the disease has been produced by inspissated faeces long retained, by indigestible food, by vitiated and acrid secretions, by translated rheumatic irritation, by malarial fever, or by epidemic influence ? If no inquiry is to be made in regard to these questions, and remedies are not to be adapted to the removal of the cause, then leave the case to nature ; for she is a skillful physician, and will cure nine- tenths of all these cases unaided, which is far better than the phy- sician will do whose prescriptions have no reference to the cause. He may occasionally succeed in giving assistance, for he may happen now and then to meet with a case adapted to his treat- ment ; but who would not rather trust the skill of nature, than be placed in the hands of such a " doctor" ? Where the dysentery results from cold, the patient should be placed in bed, and such simple means employed, as may be at hand, and adapted to promote free perspiration. Our sudorific tincture, is an excellent prescription in such a case, and it is about all that will be found necessary to be given internally. As an adjuvant, a sinapism or hot fomentation may be applied to the abdomen, especially over the principal seat of pain. If the pain is severe, a small dose of morphine may be given; or what is better, especially if the motions of the bowels are fre- quent, an injection of starch and laudanum may be administered, and the patient requested to retain it as long as practicable. This should be repeated after every discharge. Or a pill of opium may be introduced as a suppository into the rectum; and repeated when it comes away. This is more likely to be retained and ACUTE DYSENTERY. 431 control the tenesmus than either of the other modes of adminis- tering opiates. On the other hand, if the disease is produced by the presence of irritating substances in the bowels, the first indication is their removal; and for this purpose no remedy is better than our neutralizing physic. This should be prepared by adding about half an ounce to a pint of boiling water, and after steeping some minutes, strained and sweetened; and given in wine-glassful doses every second hour until the cathartic effect is produced. As a substitute for this, where one is desired, I have found half a grain of podophyllin combined with two grains of leptandrin to answer an excellent purpose. This should be repeated once in four hours until it produces a free action of the bowels. When this is accomplished, if the symptoms do not subside with the aid of the sinapism and fomentations, to be used simultaneously with the exhibition of the cathartic, it should be followed by suit- able doses of morphine and ipecacuanha to relieve the pain and promote diaphoresis, or our diaphoretic powder may be given. Where the discharges are frequent and the tenesmus great, the starch and laudanum enema, or opium suppository should be employed after each movement of the bowels. I was accustomed in former times to give, very frequently, in these cases, as a cathartic, our antibilious physic with raspberry leaves made into a decoction. This is a very safe, efficient and active cathartic, and, where convenience or other circumstance suggested a substitute for the agents above mentioned, I should now employ it. The raspberry leaves appear to prevent griping, and they act as a mild astringent without in the least irritating the bowels. You should in no case of this kind overlook the importance of revulsive measures, such as the sinapism and hot fomentations to the bowels. They are means always at hand, and as they are highly corroborant to the radical remedies, should never be omitted. Mucilaginous drinks should be used to satisfy thirst, not only because of their adaptation to that object, but because of the soothing and sheathing effect which they have on the irritated mucous membrane. Their use is highly important. The bark of Ulmus fulva, or the root of Althaea officinalis is all that need be desired for this purpose. 432 ACUTE DYSENTERY. Where there is derangement of the stomach in the early stage, as indicated by nausea and vomiting, it will be well to premise all other treatment by the full operation of an emetic. This will exert an important influence on the subsequent course of the disease, and is a highly commendable measure; for, if you undertake to remove accumulations from the stomach by cathartics, it may require two or three days to accomplish the object; but a brisk emetic removes them at once, and prepares the way for a more efficient action of your cathartic. The emetic so frequently referred to, (the lobelia and eupatorium) I regard as equally adapted to this case. I have sometimes administered our emetic powder * but if this is employed, it should be in the form of an infusion. I very much dislike these impalpable powders, containing indigestible, woody matter, calcu- ted to adhere to the surface of the mucous membrane, and keep up an irritation long after you desire the action of your medicine to cease. I have no objection to the administration of soluble powders in substance, but as a general rule, where a tincture, infusion, or solution can be used, it is preferable. In preparing starch for an injection, it should be made some- what thinner than when used for ordinary purposes. Instead of starch, any other mucilaginous fluid, as the infusion of slippery elm, or of marsh mallows may be used. The quantity used at a time should not exceed a gill, with a drachm of laudanum, and whether the injection is employed or the opium suppository, it should in either case be repeated as frequently as it passes away; for by neglecting this, the disease will get a start of you which it may be difficult to regain. If you are called at a late period to a case of sporadic and uncomplicated dysentery, and find the bowels in a soluble con- dition, as is usually the case, or after the action of your first course of medicine you have brought about this condition, but find that the disease does not yield, you must hold a gentle * ft Ipecac, ) __ _.. Lobel. pulv. | aa 3lJ' Capsicum An. pulv. gr. vj. Water, Oj. F. decoct, and strain. ACUTE DYSENTERY. 433 though firm and steady hand. Do not thunder away now with your heroic measures as if resolved to kill or cure at once. You may possibly cure some, but you will, by such a course, send many more to the grave. The cause being removed, if the inflamma- tion does not subside, it is because it has reached a point at which it has become an independent or self-sustaining disorder. Under such circumstances you should employ no active purga- tives, but rely upon mild and gentle means. The question then arises, what are our remedies in such cases ? On this point there is great diversity of opinion. I have seen excellent effect from small doses of our neutralizing physic, repeated sufficiently often to keep up a gentle action of the bowels ; but I think I have seen still better results from the use of pure salad oil for the same purpose. This may be given in doses of from one to four teaspoonfuls once in two hours, and may be relied upon as the only aperient necessary. With either of these aperients it will be necessary to administer some soothing adjuvant, for which purpose our diaphoretic powder is a very good article. It determines to the skin, and while it does not irritate the bowels, it tends to restrain the desire for frequent evacuations which so much distresses the patient, and aggravates the disease. It may be given in 10 grain doses, as often as necessary to maintain its anodyne influence. In connection or in alternation with this, an injection may be given two or three times a day, prepared as heretofore directed, or the opium suppository may be used instead. As a change in the character of the injection I have used with advantage, a mild solution of tannin combined with tincture of opium. Or instead of the tannin, an infusion of rasp- berry leaves, or of oak bark may be employed, especially if there is diarrhoea. These means may be repeated as circumstances require. Where there is reason to believe the dysentery is caused by worms, as is frequently the case in children, your course is plain; all you have to do is to remove the worms. Some simple pal- liative means may be used to relieve the urgency of the symp- toms, but the main reliance should be on adequate vermifuge treatment. But the most important form of this disease is that in which it 28 434 ACUTE DYSENTERY. prevails as an epidemic, and especially where associated with malarial influence, as it almost invariably is in this country. Where this is the case, I need scarcely say what my views of treatment are. I have so often insisted on the importance of removing malarial disease in the start, wherever it is found to be present, either as a primary or secondary affection, that you cannot be in doubt as to the course I should pursue under such circumstances. If called to a case of dysentery occurring under malarial influ- ence, I should seek of course to learn all the history and peculiar- ities of the attack as in other cases, and should adapt my pre- scriptions to those peculiarities; but for the arrest of the malarial fever, which is usually the paramount disorder in such cases, I should rely upon nothing but the quinine and iron. If the best time for the administration of these remedies was not present, I should premise their exhibition by such palliative measures as have been recommended in other cases. I would move the bow- els if they were torpid, and stimulate the liver if that gland was inactive, by such aperient or cholagogue medicines as the neu- tralizing physic in the one case$ or the podophyllin and leptandrin in the other. If the stomach were evidently deranged by accumu- lations I would empty it by an emetic as in cases before mentioned. The action of such agents where their use was indicated would, without doubt, render the system more susceptible to the influence of the antiperiodic remedies, but harm produced by a single exacerbation of fever would far overbalance all their beneficial effects. If therefore a remission were present, or the time when one might have been expected had come, whether the febrile symp- toms had subsided or not, I should first of all give efficient doses of quinine and iron. The administration of the antiperiodic medicine is not however incompatible with the application of the sinapism and fomenta- tions, with the use of diaphoretic medicines, such as morphine and ipecacuanha, diaphoretic powder, or sudorific tincture, nor with the employment of mucilaginous injections with laudanum or the opium pill as a suppository. Indeed, these various measures can never be out of place in dysentery in any form, and although merely palliative in cases of the kind under consideration, that is, inca- ACUTE DYSENTERY. 435 pable of affecting a cure so long as the malarial poison is acting upon the nervous system; yet they are so highly corroborant, and tend so much to mitigate the sufferings of the patient, that they should in no case be omitted. This disease prevailed very greatly within the field of my prac- tice last season, and all the cases which fell under my observation were impressed with the periodic feature; some indeed were dis- tinctly intermittent in their character. I treated them in the manner just described; came right in with my antiperiodic medi- cine, unless the patient was in the height of an exacerbation when first seen, and in almost all cases thus treated, I was saved the necessity of giving either an emetic or cathartic. I do not say this will always be the case, but I have generally found the bow- els to resume their proper motions, or at least become more tract- able under mild aperients, after the system was brought under the influence of the antiperiodic remedies. Such, I say, was my course in the epidemic of last year, and while the disease was carrying off persons in every direction, I have the satisfaction of knowing that not a patient to whom I was called died. I do not entertain the least doubt of the correctness of my views of this disease, namely, that the fever is the principal dif- ficulty, and the dysentery a mere epidemic feature of it. You will, indeed, find a concession to this effect, in some of the more recent authorities. Dr. Wood says that " dysentery is a mere attendant on the fever in this case," and that the colitis, in some severe and obstinate cases, ceases " almost immediately when the prop which supports it is removed." Still he does not recommend the use of quinine until " an intermission, or a regular remission, with only so much general action in the interval as may be supposed to be sustained by the local disease" has been obtained, and then only " after a thorough preliminary evacua- tion of the bowels, and the loss of blood, if that be deemed neces sary." The Doctor certainly does not conform his treatment to his own philosophy. No one denies that the cause should be removed. If accumulations are the cause, the bowels should of course be evacuated; if an excess of blood in the system be the cause, a part of it should be lost; (though I would suggest that there are ample openings provided for this purpose by nature,. 436 ACUTE DYSENTERY. rendering the lancet unnecessary,) but if malarial fever be the " prop" why not " knock out that prop," to use a common phrase, by the only appropriate or efficient means, an antiperiodic pre- scription. If it is replied that the quinine is more efficient after a cathartic, I reply, it is equally true that a cathartic will operate much better after the administration of the quinine ; and I see no reason why the radical measure should be delayed at the expense of valuable time, to await the action of a mere adjuvant. On the contrary, having for a dozen years treated this disease upon the very doctrine now beginning to be recognized, I can assure you that what reason and analogy in this case so strongly suggest, is, by experience, demonstrated to be sound philosophy. But, gentlemen, a case will occasionally occur, which will not be so easily managed. There may be some peculiarity in the constitution of the patient which you have not discovered, which renders the disease uncommonly obstinate; or you may have been called after the disease has been allowed to progress too far ; or after it has received such an impulse by improper treatment that ordinary measures prove incompetent to arrest it; or your failure may be owing to some influence for which you may not be able to account. In any such case you will have your skill and judgment put to a severe test. Where the inflammation was very extensive, I have derived much advantage from the application of a few cups along the track of the colon before and behind. In connection with this measure I have given a pill of nitrate of silver £ gr. finely pul- verized and mixed with two grs. pulverized gum arabic moistened with water, and repeated it every three hours ; while the bowels were kept restrained by a pill of opium 4 grs., surrounding a solid piece of nitrate of silver £ gr., introduced into the rectum as far as practicable with the finger. The opium pill should be repeated whenever it comes away, in order to keep the system freely under its influence, and thus subdue more permanently the spasmodic action of the bowels. The nitrate of silver pills should be continued for twenty-four or thirty-six hours and then sus- pended, when they will usually have relieved the capillary conges- tion so commonly present both in the skin and mucous membrane of the bowels, and will be followed by free bilious evacuations. ACUTE DYSENTERY. 437 During the use of these pills, it should be observed, most other medicines should be suspended, as they have a wide range of incompatibles. Little or no salt, even, should be allowed while they are being given, as it would decompose the nitrate of silver. I have seen but one or two cases where the injections or the pill would not, after some perseverance, be retained and restrain the discharges, and in these cases I gave by the mouth a pill of two grs. of opium surrounding one of the pills composed of nitrate of silver and gum arabic. This seemed to have the desired effect, and by repeating the opium sufficiently often to keep the system under its influence, say once in 4 to 6 hours, I was able to relieve the spasmodic action of the bowels. If the dysenteric discharges continue, notwithstanding these pills, with no faecal or bilious matter, a pill should be given com- posed of podophyllin one-fourth of a grain, leptandrin one-half a grain, and extract of taraxacum a sufficient quantity, and repeated once in twelve hours, until the dejections become bilious. I need scarcely say that the diet throughout the treatment must be very simple and light. Attention to this is the more important as there is sometimes an appetite, which if indulged, would soon convert a moderate case into one of great severity. The convalescence must be managed with great prudence. The patient should keep within doors much longer, generally, than he thinks necessary, and when he begins to take exercise he should do so very gradually, being careful not to fatigue himself, nor be exposed to cold or dampness, nor sudden atmospheric changes. He should continue to be restricted to plain, digestible, unstimulating diet; and his bowels should be kept in a soluble condition by the occasional use, if necessary, of a pill of podo- phyllin, leptandrin and extract of taraxacum. LECTURE XXYIII. CHRONIC DYSENTERY, ETC. Symptoms— Constitutional Derangement—Post Mortem— Cause— Treatment—Mild Cases— Ulceration—Diarrhoza— Varying Rem- edies—Prolapsus Ani—Diet. Peritonitis : Inflammation op the Peritoneum — Preliminary Remarks — Varieties — Acute— Symptoms—Puerperal— Tympanitis—Periodicity—Post Mortem — Cause—Diagnosis—Prognosis— Treatment— Chronic Form— General Remarks—Symptoms—Treatment—Clinical Case of low Fever. Chronic Dysentery is not a very rare disease. Either associ- ated with some other affection or in its uncomplicated character, it is perhaps as frequently encountered by the practitioner as any other disorder. It is generally connected with chronic enteritis, as the irritating evacuations incident to disease of the small intes- tines can scarcely fail to propagate such disease downward into the large intestines; and even where the original disease is dysen- tery, the inflammatory condition, when protracted into the chronic form, is very often extended, not only throughout the colon, but to the small intestines also. It is therefore not at all uncommon to have a union of the symptoms of chronic enteritis, with those of chronic dysentery. I shall give you merely a general outline of the symptoms, without dwelling upon them at great length. The skin is always more or less inactive in this affection, being generally very dry, parched and husky, owing to inactivity of the capillary circula- tion. The bowels are usually loose and irritable, unless the lesion is confined to the lower portion, in which case they are generally CHRONIC DYSENTERY. 439 costive. If the small intestines are involved in the chronic inflam- mation there will be a constant tendency to diarrhoea. The dis- charges may not be more frequent, but their character will be very different from that of the purely dysenteric discharges, where the lower bowels only are diseased. The frequency in either case is exceedingly variable, depending, no doubt, on the intensity of the diseased action, the constitutional condition of the patient and his habits in regard to diet, exercise, &c. In some there will be but two or three motions of the bowels in twenty-four hours, in others they will number as many as twenty or thirty and some- times more. In simple chronic dysentery the discharges are generally very small, consist chiefly of mucus, or that and blood, and are attended with tenesmus. When feculent matter is discharged, it has, generally, the consistency of ordinary alvine evacuations, but will either be surrounded by a coat of mucus and perhaps streaked with blood, or else the morbid excretions will be found involved between layers of faecal matter. If the liver is torpid there will be constipation and diarrhoea alternately, with clay colored dejec- tions ; but the liver may become over excited and the discharges assume an acrid bilious character, and unless corrected, increase the disease, or at least its most distressing symptoms—the tenes- mus and tormina. Prolapsus ani is often a result of the spasm of the muscular coat of the rectum, especially in children. There are generally symptoms of constitutional derangement, except in very slight cases, as evinced in the condition of the skin above described, an accelerated pulse, and a slight fur on the tongue. These symptoms, with all others pertaining to the case, will of course be modified by the intensity, extent and com- plications of the morbid condition. The post mortem appearances exhibit the usual indications of chronic inflammation, redness, thickening, and very often ulcer- ation. In cases of some standing, unmistakable cicatrices may sometimes be observed, while other ulcers may be seen in every sta^e of progress. The small intestines and stomach in fatal cases, usually become involved also, though sometimes little or no traces of lesion are found in them. The liver is often found to 440 CHRONIC DYSENTERY. contain abscesses, or to be otherwise affected according to the nature and extent of its implication in the morbid condition. Of the cause of this affection it is scarcely necessary to speak, since it is usually a consequence of the acute form. It some- times, as has been stated, results from chronic enteritis; it is not unfrequently a sequel of typhoid or other low fevers, and it may, to a limited extent, be produced by an extension of hemorrhoidal inflammation. The duration of the disease has, of course, no natural limit, except that of life itself, and mild cases seem to have little influ- ence upon the general health. But where the disease extends to any considerable distance in the bowels, its tendency is con- stantly to undermine the constitutional vigor, until the vital powers finally give way and the patient sinks into a low hectic condition, marked by great emaciation and nervous excitability, and finally yields to his fate. Proper treatment, however, employed before the general health is entirely destroyed, will seldom fail of restor- ing the patient to a healthy condition. In the treatment of chronic dysentery we cannot be guided by a knowledge of the cause as in the acute disease, for, whatever may have been the original difficulty, that may be supposed, in most cases, to have passed away, and the disease under consider- ation is a morbid condition of the parts from which, through local or general debility, the system has been unable to relieve itself. Nevertheless, if there is an existing cause operating to perpetuate the disorder, it should certainly be removed. If the dysentery is confined to the lower part of the bowels, with the usual symptom of costiveness in such cases, your main reliance will be in mild aperients. To fulfill this indication, I know of nothing better than our compound neutralizing physic, which will not only increase the activity of the bowels, but correct any morbid secretions. I usually combine with this medicine a gentle tonic, as the wild cherry bark, which operates as a sedative as well as a tonic. This prescription should be repeated often enough to secure one or two alvine evacuations every day. The same medicine will be highly beneficial also where there is diar- rhoea, for the rhubarb always leaves behind its aperient action an astringent effect, which, with the cinnamon, will do much to CHRONIC DYSENTERY. 441 restrain the bowels when too loose ; but if it should prove insuf- ficient, some efficient astringent may be combined, or alternated with it. You will frequently find patients who, while laboring under chronic dysentery, will attend to daily business, and, during the excitement of the day, experience very little disturbance; but when evening arrives and they become quiet, the dysenteric dis- charges set in and cause more or less trouble and distress during the night. In these cases a dose of our diaphoretic powder, on going to bed at night, will quiet the irritation cf the bowels, and moisten the skin, by determining the circulation to the surface. As a substitute for this, a small mucilaginous injection containing laudanum may be employed, where the irritation is merely local; but, as it has not the diaphoretic influence of the other prescrip- tion, it is not so useful where there is a dry skin and some general excitement. Where the character of the evacuations and the other symp- toms palpably evince ulceration of the mucous membrane, I have given a pill composed of one-eighth of a grain of nitrate of silver enclosed in gum opium. This will usually pass through the stomach and upper bowels before the opium is dissolved, and then the caustic will act directly upon the ulcerated surface. In connection with all other measures in the treatment of chronic dysentery, and under all circumstances, particular atten- tion should be given to the condition of the skin. The direct sympathy existing between the cutaneous and mucous surfaces, heretofore so frequently adverted to, renders this indication highly important in the treatment of chronic dysentery. Bathe the surface night and morning with broke water and spirits. This tends to quiet irritability, and if followed by the diaphoretic powder in the evening, will very generally secure a comfortable night's sleep. It also favors the removal from the system of morbific accumulations, by opening the pores of the skin, and promoting the healthy discharge of its functions. Where there is obstinate diarrhoea in connection with the dysenteric symptoms, it will become necessary, as wras before stated, to employ more astringent remedies in addition to those already mentioned. Here the marsh rosemary will be found of 442 CHRONIC DYSENTERY. great service, though in its absence any of our unirritating astringents may be employed, such as the geranium, blackberry, &c. As a substitute for the diaphoretic powder, I have, under such circumstances, sometimes given equal parts of comp. tine. of catechu and paregoric in moderate doses, with good effect. But where there is constipation, positive astringents should not be employed, for they will tend to increase it without relieving the dysenteric symptoms. Chronic dysentery will not yield at once to any mode of treat- ment, but requires patience and perseverance to effect a cure. You will find it often necessary after having employed certain remedies for a while to substitute others, not only because you desire to satisfy the anxiety of your patient, but because medi- cines when employed for some time actually cease to have their ordinary influence, owing to the system's becoming insensible to their influence, through habit. In addition to the articles already mentioned, I will name the decoction of raspberry leaves, which may be given in doses of a wine-glass full twice a day. It is an excellent astringent, though mild and soothing to the mucous membrane. Where astringents by the mouth, are contrain- dicated by constipation, they may be used in the form of a mild infusion as enemata. A weak decoction of oak bark, for instance, administered in this way, may be of much advantage. Where there is extensive gastro-intestinal irritation, the infusion of staphylea, which I have so frequently recommended for that condition, will prove a valuable tonic, while it seems really to allay irritation. I stated, while speaking of symptoms, that prolapsus ani frequently occurs in chronic dysentery, especially with children. I have frequently met with this occurrence, and as it is one which always gives much distress to the little patient and alarm to the parents, and is withal sometimes difficult.to relieve, it may occasion some trouble and embarrassment to the inexperi- enced practitioner. I will therefore briefly state the method which I have always pursued with success. The phenomenon is merely a turning out, or protrusion of the mucous membrane of the rectum, which is retained in this position by the spasmodic contraction of the sphincter ani muscles. "When it first occurs, it CHRONIC DYSENTERY. 443 exhibits a red tumor of greater or less dimensions, and if allowed to remain long, the color will be changed to a dark purple or livid hue. In some cases the gut is easily returned, and the mother or nurse, if properly informed, will have no difficulty in doing it. But sometimes it presents a case of much difficulty, and I have been called to cases where the efforts of friends and physician had failed. The means I have found always successful are very simple. Oil a piece of soft linen, lay it upon the tumor, and press it with the finger into the intestine. If this be done gently but firmly, the sphincter will relax, and the intestine will pass in with the finger and linen. The finger must not be withdrawn at once, but you should wait until you feel the sphinc- ter contract upon your finger and then carefully withdraw it, and remove the linen. To prevent a recurrence, a compress, consisting of several folds of linen oiled and applied to the anus, may be retained there by means of a T bandage. The bowels should be kept in a soluble condition, while soothing astringent or anodyne injections should be employed to overcome the local irritation and tenesmus. Where the prolapsus depends upon debility and relaxation of the bowels, daily bathing the abdomen and loins with a decoction of oak bark, and letting the patient take a " sitz " bath of the same, will have a tendency to overcome the difficulty. The diet is of great importance in the management of chronic dysentery; and on this subject I refer you to what was said under the head of indigestion. The directions there given are perfectly adapted to the present case. A mild, unstimulating diet, easily digested, and in moderate quantities, should alone be allowed. I omitted to mention a remedy while speaking of diarrhoea, which, I am confident from the trials I have made with it, is of great value in that affection. I have found it equally useful in diarrhoea connected with chronic dysentery, and am anxious to see its virtues thoroughly tested. It is a plant called in botany Rochelia Yirginiana, and is a species of the stick tight or beg- gars' lice. The root is spindle-shaped, but thickly set with small rootlets, it has a peculiar but very bitter taste, and when chewed, is nearly all converted into mucilage in the mouth. I 444 PERITONITIS. have seen cases of diarrhoea depending on relaxation, and others connected with chronic dysentery, relieved at once by the patient chewing and swallowing a piece of this root not an inch long, and the daily use of it appeared to overcome obstinate diar- rhoea. Still I have not sufficiently tested the agent to make it a leading article in my treatment. To enable you to recognize it I will give you a description of the plant. The root as above stated, is spindle-shaped, with many small fibres, and has a darkish color. It is biennial, and is only fit for use the first year, being woody the second. Lower leaves, broad ovate, sub cordate, acuminate, scabrous and dark green above, pilose and lighter colored below. Racemes divaricate, axillary; fruit covered with hooked bristles; upper leaves, lance oblong. The plant does not send up a stem the first year, but forms a spreading tuft of broad, dark green leaves. In Eaton's North American Botany this plant is called an annual, but this is a mistake. PERITONITIS—INFLAMMATION OF THE PERITONEUM. Having occupied as much time on inflammation of the mucous surface of the bowTels as can be allotted to that part of our subject, we will, if you please, pass to the consideration of peritonitis, or inflammation of the serous membrane of the abdominal cavity. This membrane, as you are aware, lines the parietes of the abdo- men and affords a covering, more or less complete, to all the abdominal and pelvic viscera. It is therefore in very intimate relation with the intestinal canal, and with several other organs in this region, into which we have yet to pursue that form of dis- ease which is now occupying our attention. As a primary or independent affection peritonitis is rarely met with, but as resulting from wounds or other local injuries, and as associated with puerperal fever, and with malarial and protracted cases of typhoid fever, this form of phlegmasia may, upon the whole, be regarded as somewhat frequent in occurrence. Peritonitis is susceptible of the usual distinctions—acute and chronic—but the line of demarcation between the two forms is so indistinct, that but little advantage can be anticipated from their separate consideration. Our attention will first be directed to the acute form, after which a few words will suffice for all I have ACUTE PERITONITIS. 445 to say in regard to the other. Some authors have made other divisions in treating of peritonitis, having reference to the precise locality of the inflammation. In this way Cullen made three spe- cies, namely, peritonitis propria, peritonitis omentalis and peri- tonitis mesenterica. Others distinguish several varieties, depend- ing upon the location of the disease or the particular viscus whose serous covering is the seat of inflammation. But such distinctions are of no practical importance and I shall not observe them. I shall, however, have occasion to describe several modifications or varieties of the disease as produced by different causes or occurring under peculiar circumstances. The symptoms of peritonitis proper do not, however, materially vary, except perhaps in severity, whatever may be the origin of the inflammation or its complica- tions, though they may of course be associated with and modified by the symptoms of attendant affections. ACUTE PERITONITIS. This disease is most frequently encountered in practice, in that variety denominated puerperal pentonitis. The condition of all the organs at the termination of the period of gestation, and the debility resulting from the relaxation of the tissues, and the col- lapse of the parts, which must follow parturition, seem strongly to predispose them to inflammatory action; and the serous covering of the body of the womb cannot but partake of the common tendency. Here we have, I conceive, a striking illustration of the principles which I have attempted to impress on your minds, as involved in the phenomena of inflammation. We have here a combination in many cases, of the two proximate causes of inflammation;—a relaxation of the vessels and an impoverished state of the blood. The general symptoms of peritonitis will now be briefly stated. It generally comes on suddenly without much premonition. The first symptom is often a very severe, sharp pain in the abdo- men, usually in the hypogastric region. Or a slight chill may precede the pain. When the patient is in childbed some slight indiscretion may suffice to bring on an attack. She may, for instance, after lying for a while under too much covering, become uncomfortably warm, when a sudden removal of the bed clothes exposes her to the cool atmosphere; a slight chill is the conse- 446 ACUTE PERITONITIS. quence, and this is either accompanied or soon succeeded by the pain, evincing peritoneal inflammation. This is not always the result of exposure under such circumstances, but where there is a predisposition to the disease such exposure may be sufficient to develop it. There is a form of puerperal peritonitis supposed by most authors to be highly contagious ; and it becomes a matter of great consequence to know whether it is really so or not, as connected with the lives of patients and the reputation of the practitioner. If it could be clearly shown that the disease is contagious, and liable to be conveyed from patient to patient by the medical attendant, a plain course of duty would be presented to him as a conscientious man, namely, to avoid for a time all obstetrical practice, after having attended a case of this description. I have very great doubt, however, as to the contagiousness of the disease. I have never seen anything sufficiently conclusive to convince me that there is any contagion connected with it. Where the case commences with a chill, this is immediately succeeded by decided febrile reaction, attended by the symptoms of local inflammatory disease. The skin gradually becomes hot, and the pulse frequent, small, hard and wiry. The frequency of the pulse is peculiarly diagnostic, for in ordinary inflammatory dis- eases the pulsations seldom exceed 100 per minute, while in peri- tonitis they range from 110 to 150. The urinary secretion is diminished in quantity and of a^ higher color. The tongue is covered with a slight coat of a white or yellowish hue. There is always tenderness of the abdomen, which may, however, be more manifest in some particular place, corresponding with the locality of the inflammation. If the disease is located on the stomach, the tenderness will be most distinct in the epigastrium, if on the liver, in the right hypochondrium, and so of other organs. But wher- ever the inflammatory action may be first developed, there is a tendency to its diffusion throughout the whole extent of the mem- brane. The whole abdomen thus becomes exceedingly tender to the touch, and even the slightest motion is the cause of pain, so that patients are usually inclined to lie perfectly still, and generally on the back, with the lower limbs drawn up, to pre- vent tension of the abdominal muscles. The effort of coughing, ACUTE PERITONITIS. 447 sneezing, vomiting or defecation, in short, any action requiring contraction of the abdominal muscles, occasions suffering. To avoid pain, patients will frequently postpone as long as possible the evacuation of both the bowels and bladder. Even the motions necessary to natural respiration are sometimes the cause of so much pain that the patient breathes with the thoracic muscles alone, even suspending as far as possible the contraction of the diaphragm. I have never recognized the hurried breathing de- scribed by some writers, but the inspirations are short, and the respiration has a kind of panting character. Sometimes a slight sound will mark every expiration. This is often the case also, with children, where there is inflammation of the bowels, and the difficulty of breathing is sometimes referred to disease of the lungs; but it is very easy to distinguish between this panting, grunting respiration and the hurried breathing characteristic of pulmonary inflammation. The abdomen is usually tumid or swollen at an early period of the disease, and sometimes decidedly tympanitic, though tym- panitis proper is more commonly a symptom of the advanced stage. The tension of the abdominal parietes which attends the com- mencement of peritonitis, may usually be somewhat relieved by an evacuation of the bowels, but the tumefaction and tympanitis which subsequently exist, will persist, notwithstanding there may be constant diarrhoea. There are, however, occasional cases where a distended condition of the abdomen is not present; the abdominal muscles being contracted down so as to give the abdo- men a flat or even concave appearance. When the inflammatory action has its principal seat in any particular locality, the fact may generally be ascertained and the extent of active disease determined by the pain felt under pressure with the hand; especially if the patient is of a spare habit. If the epiploon is the special seat, the tenderness will extend, it is true, over the fore part of the abdomen to some extent; but it may be known by the fullness in the middle of the abdomen, and, when there is effusion into the folds of the omentum, by the inequalities resulting from the filling of circumscribed sacs, which will be felt as distinct tumors of various sizes on the surface. When the disease results from an impacted condition of the colon, 448 ACUTE PERITONITIS. as it sometimes does, a circumscribed tumor may be felt in the location of the difficulty. This is probably most commonly the case at the head of the colon, in which case the pain and swell- ing both will commence in the right iliac region, and be most manifest there, perhaps, throughout the course of the disease. But it may originate from this cause, at any point in the course of » the large intestines. I remember a case, in which there was a generally diffused inflammation of the peritoneum; but from the history of the case, as well as present symptoms, I concluded the disease originated and still had its principal seat in or about the left hypochondrium, and judging that it resulted from obstruc- tion in the colon, I evacuated the bowels thoroughly. The result was an immediate subsidence of the local symptoms, and the speedy disappearance of those of a general character. Nausea and vomiting are generally regarded as denoting the involvement of the gastric portion of the peritoneum, either by its originating there or having reached that part by extension. Where there is con- gestion of the liver, however, these symptoms may occur from that cause, even though the serous surface of the stomach is unaffected. It will therefore be necessary to ascertain whether there are diagnostic symptoms of hepatic engorgement, not only with a view to the determination of this point, but also to the indications of general treatment. If the vomiting or nausea depend on biliary derangement there will be a loaded tongue, but when they depend on gastric irritation, the tongue will be red and irritated as here- tofore described ; but where there is no disturbance of the stomach the tongue will present a thin white coat and be in a moist con- dition. Irritation of the stomach is often a troublesome attendant of peritonitis. It interferes with the operation of the medicines necessary in treatment, and I always look upon it as one of the most unfavorable circumstances likely to be connected with peri- toneal inflammation. Constipation is a uniform symptom of peritonitis in the earlier part of its course, whether it is the parietal, the visceral or epi- ploic portion of the peritoneum that is specially involved. But in protracted cases the mucous surface of the bowels becomes involved, by sympathy, and then diarrhoea generally appears. This, too, may be regarded as a very formidable symptom. ACUTE PERITONITIS. 449 Periodicity is a symptom which often attaches itself to this disease. I have found a large majority of the cases of peritonitis, to which I have been called, to be more or less modified by mala- rial influence. In calling attention to this fact, in relation to this disease as well as to others, my object has been, and still is, to impress your minds with facts gleaned from long experience. While speaking of the general principles in relation to malaria, and its effects on the human constitution, I announced its great tendency to impress its influence upon nearly every disease to which man is liable, and in adverting to this point in relation to individual diseases, I am merely reiterating and illustrating that tendency. Should the frequent reference which I make to this interesting fact, lead any to charge me with riding it as a " hobby," be it so; I shall nevertheless endeavor to perform what I conceive to be my duty. The symptoms of the malarial com- plication you will not be at a loss to recognize, and its treatment will not differ from that required for remittent or intermittent fever. The post mortem phenomena are such as might with reason be expected. Effusion is often found either generally diffused through the sac, in the folds of the epiploon, and in the folds of the mesentery, or connected with the convolutions of the small intestines. Adhesions between portions of the peritoneum are often found, and sometimes sacs or small isolated pouches of serous membrane are formed in this way, which, being filled with the liquid effused, explain the nature of tumors that have been observed during life. The effusion is sometimes yellowish and watery in appearance; and sometimes curdled and milky. Where the disease has been very rapid, so that death has occur- red at an early period, a considerable degree of redness will designate the parts immediately involved, and this will constitute the only pathological change observable; but where the case has been protracted, collections of coagulable lymph, sometimes form- ing partially organized membranous tissue, are found between opposite surfaces of portions of the peritoneum. This substance has, indeed, been found, sometimes, actually to contain nerves and blood vessels in its structure. This produces adhesions of greater or less extent, and forms, occasionally, the distinct sacs spoken 29 450 ACUTE PERITONITIS. of a few moments ago. Where the disease has resulted from perforation of a viscus, the fact will be indicated by the character of the contents of the peritoneal cavities. In that case also gas of a more or less foetid character will escape when the first incision is made through the abdominal wall. In regard to the cause of this disease, I need only recapitulate what has been said already. The most common cause is exposure to sudden changes of temperature, especially where there exists a predisposition, from constitutional peculiarity or debility and an impoverished state of the blood, or from injury to the membrane resulting from parturition, &c. Malarial fever also may develop this form of local disease where there exists a predisposition to it. It sometimes arises from disease within the intestinal tube, as when inflammation of the mucous membrane of the stomach or bowels extends to the other coats; when an ulcer perforates the intestinal wall; or when there is obstinate obstruction in the bowels from hard- ened faeces, from strangulation or from intussusception. Inflam- mation of the body of the uterus is sometimes extended to its serous covering; so also of the ovaries; of the mucous and mus- cular coats of the bladder; of the substance of the liver, or spleen, &c. Peritonitis is sometimes the result of local injuries, such as wounds and bruises; and of surgical operations for strangulated hernia, tapping for ascites, &c. The diagnosis in this disease is not generally attended with much difficulty, unless by reason of complications. The only diseases with which it is likely to be confounded are colic, gas- tritis and enteritis. From colic it may usually be distinguished by the absence of the peculiar paroxysmal pains of colic; by the low grade of continuous pain experienced in peritonitis ; by the greater frequency of the pulse in this disease than in colic; by the extreme tenderness of the abdomen in peritonitis ; by the peculiar distressed and anxious expression of the countenance, and by the indisposition to move, where there is peritoneal inflam- mation ; while in colic there is constant restlessness and changing of position. It may be distinguished from inflammation of the mucous surface of the alimentary canal, by the tendency to constipation; by the absence of mucus, serum, and blood in the discharges; by the sharper pain, the greater tenderness ACUTE PERITONITIS. 451 under pressure, the fullness and tension of the bowels; and by the low grade of the constitutional symptoms, as observed in the frequent, feeble pulse and nervous depression. From rheumatic and neuralgic affections, the above diagnostic symptoms will be all-sufficient to enable any intelligent physician to distinguish this disease. The prognosis is not generally unfavorable under judicious management. Although the disease is generally rapid in its course, and when very severe tends to a speedy fatal termination, it is, nevertheless, as amenable to prompt and appropriate remedies, as any other form of inflammation, and hence it does not often prove fatal in the hands of a skillful physician. When there is a ten- dency to a fatal result, the pain mostly subsides, the pulse becomes more rapid and feeble, and the skin cool; slight delirium occurs which results in a comatose condition; hickup perhaps ensues, which is a most formidable symptom, and is soon followed by death. Where the tendency is favorable, an opposite train of phenomena will of course be developed. The pulse becomes less frequent and fuller ; the skin acquires more natural warmth, a free and healthy perspiration appears on the whole surface, the flow of urine increases, and deposits a sediment common to the declining stage of inflammatory diseases. This is a highly favor- able prognostic symptom. The deposit will usually be either phosphate of lime or uric acid. In speaking of the treatment of peritonitis, I shall not dwell on the course recommended in the authorities. Among them there is perhaps as much concurrence in the treatment of this as of any other disease. Bleeding appears to be looked to as the only hopeful measure, and from the unanimity with which it is recommended, I should be inclined to regard it with more consideration than I do, were it not for two or three facts. The first fact is this, that under the blood-letting treatment the disease has always been attended with a melancholy fatality; a second fact is that under a different course, such as I shall soon present, the disease is seldom fatal, and a third fact is the notorious change that is taking place in the practice of even the old school physicians in regard to this mode of treatment. I might here also refer to the general principles, established in regard to the 452 ACUTE PERITONITIS. loss of blood, as favoring rather than relieving inflammatory action; and remark that however plausible the opinions of the advocates of blood-letting may be rendered by the mode of their presentation, and however respectable the names of those advo- cates may be, we should certainly suspect some gross error, when we find a demonstrated fact in natural philosophy standing in stern opposition to human opinions. I feel confident that when you shall have thoroughly examined this subject, you will find that peritoneal inflammation does not furnish an exception to the general rule to which I refer. The cause of the disease is, of course, a subject of much impor- tance in this as in other forms of inflammation. Where there are accumulations in the stomach or bowels or both, they may be the cause, and their removal may promptly relieve the case ; but if these are not the cause they should be removed, as they will tend to aggravate the symptoms and prevent a cure. A prompt emetic, if indicated by the condition of the stomach, will be of much use, besides the local relief afforded by it, in equalizing the circulation, and arousing the secretions. And here the infusion of lobelia and boneset will prove to be admirably adapted to the indi- cations. For the evacuation of the bowels you will need a thorough cathartic. For this purpose I am in the habit of employing our anti- bilious physic, to which I add a small quantity of podophyllin. Where there is an impacted condition of the colon, the action of the cathartic may be very advantageously promoted by a laxative enema. The action of a cathartic under such circumstances is highly beneficial, as it not only unloads the bowels and removes the cause where the disease has this origin, but by its stimulating effect on the mucous surface, it acts as a revulsive measure, relieving at once, in many cases, the inflammation of the serous membrane. The medicine I have recommended for this purpose will also act upon the liver, and relieve or prevent hepatic torpor and consequent portal congestion. The measures I have recommended are manifestly, as you will perceive, adapted to all cases where there are accumulations in the alimentary canal. If the disease results from cold, a free and copious perspira- tion should be induced. If indicated, the measures just advised will tend to promote this object, while other means may be ACUTE PERITONITIS. 453 employed at the same time. But where it is not deemed best to give an emetic or cathartic, the object may frequently be effected by simple diaphoretic teas. If however these are not sufficient, the sudorific tincture, or the diaphoretic powder may be admin- istered. If the disease does not yield under such treatment, hot fomen- tations should be applied to the abdomen. A hop poultice, or a bag of hops wrung out of hot water will answer an excellent purpose. But should the case still prove obstinate, although at first it may not have been thought necessary to employ a cathar- tic, it will now be necessary to resort to that measure, for if not as an evacuant, it is required as a revulsive and depletive agent. The cathartic medicine above recommended will prove all-suffi- cient, and will be more efficient, as a means of depletion in remov- ing from the blood those matters and elements which interfere with healthy secretion and free capillary circulation, than blood- letting, even though carried to the utmost limit of heroic practice. In addition, however, to these measures, others may be employed, if necessary. Cups may be applied on that part of the abdomen where the most pain and tenderness is felt. They may be used dry, or if local depletion is deemed desirable, the scarificator may be employed. You cannot in this way abstract enough blood to injure the quality of the circulating mass, yet you may exert a prompt and efficient derivative influence upon the disease. Upon the removal of the cups the surface should be immediately cov- ered with the hot fomentation or with a bread and milk cata- plasm. This last mentioned article, applied to the whole abdom- inal surface, is of very great advantage, as it keeps up a constant moisture and relaxes the abdominal muscles; and in this way affords as much comfort to the patient as any thing that can be done. If the inflammation still persists, it will be necessary to repeat your cathartic treatment the second, and perhaps the third day ; though the agent employed may be more mild after the bowels have been thoroughly evacuated. I have found a combination of castor oil and spirits of turpentine a good remedy. This combi- nation stimulates the vessels involved to increased action, and produces sufficiently copious evacuations. If the symptoms 454 ACUTE PERITONITIS. demand it, the emetic may also be repeated; but by all means there should be kept up a constant perspiration. This will tend to reduce the inflammatory action, and with it you will find the pulse gradually to decline in frequency. Where the disease is distinctly marked with periodicity, I hesi- tate not in the least to say, that sulphate of quinia and prussiate of iron should be given, as soon as that fact is ascertained. The only rules to govern the treatment of the case, in reference to this feature, are those so fully stated while treating of malarial fever. Let the malarial fever be arrested as the first and most important indication. If you fail to prevent an exacerbation by your first prescription, it may be well to administer a cathartic, and then in the next remission continue the antiperiodic medicine ; and in this way alternate your treatment until the paroxysms are arrested. I here again repeat, that you need have no apprehension of injury to your patient from the antiperiodic remedies, though there may be a very high grade of inflammation; but very often the inflam- mation will seem to be quenched by the medicines, like fire over- whelmed with water. A perspiration, in such cases, follows the administration of the medicines, and neither malarial nor perito- neal fever reappears. This, however, will only be the case where the inflammation is dependent upon the malarial fever. Where the fever is merely secondary to the inflammation in the begin- ning, or where the inflammation has progressed so far as to become a self-sustaining morbid action, the symptoms will not so easily subside. Still, they will be decidedly mitigated by an arrest of the periodic fever, and a cure very much promoted. An obstacle has been removed which must have utterly subverted all remedial measures so long as it remained. Y'ou will now be prepared to proceed with such further treatment as the case may demand, on the general principles already laid down. I will add that some of our practitioners, and the late Professor Morrow among the rest, have spoken in high praise of the spirit sweat in this disease, and I see no reason to doubt its efficiency. I have not found occasion for its use in this affection and cannot therefore speak from experience. I have however employed it with excellent effect in other cases, where indications similar to those presented here were to be fulfilled. CHRONIC PERITONITIS. 455 Should the case run on until the strength of the patient is very much reduced, it will become necessary to sustain him with tonics and perhaps stimulants. Carbonate of ammonia, staphylea tea, wine whey, and other agents of these classes may be employed, in connection with rubefacients and other revulsive measures externally applied. An irritating plaster applied over the entire abdomen will be of great benefit where the case is thus tedious. It is scarcely necessary to say that the diet during the whole course of acute peritonitis must be light. It should be taken only in the liquid form, and be such as to furnish little or no excre- mentitious matter. After the inflammation is subdued, the diet may be gradually increased in quantity, and in its stimulating qualities. Convalescence must be managed with great care ; all exposure must be avoided, and everything which, by impairing the equilibrium of the circulation, would tend to reproduce the inflammation, must be guarded against. CHRONIC PERITONITIS. The attack of peritonitis is sometimes so insidious as scarcely to deserve the title of an acute disease. Still, the nature of the morbid action only differs in rapidity or intensity from the ordi- nary acute form, and the symptoms so far as observable are the same. Even the anatomical characters, where death follows such an obscure case, are entirely similar to those observed where a protracted case of acute peritonitis finally proves fatal. Occa- sionally, it is true, a tuberculous condition of the peritoneum is discovered, but there are no symptoms during life, pointing with certainty to such a condition. Where there is a scrofulous dia- thesis, a hereditary tendency to tuberculous disease, and where a low grade of peritoneal inflammation is accompanied by glandu- lar swellings, and especially if there are tubercles in the lungs, it will be reasonable to suspect that the state of the system is the source of the local disease in question. Generally, however, chronic peritonitis is merely a continuation of the acute form, which, having partially worn itself out, or hav- ing been modified by treatment, is reduced to a low grade of morbid action, having no definite tendency to terminate either in health or dissolution. In this state, the affection may continue for 456 CHRONIC PERITONITIS. an indefinite period, presenting all the time, more or less clearly, the ordinary symptoms of peritonitis. There will be tenderness and even sharp pain on pressure, in the abdomen generally, or confined principally to a particular locality. There will be diarrhoea, alternated perhaps with constipation, according to the condition of the liver and mucous surface of the alimentary tube. There will sometimes be tumefaction of the abdomen generally or circumscribed swellings, as described in thelatter stages of the acute form, resulting from effusion, which may be so extensive as to constitute ascites. If the disease is not relieved by appropri- ate treatment, the functions of the abdominal viscera will finally become essentially deranged, the general health undermined, and death will be the inevitable result. Post mortem exploration will then develop the same phenomena as those mentioned in connection with the acute form. Adhesions will, perhaps, be more extensive, and the amoun^ of liquor effused will be greater, though occasionally the adhesions will be found to have almost consolidated the abdominal contents, leaving little or no cavity to be occupied by serum. The treatment will not differ materially from that recommended in a protracted case of acute peritonitis. You will find it neces- sary to persevere with such measures as tend to sustain the ener- gies of the system, to maintain as nearly as practicable a due activity of the skin, and other organs, and a constant equilibrium in the circulation, and to divert irritation from the peritoneum. Hence, gentle aperients, diaphoretics, and tonics internally, with nourishing food given in the liquid form and perfectly digestible, and counter-irritation over the seat of the disease, daily bathing with alkaline or salt water, and stimulating pediluvia, with rest and patient perseverance, constitute the resources upon which you must rely in cases of this kind. As a means of radical treatment, under such circumstances, I believe that more may be effected by the use of Beach's compound irritating plaster over the entire region affected, than by any other measure which may be employed. It should be so applied as to produce and keep up a constant purulent discharge from the whole surface of the abdomen, if the disease be extensive. This measure has the advantage of all other counter-irritating applications in use, in that, while its CHRONIC PERITONITIS. 457 impression is so gradual that it is not incompatible with a state of debility, and though it never occasions deep ulcers, it nevertheless produces a decided local impression, and by the copious discharge of pus which it sustains, acts as an alterant upon the general system. I Will close my remarks this morning with a brief clinical statement of a case which, although not one of peritonitis, serves to illustrate a principle which, in practice, often connects itself with this and other forms of inflammatory disease. The patient is one of your fellow students. He had been sick four days and had taken several prescriptions of his own and his room-mates', such as cathartics, sudorifics, &c, but found no benefit. The attack was one of a febrile character, and had come on very slowly. When I saw him first, yesterday morning, his pulse was very frequent and resisting, the skin a little moist, but the capil- lary circulation quite imperfect, the tongue red, dry and glossy, having very little fur upon it. There was looseness of the bowels amounting to diarrhoea, but the discharges, though yellow, did not indicate an undue excitement of the liver. The symptoms raised a suspicion of typhoid fever. There were even appearances of sudamina on his neck, but the patient assured me that these were commonly there in health. But with all these symptoms, there was another, which although very obscure, I did not fail to ascertain. This was a very slight increase of the febrile symptoms every afternoon, a restless night and more quietude towards morn- ing. My diagnosis was at once made up. We had a case of malarial fever presenting a typhoid tendency, and which if left to itself would soon develop symptoms of a very grave character. I directed quinine and iron da to be administered in six grain doses every two hours during the forenoon, and four or five simi- lar powders to be given in the same manner the next morning. He took three of the powders before the fever appeared to rise. I saw him in the evening, and observed a manifest change in his countenance, and the general tone of his system. The fever had assumed a very different type, the pulse was full and bounding, and the energies of the system seemed now fully roused for the first time since the attack. 458 CHRONIC PERITONITIS. I called upon him this morning, and found him up, dressed, and preparing to come to college. This was of course forbidden, for I deemed it necessary that he should guard against a parox- ysm to-day ; but to-morrow morning, gentlemen, he will be with you. LECTURE XXIX. DISEASES OF THE RECTUM. Stricture of the Rectum. Preliminary Remarks—Two Forms— Spasmodic Stricture—Symptoms and Causes—Treatment—Organ- ic Stricture—Two Varieties — Non-Malignant—Symptoms and Causes— Treatment— Cancerous Formation — Symptoms— Treat- ment—Radical—Palliative. Hemorrhoids or Piles. Frequen- cy and Importance—Definition— Varieties— Constitutional Con- dition—Local Development—Primitive Type—Positions of Tu- mors— Bleeding Piles— Wart-like Excrescences — Diagnosis — Causes—Treatment— Constitutional—Local—Removal by Liga- tures—Precautionary Measures. STRICTURE OF THE RECTUM. I shall now spend a short time in speaking of Stricture of the Rectum, a difficulty in some degree allied to the subject of chronic dysentery, not only in affecting the lower portion of the alimen- tary canal, but also in following or resulting from chronic inflam- mation of the rectum. This affection often calls for the exercise of as much tact and as prompt exhibition of professional skill as almost any other dis- ease. Though the case may not present very alarming symptoms, as looking toward a fatal termination, yet the extreme sufferings of the patient call none the less loudly for your prompt and judi- cious interposition, to afford relief. There are two forms in which obstruction in the rectum is found to exist. One of which may be styled Spasmodic Stricture as resulting from a spasmodic contraction of one or both of the sphincter muscles, or of some portion of the circular fibres of the 460 STRICTURE OF THE RECTUM. muscular coat of the rectum ; the organic or structural stricture being dependent on a morbid change in the structure or a carcin- omitous growth at some point in the wall of this portion of the bowels. Spasmodic stricture of the rectum is rarely an original disease, but generally results from irritation connected with hemorrhoids or following dysentery. It may, however, be produced by hard- ened faeces, long retained in the rectum; and occasionally it is dependent on irritation of the roots of the spinal nerves, which irritation is reflected to the part where the spasmodic contraction exists, generally the sphincter ani muscles. In either case, when the constriction is very great, the suffer- ing of the patient often becomes exceedingly severe. This is especially the case during the efforts at defecation, but the pain does not always cease with such efforts, not even when successful. I have seen cases, particularly those where irritable hemorrhoidal tumors existed, in which the pain was so extremely distressing as to extort a groan at nearly every breath, for hours together, from the stoutest hearted patient. In such cases, considerable consti- tutional disturbance will be likely to grow out of it. The skin becomes hot, the pulse excited, and the tongue coated, while the bowels will generally be quite costive. In mild cases there is apt to be a constant desire to go to stool; but very severe cases lack this symptom; the patient often expresses an inability to void any faeces, but feels a constant spasm accompanied with a sensation of " pulling" in an upward direction, as I have heard them express it. The spasm is so severe and the stricture so complete, often, as to preclude the possibility for the time of introducing the smallest tube of an injecting instrument. A sensation of tremor, alter- nately with more violent constriction, will be complained of, and often the patient finds relief only by a constant slight pressure with a very soft substance, applied immediately to the lower extremity of the rectum. Treatment. The indications are—first, to relieve the spasm and thus palliate the severe sufferings of the patient; and secondly, remove the cause of the difficulty. I have found an ointment prepared from the wild indigo (Baptisia tinctoria) as a STRICTURE OF THE RECTUM. 461 base, with the addition of the extract of belladonna sufficient to relax the muscular contraction. This will be greatly aided by a warm poultice of roasted onions applied directly to the rectum, and changed every hour or two. The ointment should be freely applied around the anus and within the rectum, as soon as the sphincter is sufficiently relaxed to admit it. I have also seen very great relief from a warm injection of starch with a tea-spoonful of tincture of opium, where the' rectum was not so completely closed as to prevent the introduction of the pipe of a syringe. The bowels, meanwhile, should be kept in a moderately soluble state by mild aperients, with a view to pro- duce the necessary daily evacuations and at the same time render their discharge as easy as possible, by making them soft. As good an agent to accomplish this object as you can employ, perhaps, is the compound taraxacum pill, so frequently recom- mended in other diseases; and this is particularly indicated where there is any evidence of hepatic torpor, which is seldom absent if the stricture is associated with hemorrhoidal affections. Where there is evidence of an acid condition of the alimentary canal, or of the system generally, the prescription best calculated to correct such condition and at the same time produce an aperient effect on the bowels, is in my estimation, our neutralizing physic which operates without producing sickness of the stomach, or griping or distress in the bowels. If spinal irritation is the cause of the difficulty, or is associated with it, a tender point may be found by .pressure along the spine, and cups should be applied at that point and followed by the irri- tating or compound tar plaster. Where there is inflammatory action in the lower portion of the bowels, as evinced by local or general symptoms, and whether such inflammation is the exciting cause or a consequence of the stricture—for it may be either— measures should be employed to reduce it. Cups should be applied as near the rectum as they can be placed—either on the sacrum,'or—if the patient is a male—in the perineum, and repeated the next day, if the circumstances of the case seem to demand it. In addition to this, the patient may be directed to take a warm sitz bath once or twice a day. This measure is equally applicable under all circumstances of the disease, and will be found a valu able means of relieving the spasm. 462 STRICTURE OF THE RECTUM. Whatever, then, may have caused the spasmodic stricture, th e general principles of treatment are clear. After the urgent symptoms have been relieved, and when the patient is in a con- dition to bear the remedies required for the removal of the pri- mary difficulty upon which it depends, such measures must be instituted as the nature of the case may indicate. If hemorrhoidal affections have been the source of the difficulty, the remedies which will be recommended for such affections should be used. If the stricture has been produced by dysentery, either in the acute or chronic form, then those measures which I have here- tofore fully presented for that disease will be required. In short, your prescriptions will of course be made in accordance with the condition of the system which it is found necessary to correct. Organic stricture of the rectum. This is a much more for- midable difficulty, and is attended with less promise of cure, if indeed it can be successfully treated at all. This form of disease, presenting a permanent physical obstruc- tion to the passage of the contents of the bowels, must almost of necessity be more gradual in its development and more insidious in its approach. Though the patient may be conscious of more or less uneasiness in the rectum, he will not be likely to recognize the true state of the case until the disease has made considerable progress and more or less obstruction to the passage of the faeces has been produced. A uniform attendant upon this obstruction is inactivity of the bowels, and, consequently, a hardened and costive condition of the dejections is almost sure to exist, which renders defecation more painful and difficult than it would otherwise be. The stricture in this form may, as before intimated, consist in one of two strictural modifications of the wall of the rectum; that is, in a simple non-malignant increase in thickness, or in a malig- nant or cancerous growth ; the one generally amenable to appro- priate treatment; the other, especially if located entirely within the bowel, generally unmedicable and consequently fatal. The non-malignant organic stricture may result from chronic dysentery, in which extensive induration has supervened from the inflammation, or it may be produced, partially, by cicatrization following ulceration—a process very often, if not always, attend- ant on chronic inflammation of the rectum. But probably the STRICTURE OF THE RECTUM. 463 most common cause of this difficulty is the induration which so often follows extensive hemorrhoidal swellings, and which is, no doubt, produced by the obliteration of hemorrhoidal veins under the influence of inflammatory action always attendant on severe attacks of pil.es. The obstruction may, in fact, often be traced directly to such attacks, being generally developed after the sub- sidence of hemorrhoidal inflammation. Diagnosis. This variety of organic stricture will readily be distinguished from the cancerous formation, by the absence of nearly all those symptoms of uneasiness, pain and distress which are always present in the carcinomatous growth, as well as by the difference in physical character which the two affections present; the non-malignant growth being smooth, and elastic, though per- haps lobulated; while the cancerous tumor is rough, unyielding and irregular. If the difficulty results from induration of hemorrhoidal tumors, the swelling will usually occupy one side of the passage, though it may extend nearly or quite around it. It is often located so near the orifice as to be partly external, and as it may result from more than one original tumor, each of these may remain distinct, and the whole present a smooth, somewhat elastic, though moderately hard mass, more or less completely filling up the passage. Owing to the mode of its development, the swelling will have a knobby or lobulated surface, and in some instances one or more of the promi- nences may assume a pendulous character, being attached to the main tumor by a somewhat constricted neck. If the affection is an induration following dysenteric inflamma- tion, there will be httle or no external swelling, but the history of the case and the existing impediment to the alvine evacuations will enable you readily to determine the nature of the difficulty. The stricture may, in this case also, be confined to one side of the rectal tube or it may occupy the whole circle; it may be confined to the lower portion; it may be located as high even as the sigmoid flexure of the colon, or it may occupy a considerable portion of the length of the rectum. The obstruction may be a mere thick- ening and induration of the sub-mucous and cellular membrane, or it may consist of an indurated non-malignant growth and pre- sent an undefined tumor, occupying more or less perfectly the 464 STRICTURE OF THE RECTUM. cavity of the bowels. Cases have been reported where the pas- sage was thus entirely obstructed, and the faeces, accumulating above the tumor and producing ulcerative inflammation, had ane^ channel excavated for them by that process. Such instances, however, are very rare, and even where such a result takes place, it offers but little encouragement to the hopes of the sufferer, for the constitutional disturbance necessarily attendant on such a con- dition, sooner or later undermines the health and the patient sinks. The difficulty may be dependent on the presence of one or more polypi. The polypus is a soft tumor attached by a neck to the wall of the rectum, but the growth may be so extensive as to cause obstruction. Polypi may generally be removed from the rectum by means of ligatures. Treatment. The patient should be admonished in the begin- ning that a considerable stock of patience will be necessary to sustain him through a course of treatment sufficiently protracted to remove obstructions of the kind we have been describing. I do not, of course, include polypi in this remark. Except for the purpose of correcting any general derangement of the system which may attend the case, little can be effected by medicine administered internally. It will of course be important to keep the bowels in a soluble condition, and when this cannot be accom- plished by regulation of the diet, recourse will be necessary to aperients; and in that case, the articles mentioned under the head of spasmodic stricture will be all-sufficient. Should there be evidence, however, that the local difficulty is connected with a contaminated state of the system, such as the scrofulous habit or the venereal taint, it will be important to administer a suitable alterative and continue it during a consider- able period of time. The alterative syrup or the compound syrup of stillingia may be employed in combination with such other agents as the particular condition of the system may indicate, such as iodide of potassa, or one of the preparations of iron. The main reliance in the treatment of uncomplicated, non- malignant, organic stricture, will be upon the use of a bougie introduced into the rectum, daily or oftener, and allowed to remain an hour or two each time ; gradually increasing the size STRICTURE OP THE RECTUM. 465 of the bougie as the dilatation of the passage will permit. This should be accompanied by an application of a small cup with scarification to the coccyx, which should be repeated a number of times, especially if the induration can be discovered upon an external examination. This should be followed by the application of a small caustic issue either in front of or behind the anus, and kept discharging for a long time. As has been intimated, where the obstruction is produced by a polypus, or by more than one, a ligature may be passed around the base or neck of each and drawn so tightly as to interrupt the circulation, and thus effect its removal. This may be readily accomplished with the aid of an anal speculum and such other instrument as the character of the case will suggest. The cancerous formations in the rectum will be recognized by shooting, lancinating pains, which extend up into the bowels and down the thighs, and sometimes to the neck of the bladder. The tumor when examined by the finger presents usually an uneven knotty surface, and a degree of hardness much greater than any of the formations of which I have been speaking. If it has advanced to a state of ulceration, there is an acrid discharge having a very offensive odor, peculiarly characteristic of cancerous diseases. In this condition the obstruction presents irregular, hardened, and inverted edges, and is more or less covered with fungus growths of a softer and more yielding structure. These cases come on very slowly and are usually accompanied with appearances of general ill-health,—such as a pale and sallow complexion, some emaciation, and often an edematous condition of the extremities, with a cool and clammy state of the skin. In some cases the affection is confined to a small portion of the rectum immediately within the verge of the anus; in others, it is located farther up the bowTel, and sometimes occupies a consider- able area. In other instances still, the cancerous tumor is exterior to the sphincter, but extends up by the side of the bowel in the cellular structure. I have myself treated cases of this kind. In the early stage of this variety of stricture, constipation usually exists, but after it has become an open cancerous affection, a re- laxed condition of the bowels usually comes on, and as the disease 30 466 STRICTURE OF THE RECTUM. progresses, proves an inconvenient and sometimes very trouble- some symptom. The treatment of cancerous stricture of the rectum, in cases of any considerable extent, and especially where the morbid struc- ture extends far up the bowel, will seldom accomplish more than simple palliation. But where the tumor is situated external to the sphincter muscles, and does not extend far up by the side of the rectum, and does not involve the coats of that tube, there is ground for a reasonable hope of an entire cure. Even where, upon proper examination, the morbid growth is found just within the verge of the anus, if it does not involve the muscular coat of the intestine, and the general health of the patient is pretty good, the case should not be regarded as positively incurable. Where it is deemed proper to make an effort for the extirpation of the cancerous growth, an application of the oak caustic should be applied, as extensively as the patient can bear it, and followed by a slippery elm poultice made soft and applied cold. The poul- tice should be changed so frequently as to prevent its becoming dry, and when the part which has been deadened separates and comes off, the caustic should be applied again as at first, to be followed also by a poultice. Where a part only of the tumor is covered at one time, it may be attacked in a new place as soon as the patient shall appear able to hear it, without waiting for the first slough to come off. By making these applications as thor- oughly and as extensively as practicable, you will be able to de- stroy the cancerous structure more rapidly than it can grow, and thus finally remove it, if it can be removed at all with safety. Should inflammation to any considerable extent be excited in the surrounding textures, the application of a small cup with scarifi- cation will generally be sufficient to relieve it. If this application does not act as favorably as you may desire, the sulphate of zinc mixed with acetate of lead may be substitu- ted. The action of'the.sulphate of zinc usually produces more pain than the caustic, but is not likely to excite as much inflam- mation in the adjacent vessels. It may be applied in the form of a plaster mixed with flour and a little charcoal, or the dry powder may be used. In using this, as with the oak caustic, the apph- cation of a poultice once or twice a day will be a necessary part HEMORRHOIDS OR PILES. 467 of the general course. These, now, with such collateral means of local or general influence, as the circumstances of the case may suggest to the intelligent practitioner, comprise the measures to be relied on in the radical treatment of this form of stricture. In those hopeless cases, where a merely palliative course of treatment is to be pursued, such attention should be given to the bowels as may be necessary to keep them in a quiet, yet soluble state. In case of constipation, a mild aperient may be given, and where there is a tendency to diarrhoea, which is most likely to be the condition in the advanced stage, mild, soothing, yet restrain- ing injections, and the internal administration of opium will be proper. If there is much pain or uneasiness at the same time that opium is contraindicated, the extract of hyosciamus may be given. HEMORRHOIDS OR PILES. There are few complaints for which a practising physician is more frequently called upon to prescribe, than piles, and there are few diseases in the treatment of which he will often find it necessary to exercise more skill and perseverance. It behooves us, therefore, so to consider the symptoms of the affection and the causes operative in its production, as to attain a perfect under- standing of its nature and proper management. Every person knows what is meant, in common parlance, by the term piles, and if successful treatment affords evidence of correct information in regard to the character of the difficulty, the domestic practitioner might sometimes claim higher attain- ments than some men of science. But within the profession, as well as out of it, the circumstances connected with the cause of the disease have never been sufficiently observed and considered, otherwise the frequency of its occurrence would have been greatly diminished and its treatment much more successful. The term Piles or Hemorrhoids has generally been applied to tumors that form about the rectum, either externally or internally, and also to discharges of blood, more or less copious, from the lower part of that tube. Though a free discharge of blood does frequently accompany hemorrhoidal affections, yet I am entirely satisfied that many of those cases of copious hemorrhage from 468 HEMORRHOIDS OR PILES. the rectum, met with in practice, are not referable to hemorrhoi- dal swellings; the blood merely escaping from the veins of the anus, without the existence of tumors, and unattended by much pain. Pile tumors may be said to present themselves in three general forms:—First, External Piles, situated mainly below the sphinc- ter ani muscle; Secondly, Internal Piles, located within the rec- tum ; Thirdly, Bleeding Piles, which may be either external or internal. The term Blind Piles is sometimes employed, also, to designate tumors, whether external or internal, which do not bleed. It may, however, be remarked, that the distinctions here mentioned have reference rather to the popular understanding of the affection, than to any differences in a practical or scientific point of view : in other words, the terms employed merely denote the position of the tumors or the symptom of bleeding, which may, as above remarked, occur in the absence of hemorrhoidal tumors, but the intrinsic nature of the difficulty is the same in all these varieties. The hepatic obstructions usually coexisting with hemorrhoids, and the influence such a condition of the portal circulation seems to have upon the nervous sensibilities of the system and cerebral functions, produces, in many cases, a train of symptoms which indicate what some writers have termed the " hemorrhoidal effort," or what may with propriety be called the hemorrhoidal diathesis. This state of the system is often marked b\ general nervous excitability, mental depression, and symptoms of func- tional derangement in most of the organs of the body; or, to be more minute, by general debility and uneasiness, constipation of the bowels, loss of appetite, a furred tongue, distress or colic pains in the abdomen, and more or less pain in the head, with gloominess of feeling. The constitutional symptoms may precede those of a local char- acter for a longer or shorter period, though in some instances the general disturbance is so slight as to attract little or no attention. The development of hemorrhoids proper is attended with symptoms of congestion and irritation in the rectum, in addition to those of a general character—such as a sense of weight and downward pressure in the lower bowel, frequent calls to stool without any dis- charge, with pain or uneasiness in the rectum. These symptoms HEMORRHOIDS OR PILES. 46*9 may occur and continue for a time, and pass off without the appear- ance of pile-tumors, or they may increase until the local disease is fully developed. If the attack has not been preceded and caused by constitutional derangement, it rarely fails to produce febrile action with symptoms of general disturbance. The primitive type of a hemorrhoidal tumor is merely a dis- tended or varicose condition of a portion of the inferior mesen- teric veins, produced by more or less fullness, and increased by local irritation in the sphincter muscles which generally produces a degree of inflammatory action in the vessels involved, and fre- quently in adjacent structures. Each recurrence of this local engorgement and inflammation. though terminating in resolution, can scarcely fail to produce some degree of adhesion, and consequently every successive attack increases the thickness in the coats of the vessel, until a sensible induration is produced, constituting a tumor of greater or less dimensions. If the tumor should now be laid open, it would be found to consist of the coats of the vessel thickened by adhesion with surrounding textures, with a small cavity filled with dark, venous blood in a coagulated state. So long as this cavity is continuous with the vein from which it was formed, pressure upon the tumor will cause it mostly to disappear by expelling the blood from the cavity, but when the pressure is removed, the former dimensions will be restored. But when the induration has pro- ceeded so far as to cut off communication between the vein and the varix or cavity of the tumor, the coagulated blood becomes a source of irritation and inflammation, and additional adhesion occurs by the effusion of lymph. In this way a vascular, fleshy, spongy, and somewhat elastic tumor is produced, having the char- acter, in most cases, of a slightly pendulous excrescence, attached by a narrowed neck-like base. The form of the tumor is no doubt produced by compression of the sphincter muscles. I have now given you a brief description of the different stages in the formation of a pile-tumor. But it should be remembered that though each tumor is thus formed by the enlargement of a small vein, that these veins being numerous, several tumors may be formed at the same time or in succession, and that in this way a large portion, or even the whole of the circumference of the 4-70 HEMORRHOIDS OR PILES. outlet of the rectum may be occupied by tumors varying in size from the bigness of a bean to that of a walnut or perhaps larger. Hemorrhoidal tumors may be formed at the lower edge of the sphincter, at its upper edge, or between those points. When situ- ated near the upper border of the sphincter, their position will generally be within the bowel, for the contraction of the muscle will tend to press them upwards, so that they constitute internal piles. They will, it is true, be brought down during defecation if their size is considerable, and appear externally, but will usually be drawn back as the muscles contract; though when they are very large and the mucous membrane somewhat relaxed, they often require some pressure to cause them to return. Where the tumors are formed near the verge of the anus, the action of the sphincter will be, of course, to force them downward, and hence they become more and more prominent externally as they increase inside. They may originate so low indeed, as to become covered in part by the skin as they increase in size. In some cases the varices become so distended as to burst and discharge a large quantity of dark venous blood, and this consti- tutes what is termed bleeding piles. Where bleeding occurs, though considerable soreness and pain is experienced for a num- ber of days, it usually prevents the induration that often attends an attack of piles; hence persons who are subject to bleeding piles, rarely have those permanent fleshy tumors so common in other cases. If the ruptured varix happen to be within the rectum, it forms a case of " internal bleeding piles." Where pile-tumors have been formed in the manner heretofore described, they are subject, of course, to constant attrition, inci- dent to the movements of the body whether walking or sitting, to the passage of the faeces and the contractions of the sphincter; by this means the epithelial covering often becomes so thickened and indurated that the tumors become almost insensible, and present the character of ivart-lihe excrescences occupying the verge of the anus. The inflammation in the hemorrhoidal tumors may progress so far as to result in abscess, which may produce a fistula. Or, the inflammatory action may degenerate into a degree of irritation, HEMORRHOIDS OR PILES. 471 which, without much pain, will keep up a constant secretion of mucus, as seen in chronic dysentery. A few words may be necessary on the subject of the diagnosis' of hemorrhoids. The only diseases with which this affection is likely to be confounded are polypus and prolapsus ani. It will be readily distinguished from polypus by the juode of attack and the difference in the character of the tumors. Polypus comes on in a very gradual manner, without any particular paroxysms of pain or distress; and is not when formed very tender under pressure, wiiile piles are often exquisitely tender and generally very painful, conie on more rapidly, and occur in paroxysms. Polypus has usually a smaller neck, and is less solid and elastic than the pile- tumor. From prolapsus ani piles may be easily distinguished, by the uniform or ring-like character of the swelling, and especially the red and raw appearance of prolapsus. Let us now, gentlemen, inquire into the causes of piles. On recurring to the observations already presented, while speaking of the development and symptoms of the affection, you readily per- ceive that two circumstances, or rather, conditions of the system, must exert a powerful influence in producing hemorrhoids ; I mean torpor of the liver and constipation of the bowels. As all the blood from the mesenteric veins must pass through the portal vein and its minute ramifications in the liver, it is evident that any obstruction in the latter organ must, in proportion to its extent, retard the current of blood from the intestines and dam it up in the mesenteric veins, producing engorgement of their radicals, especially of those which are lowest and most remote, as those of the rectum. But obstruction of the hepatic circulation is usually accompanied by constipation of the bowels, a condition which of itself greatly favors the production of piles. The accumulation of faecal matter in the large intestines must, of course, interfere with the free circulation of blood in the mesenteric veins, while its occasional discharge in large consolidated masses, forcing the blood down into the lower extremity of the bowels, and irritating and sometimes wounding the mucous surface, tends directly to produce a varicose condition of the hemorrhoidal veins and an inflammatory condition of the parts. As a matter of course, then, where hepatic obstruction and torpor of the bowels exist at the 472 HEMORRHOIDS OR PILES. same time, there is a twofold tendency to hemorrhoids, and what- ever operates to produce either or both these conditions should be regarded as a cause of local disease. A plethoric state of the circulation, resulting from sedentary or indolent habits, and a rich stimulating, and nutritious diet, also greatly predispose to the development of piles; and this condition may, and indeed often does, coexist with portal obstruction and constipation. Hence it is, that individuals accustomed to fives of inactivity, and who, at the same time, are fond of " good living," are so fre- quently afflicted with this disease. Pregnancy is another condition that favors the production of hemorrhoids, especially in the later stages of gestation. The pressure on the ascending vessels greatly tends to produce a con- gested and varicose condition of the hemorrhoidal veins, as it often does in those of the inferior limbs. This affection is also produced, in many cases, by the use of drastic purgatives, especially the aloetic kind; and by irritating injections sometimes employed in the treatment of other affections. Ascarides may produce it also, and it is quite a common attendant or result of dysentery or diarrhoea, especially the former, for these cases are generally attended by more or less obstruction in the portal circulation. Inflammation of the prostate and of any of the pelvic viscera may, also, be causes of piles. Where there is a strong predisposition to the affection, it will often be brought on by the friction and pressure experienced in the part, on riding on horseback. In the causation of piles we may also recognize a hereditary predisposition, which will afford, in many instances, an explanation of its occurrence under circumstances not usually sufficient to produce it; for there is no reason to doubt that hereditary tend- ency may have as much influence in favoring the development of hemorrhoids as of any other disease. Treatment. In the healing art, as in political economy and theology, it is of the utmost importance frequently to recur to first principles. Hence it is, that I so constantly urge you to regard the causes of disease as constituting the first and paramount subject for consideration in deciding upon your course of treat- ment. In recurring to what has been said on the subject of the HEMORRHOIDS OR PILES. 473 causes of piles, we shall have very little difficulty in obtaining a clear conception of the indications to be fulfilled in each case. If the disease is associated with torpor of the bowels and con- sequent accumulations in the large intestines, the first step will be to remove those accumulations, by the administration of cathar- tics. The choice of remedies from this class of therapeutic agents must be governed by the peculiarities of constitution and the con- dition of the patient at the time. If there is a red tongue and other symptoms of gastric irritation, a mild cathartic should be selected, such as the neutralizing physic or the seidlitz powders, and the administration of it repeated occasionally, until the desired effect is produced. But if no evidence of such irritation exists, the contents may be removed by a more efficient and speedy cathartic, such as the anti-bilious physic mixed with equal parts of cream of tartar. But, whatever the agent used at first, to unload the bowels, they should afterwards be kept in a soluble condition by means of some mild laxative, so as to secure an easy evacuation daily, avoiding over-action, as that would tend to aggravate the symptoms and materially add to the sufferings of the patient. If the piles are the result of hepatic congestion, or of portal obstruction from any cause, the remedies to be employed must be directed to the relief of the liver. If there are accumulations in the stomach, as indicated by a thickly coated tongue and other symptoms, a gentle emetic will do much to secure the proper action of the subsequent remedies, and will also exert a beneficial influ- ence on the hepatic torpor, and if no valid objection to its admin- istration exists, it should certainly be prescribed. Any of the emetics which I have recommended in other cases will answer the purpose here, but perhaps one of the best articles that can be used, as it evidently exerts a more direct influence on the liver than most others, is the acetous tincture of lobelia and sanguinaria. Or if the eyes exhibit a yellow tinge and the skin a sallow hue, and there is a thick yellow coat on the tongue, an emeto-cathartic dose of podophyllin or of podophyllum in powders, may be given. But if eruesis is not thought necessary, or after it has been pro- duced as at first suggested, a free cathartic effect of podophyllin and leptandrin, or of the compound taraxacum pills, should be 474 HEMORRHOIDS OR PILES. obtained, and afterwards the pills should be given in aperient and cholagogue doses, so as to procure at least one free bilious evacua- tion every day. The same pills, but in less doses, may be given in cases where there is irritation of the bowels, with diarrhoea. While these general measures for the removal of the cause in different cases are being employed, much relief to the sufferings of the patient may be afforded by mild and soothing local applications. In those cases which present a soft, elastic, and dark colored swelling, being evidently a distended varix, in which there is a severe throbbing and painful uneasiness, I have occasionally witnessed the most prompt temporary relief from puncturing the tumor, so as to discharge the accumulated blood and allow the vessel to collapse. This measure should be followed by warm and soft fomentations. But where puncturing is not deemed proper or the patient is unwilling to submit to it, a warm starch injec- tion, by its soothing influence, will sometimes afford very prompt relief, especially if followed by a soft poultice of roasted onions, applied as warm as can be borne with comfort, immediately upon the swelling. Where the spasm of the bowel is so severe as to amount to an entire obstruction, producing, as is sometimes the case, a well defined spasmodic stricture associated with piles, a pill, composed of three grains of opium and half a grain of belladonna may be introduced into the rectum. This may be done by putting the pill into the end of a gum elastic catheter, and after introducing the instrument dislodge the pill by means of the wire. If it is not deemed advisable to use the pill, an ointment made of the wild indigo as a base (Beach's yellow salve or unguentum bapti- siai of the Eclectic Dispensatory') with a small portion of extract of belladonna and a little tannic acid will be found a very sooth- ing, antispasmodic application. I have also frequently seen the sufferings of the patient greatly relieved by applying cold water freely to the part, in cases where inflammation and heat existed. It should not, however, be applied with a view of producing and continuing the sedative effect of coldness, but having applied a cloth wet in cold water, it should only be changed often enough to prevent its becoming dry—say once in three or four hours. In these cases I have also generally applied a cup to the coccyx HEMORRHOIDS OR PILES. 475 as near the inflamed part as practicable. I have also applied in similar cases, and with marked advantage, a poultice made by brusing the leaves of common house-leek (Sempervivum tectoruni), and changed two or three times a day; and in place of this I have found a soft slippery elm poultice answer a very exellent purpose, applied cool and frequently changed. Where the disease results from pregnancy, and especially after parturition, where the labor has been very severe, it is sometimes exceedingly painful; and I have seen, under such circumstances, tumors larger than a goose's egg. In such cases, the starch and laudanum injections and soft onion poultice have seemed to me to afford more prompt and permanent relief than any other measures I could employ. They may be repeated as often as necessary, to secure their continued effect. In every modification of the disease, it will be an important point, which you should never overlook, to keep the bowels free from accumulations, by administering some mild aperient, or by the use of such articles of diet as shall secure a soft and full evac- uation every twenty-four hours; but more than this, after the operation of the first cathartic, will be unnecessary, and would be likely to do more harm than good. Where a simple aperient is desired, and no other indication is to be fulfilled, a small portion of sulphur and cream of tartar may be taken every morning. For bleeding piles, such of the foregoing treatment as the cir- cumstances of the case may indicate should be employed, and in addition thereto, a strong decoction of oak bark should be used as an injection and the bowel freely bathed with it two or three times a day, or the patient may be directed to wear a compress wet in the decoction and changed as often as may be necessary to keep it moist; and if the case is attended with much pain, great advantage may be derived from bathing the tumors and adjacent parts, freely and frequently, with a liniment composed of linseed oil four parts, and oil of origanum one part. It should be applied two or three times a day, and a piece of soft linen may be saturated with it and kept constantly in contact with the tumor, at the same time that a small quantity of the oak bark decoction is kept within the bowel by occasional injections. I have, in fact, used this liniment with the addition of a small portion of lauda- 476 HEMORRHOIDS OR PILES. num, as a discutient to the more recent pile-tumors, having a somewhat fleshy character, where the swelling did not disappear with the decline of the active or acute symptoms, and with excel- lent effect. While using the liniment for the purpose of discus- sing the tumors, they should be bathed freely two or three times a day in the cold decoction of oak bark. Where the tumors have acquired a decidedly fleshy character, and especially where they have a constricted base or neck, there is no measure so effectual and speedy, and at the same time so safe, as the application of ligatures, with a view to their removal. While this means effectually removes the tumors to which it is applied, it is generally followed by the disappearance of contiguous smaller ones, so promptly and completely, as to leave little room for doubt, that the removal of the large tumor exerts a discutient influence upon those which are less fully developed. By this means, too, the tendency to the frequent recurrence of hemorrhoi- dal inflammation, under slight indisposition, will often be entire- ly broken up, and the patient enjoy in the future, complete immu- nity from such attacks. It is a very simple operation, even though the tumors may be situated within the sphincter, as they can usu- ally be brought down by a straining effort of the patient, as in difficult defecation. When the tumor appears, it may be seized with a forceps, armed with a ligature. If they cannot be brought to view in this way, there will be but little difficulty in getting at them by opening the orifice with an anal speculum. Most gene- rally, however, tumors of this kind are situated below the sphinc- ter, and the ligature may be applied without difficulty. Hence, very little instruction is necessary to enable you to perform this simple operation; all that is requisite, is a double silk cord, waxed, which should be carefully drawn so tight as to inter- cept entirely the circulation in the tumor; for if this is not done, it will greatly increase the suffering of the patient, and require to be tied again, which will produce more pain than the first ap- plication. I have, in this way, applied ligatures to quite a num- ber of hemorrhoidal tumors, and have thus far uniformly succeed- ed ; never having realized the inconvenience s suggested by some eminent surgeons ; for the pain has uniformly subsided in a few hours, and I have never yet found it necessary to remove the lig- HEMORRHOIDS OR PILES. 477 ature till the deadened tumor came away. I cannot but think that the evils resulting from the application of the cord-ligature, described by Dr. Physic, and reiterated by Dr. Gibson, were mostly imaginary, and offered as substantial objections, in an argu- ment in favor of a new method, suggested by the learned author first named. I have, in a number of instances, seen patients going about the next day after the application of silk ligatures to pile tumors, and in every case without any serious trouble following; and I must, therefore, be permitted to recommend the use of such ligatures in preference to those of Dr. Physic. The canula and wire cannot be applied, though but for a short time, without very much incommoding and annoying the patient, while the or- dinary ligature encounters no such objection; and as it may be applied so tightly at first as to render its removal and reapplica- tion unnecessary, the objection urged by Dr. Gibson has no force. If tightly applied with a double knot, it must of necessity destroy the vitality of all that it encircles, and of course the tumor loses its sensibility and cannot be the seat of pain, and there is, there- fore, no reason for removing or modifying the ligature, but it should be let alone until the slough comes off. If any inflamma- tion should supervene after the ligation of the tumor, the fomen- tations, soothing poultices, etc., recommended for that condition under other circumstances will, of course, be indicated. But I have generally found my patients far easier the day following the application of the ligature, than they were before; the ligated tumor shriveled and insensible, and the surrounding parts in a far less irritable condition. Very simple dressing may be applied, and as the tumor separates, the part readily heals without much sore- ness or discharge. Where the affection has been attended for a long time by bloody discharges, to which the system has adapted itself, a question will arise as to the propriety of promptly causing a cessation of the hemorrhage, since the system may substitute it by a lesion in some more vital locality. It is said that the results most to be apprehended, are apoplexy and pulmonary hemorrhage. Hence in patients who have a predisposition to either of these affections, the piles should either be allowed to continue, under merely pallia- 478 HEMORRHOIDS OR PILES. tive treatment, or an artificial drain by means of an issue or seton should be established, and the patient subjected to such general treatment as will fortify his system against the apprehended dan- ger, before the us« of means for the radical cure of the hemor- rhoids. LECTURE XXX. FISSURE OF THE RECTUM. Introductory remarks —Description—Appearances— Causes— Treat- ment— General—Local. Fistula in Ano : Remarks—Causes— Character—Treatment — Local and General. Prolapsus Ani : Character—Symptoms— Cause— Treatment. It is a little remarkable that a disease so common and so readily recognized, should so far have escaped the notice of authors, as not to be described, till within a comparatively recent period. Dr. Gibson considers it a rare disease ; and remarks that " although connected for the last twenty years with the largest hospital in America, I have seen very few cases which could be said to cor- respond in the symptoms, with the details furnished by writers." But my experience does not justify this conclusion; since in pri- vate practice I have frequently met with it and have treated a number of cases. This disease requires no very elaborate description, since it consists generally of a mere superficial ulceration of the mucous membrane of the rectum ; sometimes wholly within the sphincter muscles, and sometimes mainly without. The usual location will be found in that portion of the mucous membrane of the lower bowel included in the sphincter muscles; but extending above into the free membrane, and commonly so far below as to be seen. It presents the appearance of a fissure, mainly on account of the folded condition of the mucous meiabrane at this place, produced by the contraction of the sphincter muscles in closing the extrem- ity of the bowel. This fact is distincly shown by opening the sphincter with an anal speculum;—thus spreading out the mucous membrane connected with the fissure, when a superficial ulcer will be brought to view, rarely extending through the mucous 480 FISSURE OF THE RECTUM. membrane; though occasionally it will be found otherwise. The ulcers, when thus exhibited, present an indolent character, and generally have slightly irregular, indurated and raised edges; though in recent cases they have a more superficial aspect— without unhealthy induration—and have a vascular and granulated appearance. The pain accompanying fissure of the rectum occurs usually after every stool, is of a burning and shooting character, and is often very severe for an hour or two after each evacuation—especially if the bowels are costive—producing a spasmodic constriction of the rectum. This disease sometimes follows chronic dysentery, and I have also met with a few cases connected with the Mexican diarrhoea. It is likewise produced by long-continued costiveness, distending the rectum with hardened faeces. When the disease is confined to the bowel above the sphincter ani, it is productive of but little pain ; though a slight soreness and burning sensation will be experienced after every evacuation. In this case the existence of the disease will be more particularly indicated by a discharge of matter from the bowel, either mixed with the faeces or following the evacuation. When it is confined to the folds of the mucous membrane below the sphincter muscles, a slight burning will be experienced after the evacuations, followed by a troublesome itching sensation. More or less discharge of a muco-sanious appearance, mixed with pus of an unhealthy and offensive character, accompanies the dis- ease wherever it is located. In severe and extensive forms of this disease, the irritation produced by it often extends to the bladder, producing irritation and pain in evacuating the urine. The local affection is generally associated with an unhealthy state of the general system. This is clearly shown by the pale and sallow complexion, associated with more or less disturbance in the digestive functions and general derangement of the secre- tions. In the treatment of this difficulty, the main indication will be fulfilled by removing the cause that produced it and restoring the general health of the system. FISSURE OF THE RECTUM. 481 The remedies heretofore directed for chronic dysentery or diar- rhoea, will be equally appropriate when they are complicated with this disease. If caused by hardened accumulations in the rectum, they should be removed, and the bowels kept in a soluble state with mild aperients—such as the taraxacum pill, cream of tartar and sulphur, congress water, or some other inoffensive and mild remedies; or, if it will answer, suitable articles of diet; while a healthy condition of the skin should be promoted by appropriate bathing, and of the other secretory organs by suitable remedies calculated to bring into action their depurating influence upon the general system. The remedies most in favor with our practition- ers for a general vitiated state of the system, are the alterative syrup of our dispensatory and the syrup of stillingia, which, in such cases, should be given for some time. The local measures are no less important in these local and long standing diseases, than those of a general character, though, by restoring the general health and removing the exciting cause, most cases would, no doubt, ultimately recover. But appropriate local appliances will hasten, in all such cases, the final cure. Those cases presenting the callous edges with an indolent gen- eral appearance, will be more promptly relieved by the application of the oak caustic. I should remark that the edges and unhealthy granulations should be barely touched with the caustic, as more than this will be certain to produce too great a cauterization. It can be applied by opening the bowel, as for other purposes, with the anal speculum, so placed as not to cover the fissure, or it can be turned when introduced. The part to which the caustic is applied immediately turns dark, when it should be washed off with diluted vinegar, to prevent its further action; and you should be very particular to see that the application is entirely confined to the points desired. One application of the caustic will usually be sufficient, as when the morbid structure, destroyed by the appli- cation, comes away, the fissure will present a soft and healthy flesh-colored appearance, and with other mild and simple means, will very shortly be cured. The application of, the caustic should be followed by a soft slippery elm poultice to the rectum, and the patient advised to keep still for a few days, in order to allow the irritation to subside and afford greater convenience in changing ol 482 FISTULA IN ANO. the poultice, which should be done three times a day. After the irritation has disappeared, the parts may be washed two or three times a day with a decoction of hydrastis canadensis, and then dressed with any simple plaster ; such as our black salve or the yellow ointment. If it should be found that the first application of the caustic, with the subsequent treatment just recommended, was not suffi- cient to remove the induration and excite healthy action in the parts, or if fungus granulations should sprout up, the parts may be washed every second day with a saturated solution of the sesqui-carbonate of potash, or they may be touched with a pencil of nitrate of silver, which rarely fails to excite a more healthy condition. If the applications should at any time induce a spasmodic action of the rectum, which the soothing influence of the poultice is not sufficient to relieve, an ointment prepared from the wild indigo, with a small portion of the extract of belladonna, may be applied to the parts, two or three times a day ; or the patient may be directed to sit over a decoction of hops, which will rarely fail to afford relief. This may be repeated at any time when the pain is severe. In less severe cases, not exhibiting the callous and indolent edges, the application, for a few times, of the sesqui-carbonate of potash, in-the form of the dry powder, by filling the fissure with it, and the subsequent use of the hydrastis, will obviate the necessity of the more severe application of the caustic. Or the nitrate of silver may be applied every second or third day with similar effect. But where there is great relaxation of the bowel, it will often be necessary, in addition to the means just considered, to use as a wash, either by injecting into the bowel, or washing freely with it, a decoction of oak bark once or twice a day. FISTULA IN ANO. It may be thought, that in considering this disease in con- nection with the subjects embraced in the theory and practice of medicine, I am traveling out of the record, or that I am discussing a subject legitimately within the province of surgery. When this disease was mainly treated with the knife, the position assigned it FISTULA IN ANO. 483 was proper; but since other measures are found more successful, and the use of the knife can be altogether dispensed with, in its treatment, the subject should be considered in this connection. The term fistula is used to designate a small, narrow, deep- seated ulcer, and when used in connection with disease of the rectum, it is called fistula in ano or anal fistula. This disease consists in a small orifice situated near the lower extremity of the bowel, sometimes external to the sphincter mus- cle. In other cases the external orifice of the fistula is found from one to three inches from the anal out-let; in either case, the fistulous pipe passes up by the side of the bowel, above the sphinc- ter muscles, and enters the intestine obliquely through its several coats into the cavity of the gut. The point at which the fistula enters the bowel, is, generally, immediately above the sphincter muscle, though in some cases it is found higher up. Those cases having openings both internally and externally are called com- plete fistulas. In other instances the fistulous tube passes through the cellular structure at the extremity of the bowel, and extends up some dis- tance by the side of the intestinal tube without entering it, consti- tuting what is called an incomplete or blind fistula. Fistulous pipes sometimes commence in the mucous membrane of the lower part of the bowel, and pass through its several tunics into the cellular structure by the side of it, without communicating externally. This is called the internal fistula, and seldom con- tinues long before the matter finds its way through the integu- ments. These several fistulous formations generally result from ab- scesses occurring in the vicinity of the rectum, which, from the loose character of the cellular structure at this place, prevents an immediate union in the breach of continuity, but readily healing at the surface; thus retaining a portion of the matter formed, which burrows still deeper, and extending in both directions, till at length it finds an outlet internally into the bowel, and at the same time, perhaps, discharges again through the integuments at the surface. After the opening is complete into the intestine, some portion of their contents finds its wray into the opening thus made, and passing down through this artificial tube, emerges, 484 FISTULA IN ANO. with the secretion from the fistula, through the integuments. The inflammatory action accompanying the several stages of this process produces more or less adhesion and induration, while the secretion of pus and the feculent matter from the bowel, soon form a track of a permanent character, which shortly takes on the function of a secreting mucous surface. It will be observed, from the descrip- tion I have given you of the phenomena of fistula, that a small tube-like opening, sometimes externally and into the bowel, but sometimes only externally or internally, with an artificial mucous membrane lining it, and an indurated condition of the adjacent cellular structure, constitute the character of fistula in ano. The disease may consist of a single incomplete pipe, or there may be half a dozen or more occupying the main circumference of the rectal outlet, in different stages of progress, from an imper- fect burrowing sore, to a deep-seated and complete fistulous tube. They may also be connected with very little constitutional derangement, or they may be associated with a broken down and contaminated state of the system. As a general thing, however, anal fistulas occur in old and debilitated persons, and weak and contaminated systems. The discharge accompaning this affection is generally unhealthy and offensive, while the appearance of the local difficulty indicates a corresponding condition of the general system. Anal fistulas sometimes result from the inflammation attendant upon hemorrhoidal swellings, and they frequently follow the for- mation of abscesses produced by the common causes of inflamma- tion ; such as hardened faeces lodged in the rectum, or local injuries, and in some instances by long and protracted horseback riding. Treatment. The well settled character of fistula in ano pre- sents two main indications—first, to restore the general health of the patient; and secondly, to destroy the mucous surface lining the tubes and the indurated structure surrounding them. In fulfilling the first indication, all I propose to say, at this time, is that you should be governed by those general principles, heretofore discussed, applicable in the treatment of other disor- ders involving the general health of the system. The condition of the skin, as exercising a most important influence in the cura- FISTULA IN ANO. 485 tive process of all chronic affections, especially, should always receive a full share of attention; while the secretions, generally, as affording the necessary out-lets of effete matter from the dis- eased tissues, should also be appropriately acted upon in all such cases. The condition of the digestive organs, as preparing the aliment to supply the waste of the system, and at the same time a proper amount of healthy and nutritious food, as a prerequisite to the renewal thus made necessary, should both be the subject of your early attention. The alterative syrup, as a general agent, or the compound syrup of stillingia, may be relied upon in this disease, as the best altera- tives we possess; while the gin bitters, or the anti-dyspeptic pill, or the compound taraxacum pill, heretofore recommended for other diseases, each in its appropriate place, as the condition of the system will indicate, may be mentioned as preferable to most other laxatives and tonics in these cases. As a general rule, while the local applications are being made, patients should be kept, in the main, tolerably still and quiet; but after the principal local appliances are completed, and a healthy state of the local affection is produced, they should then be directed to take as much exercise in the open air as their strength and past habits will justify. The second indication will be fulfilled with great certainty, by the proper application of the oak caustic, or in some cases by the use of the sesqui-carbonate of potash, with the ligature afterwards properly used in cases of complete fistulas. The failure to effect permanent cures of this disease by the ordinary operations with the knife, I am well convinced, results from not first destroying the mucous membrane lining the tube and the induration connected with it; so that, if I were convinced that the common method of treating fistula had advantages, in other respects, over the method which I am about to recommend, and I desired to use the knife, I should, as a preparatory meas- ure, make use of the same means, that I otherwise do, where I apply the ligature. But I have seen such results following the operation, when the knife was used, in a number of cases,—such as the loss of the use of the sphincter muscles and a consequent inability to control 486 FISTULA IN ANO. the contents of the bowel, which never follow the use of the liga- ture,—that I cannot, in any case, recommend that operation; especially, since the course I shall recommend is equally sure, and, in its results, equally prompt, and far more safe to the patient's present and future comfort. There are various modes of using the caustic, in these cases, each of which has advantages, under certain circumstances, not common to them all. Where the fistula is not very deep, I gen- erally inclose a small portion of the caustic in one end of a lock of cotton, slightly twisted, and pass that part of it up the fistula with a probe, and allow the cotton to remain till the caustic dis- solves, when the cotton can be drawn away by that portion of it which was allowed to be without. But if the fistula is deep seated and extends far up by the side of the bowel, a saturated solution of the caustic may be thrown up the pipe, with a long, probe- pointed syringe. In this way, not only the extremity of the fistula may be reached, but every part of the lining surface will be cauterized at the same time, and thus be entirely destroyed and carried away in a day or two. This application should be repeated as soon as the slough made by the first injection comes away, and thus be continued till the induration is removed; when, if it be an incomplete fistula, it will readily heal. Care, however, should be taken, while it is healing, not to allow the orifice to close at the surface till it has filled up from the bottom. This can be readily effected by introducing a tent every day, when it is dressed, while the healing process is going on. It will gener- ally be necessary, while the caustic is being used, to apply a soft slippery elm poultice to the part, and change it twice a day. If the fistula passes through into the bowel, the application of the ligature will be necessary to the cure; but this should not be ione till after the callus has been removed by the application of the caustic, as just directed. Various methods have been suggested for the introduction of the ligature. A very convenient and simple method, and one generally readily performed, is to have a probe made of flexible and inelastic metal, with an eye to it, which, armed with a double silk or linen thread, should be passed up the fistula until it meets the finger previously introduced up the bowel, and thus it can be FISTULA IN ANO. 487 readily bent and directed down towards the anus and passed out, when, from its flexibility it can readily be withdrawn, and thus the Avail of the fistula will be included. The ligature should then be loosely tied, so that a small, smooth, wooden or ivory " toggle," about an inch long, may be passed under it, and a turn or two taken for the purpose of tightening it. It should thus be turned every day, more or less, as the patient can bear it, till it comes away. Meantime, the patient should keep still, and if the parts should inflame, a soft elm poultice should be applied. When the ligature is through, the fistula will be cured; and, as the indura- tion has been previously removed, it will not be likely to return. It has this advantage, over the common method with the knife, that the fibers of the sphincter muscle unite again, as fast as they are separated; thus securing to the patient an immunity from the risk of a serious deformity, often following the operation with the knife. It has occurred to me as somewhat strange, that the deformity referred to did not more frequently occur than it does, since the fibers of those muscles are wholly separated at once, and prevented from immediate union by a plug of lint, in order to secure the discharge of the callus, connected with the fistula, and ward off a return of the disease. The common needle-eyed silver probe, if not too large and stiff, may be used in the same way as the flexible one. I have used it myself in a few cases; and when the opening into the bowel is not too far up, the operation can be accomplished without much difficulty. The instrument invented by Dr. Gibson, of Philadelphia, I have no doubt is a valuable contribution, and better, perhaps, than anything heretofore suggested for this purpose. It consists of a small silver canula, slightly curved, about five inches long, together with a portion of the mainspring of a watch, filed down to suit the opening in the canula, with one end made of a small silver bulbous point, and the other having an eye. The spring, thus prepared and armed with a ligature, is passed through the canula, previously introduced up the sinus, and through into the bowel, with its end in contact with the finger previously in the rectum. The spring, Avhen passed into the canula and coming in 488 PROLAPSUS ANI. contact with the finger, will readily be directed, brought through the rectum, and drawn out. That form of fistula occurring on the inside of the bowel and extending through into the cellular structure, will generally be cured by touching the inner surface with the nitrate of silver; or if it is found, upon examination, to have somewhat calloused edges, a very slight touching with the oak caustic, and then filling up the orifice with a short piece of candlewick, allowing the other portion to remain out of the bowel, in order to its more ready removal, will be necessary. This should be repeated every day and the fistula carefully cleansed, and another pledget again intro- duced. The object of thus filling up the fistula, is to prevent any of the contents of the bowel passing down into it, and thus interfering with the adhesion desired. In making these applica- tions, in this form of the disease, the aid of the anal speculum will be indispensable. When there is not any considerable irritation in the parts, so as to require the application of a poultice, any simple salve, such as our common black salve, will be all the dressing necessary in the case. When, however, the applications produce irritation and pain, the parts may be fomented, two or three times a day, by the patient sitting over a vessel of hot hops, in addition to the appli- cation of the elm poultice. Or a soothing starch and laudanum injection may be used, two or three times a day. Or, if the irri- tation connected with it produces a spasmodic action of the sphinc- ter muscles, the belladonna ointment, heretofore directed in other affections of the rectum, may be used. In making these differ- ent applications, it will generally be necessary for the patient to wear a T bandage. With these measures, efficiently and properly applied, I have no hesitation in bespeaking for you, when you shall have assumed the responsible duties of the profession, uniform and general suc- cess in these cases. PROLAPSUS ANI. This affection consists in a descent of a portion of the rectum through the sphincter ani; presenting a red or purple, and irri- PROLAPSUS ANI. 489 tated tumor-like projection below the external orifice of the bowel. In slight cases, however, the tumor consists of mere folds of the relaxed mucous membrane, projecting below the sphincter muscles and presenting the appearance of a fungus growth attached to the circumference of the anal out-let. But where the tumor is larger, and more projecting, the whole structure of the bowel becomes inverted, accompanied with a more sensible constriction of the sphincter muscles. Instances are mentioned in the books, in which the colon and even the coecum have been forced through the rectum. These are extreme cases, and may challenge our credulity, yet the extent of the prolapsus differs greatly in differ- erent cases; but, in most instances, the invaginated portion con- sists only of the mucous membrane. It is not very common for this difficulty to come on all at once; but by a slight and gradual increase. Where relaxation of the bowel exists, it gradually augments in size until the whole structure of the bowel protrudes. It will at first be observed to consist of a small rounded tumor at the verge of the anus, occur- ring only when the patient is in the act of defecation ; and usu- ally disappearing spontaneously; or it can be returned with little difficulty, by slight pressure. If not relieved, it will be found to gradually increase in size, and will require more force, and often assistance to return it. In this case, if allowed to remain any great length of time, the contraction of the sphincter muscles interrupts the circulation, giving the tumor a dark purple appear- ance, and would, no doubt, if not relieved, result in mortification. But it does often remain protruded for a long time, without pro- ducing any serious inconvenience. This, however, is where the inverted portion is confined to the folds of the mucous membrane, and where no great irritability of the sphincter muscles exists at the time. Though it does generally make its appearance very gradually, yet in some cases the protrusion occurs very suddenly, when in the act of defecation, where relaxation of the bowel had previ- ously existed, and often causes great alarm, as it presents a fright- ful appearance. The causes of prolapsus of the bowel are any influences that produce an undue relaxation of the parts involved. It is a com- 490 PROLAPSUS ANI. mon sequel of chronic dysentery, and sometimes accompanies the acute form of that disease. It is very common among children during their second summer, where great relaxation follows the long continued irritation of the bowels, attendant upon such cases. The long continued use of aloetic purgatives, has been followed by prolapsus of the bowel; so also the local irritation produce d by worms, especially the ascarides, and by other irritating sub- stances lodged m the rectum, has been known to be followed by this difficulty. I have also met with a few cases following the severe straining and pressure attendant upon parturition. This is more apt to accompany those cases, in which great atony of the lower bowel had previously existed for some time. Prolapsus of the rectum is usually accompanied by an irritated condition of the bowels, and if diarrhoea is not an attendant upon it, that difficulty is very likely to be developed by any slight occur- rence calculated to produce it. This disease is mainly confined to children, though it some- times occurs in advanced age and more rarely in the meridian of life. Treatment. The treatment of prolapsus ani may be said to be palliative and radical; or that which is necessary to return the invaginated part, and that which is necessary to prevent a descent. Various methods and expedients have been recommended for the purpose of reducing or returning the prolapsed bowel. In general, where the protruded part consists of folds of the relaxed mucous membrane, the patient, if a child even, unless too young, will be able by slight pressure to return it. Or at any rate, very little constant pressure in such cases, by an assistant, will be all that is necessary. So, also, in the ordinary cases met Avith, where the boAvel proper protrudes, slight, uniform, and constant pres- sure with a soft, folded, linen rag, wet in warm water, will be suf- ficient to accomplish it. But cases are occasionally seen in which all the pressure that can be safely made, will not be competent to effect its return. And I have found, in several instances, the oiled finger, even, as recommended by Dr. Wood, not to succeed in replacing the bowel, and causing it to remain. For, hoAvever much you may oil the finger, the mucus of the bowel possesses PROLAPSUS ANI. 491 the property of adhering to the finger, to an extent sufficient for the bowel to folloAv it, when it is withdrawn. It was in a case of this kind, Avhere every effort had failed in permanently replacing the protruding bowel, that I resorted to the expedient of pressing up before the finger, a soft, oiled rag, and thus succeeded in com- pletely replacing the protruding parts; and, after waiting a few moments for the sphincter muscles to contract, was able to with- draw the finger without the bowel folloAving — Avhen the rag was readily removed. You may think this rather an unimportant and trivial matter, but my word for it, you will not think so when all other knoAvn methods shall fail you. After the bowel has been returned, you should keep the patient quiet for a short time, and make gentle pressure, by means of a compress and the T bandage. And the bowels should be kept moderately open with mild aperients, or what is better, if it can be made to answer the purpose, the use of an appropriate diet; such as rye mush and molasses, or, what is now a very popular article of diet for such purposes, and I think deservedly so, cracked Avheat or "grits" boiled, and used similar to rice or hom- miny. But many of these cases will be accompanied by a con- stant tendency to diarrhoea, which will be necessary to be kept moderately restrained. For this purpose, small doses of the compound neutralizing physic, say dessert-spoonful doses for chil- dren, may be given three or four times a day. If this is not suf- ficient, a decoction of blackberry root may be used, and will be found a valuable astringent and tonic. It should be given to a child two years old, in doses of a tablespoonful, three times a day. Or, if a more decided astringent is required, the compound tincture of catechu and paregoric, in equal parts, may be given in teaspoonful doses, as often as may be- necessary to keep the boAvels moderately restrained. While these general measures are being used, others of a more local character are not much less important. The patient should be directed to guard against straining, when at stool, and to effect this Avith certainty, defecation should be performed in as nearly an erect posture as possible. The bowel should be freely bathed after every evacuation, especially if it comes down, with a strong decoction of oak bark, and be followed with a compress wet in 492 PROLAPSUS ANI. the same, and retained there with the T bandage; changing it sufficiently often to keep it moist; while the lower part of the abdomen and back should be freely bathed with the same astrin- gent decoction, twice a day, and a small portion of it should be thrown up the bowel with a syringe, three or four times a week. With these measures, perseveringly applied, I have seen many cases of an obstinate character, both in adults and children, per- manently relieved. But an occasional case will be found, in aged and debilitated persons, in which ulceration and unhealthy granulations exist on the mucous membrane of the rectum. In addition to the means just alluded to, the ulcerated points will be required to be touched, Avhen the bowel protrudes, for a few times, with the nitrate of silver; or the granulated surfaces may be sprinkled over with the powder of the sesqui-carbonate of potash, till a more healthy condition is produced. These cases will be benefited by an injection of a decoction of the hydrastis canadensis. LECTURE XXXI. COLIC. Varieties. Spasmodic or Wind — Bilious — Painters'. Wind Colic: Symptoms—Cause—Treatment Bilious Colic : Symp- toms—Nature— Cause—Fatality—Anatomical Character—Treat- ment—Particular Remedy—Dioscorea—Remarks— Other Treat- ment. Painters' or Lead Colic: Distinction—Symptoms— Paralysis—Chronic—Cause—Remarks—Diagnosis—Prognosis— Anatomical Character— Treatment—Prevention. In treating on the subject of colic, authors generally describe three varieties. Some recent authorities mention others which are more or less important. But for practical purposes it will suffice to follow the usual divisions. The first variety is wind or spasmodic colic; the second is bilious colic ; and the third is lead or painters' colic. Each of these varieties develops symptoms somewhat peculiar, and requires a different mode of treatment. It will, therefore, be better to consider the different varieties separately, than to attempt the discussion of them all together. Wiud or spasmodic colic occurs among children as well as adults. It frequently arises from over-distension of the stomach by cold substances, such as frozen apples; from articles that generate Avind in the stomach; from the fermentation of undi- gested food ; and, in infants, from the souring of milk on the stomach. It is very apt to occur in dyspeptic subjects, and is by turns very painful, from the excessive accumulation of gas in the bowels, which is either belched up from the stomach, or passed off by the intestines. It may be caused by acrid secretions pro- ducing a spasm of the muscular coat of the bowels when they are 494 WIND COLIC. in a torpid condition ; though this is rarely the case, as the irri- tation would be likely to increase the peristaltic action, and diar- rhoea would shortly folloAV. It may, hoAvever, be excited by the sudden obstruction of gaseous accumulations from " taking cold." Repelled cutaneous eruptions are enumerated among the causes, but as this Avould be likely to produce irritation or inflammation, it may be considered equivocal. It is also said to be produced by translated rheumatism, but this is rather doubtful, as, in that case, it would more probably assume the character of bilious colic. It usually comes on suddenly, and as often suddenly disappears, depending on the course pursued for its relief, on the character of the cause, on the effects produced in relieving the system of the offending cause, and somewhat on the peculiarities of the consti- tution affected. It rarely produces any constitutional disturbance ; the pulse is seldom excited, nor are the secretions particularly deranged. The accompanying pain, though more or less con- stant, is usually paroxysmal. Pressure, in wind colic, rather gives relief; but, in inflammation of the bowels, increases the pain. This form of colic is painful while it continues, but rarely proves fatal. In some cases, hoAvever, the continued irritation Avhich must, more or less, necessarily attend the acrid accumulations, would, if not relieved, excite a grade of inflammatory action that might prove fatal. The same result might follow the great dis- tension of the bowels from accumulations of flatus. The treatment is very simple, though this will depend some- what on the cause of the disorder. If it arises from taking into the stomach a large amount of fruit, frozen or otherwise, or any other irritating substances, or if the patient has taken a full, hearty meal, the most reasonable course would be to give an active and speedy emetic. This will generally afford prompt relief. But if an emetic will not ansAver every purpose, a brisk cathartic should be administered. Our anti-bilious physic is a remedy of great value from its speedy and easy action, though I do not recommend it so often as I formerly did, or as some of our physicians now do. In the treatment of diseases, generally, cathartics are not so frequently indicated as they formerly Avere. Since the prevalence of cholera in 1834, a greater tendency to BILIOUS COLIC. 495 gastro-intestinal irritation is found to exist. But in this,particu- lar form of disease, when the bowels are loaded with acrid accu- mulations, there is nothing more certain to afford relief than the mild and copious action of our anti-bilious physic. Where the symptoms are urgent, a cathartic injection may also be resorted to, and this may be all that will be necessary, as it frequently affords immediate relief, and gives time for the operation of the physic. If some anti-spasmodic—such as the infusion of assa- foetida, castor oil, spirits of turpentine and molasses—is added to the injection, it will prove more effective and immediate in its action. Fomentations on the abdomen, when the pain is severe, will have a good effect. If, however, the pain is intolerable, and the object is to afford temporary relief before the main indication is fulfilled, the sudorific tincture may be given, and it will gener- ally answer the purpose. Or you may administer teaspoonful doses of equal parts of tinct. opium, tinct. camphor, and essence of peppermint. It will generally be necessary to obtain tempo- rary relief before resorting to more active treatment with chil- dren, as they are liable to be thrown into convulsions. The dose of the sudorific tincture should be adapted to the age of the patient; fifteen or twenty drops will be proper for a child fifteen months, old, and should be repeated once in two hours till the sys- tem is relieved. You may then follow immediately with the neu- tralizing physic, which corrects the acidity of the stomach and bowels, and often acts as promptly as an anodyne, although it possesses no anodyne property. I have seen children relieved immediately by this means. If great irritability of the stomach exists, sinapisms to the epigastrium and small doses of the neu- tralizing physic will rarely fail to have a good effect. BILIOUS COLIC. Bilious colic is a more serious and formidable difficulty than wind colic. The latter is often mistaken for it, and it is therefore thought to be far more frequent than it really is. In fact, how- ever, bilious colic seldom occurs in a life-time of practice, and this simple fact almost precludes the idea of its being connected with the liver, as the term seems to indicate. We so often find both functional and structural disturbances of the liver, that it would 496 BILIOUS COLIC. seem, if bilious colic is dependent on that organ, it would be more common. At the same time, I do not deny that the liver may become involved, that it may be too active or torpid, during the progress of this disease. But its rare occurrence in this country, and the fact that all the cases which I have treated,—being only some three or four in twenty-five years' experience, — were promptly and permanently cured by a remedy which produces no cathartic action of the boAvels, and no apparent action of the liver, have satisfied my mind that it is not in any way necessarily dependent on hepatic disturbance. Bilious colic is sometimes preceded by symptoms resembling those of the forming stage of our autumnal fevers: derangement of the stomach; sense of weariness; loss of appetite; a furred tongue, and feelings of more or less debihty. There is constant pain during the whole progress of the disease, aggravated by regular paroxysms of increased suffering, and amounting between the paroxysms, to uneasiness, rather than pain. This is at first located in the centre of, but gradually diffuses itself over the entire abdomen; and is accompanied by febrile reaction, which constitutes a marked difference between bilious and wind colic. This febrile state of the system is preceded by a chilly sensation, and is attended with frequent pulse, dry skin, furred tongue, and bilious vomiting. From the latter symptom the name of the disease is derived. But the vomiting at first is not of a bilious character. It is only after the contents of the stomach are dis- charged, and the nausea continues, that bilious matter is thrown up. The effort of vomiting often produces a regurgitation of bile into the stomach. The tongue is usually covered with a whitish coat, which, as the disease progresses, becomes thicker and more yellow. The abdomen is distended, and in the latter stage of the disease is tender and painful under pressure, Avhich, you will remember, is not the case in spasmodic or Avind colic. Febrile symptoms are common to bilious colic and peritonitis. But they may be distin- guished by the absence of bilious vomiting and paroxysms of pain in the latter, although vomiting occurs in peritonitis, Avhen inflam- mation exists in the peritoneal covering of the stomach. The BILIOUS COLIC. 497 reliable symptoms are the severe paroxysms of pain, uneasiness and restlessness, in this disease, and their absence in peritonitis. In regard to the nature of the disease, but little can be said with any certainty, and in such, cases, I am inclined to think it is wise to say but little. When I have no opinion, I desire to express none, and, in this case, the best I can do is to give the opinion which I have formed from reading and reflection, and a limited experience in this disease. It is my impression that bilious colic is really a nervous disease, and that the essential difficulty is spasm of the muscular coat of the bowels. My reason for this opinion is based upon the results of treatment and post mortem developments. I have seen bilious colic continue after copious evacuations of the bowels had been procured. If, then, the accu- mulations in the bowels were the cause, why did the symptoms continue ? Or, if the biliary secretion was the cause, why did not the symptoms subside when that accumulation was discharged ? But, so far from this, all the cases which I have treated were relieved without any evacuation of the bowels, till after the spasm had completely ceased. If I was not in possession of the remedy which I will soon describe, I should administer powerful anti- spasmodics. If this opinion is not satisfactory to you it is to me. The most common cause of bilious colic is exposure to sudden changes of temperature, when the system is predisposed to the existence of irregular neuralgic diseases. By such exposure the neuralgia is suddenly transferred to the muscular coat of the bowels, and a spasm is the consequence. The natural peristaltic motion of the bowels is thus arrested, and the biliary secretion, Avhich should pass down into them and perform its office in the process of digestion, is retained in the duodenum. From the effort of that organ to rid itself of the offending irritant, which is com- pletely barred from a downward passage by the spasm, it is car- ried up, by the inverted peristaltic motion of the duodenum, into the stomach, and is thence thrown up by vomiting. This course continues until the spasm of the bowels is relieved and the secre- tion from the liver resumes its natural direction. So also any other circumstance calculated to bring on a spasm and the conse- quent obstruction, may develop this disorder. It may, in this way, follow translated rheumatic affections, or other nervous dis- 32 498 BILIOUS COLIC. eases. The opinion, therefore, that it is produced by vitiated bilious secretions is, undoubtedly, erroneous. For, in cases of overaction of the liver, and consequent discharge of vitiated bile into the boAvels, the effect would be irritation of the mucous mem- brane and consequent diarrhoea. This view of the subject is com- patible with the soundest induction from the facts of the case, and is fully sustained by the phenomena of the liver already de- scribed. The fatality often attendant on the drastic-cathartic course, which prescribes the whole array of purgatives, from senna and manna through the long catalogue of oil and turpentine, calomel and jalap, aloes and scammony, croton oil and elaterium, and, finally, to cap the climax of folly and empiricism, large doses of metallic mercury, is strongly confirmatory of the vieAVs which I entertain, and upon which I predicate the treatment which I have to recommend. I am convinced that very few cases would prove fatal, Avith proper treatment. High febrile action, rapid pulse, sallow complexion, a greatly swollen condition of the bowels, extreme restlessness and continued constipation, would be porten- tous of evil — especially if these symptoms were apparently increasing ; while an amelioration of the general symptoms would indicate favorable results. The anatomical developments, owing to the comparative rarity of the disease, and the few opportunities consequently afforded for post mortem investigations, are less perfectly understood than could be desired, and our knowledge is, therefore, too limited to form an adequate opinion of its true character. We may suppose, however, that they would be as different as the causes producing it. So far as they have been observed, the appearances very satisfactorily sustain the views which I have set forth in account- ing for the symptoms of the disease. If it should appear that the passage could not have been obstructed by introsusception, nor by inflammation arising from an impacted condition of the bowels, then it Avould be evident that the " obstruction must be caused by some derangement or deficiency in the action of the muscular coat of the intestines." And this accords Avith the developments Avhich have been observed. A considerable portion of the bowels is usually found presenting a " cord-like contraction" below a BILIOUS COLIC. 499 distended portion, which has evidently resulted from the accumu- lations produced by the obstruction. All cases terminating fatally will have more or less evidence of inflammatory action, as a necessary consequence of the continuance of the obstruction. This is inevitable, and has been uniformly observed. The remedy upon which I rely in the treatment of bilious colic is dioscorea villosa. I have used it with entire success in all the cases that have come under my care. In one case that had been previously treated forty-eight hours with injections, fomen- tations, anodynes and cathartics, without success, the patient was relieved in half an hour by taking one dose of dioscorea. In an- other case, to which I Avas called in the night, the patient, who had been suffering severely for twelve hours, was perfectly reliev- ed in a few minutes and soothed into quiet sleep. It has never been known to fail, and I should rely upon it with entire confi- dence in all cases of this disease. The philosophy of its thera- peutic action may not as yet be fully understood or clearly explained. That it is eminently adapted to the case is very cer- tain, and that, after all, is the main point in practice. You may be interested to learn, that the knowledge of its virtues was in possession of the same old German, who has given name to our Bones' Bitters, and who was also famous in his neighborhood for the treatment of bilious colic. The recipe was obtained from him by a medical student, whom he had successfully treated in that disease, after he had been given over by other physicians. The plant is commonly called yam, and is a very modest and interesting little vine, with perfect cordate and nerved leaves, of a light green color. Once seen, it will rarely be forgotten or mis- taken. The root lies horizontally just under the surface of the ground, and is of uniform size, both ends appearing truncated. The vine shoots from the body of the root at different points, fre- quently three or four from a single root. The root is woody, varying in size, from that of a goose quill to half an inch in diam- eter, and is from six inches to one and a half feet in length. About an ounce of the root is made into a decoction in a pint of water, and half of this quantity is given at a dose. If you have not this remedy at hand, it is important to know what is next best. .1 Avould not advise an active purgative treat- 500 BILIOUS COLIC. ment till the spasm of the intestine is relieved. This may seem to be the first indication; still, if it be a well defined case of bil- ious colic, I should first of all relieve the spasm, and then the bowels will often act without much assistance. You can not expect to derive benefit from purgatives, until the principal diffi- culty is removed. And for this purpose I should give powerful antispasmodics and active diaphoretics, with counter-irritation over the bowels. Assafoetida, with the sudorific tincture, may be given in drachm doses, and repeated once in two hours, till the patient is relieved; or, if the stomach is irritable, the preparation may be administered in the form of enema, and a pill of assafoet- ida and gum opium given in doses of two grains each, and repeat- ed every two hours. In severe cases, I should have no hesitation in administering chloroform in sufficient quantity to produce its full effect, at least when the dioscorea could not be obtained. When the measures first resorted to fail, the aperient recommend- ed by Dr. Abercrombie, being, as it is, an excellent antispasmodic, might be used with the prospect of favorable results. He recom- mended small doses of aloes and hyoscyamus frequently repeated. If all these means should fail, more active measures would be worthy of consideration. In such cases, I should be inclined to administer quinine and opium, and, from theory merely, would advise you to try it, especially in the western country. Cupping over the bowels, when inflammatory symptoms existed, might also be resorted to, at any time during the progress of the disease. I have also seen excellent effects produced, when there was severe pain connected with fever, by applying a large folded towel wet in cold water, and repeated once in three or four hours, or as often as it begins to get dry. An old school physician of great respectability and skill, from Connecticut, informed me, that he had a remedy which had proved successful, in this disease. It is very similar to the remedy call- ed by Dr. Beach " Hull's bilious colic physic," and is composed of warming aromatics and active physic. The prescription is as iblloAvs; LEAD COLIC. 501 # Mace, Cloves, Ginger Root, Nitr. Potass, y da 31J. Gum Myrrh, Spn. Saffron, Cinnamon, Aloes, gij. Pulv. Mix. Dose 30 grs. every two hours. It will be perceived that this prescription is a stimulating, aromatic purgative, and I have no doubt, might have the effect of quieting the irritability of the stomach, and relieving the spasm of the bowels. At the same time, its cathartic properties would be likely to increase the peristaltic action, and thus answer the twofold indications of the case. LEAD COLIC. The third variety of colic is variously denominated colica pic- tonum, or painter's colic, and saturnine or lead colic. It gene- rally comes on very gradually, perhaps as much so as any other disease. It is supposed, and in fact known, to be produced by the slow action of a specific poison. Before any of its local symptoms are fully developed, there will be, for some days, more or less depression of the nervous functions, despondency, mental debility, and a disinclination to either mental or physical effort, with a feeling of wretchedness and gloom. If it should be the first attack, the patient will scarcely suspect the cause of his symptoms, or be aware that they are the premonitory encroach- ments of this disease. The first symptom of positive derangement is a sense of weak- ness, a sinking, collapsed feeling in the epigastrium,— a symptom peculiarly characteristic, and appearing before any positive pain is developed. This uneasiness, first felt in the epigastrium, grad- ually extends down into the umbilical region. It finally increases into a distinct pain, described as a kind of twisting sensation, similar to spasmodic action. And it is found that the bowels reallv are in a state of permanent muscular contraction, and the intestines in a positively twisted condition. Nausea is among the early symptoms, and sometimes, though not often, increases until vomiting follows. The ejections, however, are not of a bilious character, but are merely the natural contents of the stomach. % 502 LEAD COLIC. Before the disease is fully developed, the patient has a constant desire to evacuate the bowels; yet his efforts to do so are entirely ineffectual, for they are almost always obstinately constipated. A physical examination of the bowels shoAVS a very different condition from that of any other form of colic. In the other two varieties, there is usually a full, and in many instances, tympanitic condi- tion of the abdomen, while in this you find precisely the reverse. And it may be regarded as a diagnostic symptom. The bowels are retracted, with a hardened and tense condition of the parietes. The testicles are not unfrequently drawn up, and the irritation often extends to the neck of the bladder, producing difficult uri- nation. The tongue exhibits a very peculiar appearance, differ- • ing from that in almost all other diseases. It is very little furred, but appears bleached, or white, and is soft, relaxed and flabby, while in bilious colic it is thickly coated. The urine is always scanty, and sometimes almost entirely suppressed. The pain, described as being of a twisting nature, is not aggra- vated by pressure, as you will remember it is in bilious colic, while in wind colic it is relieved. This peculiarity, with the retraction of the intestines, will enable you to distinguish lead colic from the other varieties. You will bear in mind, however, that in the last stage of the disorder, when fatal inflammation has set in, a tympanitic condition of the intestines will be found, which might be mistaken for some other disease of the bowels. Inflam- mation is not a necessary attendant on lead colic, but, where it is complicated with inflammation, you would naturally expect to find the abdomen in a tympanitic condition, and such is the case. Post mortem examinations do not usually shoAV positive disorgan- ization ; yet we occasionally find it present, though it is not diag- nostic. Paralysis of some part of the system is sometimes an attend- ant symptom. Sometimes it is confined to one arm, sometimes to a loAvcr limb, and in some cases the tongue is completely para- lyzed. The authorities speak of a form of paralysis, Avhich is considered to be the result of the poisonous influence of lead, and is confined to the forearms. I have seen cases of this kind. Besides these general symptoms, there are others quite uni- formly attending the disease. Patients almost always complain of LEAD COLIC. 503 a severe pain in the small of the back, which they suppose results from the pain in the bowels, but which, in fact, is precisely the re- verse. In such cases you will find tender spots along the spine. Perhaps there is no malady in Avhich restlessness is a more trouble- some symptom. The patient experiences a constant uneasiness, and a desire to change his position. He gets up and walks about the room, gets on his knees, stretches himself across a chair, and assumes the most unusual and grotesque attitudes. These ma- neuverings may seem ludicrous and uncalled-for to the looker-on, but the patient is earnestly seeking temporary relief from his intolerable uneasiness and distress. The pain is more or less con- stant, but more severe in paroxysms, and in this respect is similar to other forms of colic. If the patient vomits freely, there is a complete temporary subsidence of all the urgent symptoms; yet the sensation of extreme Aveakness continues, and the respite from suffering is only transient. Patients usually complain more at night than at other times; not, probably, because there is really an aggravation of the symptoms, but they find less to divert their attention from their own sufferings, and time wears heavily away in the silence of night. The pulse is usually slow and hard, and, if inflammation sets in, becomes affected as in other inflammatory diseases. The skin over the whole surface is exceedingly dry and parched, but not hot, Avhile the extremities are decidedly cool. But if the disease is complicated with active inflammation, or febrile action, you will find the skin hot and dry, and the pulse frequent, small, tense and hard, according to the constitution of the patient. The coun- tenance, in all cases, is sunken, exhibiting marks of extreme suf- fering, and in some instances having a dark grizzly appearance. I have already remarked that constipation is generally attendant. Where the operation of medicine is procured, the evacuations are very peculiar, having a dark or green appearance, and being usu- ally found in lumps, thus showing a contractile and spasmodic con- dition of the bowels. Lead colic occasionally becomes chronic. Nutrition is then impaired, a constant uneasiness is experienced in the abdomen, and the Avhole system becomes emaciated. The poisonous influ- ence of the lead continues to operate until all the secretions are 504 LEAD COLIC. disturbed, and every function of the body is performed imper- fectly. As to the cause of the disease, very little need be said. The name itself implies that it arises from the poisonous influence of lead on the system. This influence may be communicated in vari- ous ways. Persons have been known to take the disease by drinking water caught on the roofs of houses covered with lead, and also from eating fruit preserved in vessels lined with lead. But the most common cause is the absorption of lead through the skin and lungs, and the most common subjects are painters, gla- ziers, and manufacturers, Avho are frequently brought in contact with the article in some of its preparations. In places where these preparations are extensively manufactured, it is a very com- mon disease, so much so as to be considered endemic, and indeed it is thought by some to be occasionally epidemic. But I cannot conceive how a disease, acknowledged by all to be produced by a local specific poison, can properly be considered epidemic. It may be that an epidemic influence would predispose the system to be more readily affected by a local poison, but it should not, therefore, be said that it is an epidemic disease. Great improvements have been made, within a few years, in the processes of lead-manufacture. The fumes of heated lead are, perhaps, the most prolific cause of the disease, and the chief improvement, I understand, consists in an invention by Avhich this cause is obviated. But I regret to find, on visiting the manufac- tories in this city, (Cincinnati,) that this improvement has not been introduced, and that lead colic is very common among the workmen. If motives of philanthropy were as strong as the in- stinct for "making money," the occasion for this remark would not long exist. You will already have observed that the diagnostic symptoms are, retraction of the bowels, with a hard and sometimes knotty feel, without tenderness; paroxysms of pain; a cool skin and unexcited pulse. In addition to this, the history and circum- stances of the case will naturally suggest the nature of the dis- ease. If the patient is engaged in the manufature of lead, or follows the occupation of a painter or glazier, or is otherwise brought in contact with the poison, and has the symptoms just LEAD COLIC. 505 described, we would be justified in concluding that it Avas a case of lead colic. The prognosis, as a general thing, may be considered as favor- able. In a large majority of cases, when the cause is removed, the system will be able, without the assistance of further med- icine, to recover. But a proper course of treatment Avill cer- tainly shorten the disease in its course, and save the patient from a vast amount of suffering. In regard to the anatomical developments little can be said, as pathological researches have not thrown much light on the sub- ject. The bowels, and especially the colon, are often found almost closed up by the muscular contraction, though they exhibit no traces of local inflammation. The nervous system has been carefully examined, and in some cases the brain and spinal mar- roAV have been found seriously involved, while in others they exhibit no traces of disease. But since we find cases of local paralysis, depending on the disease, it is reasonable to suppose that the poison acts on the nervous system. In the treatment of this disease, the indications are to mitigate the immediate sufferings of the patient, and eliminate from the system the poison that produced the difficulty. The remedy which I am about to recommend for this purpose, was at first used empirically, like nearly all others. But the theory of its operation is exceedingly plausible, and its action, so far as my experience goes, fully sustains the theory. And I think that a careful analysis of its operation and effects will recommend it to any physician, and especially to the chemist, as admirably adapted to fulfill the indications. We have, then, in our Pharmacopoeia, a remedy called White Liquid Physic, the formula of which is as follows: # Sulph. Magnesia, 3 xij. Nit. Pottass, 3 ss. Sulph. Acid, 3 j- Boiling water, qt. j. Mix. This prescription is administered with a view to neutralize the poison, and act as a purgative. Admitting that the system is poisoned by the absorption of lead, you will perceive, on a moment's reflection, the operation of this remedy. It contains an 506 LEAD COLIC. excess of free sulphuric acid, which unites with the lead, and forms the sulphate of lead—a harmless and insoluble salt. If it be asked how the sulphuric acid can reach the lead, the answer is perfectly simple and philosophical. For if it is reasonable to suppose that the dry lead is absorbed into the system and circu- lates in the fluids of the body, or remains stationary in certain parts, it is even more reasonable to suppose that the liquid antidote may be absorbed and circulate in the same way, and thus reach and combine with the lead in an inert compound. It is generally admitted by the profession, that other medicines are absorbed into the circulation when taken into the stomach, or otherwise brought into contact with the system. So it is with this. The sulphuric acid is absorbed, and, being carried through all the ramifications of the circulating system, sooner or later comes in contact with the lead, in whatever form it exists, whether as the carbonate, acetate, or any of the oxides, and, having a stronger affinity for that metal than any of the acids with which it may be combined, unites Avith it to form the inert sulphate, Avhich can be thrown off at leisure. This remedy should be given in tablespoonful doses every few hours, until a full and free action of the bowels is produced. The sulphate of magnesia, which it contains, will act as a cathartic, removing effete matter. After a thorough evacuation is obtained, the medicine should be continued in smaller doses, to keep up a gentle action of the bowels, and give time for a thorough absorp- tion of the acid. If it should be necessary to aid the cathartic action, you may resort to the use of liberal lavements with a tube and pump. By this means you will secure an evacuation of the loAver bowels, and thus give the contents of the upper portion of the intestines room to settle doAvn. The common stomach pump, Avhich you will find in most apothecary shops, will answer every purpose. The injec- tion, in this case, should be of a cathartic character, instead of simple water. I have used our anti-bilious physic, in double doses, and usually with good effect. Castor oil, turpentine and molasses may also be used. A weak solution of tobacco—say a drachm to a pint of Avater, and one-half at a time—is another remedy; but you should be very cautious in administering this LEAD COLIC. 507 article, as it often produces the most alarming symptoms—nau- sea, cold sweat and extreme prostration. When the sufferings are very severe, it is important to relieve, as much as possible, the urgent symptoms. For this purpose, I would recommend a preparation of morphine and assafoetida, which is an excellent anti-spasmodic. You may also apply hot fomentations over the abdomen. You cannot expect the cathar- tics, or any remedy, to give immediate relief. The cure must be effected gradually, and you should therefore palliate, as much as possible, the sufferings of the patient, while the main curative remedies are operating for the removal of the cause of the dis- ease. When I have found it desirable to mitigate the pain in the small of the back, I have been in the habit of applying a cup to the tender spot, with decided benefit. Since we find in this disease palpable derangement of all the secretions, it is of the highest importance to induce free perspi- ration. By this means the secretory organs will be opened, a large amount of matter, embarrassing to the system, and productive of injury, will be thrown off, and patients rendered more calm and easy. If the morphine and assafoetida do not act in this way, to the extent desired, you may administer our sudorific tincture in conjunction with some mild diaphoretic tea. In this connection I will mention another article, which may be used to fulfill the above indication, and which also has a high reputation as a cura- tive remedy. It is the glechoma hederacea, commonly called ground ivy, or Gill-over-the-ground. I have been told, by a num- ber of painters of considerable intelligence, who were subject to lead colic, that they have used the article with complete success, both in warding off the disease in its early encroachments, and curing it Avhen fully developed. It is a modest little plant, found in almost all the woods and bottom lands of the West, and is given in decoction. Alum has been recommended, as a curative measure, by some of the highest authorities. Dr. Eberle and Dr. Wood have both used it Avith prompt success, in cases which " had resisted mer- curial treatment." And yet Dr. Wood calls in question its modus operandi on the cause of the disease, without giving, as you will 508 LEAD COLIC. observe, any substantial reason for so doing. Whereas, the fact is well known that the sulphuric acid, contained in alum, has a stronger affinity for lead than it has for alumina, and it requires something more than Dr. Wood's mere dictum to set aside the theory that this acid can " follow the salt of lead in its course through the system, and change it, wherever overtaken, into the sulphate." A few words in regard to prevention. It is as much the duty of the physician to prevent disease, when he can, as to cure it. You should caution your patients not to allow lead to come in contact with the skin. And indeed you will often see painters, and other Avorkmen, who are prudent, using the precaution to slip on a suit of over-alls, protect the hands with gloves, and bathe every night in greatly diluted sulphuric acid. They should espe- cially Avash their faces and hands two or three times a day, when at work, and also be careful, when working in rooms, to have a free circulation of air. It is probable that the turpentine, with which the lead is mixed, renders it more easily absorbed. People should, therefore, be Avarned against going into or living in houses newly painted. I haAre, in a number of instances, been called to see whole families, who were suffering from nervous diseases occa- sioned by sleeping in such houses. The symptoms, in such cases, are, usually, nervous excitement, pain in the back and head, with slight nervous fever, and some uneasiness at the stomach. Re- moval from freshly painted rooms, if possible, thorough ventilation at all events, attention to the diet, and mild evacuants, giAing the preference to lavements, and proper diaphoretics, will generally be all the measures necessary in such cases. LECTURE XXXII. OBSTRUCTION OF THE BOWELS, ETC. Obstruction of the Bowels. General Remarks — Symptoms — Causes — Treatment — Concluding Remarks. Constipation : General Remarks—Symptoms—Causes—Treatment—Case stated —Diet—Treatment of obstinate Cases. In connection with the subject of colic, I desire to detain you a short time in making a few remarks on a subject allied in some respects to those we have just been considering. Obstruction of the bowels often results from other causes than those connected with colic, and it is to these difficulties I desire to call your atten- tion at this time. Those cases resulting from an impacted condition of the colon, generally come on slowly, and without manifesting any particular symptoms for some time. The extent to which the bowels some- times become impacted is almost incredible, and is accompanied of course with loss of action in the bowels, and with more or less of dyspeptic symptoms. In some cases, it is said, individuals have gone for months without jiaving a passage. In cases of impacted colon, when measures, such as injections, have been taken to procure a passage, the entire contents of the boAvel below the obstruction may be brought away without affording relief. The symptoms that usually accompany these cases are, more or less local pain; the tongue generally furred, being covered with a white coat; a bad taste in the mouth; a feeling of general debihty, and the skin dry, though without any febrile symptoms as shown by the action of the heart. The stomach also, sooner or later, sympathises, and becomes irritable, and sometimes there 510 OBSTRUCTION OF THE BOWELS. is vomiting of bilious matter. It is said that in some cases ster- coraceous matter has been discharged in this way, where there was obstruction merely from accumulation. If the accumulation is great, more or less distension of the abdomen will be observed, and always upon examination a feeling of irregularity will be dis- covered in the region of the colon, and often very sensible at some particular spot. This I have seen in a number of cases; in some instances the hardened and impacted accumulations could be distinctly felt in the right groin, at or near the head of the colon; while in other instances it Avas found equally distinct in the opposite side, at the other end of the large bowel. These cases, however, exhibited symptoms of inflammatory action, pro- duced evidently by the accumulations, since the symptoms sub- sided entirely upon their removal. Associated with the general symptoms of fever, was a sensible pain, and great tenderness upon pressure at the point of the accumulation. Generally, in cases of obstruction in the colon, unless inflammation is excited, there is but little general disturbance, nor does the stomach become greatly affected, except with the less marked symptoms of indigestion. Cases are related in the journals and books, of individuals who have had but one or two evacuations from the bowels in a year'or longer, and that, too, without apparently suf- fering materially in health or comfort. Permanent obstruction of the bowels may result from tumors originating in the mucous or muscular coat, thereby preventing altogether, or in part, the free passage of their contents. This condition of things will generally be manifest by the gradual manner of its occurrence, and from the general and constitutional symptoms Avhich such a state of the system would naturally excite. Of this character, cancer is supposed to be the most common, and when this is found to be the nature of the case, it is of course hopeless and incurable. But the most common cause of obstruction, except that which depends upon mere accumulations, and by far the most singular cause, is found in the invaginated condition of the boAvels. This is called introsusception or invagination, and by some of the authorities, ileus. This is a mere introduction or falling in of one portion of the boAvel into another. It usually takes place from OBSTRUCTION OF THE BOAVELS. 511 above downwards, but I believe cases are mentioned where the reverse has been found. It occasionally occurs in the progress of bilious colic, from the spasmodic action of the bowels usual to that disease. It is supposed to be possible that this invagination may occur in almost any portion of the boAvels, but the usual point at which it is found is at the union of the small with the large intes- tines. The peculiar arrangement of the intestinal tube, at this particular point, affords a reasonable explanation for its greater frequency there than elsewhere. But I have myself observed it at the sigmoid flexure of the colon. An illustration of the par- ticular manner in which introsusception takes place is very well showTn in a common complaint among children, which I have also frequently seen in adults, to wit: prolapsus ani. Here it will be observed is a natural fixed point, made by the sphincter muscles, at the loAver extremity of the intestines, and, from the loose and relax- ed condition of the bowels, together with more or less spasm of the muscular coat immediately above this point, the portion above the sphincter is forced through that opening, during defecation, and protrusion of the irritated boAvel is the consequence. From the obstruction in the capillary vessels, caused by the stricture from the spasm at the invaginated point, gangreen and sloughing are very likely to follow. When this does occur, death is the usual and natural consequence, though a few cases have been observed, where adhesions had formed between the opposing surfaces of the intestines, thus invaginated, while the slough was thrown off and discharged from the bowel. The stercoraceous vomiting has generally been considered the main diagnostic symptom of introsusception of the bowel. But since it has been knoAvn to accompany cases of obstruction arising from other causes, it cannot be relied on with entire confidence. Yet it so rarely occurs from other causes of obstruction, and is so invariably connected with introsusception, that its presence, as a general thing, is even more than prima facie evidence of this difficulty. It should not, however, be relied on exclusively, since other evidences, confirming this conclusion, can be easily recog- nized. When this symptom occurs in the progress or at any stage of bilious colic, it may be reasonably concluded that introsusception has taken place. So also when it occurs suddenly, Avithout any 512 OBSTRUCTION OF THE BOWELS. previous indisposition, or when it follows the operation of a cathar- tic administered for an ordinary disease, and, at the same time, a fixed pain with a distinct tumefaction, and more or less tenderness at some point in the track of the colon, can be perceived, the existence of introsusception would be reasonably inferred. The case reported by Dr. Bigelow, of Hon. Hugh S. Legare, then Attorney General of the United States, under the adminis- tration of Mr. Tyler, was a remarkable instance of obstruction from tAvisting of the bowels. This took place at the sigmoid flexure of the colon. The spasm of the bowel had partially drawn the sigmoid flexure into the right hypochondrium, and the bowel had become so twisted as to present a firm cord or neck to the twisted portion, and upon untwisting it, it was found that four turns had been made, or " two entire revolutions." The most common cause of obstruction from an impacted con- dition of the colon, is sedentary habits, or long continued confine- ment, or it may depend upon inactivity of the bowels, growing out of indigestion or chronic affections of the liver. Obstruction may also be produced by solid concretions, such as gall stones, or by the long continued and daily use of calcareous substances, or by the frequent use of preparations of magnesia, taken for a long time as physic. Nuclei may be formed out of some solid sub- stance accidentally swallowed, around which the secretions from the liver and other glands, tributary to intestinal accumulations, may form concretions, which will be gradually increased till ob- struction to the bowels occurs. The most common cause of obstruction, produced by invagina- tion, I have no doubt, will be found connected either with a rheu- matic or gouty condition of the system. The few cases of this description which have come under my observation, have all resulted from a sensible and sudden translation of rheumatic affec- tions to the intestines. And I have httle doubt, that, if intro- susception had not suddenly occurred, the disorder would have resulted in bilious colic. Treatment. In cases of obstruction of the bowel, from accu- mulations in the colon, the only indication presented, will be a free discharge from the bowels. This may, in some cases, be accomplished, to a satisfactory extent, by the use of a stimulating OBSTRUCTION OF THE BOAVELS. 513 and purgative injection. If this should not be adopted, or if tried and found unsuccessful, a free and speedy cathartic should be given. Our anti-bilious physic is well adapted to fulfill this indi- cation ; and it may be aided, when the bowels are found unusu- ally torpid, by an injection of a double portion of the same pow- der, or, if preferred, four ounces of castor oil, a drachm of spirits of turpentine, and a sufficient quantity of warm water. This may be thrown far up the bowel by means of a gum tube and a stom- ach pump. If the bowels fail to respond to these several calls upon their dormant energies, you might then administer one grain of podophyllin and two of leptandrin, repeated every four hours, till their cathartic action is produced. These means, or such of them as the circumstances of the case seem to indicate, will rarely fail to afford relief. In cases of obstruction of the bowels dependent on introsuscep- tion, it will be worse than useless to attempt to force a passage with active cathartics; as in that case the action of the purgative only adds to the existing spasm, and greatly diminishes the chances of relief. The indication in these cases is not so much to procure an operation of the bowels, as to relax the spasm and to relieve the invaginated condition, when the natural peristaltic action of the bowels will generally be sufficient to secure their evacuation. This indication will generally be fulfilled by the use of large quan- tities of anti-spasmodic and cathartic lavements, thrown far up the bowels with the force pump and tube, and by the internal administration of mild, aromatic, anodyne anti-spasmodics and aperients, together with applications of fomentations to the abdo- men, or the use of a large cup, such as a very large tumbler with the air exhausted by a lock of light burning cotton, or some other similar application, such as the exhausted receiver, applied imme- diately over the seat of the obstruction. This, by drawing up into the exhausted vessel, a large portion of the integuments, would tend to relieve the internal viscera of the superincumbent pressure, and thereby favor the internal expansion, and make- more direct room for the invaginated bowel to be drawn out. It has been found in a number of cases to afford immediate relief. The injection should be composed of a solution of ten grains of the extract of hyoscyamus, an infusion of a drachm of assafoetida,. 33 514 OBSTRUCTION OF THE BOWELS. and a gill of castor oil, in a sufficient quantity of warm water to fill the boAvel as full as it will hold. It should be repeated if it comes aAvay. This measure is probably more reliable and more frequently successful than any heretofore used. There is no probability that fluids thus thrown up the bowel with whatever force, or however far short of the head of the colon, can pass the ileo-coecal valve. But it is not only possible that the bowel below the obstruction may be so far distended, with a Avarm, soothing and anti-spasmodic fluid, as to draw down the head of the colon, and thus leave the invaginated portion, but it accords with experience and sound philosophy, and has been done in many cases. I have myself seen two well marked cases, resulting from translated rheumatic affections, in which stercoraceous vomiting had existed for a number of hours, very speedily relieAred, and the patient finally restored by this measure. It should be accompanied or preceded, if the case is not an urgent one, especially when the stomach is very irritable, by small doses of our common neutral- izing mixture, with a sinapism to the stomach, repeated every hour, till the irritation of the stomach is relieved. It may then be increased to an extent sufficient to correct acid secretions, and moderately and quietly increase the peristaltic movement of the boAvels. It thus tends to divert and relieve the spasm, while, at the same time, it secures the constant fluidity of the contents of the bowel above the invaginated portion, and in this way keeps up a condition of the parts involved exceedingly favorable to relief. Tobacco injections have been resorted to in this affection, but from all I can learn in relation to it, the practice has not Avon for itself that favor which its early advocates seemed to claim. It is a most potent remedy, and should be used with great care. I have never used it in this affection, but have seen it used in one or two other cases, in which it exerted a poAverful influence, pro- ducing nausea and vomiting, accompanied Avith extreme prostra- tion, a mere thread of a pulse, and a cold, clammy SAveat; in each case the patients recovered from its effects. It is safe to make a decoction of a drachm in a pint of AYater, and use half of it at a time. In cases attended with severe suffering, resulting from the OBSTRUCTION OF THE BOWELS. 515 spasmodic action of the bowels, it may be necessary to administer pretty large doses of opium. The objection to the use of opium in cases of obstruction from torpor of the bowels or an impacted condition of the colon, does not exist in spasmodic cases. On the contrary, it is one of the best anti-spasmodics that can be given in such cases. Almost every practitioner has his favorite prepa- ration of this drug. But its general influence on the system is, no doubt, nearly the same, whatever preparation may be used. In combination with other therapeutic agents, however, important indications may be fulfilled, which can not be by the simple rem- edy alone, without, in the least, impairing the specific action of the opium. Our diaphoretic powder is perhaps the best prepara- tion in these cases, and should be given in ten grain doses every two hours, till the object is attained, or the specific effects of the opium are produced. Many valuable lives doubtless have been saved by persevering efforts of the physician, and you should not abandon your patient, though disappointed in your expectations, in the administration of your favorite and most successful measures. If therefore, you have administered one after another of those remedies, which rea- son and experience alike suggested, till you have gone through with all your reliable measures; still, if the patient is not evi- dently in articulo mortis, you should not abandon the case as entirely hopeless. I have stood over patients, in many instances, when but few rays of hope were left to encourage to perseverance, and while the friends were almost disposed to censure me for the administration of medicine, and have, in such hopeless cases, so frequently been rewarded by seeing my patients revive and finally recover, that I cannot too earnestly impress upon your minds the importance of hopeful perseverance. After every thing else has been tried in vain, and there appears to be otherwise no hope, the abdomen might be opened, and the twisted or invaginated state of the bowels relieved. This has been successfully performed in a few instances, and, when the constitution is othenvise healthy and in good condition, I should have no hesitation in recommending the operation as not only practicable, but by no means to be omitted. 516 CONSTIPATION. CONSTIPATION. I propose, in the present lecture, to confine my observations to that habitual form of constipation which is dependent upon a want of that regular action of the bowels necessary to health, which is not connected with any other affection, and does not produce any Bpecial symptoms of active disease. This course is rendered proper, since we have already considered, or shall hereafter con- sider, the various affections in which constipation is a prominent symptom. In prescribing for a case of this kind, it is necessary to take into consideration the habits of the individual, and the character of the evacuations. Only a small portion of what an individual, in health, takes into his stomach, if the requirements of the sys- tem are regarded, is destined to be evacuated by the bowels. The amount thus removed, is made up, in a great measure, of those effete and waste materials which every system, in a healthy con- dition, daily eliminates for the purpose of that constant change and removal necessary to perfect health. If, therefore, an indi- vidual takes but a moderate quantity of simple food, and it is ascertained, on particular inquiry, that his evacuations are of a healthy character and of proper consistency, though they should not be as frequent as might otherwise be necessary, it would not be best, in such a case, to interfere; as I have generally found the attendant circumstances show that there is sufficient elimina- ation of waste material through the other emunctories of the sys- tem, the skin, kidneys and lungs, to admit of perfect health. I have witnessed cases of this kind in numerous instances, among adults, as well as children. I have often seen the healthiest and most robust children have evacuations only every other, or every third day, while the discharges from the bowels were not costive, and were otherwise of a healthy character. In such cases, the greater part of the food is appropriated, and leaves but a small amount to pass off with the effete matter eliminated from the glands about the bowels. It may thus be seen that the regular diurnal movement of the bowels, so essential to a perfect state of health in a majority of individuals, may be greatly Araried Avithout CONSTIPATION. 517 impairing the healthy condition of the system. If the statements made by some of the authorities are reliable, the extent to which the systems of many individuals can tolerate costiveness, without any apparent evil effects, is truly astonishing. In recurring to my own experience, I can account for the apparent good health which such individuals enjoy, only on the theory of the vicarious or substituting action of other organs of the body. But, although the evidences of derangement are not immediately manifested to any great extent, in such cases, yet subsequent observation will generally show that the system will, sooner or later, suffer penal- ties usually proportioned to the extent of the violation of organic laws. Hence, it is no unfrequent occurrence, that systems thus disordered are afflicted with rheumatic or gouty disorders, or " blessed " Avith a succession of boils, or chronic ulcers, or other anomalous eruptions. Individuals who are having evacuations from the boAvels only once in three or four days, or as many weeks, to say nothing of double and treble that number of months, as stated by some of the authorities, should be admonished that the habit is fraught with peril. In this form of constipation, although it is unconnected with organic disease, and though no general acute symptoms either of functional disorder or nervous suffering are present, the system becomes so far deranged as to manifest an evident abnormal state in many of its functions. Thus a coated tongue and bitter taste in the mouth will generally be complained of. Sometimes there is nausea, and a sense of fulness in the stomach and bowels, with sour eructations, borbarigmi and vertigo, frequent turns of head- ache, foul breath, an offensive state of the other excretions, and often a strong urinous smell, and a dry, harsh state of the skin. If the bowels are not greatly distended with flatus, a hard, une- ven condition, especially in the course of the colon, will be felt. If the inconveniences of all these abnormal derangements, with the general contaminated state of the system which is sure to fol- Ioav, were all the evils that grow out of a habit of long continued constipation, the reasons for the removal of the difficulty would not urge themselves so forcibly upon us. But where experience teaches us that this state of the system lays the foundation for more serious and formidable diseases, such as enteric febrile dis- 518 CONSTIPATION. orders, hemorrhage of the lungs and bowels, hemorrhoidal affec- tions, and stricture of the rectum, dyspepsia, apoplexy and epi- lepsy, and many other affections, it becomes a matter of no light consideration. Besides these diseases of the physical system, the moral and intellectual faculties are probably no less frequently disordered. Hence, melancholy and hypochondriasis, with an attendant metamorphosis of temper, and even mania, are common in this disease. Constipation, like many other affections, appears sometimes to be hereditary, or, at least, is evidently constitutional in some families. But where this is the case, we generally find a substi- tuting evacuation in the more copious secretions from other organs. It is most common to persons of sedentary habits, such as students, professional men, shoemakers, tailors and artisans, and it is a frequent attendant on sea-faring individuals, so that, though they may have a safe and prosperous voyage, yet they may have a " hard and troublesome passage." Conducive, also, to constipation or torpid bowels, is too great refinement in living, or the use of those articles of diet that contain a small amount of excrementitious matter, thereby not affording that stimulus to the bowels ordinarily required. It may also be produced by the free use of stimulating and astringent condiments and drinks, such as cinnamon, cloves and spices, and port and some other varieties of wines. Another prolific source of evil, and, indirectly, a cause of habit- ual constipation, is the frequent use of purgatives, which many nervous and hypochondriacal persons are in the habit of taking, without reference to the ultimate influence they must have on the bowels, and without a thought that anything else but purgatives will ansAver their purpose. In fact, they seem to think it is only necessary to eat and take physic. Habitual constipation, I am well convinced, is produced, also, by the free use of calomel and other preparations of mercury, in the treatment of fevers and other diseases, as well as the domestic use of that drug, so often taken to obviate costiveness,—the very disease, perhaps, its use has created. By its over-stimulating influence on the liver, an indirect torpor is produced, and, as the secretion from that viscus is the only natural purgative of the boAvels, when it is deficient, CONSTIPATION. 519 the bowels, as a matter of course, become costive. Constipation is also a very frequent attendant upon pregnancy, being produced, in part, by the want of the accustomed exercise which that state usually requires, and, in part, by the mechanical impediment which the gravid uterus imposes upon the large bowels ; to obvi- ate Avhich is sometimes a difficult matter, and not unfrequently one of great importance. Treatment. That form of constipation which is generally met with, requires no active treatment; the use of the means which I will soon recommend will be all that is necessary to remove the difficulty. But we occasionally find cases that require the employment of tolerably active measures to remove the accumu- lations which this state of the system has produced in the large intestines, and here and there we find a case in which the most active measures, and a resort to all the adjuvant means which experience can suggest, are necessary. When a full cathartic action is required, few remedies, and none, according to my expe- rience, Avill be found so well calculated to fulfill this indication, as our anti-bilious physic with equal quantities of cream of tartar. It has the advantage of being mild in its action, and quick and thorough in its operation. It will rarely disappoint the expec- tations of the physician in this respect. The two should be given in drachm doses, each, in half a tea-cupfull of cold sweetened water, and repeated in two or three hours if it does not operate. If, however, the case should prove more obstinate than was expected, its operation should be assisted by an injection. This should be made of castor oil, turpentine and molasses, or two drachms of the anti-bilious physic may be mixed in half a pint of warm water, and thrown far up the bowel with a force pump and tube. This course will rarely fail to afford the desired relief. But now and then a very obstinate case occurs, in which such a degree of insensibility of the bowels exists that no ordinary measures will be sufficient to answer the purpose. I have, in a few cases of this kind, found two grain doses of podophyllin and four of leptandrin to produce most copious and bilious evacuations, in about six or eight hours, without the aid of injections. If its action did not begin to be felt, either on the stomach or boAvels, in about four hours, it should be repeated in slightly increased 520 CONSTIPATION. doses. The first effect of this medicine, in these large doses, is often a most copious emesis, which will rarely fail to be followed by a similar copious action of the bowels. This remedy will be indicated in any cases where the constipation is dependent on torpor of the liver. But where the constipation is not peculiarly obstinate, the remedy should be commenced in much less doses, say half a grain of the podophyllin and one grain of leptandrin, and repeated every three hours till the cathartic influence is realized. In this way it rarely fails to bring aAvay free bilious stools. It has another advantage, also, in that its action both on the liver and boAvels is more permanent, and torpor of those organs is much less likely to follow its action, than almost any other remedy I have ever used. With these various measures properly employed, I do not hesi- tate to promise success more prompt and certain than can be expected from any other means that I have seen tried. I very Avell remember an interesting case in a neighboring town, Avhich I was invited to see. It was that of a young physician of respect- ability ; nearly all the physicians of the town, some four or five, were in consultation, but bad given up the case as beyond the reach of remedies. Upon examining the patient, I found a full and distended state of the bowels, to which a large blister had been applied. The stomach had become very irritable, so that medicine had recently failed to remain on it. After the exam- ination, I found it to be the opinion of all the gentlemen present, that it was useless to attempt any further measures. My views being sought, they were surprised upon being told that I thought the patient ought not to die, and they desired to know how it could be prevented. I suggested the course which I should pursue, if the patient were mine, and that course was adopted. A soft bread and milk poultice was applied to the blistered surface, and dessert- spoonful doses of a decoction of our compound neutralizing physic were administered every half hour, until the irritability of the stomach was relieved, and then folloAved by a full dose of the anti-bilious poAvder. By the next morning, the physic had oper- ated, the patient was relieved, and finally recovered. In cases of habitual constipation, Avhere there is no evidence of any great accumulations in the boAvels, it is not necessary to CONSTIPATION. 521 resort to active cathartics. The indication then to be fulfilled, is to obviate the influences or remove the cause, producing the dif- ficulty. The habits of patients should be attended to; they should be directed to take as much exercise in the open air as they can well endure. The directions I have heretofore given, when speaking of indigestion, equally apply to this form of disease. But one of the most important points to be gained, is to induce habits of regularity, either by the use of suitable diet, simple lave- ments, or the administration of such gentle tonics and aperients as will overcome the torpor of the bowels. When the case pre- sents no general indication for the use of tonics more than is manifest from the mere atony of the digestive organs, the demands of the case will frequently be answered by an appropriate diet, and attention to the cause of the disorder. Rye mush and molas- ses may be mentioned as efficient in keeping the boAvels open. Bread made of unbolted flour will sometimes answer a similar purpose. The free use of fruit, Avhen the patient can bear it, frequently has the same effect. The old fashioned rye and indian bread, if used as the main article of diet, of the bread kind, will rarely disappoint your expectations. It affords an amount of nu- triment sufficient for the system, and will be as acceptable to the taste as any bread that can be used. If the bowels cannot be kept open and properly regulated by attention to diet alone, the patient should be directed to take a lavement of cold water, or, if necessary, to begin Avith, molasses and warm water may be substituted, at a stated period, every day, in order to induce a habit of regularity at stool. This will often answer quite as good a purpose as physic, and is much to be preferred, in most respects, if practicable. The necessity for the habit of regularity in these cases, is of too much importance to be slightly passed over, since experience teaches that regularity of the bowels is often as much under the influence of habit, as the return of hunger or any other demand of the system. Patients should therefore be directed, at a par- ticular and stated time every day, to solicit a call for an evacu- ation from the boAvels, whether there is any inclination or not, and the aid of the lavements will rarely fail to answer the purpose. 522 CONSTIPATION. But when constipation is connected with hepatic obstruction or general debility, these simple hygienic measures will scarcely be sufficient, and resort to medicine becomes most generally imper- ative and necessary. Such cases will usually be benefited by using in combination moderate tonics and cholagogue aperients. There is perhaps no one remedy more beneficial in such cases than our common gin or Bone's bitters, with the addition of a small portion of podophyllum, administered in sufficient doses to pro- duce one free evacuation a day. When thus prepared and given, you may expect, in a short time, to discover its action on the liver, by a change in the character of the evacuations, accompanied by general improvement. In those cases which will bear this stim- ulant, feAY if any other general remedies will be required. If there is a mere torpor of the bowels, without any particular inac- tivity of the liver, and especially if there are any objections to the use of the bitters, one or two *anti-dyspeptic pills may be given every night; this will generally procure one free evacuation every morning. Or the compound taraxacum pill may be used to fulfill this indication. * # Ext. Gentian, } Ox. Bismuth, >• da 3 ij Pulv. Aloes, ) Colocynth, f Gamboge, > da 3i Cast. Soap, J Oil Cloves, 3^s Mix, form pills ordinary size. Dose 1 to 4. LECTURE XXXIII. CHOLERA MORBUS OR SPORADIC CHOLERA. Introductory Remarks— Character—Symptoms— Cause — Predis- position — Anatomical Character — Diagnosis — Treatment. In the consideration of this subject, I shall not include the Epi- demic variety of the disease, nor Cholera Infantum, as the former will folloAV what I propose to say on the subject of Cholera Mor- bus, and the latter will be discussed separately. There are few diseases more common during the summer months than Cholera Morbus, or as it is called by some modern authors, Sporadic Cholera. The leading characteristics of this disease are vomiting and purging; while the character of the evacuations depends upon the cause of the disease, and the attendant circumstances of the case. In most cases the contents of the stomach and bowels will be discharged, and in severe cases the dejections, following the ordinary accumulations, will present a thin, dirty yellow color, and from that to an almost colorless liquid, having a slight milky, or flour-gruel appearance; while in some very severe cases I have witnessed the peculiar rice water evacuation, considered so characteristic of Asiatic cholera. But in less violent cases, after the contents proper of the bowels have been discharged, the de- jections assume a more bilious appearance, and are not so copi- ous, and are mixed with more or less slimy and albuminous matter. In the more aggravated cases, little else is thrown from the stomach, after the first free emesis, than the fluids that are taken in, mixed Avith a glairy mucus. But in the less severe cases, the act of vomiting increases the biliary secretion, and changes the peristaltic movement of the duodenum, and bile is thrown off. 524 CHOLERA MORBUS. And in some cases, when over-action of the liver and an attend- ant accumulation of bile has taken place in the stomach, bilious matter will be thrown up from the beginning. This is not, how- ever, in my experience, a common occurrence. The vomiting and purging, in most cases, come on in parox- ysms, occurring every ten or fifteen minutes; often simultaneous, but more commonly the vomiting takes place first, and immedi- ately thereafter, there is a call for the stool. For a few moments the evacuations seem to give relief, and the patient lays back in bed exhausted and comparatively easy. Thus the case progresses, with alternations of ease, and paroxysms of vomiting and purg- ing, until the patient becomes exhausted, the extremities become very cold, and there is generally an exudation of a cold, clammy perspiration from the surface, and severe cramping of the mus- cles. Finally, rice water discharges, with a general collapsed condition of the system, occur, and the patient sinks into a com- atose condition, and dies from exhaustion of the vital forces, in a state of universal congestion. Or, as is more commonly the case, the system rallies, the vom- iting and purging become less frequent, the extremities become warm, and finally a reaction comes on, and the patient gradually recovers under a slight febrile excitement, which soon subsides and leaves him entirely relieved. The vomiting and purging rarely commence suddenly, but are preceded by more or less uneasiness, sometimes with severe gri- ping pains through the bowels; and generally a great commotion is felt, with a sensation of fermentation, together with slight nau- sea, for some time previous to the full development of the disease. Often a sensation of fullness and a burning feeling in the stomach, precede an attack of cholera morbus. When fully developed, few diseases are, for the time being, more distressing and severe; but in most cases it is a self-limited disease, subsiding spontaneously when the accumulations have been discharged. And even where the irritation is disposed to be per- sistent Avhen left to itself, it Avill generally soon yield to appro- priate remedies. During the active symptoms of cholera morbus, it is very rare for the system to exhibit any general evidences of fever; though CHOLERA MORBUS. 525 the patient is often tortured Avith an insatiable thirst, the pulse being small and the surface of the body cool, especially that of the extremities, which are often extremely cold. But after the vomiting and purging have ceased, whether from a spontaneous decline, or from the aid of medicine, a moderate degree of febrile reaction usually occurs, and in some instances a high grade of fever supervenes, with a persistence and severity not common in such cases. In most instances, the fever is of but short duration, and leaves the patient only moderately debilitated, rapidly to recover. If irritating or drastic medicine has been administered during the active stage of the disease, or following its decline, the febrile reaction is more likely to be severe, and to continue for a much longer period, and may degenerate into a low grade of irritative fever, Avhich, if improperly managed, may prove fatal. However severe the attack, sporadic cholera, if properly treated, rarely proves fatal, and indeed, without any treatment, a large majority of cases will get well. Causes. During an extensive practice of many years' dura- tion, in a section of country where cholera morbus may be con- sidered as one of the most common diseases, I have no recollec- tion, and no impression has been left on my mind, of ever havino- met with a case of well defined cholera morbus, in which I was not enabled to trace the immediate exciting cause of the attack to some article either of diet or drink taken into the stomach. I do not intend to include, in this remark, those cases of bilious vomiting that sometimes attend the early stage of bilious fever • nor those cases of masked intermittent fever that I have often seen, Avhich show themselves in the form of vomiting and purging at the regular periods for the paroxysm to return; nor those cases of irritation of the stomach, produced by worms in children. I apply it simply to the ordinary cases of sporadic cholera so com- monly seen during warm weather. There is no doubt, however that many circumstances greatly modify the organic functions and thereby produce an unusual predisposition to cholera morbus. The occurrence of warm weather, with its relaxing influence on its first approach, tends to derange the functions of the system, so that upon slight exciting causes, the disease may be developed. 526 CHOLERA MORBUS. This circumstance, in connection with the free use of green suc- culent vegetables as a diet, readily accounts for the freqent occur- rence of cholera morbus, during the early part of summer. It is also quite common during early autumn, when fruits and melons are plenty; as they abound in saccharine elements, and thus furnish the materials for fermentation, and most persons are apt to partake of them to excess. There is no doubt, also, that the enervating influence of marsh malaria, occurring at this season of the year, affords an additional reason for the frequent occurrence of the disease. A sudden check of the perspiration, when only the ordinary food and drinks have been taken, may be occasionally the only apparent cause of the disease; but in this case the stomach will be found to contain imperfectly digested food that had been previously taken. Unfermented cider often gives rise to the disease; and persons unaccustomed to the use of stimulating drinks, as Avine or other spirits, are liable to be attacked after too freely indulging in them. In short, all sub- stances furnishing the elements for fermentation, occasionally produce an attack in a person whose system is predisposed to the disease. In connection with predisposing causes may be mentioned family or hereditary predisposition. This we often meet with, and it should always be borne in mind Avhen giving directions concerning articles of diet in such families. In short, any cir- cumstance productive of a tendency to irritation in the gastro- intestinal mucous surfaces, may be considered as predisposing to cholera morbus ; while any substances taken into the stomach, in this condition, which are not readily digested, may act as exciting causes, and develop the disease. In the anatomical character of the disease there is but little of interest. The symptoms and history of the case point with great constancy to the existence of gastro-intestinal irritation; and it can scarcely be supposed that any other evidences of structural disease which might be discovered upon post mortem examina- tion, would bear any special relation to the disease, but should rather be considered as accidental. Opportunities are so rarely offered for investigation into the morbid phenomena of cholera morbus, that little can, with any show of reason, be said on the CHOLERA MORBUS. 527 subject. The essential nature of the disease is, without doubt, an acute attack of gastro-intestinal irritation, produced by the direct irritating influence of various substances taken into a stomach already predisposed by the influence of season, thermometric changes, and other conditions of the atmosphere, or hereditary tendencies. Diagnosis. But little difficulty will be found in recognizing cholera morbus. The peculiar rice water discharges and tend- ency to collapse, which are uniform attendants upon Asiatic chol- era, together with its epidemic prevalence, will generally enable you to distinguish it from sporadic cholera. The existence of general febrile symptoms, and the general constitutional distur- bance which precedes an attack of bilious fever, in which bilious vomiting and purging are present, will be sufficient to mark the distinction between bilious fever and cholera morbus or sporadic cholera. The only disorders for which cholera morbus has much risk of being mistaken, are the effects of " certain mineral poisons." Says Professor Wood, " I have seen the operation of calomel in some instances so exactly like cholera morbus that the most expe- rienced eye could scarcely have detected the difference. But in poisoning by corrosive substances, the vomiting generally pre- cedes the purging by a considerable interval, the discharges' are seldom so highly bilious, and the poison may often be detected in the evacuations." Treatment. From what has been said it is evident that the tAvo main indications are, to remove the cause of the disease, and to allay the irritation that has been caused by it. If the case is seen before the accumulations have been removed, and the patient is nauseated and imperfectly discharging the con- tents of the stomach, the natural efforts of the system should be aided in more freely ejecting the offending materials. In many cases, all that will be required to accomplish this object, will be to have the patient drink freely of some warm diluent fluids ; even drinking plentifully of warm water will sometimes answer the purpose. But if this is not found, or should be thought insufficient, a full draught of a decoction of boneset will rarely fail to answer the purpose. This is to be preferred in all cases where it will answer, as ordi- 528 CHOLERA MORBUS. nary emetics, however mild, must of necessity produce more or less irritation, and should not, therefore, be given, unless indispensa- ble. If an emetic proper is determined upon, one that will operate the quickest, and with the least irritation, should be preferred. There is probably no one of this class of remedies that is more speedy, and that can be relied upon as producing less local irrita- tion than an infusion of lobelia and eupatorium. After the emetic is administered, or in case it is not thought necessary, a large sin- apism should be immediately applied over the stomach and extend- ing upon the bowels; while teaspoonful doses of the compound neutralizing physic should be given every half hour; and the patient must be enjoined to remain very quiet, and to resist as much as possible the inclination to vomit. In the meantime, the patient should not be allowed to take more than one or two teaspoonfuls at a time, of any fluid into the stomach; this may be of ice-water, if it is at hand and suits the stomach, or of a weak infusion of spearmint, from which I have often seen very good effects. The neutralizing physic should be continued in the small doses before directed, every half hour, until the vomiting is checked, which, allow me to remark, will seldom belong delayed, for I have rarely seen a patient reject the second dose. It is true that cases will occasionally be met with, in which, after the stomach is relieved of its burthen, so much sensitiveness and irritability will remain, that the very thought of medicine is repulsive, and its appearance will make the patient gag. In these cases I have found very small doses of morphine to answer an excellent purpose in quieting the nausea and arresting the exces- sive irritability of the stomach, and also in restraining the bowels. It should be given, hoAvever, merely as a local sedative, and not with a view to its general influence. From one-twentieth to one- sixteenth of a grain may be given and repeated every half hour for three or four times. The morphine will be more likely to be beneficial in those cases connected with bilious vomiting, as then the action of the opiate in arresting the secretion of bile is an important indication. In many cases, Avhere the constant regurgitation of bile into the stomach keeps up such an irritable condition of that organ as to render it difficult to retain medicine long enough to have any CHOLERA MORBUS. 529 effect, I haA-e seen most prompt and satisfactory results from administering teaspoonfull doses of strong, clear coffee, repeated every few minutes. I cannot, however, refrain from impressing upon your minds the confidence, that a long experience justifies me in reposing, in the effect of the sinapism to the stomach, and the small doses as directed of the neutralizing medicine, in allaying the irritation of the stomach; seldom having to resort to any other measures for that purpose, except in those cases where it is necessary first to administer an emetic. When diarrhoea continues after the irritation of the stomach has been relieved, the neutralizing medicine should be continued, but in much larger doses, until its effect is seen in the evacuations, when it should be suspended. For this purpose it may be given to an adult in the dose of from half a fluid ounce to an ounce, and repeated eArery two hours. During the active symptoms of cholera morbus, nothing should be taken into the stomach excepting what is absolutely necessary, and of that but httle at a time. And even after the disease is relieved, the patient should be directed to use a very simple and mainly farinaceous diet for a number of days, lest the irritation be prolonged and the case degenerate into chronic disease. If, however, the diarrhoea should persist, after the measures already suggested have been tried, without much evidence of local irritation, I have found the tine, catechu and paregoric in equal parts, administered in teaspoonfull doses after each evacuation, to answer an excellent purpose. But if the disease has produced a high grade of irritation, which shows an unwilhngness to subside, after the urgent symp- toms have been measurably relieved, the mustard poultice should be followed by the hot hop fomentations, and the patient directed to take small quantities of marsh mallows mucilage, and not to take anything else into the stomach, and the bowels should be restrained by the occasional administration of a starch and lauda- num injection. Or if the irritation should not seem inclined to subside under the influence of the appliances already suggested, a number of cups should be applied to the epigastrium, and they may be fol- 34 530 CHOLERA MORBUS. lowed by the fomentations. Or the croton oil may be rubbed over the stomach, which, when thus applied after cupping, will rarely fail to produce a full crop of fine pustules. The irritation referred to will be indicated by the redness of the tongue and great tenderness of the epigastrium. Those cases of periodical cholera morbus, to which reference has been made, I have fully considered when speaking of the modifications of intermittent fever, and masked ague. They should be treated in every respect like the common form of chol- era morbus till the intermission occurs, when, without reference to the previous symptoms, the anti-periodics should be given in liberal doses, with a view of preventing another paroxysm. LECTURE XXXIY. EPIDEMIC CHOLERA — ASIATIC CHOLERA — MALIG- NANT CHOLERA — SPASMODIC CHOLERA — CHOL- ERA ASPHYXIA. Introductory Remarks — History— Progress — Appearance in Uni- ted States — Symptoms — Stages — First, Cholerine Stage —Sec- ond, Positive Invasion— Third, Collapse—Symptoms of Each Stage — Reaction — Convalescence — Variations — Anomalies — Blood in Cholera—Rice-water Discharges — Anatomical Charac- ter — Causes — Predisposing — Exciting. The great fatality by Avhich this terrible scourge of the human family has hitherto been characterized, demands at the hands of the medical profession, a thorough investigation of the etiology and nature of the disease, and of the comparative results of the various methods of treatment, which have been employed in dif- ferent places and under different circumstances. Indeed, Ave might better say, that where the profession have been so uni- formly unsuccessful in treatment, where they have been so sig- nally baffled in every effort they have made to arrest a disease or even to mitigate its violence, as they have in regard to this epi- demic, there is no room for any sentiment except profound humil- itv in view of the past, and an ardent desire to receive sugges- tions and duly weigh propositions from every quarter, with a hope of being prepared more successfully to cope with this fell destroyer, when next it shall appear in our midst. Though my experience in the treatment of this disease has not been as exten- sive as I could have desired, previous to being called upon to discuss its character and proper management, and though my field of observation has been more limited than those of many others, 532 EPIDEMIC CHOLERA. yet I have made some observations, and am prepared to make a few suggestions, which, with some deference, I shall present to you before dismissing the subject. My views will not, of course, have as much weight, as if they were the result of long and exten- sive experience, yet I bespeak for them a candid and deliberate investigation, and if not consistent with ascertained facts, nor sustained by future observations, let them share the appropriate fate of errors. My principal reliance, however, in the consideration of chol- era, will be, upon information derived from the reports of others who have had experience in its treatment. And while none can boast success, in this respect, sufficient to justify a claim to exclu- sive orthodoxy, there will certainly be found a wide difference between the results of different modes of practice. These are before us, and constitute a common stock, upon which all may draw, and although the most successful system may not gain our exclusive confidence, yet the least successful will not be devoid of interest and instruction. The statistics of the latter may serve as admonitory warning; while the suggestions of the former may afford us starting points, from which we may now set out to make further progress, in preparing to grapple with this pestilence. The little that is known, of practical value, in regard to this formidable malady, justifies the opinion that much remains yet to discovered. It will be proper to commence the consideration of epidemic cholera with a brief glance at its history. Although unknown in this country until 1832, it existed in Asia as early, certainly, as 1774, and probably earlier. It prevailed there at different times and places until 1817, when it broke out with terrible severity in Bengal, and committed great devastation in the British army, stationed in the North-eastern districts of India. From Bengal it spread in various directions, so that by successive advances, during the years 1818, 1819, and 1820, it appeared in all parts of the peninsula of Hindostan, traversed the Burman Empire, Siam, and the peninsula of Malacca, in the South-east, and ex- tended to China and Chinese Tartary, in the North-east. Within the same time it also visited Ceylon, Sumatra, Borneo, the Phil- EPIDEMIC CHOLERA. 533 lipine islands, and even the distant islands, Mauritius, and Bour- bon. Its progress to the North-west, beyond the boundary of India, was not at first as rapid, nor as steady as in other directions. It does not, indeed, appear to have passed the Indus until 1821, in which year, it made its appearance in Persia and on the Arabian shore of the Persian gulf. Ascending the Tigris and Euphrates, it was stayed by the approach of winter; but in the spring of 1822, broke out on the Eastern border of the desert which sepa- rates Syria from Mesopotamia. It did not, however, cross the desert uutil November, when it broke out in Aleppo. It again subsided during the winter, and reappeared in the spring of 1823, ravaging in the course of the summer the Syrian towns on the Mediterranean coast. In this year, also, having traversed the Persian empire, it broke out at Astrachan, a Russian city at the mouth of the Volga, and at other places on the shore of the Cas- pian sea. Having now reached the North-western border of Asia, it made no farther progress in this direction until 1828, when it appeared at Orenburg, on the confines of Russia in Europe ; but it still seemed to hesitate, oscillating as it were, until 1830, when it entered Europe, appeared on the shores of the Black sea, pen- etrated the centre of Russia, and guided by the channels of the Volga, the Don, and their tributaries, reached Moscow — where it prevailed during the winter, and in 1831 attacked St. Peters- burg. During the last mentioned year, it extended also to Po- land, Prussia, the German States, and Hamburg, on the western coast of Europe; crossed the North sea; appeared, in October, at Sunderland, on the North-eastern coast of England, and at Edinburg in Scotland, in January, 1832. Rapidly as the epi- demic had extended during the previous year, its progress was still more rapid in 1832. In this year, it broke out in London and many other places in England, extended to France and Spain, crossed the Atlantic, and appeared, in June, first at Quebec, then at Montreal; and, pursuing the course of the St. Lawrence and the Lakes, reached the valley of the Mississippi. But the mouth of the St. Lawrence was not the only avenue through which this invading foe gained access to our country. 534 EPIDEMIC CHOLERA. It appeared at New York almost simultaneously with its attack on the Canadian cities. From New York it passed up the Hud- son to Albany, and southwardly to the waters of the Delaware and Chesapeake, reaching Philadelphia on the 5th of July, and Baltimore within the same month. It appeared on an island off Charleston, South Carolina, in November; in February, 1833, broke out at Havana, in Cuba, and before the close of this year, had extended to Mexico. Thus within the first year after its access to our shores, this epidemic spread over the greatest portion of North America. It subsided, especially in the Northern States, during the winter, but repeated its ravages during the spring and summer of 1833, and again, to some extent, in 1834. It did not, in its first visit- ation to our country, molest the settlements on our Pacific sea- board, but having reached the borders of the unbroken A\il- derness and almost untrodden plains, this messenger of terror seemed to regard its mission as closed for a time. And now like some monstrous bird of prey, satiated temporarily with the rava- ges of three summers, it spread its pinions, and soaring above the snow-clad summits of the Rocky mountains, and casting a contemptuous glance at the sparse population of Oregon and Cal- ifornia, took its flight across the broad Pacific, and settled down upon its native soil. During the rapid extension of the epidemic in a western direc- tion, its influence was propagated also to the north and south of what might have been regarded the main track of its progress, but not so rapidly in Europe as in America. Thus, the disease reached NeAV Orleans a year before it appeared in SAveden, and four years before it prevailed in Sicily. It did, however, over- run Arabia and Egypt in 1831, as if by a detachment marching due west from the Persian gulf. But the chief line of its pro- gress, after leaving Asia, was through the centres of Asia and North America, and in this line, it traveled, as Ave have seen, Avith variable speed, but upon the Avhole, with remarkable rapidity, for, from the time of its appearance in Russia, in 1830, it required but two years to reach the Mississippi valley, notAvithstanding the interruptions of winter, which always retarded its progress and generally arrested it. It did not, hoAvever, attack all the towns EPIDEMIC CHOLERA. 535 and cities which lay in its course, but seemed to exercise a very capricious discrimination in selecting its points of attack. Gen- erally, it is true, it seemed to prefer low, filthy, and densely pop- ulated districts, but sometimes places of this character were passed by, while the inhabitants of the most elevated, clean, and isolated dwellings were chosen as its victims; facts which completely sub- verted every hypothesis, and baffled all conjecture as to the cir- cumstances calculated to induce an invasion of the malady. The intensity of the morbific influence was by no means uni- form. Where the disease prevailed in a district, one or more points, Avere generally selected in which the epidemic force ap- peared to be especially concentrated, while the inhabitants of the adjacent territory suffered from irregular, predatory visitations, as if from scouting parties detached from the main body. The epidemic usually appeared the second and sometimes the third summer in places where it broke out during the first season of its preA'alence ; but in some instances towns which escaped at first and which began to be regarded as exempt from the disease, were attacked during the second or third year. Such is a brief historical sketch of the first visitation of Asiatic cholera to Europe and America. Having in this manner encir- cled the entire globe, and ravaged almost every important district inhabited by man, it confined its operations for awhile to the East Indies, where it has appeared to be endemic, scarcely failing to prevail to some extent every year since 1817. In 1847, however, having, as we may suppose, recruited its exhausted forces by a truce of thirteen years—for I can scarcely divest it of the mili- tant character—it again took up the line of march intent on for- eign conquests ; but not finding much new territory worth invad- ing, it chose to pursue its former course, and triumph again on the field of its former victories. Its progress, in this second incursion, has not varied, essen- tially, from that of the first, and although its violence has gener- ally been less severe, its type and habits have been about the same. As it has advanced westward it has, as before, generally subsided in the east; so that, in its progress, it may be compared to a terrific storm, its approach foreshadowed by omens of calamity, its prevalence overspreading the land with gloom and devastation, 536 EPIDEMIC CHOLERA. and its departure, in sullen grandeur, leaving to the mourning inhabitants the melancholy assurance, that others are now suffer- ing what they have just endured. Thus have Europe and America been visited a second time by this dreadful scourge. This country, indeed, has not yet been relieved entirely from the second invasion. During the last two summers, (1849 and 1850) it has reveled in nearly all our towns and cities, and in many rural districts, and has at last attacked the inhabitants of the Pacific coast. It is highly probable, that, during the approaching summer, its ravages will be to some ex- tent repeated among us; at least it behooves us all to be, as far as possible, prepared for it. From this brief sketch of its history, we may, I think, derive the following facts in regard to the habits of malignant cholera. First: that it is endemic in India, but occasionally becomes epidemic, radiating, so to speak, from that central point in every direction to greater or less distances. Secondly: that occasion- ally its tendency is more especially in a western course ; and that when this is the case, its progress, though fitful and vacillating at times, is generally marked by increasing rapidity. Thirdly: that natural obstacles, such as deserts, mountains, and oceans, though they may temporarily check, can interpose no impassable barrier to its progress. Fourthly: that winter usually causes it to subside, except where the weather is mild, or where a kind of artificial summer is sustained, as in the cellar-like habitations of the peasantry in Russia. Fifthly: that, though it appears to prefer natural channels, such as the courses of rivers, or other pub- lic thoroughfares, in its advances; and though it usually selects low, filthy, and crowded localities as points of attack, yet in neither of these respects does it observe any uniform rule. Finally: that, its prevalence in any place seems to be dependent on the presence of some unseen influence not usually existing there, and capable, according to some law by which it is govern- ed, of more intense concentration in particular localities than in others, in the immediate vicinity. Let us now pass to the consideration of the symptoms of epidemic cholera, or in other words, to an inquiry into its private history and character. For the purpose of a more clear description, I shall EPIDEMIC CHOLERA. 537 regard the disease as embracing three stages, and shall therefore present this branch of the subject under the following heads: 1. First, or premonitory stage, 2. Second, or active stage, 3. Third stage or collapse, 4. Reaction and convalescence. 1. First or premonitory stage. What are usually called the "premonitory symptoms" of Asiatic cholera, have reference, first, to the whole community, and, secondly, to single individuals. When the epidemic influence of this disease exists in any district with sufficient intensity to render an out-break of the pestilence probable, that influence will be felt by most of the inhabitants. This is evinced by the general prevalence of unnatural sensibility of the stomach and bowels, constituting a predisposition to disor- der in those organs. Very slight causes—so slight, indeed, sometimes, as to be unobservable,—are sufficient to produce gas- tric disturbance, moderate diarrhoea, or it may be, slight dysen- tery. As the morbific influence becomes more intense, cases of active and protracted diarrhoea become more frequent, and exhibit a more or less decided resemblance to the active symptoms of cholera. The French writers, and some others, have applied the term cholerine to cases of this kind, to indicate an attack approx- imating, but not amounting to cholera. Symptoms of this kind may exist in a community for a longer or shorter period, and then gradually disappear without the development of a single case of malignant cholera. In this case the symptoms I have described, although indicating a strong predisposition to the disease, cannot with strict propriety be said to constitute a stage of cholera. Such a state of things may be regarded as a general premonition that the community, where it prevails, is threatened with a visitation of the malignant malady. But where an individual, situated in or near a locality where cholera actually prevails, experiences the intestinal disturbance, he will seldom fail of having the disease, unless promptly relieved. Hence, under such circumstances, an attack of diarrhoea or " cholerine," even though but slight, should be regarded as the premonitory, incipient, or first stage of cholera. The premonitory stage varies much in different cases both in 538 EPIDEMIC CHOLERA. the character and duration of the symptoms. These may be stated in general terms to be : gastric derangement, evinced by irregular appetite, fur on the tongue, and sometimes pain or full- ness in the head and slight vertigo, and, in some instances, nau- sea and vomiting ;—intestinal disorder, attended with diarrhoea, slight colic pains perhaps, the discharges becoming light-colored and thin, if not so at first, and each evacuation attended with a sensation of great debility;—nervous disorder, evinced by the cerebral symptoms already mentioned, and often by neuralgic pains and spasmodic twitchings of the muscles. In some cases there are slight febrile symptoms, but generally there is a great tendency to relaxation of the skin and perspiration. The urine and other glandular secretions are very scanty, and become more and more so—the alvine discharges may have been bilious at first, but soon lose that character, and assume a turbid, dirty-white appearance. Such are the symptoms of a well marked premonitory stage. Very often many of these symptoms are wanting, a slight diar- rhoea, with some uneasiness in the stomach and a feeling of languor, may be the only departures from ordinary health, preAious to the commencement of the malignant disease. This stage may con- tinue for a longer or shorter period, from an hour or two to seA'- eral days ; or it may be wanting altogether, and the active symp- toms of cholera take the individual by surprise. 2. Second, or active stage. When the case commences with the symptoms above described, they may gradually increase in activity, and develop the malignant disease, without any definite point to distinguish the commencement of the second stage. Generally, however, these premonitory symptoms are suddenly changed into those of a more active and alarming character; and sometimes, as was before stated, the full force of the disease is suddenly experienced. Almost all reports which have fallen under my notice concur in stating that, in a majority of cases, the active symptoms of an attack of cholera, or those which I shall describe as commencing the second stage, show themselves first between sunset and sun- rise ; and, according to my own observation they oftener occur after than before midnight. The active symptoms usually com- EPIDEMIC CHOLERA. 539 mence with copious watery discharges from the bowels. Vom- iting often sets in immediately, or soon follows, and cramping of the muscles is usually an early symptom. The vomiting and purging, when both symptoms have commenced, are apt to be simultaneous, very frequent, and attended with a sense of great oppression in the epigastrium, and of Aveakness and sinking away in the abdomen, and sometimes with severe spasmodic pains in the bowels. Where diarrhoea has not previously existed, the matter first discharged from the bowels usually consists of ordinary foecal substance. It may not be even thin, nor deficient in bile, but very soon the dejections assume the character of a turbid, light- colored fluid, resembling "rice Avater" in its appearance, and either odorless or having a faint, sickish smell. The quantity of this fluid is frequently enormous, and the calls for its discharge almost unceasing, though usually each evacuation is folloAved by a brief space of comparative relief. The vomiting at first, discharges the ordinary contents of the stomach, in many cases revealing the imprudence in diet which may have excited the attack—but afterwards the ejections consist of matter entirely similar to the anal discharges. Very little straining usually attends the evacu- ations either from the stomach or boAvels, yet they are expelled with force, as if by spasmodic effort of the viscera themselves. The cramps usually commence in the muscles of the extremities, but soon extend to those of the abdomen and chest. The suffer- ing produced by this symptom, in most cases, beggars descrip- tion. The muscles, by the spasmodic contraction of their fibres, are drawn into hard*knots with excruciating pain; this, after a minute or two, is followed by momentary relaxation, and then repeated; or different muscles may be attacked in succession, drawing the body and limbs into various distortions, and allowing the unfortunate sufferer not a moment's respite. The pulse may be but little affected at first, but it rapidly sinks as the above symptoms continue, becoming frequent, feeble, flut- tering, and finally, perhaps, imperceptible. The tongue is not usually much coated, but pale and moist; though there is great thirst and a sense of internal heat. The surface is covered with a copious perspiration, which increases as the case progresses; the skin begins early to assume a dusky hue, which finally deep- 540 EPIDEMIC CHOLERA. ens into a bluish, leaden or violet color, especially on the face and extremities ; it loses its elasticity, and becomes shriveled and sodden; so that when pinched into a fold it does not readily return to its natural position. The surface soon becomes cold, and there is an evident stagnation of the blood in the capillaries. The urinary and other glandular secretions are suppressed. The patient is exceedingly restless, complains of insupportable distress in the praecordia, and difficulty of obtaining a satisfactory inhala- tion of air. These symptoms may be more or less severe from the beginning, and their progress may vary in rapidity, but if not arrested they usually increase in severity, and within from two to twelve hours reduce the patient to a condition of extreme pros- tration, or Avhat I shall designate as the third stage. 3. Third, or cold stage—or stage of collapse. The pulse is now nearly or quite imperceptible at the wrist, and but a slight palpitation of the heart can be recognized. If a vein is opened no blood will flow, or at most an ounce or two of tar-like blood can be squeezed from the orifice, which forms a very loose coagu- lum on standing. The features are livid and shrunken away, the eyes have settled back in their orbits, the conjunctiA'ae are dry, injected and glaring, and the whole countenance is often so much changed as scarcely to be recognized by intimate friends. The entire skin presents a dark leaden, or violet color, the hands and feet are shriveled, and have a sodden, doughy feel; the whole surface is cold, and covered with a clammy sweat; the voice is lost or very feeble ; the breath scarcely warmer than the atmos- phere, the respiration hurried and feeble, or else slow and sigh- ing or almost imperceptible. The evacuations cease entirely in some cases, but if continued they pass involuntarily, and if there are still discharges from the mouth they come up in passive eruc- tations, sometimes followed by hiccup. The cramps also some- times subside, but more frequently continue to the last, or they return just before death,—and it is by no means uncommon to see the muscles in a state of firm contraction long after life is extinct. There is usually some stupor towards the last. This may, indeed, be an earlier symptom, but in most cases the patient is capable of being aroused, and then he exhibits his usual intelli- gence and memory. Sometimes the mental powers continue EPIDEMIC CHOLERA. 541 unobscured until about the period of decease, and after the capa- city for emotion seems to be exhausted. The patient lies per- fectly helpless, and though fully conscious of his condition, often manifests remarkable indifference to his family and friends, or even to his OAvn fate. In many cases, the patient having fallen into this stage of col- lapse, rapidly sinks into the arms of death. Sometimes, however, this stage will be prolonged by feeble efforts of the system to rally its energies into a reaction. The pulse may partially revive, and a slight warmth return to the surface, but these flattering symptoms generally subside very soon, and the patient again suc- cumbs to the ovenvhelming influence of the disease. The clammy sweat breaks out afresh, the cramps again seize the muscles, the surface becomes cold, though the patient experiences a sense of excessive heat and thirst, dyspnoea comes on, a feAv gasping efforts at respiration are made and the patient expires. The duration of this stage, also is variable, of course. Suffice it to say, that death sometimes occurs within three or four hours after the commencement of the active symptoms, or second stage, oftener at the end of eight or ten hours, and more frequently still after the lapse of a day or two. . 4. Reaction and convalescence. A small proportion of cases, in which patients sink fully into the collapsed condition, recover, or even exhibit symptoms anything like vigorous reaction. But where this is the case, at any stage of the disease, there is a ces- sation of the discharges, and a return of heat to the surface ; the color of the skin becomes more natural, the pulse is diminished in frequency but increased in force, the uneasiness and oppression gradually subside, and the patient falls into a quiet sleep. The secretions of the liver, the kidneys and other glands are restored, the patient on awaking is, perhaps, able to relish some very sim- ple nourishment, and the reaction may now be regarded as estab- lished. In a majority of cases, in which reaction occurs at all, it takes place before the occurrence of the third stage, or collapse, and the efforts of the practitioner should always aim at producing it as early in the case as possible. Reaction having been produced, the probabilities of recovery are, of course, very much increased. Still the case is, by no 542 EPIDEMIC CHOLERA. means, divested of danger. There are tAvo ways, especially, in which the patient may yet be destroyed: first, he may, from some slight imprudence in eating, exercise, or exposure, experience a relapse of the active symptoms of cholera, sink quickly in collapse and die. Such a result, is by no means uncommon, and the utmost circumspection should be enjoined in all these respects. Or, secondly, where the case has been very severe and the patient much reduced, a secondary fever may set in, characterized by low typhus symptoms, a hectic flush on the cheek, the eyes are suffused, the tongue is dry and red ; the patient sinks into a drowsy stupor; sometimes there is subsultus tendinum and low muttering delirium; papillae appear upon the face and body. Under these symptoms the patient sometimes sinks into a state of coma, and dies in a few hours; he may survive a week or more, and then sink, or possibly recover after a tedious confinement. Recoveries, under such circumstances, however, are exceptions to the general rule, especially where the original attack has been very severe and the stage of collapse protracted. Convalescence from cholera is often uninterrupted by symp- toms of general or local disease, and very rapid; the patient regaining his accustomed appetite and vigor in a few days. This is, however, more likely to be the case, where the disease is arrested early, at least before the commencement of the cold, or collapsed stage. In most cases, hoAvever, Avhere the system has been severely handled by the disease, the patient is left in a con- dition of debility. He will complain of great weakness, of unea- siness and tenderness in the epigastrium and abdomen, of irregu- lar appetite, and indigestion. His tongue will be dry and red, if not furred, the bowels irregular, the skin dry; in short, the case will present all the symptoms of gastro-intestinal irritation, from which, even under appropriate treatment, the patient may require weeks, or even months, to fully recover. Variations from the ordinary course and symptoms of epidemic cholera frequently occur, and occasionally cases are encountered which appear to deserve the epithet of anomalous. Among the more frequent variations of symptoms may be mentioned the absence of vomiting altogether, and perhaps of nausea, also, until a very late period in the case. Less frequently, yet occasionally, EPIDEMIC CHOLERA. 543 we meet with a case in which there is no diarrhoea, perhaps entire inactivity of the bowels, though in every other particular the character of cholera is clearly marked, and the patient sinks into the cold stage and dies. The cramps, too, are in some cases very mild, and in few cases entirely wanting. But the anomalous cases, to which I referred, are remarkable for the absence of all, or nearly all, the active symptoms of cholera. The patient is suddenly attacked with symptoms of congestion of the brain, or coup de soliel,—perhaps accompanied with obstinate convulsions. In these cases, occurring during the prevalence of cholera, and exhibiting the passive symptoms of this disease,—the relaxation of the tissues, the congestion of the capillaries, the cold perspira- tion, the asphyxia, and after death the presence, in some instances, of the light-colored fluid in the intestines, which would, in ordinary cases, have been discharged by diarrhoea and vomiting,—in cases of this kind, I say, we must suppose that the morbific cause has been sufficient to overwhelm the nervous system at once, so that the organs are incapable of the ordinary efforts to relieve the sys- tem. In other cases a similar train of phenomena are presented except that there is little or no cerebral oppression, nor convul- sions ; the patient yielding passively to a debilitating influence, which evidently spends its force upon the nerves of organic life and he seems, as it were to sweat to death, without either vomiting or purging. It may be well to notice, in the next place, the character of the blood in cholera patients. The lancet is in such great favor with a portion of the medical profession, that you need not be surprised to read of its employment in any form of disease; and in cholera it has, by some practitioners, been made a prominent means of treatment. Although the abstraction of blood from the vessels can never have benefited the patient, yet it has subserved a valuable purpose in exhibiting the character of that fluid during the progress of the disease. The blood obtained from patients in the stage of collapse is thick, viscid and very dark-colored, even when drawn from an artery. Indeed this is precisely the condition one would be led to anticipate from an observation of the prominent symptoms. The drain upon the system, by the copious discharges from the 544 EPIDEMIC CHOLERA. mucous surface of the intestines and from the skin, could not fail to greatly inspissate the blood; while the manifest inefficiency of the respiratory function must, of course, leave the fluid unaerated and consequently black. It forms a very loose and brittle coagu- lum in standing—and the serum which is separated from the crassamentum is in very small proportion, and has a greater spe- cific gravity and darker color than that of healthy blood. Chem- ical analysis discovers in the blood a great deficiency of water, a diminution in the proportion of fibrin, and of saline matter, and consequently an excessive proportion of red globules. In cases somewhat protracted, in which the secretion of urine was sup- pressed for some days, urea in appreciable amount has been detected in the blood. The " rice-water " evacuations of cholera, have a decidedly alkaline reaction, and consist principally of the very elements found to be deficient in the blood. According to the analysis of Dr. O'Shaughnessey and others, the liquid portion of this fluid is composed of water, carbonate of soda, and the other saline ingredients deficient in the blood, while the solid portion is made up of albumen, cassein, and fragments of mucous epithelium, de- rived from the intestines; and the fluid is totally deficient in the peculiar principles of bile. In some cases Avhere the diarrhoea and vomiting continue to a late period of the disease, the color of these discharges will become brown or even black, OAving evi- dently to the escape of the coloring matter with the serum of the blood. The anatomical characters of cholera depend, in a great degree, upon the duration of the case, and the stage in which the disease proves fatal. Where the course of the symptoms was very rapid and the patient died in the collapse, very little, if any morbid alterations will be found in any of the structures. The external appearance of the corpse will be strikingly peculiar — more changed, perhaps, from that of life, than are usually the victims of the most tedious forms of disease. The same leaden hue, and shrunken, shriveled appearance which characterizes the stage of collapse, is presented Avith httle alteration after death. It is, also, a remarkable fact that subjects who have died in this stage, will not only be frequently found with firm contractions of the mus- EPIDEMIC CHOLERA. 545 cles, as was before stated, but with palpable increase in the warmth of the surface, which will continue, perhaps, for one, two or more hours. The appearances on dissection, following an ordinary case of cholera which has proved fatal in the cold stage, may be briefly stated. The veins are engorged with viscid, black, partially coagulated blood, while the arteries are empty, with the excep- tion, it may be, of occasional clots in the aorta and left ventricle. Venous congestion is found in all parts of the system, as the brain and spinal cord, the glands, the mucous membranes, serous membranes, and even the spongy structure of the bones. The lungs, however, often appear to have escaped congestion, and the spleen is sometimes smaller and drier than in health. In conse- quence of this venous congestion, the small intestines are violet colored, or have a florid appearance on opening the abdomen — and the mucous membrane, throughout the alimentary track, is reddened and somewhat thickened. The peritoneum is dry and glossy, or else covered by a thin layer of viscid matter, causing opposing surfaces of the membrane to stick together, and the same is true of the pleura and other serous membranes. The cel- lular structure of the intestinal wall is sometimes slightly infiltra- ted with serum. The glands of Brunner and of Peyer are en- larged, and not unfrequently a vesicular eruption is observed through the extent of the small intestines, consisting of minute elevations of the transparent mucous epithelium, filled with a serous fluid, which escapes when the vesicle is punctured. The entire canal is usually distended with a light colored fluid iden- tical with that of the characteristic evacuations, though its color is sometimes changed to dark red or brown, by an effusion of the- coloring matter of the blood, and the evacuations sometimes pre- sent the same appearance before death. The mucous surface of the stomach and bowels is often more or less covered by a coat formed evidently by deposit of the floculent substance which exists in the " rice-water " evacuations; and in the stomach a glairy mucus is sometimes found adhering, in some degree, to the surface. Little change in the texture of the mucous mem- brane can be detected. The liver and kidneys afford no evidence of disease, further than by participating in the universal venous 35 546 EPIDEMIC CHOLERA. congestion. The gall-bladder is usually filled with bile, some- what thickened, but not unhealthy. The bladder is empty and contracted down to the wall of the pelvis, and its mucous surface, together with that of the ureters and kidneys, often presents a layer of substance similar to that described as lining the bowels. Where death results from fever or inflammation following an attack of cholera, the post mortem appearances are very differ- ent, and correspond with the location, extent and duration of the secondary lesion. There is, in this case, less general venous con- gestion, the blood is not generally so dark nor so nearly decomposed. The contents of the bowels are darker colored, containing bile and sometimes blood. The mucous membrane of the stomach and bowels is red, thickened and softened to a greater or less extent, presenting positive signs of inflammation, or at least a high grade of irritation. If the case has been protracted, ulceration of the mucous membrane will probably be observed. Inflammation of the liver, lungs, brain and spinal column are not unfrequent. Perhaps the most common evidences of serious local lesion are found in the brain and its meninges, and in the nervous ganglia and their investing membranes. We come now to inquire into the cause of epidemic cholera. Various hypotheses have been suggested, some of them ingen- ious, others absurd, and all lacking that degree of evidence neces- sary to establish a claim to entire confidence. All must, how- ever, agree that the specific cause of cholera is some invisible influence, which either does not ordinarily exist, or is only occa- sionally operative. A great effort has, for instance, been made to prove that the impregnation of the water with lime is the cause of cholera. The argument is based upon the fact that countries where the limestone formation occupies the surface, and Avhere the water used by the inhabitants is more or less impregnated with that earth, have been more generally overrun by this pesti- lence, than those wThere primitive and sandstone formations, and consequently soft water, prevailed. But although this local influ- ence may, and probably is a predisposing cause to the prevalence of cholera, yet some other influence must be assumed to account for its occurrence. Why has it not always prevailed in lime- EPIDEMIC CHOLERA. 547 stone districts ? And why, since it appearance, does it not con- tinue among us, as our wells and streams are still impregnated with lime ? and again, how does it happen that it does not en- tirely avoid those places where the water is soft, and limestone unknown, as is the case at Bangor, Maine, and other places which might be named, where cholera has occurred with great fatality ? What then is the subtle, intangible, invisible, and yet remarka- bly influential principle which constitutes the specific cause of cholera; a cause which, although its efficiency is often promoted by circumstances which predispose to or excite morbid action in the system, yet is capable, when concentrated, of producing cholera, without the aid of any apparent predisposing or exciting causes ? After examining all the hypotheses which have fallen under my observation, such as those referring it to the influence of the planets, to the approach of comets, to meteoric changes or peculiar electric states of the atmosphere, to malaria, to atmos- pheric fungi, and to invisible animalculse existing in the air—my mind is more strongly impressed with the last mentioned proposi- tion than any other. The habits of the epidemic, its capricious movements, its apparent obedience to whimsical impulses, similar to those Avhich govern the movements of swarms of visible insects or of flocks of birds, concentrating in masses in certain localities, while small detachments of erratic stragglers may be seen flying about at different distances from the main body, seem to favor this hypothesis. The objections to this theory, as mentioned by Prof. Wood, are " its utter want of proof," and the " fact that the cause of cholera, whatever it may be, withstood the severity of the winter at Moscow." I acknowledge there is the absence of demonstrative proof to sustain this hypothesis, and the same is true of every other theory of the cause of cholera; but I do not profess to adopt it as unquestionably true, but to be con- strained to favor it, as being sustained by more probabilities than any other doctrine. The fact that the disease prevailed at Mos- cow during a Russian winter, has some force as an objection, but when we observe that the general tendency of cholera is to sub- side on the appearance of very cold weather, and that in the cell-like huts of the Russian peasantry, to which the disease ap- 548 - EPIDEMIC CHOLERA. pears to have been principally confined at that time, a high degree of temperature is constantly maintained during cold weather, the objection is well nigh removed. It may be further suggested that we are all familiar with the fact that many visible insects exist in a dormant state during winter, and make their appear- ance during intervals of mild weather, and in dwellings which are kept warm. But as it has been already suggested, there are predisposing and exciting causes which favor the development of cholera, and doubtless serve, in many cases, to increase the violence of the symptoms. Whatever has a tendency to impair the general health, or to diminish the vital forces, may be regarded as a pre- disposing cause. Previous disease, old age, irregular, intemper- ate, and vicious habits, deficiency of food, confinement to veget- able diet, exposure to confined, damp and otherwise vitiated air, as where many persons are crowded together in prisons, ships, camps, &c, protracted depression of spirits from grief, fear or other emotions, any and all of these, with many other circum- stances, calculated to reduce the constitutional stamina, may be regarded as predisposing causes of cholera. It may also be proper to remark here, that not only are persons in debilitated conditions, or with shattered constitutions, more liable to take the disease, but they are less likely to recover from its attack. The exciting causes of cholera do not materially vary in char- acter from those named as predisposing, except that their impres- sion is more suddenly produced. Any circumstance or occur- rence, calculated to derange suddenly the organic functions, may excite an attack of cholera in persons laboring under the specific cause. Hence, the sudden exposure of the person when warm to cold, or dampness, by checking perspiration and destroying the equilibrium of the circulation, is a frequent exciting cause. Un- wholesome food or drinks, such as unripe fruit or indigestible veg- etables, impure water, fermenting liquors, as cider, &c.,or over- loading the stomach with even wholesome food; the use of very cold drinks, as ice water; purgative or irritating medicines; im- moderate exercise; sudden mental emotion, and many other things, may be named under this head. LECTURE XXXY. EPIDEMIC CHOLERA —Continued. Nature of Cholera—Primary Seat—Prognosis—Treatment of dif- ferent Stages. Treatment of First Stage— Treatment of Second Stage—Treatment of Third Stage—Dr. Morrow's Treatment— Dr. Jordon's Report— Concluding Remarks. It Avill not be necessary to spend much time in discussing the nature and diagnosis of Asiatic cholera. That it is not essen- tially an inflammation of the mucous membrane of the alimentary canal, as has been urged by some, is, to my mind, evident from two or three considerations. First—where the disease is arrested before the collapse, there are no symptoms of inflammation pre- sented in many cases, but patients recover with great rapidity. Secondly—when the patient dies during the stage of collapse, the post mortem appearances are not such as usually follow inflamma- tory action. The congestion of the gastro-intestinal mucous mem- brane does not materially differ from that of all other structures in the body, and there are no more symptoms of inflammation in the alimentary canal than are found in the kidneys, bladder and skin. Thirdly—inflammation of the stomach and bowels, when produced by any other cause than that of cholera, is not attended with the peculiar discharges, cutaneous congestion, and seldom by the muscular spasms, characteristic of cholera. That there is a degree of gastro-intestinal irritation I do not deny—but this is not the disease; it is merely an attendant of it. Extensive irri- tation of the Avhole intestinal mucous surface may, and frequently does occur, Avithout producing any symptoms resembling cholera. The primary morbid impression appears to be made on the nervous centres of organic hfe, the cerebral centre being but 550 EPIDEMIC CHOLERA. little affected in the beginning. This impression is probably pro- duced by a poison, which, having gained access to the system, manifests a specific affinity for the sympathetic ganglia. The consequence is general organic enervation, and of course debil- ity of the gastro-intestinal canal. This debility is attended with a degree of morbid excitability which predisposes the mucous and muscular coats to become irritated; and, conversely, an irritating influence acting directly on the mucous surface may constitute a predisposing or even an exciting cause of cholera, by its debilita- ting effect upon the splanchnic nerves. Then, when the full force of the poison is experienced in the nervous centres, an enervated and relaxed condition of the mucous membrane is the necessary consequence; and the watery and plastic portions of the blood are permitted to escape from the blood vessels, and hence the diar- rhoea with rice water discharges. The influence of the poison is doubtless felt throughout the system at the same time, producing irritability of the cerebro-spinal nervous system, as evinced by the muscular spasms, and enfeebling the circulatory apparatus. The blood is probably in some measure vitiated by the direct influence of the poison on the heart, arteries and capillaries, and thus pre- disposed to decomposition, while the loss of the fibrin and serum, in the copious discharges, produces increased embarrassment in both the systemic and pulmonic circulation; and the consequence is, imperfect aeration of the blood, oppressed respiration, greatly diminished calorification; stagnation of blood in the capillaries; coldness of the surface ; increased by evaporation of watery exu- dation from the relaxed skin; collapse is the consequence, and death results from asphyxia. All this may, and evidently does occur without any such structural lesion as is implied in the term inflammation or even a high grade of irritation. Should vigorous reaction be established, cholera is at an end, and the irritation and inflammation to which the tissues, and especially the stomach and bowels haATe been predisposed by the disease, may or may not follow as sequelae. In describing the general symptoms of this disease, I endeav- ored to make sufficient distinction between the different stages. It strikes me, however, that a few remarks may not be out of place here, touching the meaning of the word collapse, and the symptoms of EPIDEMIC CHOLERA. 551 the stage to which it is applied. It is somewhat vaguely employ- ed in this relation, and hence different significations have been attributed to it. Some appear to use it as implying an entire loss of pulse and of action in every part of the body; but such a condition would be death itself. Others apply the term, and, as I think, correctly, to a condition of the system in which the capil- lary circulation is almost entirely suspended, the surface cold, the nails purple, the skin dark colored, shriveled and inelastic, and the pulse exceedingly small, or absent at the wrist. This disease is so peculiar in its symptoms and the circumstan- ces under which it occurs, that its diagnosis can cause but little difficulty. There is, it is true, considerable resemblance between the symptoms of this disease and those presented by a severe case of cholera morbus or sporadic cholera,—as it is now frequently termed—and it is a question still debatable, whether malignant cholera is not the same disease as cholera morbus, differing from it only in the presence of an epidemic influence, which predispo- ses the whole community to the disorder, multiplies the number of cases and greatly increases the malignancy of the symptoms. To this last opinion I am decidedly inclined, for I have met with cases of sporadic cholera which differed from the epidemic disease only, in being isolated and in lacking the mental apathy and over- whelming severity of the general symptoms; but the character of the evacuations, the cramps, the color of the skin, the cold perspiration, the feeble pulse—in short all the symptoms of Asiatic cholera were present, and had the epidemic influence been pre- valent, I should not have hesitated in pronouncing them, cases of that character, and would, I have no doubt, have lost them. As it was they yielded to treatment and recovered. As a general rule, then, and one sufficient for all practical purposes, the diag- nosis of this malady may be based upon the prevalence, in the community, of the peculiar epidemic influence, producing a general feeling of nervous depression, and a tendency to gastro-intestinal disorders under very slight exciting causes ; for Avhether cholera morbus is a distinct disease or not, occurring under such an influ- ence, it will invariably assume the character, involve all the danger and demand the same treatment, as the malignant disease. From what has been already said, the general prognosis of this 552 EPIDEMIC CHOLERA. disease would be set down as unfavorable; such is undoubtedly the case where the disease is allowed to progress to the third stage. Very few patients ever rise from that state of physical prostration and mental apathy, characteristic of the stage of col- lapse. But in the second stage a large majority of cases yield to judicious treatment, and in the first or forming stage the disease has generally manifested a degree of tractability equal to, if not greater, than that of epidemics generally. Hence, the farther a case has progressed, other things being equal, the fewer are the chances of recovery. The manifestation of heroic courage, the possession of a good constitution, and a disposition of the system to respond to remedies, are favorable circumstances; Avhile those of an opposite character are of course unfavorable. Treatment. Where you have an opportunity to prescribe dur- ing the forming stage, your treatment may in most cases be quite simple. In many cases I have found our sudorific tincture, given in teaspoonful doses every hour, sufficient to arrest the diarrhoea in a very short time, where the patient would lie down and keep quiet. Where the symptoms were more urgent I have relied upon the following: Tfc Tincture of Opium, " Camphor, Essence of Peppermint, da Dose—One drachm every hour, until the diarrhcea is arrested. This I have seldom known to fail. The patient should, how- ever, by all means, lie down and keep perfectly still and composed. Indeed, I have no doubt, that the horizontal position, mental com- posure, and the avoidance of every thing calculated to disturb the stomach and bowels, would be sufficient without medicine to prevent a development of the disease in most cases, if resorted to in the cholerine stage, unless there is an overloaded state of the alimentary canal. As a substitute for the tinctures just men- tioned, the following powder may be given. Jfc Gum Opium, pulv. " Camphor, " " Kino, " a« gr. j Capsicum, " gr. ^ This should be repeated at the end of the first hour, and then after every evacuation. A preparation which may be termed EPIDEMIC CHOLERA. 553 spiced or aromatic brandy has been found very efficient also in arresting diarrhoea. # Pulverized Cinnamon, Cloves, and Gum Guiacum ad 3j. Best French Brandy Oij. Dose, two teaspoonsful every hour, as long as necessary. This may be used as a substitute for the prescriptions mentioned before, or may be alternated with either of them. If there are crude indigestible matters in the stomach, they should be removed promptly by an emetic. For this purpose the acetous tincture of lobelia and sanguinaria, aided by a warm infu- sion of mustard or of that and cayenne pepper, can scarcely be sub- stituted by a better prescription. The emetic should be immediately followed by a large dose of the compound neutralizing physic, say one gill of the infusion every hour, until the color of the medicine appears in the dejections. If there is active diarrhoea, the spiced brandy may be alternated with the doses of neutralizing medicine. After the operation of the cathartic, the discharges may be arrested, if necessary; by either of the preparations already named. Or, what Avill be sufficient in most cases, tincture of catechu, or kino and paregoric combined in equal parts, may be given in doses of two drachms after each discharge. Or, instead of the catechu, kino or any other astringent, I prefer the marsh rosemary, (statice limoneum,') if it can be obtained. This may be given in doses of two ounces alone or with a teaspoonful of paregoric, after every motion of the bowels. Instead of the neutralizing physic, some of our practitioners have given the anti-bilious physic, with good results. If there is torpidity of the liver, as shown by the character of the discharges, small doses of podophyllin and leptandrin may be given, say pod. gr. \, lep. gr. £, and repeated once in three or four hours, until bilious evacuations are produced. But should there be severe diarrhoea, it will be best to check it at once with one of the prepara- tions named for that purpose, without waiting for the cathartic to operate. If the case has reached the second stage, your treatment will require to be characterized by much promptness and energy. Here, also, if there is nausea, and evidence of accumulations in the stomach, the emetic is indicated, and should be given, so as 554 EPIDEMIC CHOLERA. to produce the most "prompt and thorough action. The same arti- cles mentioned in the first stage may answer the purpose, but I prefer a combination of common salt and cayenne pepper, pre- pared as folloAvs : # Common Salt 3j. Pulverized Capsicum 3j. Boiling water 0 ss. Dose, a wine glass every ten minutes, aided, if necessary, with mustard tea, until thorough emesis follows. I have seen the most satisfactory results, in some cases, follow the use of this prescription ; the discharges from the bowels have stopped, cramps have ceased, and all untoward symptoms have terminated with the operation of the emetic. This, I am aware, is an off-hand prescription, but is none the worse for that, espe- cially if successful. After the emetic, if one is given, and if not, then as a first indication, chech the diarrhoea. The patient must, by all means, be kept in bed, and as quiet as possible, and he should be instructed to resist the tendency to motion of the bowels, and if necessary, assisted in this by an attendant, pressing a thickly folded towel against the anus. Hot bricks should be put to the feet, and a strong sinapism placed over the entire abdomen. While these measures are being applied, the patient should take internally the sudorific tincture; the tincture of opium, camphor and pepper- mint ; or the powder of opium, camphor, kino and capsicum. But whichever is given, the dose should be larger, and repeated at shorter intervals than directed in the first stage. If narcotism is apprehended, from the frequent repetition of doses containing opium, the aromatic brandy may be given alternately, which is, indeed, a highly judicious practice in most of these cases, as there is nearly always a tendency to sink rapidly into a state of pros- tration, which the spiced brandy may prevent. While the foregoing treatment is being employed, stimulating applications should be made to the Avhole length of the spine, with a view of arresting the spasms. The tincture of cayenne may be applied to this region by brisk rubbing with the hand, or Avith flannel, and followed by a sinapism extending from the top of the neck to the coccyx. Dry heat and friction should, at the same EPIDEMIC CHOLERA. 555 time, be applied to the whole surface, and especially to the extremities. Hot bricks, or irons, should be kept to the feet and hands, and bottles of hot water, or bags of hot sand or salt, should be placed along the limbs and body. As a stimulant application to the surface I have usually employed dry cayenne briskly rubbed upon the skin, and then dampened with cold water. This is the most prompt and unfailing method of producing reaction in the skin, that I have ever tried. Where a muscle is drawn into a knot, pressure and friction should be made upon it until the spasm yields. Much relief may be afforded to the patient in this way. To allay the nausea, so generally present, the compound neu- tralizing physic, in teaspoonful doses of the infusion, every half hour, is of great value. Instead of this, the following prescription has been employed with excellent effect: Tfc Aqua Camph. " Mentha Sativa (spearmint.) " Mentha Piperita (peppermint) da 3j. Paregoric Elixir 3ij. Mix, and give ten or fifteen drops every 15 or 20 minutes. To overcome the torpidity of the liver, so common in cholera, small doses of podophyllin and leptandrin, as directed in the forming stage, should be given. The administration of this medi- cine may be commenced as soon as it will lie on the stomach, and the dose repeated once in three hours, until the biliary secretion is aroused. Little good, however, will result from any efforts to reach the liver while the diarrhoea is continued. Let it be borne in mind that, whatever may be the mode of treatment adopted, every effort must be vigorously made. Nothing is to be deferred to the next hour that can, with propriety, be done in the present, and no hope is to be entertained that the disease, having spent its force, will release its grasp. A vascil- lating or capricious resort to various remedies should be avoided. Some practitioners become so excited in treating cholera, that they fly from one remedy to another, without taking time fairly to test the efficacy of any. You should keep perfectly cool, and self-pos- sessed—your own safety demands this—and having decided on your mode of treatment, follow it up with energy. If an agent known to be potent, fail at first, repeat it; if it fail again, repeat 556 EPIDEMIC CHOLERA. it once more, and thus by dint of perseverance you will often finally secure the desired result. If, under the foregoing and kindred measures, the collapse comes on, little can be done except to continue the treatment, with, if possible, increased activity. If the patient is already in the third stage when you are called, commence, and continue the application of the internal and external measures already describ- ed ; and although the probabilities of cure are very much dimin- ished at this stage, you may possibly be successful. The course I have now described is that pursued by myself, and in view of the results, as compared with those obtained by other practitioners, I feel safe in recommending it to you. That it will save all your patients, I do not pretend to hope, but that it will, if vigorously carried out, relieve all cases which can be cured by any means hitherto employed by the profession. The formula? employed have been derived from various sources, and several other measures might have been enumerated, which I have tried, and some of which have been earnestly recommended by others ; but I have aimed to mention those only which have seemed to be effi- cient, in my practice, in meeting the indications for which they were prescribed. I will now present you with synopses of the modes of treatment recommended by certain practitioners, whose extensive experience and eminent success in the management of this dreadful malady, entitle their suggestions to much consider- ation. I Avill read first, extracts from a Lecture delivered by the late Professor Morrow, in this Institute, and published in the Eclectic Medical Journal, Vol. I, p. 277. " The treatment pursued in each individual case, was regulated by the condition of the patient at the time of being called. In a very large majority of the cases that came under my notice, the patients Avere affected with diarrhoea, great prostration of strength, nausea and vomiting, with slight spasms. In the early periods of such cases, the patient Avas directed to go to bed, if he or she had not already done so, and Avas directed to take freely of the neutralizing cordial preparation, composed of equal parts of rhu- barb root pulverized, salcratus, and peppermint plant, powdered ; one pint of boiling Avater being added to half an ounce of this com- EPIDEMIC CHOLERA. 557 pound. After simmering it for half an hour, it was Avell sweet- ened with white sugar, and strained, and when nearly cold, two or three tablespoonsful of good French brandy were added, and the patient Avas directed to take this Avarm, every fifteen or twenty min- utes, in doses of two tablespoonsful, in connection with a preparation, made by adding one ounce each of pulverized cinnamon, cloves and gum guiacum, to one quart of good French brandy, in doses of from two teaspoonsful to a tablespoonful every twenty minutes, to an adult, placing immediately around the body of the patient, hot bottles of water, hot bricks or stones, and covering the patient well in bed with a suitable quantity of Avarm clothing. This course will soon produce a warm, copious perspiration, which should be continued for six or eight hours at least, and if the case is a severe one, a moderate moisture of the skin should be kept up for a longer period. " This course usually puts an effectual quietus on the nausea, vomiting and diarrhoea. " This plan of management is nearly positively certain of suc- cess, if properly carried out in every case, in the earlier stages of its progress, and, as a general rule, there is but little difficulty in carrying it into the desired extent of operation, in fulfillment of the great indications for which it is intended. " In those cases, however, which were marked by strong spasms and violent vomiting and purging, from the commence- ment, and Avhich had not already passed into the stage of collapse, or if this train of symptoms was present at the time of seeing the patient, whether the attack commenced with them or not, I usually commenced the treatment with an emetic of the following compound: Take of saturated acetous tincture of sanguinaria canadensis, of lobelia inflata, tinctured in the same manner, in vinegar, and spirituous tincture of aralia spinosa, (southern prickly ash,) equal parts, and give it in doses of from one to two table- spoonsful or more, mixed in a little warm water, or hot tea, SAveetened, every ten minutes, till it vomits the patient freely five or six times. This, in all cases, seemed to exert a powerful con- trolling influence over the subsequent course of the symptoms of the numerous cases in which it was used. Perspiration was much more readily induced, and continued without the necessity of using 558 EPIDEMIC CHOLERA. a course of measures so efficient as those first indicated, or rather under the same, less vigorously applied. " A preparation composed of equal parts of the oils of pepper- mint, cloves, anise, and cajeput,with a quantity of alcohol, equal to one-half or a little more than one-half of this mixture of the oils, to cut them, and alloAV them to mix intimately, Avas found to possess a high degree of value in the treatment of severe cases of cholera. This, I understand, was a favorite remedy in the treat- ment of this disease, in 1832, and was extensively used by the late Dr. Anthony Hunn, a celebrated medical reformer, of Ken- tucky, and is still known by the name of ' Hunn's Life Drops,' in some parts of the country. In several very severe cases, this compound manifested great controlling powers, in doses of from one teaspoonful to a tablespoonful every 15 or 20 minutes, mixed Avith half a glass full of hot brandy sling. In one case in which the patient was in violent spasms in all the flexor muscles of the body, Avith the thighs drawn up against the abdomen, and the legs against the thighs, the neck and head forward on the breast, with a violent state of contraction of the abdominal muscles, two teaspoonsful of this compound were given with apparently but little effect, but this was followed in ten minutes by a tablespoon- ful, which soon effected the desired relaxation, and relieved the patient. He described the influence as very poAverful, and pen- etrating even to the extremities of his toes and fingers. This powerfully concentrated medical compound manifested very supe- rior poAvers in those cases in which the patient was rapidly ap- proaching the state of collapse, or even in the earlier periods of that stage, accompanied at the same time with obstinate nausea and vomiting, as well as profuse rice-water discharges from the boAvels. In several cases, after the relief of the spasms, nausea and vomiting, an obstinate and moderately profuse diarrhoea still continued, one-half to a teaspoonful of this preparation was given Avith complete success. " There Avere several cases of this complaint, in which, after vomiting, cramps, and pains Avere all relieved, the patient was annoyed with a frequent desire to have a discharge, but could only pass a little slimy mucus, similar to the discharges in dysen- EPIDEMIC CHOLERA. 559 tery. From ten to fifteen drops were given every hour, with almost invariable success in cases of this kind. " In one or tAvo cases of collapse which were treated by me, I found the sudorific tincture a most invaluable medicine, given in doses of a teaspoonful every fifteen or twenty minutes, in a little hot catnip or peppermint tea. It quieted the deep seated nausea and distress, and restored the lost circulation with singular energy and promptitude. " The application of blankets over the whole body, as hot as could be handled, often dipping them in boiling hot water, was found to exert a most beneficial influence. The rule adopted in reference to their use, was to wring them partially dry after im- mersing them in the water, and then apply them by wrapping them around the patient's entire body, leaving the head and neck free, and covering him over with dry bed clothing, and allow them to remain usually fifteen or twenty minutes, when they should be taken off and new hot blankets applied as at first. Re- action and a copious perspiration generally took place in the course of an hour or tAvo after commercing these applications, especially when aided by the use of proper internal stimulants, anti-spasmodics and sudorifics. " The extract of plantago cordata, also manifested powers of no inconsiderable value, when given in the form of pills of two grains or more at a dose, and repeated in the course of an hour, in common cases not marked with symptoms of unusual severity, for the purpose of quieting the nausea and vomiting, and arrest- ing the diarrhoea. The results which have been consequent on the course of practice above indicated, have been highly satisfac- tory." A vast amount of statistical evidence of the success attending Eclectic practice, in the management of cholera, might be derived from the reports of individual practitioners ; but these may be found in our medical Journals, and it seems unnecessary to occupy your time by reading them here. Suffice it to say that, after making ample allowances for what is challenged, by some, as ex- aggerations,—a charge, however, Avhich is as likely to be merited by old schoolmen as by Eclectics—there can be no reasonable doubt in the mind of the impartial inquirer, that success greatly 560 EPIDEMIC CHOLERA. preponderates on the side of the anti-mercurial mode of treat- ment. There is, however, one report, which, coining from a pub- lic institution, in Avhich the Eclectic practice was tested, and ema- nating officially from the hand of a responsible, public functionary, may be regarded as testimony to which no objection can be raised. This report, gentlemen, I propose to read; it may be found in the Eclectic Medical Journal, Vol. 1, N. S., p. 410. " Report of Dr. J. H. Jordon, Attending Physician of the Cincinnati Cholera Hospital to the Board of Health. " Gentlemen :— I have the honor of submitting the following as a report of the Fourth Street Cholera Hospital of Cincinnati, for the time of my connection with that Institution — being from the 6th of June till the 18 th of August — the period of its suspension: There were admitted as patients, from the 6th to the end of June............................................ 100 During the month of July.............................. 139 From the 1st to the 16th of August...................... 27 266 These may be classified as follows, so far as known: Nation. No. Admitted. Irish.................... 92 German.................. 83 American................ 40 English.................. 24 French.................. 5 Scotch.................. 4 Colored................... 4 Italian................... 1 Welsh................... 1 Unknown................ 12 Total............... 266 200 66 100 " By estimating the aggregate mortality from all causes, and the relative proportion of deaths and cures, we have the follow- ing: Whole number of admissions............................ 2i>G Wliole number of deaths.......................... \ 100 Whole number cured............................ iqq " Showing a mortality in proportion to the number of admis- Males. Females. No. Deaths. 65 27 31 58 25 41 31 9 13 21 3 4 4 1 3 4 0 0 3 1 o 1 0 0 1 0 1 12 0 5 EPIDEMIC CHOLERA. 561 sions, of 37.59 per cent., which for convenience may be styled three-eighths or 37^ per cent. Such are the aggregate results, for which, however, other causes than cholera are, to a considerable extent, responsible. " As this hospital was established expressly for the reception of cholera patients, and as much interest is felt in the result of the treatment of that disease, it is necessary to exhibit distinctly the mortality which may be fairly ascribed to cholera, and the ratio of mortality among those who were treated for cholera in this hospital. By doing this, we can ascertain the exact degree of success Avhich has attended our efforts for the relief of that dis- ease, and learn to estimate its probable mortality in future attacks. " We must therefore estimate the number of those Avho cannot be regarded as cholera patients, which is as follows: Among the deaths, there were five who died of narcotism from drugs taken previous to admission; three who died of delirium tremens ; five who died of nervous fever, (more properly speaking, perhaps, of opium fever;) and eight who died of ' other diseases'—making tAventy-one. These of course should not be reckoned in the account as cholera deaths. In addition to these, there Avere five others that were not strictly cholera cases—four of whom Avere cured, and one remitted to the Commercial Hospital—making in all twenty-six. Not reckoning these in the account, the mortality will be found a fraction less than 33 per cent, or 32.9. This, it Avill be seen, is but little more than one half as great a mortality as has been exhibited in the treatment of cholera this year in the hospitals of Paris, although attended by the most eminent men in the medical profession. " But there is another fact which must be mentioned. Besides the foregoing twenty-six cases, there were thirty in articulo mor- tis Avhen admitted, who died on an average in less than an hour. " That there should be so large a proportion of the cases in articulo mortis when admitted, may excite some surprise—unless the statement be accompanied with an explanation. A number were brought to the hospital in this condition from steamboats immediately on their landing, having lain in a state of collapse 36 562 EPIDEMIC CHOLERA. frequently for hours previous to their arrival at this port. Some were in this condition when found, by the ward committees and benevolent individuals who interested themselves in behalf of the poor, and were brought here with the vain hope that they could be cured. But I am compelled to say, that a large proportion were cases that had been treated by physicians until past all hope of recovery, and then sent here by those physicians, or by their directions. As it could not be expected that such a measure could be of any service to the patients, and it could only serve to increase the apparent mortality of the hospital, I leave it to others to conjecture the motives of such a course. " By subtracting this number also from the number of admis- sions and deaths—and it is but just to do so, as I cannot be held responsible for cases that were too' far gone when received to admit of treatment—Ave are enabled • to arrive at the true num- ber of cholera cases treated, together with the exact number of deaths among the same, which are as follows: Whole number of cholera patients treated,......210 Whole number of deaths,..................... 49 Discharged cured,..........................161 " Comparative results : Cures, 76§ per cent.; Deaths, 23£ per cent. " In comparison Avith other hospitals of the kind, this would be regarded as a small mortality; and yet the greater portion of these deaths were due to the advanced stage' of the disease in which the patient was received. If all had been removed to the hospital upon the first appearance of cholera symptoms, I am con- vinced the mortality would not have exceeded 10 per cent — probably much less. "That this hospital was placed under the most unfavorable circumstances amidst the ravages of an unusually severe epidemic, is evinced by the fact that between an eighth and a ninth of all the patients admitted were actually dying Avhen received, and lingered generally less than an hour; and that- about an eighth of all that Avere cured, or.TAVENTY, Avere, when admitted, in that extreme and pulseless collapse, from Avhich recoveries are rare. Under these unfavorable circumstances, it could not be expected that the results of the treatment Avould have been as successful in the hospital, during the severest period of the epidemic, as EPIDEMIC CHOLERA. 563 they were, or should have been, during the milder form of the disease in the month of May, and under the more favorable cir- cumstances of private practice ; yet if we compare the true chol- era mortality of the hospital, throughout the severest period of the epidemic, with the mortality of private practice as reported to the Board of Health during the month of May, the mortality of the hospital will be found scarcely equal to that of private practice. " On the other hand, if we compare the mortality of cholera patients in the Cincinnati Hospital with the mortality of cholera hospitals in Paris, attended by the most learned and distinguished medical faculty in the world, we find the treatment in the Cin- cinnati Hospital has produced far the most favorable results—the ratio of mortality being less than one half as great as the mortal- ity in Paris ! (The cholera mortality of the Parisian hospitals, according to their reports in May, was 62 per cent., nearly three times as great as that of the Cincinnati Hospital.) " When this hospital Avas established, it was expected that a mortality of 50 or 60 per cent, would characterize its reports ; Ave have therefore great cause to rejoice at these unusual results, and it may not be amiss to inquire into the cause of so gratifying an issue to our labors. " I have not the vanity to claim any peculiar talent, skill or any other merit, except a conscientious discharge of my duty. What- ever credit may be attached to these results, must be ascribed mainly to the principles of treatment which were adopted and faithfully carried out—principles which have stood the test of manv years' experience in this country, and have never yet failed to demonstrate their superior value. These principles have been derived from the Eclectic or American system of medicine,— a system peculiar to our own country, and widely distinguished in many respects from the old school or European system, which claims a foreign and antiquated origin. The Eclectic system, which excludes mercurials and general depletion by the lancet, as Avell as many other injurious agents, both in this and in all other diseases, recognizes a ATariety of stimulating, sudorific, diu- retic, astringent, alkaline, antispasmodic, cholagogue, and emetic remedies, as "appropriate in the treatment of cholera; and aims 564 EPIDEMIC CHOLERA. to substitute safe, simple, and sanative agents for those which tend to create or aggravate disease by their own poisonous nature, or to produce permanent debility. " It will not be expected, I presume, that I should give a detailed report of the treatment on the present occasion. To do so, would make a voluminous document, only appropriate to the pages of a medical journal. Should the epidemic threaten to visit our country again, I may select something from my experi- ence and observations suitable for publication, for the benefit of the public, in regard to the prevention and cure of this disease. For the present I will only remark, that the course designated by the above general terms, was adopted and thoroughly carried out. I will add, however, that my experience in the hospital has ren- dered me still more averse to the use of pernicious drugs, and more in favor of a mild and simple practice. By far the worst cases to treat were those which had previously been drugged with opiates and mercurials. Even the state of pulseless collapse, unmodified by any medicine, was far less formidable to encounter than a condition less advanced in the disease, but laboring under .the influence of mercury and opium. " A majority, if not all the twenty who recovered from a state of collapse, had received no treatment of consequence preA'ious to .admission. " As to the cause or theory of the disease, so much has already been said by medical writers, that it is needless to accumulate additional speculations. That the liver, however, is not the seat of the disease, nor its derangement the cause of it, either remote or proximate, my experience has abundantly satisfied me. Hence, the impropriety of giving calomel or harsh cholagogue medicines. Such remedies, in a milder form, may frequently be necessary in the convalescent stage, but in my opinion are never indicated until after the formidable symptoms of the disease are subdued. I conceive it one of the fatalest and most unpardonable mistakes to ascribe the disease to a derangement of the liver! Remove the cause and restore a healthy action of the system, by means of stimulants, sudorifics and alkalies, aided, if necessary, by external heat; allay urgent symptoms, if present, by the use of astrin- gents, anti-spasmodics, and outward applications in the form of EPIDEMIC CHOLERA. 565 sinapisms and rubefacients ; do this, and in nine cases out of ten the liver will take care of itself; at least, such has been my expe- rience. " The experience of this Hospital, I believe, fully proves that the cholera, if rightly treated, is not so formidable a disease as has generally been supposed. ' I must confess, however, that much depends upon promptness and early treatment. Guided by experience in this matter, I would, therefore, respectfully suggest to the Board of Health, that in any future invasion of cholera, the public safety requires that every family should be supplied with some safe and efficient cholera remedy, accompanied by brief directions as to diet and other things. By pursuing such a course the premonitory symptoms could be promptly met—but few cases would assume a formidable type, and the loss of life might be reduced to an inconsiderable amount, compared with the usual mortality of this disease. Any knowledge of this kind, in my possession, I shall be happy to furnish to the Board, at any time, if desired. " In conclusion, gentlemen, I must acknowledge my obligations to you for your hearty cooperation—the efficient aid I received at your hands, and the promptness with which you responded to every call in behalf of the Hospital. Your laudable and efficient endeavors in behalf of the afflicted destitute during the late epi- demic, at the sacrifice of time and private interests, not only at the Hospital, but on any and every occasion, richly entitle you to the gratitude of your fellow citizens. Such devotedness to duty, and the cause of suffering humanity, should not, and I trust will not, go unrewarded. " I am, gentlemen, " Your obedient servant, "J. HENRY JORDON, M. D., " Resident Physician. " Cincinnati, Aug. 18,1849." And now, gentlemen, I have detained you long enough with this subject. I might spend hours in presenting the various theo- ries, speculations and remedies, which have, from time to time, been submitted to the public, but it would be a sheer waste of time. I believe you are now in possession of all the really valu- 566 EPIDEMIC CHOLERA. able knowledge which has as yet been attained, and more than this you do not desire—idle or visionary speculations are not Avhat you seek from my lips, and to such I shall not ask you to listen. That much is yet to be learned, in reference to this modern scourge of the nations is most certain, and to you lies open the broad field of research. As intimated in the lecture of yesterday, it is highly probable that you will be called upon during the next summer, to measure arms with this giant disease. Your position will be that of danger and responsibility, but I trust you will exhibit that true courage Avhich should characterize the enlightened and philan- thropic physician, and that while you guard well your own health, and labor to save the fives and mitigate the sufferings of commu- nity, you will make such observations as will enable you to add to the common stock of professional knowledge, in regard to the nature and management of epidemic cholera. LECTURE XXXVI. MILK SICKNESS —SICK STOMACH. Introductory remarks—Symptoms—Case of Milk Sickness—Treat- ment— Character— Cause—Nature— Treatment—Note— Other Cases—Quotation from Dr. Haynes — Dr. Mc Call's views — Cause— Treatment. Before leaving that group of diseases involving the gastro- intestinal mucous surfaces, I desire to call your attention this morning to the consideration of another disease in which those parts are more or less affected. It will no doubt be to you, as well as to a large majority of the profession, an entirely new dis- ease. You will find it described in none of the authorities, and, so far as I have observed, not correctly described by any of the periodicals, except in one or two instances. It is usually called milk sickness, and has been styled, in some sections of the coun- try, sick stomach, from the fact that this is the leading symptom of the disease, at nearly every stage of its progress. It is a pecu liar disease, and I am quite convinced is sui generis in its char acter, essentially differing from any disease heretofore described in the books. It is considered by some physicians, who have come in contact with it, to be merely a modification of bilious fever. But after hearing a description of it and noting the striking dissimi- larity between the symptoms of this disease and bilious fever, I think you will conclude with me that it is totally different from the latter, produced by a different cause, and, in short, is alto- gether a nondescript. During an extensive practice for upwards of tAventy-four years, in malarial regions, where almost every modification of bilious fever has, from time to time, presented itself, I have never seen anything, aside from the few cases of the disease itself, to which I shall presently refer, that suggested even a suspicion of the existence of symptoms similar to those of 568 MILK SICKNESS. milk sickness. If it is a modification of bilious fever, I certainly would have seen some of its characteristic symptoms in some of the numerous cases of malarial disease that have come under my observation; or the books, in describing the latter, would have con- tained the leading train of symptoms, from which I could have inferred that milk sickness was allied, in some masked form, to bilious fever. But, as I have already said, you will not find it described in any of the books, and the only reference to it, that I have seen, has been in newspaper squibs, or in some remote and obscure periodical of the times. I have heard that an article upon the subject was written by Dr. Drake, some years since, but I never saw the article myself. My first experience, therefore, and in fact my only experience in the disease, was derived from witness- ing a few cases many years ago. I had barely heard at that time some traditional accounts of it from persons who had lived in the vicinity Avhere it had occurred, and, as it had not been known in the region of country to which my practice had been confined, I paid but little attention to those statements until called to see my first case. Perhaps I cannot give you a better idea of the disease itself, than by detailing the history of this case, and some of the others I subsequently treated. The first case occurred in the winter of 1830. I was called about five o'clock in the morning to see a patient who had arrived the previous evening in a jumper, or off- hand sleigh, from Marion, Marion county, Ohio, about forty miles from Worthington, where I then resided. On arriving at the house where he put up, I learned that he had had an attack of the same disease early in the preceding fall, and this was the first time he had been able to leave home. His system was still enfeebled from the effects of the disease or the medicine, chiefly, as I belieA'e, from the latter, and he, aftenvards, became convinced of the same thing. But whichever was the case, and whether it was on account of either or not, his present attack, as he said, was far more vio- lent than the first. He was opposed to calling a physician, for two reasons; one was, that he had no confidence in any one who had no experience in the treatment of the disease, and the other Avas, that the only physician in whom he had confidence, was the one who had treated him before, and who, as he thought, had MILK SICKNESS. 569 saved his life. That gentleman was then in Columbus, about nine miles south from where we were, and was expected through our place on the next day. The patient, therefore, concluded to bear his sufferings as well as he could until the physician should arrive. But the symptoms developed rapidly, and his sufferings became intolerable. I was therefore sent for, and I found the patient in the condition I will describe. He was naturally a strong, healthy, vigorous man, by the name of Calvert, a tavern-keeper in Marion. At the time of his first attack, his physician, whether he considered the disease a pecu- liar one, or a modification of bilious fever, seemed to think the only indication was to produce an active cathartic action and the constitutional influence of mercury. Consequently he continued the use of calomel for several days, Avithout any perceptible effect, and finally had recourse to rubbing the gums with corrosive sub- limate, which resulted in producing two large depressions or holes in the tongue, which had healed over, and in which I could easily lay the end of my finger. The whole internal lamina of the lower jaw had sloughed off, leaving his teeth exposed down to the end of the roots, and yet this individual supposed the physician had saved his life. He had recovered his strength sufficiently to start for Columbus, and when about eight miles from Worthington, the previous evening, he felt the uneasiness in the stomach peculiar to the disease. This gradually increased into a positive nausea and burning sensation in the stomach, which, though it did not then produce emesis, completely prostrated him so that he fell back in his sleigh, and in that condition he reached the tavern. Soon after his arrival, he commenced vomiting and thus I found him on entering the room. As soon as he had vomited, he fell back on his pillow apparently easy and free from nausea. The appearance of the discharge was very peculiar, having a blueish green color and a perceptible acid odor. After lying apparently easy for ten or fifteen minutes, he began to complain again of the burning uneasiness in the stomach, became exceedingly restless, turning from side to side, and throAving his limbs about, seemingly in the greatest distress, until, at length he threw up precisely the same kind of fluid as on the former occasion, and then again fell back perfectly free from uneasiness or pain. I sat there exam- 570 MILK SICKNESS. ining his pulse, looking at his tongue, and inquiring into the his- tory of the case and the nature of the symptoms, for an hour and a half before I was able to form an opinion on which to predicate a course of treatment. I found a small and rapid pulse, though not as rapid as we find in gastritis, with coolness of the extremi- ties, no unnatural heat of the surface, nor much thirst. The tongue was thickly covered with a whitish coat, but there Avas no redness of the edges, and no great tenderness of the epigastrium upon pressure. The bowels were obstinately constipated; the urine was decidedly diminished in quantity, but not of that red color common to most inflammatory diseases. The skin was dry, but not husky as in inflammatory diseases of the stomach. In about ten or fifteen minutes the uneasiness in the stomach began to return; the burning sensation then increased until the same peculiar substance Avas thrown off, which he complained of as being exceedingly acrid and irritating, comparing it to the oil of vitriol. His countenance had a pale and anxious expression, though not of that sunken and exhausted appearance common to inflammation of mucous surfaces. The respiration was rather slower than natural, and a little irregular at times. This patient recovered immediately upon the treatment which I shall presently describe, and was able to return home in three or four days after I first saw him ; not venturing to prosecute his journey to Columbus. He was favorably impressed with my treat- ment, as contrasted Avith that he received in the first attack, and the more so as the last attack was much the severest. Of course he did not fail to herald the matter on his return, and the conse- quence was that I Avas sent for in a short time to see two patients in DelaAvare, a town in which there was a surplus of resident physicians. The disease Avas rife in that neighborhood. These two individuals, a mother and daughter, were taken simultane- ously, and in each case the attack wras brought on by eating some butter procured from the table lands lying west of DelaAvare, in the township of Radnor—a region which became so notorious for producing milk-sickness that the inhabitants of Delaware Avould never purchase the butter manufactured there at certain seasons of the year. The symptoms in these two cases Avere precisely the same as in the case already described, except the old lady MILK SICKNESS. 571 was more infirm, and her system less able to resist the encroach- ments of disease. She had been given up by the attendant physi- cian to die, and, when I saw her, was almost pulseless, the extremi- ties cold, and her strength so exhausted that she could not raise her head or articulate aloud. She was still vomiting, the eyes were sunken, and there was every appearance of a rapid and fatal result. The daughter was not so far-gone. They had both been sick forty-eight hours, but the daughter still had considera- ble strength, and could satisfactorily describe her symptoms. The appetite, in all these cases, was entirely suspended. The general character of this affection and the diagnostic symp- toms of bilious fever render it by no means difficult to distinguish the two diseases. If the disease is not developed immediately after taking the article which causes it, the first symptoms will be lassitude and listlessness, somewhat characteristic of the form- ing stage of fever. But in any stage of the disease there are no morning remissions and evening exacerbations, no peculiar pains in the extremities and back, and no bilious vomiting as in those cases of fever in which vomiting is a prominent symptom. And, what is remarkable, very little febrile reaction supervenes upon relieving the urgent symptoms of the case. The pulse rises in fullness and diminishes in frequency. The only disease to which it bears any resemblance is inflammation of the mucous surface of the stomach, from which, however, it will always be distin- guished by the peculiar appearance of the matter thrown up, and by the absence of febrile reaction, in this affection. In view of these facts can any one, who is familiar with bilious fever, suppose for a moment that milk-sickness is a modification of that disease ? If this is not sufficient to settle the question, there are other facts worthy of consideration, especially as con- nected Avith the cases of which I am speaking. It is well known that DelaAvare occupies a very healthy site, and is extremely free from the miasmatic fevers of the west. The surrounding country is hilly, and owing to the abundance of sulphur springs, and the salubrity of the place, it is a common resort, during the summer months, for persons wishing to recruit their health. Besides this, every case of milk-sickness that occurred in Delaware could be referred to an immediate known cause. In every case it was 572 MILK SICKNESS. ascertained that the patient had eaten, either the flesh of cows or cattle that had fed upon an unknown weed or vegetable, or upon the flesh of calves that had suckled cows afterwards affected with the trembles, or upon the milk, butter, or cheese of such cows. This fact not only helps to distinguish it from bilious fever, but throws some light upon its cause and will be referred to again. It may be asked, what is the nature of the difficulty ? I reply that, although I have never witnessed post-mortem examinations of patients who have died of this disease, yet all the symptoms indicated a Ioav grade of irritation confined to the stomach and not amounting to inflammation. During the whole progress of the disease, I discovered no symptoms of inflammation, nor did the boAvels become involved; on the contrary, they were always constipated. The discharges from the stomach were never bil- ious, but always acid and of an acrid character. I did not test the discharges in the cases to which I refer, but the descriptions given by the patients of their smell and taste were to this point. I regret now that I was not more careful in my investigations of their character, but in my early experience in the treatment of diseases, my main object was to cure them. It is, however, evi- dent to my mind, that the matter thrown off from the stomach is a secretion or effusion flowing from a low kind of irritation Avhich is set up by a specific local poison in the stomach. I am justified in taking this position by the symptoms developed during the pro- gress of the disease. As soon as patients have vomited they He down relieved and perfectly easy, and can tell almost the very moment when the accumulation commences again. I was partic- ularly struck with this fact in my first case, and noticed it in every subsequent case. The patient gradually becomes worse and worse, until the system is exhausted and overcome, or reaction takes place, the influence of the poison is removed, and the pa- tient recovers. I believe no well settled or generally satisfactory explana- tion of the real cause of this disease has been offered. Every individual naturally tends to some kind of a conclusion, though it may not be sustained by facts. Some refer it to this plant and some to that. If I am not mistaken, the Legislature of Ohio MILK SICKNESS. 573 once offered a reward to any one who wTould discover the real cause of trembles in cattle. The effects produced by eating the flesh, milk, butter, &c, of cattle affected with the trembles, to which I before alluded, have led to the supposition that that dis- ease in cattle and the milk-sickness Avere produced by one and the same cause. Now it is not unreasonable to suppose that trem- bles may be produced in cattle after eating the Rhus Toxicoden- dron or poison ivy, an article Avhich is also sometimes adminis- tered in cases of paralysis for the purpose of producing muscular action, or arousing the nerves concerned in muscular action. It is possible that this is the plant which has caused all the mischief; another circumstance also points to the same conclusion. It is said that cattle confined to pastures of tame grass never have the trembles, and that the disease in the human system has never occurred from eating the flesh or milk of animals thus confined. But it occurs at particular seasons of the year, when the weather is extremely dry and green vegetation scarce, and is most com- mon among cattle that graze in the woods, on the borders of prai- rie and table lands where this plant abounds and presents a tempting appearance to hungry cattle, on account of its peculiar verdancy. This, together with the history of the disease, so far as known, and the traditions prevalent in regions where it is most common, have led me to suppose that its origin may be found in the poisonous properties and effects of the Rhus Toxicodendron. I throw this out, however, merely as a suggestion, and not as a well attested fact, and I give it to you for what it is worth. Of course my opportunities for investigating the disease or its origin have been too limited to warrant any great degree of confidence in this theory. It is, after all, perhaps, of equal, if not greater practical impor- tance to select a successful remedy for the disease. On this point I am prepared to speak with more confidence, and I will now detail the course of treatment which I pursued in the few cases I was called to attend, remarking, at the same time, that I would not press it with undue earnestness, but merely recommend it as valuable until a better is discovered. The remedy which I found most efficient in neutralizing the acidity, and allaying the irrita- tion of the stomach, was our neutralizing physic. I had no case 574 MILK SICKNESS. in which the patient vomited after its administration. Its com- position seems to be precisely suited to the condition of the stom- ach and should be given in tablespoonful doses every time the peculiar burning sensation is felt. In the first case I treated, I first cave, by Avay of experiment, a dose of the white liquid phy- sic—a preparation of rochelle salts, nitrate of potass, and a small portion of muriatic acid, but this added only fuel to the fire, and the patient complained that it made him worse. I next gave him the neutralizing mixture. Its effects were immediately and plainly visible, and the patient remarked, with much satisfaction, that I had " hit the nail on the head that time." Every time the burn- ing sensation was felt, I gave him a spoonful of the medicine. This was the main reliance, although I thought it well enough to apply sinapisms to the stomach, and hot bricks to the feet, and I kept him still for a number of hours until the stomach was entirely relieved. Afterwards, to gratify his desire more than anything else, as he thought it strongly indicated, I gave him a cathartic. I have not forgotten the peculiar wording of his request—he wanted " a physic that would operate like a saw mill!" I gave him a large dose of our anti-bilious physic, and it fully answered his expectation. The next day he was able to be about the house, and on the next set out for home. The other cases which I men- tioned, were treated in the same way, except that I did not give a cathartic to the old lady, on account of her exhausted condition. Finding it necessary, in her case, to recuperate the system as fast as possible, I bathed her surface with stimulating liniments, and gave her, at the same time, a little beef tea. I also directed the administrations of injections, which, by the way, is a very safe measure for evacuating the bowels when great irritation of the stomach exists, and I Avould recommend it under most circum- stances. By these measures and fomentations she was in a short time soothed into quiet and refreshing sleep, the circulation returned, and, before noon of the next day, reaction had taken place, and she Avas in a comfortable condition. Of course it required longer time in her case, to repair the system, but the daughter Avas up and about the house in a short time in usual health. I would further add, in regard to treatment, that you should MILK SICKNESS. 575 never allow the stomach, Avltile irritated, to be overloaded, even with Avater, or your treatment will be thwarted. The diet should be of the mildest possible kind—mere rice-water or gruel—until all the symptoms have subsided. In conclusion, I would remark that in all the cases Avhich I have treated—amounting in all to eight or ten—there was a striking similarity in the symptoms, requiring but little modifica- tion in the treatment, and all recovered promptly. I do notAvish to exaggerate the benefit of this mode of treatment, but I have thought it due to you, and to the world, to give my experience, being ready, at the same time, to adopt Avith alacrity any superior measure which future experience may develop. Every practi- tioner should take upon himself, not only for his OAvn benefit but that of the profession generally, to communicate, through the peri- odicals, or otherwise, any peculiar features of disease that he may meet Avith, or any successful remedies he may discover. [Note.—Since this lecture was delivered, in casually turning over a feAV numbers of the " Philadelphia Journal of the Medical and Physical Sciences," for the year 1822, edited by Professor N. Chapman, I found in one of them descriptions of the milk sickness, by three different physicians. It seems these communi- cations Avere first published in the " Western Quarterly Reporter," at Cincinnati, and were quoted from that paper by the editor of the Philadelphia Journal. These communications, it will be seen, perfectly coincide, in their descriptions of the disease, with my own observations. I reproduce the shortest one, and will make a few extracts from others in relation to the cause, &c. The shorter article was written by a Doctor Haynes, of Dayton, Ohio, and is as follows: " This disease prevails chiefly in the neighborhood of heavily timbered, level, and consequently rather wet oak land. " Cattle,, sheep and horses, which range in these tracts, are subject to a peculiar disease, known among the people by the name of the trembles, which they suppose to be produced by their eating of a plant, as those animals which range in the neighboring barrens or beech land, are free from the disease until they find their Avay into these low bottoms; and so well are the people acquainted Avith this fact, that if they see -cattle that have been 576 MILK SICKNESS. accustomed to range in the barrens, enter these suspected ranges, they foretell the sickness of the calves, and of the family using the milk. Calves are seized with trembling and vomiting during, or soon after, sucking, and frequently die of the disease. The milk has the same effect upon dogs. Children drinking the milk, leave the table and vomit. Upon adults its effects seem to be less sudden, but eventually more severe. It seems someAvhat singular that milch cows escape the disease, while their milk produces it in other animals. It seems as if the deleterious matter were elimi- nated from their systems through the lactiferous vessels. " Beef and mutton produce the disease. Several instances have been related to me, in which beef and mutton killed in the neighborhood before mentioned, have sickened all who ate of them. Some who have had the disease, say they can instantly discover, by a peculiar taste, such beef or milk as will produce the sick stomach. Dogs eating the flesh of those animals Avhich die of the trembles, as it is called, sicken and die with vomiting and that extreme debility characterized by trembling and inability to stand or walk. " If cows are kept in pastures, and not suffered to run in the woods, their milk may be used Avith impunity. That there are difficulties in admitting the opinion that this disease is caused by some vegetable poison, and in proving it to be true without a direct experiment, is acknowledged ; but taking into consideration the testimony that has been advanced, and the almost universal sentiment of the people who have experienced the disease, and have had it in their families, there appears to be much probability; and an opinion so general as this is among the people, ought not to be rejected without candid investigation. " An attack of the sick stomach is preceded by universal debil- ity, more particularly felt in the loAver extremities ; impaired appetite, nausea, occasional vomiting, and an offensive breath, so peculiar as to be instantly recognized by any one conversant with the disease. In some, these symptoms constitute the whole of the disease, and exist for seA-eral Aveeks. In others, they are fol- lowed, after some days' or weeks' continuance, by a more severe and general attack, characterized by great debility, sometimes irregular chills and flushings, a sense of great oppression about MILK SICKNESS. 577 the prajcordia, anxiety, deep respiration, heat in the region of the stomach, compared by the patients to fire, boiling water, &c. • thirst, nausea, and at longer or shorter intervals, according to the violence of the attack and to the period of the disease, violent retching and vomiting. " In the arterial system, the disease puts on a variety of aspects in different persons, and in different stages of the disease. In the same person changes take place not unfrequently in the space of a few hours. The heart beats with such violence in some cases, as to elevate the bed clothes, and to excite horror in the physician and bystanders, on laying the hand upon the patient's breast. It seems to labor convulsively, and as though it were clogged in its motions by a superabundance of blood. The larger vessels partake of the heavy, throbbing and laborious motions of the heart. The blood forsakes the surface, especially that of the extremities, leaving it cold, and seems to rush to the larger inter- nal vessels, engorging the viscera, and producing that oppres- sion and anxiety about the prsecordia, sighing in respiration? palpitation of the heart, &c. The patient feels nothing which he can strictly denominate pain; but the sense of heat, the oppres- sion, the palpitation of the heart, and the violent efforts to A7omit, constitute an extreme degree of distress. " In other cases there is much less of this turmoil of the sys- tem. The patient, in the intervals of vomiting, lies in a stupid, listless condition, from which he is roused only by a returning fit of vomiting. " The state of the pulse varies with other symptoms. In the early stage of the disease, it is sometimes full and tense, at others full and soft. Later in the disease it is slow and weak, exhibiting little or no febrile action, except it be of suffocated, or at least, unequal excitement. The bowels are obstinately costive, and the stomach so irritable, that medicines and drinks are rejected soon after they are swallowed. In the early period of the disease some bile is discharged, but never, I believe, in great quantities. The matter ejected afterwards seems to be little else than the drinks, &c, taken in, mixed perhaps with a secretion from the stomach ; and in violent cases, a flaky substance, varying in color from a light brown to a deep black, is mixed with the fluids." 37 578 MILK SICKNESS. The following extracts are taken from an article written by Dr. Asa Coleman. He thus describes the symptoms: " The vomiting often returns every hour or two, during a whole week together, and the patient experiences some relief after each effort. During this stage of the disease, the strength is much prostrated; the patient complains of great distress and a burning sensation at the stomach; the bowels become obstinately costive; the thirst is frequently great; hot belchings and hickup are often troublesome; the tongue is slightly furred, and the breath has a peculiar, disagreeable smell, resembhng that of a person under a mercurial course." The following extract gives the Doctor's views of the medical treatment. " In the first stages," he says, " an occasional use of emetics, cathartics, and laxatives, with rest and the use of fight, wholesome food, will generally clear the system from its effects in a feAV weeks. In the more active forms of the disease, the exhibi- tion of medicine is often extremely difficult, owing to the great irritability of the stomach. Emetics are then absolutely hurtful, especially antimonials, because of the irritation they excite in the stomach. In some cases where there was much retching to vomit, without throwing much up, I have directed a strong infusion of chamomile flowers, or warm water, to clear the stomach of its foul contents (with great advantage.) Cathartics, especially of the saline kind, afford considerable relief, if the stomach will retain them sufficiently long to permit them to act on the bowels. It is generally necessary to assist their operation by the use of stimu- lating enemata, in order to overcome the obstinate costiveness. These remedies must be repeated daily during the continuance of the disease. Before resorting to the use of cathartics, however, I generally have recourse to some medicine for the purpose of allaying the irritability of the stomach, and to check the vomiting until the cathartic has time to operate. This is often difficult to accomplish. For this purpose I have found a solution of a few grains of carbonate of potass in water, very serviceable, when often repeated; sometimes I have added a few drops of tincture of opium. The sugar of lead is another remedy, that I have seen advantageously used to allay the vomiting, till the operation of a cathartic could be produced. The operation of a cathartic gen- MILK SICKNESS. 579 erally affords a considerable alleviation of the general symptoms ; a large blister over the stomach appears to be of much service ; bathing the feet in hot water, and applications of mustard to the feet and wrists, are usually resorted to. The general warm bath has been employed in some instances with advantage." In regard to the cause and nature of the disease, the writer remarks : " There are some circumstances connected with the history of this disease, so peculiar as to make them quite interest- ing. It is noAv a generally received opinion in the parts of the country where it prevails, that it is produced by some peculiar poison of the vegetable kind, and that the human system is affect- ed with the disease only in consequence of using food that has been under the influence of this poison, such as milk, butter, or the flesh of animals laboring under the effects of this disease. The idea of a disease so formidable, produced in this manner, may appear somewhat chimerical to some, but there are many circumstances that favor the conclusion, and leave little doubt in my mind of its being the fact. " 1st. That domestic animals become affected with this disease, and under certain circumstances only, and that they are not sub- ject to it except in parts of the country where the human species are subject to it. That cattle become affected with the disease from eating some vegetable poison, is inferred from these circum- stances ; cattle in pasture fields, where the ground has been cul- tivated, are not subject to it, it being only those that run at large in the woods and commons. I will state one of many instances that have fallen within my observation, in support of this opinion: A piece of woodland was enclosed as a sugar orchard, in which there Avas no water, either running or stagnant; situation high and dry; if an horse or ox were suffered to graze in this enclosure, for twelve or twenty-four hours, it would certainly become affect- ed, and perhaps die in a day or two; while cattle in a pasture field adjoining, have grazed the Avhole season without any symp- toms of it. It may be inferred from circumstances like the above that it is not the effect of impure water. Many instances have been related to me by persons of credibility, of horses escaping from the stable and not remaining in the woods more than twelve or tAventy-four hours, becoming so much affected as to die in a 580 MILK SICKNESS. day or two, having all the peculiar symptoms of this disease in brutes, and this often in the winter season, when the ground was covered with snoAV ; from Avhich circumstance it is suspected to be a vine, or some plant not easily affected with the frost. The dis- ease is most fatal among cattle and horses in the fall months, but they become affected with it at all seasons of the year, Avhen turn- ed to the woods." * * * " 2nd. That the milk, butter, beef, or the flesh of any animals, killed Avhile laboring under this disease, will produce disease again in other animals, is proved by daily experience; sucking calves, which have no food but the milk of an affected cow, will show the peculiar symptoms, and often die of the disease ; persons making use of the milk or butter, from the same cow, at the same time, will become affected. " The milk given to domestic animals when the sucking calf shows symptoms of it, will produce the disease upon them, and this often Avithout the cow's appearing much affected by the dis- ease, a milk cow seldom showing many symptoms of it when reg- ularly milked; the poison appearing to pass off principally by that secretion. " I saAv an instance of a whole family becoming sick with this disease, some of them in a few hours after dining upon a loin of veal, in Avhich it was afterwards satisfactorily ascertained that the calf labored under the disease at the time it was butchered, being sold in the market by an unprincipled person." * * " Mr. Thomas Hill, a respectable farmer, living near the south- west branch of the Miami river, informed me that having an ox die of this disease in his yard, and neglecting to remove it, his hogs, about seventy in number, devoured the carcase, and out of the above number about forty died in the course of twenty-four hours; the hogs were in good order, and appeared to be healthy previous to their feeding upon the carcase of the ox." * * * * " Perhaps a strong evidence of the origin of this disease being in some poisonous vegetable, may be draAvn from the total exemp- tion of those persons from it, who are particular as to the meat, milk, butter, and cheese they make use of, in situations Avhere the disease has been most common; cattle and horses are also MILK SICKNESS. 581 perfectly exempt from it while kept in pasture fields where the ground has been cultivated, or in the stable." ****** " This disease is perhaps not dissimilar in many respects to diseases produced by some of the vegetable poisons of the narcotic class, with which we are acquainted, a large portion of it pro- ducing stupor, nausea, anxiety and vomiting, with other marks of an inflammation of the stomach; sometimes vertigo, pain in the head, and delirium, Avhere the disease is violent; the inflammation of the stomach perhaps is most generally of the erythematic kind, sometimes evidently of the phlegmonous. As to the particular modus operandi of this supposed vegetable poison in producing the constitutional affection Avhich evidently takes place in what I have termed the chronic form of this disease, as Avell as in its active form, I shall not attempt to explain or hazard an opinion upon, i " The foregoing remarks Avill apply to the disease described, as it has appeared for several years past. The last season it has been much more preAralent than usual, and unusually severe in its symptoms. It is now the middle of January, 1821, and the complaint is still common, and unusually fatal. The uncommon prevalence of the disease during the season, has been attributed to the unusual dryness of it, which produced a great scarcity of vegetable food for cattle, thereby inducing them to eat anything green, Avhich has rendered it very fatal to them; and conse- quently, by inattention or skepticism as to the cause, has made it very prevalent and severe with the human species. The symp- toms attending the disease the past season, have been more in- flammatory than usual, and the affection of the brain greater, requiring early and copious blood-letting; some cases have ter- minated fatally in two or three days, from the active form of the disease supervening, where medical aid Avas not early called for, or improperly applied. The disease has been attended with a peculiar pain in the head, often Avith a stupor or coma, which, if not relieved by early blood-letting, has soon been followed by insensible stupor, or high delirium, and has soon destroyed the patient. In some cases a dilatation of the pupils of the eyes has been observable. A free use of the lancet, cathartics, epispastics, 582 MILK SICKNESS. and the use of alkalies, has been the most successful mode of treatment." I conclude by giving a few short extracts from an article written by Dr. Alexander McCall, of Tennessee, " on an extraordinary disease of Tennessee." He says: "Among other plants" — in the vicinity which he describes —" is one called, by the country people, ' Indian Hachy,' which is said to have been used medicinally by the Cherokee In- dians for some purpose. But it is now chiefly remarkable for imparting to the milk of cows that feed on it, certain properties highly pernicious to the health of animals when taken into their stomachs. This plant, the botanical title of which I do not know, is perennial, sprouting up early in the spring, and flowering in July; its blossoms are of a bluish color, fixed closely to an up- right stamen of three or four inches in length. The root is some- what bulbous, and the leaves bear a slight resemblance to the arum triphyllum when young and tender. So Avell convinced are the inhabitants of Goose Creek that this is the particular plant possessed of such highly detrimental qualities, that they have fenced in all those places where it is known to grow, with a view of preventing the access of cattle to it." * " After swallowing the milk, the person in a short time suffers from thirst, nausea, vertigo, confused or imperfect vision, vomit- ing often ensuing"— * * " In the year 1820, the citizens of Hartsville, a small village near Goose Creek, were almost all made sick, by partaking of beef sold in their market." * " Dogs, cats, hogs, buzzards, crows, or indeed any animal eating of the vitiated milk or flesh, are affected in a similar manner, and generally die in a few days. I saw a dog pass through every stage of the disorder. He had fed on the flesh of a calf which died by sucking its mother's milk." * "-------persons poisoned, and particularly by the rhus radi- cans, unless completely cured, are liable to similar repetitions of attack." * * * " In treating the complaint, it has been found advisable always to administer an active emetic as soon as it has been ascertained that poisoned milk or meat has been taken into the stomach. Great relief is afforded by the free use of the MILK SICKNESS. 583 lancet during the early stage of the fever. Charcoal and spirit of turpentine early exhibited, are considered very beneficial. Laudanum has been given to relieve pain in the region of the stomach. But sinapisms and blisters applied over the chest and epigastrium, are said to effect this purpose more promptly." LECTURE XXXVII. WORMS. Remarks— Varieties. First Variety— Character—Appearance— Situation. Second Variety— Character—Appearance—Situation. Third Variety—Character—Appearance—Situation. Fourth Variety— Character—Appearance—Situation. Fifth Variety— Character—Appearance—Situation. General Symptoms— Origin —Spontaneous—Propagation—Remarks—Anatomical Character —Treatment for Lumbrica and others—-Treatment for Tenia— New Remedy. It is well established by scientific investigation, that almost every animal furnishes a nidus or nest for the growth of para- sitic animals having a distinct organization and existence. The human body is not an exception to this rule. Parasitic varieties of Entozoa are found in the human stomach and intestinal track. The whole subject of Entozoa has been largely investigated, and you will find in the books more minute anatomical descriptions of the different varieties than I propose to give. It will suffice for the purposes of this lecture, to describe the five A^arieties most usually met with in the human alimentary canal. There are oth- ers than these that I myself have witnessed, but they are of too rare occurrence to be of any practical importance. The first is the long, round worm, technically called ascaris lumbricoides, or lumbricus. It is so named from its resemblance to the common earth-Avorm, and is supposed, by some authorities, to belong to the same species. It is, however, an entirely differ- ent animal, and belongs to another genus. It is scarcely neces- sary to give a minute description of this variety, as every one is more or less familiar with its appearance. I will remark, how- WORMS. 585 ever, that it varies greatly in size, and from four to eighteen inches in length. It is of a rounded shape, tapering at both ends. I have here a drawing of one, which you will see is a very correct representation. It varies also in color, having, in some instances, a whitish pink hue, and in others a dull, dirty yellow color. It is supposed to feed on the chyme found in the intestines, upon absorption from which the growth of the human system depends. It is distinguished by three tubercles or valves, surrounding the mouth, which open and shut, and by having a canal nearly through its entire length. This canal is of a broAvnish color, rather straight, and terminates a little anterior to the caudal extremity ; yet in the larger portions of the worm, it is somewhat tortuous. The structure is muscular, with nerves and blood-vessels, and more or less cellular membrane, somewhat translucent, so that in the larger ones, the ovi-ducts, which resemble small worms, are visible. I have specimens of that kind selected from a large number—some forty or fifty which were expelled at a single evac- uation. One might easily have mistaken the ovi-ducts visible in the larger specimens for inchoate worms. The sexes exist in separate worms, the female being the largest, while the male is more pointed at the posterior extremity, which is curled up, and from which, by turns, a double penis is protruded from a sheath. They are readily distinguished, on careful examination, both by their general appearance and by their sexual developments. The females may be known by the sexual organs, the ovaries and ovi-ducts. Both the latter are white and thread-like organs. The ova have a thin shell about the 25th of a line in length. The males are not so numerous as the females, and I have thought are more difficult to expel from the intestines. This variety of worms is usually found in the small intestines. As I have already remarked, it is supposed to subsist on the chyme. Whether mucus is a necessary part of its food or not, there is usually a large amount present. Of this the nidus is formed, and without it, it would scarcely be possible for the Avorm to exist in the bowels. Whether the presence of worms predis- poses to tho formation of mucus, or whether the mucus forms a pabulum necessary to their germination, are questions not easily solved. But they do not appear to be tolerated without the pres- 586 worms. ence of mucus. They often penetrate the intestinal tube and pass into the abdomen. I have seen one or two instances of this in making post-mortem examinations, where I found they had become entangled in the coagulable lymph, resulting from the inflammation, which was followed by adhesion. The second variety is the ascaris vermicularis or oxyuris ver- micularis. It is also improperly called thread worm, for there is another variety more like a thread than this. It is commonly called the maw-Avorm, and is the smallest known. The male is said not to exceed two lines in length or perhaps the fourth of an inch, while the female is five or six lines, or half an inch long. It is very slender, and about the size of a common small sewing thread. This species inhabits the rectum mainly, and is fre- quently found in great numbers, though it has been seen else- where in the ahmentary track. You will see in this engraving, which I have here, one largely magnified, while the others are represented of the natural size. This is the Httle worm so trouble- some to children, although it is not peculiar to them, but is occa- sionally found in adults. Although of a different species, it is of the same order and family wTith the round worm, and is said, by some, to develop itself, or exhibit a state of action periodically. During its period of quiescence, it is supposed to lodge in the mucous folds of the intestines. At a certain stage of its existence, not entirely de- termined,—and indeed the whole theory may be doubtful,—it evolves from its nidus, and produces great irritation, which is said to be periodical, occurring usually at night. The child runs about during the day apparently well, but when night comes it com- plains of itching in the rectum, which sometimes amounts to very great inconvenience and distress. These, however, are peculiar- ities not so well settled as others. That the worm does exist mainly, though not exclusively, in the rectum, and that it does produce great local disturbance, is well determined, and that the itching may come on most generally towards evening, is quite probable, though I have seen its irritation produced at every pe- riod of the day. In females these worms sometimes pass into the vagina, and produce no little uneasiness. The male species has a spiral or coiled appearance ; the head worms. 587 is not much thicker than the tail, the head of both male and fe- male, under the microscope, shows a transparent tuberosity, form- ing lateral Avings. The female is larger and straighter, but about one-third from its head is considerably increased in thickness, then contracts and gradually tapers to a size too small to be seen by the unaided eye. The third variety is called tricocephalus dispar, or the long thread worm. You see in this engraving a specimen considera- bly magnified, retaining, however, its correct proportions, while beloA? it is represented in its natural state. This worm is de- scribed as from one to two inches in length. I think this is short of the size to which it often arrives: I have seen it four inches long. It is like a small thread, except at the posterior extrem- ity, Avhere it is enlarged. As far as my observation extends, it is not a very common worm. Its shape is somewhat like that of a cat-fish reversed, being largest at the caudal extremity. About two-thirds of the anterior extremity is a delicate capillary, the size of a small hair; the other extremity is as large as a sewing thread. It is of a light color. It has a straight alimentary canal passing directly through it, except in the large portion, where it is slightly tortuous. The male is much smaller than the female, and differs slightly in shape. It has a very small and pointed posterior ex- tremity, of a spiral appearance, with a long penis invested in a proper sheath; Avhile its anterior part is a mere capillary. The female has a longer anterior capillary, while its posterior extrem- ity is straight and only slightly bent at the end. They are prop- agated by ova, which are oval, with a tough shell, and belong to the same family with the two preceding varieties. The fourth variety is the taenia solum, vulgaris, &c, or com- mon tape worm. Of this family there is perhaps but one variety in the United States, though there is another peculiar to other sections of the world. I have here a drawing of a section of the common tape worm. It varies greatly in size and length. The ordinary length is from seven to fifteen feet, while it is sometimes said to arrive at the enormous length of a hundred feet, which I am disposed to doubt. It is of a flat, ribbon like shape, from three to five lines in breadth in the largest places, and tapers to almost a mere thread at the caudal extremity. It is of a white or yel- 588 WORMS. lowish color, and is made up of numerous segments, which seg- ments or joints are most distinct and perfect at a distance from the head. Each of these segments, as you will see from the draw- ing, resembles a gourd-seed, or is quadrangular in shape. The head is smaller than most of the body, and has a small papilla in the centre Avith openings. From two of these openings there are canals passing down the body, which communicate with each other by means of transverse tubes, and, what is singular, these canals, after passing through the neck, are not entirely within the body of the little animal. It is supposed that these worms can exist or reproduce themselves if but a single joint is left in the alimentary canal. This I consider very doubtful, unless the head is left. For joints are developed only from the neck, and push those first formed still further back. The posterior joints are therefore the oldest and most perfect, and often come away filled with mature ova. They are replaced by new joints, and it there- fore seems necessary to expel the head of the animal to prevent reproduction. This variety is hermaphrodite. It is supposed that the ova, as they escape from the animal, are fertilized by a fluid which is made to flow from its vesicles by the pressure of the ova in passing out. It inhabits the small intestines. Vogel, p. 424, says: "It cannot be denied that the tape wTorm,by its presence in the intes- tinal canal, may cause derangement of the organism; nevertheless its pathological importance is commonly overestimated. It often remains in the body for a long time without its presence being re- vealed by the slightest symptom; sometimes, particularly when of great size, its movements become annoying and unpleasant." The fifth variety is called taenia lata, brothiocephalus latus, or broad tape Avorm. It is said never to have been seen in the Igni- ted States, though some Avriters claim that it has been imported. It is peculiar to Russia, Poland, Eastern Prussia. SAvitzerland and some parts of France, and Vogel says that if it is found else- where, " we may be assured that the patient is a native of one of the above-named countries, or at least has caught it there." It is much broader and its joints shorter than the common long tape worm. It differs from the taenia vulgaris by the joints being more perfect, well developed, and thrown off in connected rows, WORMS. 589 and by a cavity in the centre and not in the border of the joint. It varies in length from one to twenty feet. These are the varieties of Avorms usually described by the au- thorities. I have seen what appeared to be a different variety. Some few years since I was called to see a child having all the ordinary symptoms of worms. After taking some active Avorm medicine, the child evacuated nearly a quart of little animals entirely different from any thing I ever before saw, and from any thing that I have found described in the books. They had the appearance of Avorms in the chrysalis state, and were about three- fourths of an inch in length and perhaps two lines thick. They exhibited the corrugated appearance of some varieties of larvae, which you have no doubt seen in the ground, vulgarly called slugs. As I did not have an opportunity for a very careful examination, I can say but little on the subject. Almost every variety of symptoms is found to result from ver- minous irritation in the human system. But the symptoms most frequently occur in children, and are generally produced by the long, round or common worm. You will find the abdomen promi- nent, full or bloated; the appetite exceedingly variable,—sometimes deficient and sometimes voracious. The breath is usually often siAre; the tongue generally has a white coated appearance, and often the upper lip will be much swollen. In some cases the eye- lids become edematous, and so swollen that the child can hardly see ; in others edematous patches will present themselves in other parts of the body. I recollect of seeing a child on one occasion with a sac of water on the end and lower part of the penis, in- volving the frenum and a portion of the prepuce. I suspected, from the symptoms, that worms were the cause of the difficulty, and on administering worm medicine the swelling disappeared. In another case the child's face was so swollen that its eyes Avere closed, and an eruption appeared resembling that of scarlet fever. But the peculiar symptoms of scarlet fever being absent, I sus- pected the presence of worms, from the fact that all the children of the family were subject to have them. The mother was an in- telligent, self-possessed lady, who never sent for a physician until she really had cause for alarm. In this case I found the child lying in a stupid condition, with a high fever, his face red, as in 590 WORMS. scarlatina, SAVollen and disfigured, and his eyes closed with the tumefaction. I administered worm medicine, and, on calling the next morning, I found it had operated freely, but had not started the worms, and the symptoms were not in the least ameliorated. The eyes were still closed; the child could be roused with diffi- culty, and I was doubtful of his recovery. Upon giving the case a thorough reexamination, my opinion as to the cause of the dif- ficulty was confirmed, and I therefore repeated the medicine. When I called in the evening he was up and playing round the house, having obtained relief, about an hour before I called, by evacuating forty-seven worms, not one of which was less than ten inches long. Children troubled with worms, frequently start in their sleep, and are apt to have restless nights. Almost all children of ner- vous temperament will be subject to this starting during febrile action, and it cannot be considered a diagnostic symptom of Avorms. Another common symptom, is a peculiar paleness around the mouth, extending up the sides of the nose, though I have seen it Avhen the patient was otherwise affected. It probably results from gastro-intestinal irritation. Itching in the anus is the most common and only particular effect produced by the small worms, and you can imagine that this irritation may be sufficiently exten- sive to disturb the general system. Corea sometimes, and epi- leptic fits, very often result from verminous irritation; but the latter are usually harmless Avhen properly treated. A peculiarly dry, choking cough, is a very common symptom. Children almost invariably have a dry cough, and a tendency to swalloAv as though they were choked. It is said by the authorities that most children affected by worms are subject to indigestion; but I have observed that the most vigorous, healthy children are most obnoxious to them, while those of nerA-ous temperament and spare habits are least liable to be troubled ; and I suppose their nervous systems are too sensitive to tolerate the long-continued irritation which would be likely to be set up by the presence of worms. Evacuations would most probably soon follow. It is a most remarkable fact which I have never seen stated in the books, and to which I would call your particular attention, that lying-in women are quite subject to worms. I have, in a WORMS. 591 number of cases, found fever following child-birth, which was not amenable to ordinary remedies, but which was relieved immedi- ately upon the evacuation of worms. And where there are no other circumstances to account for symptoms of this kind, I am universally in the habit of administering worm medicines, and almost always with success. Whether the period of gestation favors the formation of worms, I am not prepared to say, but am inclined to that opinion. The fact stated is one that you should bear in mind, as you might otherwise administer purgative medi- cines of various kinds without giving any relief. In regard to the origin of worms, the subject is involved in obscurity and doubt. By some they are supposed to be spon- taneous. This view is maintained from the supposed fact that children are born with worms, and that they are found in the intestines of premature or still-born children. This fact seems to imply an origin from some other cause than an extrinsic one, but it may be doubted Avhether it proves a sponta- neous origin. Another theory accounts for their existence by propagation from progenitors of like species. But this theory, you will see, does not touch the question of the first origin. It merely supposes that this class of animals is continued by the exercise of its reproductive powers, as in the case of other ani- mals. The question still remains, do they now in any case originate de novo from the direct and immediate exercise of creative poAver ? This appears to me to be the only question; for, to say that matter, or the elements of matter, acting under established laAvs, known or unknown, may be arranged in collocations favorable to the development of these, or any other organisms, is simply to take for granted that the germ, the vital principle of the organism, has been previously created. Or, if it is denied that anything is thus assumed, and if it is still maintained that the first existence of these organisms, necessarily or otherwise, grOAVs out of certain colloca- tions of matter, even then, I ask, what additional light is shed upon the question ? In either case the beginning is equally dependent on creative power, and equally beyond our compre- hension. It seems, however, to simplify the matter somewhat, to follow the numerous analogies of nature, which favor the theory of the original creation of the type, with the power of reproduc- 592 worms. tion. The conclusion would then be inevitable, that these ani- mals, like all others, are now generated only by propagation. To support this conclusion, as well as to show the state of Ger- man opinion, I quote the following from Vogel's Pathological Anatomy, page 382, et seq.: " Respecting the origin of parasites, there have existed from the most remote periods, when they were first remarked, till the present time, two opposite opinions. According to one view they are generated, in the same manner as most other animals and plants, by propagation from progenitors of like species; according to the second view, they originate from equivocal generation. That many parasites can, and actually do, arise by descent from parents of a similar kind (by germules, seeds and ova,) is at the present day allowed even by the believers in equivocal generation. The controversy hinges only upon the question: can some para- sites, in certain cases, also originate de novo, or are those at pre- sent occurring invariably, and in every case, derived from parents of like species ? A positive reply to this question, based upon convincing observations and researches, is as little possible now as at the time when Pallas wrote his interesting dissertation upon the subject,* although since that period numerous eminent hrtesti- gators have devoted their attention to the formative relations of parasites; but, nevertheless, it appears to me that a majority of important reasons favors the vieAY that at the present time no par- asites are spontaneously developed, but that all are, in some way or other, derived from parents of like species." Vogel then gives a " brief abstract" of " the doctrine of spon- taneous generation," as follows: "The idea of spontaneous generation is a philosophical necessity. All organisms with which we are acquainted, that are now derived from parents of like species, must at one time have arisen in another manner without parents. Whatever name may be applied to this primitive origin, or Avhatever vicAv may be taken of it, whether it be termed crea- tion, or receive any other name, it is, in reality, spontaneous gen- *P. S. Pall;n, de infestis viventibus intra viventia. Lugduni Batavoram, 1760. " Tmditis nunc omnium scntentiis de viventium intra viventia origine, cxpositisque argumentis propugnantibus singulas et contrariis, cujuslibet, erit verosimillimam mente, comprobare, donee experimenta quit in hac parte maxi- mopcre deficiunt, ccrtos nos reddunt." WORMS. 593 eration, in contrast with derivation from parents. This necessity of a spontaneous origin of the organisms at present existing is, moreover,' daily proved by experience. Geology demonstrates that many, indeed the greater number of the organisms now on the earth's surface, did not exist at an earlier period, since we find no vestiges of them. Accordingly, it is undeniable that spontaneous generation occupies a prominent position in the his- tory of the world, as a mode of origin of all organisms. The question, therefore, turns only upon this point: can existing organisms, which at a former period originated spontaneously, and have subsequently propagated themselves in another manner, again rise spontaneously ? or, in other words, is there a repeated spontaneous origin of creatures of the same species. " Let us noAV consult experience for materials in order to reply to this question. We find that in all cases where opportunity has been afforded of tracing, by direct observation, the origin of an organism, it has taken place by propagation; whilst, on the con- trary, not a solitary unexceptionable observation of a spontaneous origin exists in the records of natural history. Analogy is, there- fore, completely in favor of the view that propagation is the only manner in Avhich existing organisms are engendered. The value of this evidence is further enhanced by the history of science. In earlier times it was admitted that even the vertebrate animals were produced by repeated spontaneous generations: geese and ducks from barnacles, (Lepas;) the batrachia and serpents from mud; and still, at later periods, insects, as the coprophagi, from dung ; and fleas from putrid urine. No one, at the present day, doubts that all these animals are generated by propagation alone. Indeed, in modern times, chiefly through the labors of Ehrenberg, even the generation of infusoria has been limited to the propaga- tive system. Analogy would, therefore, lead us to conclude that parasites are also produced in this manner alone. The objections which have been urged against this view, and the arguments which have been adduced in favor of a spontaneous production of parasites, rest chiefly on the ground, that in many cases the origin of these organisms, by means of propagation, is inexplicable; and is, therefore, held to be impossible. But it is overlooked that the assumption of their spontaneous origin is, in reality, merely a 38 594 WORMS. formal explanation, which leaves us completely in the dark respecting the true reasons and conditions of their production. Moreover, many of these reasons have latterly become invalidated by the progress of knowledge, since not merely the possibility, but also the reality, of their propagation to other organisms, and the inducing conditions, have been demonstrated in various para- sites ; and although in this respect, at present, much appears mys- terious, yet the numerous experiences of later years must raise a hope in every unbiased observer, that the further advancement of knowledge will clear up the obscurity which, at present, envelops this province, and will establish the origin of all parasites by propa- gation, to the exclusion of spontaneous origin. The prevalence in the belief of spontaneous generation was an important obstacle to the progress of knowledge, since it hindered accurate investiga- tions regarding the formative relations of parasites ; and, with the general diffusion of the view, that all parasites originate by propa- gation, observations concerning their actual transference from one individual to another, will, doubtless, also accumulate." " If, then," continues Vogel, " we assume that parasites are invariably derived from parents of the same kind, and are never produced spontaneously, it folloAvs that they are never a true pro- duct of a disease, and cannot, therefore, originate directly from degenerated particles of the body, depraved secretions, kc. It is, however, undeniable that morbid changes of portions of the body frequently exercise a certain influence upon their origin. These changes may favor their development, and, indeed, alone render it possible, by inducing conditions essential to it; they can again prove injurious to it, since they may remove conditions ne- cessary to its occurrence. Thus, for example, vegetable parasites (fungi) do not in general develop themselves upon mucous mem- branes, until, by morbid processes, a deposit of coagulated fibrin, which serves as a bed, has become prepared for them, and until this exudation has passed into a state of putrid decomposition. An abundant secretion of mucus favors the development of worms Avhich have entered the intestinal canal from without. Some states of the organism, on the contrary, disqualify it as a habitation for parasites. Thus, most of the entozoa in the intestinal canal are expelled by increased peristaltic action; some fluids of the body, WORMS. 595 as bile, urine, gastric juice, and some medicines, prove deleterious, and indeed, fatal to some of them; inflammation, or at least sup- puration, may injure, and even destroy them." In connection with the fact that an abundant secretion of mucus is always attendant upon verminous irritation, I wish to add a practical remark. Accumulations of mucus may often result from irritation produced by other causes. And it will, therefore, be- hoove you not to be too hasty in inferring the existence of worms from this consideration alone. But if the family predisposition was known to favor their existence, it would generally be sufficient ground to warrant the conclusion. If, however, the family pre- disposition was against the opinion, further investigation should be made to ascertain if there was not some other cause of the phe- nomenon. It is also important to bear in mind that the traditional notion, that worms naturally exist in the human stomach, and should not be removed unless they produce constitutional effects, is absurd and groundless. However much they may indicate func- tional derangement, yet they are not always present. As worms rarely cause death, opportunities seldom occur for anatomical observations. In such cases as have been examined, ac- cumulations of mucus, and more or less irritation, have been found to exist. The latter appearance, however, might have been the effect of adjacent inflammation. In one case, perforation of the intestine Avas found, and the worm had lodged in the cavity of the abdomen. Some varieties have the ability to insert their capillary heads into the membrane. In regard to the treatment for worms, the remedies are various. Every physician has his favorite. The treatment, of course, must be varied according to the symptoms of each case. If, for in- stance, you are called to treat a child in convulsions, where worms are supposed to be the cause,—and in the majority of cases such is the cause—the first indication is to relieve the convulsions. I have little confidence in a warm bath, which is the popular remedy for such cases, but prefer brisk friction and warm applications to the abdomen, with stimulating friction of the spine. I also bathe the head Avith warm water and fan it, and apply hot water and sinapisms to the feet, if they are cold. An anti-spasmodic should be administered immediately. Our sudorific tincture is an excel- 596 AVORMS. lent remedy, but should be given with care to young children. From half to a teaspoonful would not be an overdose for a child of from two to four years of age. Equal parts of the tinct. asafoetida and sulphuric ether make an excellent remedy. I have also given chloroform with prompt relief. Such convulsions ap- pear exceedingly alarming, but are not particularly dangerous, and soon pass off. After these symptoms are relieved, a decoction of our anti- bilious physic, with pink and wormseed, given in sufficient doses to produce free evacuations from the bowels, and repeated two or three days, will usually be successful, and in such cases has been my main reliance. It is equally reliable in the treatment of the small long thread-worm, which inhabits the same portion of the intestinal tube. It is composed as follows : # Anti Bil. Phys. } Spigelia Marilandica, >• da 3iij. Chenopod. anth. ) Decoct. 1 pt. water—Dose, tablespoonful. When this course is pursued, you will scarcely ever fail to pro- cure relief on the first day, and almost certainly on the second. If, however, it has been necessary, I have been in the habit of re- peating on the third day. And such has been my success with this measure, that, Avhen relief was not obtained on the third day, it was conclusive evidence to my mind that the symptoms were deceptive. There is a popular prejudice against pink in many communities. on account of the apparently alarming symptoms it sometimes pro- duces. These, however, are evanescent and perfectly harmless. You Avill frequently find periodical fever associated Avith worms, which, in many instances, will subside on expulsion of the worms. But when it is dependent on malarial influence, it will not thus yield, and then it will be necessary to administer anti-periodic remedies. When the pink mixture has failed, I have substituted, with abundant success on several occasions, a combination of the extract of spigelia and sulphate of iron, administered two or three times a day, and followed by a brisk cathartic. I recollect one case in particular, in which every other remedy had failed, and this AVORMS. 597 Avas resorted to with complete success. An enormous quantity of worms was discharged, and I think in this case there were three or four, at least eighteen inches long, and of a corresponding size. You can imagine they were difficult to remove. A favorite recipe for worms, where the patient is not much sick, is the folloAving: Tfc Oleum Chenopod. 3ss. Castor Oil, 3j- Oil of Spike, 3iij. Spirits Turpentine, 3ij. Croton Oil, Gtts xvj. Mix. A teaspoonful should be given once or twice a day, and it will be found less troublesome to administer than medicines, which have to be given every hour or tAvo. In this combination you have excellent anthelmintic and efficient purgative properties. It should be thoroughly mixed to guard against the effects of the croton oil. A favorite remedy with the planters of the South, is the Pride of China, or melia azedarach, given in decoction, in the use of which I have had no experience. Analogous to this, in some respects, is the burr of red cedar, the efficacy of which probably depends on the turpentine it contains. These, then, are the chief remedies for the common round worm, and also for the thread worm. The ascarides, or that variety which infests the rectum, can best be removed by local treatment, though the vermifuge and cathartics will rarely fail to bring away more or less of them. I have uniformly succeeded in dislodging or discharging this variety with injections of moderately strong salt and water, or soap suds, repeated every day or so, for some time. In addition to these, I have also injected a solution of copperas, say a drachm to a gill of warm water. When irritation, amounting to dysentery, fol- lows or is produced by these Avorms, an injection of althea or slippery elm, or the common starch and laudanum injection, may be used. The symptoms of the tape-worm are somewhat peculiar and worthy of brief consideration. It usually inhabits the small in- testines and most generally exists singly. It rarely occurs in children or aged persons, though I believe it has, in some cases, been found in the former. It is comparatively rare in persons of 598 WORMS. any age. In my own practice, I have never met with more than two or three cases. It is said that tape-worms sometimes exist for a considerable length of time without producing much inconven- ience or suffering. The disturbance they occasion is not gener- ally that of severe pain, but uneasiness and distress, which often, sooner or later, impairs the general health. The symptoms usu- ally complained of, are, more or less uneasiness in the head, gen- erally in the forehead, sometimes amounting to pain, slight giddi- ness and ringing in the ears. The eyes often have a heavy feeling and the patient is frequently rubbing them; the lids become ede- matous, which is also a frequent symptom of the common round worm; the pupils are sometimes dilated, and you will often see spasmodic twitchings of the muscles, both of the eyes and lids. There are frequent changes of the countenance, at one moment being highly flushed, and then again being exceedingly pale. Twitching of the muscles, particularly about the mouth, and a pinched or contracted appearance of the nostrils, accompanied with an itching sensation, are very common. The appetite is variable, being sometimes voracious and at others deficient. The breath is always offensive and the tongue usually furred. There are frequent turns of nausea and sometimes ejections of frothy mucus. There is often, as with children having the common worm, a gra- • ting of the teeth while asleep, fullness of the abdomen with con- traction about the navel, and a sensation after sleeping all night, of an animal moving about in the bowels, accompanied by fugitive, shooting pains; all these symptoms subside after eating. The patient, as these symptoms gradually increase, becomes weak and nervous. And finally, worn down with the excitement, he be- comes hypochondriacal and sometimes deranged. The most une- quivocal symptom, is a discharge of some portion of the joints of the worm. In regard to treatment, I have, in the few cases that have come under my observation, procured relief by the use of a decoction of the pomegranate bark, continued for a feAv days, and then fol- lowed by purgative doses of spirits of turpentine. The decoc- tion was made of an ounce of the bark to a pint of water, and taken on an empty stomach. This was continued a few days, and then followed with about one ounce of the spirits of turpentine WORMS. 599 and the same quantity of salad oil. If it did not operate in two hours, I followed with a dose of our anti-bilious physic. This will rarely fail to operate freely, and will usually give relief. Some physicians have found the turpentine equally effective in much less doses than I have here recommended; but the amount I have been in the habit of giving is not as large as you will find recommended in some of the authorities. The root of the aspi- dium filix mas, or male fern, has a reputation, in some sections of the country, not equaled by any other article of the materia medica; but whether this is well founded, I am unable to say from personal experience. There is doubtless, however, some foundation for the opinion so generally entertained in regard to it. The Boston Medical and Surgical Journal contains one or two communications in regard to a new remedy, which, from the character of the Journal, and the apparent truth and simplicity of the statements, I here copy: Vol. 45, p. 201— " The following letter," says the Editor, " is from Richard Soule, Esq., of Boston, a gentleman of the highest respectabil- ity, whose only object is to make known extensively, among phy- sicians, what he considers a specific for the destruction of the tape-worm," &c. " Dr. J. V. C. Smith— Dear Sir:—The merits of the very sim- ple pumphin-seed cure for tape-worm, rest on the testimony of those who have thereby succeeded in expelling these troublesome intruders from the premises they had occupied for years; and the accidental agency the writer has had in one of these cases, has brought a number of applications for the recipe. Should you deem it of sufficient importance to occupy a page in your widely circulated Journal, it may serve to relieve some afflicted one who cannot well avail himself of the physician's aid, and also give to physicians a new remedy; I therefore place the recipe at your disposal. Yours, assuredly, R. S. " Cure for Tape-worm.—Procure sufficient seed of the pump- kin, (those grown in the West Indies are the best), to make two ounces after removing the outside shell of the seed; put them into a mortar and add half a pint of water; pound them well up, 600 WORMS. and make a liquid orgeat of them, which strain through a cloth. Drink this mixture in the morning on a fasting stomach. If it does not operate in the course of an hour and a half, take one ounce of castor oil. Drink all the time as much fresh, cool water as the stomach can bear or contain; that is, drench yourself with water. After taking the orgeat, if the stomach is well rubbed with ether, and an injection of about 60 drops of it is taken, you will find it an assistant to the orgeat, but this may not be neces- sary. Should the first application of the remedy not answer, repeat it the next morning, and there is no doubt your complaint will be removed. The worm will leave the patient all at once, and probably entire. This can be ascertained by finding the small end or head of it, which tapers off almost to a point." The writer adds, in a postscript, that he had testimony from a friend in New York, that this remedy had " cured probably a dozen different persons afflicted with the tape-worm, and who had been given over by their physicians." In one case the worm expelled, " Avas 34 feet long, and each link about one inch." He also mentions a lady in Boston, who was restored to perfect health, by the same means, after years of prostration and efforts for relief. In the same volume, page 274, another correspondent says that he recommended the above remedy to an intimate friend, who, " for want of West Indian, or other pumpkin seeds, took un- dried acorn or marrow-squash seeds, and proceeded, secundem artem, following the orgeat, in about one hour and a half, with about six drachms of castor oil, taken in two spoonsful of Hol- land gin. He drank very httle Avater twice, drank and ate noth- ing else till noon, when the only effect of his faith and practice was manifested ' in one liquid discharge, containing\the squirm- ing worm; at one end about one-third of an inch broad, taper- ing down to nothing.' " F. W. Craigin. The medical periodicals have recently mentioned another rem- edy— the product of Braycra anthelmintica, and known by the common name of Kousso. POSTHUMOUS WRITINGS OF THE LATE PROF. T. V. MORROW, ON THE THEORY AND PRACTICE OF PHYSIC. I. FEBRIS INTERMITTENS, OR INTERMITTING FEVER. This is a form of disease of great frequency of occurrence, and is characterized by a succession of regularly recurring paroxysms, each of which is followed by a distinct intermission, the duration of which varies materially in different cases, according to the type which the attack assumes. The paroxysm or fit, when formed, includes three stages or periods, sufficiently distinct in their features to entitle them to a separate consideration, each successive one being appropriately regarded as the immediate consequence of that which next pre- cedes it. Like other forms of fever, the paroxysm, or attack, is preceded by a train of symptoms, which vary according to the special nature of the cause which gave rise to them, and the character of the constitution in which they occur, modified also by the pecu- liar epidemic constitution of the year. This series of symptoms constitute what is called the forming stage. Among those which more commonly mark this period, may be reckoned a slight sense of weariness, occasional yawning, stretching, lassitude, loss of appetite, a slight increase in the irritability of the stomach, some- times nausea, a bad or bitter taste in the mouth, the tongue being slightly furred, and generally an uneasy sensation in the stomach and bowels, a slightly uncomfortable feeling throughout the whole body, and a disinclination for either mental or corporeal exertion. Other cases may be marked by additional and different phenomena during their premonitory stages. After the premonitory symptoms continue a longer or shorter period, the proper paroxysm of the attack is ushered in by its 604 INTERMITTENT FEVER. cold stage, which is the first period of the three already referred to as constituting the division of the paroxysm into three stages, and which may be regarded as the first infallible evidence that the cause, or causes, have acquired a predominance over the re- storative, or resisting powers of the constitution—for at least a limited period. This stage is usually marked by the following symptoms: a sensation of cold is felt more commonly in the extremities or back, which may be at first very slight, but gra- dually increasing until the patient becomes very uneasy, changing his position frequently, the extremities getting still colder, and in many instances feeling somewhat benumbed. The mind seems to be very restless as well as the body ; it is, with much difficulty, fixed or concentrated on any particular subject. The feet and hands become very cold, and an universal paleness of the skin takes place. Sometimes a general shaking of the whole body occurs, and there is a shrinking of the volume of the body from a reces- sion of blood from the superficial capillaries, a hurried and some- what irregular respiration, a limpid and pale condition of the urine, and often a desire to evacuate the contents of the bladder, nausea and vomiting, and an oppressed and uneasy sensation of the stomach. The pulse is small, frequent, contracted and firm, thirst is urgent, mouth dry and contracted, confusion and dejec- tion of mind. The chills are usually diffused over the whole body, sometimes, however, confined to one particular part of the body. The duration of this stage varies from a few minutes to several hours. The chilly sensations, in many of these cases, are very much intermixed with flashes of heat, especially towards the con- clusion of this stage. The nausea and \Tomiting are generally more severe about the time the hot stage is about overcoming the cold. Next follows the hot stage, which is marked by the following symptoms: the countenance is flushed ; a hot, husky and dry state of the surface of the body; thirst still continues great; strong, full and hard pulse generally; volume of the body increased; respira- tion free and full, though somewhat hurried ; pain in the head, back and loins increased ; urine small in quantity and deep colored ; temperature of the body always considerably above the INTERMITTENT FEVER. 605 natural standard, and the strength is frequently increased for the time being. This often lasts considerably longer than the cold. The SAveating stage commences by a perspiration on the fore- head, which gradually extends over the whole body, and Avith this comes a general abatement of all the symptoms of the previous stage. The pulse loses its hardness but retains its fullness, urine becomes sedimentous and increases in quantity, respiration free and easy, pains subside, and the patient passes into a state of apyrexia, or convalescence, gradually. The period of intermission is far from being a state of perfect health. There are during the whole of this period certain symp- toms present, which indicate the presence of disease, such as a sense of languor, lassitude, weariness, on slight exertion of either body or mind, increased frequency of the pulse over the standard of health, pale and sickly aspect of the countenance, preternatural irritability of the system, an unusual sensibility to cold on expo- sures, and in most cases an impaired state of the appetite and the poAvers of digestion. Intermittents not only have the various types of quotidian, ter- tian, quartan, and their several complications, but present them- selves under the different varieties of inflammatory, gastric, congestive and malignant. The inflammatory variety is characterized by a pretty severe chill, which is generally short; high, vigorous and strong reaction ; the hot stage is usually much protracted, skin hot, and very red. This variety more commonly occurs in young, robust and ple- thoric subjects, and is very apt to take place in the spring and winter ; the quotidian is much more apt to have this character than the tertian, and the tertian than the quartan. The inter- missions, in cases of this kind, are short and very imperfect; the pulse remains somewhat quick and hard, and there is more or less increase of temperature of the skin during the Avhole period of apyrexia, with frequent transient pains, and often a dry, hacking- cough and an irritable and fretful temper. The congestive intermittents are by no means frequent, and occur in individuals of the nervous temperament, of a relaxed and debilitated habit of body, and are characterized by tedious chills, and a feeble and Arery imperfect reaction, a sense of weight and 606 INTERMITTENT FEVER. oppression, more especially in the breast; a small and weak pulse; frequently a fainting tendency is noticed; sometimes coma and a deep oppressive pain in the head, countenance pale and somewhat contracted. During the fever there are often chilly sensations externally, and a sense of oppressive burning heat internally. Gastric intermittents are such as manifest a striking amount of irritability of the stomach and bowels, accompanied with a redundancy of the biliary secretion, which, in connection with other morbid accumulations in the alimentary track, act as sources of irritation, and give rise to frequent nausea and vomiting, pain in the head, foul and bitter tongue, thirst and a desire for acid drinks, a yellow tinge of the skin and tunica conjunctiva, sense of weight and fullness in the right hypochondriac region, high col- ored urine charged with bile, and a decided aptitude for the pro- duction of visceral obstructions, such as induration of the spleen and liver. This is, perhaps, the most frequent modification which is met with by the practitioner. Malignant intermittents are those which are characterized by very copious, debilitating and foetid sweats, and frequent hemor- rhages from the various outlets of the body. They are very dan- gerous, and occur more commonly in hot climates and run- their course with much rapidity. Intermittents are known to assume, in some instances, an irreg- ular and anomalous character. In some cases the stages are reversed, and in others, one of the regular stages is substituted by some other symptom; as, for instance, perspiration by diarrhoea, nausea and vomiting as substitutes for chills, and, in other cases, some one of the stages appears to be entirely absent. The attacks of this disease, in cases of young children, are much more indistinctly marked, in its various stages, than in adults, or even in more advanced children. Still, however, the accurate and critical observer can recognize its various stages, Avith a reasonable degree of certainty. The cold stage is more obscurely developed than any of the others, and is usually mani- fested by a paleness of the skin, a shriveled and shrunk appear- ance of this tissue, stretching and yawning, &c. The consideration of masked agues will be reserved for a future chapter. INTERMITTENT FEVER. 607 Intermittents are not unfrequently complicated with various other affections, such as dysentery, splenitis, jaundice, cholera morbus, &c. A large train of morbid phenomena may follow, as consequences of long continued and repeated attacks of intermittent fever ; but they also possess the acknowledged power of modify- ing, to a great extent, and indeed of removing completely, many other forms and modifications of disease. A patient observation of the natural tendencies to a sponta- neous termination of intermittents, has resulted in the conviction, on the part of those who have made these investigations, that the quotidian type manifests a pretty well marked inclination to come to a close on the seventh day of the attack, tertians on the four- teenth, and some say the twenty-first, and quartans at or about the end of the sixth week, if uninfluenced by any treatment whatever. Intermittents are not to be regarded as dangerous, as a general rule, more especially in temperate latitudes; but in the more tropical regions they are more apt to assume a malignant charac- ter, and consequently a much greater liability to a fatal termina- tion exists in cases of this kind. Mild and regular intermittents are easily cured, when judiciously treated—the more irregular, the more difficult to effect a cure. Among the symptoms which indicate danger, may be mentioned a tumid and hard abdomen, delirium, difficult and oppressed res- piration, with a swelled state of the tonsils, profuse and long con- tinued and offensive diarrhoea, bloody urine, and when the patient remains much oppressed and debilitated during the intermission. The favorable symptoms are, the appearance of scabby and humid eruptions about the mouth, the reappearance of suppressed discharges, whether morbid or natural, a moist and soft state of the tongue and skin, and improvement of the tone of the diges- tive organs. Tertians seem more readily removed than quoti- dians, and quotidians than quartans. A postponing is also more favorable than an anticipating intermittent. Sometimes these cases lose their intermitting character and become remitting, Avhich is of course an unfavorable change. Causes. The cause which more than all others seems to be most concerned in producing this disease is malaria or miasms, 668. • INTERMITTENT FEVER. :4 arising from the putrefactive decomposition of vegetable mat- ter, and abounding in low, rich and marshy districts, operating much more extensively during certain years than others. Worms, the suppression of customary evacuations, as well as a varietv of morbid accumulations in the alimentary track, have been instru- mental in producing this complaint. Exposures to cold and check of perspiration have acted as the immediate causes of its invasion in a vast number of cases, especially those in which a predisposi- tion has been generated in the system by the influence of Mala- ria. Indeed it may, with great propriety, be remarked, that al- most any cause calculated to disturb, to any considerable extent. the vital operations of the human economy, will give rise to an attack, when the system has been previously prepared by the grad- ual influence of Miasmata. As to the period which intenrenes between the first impression of the malarious cause and the de- velopment of the actual attack, sufficient testimony has accumu- lated on this subject to render it certain, that it is very various in different individuals, dependent, no doubt, on the intensity of the action of the cause, and the diversified susceptibilities of the in- dividual subjects of the attacks. Intermittents occurring in the Fall are called Autumnal Intermittents, those occurring in the Spring are called Vernal. Eclectic Reformed Treatment. I deem it Avholly unnecessary on this occasion to mention the details of the ordinary methods of treating this complaint, according to the various systems and plans at present followed and practiced by their respective vota- ries ; neither do I regard it as a duty properly incumbent on me to bring forward the numerous, and, to my mind, insurmountable objections which undoubtedly exist against numerous portions, if not the Avhole, of any one of the prevailing schemes of medical practice. They all perhaps contain some features which are to a certain extent valuable and worthy of adoption, which the dis- criminating, enlightened, highminded and liberal advocates of Medical Electicism and Reform will find no difficulty in incorpo- rating as a part of their medical principles and practice. As a preliminary step to the institution of a course of treatment in any given case, it becomes the duty of the practitioner to make himself intimately acquainted with the Type of the case before INTERMITTENT FEVER. 600 him, Avhich is practicable in all cases in wThich the attack has pro- gressed far enough to develop its true character. But the prac- titioner should be remarkably careful not to suffer himself to be misled by the information elicited on examination of the patient or friends, in regard to the phenomena attending previous parox- ysms, and the order and succession of their symptoms. It not unfrequently happens that the previous observations of the patient have been so inaccurate on this subject as to disqualify him, in a good degree, from giving anything like an intelligible and satisfactory account of the progress of his own case. The cold stage of the paroxysm is so very slight in many cases, as to escape not only the notice of the patient himself but all who may be present. I have examined hundreds of cases of this complaint, in Avhich the patient denied at first the existence of any such stage, but upon a more critical and searching inquiry, Avas led to see and acknoAvl- edge his error. You cannot therefore place implicit reliance on the statements of patients at all times, more especially those whose mental constitution and habits of thought have not duly qualified them to make accurate distinctions and critical observations. It is a matter of the highest possible moment to the practitioner, to have accurate conceptions of the nature and type of his pa- tient's case, in order that he should be duly qualified to direct, in the best manner for success, its subsequent treatment. The state of the patient is generally such as to require pretty efficient evacuations, either by A'omiting or purging, and some- times both. As a general rule, however, the administration of a mild but thorough cathartic will be found all that is necessary in this wray, and for this purpose perhaps none will be found better than the common anti-bilious physic, which should be given in closes of two teaspoonsful of the poAvder, to which half a teacup- ful or more of boiling Avater had previously been added, well mixed and sweetened, the whole, for an adult, taken at once. This dose operates Avith singular briskness and energy as a cathartic. Some- times, however, Avhen the stomach is much loaded by morbid ac- cumulations, it operates by vomiting also, and has been found amply sufficient in many cases to break up the attack at once, Avithout the aid of tonics. The tonic and stimulant which I have found more universally successful than any other, for the last ten or 39 610 INTERMITTENT FEVER. twelve years of my practice, is what is usually denominated the ague bitters, the composition and preparation of which is as fol- lows : sulphate of quinine 30 grs., cream of tartar and pulverized cloves each one ounce, whisky one pint; mix. Of this give one tablespoonful every hour during the intermission, until about three hours before the next paroxysm is expected. The dose should then be doubled, viz: give two tablespoonsful instead of one at the same intervals. It may sometimes be necessary to give these double doses once every half hour for two or three hours previous to the expected paroxysm, when the case proves unusually obsti- nate. This course very rarely fails of success when it is premised by suitable evacuation. It often arrests the chill within the first day or two, and seldom requires longer than three or four days for arresting both paroxysms of the double tertian. But this tonic should be continued for several days after it has been successful, for the purpose of preventing a relapse, in less frequent and smaller doses. Say one tablespoonful once in two hours will be sufficient for that purpose ; especial care should be taken to have the patient in a high state of stimulation about the time which marks the return of the paroxysms. Should the bowels require to be opened after the chill is prevented, care should be taken so to time the purgative that its operation should not come on at or near the time of the return of the paroxysm, inasmuch as such an event would be liable to increase the chances for the success- ful return of the cold stage of the paroxysm. Should the stomach be nauseated with a loaded or oppressed state of that organ, bitter taste in the mouth and furred state of the tongue, such a condition calls for the use of an emetic, which should be accordingly given at any stage of the disease. The common emetic powder or tincture would form a commodious prep- aration for this purpose. The following plan for the arrestation of the paroxysms of an intermittent, has proved eminently successful in my practice in nearly every case in which it has been tried. Tayo hours before the paroxysm is expected, place the feet of the patient in hot water or weak ley, and at the same time administer freely of hot or warm sweetened herb teas, such as catnip, pennyroyal, INTERMITTENT FEVER. 611 balm, sage or ginger. After soaking the feet 15 or 20 min- utes, let the patient get in bed and have a hot brick placed to his feet, and take, in connection with the tea, a teaspoonful of su- dorific tincture every 20 minutes or half hour, until the patient should get into a state of profuse perspiration, which should be continued for an hour or two after the time of the chill. It gen- erally requires three or four teaspoonsful of the sudorific tinct- ure, as Avell as copious draughts of the herb tea, to be taken every ten or fifteen minutes throughout the whole period, to keep up the perspiration as freely as it ought to be in order to be success- ful. It is distinctly understood that in all cases, suitable evacua- tion by vomiting and purging, or either, as the case may require, should be premised in order to ensure the desired success accor- ding to the foregoing plan. This mode of treatment scarcely ever fails in preventing the paroxysm the first or second trial, provided it is carried out with a suitable degree of energy and care. The point, however, in which the practitioner is most liable to fail, is in neglecting to commence soon enough to bring the patient fully under the influence of the means, before any sign of the fit approaches. After preventing the paroxysms in this way, it becomes necessary to repeat the same measures for two or three successive days, to ensure a greater exemption from any liability to a return. In order further to ensure the success of these measures, the use of from one to two table spoonfuls of the vegetable wine tincture every two hours through the day, during the intermis- sion, will be found highly useful as a febrifuge and tonic. The paroxysms of an intermittent may, with a good degree of certainty, be arrested by a pill composed of extract of cornus florida 3 grains, piperine 1 grain, given every two hours during the intermission, in conjunction with a strong decoction of the senecio gracilis in doses of two or three tablespoonsful every half hour during the intermission, in like manner with the pills. The paroxysms of intermittents may also be arrested by the operation of an emetic given with a view to have the patient fully under its influence at the time of the accession of the fit. The common emetic powder may be chosen for this purpose, and admin- 612 INTERMITTENT FEVER. istered in doses of one teaspoonful every ten or fifteen minutes, in a strong decoction of boneset tea. Commence at least one and a half or two hours before the expected attack of the parox- ysm and continue till some time after it should have developed itself. II. REMITTING FEVER. There seems to be quite a striking similarity between this and the Intermitting, at least m very many particulars. They are doubtless the result of the same cause, and have the same gen- eral types, yet differ in the degrees of their violence, and dura- tion of their respective paroxysms. But in consequence of a decided modification of character, arising from the absence of anything like an intermission of the febrile phenomena, a corres- ponding modification of treatment becomes indispensably neces- sary for the successful management of this form, and this fact alone would constitute a sufficient reason, to bestow on each a separate and distinct consideration. The symptoms which exist during the forming stage, are simi- lar to those of the forming stage of intermitting or other fevers: such as languor, yawning and stretching, sense of weariness in the limbs, nausea, want of appetite, slight chilly sensations, cos- tiveness, or at least an irregular state of the bowels. These con- tinue for a longer or shorter time, when the attack is not unfre- quently ushered in by a chill; in some cases pretty severe, in others less distinct. These chilly sensations, in many cases, are the first manifestations of deranged health. They are commonly alternated with flashes of heat, which gradually gain the ascend- ancy, and a higher or lower grade of fever is at length estab- lished, which is accompanied by a general aggravation of the symptoms, pains in the loins, back, limbs and head, increased in violence, a sense of fullness of the epigastrium and hypochondriac regions, Avith a sense of oppression in the neighboring parts, yel- lowish tinge of the eyes and skin, nausea, and frequently bilious vomiting, urine scanty and high colored, often tinged with bile, the pulse full and frequent, but not apt to be very hard; oppressed and 614 REMITTING FEVER. anxious respiration, skin dry and hot. These symptoms continue with a greater or less degree of force, for about 24 hours, Avhen an abatement or remission occurs in their violence; a gentle moisture is apt to take place, over the face and upper portions of the body; the remission usually takes place in the morning, but during this period, (which lasts but a short time) the febrile heat does not entirely subside, the pulse remaining in a state of irri- tated excitement, with a certain degree of fullness and hardness. In other words the febrile phenomena do not entirely subside. Very soon, however, the symptoms of the previous paroxysm re- turn, and pass through a period of time similar to that which was occupied by the first, when again a remission occurs, and thus a regular series of exacerbations and remissions follow each other, establishing periodic revolutions, which more frequently assume the double tertian type than any of the other types of intermitting fever. Sometimes, however, they take the quotidian form. The preceding description will enable any one to form a pretty cor- rect conception of the nature and character of these cases, espe- cially as they manifest themselves in mild and temperate lati- tudes. It cannot be denied, however, that they are subject to a vast variety of modifications, dependent upon the nature, as well as the intensity of the action of the causes which may give rise to them ; likewise to the character of the constitution of the pa- tient, as well as to the climate and the nature of the prevailing epidemic of the season; all of which influences impress their char- acteristic features to a greater or less extent on any given case of this complaint. A proper appreciation of all these circumstan- ces will enable the practitioner to form much more rational con- clusions and critical inferences, touching its nature and ultimate tendencies. There is, perhaps, no form of fever which is subject to as great a variety of changes and fluctuations in the respective grades of its violence and mildness, as the one now under consid- eration. While in some of the more temperate latitudes Ave find it, at least at certain seasons, prevailing in a form so mild as scarcely to give evidence of any sensible impairment of the vital powers of the patient; wc discover it, at the same time, in a form so malignant in some of the intertropical climates, and invading REMITTING FEVER. 615 the sanctuary of life with a rapidity so fearful as to produce Avell grounded apprehensions, that the pathway of its turbulent march Avill soon be marked by the graves of hundreds and thousands of those Avho have fallen speedy victims to its awful ravages. Even mild and regular remittents may assume an aggravated character, if suffered to go beyond the ninth or tenth day unchecked. In such cases the tongue becomes more completely loaded, being dry along the middle, with a thick brown fur; delirium is more apt to take place; there is a much higher temperature of the skin during the exacerbation; the skin also acquires a deeper yellow- ish color; the bowels more completely distended Avith wind, and tenderer to pressure; debility increases ; the discharges from the bowels becoming watery and much more offensive, accompanied sometimes Avith retention of the urine and much restlessness. The malignant remittents of hot climates are marked with symptoms manifesting a high degree of violence, the attack being ushered in usually Avith a short, and not very severe chill, which, however, is soon followed by an intense grade of reaction, which goes on to increase Avith fearful impetuosity, accompanied with ex- treme thirst, headache, pains in the loins and extremities, great constriction, anxiety and oppression in respiration, nausea, a sense of fullness and weight in the stomach. These symptoms continue for about 24 hours, and a remission takes place, which, in many cases, approximates the character of an intermission; but this ominous calm is destined to hold its sway but a limited period, and serves only as the precursor of a more awful and turbulent conflict between the disease and the vital powers. The eyes now become red, watery, and somewhat intolerant, in many cases, to light; the distress in the epigastric region becomes very severe and extremely oppressive, with constant inclination to retch and vomit. These continue some time and again suffer an abatement. There often appears a clammy perspiration during the subsidence of the more threatening symptoms, and, in this Avay, the dis- ease continues to have its exacerbations and remissions, until it approaches to the point of a salutary crisis, or terminates fatally, Avhich often happens between the sixth and tenth day, sometimes earlier, at others later. In the more advanced periods of the attack, the fever usually loses its remitting character, and assumes 616 REMITTING FEVER. more of the low continued typhoid type, with very great pros- tration and delirium. Sometimes the skin becomes cool, at oth- ers it has the peculiar hot character, called color mordax, quick and irregular pulse, the urine dark, offensive, and sometimes sup- pressed, lips dark, livid and swollen, tongue dark-brown or black, and clammy, the eyes usually red, watery and somewhat sunken, the discharges from the bowels reddish, wratery, dark-brown, of- fensive and bloody, sometimes very copious, attended with a tym- panitic state of the abdomen, petechia and hemorrhages mark the approach of a fatal termination. The violence, danger, and ra- pidity of the progress of the case will depend very much on the manner of the commencement of the attack. If it be ushered in with symptoms of an aggravated character, the subsequent course will be correspondingly rapid, dangerous and violent. In the progress of these cases, there is noticed a very striking tendency to the manifestation of local inflammation in some of the organs and tissues of the body, at some seasons much more apparent than others, and exhibiting itself much more frequently in particular parts than in the various parts promiscuously, doubtless attribu- table to some inexplicable condition, in the nature of the cause, which gives rise to the attack. In consequence, hoAvever, of a great liability existing to the development of a deranged condition, in a prominent degree, of two important organs of the body, namely : the alimentary canal and the liver, the division of this disease into the gastric and hepatic modifications has very gener- ally obtained, in the works of most of the systematic writers; a division Avhich it may not be the best policy, on our part, tp lose sight of entirely; although it must be confessed that this disease, as it appears in different climates and at different seasons, assumes almost every variety and shade of character, of Avhich the human mind can form anything like a distinct conception. These known and acknowledged variations of character Avould tend largely to invalidate the propriety of the existing divisions of authors, but inasmuch as it Avould serve as a kind of basis, and facilitate the acquisition of a knowledge of the character of individual cases to retain them, it is deemed most proper, with a distinct understanding, hoAvever, that they are subject to an infi- nite variety of change. REMITTING FEVER. 617 The gastric modification is marked by the following phenomena: nausea and vomiting, sometimes a yellowish bile, a bitter taste, a yellow fur on the tongue, which often becomes dry, cracked and brown, or black, an entire distaste of food, and a total loss of appe- tite, a turbid, yellow urine, great weight, anxiety and oppression in the prsecordia; bowels somewhat tender to pressure externally applied, pains in the loins and knees, also in the forehead, and often, Avhen a more confirmed state of gastro-intestinal inflamma- tion takes place, a red and fiery edge and tip of the tongue, and after the brown or black crust scales off, the Avhole surface of the tongue exhibits a smooth, shining, red appearance ; the stools become watery and reddish, resembling the washings of flesh ; difficulty of swallowing, and not unfrequently retention of urine. The hepatic modification is indicated by an intense degree of febrile heat, early delirium, violent pains in the head, fullness and tension in the right hypochondriac region, Avith pain and oppression in the same, much irritability of the stomach, and fre- quent and rather forcible vomiting, without the ejection of bile, but a glairy mucus mixed with the materials that may have been taken into the stomach, yellow tinge of the skin and eyes; very often, in the more advanced period of the disease, a large quantity of black, pitch-like matter is discharged from the bowels. There can exist but little doubt that the liver, in this case, is in a state of great sanguineous congestion, and, of course, in a very torpid state, evinced by the absence of bile in the discharges, the clean state of the tongue, torpor of the bowels, the color of the skin, as well as by the excessive and continued retching and vomiting. The black bilious matter, which is often copiously evacuated, towards the close of this form of remitting fever, often may be regarded as a kind of healthy, critical evacuation, for it is almost universally folloAved by a decided abatement of the urgent symp- toms of the case. There is no feature more prominently conspicuous in the nature of remitting fever, than the constant tendency there is to the development of a high degree of irritation, or inflammation in the mucous membrane of the stomach and bowels. Indeed, so univer- sal was this feature, that the celebrated Broussais adopted the sweeping conclusion, that there was a state of gastro-cnteritic 618 REMITTING FEVER. inflammation in all cases of this kind, in a condition of active and complete development; and upon this great pathological hypothesis, he based the doctrines, mainly, of the physiological school, which have exercised an extensive influence on the fortunes of medical science for the last thirty years. However plausible and ingenious the arguments may be to sustain this doctrine, there can be no rea- sonable doubt that a state of high irritation has often been mistaken for confirmed inflammation, and that they have failed to make those distinctions betAveen these conditions, which can be readily drawn by that class of pathologists, whose mental visions are not clouded and paralyzed by the absorbing behests and despotic sway of any one special opinion, which seizes, with avidity, all that appears to sustain, and rejects, sometimes Avithout examination, whatever appears to come in conflict with it. Remittents may change their course, so as to become inter- mitting. In the same manner, intermittents may change to the remitting form of fever. The latter, however, is the most fre- quent. It occasionally happens that other forms of disease are developed, or rather seem to folloAV as consequences of a long continued prevalence of this disease. Among those which have been known thus to folloAV, may be enumerated hepatitis, neuralgia, epilepsy, pleuritis, dropsy, dyspepsia, paralysis, pain, swelling and en- largement of the joints, chronic forms of rheumatism, mania, chorea, &c, &c. Causes. Under this head it seems only to be necessary to refer the reader to Avhat have already been enumerated as the principal causes of intermitting fever, and among these we need look but little further than malaria as being the great common source, and, indeed, almost the only cause of these two forms of human malady so universally and extensively preAalent. Some other causes are occasionally instrumental in giving rise to this complaint, such as Avorms and morbid accumulations in the ali- mentary track. Eclectic reformed treatment. So far as regards the indications to be fulfilled, in the treatment of any given case of this com- plaint, there can be but one opinion among all medical men, who are adequately acquainted Avith the laws by which the human REMITTING FEVER. 619 body is governed in a state of health and disease. But among these guardians of the public health, on the subject of the proper means and modes of fulfilling the required indications, much diver- sity of opinion does, at the present time, unquestionably exist, and will, doubtless, continue to be cherished. The proper indications are, to remove all morbid accumulations from the stomach and bowels, restore the equilibrium in the cir- culation and excitability of the system, excite the various organs to the due and proper performance of their respective functions, more especially the skin and the capillaries, Avhich are in a state of torpor and inactivity. In a vast majority of the cases of remitting fever, it would be proper to commence the treatment by the administration of an emetic, composed of equal parts of lobelia inflata and sanguina- ria canadensis in the form of acetous tincture, prepared by adding a quart of vinegar to an ounce each of the foregoing articles, in a state of fine poAvder. The emetic tincture should be com- menced in doses of two teaspoonsful, and increased one teaspoon- ful every ten or fifteen minutes, until free, full and copious vomit- ing, as many as three or four times, is produced, with a pretty distinct general relaxation and copious moisture of the skin. The emetic should be mixed in a little tea of the eupatorium perfo- liatum or chamomile flowers, which should be drank freely during the operation. The symptoms which more particularly indicate the use of an emetic, are headache, a furred state of the tongue, nausea, and occasional vomiting of a muco-bilious matter, bitter taste, a yellowish coat, and a sense of load and oppression in the region of the stomach. Provided you can have the selection of the time, it will be found that the commencement of the remission will be the best time for the administration of the emetic ; if given then, the free, full and proper effects of its operation will be much more readily produced and exercise a more salutary influence, producing a more perfect relaxation, breaking up the chain of morbid phenomena much more completely, and in many cases, converting a slight remission into a complete intermission. If, however, the use of an emetic is attempted during the rise of the exacerbation of fever, the practitioner must be prepared to anti- cipate increased difficulties in producing the desired operation, and 620 REMITTING FEVER. as a matter of convenience, will find it necessary to occupy a much longer time in its administration, and give a larger quan- tity of medicine. A much greater degree of spasmodic constric- tion has to be overcome, which affords, at once, a satisfactory so- lution of the attending circumstances of such a case. Some two or three hours after the operation of the emetic has ceased, and the stomach is completely calmed, as a general rule, a purgative will be found highly useful to carry off the morbid and vitiated contents of the bowels; and nothing seems to answer this purpose better than the anti-bilious physic, in doses of two teaspoonsful mixed in a little water and vinegar sweetened. The water should previously be added to the powder very hot, and then alloAved to stand till nearly cold, when the vinegar and sugar should be added, and the whole well mixed by stirring to- gether, and taken at once. If this should fail to operate with sufficient energy in the course of tAvo hours, then an additional teaspoonful may be given in like manner. However, it very rarely happens that the first does not produce the desired oper- ation. This anti-bilious purgative is perhaps one of the best forms of cathartic medicine known to the medical profession, and is admirably adapted to the fulfillment of the purposes of a ca- thartic, being safe and mild, yet uncommonly brisk, energetic and efficient in its operation, void of any danger, especially in the earlier stage of disease, of developing anything like gastro-intes- tinal irritation or inflammation, or of producing too great a degree of prostration of strength; the system speedily recovering its previous energy, and in very many cases Avith decidedly increased powers to perform its varied functions. Among the most important indications requiring to be fulfilled may be mentioned the production of an equal state of the circu- lation and excitability,by bringing about a free, uniform, equal and genial perspiration, an effect highly desirable in the treatment of any form of fever, but more especially so in the present. With a vieAv of producing this desirable result, let the patient have his feet soaked thoroughly for fifteen or twenty minutes in weak warm ley water. After being put in bed, let the whole surface be thoroughly bathed by means of a soft flannel cloth or sponge moistened with the same. This bathing process should be carried REMITTING FEVER. 621 out by means of brisk and active friction over the whole extent of the body, with an additional degree of force and energy along the course of the spine, and in the palms of the hands and soles of the feet. The whole surface of the body should be repeatedly bathed over in this manner, with the view of producing a suffi- cient degree of relaxation, tafaA^or the occurrence of a perspira- tion, to relax the constricted capillaries, to remove from the sur- face that mass of impure, sebaceous, concrete and irritating mat- ter, wliich is lodged so abundantly on the skin in cases of this kind, paralyzing the superficial capillaries. In the meantime the pa- tient should drink freely of warm pennyroyal, catnip, balm or peppermint tea, and take once every half hour (after the skin gets a little soft and moist,) one teaspoonful of the sudorific tincture, until the patient shall have been in a free, full and copi- ous perspiration from one to three hours. Let the patient be constantly bathed so long as there is any difficulty in procuring a sweat. After the patient gets into a free state of perspiration that process maybe continued at pleasure, by the use of diaphoretic teas alone. It is a matter of no small consequence to select an appropriate period with regard to the paroxysm, to ensure success. As a gen- eral rule the period of the decline of the febrile exacerbation, or rather the approach of the remission, is the time that the effort to produce a perspiration should be made, provided the practi- tioner can conveniently command that time for this purpose. Such is the condition and state of the sensibilities of the system that all medicines appear to produce their appropriate effects more readi- ly, when there is a tendency to relaxation. And as such a ten- dency without a doubt exists, whenever a remission is about to occur, we have no difficulty in accounting for the increased apti- tude that exists in the human constitution to be operated on by medicine with more facility. Emetics, as well as cathartics, ope- rate with more force and effect during the remissions or intermis- sions of fever, than during the accession of the paroxysms or rise of the exacerbations. When there is much restlessness, the diaphoretic powders may be advantageously substituted in the place of the sudorific tincture. 622 REMITTING FEVER. If used, these powders should be given in doses of from five to ten grains once an hour to adults, in connection with some of the diaphoretic drinks already enumerated. The common sweating powders, composed of equal parts of hydrastis canadensis, sanguinaria canadensis, myrica cerifera and sumach berries, well bruised and mixed, is also a good medicine. To an ounce of this compound add one quart of boiling water and simmer for half an hour; strain and sweeten; take in doses of two or three tablespoonsful every fifteen or twenty minutes, until it produces the desired effect, which should be kept up as long as may be desirable. In many cases it may be given in larger doses, and continued as long as it may be deemed useful to keep up the perspiration. The production of a perspiration in the manner proposed, by first cleansing the surface and restoring more permanently the functions of the skin, is productive of incalculable advantage in the treatment of fevers, and should never be neglected by the practitioner. When we take into consideration the vast extent of this tissue, and perceive that it not only covers the whole extent of the body externally, but connects itself with the internal surfa- ces in the shape of the mucous membrane, and thus fines the secre- tory surfaces of nearly every important gland in the body: and when we further reflect on its extended range of powerful sympathies, and the commanding control Avhich the healthy or unhealthy con- dition of this tissue exercises over the respective capacities of other parts to perform their appropriate functions, we cease to be surprised Avhen we find so much depends on its healthy or un- healthy condition, in the fulfillment of the requisite indications in the treatment of nearly every form of disease, either acute or chronic. In the further prosecution of the treatment of remitting fe- vers, it must be recollected that the practice should be varied with a view of meeting the different symptoms of the case as they may present themselves, being careful at all times to form a cor- rect appreciation of their nature and tendency, and adapt the treatment accordingly. The preceding means and measures, changed according to the attending circumstances, will ordinarily be found sufficient for the successful treatment of these cases, when vigorously and judicious- REMITTING FEVER. 623 ly prosecuted in their early stages, with the additional use subse- quently of such a course of restorative and tonic measures, as may be best adapted to the completion of the cure. It occasionally happens, however, that even a more vigorous and effective course of evacuation is required than has already been suggested. In such cases I have found nothing to answer the purpose so Avell as the pulverized root of the podophyllum peltatum and anti-bilious physic in the proportion of equal parts ; say, take twenty-five to thirty grains of each of the articles men- tioned, mix and add two-thirds of a teacupfull of hot Avater and a tablespoonful of vinegar, sweeten and mix thoroughly, and let the patient take the Avhole at once. This dose operates with a singular degree of efficiency „and very often cuts short at once the most formidable attacks of this complaint. Its operation usually is that of an emeto-cathartic. Its cathartic operation often be- gins first, but it is generally quickly succeeded by its emetic effects, Avhich are apt to continue several hours, during the Avhole of which time the patient is much affected Avith a sense of nausea, being apparently just on the point of vomiting, and there is much apparent relaxation and prostration of strength. The purgative operation continues occasionally to return during the vomiting, and usually for several hours after the vomiting ceases. Such is the degree of relaxation that the patient often sweats freely throughout the whole period of the operation of this powerful revul- sionary measure. I have often known one dose of this medicine to prove entirely sufficient to arrest at once some of the most violent and rapidly progressing attacks of the remittent form of fever I have ever seen. It would seem that some little precau- tion is necessary for those who would propose to use it. Its use should be directed in the earlier stages of the disease to patients who have moderately strong constitutions, and during those sea- sous in Avhich there is apt to be a torpid, inactive state of the liver and bowels. Persons far advanced in disease, as well as very old, weakly or debilitated persons, should by no means venture on its use. It is a medicine of Herculean powers and should not be incautiously used. I do not now remember ever to have seen any bad conse- quences result from its administration, but can readily conceive 624 REMITTING FEVER. it mi all bruised, or pulverized coarsely, mix, and to two tablespoonsful of this com- pound, add one quart of boiling water, and simmer it for some time, till the strength is out; then give the patient, after strain- ing it, as much as a wine glass full, five or six times a day. This seems as a general thing to exert a very beneficial effect; it quiets 692 CHRONIC BRONCHITIS. the cough, facilitates the expectoration, improves the breathing, and increases the urinary secretion and promotes the discharge of it. The patient may avail himself of the benefits of the inhalation of medicated vapor with much advantage. For this purpose, take equal parts of hops and catnip, boil them well, and then inhale the vapor freely. It usually exerts a very beneficial influence; these inhalations should be used freely as often as twice daily. A combination of equal parts of the saturated tinctures of sangui- naria canadensis and macrotys racemosa, taken in doses of from one to two teaspoonsful every two hours through the day, I have often used in conjunction with the pulmonary syrup, with the most decided advantage; it not only acts as a valuable expecto- rant and diuretic, but by its powerful sedative influence it dimin- ishes the frequency of the pulse, and increases its fullness. Great advantage is obtained in the treatment of this case by the appli- cation of an extensive irritating plaster over the chest, and keep- ing it discharging copiously for several weeks. The benefits of this measure are not by any means confined to its counter-irritating effects alone, but it is so constituted as to be readily absorbed; at least, such are the facts with regard to some of its constituent actiAre principles, that they very readily pass into the system and tend to produce, in many cases, a more active alterative influence than almost any similar medicines Avould do by being taken inter- nally ; indeed, the value of this measure is almost incalculable in the management of many forms of disease. The nauseating and expectorant drops, directed for the treat- ment of the acute form of bronchitis, are remarkably well adapted to the treatment of the chronic form of the disease : dven in doses of from one to two teaspoonsful, they do not fail to afford in almost every case very decided*fcenefit, being remarkably well adapted to the promotion of the freedom of respiration and of expectoration, removing in an efficient manner the sense of con- striction and oppression which are prominent features in this complaint. XV. CYNANCHE LARYNGEA: INFLA3IMATI0N OF THE LARYNX. Until within a comparatively recent period, the attention of medical practitioners has not been drawn to this as a separate and distinct form* of disease. Many of the older writers Avere in the habit of blending this affection with croup, but it is now pretty well understood as a distinct disease, and is so described by most of the more modern systematic Avriters, some of Avhom have divi- ded it into three varieties, namely : mucous laryngitis, affecting the mucous membrane mainly; sub-mucous laryngitis, in Avhich the sub-mucous cellular tissue appears to be the principal seat, and a considerable amount of swelling usually accompanies it; and the pseudo-membranous laryngitis, in Avhich a false membrane appears to be formed, as in the same variety of croup. The mildest form of the mucous laryngitis is marked by a slight hoarseness of the voice, without pain or oppression or difficulty of respiration, and also with very little or no cough, and passes off, in most instances, without any medical interference; but when the attack is a little more severe, in addition to the above symp- toms, there is a sense of soreness, with tightness or stricture on the larynx, or at least in some part of it; a dry, husky cough, and very often a slight difficulty in the act of inspiration. These symptoms are usually very speedily relieved by the use of a proper medication. But the disease occasionally attains a still higher grade of inflammation, and then the voice is nearly entirely suppressed from the very commencement; or, at least, after hav- ing, for a short time, been very hoarse and stridulous, it becomes a mere whisper; the pain in these cases is of various degrees of violence, and is always increased by speaking and coughing, or by 694 CYNANCHE LARYNGEA. the application of pressure over the part affected. The patient feels as if there was a foreign body in the larynx; the cough is hoarse and the attempt results in a kind of grunting noise; a dis- tressing constriction of the throat is felt at all times; but very little, or scarcely any thing is raised by the act of coughing, and there is often difficulty of deglutition. Sometimes very severe paroxysms of dyspnoea and oppression of respiration are experi- enced by the patient, the mucous membrane is considerably swol- len/and there is more or less fever, and redness of the epiglottis may be noticed when the root of the tongue is pretty well depres- sed. Sub-mucous laryngitis is another variety of this malady, accor- ding to the arrangement of some of the systematic authors, but is in reality to be regarded only as a more severe form of the preceding variety, with an aggravation of most of the symptoms ; such as, the voice becomes wheezing or whispering at an earlier stage of the attack; the attempt to cough is agitating, convul- sive and very distressing; inspiration becomes exceedingly diffi- cult, and is accomplished only after the most violent efforts and a sense of impending suffocation; the patient is extremely rest- less, sometimes starting up suddenly from bed, sleeping but a few minutes at a time, and indicating by all his conduct, the most in- tense restlessness, anxiety and apprehension; the blood soon begins to show signs of deficient oxygenation by the livid aspect of the lips, and, indeed, by the paleness and lividity of the whole coun- tenance ; smallness of the pulse; a cold sweat, with a rapid exhaustion of all the vital powers, and a gradual extinction of Hfe itself takes place. This would be the ordinary course of this disease when not relieved by proper treatment. The cause of death, in cases of this kind, is undoubtedly from a deficiency in the quantity of air admitted into the lungs to produce the desired vivification of the blood, and this fluid becomes incapable of stimulating the different parts and organs into a proper kind of action. This disease is usually regarded as a very dangerous affection, more so than any other form of inflammatory disease. It runs its course with great rapidity, often terminating fatally in from two to five days. George Washington, the lamented father of CYNANCHE LARYNGEA. 695 his country, is said to have died of this complaint, but it must be admitted that it is by no means a frequent disease. The pseudo-membranous form of this disease, bears a strong analogy to the same variety of croup, and it is, indeed, a matter of question whether it ought to receive a separate and distinct consideration. There is so great a similarity in their symptoms, progress and danger, as to make them very nearly the same thing, if not identical, as to all the intents and purposes of a practical consideration. I shall therefore reserve any further remarks I have to make on this subject for the ensuing chapter, when the circumstances connected with the pseudo-membranous form of disease, as it connects itself with the respiratory passages, will be noticed with becoming particularity. Morbid Appearances. The lining membrane, as well as the subjacent cellular membrane of the larynx, usually exhibits the marks of inflammation; such as a thickened and softened state of the membrane, not only covered over with matter, but having a considerable accumulation of matter and serous fluid in the cel- lular substance beneath the mucous membrane. Causes. The cause which, in all probability, exerts the most decided influence in producing this disease, as, indeed, most other inflammatory diseases, is cold, applied either locally or gen- erally, particularly Avhen the patient is much fatigued or in a state of perspiration. Some writers seem to think there is a peculiar liability to this disease in all such persons as are specially subject to cynanche tonsillaris, which does not seem to have been sus- tained by my own observations, but, on the other hand, they seem to be quite independent of each other. Scalding water attempted to be swalloAved, a continued and powerful exertion of the voice for too great a length of time, corrosive gases, a flame of hot air, and mercury may produce this case. Typhoid fever, measles, scarlet fever and smallpox, all have been charged with exert- ing an instrumentality in producing this difficulty at different times. Eclectic Reformed Treatment. There is, perhaps, no disease which requires a more vigorous and energetic treatment at first than this. With a vieAY to this matter, active evacuation, particu- larly by lobelia emetics, becomes a matter of the first importance, 696 CYNANCHE LARYNGEA. These, in most instances, should be continued for a long time. The rum sweat, as a powerful means of producing a permanent equi- librium in the state of the circulation of the blood, should be vig- orously carried into effect at an early stage of the disease, and should be aided by a liberal use of diaphoretic and slightly nau- seating teas, such as the decoction of sanguinaria canadensis and asclepias tuberosa, each equal parts, made by adding one pint of water to one ounce of the compound, and boiling for one half hour, or until the strength is extracted; apply as hot cloths on the larynx as can be handled and wrung out partially dry, every three minutes, as a counter-irritant and to aid in the production of perspiration. Scalding water, added either to tobacco or stramonium leaves, should be applied as above directed, in regard to the cloths, and in all probability the desired effects of relaxation and reduction of the inflammation will result. The expectorant tincture should be given so as to induce some nausea and relaxation nearly all the time. I have known very beneficial effects to take place in this case from a brisk and active cathartic, composed of 30 grains pulverized mandrake, and the same quantity of anti-bilious powder, and if it does not operate freely in three or four hours, then give a second dose. This compound usually operates as an emeto-cathartic, and exercises a very favorable influence in this case. In the chronic form of this complaint, the treatment necessary for the case would bear about the same relation to the course advised in the acute, as it ordinarily does in most other inflamma- tory affections. XYI. PLEURITIS OR PLEURISY: INFLAMMATION OF THE PLEURA. This is an inflammatory disease of very frequent occurrence. affecting the pleura on one side, but sometimes on both sides, occasionally affecting both the pleura costalis and pulmonalis, but more frequently confining its principal effects to the costal portion of the pleura. In most bad cases, however, the inflammation, after commencing on the pleura costalis. extends on the principle of continuous sympathy to the pleura pulmonalis, and from thence, by the strength of contiguous sympathy, to the substance of the lungs, which is indicated by the supervention of additional symp- toms. Symptoms are severe; frequent and lancinating pain, decidedly increased by inspiration, thus causing that act to be materially abbreviated. There is also a dry cough, which is always accom- panied with pain and the expectoration of a colorless sputa. The attack is not unfrequently ushered in with a distinct chill, fol- lowed by fever of greater or less intensity, according to the severity or extent of the inflammation. The sense of chilliness, however, may be very slight, and may precede or succeed the occurrence of active pain; the pulse hard and frequent; a gen- eral diminution of the secretions, especially those of the skin and kidneys; a general flush on the face, not distinctly circumscribed, but very gradually lost in the surrounding parts. Respiration is short, difficult and painful, being performed principally by the abdominal muscles; the intercostals remaining in nearly a quies- cent state; thirst, and a costive state of the bowels, with a Avhi- tish coat on the tongue ; in some cases the patient is nauseated and a bitter or rather a bad taste in the mouth; headache and 698 PLEURISY. restlessness, with an inability to lie on the affected side, the patient often desiring to occupy a position intermediate between that on the side and on the back; he endeavors to suppress the cough on account of the pain it gives him. If there should be an extension of the inflammation to the substance of the lungs, the matter expectorated will be tinged or streaked with blood. Instead of the pain being of the severe character above de- scribed, it only amounts to what is called a stitch and a slight sense of soreness; pressure on the intercostal spaces is produc- tive of much pain. Such is a brief outline of the symptoms of this affection as ordinarily present in acute attacks. Pleurisy is liable to become chronic, in which case the symp- toms are less severe, and in several other respects considerably different from those of the acute form. The patient usually com- plains of pain, soreness, and sometimes a sense only of vague uneasiness in the side and chest; cough, in some cases, with but little expectoration; in others the expectoration is copious, and it may be either mucus or muco-purulent; the most general and constantly prevalent feature is that of dyspnoea, wliich, in some cases, is very distressing, and in others less severe; the chest is often considerably enlarged on the affected side, the enlargement being particularly conspicuous on the affected side and towards the lower portion of the chest—this enlargement having the effect of increasing the width of the intercostal spaces. This enlarge- ment of the capacity of the thoracic cavity on the affected side is mainly attributable to an accumulation of a sero-purulent fluid in the pleural cavity. The patient becomes pale, emaciated, and with a slight hectic kind of fever, with morning remissions and evening exacerbations, not unfrequently accompanied with night sweats; a burning sensation in the palms of the hands and soles of the feet. There is a displacement of some of the abdominal viscera to some extent, such as the liver, spleen, stomach, and colon in a downward direction, so much so as, in some instances, to cause the margin of the liver to project beyond the edges of the ribs. It often happens that there is a displacement of the heart, pericardium and mediastinum, by the nature and position of the accumulation. Percussion, Avhen applied, produces a very dull sound. The symptoms, in many of these cases, are such as are PLEURISY. 699 usually found connected with the more advanced stages of that form of consumption, which arises from chrome inflammation of the pleura, and may with propriety be considered as such. Causes. Exposure to cold is by far the most frequent cause, and the certainty of its influence is greatly enhanced by the indi- vidual being in a state of relaxation and perspiration, or in a state of debility from fatigue. This disease may, however, result from external injuries of various kinds, or from the translation of gout or rheumatism; also from recession of numerous eruptive diseases, from the suppression of customary evacuations, from the prema- ture healing of old ulcers, exposures to moisture and dampness. And it may be produced by some peculiar epidemic constitution of the atmosphere, and, like other epidemics, prevail generally. Diagnosis. This disease may be confounded with inflamma- tion of the lungs by a careless and inattentive observer, but may be pretty readily distinguished from it. The pain in pleurisy is of a severe lancinating and shooting character, greatly aggrava- ted by a deep inspiration or by a cough. In peripneumonia the pain is duller, of a heavy and oppressive character, and not so pungent and shooting, except when there is an extension of the inflammation to the pleura, when the character of the pain, as a diagnostic, cannot be rehed on with any certainty. The matter expectorated in pleuritis is mucus—transparent, whitish and vis- cid, and as a general rule, free from blood, except in those cases in wliich the inflammation extends to the substance of the lungs, when it exhibits streaks of blood. In peripneumonia it is viscid, and tinged with blood. A deep inspiration is not productive of so much pain in peripneumonia as in pleuritis. Percussion pro- duces the same sound on either side in pleuritis, but a dull sound on the affected side, and a clear one on the unaffected side in peripneumonia. Notwithstanding pleurisy is a very painful disease, yet if the treatment be conducted in a proper manner, there is ordinarily but Httle danger of a fatal termination. Eclectic Reformed Treatment. The treatment in cases of pleu- risy should be commenced, generally, by the use of a moderately mild and efficient emetic, and for this purpose, none answers a better purpose than the acetous tincture of sanguinaria canaden- 700 PLEURISY. sis and lobelia inflata, in doses of from one-half to a tablespoon- ful, given every ten minutes, mixed with a small quantity of a strong infusion of eupatorium perfoliatum, until it produces full, free and copious vomiting, at least as often as three, four or five times. Many patients object to this practice, on the ground that the act of vomiting will be productive of too much pain and dis- tress. But they soon see the groundless character of their fears, after having swallowed a dose or two, and the relaxing effects of the medicine begin to be manifested. It is also very proper, imme- diately after the sickness begins to subside, to take measures to insure a copious perspiration, by soaking the feet thoroughly in hot ley water, and sponging or bathing the legs in the same. The patient should also be directed to drink copiously of a decoc- tion of asclepias tuberosa and eupatorium aromaticum, equal parts, say one half ounce of each, added to one pint of boiling water, and after allowing it to steep half an hour or longer, it should be taken in doses of from two to three tablespoonsful every ten or fifteen minutes, placing, at the same time, a hot brick to the feet, and an extensive mustard plaster to the side affected, and allow it to remain as long as may be necessary to redden the skin completely, and relieve the pain. For the purpose of pro- moting perspiration, after the removal of the plaster, a bitter herb fomentation should be applied as hot as can be conveniently borne, and changed frequently; the bag containing the herbs should be wrung out and its application renewed as often as once in ten minutes. This not only aids powerfully to produce the desired moisture of the skin, but also answers a valuable purpose as a counter-irritant, and should be especially used in connec- tion Avith other efforts to produce perspiration. The frequent repetition of the mustard plasters, when there is very severe and intense pain, is a measure of primary importance, and should, by no means, be neglected by the efficient and energetic practi- tioner. The bowels also ought to receive a due share of attention. The common hydragogue purgative will be found a very useful form to depend on for purgation in this case, and should be promptly administered, in doses of from one to two teaspoonsful every two hours, until it operates freely three or four times. The emetics PLEURISY. 701 ought be repeated whenever the circumstances of the case are such as to make their repetition a desirable matter. The application of strong stimulating liniments over that por- tion of the chest, on which the principal affection seems to exist, will be useful. The following combination of the following essen- tial oils seem to be well adapted for this purpose, in connection with the tincture of capsicum. Take tincture of capsicum 3iv, oils of cloves, sassafras and cedar, each 31J, mix, and rub the parts affected some four or five times daily. Much advantage in the treatment of pleurisy often results from the use of a strong infusion of equal parts of eupatorium perfolia- tum and asclepias tuberosa, in connection with one fourth of a part of pulverized root of the sanguinaria canadensis; one quart of boiling water should be added to one ounce and a half of the compound, and be allowed to steep half an hour, and from two to three tablespoonsful should be poured off through a strainer, and sweetened, and be taken every half hour, with a view not only to produce diaphoresis, but also a slight sense of nausea, and a freedom of expectoration as well as to have some diuretic and laxative influence. The application of large poultices of roasted onions to the side, and occasionally renewed, has been productive of much benefit in the treatment of this case. It appears not only to act favorably as a counter-irritant, but likewise well calculated to promote the ease of expectoration, and to increase the urinary discharge, all of which indications it is highly desirable to fulfill in the treat- ment of this malady. In cases where there is great activity and concentration of pain, which does not yield promptly to ordinary measures, scar- ifying and cupping the side may be found of the utmost impor- tance5 to the refief of the sufferings of the patient. xVnother simple measure may be mentioned as worthy of adoption and con- fidence, namely: the inhalation of the vapor of bitter herb fomentations, such as hoarhound, catnip and hops, with a view to aid in the production of diaphoresis, and to render the expulsion of tenaceous mucus a matter of much greater ease to the patient than it would be without such an agency. Occasionally, much good may be done by taking a good rum sweat in the earlier 702 PLEURISY. stages of the attack, which is conveniently done by placing a common saucer under a chair, filled Avith spirits sufficiently strong to burn by the application of a taper, taking care at the same time to have the chair sufficiently elevated, so as not to endanger the the burning of its bottom, also to surround the patient's body, Avith the exception of the head, after divesting it of clothing, with a blanket so wrapped round as to confine the steam or vapor of the burning spirits. This should be in operation as long as from ten to fifteen minutes, which has the effect of producing a copious perspiration, and it will be found well to continue the use of warm diluent drinks, after placing the patient in bed and putting a hot brick to his feet. The patient may thus be kept in a state of perspiration almost any length of time that may be thought desi- rable. So far as it relates to the treatment of chronic pleuritis, we should be guided in the selection of our measures by the peculiar condition of the patient, and the state of the case gener- ally. Some of the measures already advised for the acute form will have an appropriate application for the chronic; such< as emetics, and mild cathartics, and laxatives. Emetics ought to be given as often as once in a Aveek in most of these cases, in some instances more frequently; so also ought purgatives. The strong infusion of apocynum cannabinum and asclepias tuberosa, equal parts, should be taken freely for the sake of its laxative, expecto- rant and diuretic properties. An infusion which is prepared by adding one ounce to a pint of boiling water, should be given in doses of one or two tablespoonsful every hour or two through the day. An irritating plaster should by all means be applied on the affected side, and kept discharging liberally for several weeks, and should be reneAved as often as once a day. A valuable ex- pectorant preparation and alterative, is equal parts of the tincture of sanguinaria canadensis and macrotys racemosa, given in doses of a teaspoonful once an hour or two; this compound not only acts as an excellent expectorant, but also as a valuable sedative, diminishing the general irritability of the system, and the fre- quency of the pulse, and increasing its fullness. The pulmonary syrup will be found a valuable medicine in the treatment of this form of malady, in doses of a wine glass full, PLEURISY. 703 morning, noon and night, half an hour before eating. Bathing the whole surface of the body with a preparation of equal parts of ley water and common whisky, once or twice a day thoroughly, will be found a useful auxiliary in the treatment of this case; at least in most cases. XV. PNEUMONIA—PERIPNEUMONIA: INFLAMMATION OF THE LUNGS. This is a disease of pretty frequent occurrence, and its attacks are usually ushered in by a well marked chill, especially in cases of adult persons, Avith a sense of much soreness and oppression in the region of the lungs, sometimes affecting one and sometimes both lungs. The chill is succeeded by a febrile paroxysm, wliich may continue a longer or shorter time, with its characteristic in- tensity. The patient has more or less pain, which is increased by a deep inspiration, Avhich may precede, accompany, or follow the fever, but more commonly accompanies it. The severity of the pain will be proportioned to the extent and intensity of the inflam- mation, and Avill have a more decidedly lancinating character when the pleura is more especially involved in the inflammation. Indeed the darting, shooting and lancinating character of the pain, is al- most exclusively owing to this circumstance, and coughing or pres- sure on the intercostal spaces, is calculated to increase it. The sharpness and the severity of the pain decline as the patient comes under the influence of appropriate treatment. In some cases, in- stead of the pain mentioned, there is only a sense of oppression and soreness, which may be increased by taking a deep inspira- tion. The breathing is always quickened to the number of fif- teen or tAventy per minute above the natural standard of fre- quency. There is always a feeling of oppression in the chest, which is increased by every attempt to talk or make use of any thing like a muscular effort. When the dyspnoea is very violent, with a deep purple hue of the countenance, much danger is indi- cated. Cough, more or less severe, is always present; it is at first somewhat dry, and very little is expectorated; but, as the case advances, the expectoration increases. At first, it consists PNEUMONIA. 705 mostly of a tenacious, ropy, transparent mucus, which is quite dif- ficult to raise, but it soon afterwards becomes somewhat of a rusty or reddish color, being stained more or less with blood, often pretty uniformly mixed with the tenacious, semi-transparent mucus, bearing some resemblance to port wine. In some cases the cough is not accompanied with pain; in others, it is exceedingly painful and severe. The character of the matter expectorated is, in all probability, the most reliable symptom to indicate the exact nature of the disease. As the disease advances towards a more favorable state, the expectoration becomes much easier, and there are much larger quantities thrown off, which are much les3 tenacious. Some- times nearly pure blood is throAvn up, but cases of this kind are not A'ery frequent. The degree of fever in these cases is remark- ably various, amounting in some instances to an almost impercep- tible degree of excitement; in others, to a very intense degree of excitement. The amount of excitement noticed in cases of chil- dren, varies in a great variety of ways, both in respect to its intensity and continuance. Indeed, the same may be said with regard to nearly all the prominent symptoms in cases of children, for nothing of the same uniformity of character marks these cases. Although the essential nature of the disease may be the same, yet their manifestations are in very many cases unlike. In addition to the symptoms already named, the flush on the face is more distinctly circumscribed than in any case in Avhich the pleura is implicated in the inflammation to any considerable extent, as in some cases of pneumonia, in which the lungs alone are the seat of affection. The fever present assumes the re- mittent form, having morning remissions and evening exacerba- tions ; the pulse is full and strong, and only moderately accelera- ted ; considerable thirst, and dry, hot and constricted state of the skin ; urine high-colored and diminished in quantity; tongue hav- in0, a white coat on its surface, and afterwards a darker and thick- er crust; loss of appetite is great, and there is usually a costive state of the bowels. In a very few instances, the patient is very slightly affected with pain or cough, yet they are said to be entirely wanting in some instances. In well marked c;.ses of this kind, percussion produces a dull and somewhat flat sound. Auscul- tation throws considerable light on this subject, especially indica- 45 706 PNEUMONIA. ting the stage, degree and extent to which the lungs are affected. A sedimentous urine occurring in connection with a gently moist and soft state of the skin, is justly regarded as a favorable symp- tom, respecially when accompanied by an easy and more copi- ous expectoration, and with diminished frequency and increased freedom of respiration. In those cases called double pneumonia, where both lungs are inflamed, the strength is much more rapidly exhausted, and the countenance is much more affected with an appearance of anxiety. Diagnosis. Peripneumonia is distinguished from pleurisy, by the pain being of a dull, heavy and oppressive character, whereas in pleurisy it is of a sharp, lancinating nature; the flush on the cheek is pretty distinctly circumscribed and abruptly terminated in pleu- risy, more diffused in peripneumonia; the patient lies on the sound side in pleurisy, on the affected side in pneumonia. Percussion produces on the affected side in inflammation of the lungs, a dull sound, and in pleurisy the same sound on both sides, which is clear. Pressure on the epigastric region, upward towards the lungs, in peripneumonia, produces cough, oppression and a sense of suffoca- tion and pain, but in pleurisy the pain and sense of oppression is not materially aggravated. Pressure on the intercostal spaces, increases the pain very much in pleurisy, but not so in inflammation of the lungs. A deep and full inspiration, aggravates the pain more in pleurisy than in pneumonia. From bronchitis of the acute kind, this affection is distinguished by the character of the matter expectorated. In peripneumonia it is of a rusty, viscid character, and in bronchitis it is more abun- dant, but not so tenacious or viscid. The sensations in the chest, in bronchitis, are more those of oppression than pain. In bron- chitis, there is a decided pain over the eye ; not so in pneumo- nia. There is a diffused flush on the cheek in bronchitis, and in pneumonia it is circumscribed when the inflammation is confined mainly to the lungs. There is in bronchitis a sense of oppression rather than of pain, in the chest; not so in cases of inflammation of the lungs, the sensation being that of pain of the dull and some- Avhat oppressive kind. The symptoms will senre to make the necessary distinctions in these two cases. Prognosis. This is by no means a very fatal disease, especi- PNEUMONIA. 707 aUy under the preservative influence of a well regulated course of treatment. In all its ordinary forms it has yielded with astonish- ing rapidity to the mild yet efficient power of the curative means of the eclectic practice. The fatality mentioned by most of the systematic writers of the old school, without doubt, is in a great measure attributable to the defective measures of medication, more than to any necessary fatafity in the character of the disease. When it occurs in children, it is not so readily managed as when it takes place in adults, neither are the evidences which we de- pend on for its recognition so readily perceptible, but a careful and scrutinizing examination scarcely ever fails to lead us to cor- rect conclusions on the subject. Causes. The causes which may produce this disease are quite numerous, and among those which are most frequent in their ope- ration may be mentioned vicissitudes in the weather, exposures to cold and moisture, especially when the individual is in a state of perspiration, after having undergone some fatiguing exercise. This is more especially apt to produce an attack when the patient is laboring at the same time under the influence of catarrhal affec- tions. Violent exertion of any description i3 very apt to lay the foundation for an attack; excesses in drinking, suppression of customary evacuations, are quite apt to produce it, as well as re- cession of eruptive affections, translation of gout and rheumatism, and wounds and injuries of various kinds. Eclectic Reformed Practice. So far as it relates to the course of treatment which ought to be adopted in the management of this disease, I have only to remark that it ought to be similar to that already recommended in pleurisy, namely: by first adminis- tering an emetic composed of equal parts of lobelia seeds and leaves, ictodes foetida, ipecac and sanguinaria canadensis, the roots all finely pulverized, and given in doses of from half to a tea- spoonful, mixed in a strong infusion of eupatorium perfoliatum, every ten or fifteen minutes, until it operates freely, taking care to aid its operation by giving the patient pretty liberally of the above mentioned infusion. This operation promotes in a most decided manner the general equilibrium of the circulation, im- proves the respiration, facilitates the expectoration, and subdues the pain and fever. The emetics should be repeated as often as 708 PNEUMONIA. circumstances might seem to require, and carried to the extent of producing the effects above mentioned. The acetous tincture of lobelia inflata and sanguinaria canadensis wiU be found a valu- able form of emetic in cases of this kind, more particularly in such cases as where expectoration is very difficult from the great tenacity of the mucus, and I should be inclined to think it is bet- ter than any other form for children. After the emetic operation is fully over, the patient should have the feet soared in hot ley water, and his legs, thighs and whole body most actively bathed with the same, by means of flannel cloths well moistened with the same and applied by making brisk frictions, and then subjected to the influence of rum sweat, for which, directions have already been given under the head of the treatment of pleurisy ; which see. The patient should take liber- ally at the same time of some diaphoretic tea or infusion, which possesses also expectorant properties, and I have found the fol- lowing preparation well adapted to the fulfillment of these indica- tions, viz: take of the asclepias tuberosa two parts, eupatorium perfoliatum one part, and of sanguinaria canadensis one half a part, all properly bruised, and to two ounces of this compound, add one quart of boiling water, and allow it to steep or simmer a suitable length of time to take out the strength, then strain and sweeten, and give from one to three or four tablespoonsful of the preparation, usually as often as once in a half hour or hour. This will generally sweat the patient freely, and this effect should usually be kept up for several hours. We should not forget to apply, at a very early stage of the treatment, an extensive mus- tard plaster to the side and over the affected lung, and allow it to remain until it produces a reddened state of the skin, and after removing it, the common bitter herb fomentation comes in admirably, in conjunction with proper diaphoretic measures, such as the infusion above mentioned. This fomentation also acts favorably as a counter-irritant, and, as an auxiliary measure to produce perspiration, it should be applied as hot as can be borne, and reneAved every fifteen or twenty minutes. A brisk and moderately active cathartic becomes necessary in the treat- ment of this case whenever the bowrels are confined. The com- mon hydragogue purgative answers this purpose very well in PNEUMONIA. 709 doses of from one to two teaspoonsful mixed in water. If this should not operate properly within two hours, the doses may be repeated until the desired effect takes place. Another measure will be found singularly useful in the treat- ment of these cases, notwithstanding its great simplicity of char- acter may render it with some an unpopular measure. I here refer to the inhalation of medicated vapor, and for this purpose a very convenient preparation is made by boiling equal parts of hops and hoarhound in equal parts of water and vinegar, and di- recting the patient to inhale the vapor thus produced freely every two or three hours. This almost always has the effect of render- ing the respiration easier, and promoting the freedom of expec- toration, divesting the mucus of that extraordinary tenacity which it has in most cases of this disease. In very severe cases of this complaint, AA'here there are great pain and oppression, decidedly beneficial results follow from the repeated application of the scar- ificator and cups to the side, producing an evident reduction of the inflammatory excitement. Long continued nausea, with occa- sional ATomiting, is a remedial measure, in the treatment of this case, of the very first importance, and in order to produce such effects in the very best manner, I know of nothing better than the acetous tincture, of sanguinaria canadensis and lobelia inflata, given in doses of from a half to two teaspoonsful once in a half hour, mixed in a little warm catnip or pennyroyal tea, so as to keep up a gentle state of nausea and relaxation for several hours, and when you desire to produce vomiting, the quantity of the medicine may be slightly increased. This usually has the effect of diminishing the frequency and reducing the hardness of the pulse, and also diminishing the febrile heat and producing gene- ral relaxation and perspiration. It is also well calculated to im- prove the respiration and promote the freedom of expectoration, very materially improving the condition of the patient in several respects. Large onion poultices have been applied over the wThole extent of the chest with decided advantage. The practitioner should not fail to resort to the frequent and industrious use of the ley bathing, which is invariably productive of much advantage. When there is dryness of the skin and increased temperature, a strong 710 PNEUMONIA. decoction or infusion of the ceanothus americana, taken in doses of two or three tablespoonsful once in half an hour, is highly recommended as an expectorant, diaphoretic and diuretic, in this form of disease, more especially in the more advanced stages of it. I am not very well prepared to decide on the claims of this article to professional confidence, never having had much expe- rience in its use in cases of this kind. The foregoing plans of treatment, varied and modified accor- ding to the circumstances of each individual case, will be found very successful in combating the ravages of this malady. XVI. PNEUxMONIA BILIOSA—BILIOUS PLEURISY. This form of disease is of pretty frequent occurrence in the cold season, and in the miasmatic districts of the west and south- west, as well as in the south, and is a complication, usually, of the symptoms of remittent fever with those of pneumonia ; sometimes, however, the symptoms of hepatitis and pneumonia concur in the same case, giving us a modified form of the disease in question. Symptoms. The attack may be, and generally is, ushered in with a distinct chill, which is followed by a paroxysm of fever ter- minating in a remission or intermission, in the same manner as the ordinary bilious remittent fever is; assuming the quotidian, tertian, double tertian, or some other type, and may continue a day or two without developing the pneumonic symptoms; but generally they commence within the period indicated. In other cases, instead of commencing in this manner, the pulmonary or pneumonic symptoms are first developed, such as pain, oppres- sion, and tightness in the chest, with difficult, short, oppressed and hurried respiration, cough, bloody expectoration, and fever; but after it continues a short time, then the symptoms of remit- ting fever may come on, or those of hepatic derangement, with- out the well marked evidences of the above mentioned form of fever; in this case the skin and eyes will become tinged with an icterode hue, the tongue coated with a yellow fur, and there is a sense of fullness, pain and oppression in the right hypochondriac region, sometimes in the left, with a pain extending to the shoul- der. The fever in this case does not seem to assume the remit- ting form, neither does there appear to be so much gastric derange- ment as when the case is marked especially by the remitting form of fever. Nausea and vomiting, with a yellowish brown 712 BILIOUS PNEUMONIA. urine, are also symptoms of this. But by far the most frequent form which it assumes is that of the pneumonic symptoms, in con- nection Avith those of remitting fever. In addition to the symp- toms indicative of inflammation of the lungs or pleura, or both, the patient experiences pain in the back and limbs, also in the right hypochondriac region, also a sense of oppression in the same region; yellowness of the skin and tunica, conjunctiva, and some- times mucus and bloody stools, a yellow or brownish coat on the tongue, bilious vomiting, the accompanying fever having a some- what remitting form, although not so clearly of that character on account of the influence of the pneumonic inflammation in giving it a tendency to the continued form; the pulse is usually small, tense and quick, though in a feAv cases moderately hard, strong, and full. Cough, with bloody expectoration, are among the symp- toms, in the event the substance of the lungs is involved in the inflammation. But if the pleura costatis is alone the seat of inflammation, then Ave will not find the bloody expectoration to accompany the attack, but instead thereof a tenacious, transparent and ropy mucus. Diagnosis. There is perhaps no form of disease which is Hable to be confounded with this, with the exception of bilious remit- ting fever, from which it is easily distinguished by the pneumonic symptoms, and the less clear and distinct features of the remis- sions and the exacerbations. Attacks of this disease are more especially apt to occur in miasmatic districts, after the prevalence of bilious intermitting and remitting fevers, during the later and colder periods of the fall, or winter and spring. The symptoms of the remitting fever are apt first to be introduced, and they are very often ushered in by a distinct chill, and the pectoral svmp- * toms are not apt to come on until some two or three days have elapsed. However, in some instances symptoms of pneumonic inflammation occur simultaneously with the symptoms of remitting fever, and thus they go on in conjunction, one with the other. Eclectic Reformed Practice. In this case as well as in most other attacks of thoracic inflammation, the advantages of emetics are such as to make them medicines of primary importance in the treatment. That is especially the case in the present form of disease, on account of the evidences of biliary derangement and BILIOUS PNEUMONIA. 713 hepatic torpor, both of which are conspicuous features in the present form of disease. In most of these cases it will be found highly advantageous to commence the treatment several hours before giving a regular emetic, by the administration of four or five grain doses of the hepatic powder, mixed with a little of the warm tea of the eupatorium perfoliatum, as often as every twenty or thirty minutes, until the stomach becomes decidedly nauseated, and a favorable effect is produced on the liver. The preliminary treatment will favor in a most decided manner the action of the emetic, which should be composed of equal parts of the finely pul- verized lobelia inflata leaves and seed, the root of the sanguin- aria canadensis and ipecac. This compound powder should be administered in doses of from a half to a teaspoonful every ten or fifteen minutes, until it operates thoroughly some three or four times, producing the evidences on the organism of a strong emetic influence. A thorough purgative influence will be found highly useful, and for the fulfillment of this indication equal parts of the finely pulverized root of the podophyllum peltatum, and leptandria virginica may be given in doses of one teaspoonful mixed in a little warm, sweetened water, once in five hours, until it operates freely on the bowels, liver and stomach. Not a little advantage would result from the application of an extensive mustard plaster over the region of the liver and thorax, allowing it to remain until a thorough redness was produced over the wThole extent of the surface. The practitioner, however, will not fail in this case to see the necessity of fulfilling the important indication of producing free perspiration by the use of nauseating, expectorant and diaphoretic medicines. A good formula for this purpose is found by taking equal parts of the asclepias tuberosa, sanguinaria canadensis, and eupatorium perfoliatum; to an ounce of this compound add one quart of boiling water, and allow it to steep or simmer some half hour or longer; strain and take warm as much as two or three tablespoonsful, as often as once every fifteen or twenty minutes, using at the same time the ley bath freely, by active frictions over the skin until sweating takes place, and this should be continued for several hours. This measure is very well adapted to restore the torpid hepatic functions, as well as to produce a gently 714 BILIOUS PNEUMONIA. relaxed state of the boAvels, promoting at the same time the free- dom of expectoration and the ease of respiration. The repetition and change of these several measures, according to the attending circumstances of each individual case, will be as a general thing found adequate to the successful management of these attacks. In some feAv obstinate cases, it may be deemed advisable to apply the scarificator and cups, when there is great obstinacy in the attack, not only over the region of the lungs, but also over the hepatic region. In cases characterised by a sense of great tightness and oppres- sion in the chest, with difficulty of expectoration, the following cough drops will be found singularly efficacious. ft Tinct. of Bloodroot, Syrup of Ipecac, Squills, \ad 3j. Mix. Tinct. of Balsam Tolu, Paregoric, Dose—one drachm. XVII. PNEUMONIA TYPHOIDES: TYPHOID PNEUMONIA. This pneumonic inflammation occurs in connection with the operation of influences calculated to produce what is commonly called a typhoid condition of the system, in which the nervous system, as well as the brain, seems to be prominently involved, having the effect of impairing the condition of the blood, not, in- deed, unfrequently occurring in the course of an attack of typhus fever, but more frequently coming on with the characteristic fea- ture of typhoid pneumonia from the beginning. Symptoms. The symptoms indicating the pneumonic inflam- mation are very much such as are noticed in common cases; such as pain, which may be either of the acute kind, or to some extent, obtuse; but, in some instances, it appears to have the darting, shooting severity of neuralgic pain. When of this char- acter, it may extend to parts not specially implicated in the inflammation; there is also cough and dyspnoea, with the sense of oppression ; and a quite peculiar symptom in this case is the character of the matter expectorated, which is bloody from the commencement, and, in many instances, it consists almost entirely of pure blood, and does not possess, from the commencement, that tenacity which characterizes the matter expectorated in other forms of pneumonia. In quite a number of cases of this sort, there is scarcely any perceptible pain, sometimes the matter ex- pectorated is brown, black, and somewhat foetid. The general complexion of the symptoms is that of depression, arising, most probably, from the state of the brain and nervous system; the tongue is covered often with a dark or brownish fur, and some- times black sordes collect on the gums and around the teeth, as in regular typhus; pulse, although hard and of pretty good vol- ume at first, soon becomes soft and quite compressible, and in the 716 TYPHOID PNEUMONIA. more advanced periods of the disease, it becomes very weak, irregular and small. There is usually some stupor of the sensorial functions, and, in- deed, of all the functions of the system, to a greater or less extent; the flesh on the face is a deep and dark red, or rather purple red color; the skin is hot and dry in the earlier periods of the attack, but a more cold, clammy, and sticky state of the perspirable matter in the more advanced stages of the disease. There is also a state of obtuseness in the intellectual operations, which soon degenerates into a low sort of delirium. The surface is often covered with petechia. A dull sound is produced by per- cussion, and the respiratory murmur, commonly noticed in persons in a state of health is greatly changed. A sort of mucus or rat- tling sound takes the place of the regular and healthy sound. There is, perhaps, very little risk of ever confounding this case with any other malady; its distinctive characters are so strongly marked that any practitioner, failing to recognize it properly, would be justly chargeable with incompetency of qualification to perform the plain and unmistakable functions of his profession. So far I as have noticed this malady, it is very readily recognized, and it may be regarded as a disease much more liable to pre- vail during the cold and variable seasons of fall, winter and spring than during the summer. Eclectic Reformed Treatment. There can be no doubt of the necessity of moderate evacuation in the treatment of this malady in the earlier periods of the attack, not only for the moderating of the existing febrile excitement, but for the purpose of promo- ting the freedom of the expectoration, and divesting the pneu- monic symptoms of their severity. And the principal purpose of the practitioner should be to select such evacuants as would be well calculated to fulfill the required indications, without prostrating the Aital energies. A commodious emetic for this purpose would be formed of sanguinaria canadensis and lobelia inflata, in con- nection with eupatorium perfoliatum, in the proportions of one part of each of the tAvo former, to two parts of the latter, in the form of infusion or decoction. One pint of boiling water should be added to one or two table- spoonsful of the foregoing compound, and it should be simmered for half an hour, or allowed to steep the requisite length of time, TYPHOID PNEUMONIA. 717 strained, SAveetened and given in doses of two or three table- spoonsful every ten or fifteen minutes, until free, copious and thorough vomiting shall take place three or four times, when its administration should be discontinued. This emetic, it will be very evident to all who are properly acquainted with its proper- ties, is well calculated to produce its effects without much reduc- tion of the vitality of the system. The expectorants and the dia- phoretics should also have a sustaining quality in their composition. The diaphoretic preparation, composed of sanguinaria canaden- sis, myrica cerifera, sumach berries, and hydrastis canadensis, equal parts, all being well bruised or pulverized, and to two table- spoonsful, add three-fourths of a quart of boiling water, and allow it to steep or simmer a proper length of time, and give two- or three tablespoonsful every ten minutes or not so often, quite warm, Avill be efficacious, as well as to make use of the ordinary means, such as bathing with the lye bath. Mild and unirritating cathartics may be used AYith much advantage, such as a combina- tion of equal parts of neutralizing physic and leptandria virgin- ica, both in a state of fine powder, in doses of one or two tea- spoonsful to an adult subject, mixed in a little Avarm tea or water. In some instances, however, when a little more active, brisk and efficient cathartic is demanded, the anti-bilious cathartic would come in very properly. The apocynum cannabinum and asclepias tuberosa come in very appropriately together, as expectorants, diuretics, and sus- taining diaphoretics, well suited, from their peculiar properties, to the treatment of these cases, in the form of infusion or decoction. Ordinarily, it would be proper to give from one to three table- spoonsful once in one or two hours. Decided advantage may be obtained in these cases by suitable counter-irritation, such as sinapisms, bitter herb fomentations, &c. as well as by the inhalation of the medicated vapor of peach leaves and hops. The repetition and change of the foregoing measures, accor- ding to the peculiar features of each individual case, will, as a general rule, be sufficient to bring attacks of this disease to a safe and salutary termination, provided the practitioner be timely in attendance on the case. XVIII. ACUTE GASTRITIS : ACUTE INFLAMMATION OF THE STOMACH. This disease usuaUy affects the mucous membrane exclusively at first, and in bad cases it extends to the other membranes of the stomach. It may exist either in the acute or chronic form, and considering the very exposed condition of the stomach to the action of irritating influences, it affords matter for some surprise, that it is not more frequently the seat of inflammation than it is; but nature has supplied this great central organ bountifully with preservative powers, Avhich tend to resist efficiently the action of irritating agents. When about to be assailed by any cause which has poAver to disturb its natural functions, it calls up to its aid all the powers of the system with a promptitude which is truly wonderful, and thus wards off mischief Avhich otherwise might become the source of much subsequent evil to the human organism. Notwithstand- ing the great powers of resistance to the effects of the ordi- nary irritants calculated to produce inflammation, no organ in the human body so promptly feels the sufferings of other organs and tissues, as the stomach ; for no sooner does any part of the system become the seat of irritation or inflammation, than the func- tions of the stomach are more or less affected, showing at once the great facility with which disturbing impressions reach the stomach, and the active play of sympathies existing between that organ and every other part of the body. Symptoms. From the commencement of bad attacks of this disease, there is severe burning and lancinating pain in the stom- ach, Avhich is much increased by pressure, or by a deep inspira- tion, or by SAvalloAving hot or even warm drinks; nausea, and fre- quent vomiting, Avhich is also increased by hot or Avarm drinks ; thirst is very urgent for cold drinks, which afford temporary ease, ACUTE GASTRITIS. 719 but are immediately rejected when they acquire the temperature of the stomach ; a costive state of the bowels, with more or less fever; a constant sense of uneasiness and oppression about the stomach, with a small, hard and frequent pulse, and a rapid extinction of muscular power; and often much difficulty of swallowing, from the existence of a spasmodic tendency of the cardiac orifice of the stomach. The substances thrown up from the stomach, are first, the contents of the stomach, chyme, mucus, and afterwards bile, &c. Sometimes the matters thus thrown off are mingled with more or less blood. The tongue is often covered with a whitish fur, with the exception of its tip and edges, which are red and fiery ; in fact, the papillae on the whole surface of the tongue are consid- erably reddened. Sometimes the whole surface of the tongue ex- hibits a smooth, red and slippery appearance, without any mucus coating whatever. The patient is restless and unable to sleep, and lies on his back with his thighs drawn up towards the abdo- men, his legs flexed on his thighs, and his head and shoulders somewhat elevated, to relax as much as possible the abdominal muscles; countenance indicating anxiety and distress; respira- tion somewhat hurried and short; skin very dry and hot; urine high colored and scanty, and often a dry sort of paroxysmal cough. In milder forms of this malady, the symptoms, of course, are all of lighter character. Instead of the severe nausea and distress- ing vomiting, there is only, perhaps, a very slight sense of sick- ness or disposition to vomit; in the place of the severe pain, we often hear the patient complaining of a very slight sense of op- pression. It not unfrequently happens that this affection exists without all or even a majority of the characteristic features, and it is even alleged by some very Avell informed practitioners, that none of the characteristic symptoms exist in many cases, which nevertheless are found, on dissection after death, to be proper cases of this complaint. When this affection occurs in connection with some other form of disease, it never fails to exert a consider- able influence over the disease on which it depends as a symptom of incidental development. The duration of this complaint is very uncertain, being nearly if not altogether dependent on the nature of the cause and the in- tensity of its action, as well as upon the state of the constitution 720 ACUTE GASTRITIS. of the individual upon whom it operates, at the time, he may be subjected to its influence. Some cases, which are the result of active poisoning, prove fatal in a very few hours; others, resulting from different causes, may progress very slowly, and terminate at last in the chronic form of the complaint, and be protracted for many years. As to the post mortem appearances of those who have died of inflammation of the stomach, quite a diversity will be noticed even in those cases whose exterior evidences are very similar. Among those noticed in different cases, may be mentioned a contracted state of the stomach with its internal surface, exhibiting a wrin- kled appearance, being covered over with a purulent viscid mucus, upon the removal of which, the stomach, on its internal surface, exhibits the usual marks of inflammation, of redness, and an injec- ted state of its blood vessels, and, in some instances, well devel- oped marks of ulceration. The color of the internal surface is either of a bright red, brownish or a livid red, the signs being re- markably various in different cases. Diagnosis. It becomes a matter of the highest moment to dis- tinguish this disease from several other forms of human maladies, to which it bears a very close analogy. It is distinguished from spasm, and the pains arising from flatulence, by the effects of pressure over the region of the stomach. When that organ is in a state of inflammation, this produces a decided increase of the pain and suffering; whereas, in spasm and flatulent pain, it relieves the patient. The skin is hot and dry, in cases of gastritis ; nearly natural in spasm and flatulent pain. In gastritis there is fever, and pulse very much accelerated; in spasm and flatulent pain, no fever and very little or no disturbance of the pulse. In gastritis, the patient lies on his back, with his knees drawn up towards the abdomen, and seems to be very careful in all his mo- tions ; while in spasm he writhes and twists, and changes his position very frequently. In gastritis there is violent vomiting, while in spasms and flatulent pain there is none. As a general rule, warm drinks excite vomiting in gastritis, but do not in spasms. Gastritis is continuous, and spasms and flatulent pains are parox- ysmal. Gastritis is distinguished from hepatitis by the difference in the ACUTE GASTRITIS. 721 degrees of muscular prostration, which is very much greater, as the pulse is smaller, in gastritis than in hepatitis. Warm drinks excite vomiting at once in gastritis, but do not in hepatitis. The tip, margin and papillae of the tongue, generally are red, and ex- hibit a fiery appearance in cases of gastritis ; but in cases of hep- atitis, the tongue is covered with a yellow or brownish fur, and destitute of the fiery redness of the tip and margin, so conspicuous in gastritis. The pain arising from hepatitis extends with much severity to the shoulder, but does not in gastritis. The pulse, in gastritis, is small and tense, but in hepatitis it is full, hard and strong. This affection may be distinguished from pleuritis by the char- acter of the pain in gastritis being burning, and in pleuritis being lancinating and severe, and the condition of the pulse being in cases of gastritis small and tense, but in pleuritis hard and full. In gastritis the muscular poAver is much prostrated, in pleuritis not so much. A deep inspiration increases the pain in pleuritis more than it does in gastritis. Causes. This difficulty is very often the result of overdisten- sion of the stomach, by too strong and stimulating articles of diet and drink, especially after that organ has become much debilita- ted and deranged from the repeated effects of these agencies. Perhaps the most frequent causes that are concerned in produ- cing these cases, are the corrosive, acrid, mineral and vegetable poisons. The former, however, are much more frequently pro- ductive of these diseases than the latter, in consequence of their greater tendency to produce corrosion or destruction of the tis- sues, on which they operate locally. Predisposition to attacks of this kind is often produced by a drastic irritating course of medi- cation, without, at the same time, the production of appropriate influences to insure the proper equilibrium in the circulation and the excitability of the system. Large draughts of cold water when the individual is much heated, relaxed, and in a state of perspiration, are very apt to produce this disease. It may also be the result of the translation of gout and rheumatism from the extremities, which may take place very suddenly and be very severe. Sometimes, though rarely, it results from cold, not beino- nearly so apt to be produced by causes of this kind as most 46 722 ACUTE GASTRITIS. other inflammatory attacks, owing, most likely, to the large amount of resisting power with which this great central organ is endowed. It not unfrequently results from the influence of the attacks of certain forms of fever, such as remittent and yellow fevers. Eclectic Reformed Practice. There are few cases encoun- tered by medical practitioners which are so apt to be sources of perplexity to them as those under consideration, so far as they relate to the choice of remedial measures, with the course of medication which is most appropriate to them during their vari- ous stages of progression. It is, indeed, a more difficult matter to commence properly in one of these cases than in almost any other inflammatory form of disease. If the attack be well confirmed, it will be attended by much risk to administer any a<*ent whatever, which is calculated to produce a strong local impression on the stomach, on account of the tendency of all such strong impressions to aggravate the existing inflammation, and to fail in the production of their ulterior salutary influences. The choice of proper influences, therefore, becomes a matter of much difficulty, and is apt to place the practitioner in a some- what perplexing and awkward position. However, the choice of a proper course of medication wiU very much depend on the particular circumstances connected with each individual case. The cause that may have produced the attack, and the special attendant consequences, will of course have their proper influence on the decisions of the practitioner. If the patient has swallowed some violent corrosive poison which has speedily produced its effects in enkindling inflammation, in most cases, the better policy would be to take a proper antidote immediately, and resort to the use of an emetic, such as a strong infusion of eupatorium perfoliatum, in Avhich is dissolved, or rather mixed, one-half a teaspoonful of pulverized lobelia and ipecac, and repeat it in a few minutes if the first does not operate freely, and throw off the contents of the stomach. This treatment be- comes especially necessary in such cases, for the purpose of throwing off the poison as speedily as possible; the subsequent management in such cases being similar to those produced by other causes. ACUTE GASTRITIS. 723 If called to a case of inflammation of the stomach in its very early stage, before the well defined features of the malady in its active form shall have been developed, I have not, under such circumstances, hesitated to administer a very mild form of emetic, such as by preparing a strong infusion of eupatorium perfoliatum and chamomile flowers, in the proportions of equal parts of these two agents, giving from two to three tablespoonsful at a dose, and repeating it once in ten minutes, until it operates two or three times in a mild and moderate way. In the meantime, suitable external treatment should be had recourse to forthwith, such as soaking the feet in hot ley water, and bathing the whole body by means of brisk frictions with the same, applied by flannel cloths or by pieces of sponge duly moistened; a very extensive mus- tard plaster should be applied on the stomach, and kept on till it completely reddens the skin, when it should be removed. Prior to the application of this plaster, the patient, in severe cases, should be subjected to the influence of the rum sweat, and kept under its effects till complete and thorough sweating is the result. The fulfillment of this indication, in a proper manner, is highly advantageous to the patient, and should be encouraged by such auxiliary means as may be within the reach of the practitioner, and not incompatible with the safety of the patient; such as the application of the common bitter herb fomentation over the region of the stomach, renewing it very frequently and applying it as hot as it can be borne. This not only acts as a powerful counter-irritant, but also as a valuable means to promote the free- dom 'of perspiration, especially in all those cases in Avhich the stomach is not in a condition to receive such warm stimulating and diluent drinks as are calculated to act efficiently as diapho- retics. Make a strong infusion of peach leaves, by adding to an ounce and a half of the bruised leaves, one quart of boiling water, and allowing it to steep a half hour; strain and sweeten, and give it tepid, but not hot, in doses of two or three tablespoonsful every fifteen or tAventy minutes, until it quiets the irritability and sub- dues the inflammation of the stomach. It not unfrequently hap- pens that several of the first doses of this medicine are thrown up ; but the practitioner should persevere in its use notwithstan- 724 ACUTE GASTRITIS. ding, for it soon succeeds in producing the desired quietude of the irritated stomach, and is retained generally with much facil- ity. This remedy has often been used as the only one in these cases, with the most complete and satisfactory success. The kind of drinks most suitable in this disease, are of the highest possible moment to the success of the treatment. The best are the soothing mucilaginous kind, such as a strong infusion of the root of the althea officinalis, taken nearly cold, and in moderate quantities, but pretty frequently. The mucilages of gum arabic and of ulmus fulva likewise make very good drinks, in cases of this disease. One of the most pleasant and grateful agents which the suffering patient can take with propriety, are smaU pieces of ice being slowly dissolved in the mouth, and allowed to pass, in a very gradual manner, into the stomach. This produces a pleas- ant, cooling effect on the inflamed surface of that organ, and, in most cases, seems to exert a very beneficial effect. We should not, in the treatment of cases of this disease, lose sight of the necessity of evacuating the bowels, and for this pur- pose injections can be made more available in the treatment than any other means in the earlier stages, until the active inflamma- tory symptoms shall be subdued so that the stomach shaU not be so irritable as at first. In those cases of this complaint which are marked with such evidences as induce us to believe that there is quite an accumu- lation of acids on the stomach, the neutralizing extract becomes an highly useful medicine, and should, by no means, be omitted in the treatment of cases of this description. It may be given in doses of from a half to a tablespoonful every hour or two, until this acid condition of the stomach is corrected, or until it shall produce moderately free operations on the bowels. The hydragogue purgative may be resorted to for the same purpose; a teaspoonful dose maybe given once in two hours, until it operates briskly, Avhich it usually does in a short time, sometimes even without repeating the dose. When, however, an injection is decided on, a strong infu- sion or rather decoction of the eupatorium perfoliatum, one pint, in which is dissolved two tablespoonsful of table salt, Avell sweet- ened with sugar or molasses, thrown in by means of a large ACUTE GASTRITIS. 725 syringe, will generally operate quite actively, and after the man- ner of a brisk and active cathartic, emptying thoroughly the bowels, and producing very much the same effects as would result from an active and brisk cathartic. In the treatment of several of the severest attacks I have ever witnessed of this disease, I found the most prompt and decided relief to result from the use of spirits of turpentine, applied over the whole surface of the abdomen and the lower parts of the thorax, and immediately after smearing the surface in this manner, apply- ing a large mustard plaster, before the turpentine had evaporated, over the whole extent of surface moistened with the turpentine. This, I am aware, will look like a harsh measure of treatment to many, but is, in many cases threatening to terminate fatally in a short time, entirely justifiable, notwithstanding it may and does inflict quite a severe degree of pain on the suffering patient; but in all cases in which so important an object as the life or death of the patient is depending, we should not hesitate to call to our aid every means which may promise fairly to give us material assistance in deciding the fearful contest in favor of the pepetua- tion of the life of a fellow being. XIX. CHRONIC GASTRITIS: CHRONIC INFLAMMATION OF THE STOMACH. In the examination of the subject now before us, no feature of the case so forcibly impresses itself on our mind as the fact, that there is no well defined, distinct fine of demarkation pointing us to the characteristics which constitute the acute and chronic stages of gastritis. To point out accurately the stage at which the one ends and the other begins, will always remain a problem in pathology of difficult solution, and perhaps from the very na- ture of the subject is not susceptible of any considerable degree of accuracy, especially in those cases of the chronic form of this disease which have grown out directly of the acute. Symptoms. When chronic gastritis takes place without being preceded by the acute, it usuaUy comes on in a very gradual manner, without the development of any effects which are likely to arrest the earnest attention of either the physician or patient. The patient at first, however, feels some slight uneasiness about the stomach after eating, with a sense of oppression and general discomfort during digestion, with more than the ordinary fever and excitement from the act of digestion, and some vague and indistinct sensations of uneasiness extending from the stomach to other parts. The degree and extent of the foregoing sensations are exceedingly variable in the different cases. These symptoms, however, grow in intensity, and the patient has a burning, prick- ing and lancinating pain in the epigastric and hypochondriac regions ; sometimes this pain is confined to a very small and cir- cumscribed spot; there is also a sense of tightness and a feefing of constriction over the region of the stomach. The patient feels as if a heavy weight was pressing on this part, and in some CHRONIC GASTRITIS. 727 instances as if a bar was laid across him, and weighing him down to a very great extent. Nausea and occasional vomiting take place, especially after eating; great uncertainty and depravity of appetite ; costive state of the bowels, especially during the earlier stages of the disease. But if the irritation extends much to the mucous membrane of the bowels, which it occasionally does in the more advanced periods of the disease, looseness of the bowels takes place; the patient feels quite irritable, dejected and dis- contented, and in bad cases there is much emaciation; the skin seems to have lost its usual mobifity as it regards its poAver to move on the subjacent parts ; it seems to adhere to the muscles and other parts beneath it with great firmness. In addition to the foregoing symptoms, there is often heartburn, headache, eruc- tation of gas from the stomach, soreness on pressure, thirst, a swelled or full state of the stomach, a sensation of holloAvness or of fullness of the stomach, sour and acrid eructations of fluid, and a red tip and margin of the tongue, and an unpleasant taste in the mouth. The matter throAvn up from the stomach is very various in appearance, consistence and quality, sometimes- tinged with blood and matter when ulceration has already taken place. The substances thrown up exhibit a great variety in their appear- ances, as well as in their sensible qualities. The tongue exhibits quite a variety of appearances. In most cases, however, it is covered over with a thin, whitish or brownish fur, with a some- what reddened state of the papillae on its surface, more particu- larly on its tip and margin. In some cases, however, the papillae are pale, swollen and flabby, with an aspect of paleness over the whole extent of the mucous surface of the mouth. In the more advanced stages, not only the surface of the tongue, but the most of the buccal cavity is seen covered over with a kind of apthous exudation, which, in connection with the pale and flabby state of the papillae already spoken of, affords pretty conclusive evidence of the existence of a state of ulceration in the stomach. The pulse and degree of fever in these cases are exceedingly various ; sometimes there is scarcely any fever, and at other times quite an exacerbation comes on every afternoon and evening, the pulse being nearly natural in some cases, and quite smaU, quick and accelerated in others. 728 CHRONIC GASTRITIS. The morbid appearances in this disease are quite variant in different cases. In most persons who have died of this disease, the mucous membrane exhibits a thickened appearance, with oc- casionally ulcers on its surface, its color in some instances being dark, in others rather whitish or gray, and in others again of a darkish red appearance. Causes. This form of gastritis often results as a consequence of acute attacks. But it much more frequently comes on as an independent affection, following a long continued series of irrita- tions of the stomach. The use of spirituous liquors is a frequent cause, also strong and stimulating articles of food; over distension of the stomach; drinking too abundantly of hot strong tea and coffee not unfrequently lays the foundation for attacks of this complaint. A long continued course of very hot stimulating medicines, strong drastic and irritating doses of emetic and ca- thartic medicines, or indeed, any of the other classes of medicine may produce this case if continued too long or even in excess, especially according to the system of orthodox medication usually recommended in the leading authorities of the day, which are known to sanction too much of an ultra course of drugging the stomach and bowels, to the great neglect of the surface, not- withstanding the acknowledged importance of that very sensitive tissue, the skin, which is not only capable of receiving remedial impressions calculated to influence the condition of the organs to an astonishing extent, but of exerting almost an unlimited con- trol over the internal secretory surfaces, by its various conditions of healthy and unhealthy action. Diagnosis. This disease may be confounded with simple gas- tric debility, but can be easily distinguished from it by the effects of an emetic. If the case is chronic inflammation, the operation of the emetic will very much increase the sufferings of the patie nt; the degree of distress, the anorexia and febrile excitement will all be very materially increased. But all these sym ptoms will be relieved by that operation, provided the case is one of simple gastric debility. Chronic gastritis may in like manner be mista- ken for gastralgia, a neuralgic affection of the nerves of the stomach. CHRONIC GASTRITIS. 729 The pain in gastraglia is paroxysmal and intermittent, but in gastritis it is continuous; it is also more violent in the former than in the latter affection, and is relieved by firm pressure instead of being increased as it is in gastritis; appetite always bad in gastritis, sometimes better than usual in gastralgia; tongue is red and the breath is offensive in gastritis, but in gastralgia it usually has its natural color, or is slightly covered with a white fur, without any offensive character to the breath. In gastralgia the saliva is very abundant, no thirst, but often a repugnance to liquids. In all these particulars, it differs from the symptoms observed in gastritis. In gastritis digestion excites fever, and the food is rejected a little time after eating, but in gastralgia the pain is refieved by eating, and digestion is complete and sometimes even too good. In some cases, however, the pain is increased a considerable time after eating. Such are some of the principal points of difference between these two cases. Eclectic Reformed Practice. In the treatment of chronic inflammation of the stomach several important indications should be fulfilled, and so far as it relates to the appropriate measures to be relied on for the fulfillment of the indications in question, much Avill depend on the stage of the disease, constitution and tempera- ment of the patient, and a variety of circumstances, which may connect themselves with the case. It becomes a matter of primary importance in most cases of this disease to act on the stomach in such a way as to evacuate its contents by a remarkably mild emetic operation, which is perhaps better accomplished by the use of a strong decoction of eupatorium perfoliatum and chamomile flowers, an ounce each, to one quart of boiling water; allow these ingredients to simmer slowly one half hour, then strain and sweeten, and take from one tablespoonful to three tablespoonsful every half hour, until the patient vomits four or five times, and it may be found very use- ful to repeat this emetic at intervals of four or five days or a week, for several times. The indication which is incomparably the most important in the treatment of the disease, is to restore the lost action and functions of the skin, and to produce, as a matter of consequence, an equilibrium in the excitability and circulation. Whatever else may be attempted or done, this stands out in prom- 730 CHRONIC GASTRITIS. inent conspicuity as the greatly desired end to be accomplished by the agency of the practitioner. For the purpose of fulfining this indication, my own experience, as well as that of many others, has led me to place a very high estimate on the efficacy of the ley bath, followed immediately on each occasion of its use by a strong decoction of the bark of the quercus alba, applied in the same manner as a bath by means of very brisk and active frictions, at least as often as twice in twenty-four hours, making use for the purpose of its application, of a sponge or flannel cloth ; imme- diately on the conclusion of these bathing operations, permit the patient to remain in bed and apply something warm to his feet, as a hot brick or iron. In a short time the patient has some reaction, and the surface of the body is covered with a gentle perspiration, which often continues for an hour or more. This is a most desirable and admirable result, producing, as it does, a highly favorable change on the organism in general, and the secre- tory surfaces in particular, in the restoration of the strength and health of the patient, when used in conjunction with a few additional auxiliary measures in the treatment of this malady. In most cases of this affection, occasional operations on the bowels become necessary, with mild, unirritating and sustaining purga- tives, such as the anti-dyspeptic pills, in doses of two or three at a time, or the pills made of the juglans cinerea; the neutralizing physic makes a very appropriate medicine whenever acid abounds in the stomach or bowels, given in the usual quantities, until it operates two or three times moderately; given in the form of the powder, it often exerts a more beneficial effect than when given in the liquid form. The common restorative bitters, in doses of from one to two tablespoonsful, morning, noon and night, will be found to exert a most beneficial effect in many cases of this complaint, Avhere there is not too great a degree of irritabifity of the stomach, or too much febrile excitement. As a general rule these bitters wiU be borne by the patient very well, and they have the effect of im- proving the tone of the digestive organs generally, as well as increasing the urinary secretion, and imparting strength to the sys- tem in general. In those cases accompanied by hepatic torpor, two CHRONIC GASTRITIS. 731 or three grains of the hepatic powder, two or three times a day, in conjunction with the restorative bitters, will be found highly useful, and well worthy of adoption in the treatment of this dis- ease. The alterative syrup, in many cases of this complaint, proves highly useful, if given in doses of from a half to a Avine glass full morning, noon and night, especially in those cases in which the scrofulous diathesis obtains, marked, to a greater or less extent, by lymphatic glandular obstructions. In cases of a moderately mild and manageable character, in which no ulceration has taken place on the mucous membrane of the stomach, the adhesive and strengthening plaster will be found an invaluable measure, applied over the Avhole extent of the epi- gastric and hypochondriac regions, and worn for several weeks, renewing it, however, occasionally. But in all such cases as are very obstinate and unyielding, and especially where we have good reason to understand that ulceration has already taken place, we should by all means avail ourselves of the advantages that would probably result from the use of the irritating plaster, over the region of the stomach, and kept discharging for several weeks in succession. The beneficial effects which this application is capable of conferring on the patient is not alone attributable to its counter-irritating effects, but much more to the powerfully alterative influence which results from the absorption of the active medicinal principles with which its various active ingredients are HberaUy charged. XX. ENTERITIS: INFLAMMATION OF THE INTESTINES. In the most extended signification of the term enteritis, it is intended to comprehend any and every inflammation of any p or- tion of the intestinal track, from the commencement of the duo- denum to the termination of the rectum, affecting any of the coats of said intestinal track. This definition as a matter of course would include dysentery as weU as enteritis proper; how- ever, in the present work the term will be restricted in its signi- fication to that inflammation which more particularly affects the small intestines, sometimes extending to the colon, and at other times commencing in some part of the colon and extending to the small intestines, involving in some cases the mucous membrane only; but in most instances the mucous, muscular and peritoneal coats; and again in other cases the peritoneal and muscular coats are principally the seat of the inflammation, and the mucous membrane but slightly affected. There wiU of course be some variety in the character of the symptoms presented in these various modifications of the disease, dependent on the special seat and extent of the inflammation in each individual case. Symptoms. This disease usually manifests itself by some sHght uneasiness, which gradually groAvs into a fixed and burning pain in the abdomen, usuaUy about the central or umbilical region; when the mucous membrane is but little affected, obstinate con- stipation, pain and soreness are much increased on pressure ; nausea and occasional vomiting, sometimes so severe as to pro- duce inverted action of a large portion of the intestinal track, extending even beyond the valve of the colon, so as to throw up foecal or stercoraceous matter. The pulse is usually small, tense and frequent, and in some instances is full and hard. There is ENTERITIS. 733 fever, with a hot, dry and constricted state of the skin, with a dry and red tongue; thirst is quite urgent; the urine being small in quantity and high colored; breathing somewhat short, being performed mainly by the intercostal muscles. The patient selects the position on the back, with the shoulders somewhat elevated, the thighs drawn up towards the abdomen, and the legs towards the thighs. The patient instinctively takes this position, to avoid the pressure which the muscles might otherwise exert on the ab- dominal contents. The patient not only takes this position, but carefully avoids motion as much as possible. If the superior portion of the arch of the colon should be affected, the symptoms will bear quite a close analogy to those of pleuritis, or acute hepatitis. In all those cases in which the mucous membrane is prominently the seat of the inflammation, instead of constipation being a constantly attendant symptom, diarrhoea will take the place of that feature of the case, the bowels becoming quite inconveniently loose. Diagnosis. Enteritis may be confounded with several other forms of disease, if the practitioner be not sufficiently careful in his diagnosis; and among these may be mentioned pleuritis, from which it may be distinguished by the following features: the pulse in pleurisy is full and hard, in enteritis it is small and tense. The pain in pleurisy is sharp and lancinating, and the respiration is performed mainly by the abdominal muscles; the pain in enteritis is of a burning and lancinating character; abdomen tender to pressure in enteritis, not so in pleuritis. Enteritis may be distinguished from spasmodic pain by the thirst, heat and dryness of the skin, continuous character of the pain, the position of the patient on the back, avoiding motion, fever, and by pressure increasing the pain in the former; and the very reverse of all these being present in spasmodic and flatulent pain, viz: in spasmodic pain there is no thirst, the skin has its natural temperature and moisture; the pain being paroxysmal and intermittent, the patient is relieved by pressure on the parts affected, and is disposed to writhe about in almost every direction, during the active continuance of pain. Enteritis may be distinguished from hepatitis, by the pulse in hepatitis being full, hard and strong, and in enteritis small and 734 ENTERITIS. tense ; the pain in hepatitis extends to the clavicle and shoulder, and there is fullness and pain in the right hypochrondrium, also sometimes in the epigastrium and left hypochrondrium; the pain in enteritis is of a burning kind, does not extend to the shoulder and clavicle, and is more particularly felt in the umbilical and hypogastric regions; the tongue in cases of enteritis is red, and in cases of hepatitis is covered with a brownish or yeUowish fur, with icterode tinge of the skin and whites of the eyes, whereas they are both absent in enteritis generally. So far as relates to the morbid changes in the structure of the part implicated in the disease, they are very similar to those already described in acute gastritis. Causes. Inflammation of the bowels may be the result of the operation of a vast variety of causes. Among these one may be mentioned which is quite frequent in its operation, namely: cold applied especially Avhen the surface of the body is in a re- laxed and moist condition, producing a check of perspiration, Which may soon be followed by inflammation of the bowels. Poi- sonous drastic purges may often give rise to this condition when they are given in large quantities and "operate with especial vio- lence. The recession of eruptive diseases may in Hke manner be a cause of this complaint; the translation of gout and rheuma- tism occasionally give rise to the malady. Indigestible substances passing the stomach and lodging in the bowels, first giving rise to irritation which may be and frequently is followed by inflamma- tion; acids, depraved and acrid secretions, acting on the mucous surfaces, may produce it. Worms sometimes may produce this inflammation, especially when they are knotted and entan- gled together in a mass sufficiently large to obstruct the bowels, and cause inflammation to take place at the point thus obstructed. Prognosis. The termination of this inflammation most desi- rable is by resolution; its gangrenous termination is almost inva- riably fatal; its termination by suppuration is by no means a fre- quent occurrence. A cold and clammy state of perspiration, a small and almost imperceptible state of the pulse, a tympanitic swell- ing of the abdomen, and diffused state of the pain, are pretty sure indications of danger in this case. Eclectic Reformed Treatment. In the remedial management ENTERITIS. 735 of this form of inflammatory disease, much diversity of opinion has existed among medical authorities as to the propriety or im- propriety of the use of certain remedies and modes of manage- ment; while one class of practitioners has placed the seal of unqualified condemnation on the use of active purgatives, another has found them among the useful and important agencies of suc- cessful treatment. This subject thus at issue between the two contending parties has often elicited much warmth of controversy, and not a little ingenuity and ability have been expended in the investigation by the respective adherents of these two conflicting opinions. It seems to the author that much more has been said on this subject than has anything like a proper relevancy to the princi- pal points at issue, and further, that the subject, when duly con- sidered, in relation to all its facts, is not a debatable question at all. No fact in medicine is better established than the fact that every medicine has an effect on the human organism peculiar to itself, and unlike all others. This fact is equally true of the class of purgative medicines as of all other classes. Hence, one form of purgative, by the peculiar effects it is capable of producing, may be liable to produce bad consequences, while another, equally active, or even more so, may fail to exert any injurious tendency whatever. The difference of opinion in relation to this matter seems to have arisen in the minds of those who have participated in the discussion of the question, from having, in a good degree, failed to recognize properly this leading and essential fact. But waving any remarks on this subject, the treatment, in my opin- ion, should generally be commenced by the administration of an active and very thorough cathartic, especially if the mucous membrane be not very prominently the seat of inflammation. In that event there might, and undoubtedly would bo just grounds for some hesitation before proceeding to give very active purga- tive medicine. But the case we are now treating of, presuppo- ses that the peritoneal and muscular coats of the bowels are the principal seat of the inflammation, and costiveness is an atten- dant symptom. The podophyllin, perhaps, offers one of the best purgatives for the fulfillment of this indication, by first giving, to an adult, two grains, and repeating with' one or one and a half 736 ENTERITIS. grains, in four or five hours, if the first does not seem likely to operate freely and fully. This medicine has seldom disappointed me in the production of the most favorable effects, even when it operated a number of times very thoroughly, both as an emetic and purgative. For the same purpose, I have often used thirty grains of anti-bilious physic, and about the same quantity of the pulverized root of the podophyllum peltatum; the operation of this dose has been very powerful, and, at the same time, very effectual in arresting the progress of the inflammation, and so far modifying the subsequent course of the case as to bring it to a speedy and safe termination. So soon as it is satisfactorily ascertained that inflammation of the bowels exists, the patient should have applied, over the whole extent of the abdomen, a large mustard plaster, and it should be allowed to remain until the skin becomes perfectly reddened ; it never fails to exert a strong auxiliary influence in arresting the inflammation; this measure might be carried into effect, even before a cathartic is administered, or at least before its operation shall have taken place. As soon after the cathartic has operated, as the circumstances of the case will permit, the patient should be submitted to the influence of ley bathing, taking care to soak the feet for half an hour in the same, as hot as can be conveniently borne, and sub- mitting him to the action of the rum sweat, giving, at the same time, warm diluent diaphoretic drinks, such as an infusion of cat- nip or peppermint. Let this be taken liberally, and the patient be continued in a perspiration for several hours; at the same time, Avhile these measures are being carried into effect, much benefit may be derived from the application of bitter herb fomen- tations to the bowels, as hot as can be borne, and renewed every five or ten minutes. This measure aids most essentiallv in keeping up the desired perspiration, as well as operating as a most valua- ble counter-irritating agent. In those cases in which the patient manifests great restlessness, the diaphoretic powders, administered in three or four grain doses, every twenty or thirty minutes, in conjunction with some other sweating measures, such as a strong infusion of balm or of eupato- rium aromaticum, will be found highly valuable, and well cacula- ENTERITIS. 737 ted to promote the benefits of remedial management, in the treatment of seArere and obstinate cases. In addition to the occasional use of mustard plasters and bitter herb fomentations, a large poultice, made by cutting the root of the althea officinalis in transverse slices, bruising it well in an iron mortar, simmering it well in sweet milk, and adding a sufficiency of corn meal to bring it to the proper consistency of a poultice, may be spread, applied on the affected parts, and renewed occasionally. Onion poultices applied in the same manner, often manifest very favor- able effects in the treatment of this malady. Mucilaginous and diuretic drinks will be found very useful in the management of this complaint, such as the infusion of the althea officinalis and ulmus fulva. The application of a poultice of anthemis cotula and soft soap, will be found a measure well worthy of adoption. In very obstinate attacks of this malady, scarifying and cupping the abdomen will be found to exert a beneficial influence, and if the case seems likely to assume a chronic form, then the irrita- ting plaster should be immediately apphed, and kept discharging so long as any evidences of inflammation remain. 47 XXI. CHRONIC ENTERITIS OR CHRONIC INFLAMMATION OF THE BOWELS. CHRONIC DYSENTERY. This disease exists more frequently than we are in the habit of suspecting. Many cases usually regarded as marasmus, dys- pepsia and chronic diarrhoea, are, in reality, nothing more nor less than this disease. In most instances it is characterized by a loose state of the bowels as one of its prominent features. In a very few instances, however, the opposite condition obtains, with a very hardened condition of the abdominal walls. It must be con- fessed, hoAvever, that much obscurity exists in the character of the symptoms and disturbances of the system, which are consequent on its occurrence, so much so, indeed, as to make it a matter of much difficulty to detect the true nature of the case. Symptoms. In most cases of this complaint, there is no very distinct abdominal pain, but occasionally considerable pain is felt, when indigestible substances are passing along the bowels espe- cially ; pain and soreness are made evident by the application of pretty firm pressure; the pain and soreness are felt usually by the agitation of coughing; there are also much muscular debility and emaciation as the disease advances, with cold hands and feet. Sometimes, however, there is burning in the palms of the hands and soles of the feet, and usually slight paroxysms of fever in the eArening, with increased frequency of respiration and some slight cough; the pulse usually becoming small and weak; sometimes pain and nausea after eating, and perhaps in a few instances vom- iting also. The skin in nearly all cases dry, husky and sallow. The tongue is usually smooth and red on its edges, and not unfre- quently presents the same appearance over the Avhole extent of its surface, except the middle, which often appears broAvn ; the sleep CHRONIC ENTERITIS. 739 is interrupted more or less, the patient being uneasy and restless ; the bowels are generally loose : sometimes, however, they are cos- tive. When loose, there is often painful diarrhoea; the appetite is quite variable, sometimes rather morbid, and at others scarcely any ; the food often passes undigested, and the discharges from the bowels vary much in appearance, both in reference to color. consistence and quantity; in some instances being quite small in quantity and slimy, in others copious, dark and liquid. There is usually much irritability of temper, and an aspect of dullness depict- ed in the countenance. This disease may continue but for a short time in some cases, but in others it may last for many months, or even for several years, before either a favorable or fatal termina- tion takes place. C a v.*-:.?. These may be various. It sometimes follows as a consequence of the acute form of the disease, but it is much more frequently the result of the operation of causes wliich act directly, but in a gradual manner on the mucous membrane of the bowels. such as irritating articles of diet of an indigestible character. acids and other irritants acting on these parts. Drastic and frequently repeated purgation, especially with the strong, poi- sonous mineral medicines which are now so much in use; cold and moisture, when long continued, in low, damp situations, are very apt to produce it. P est Mortem Appearances. The appearances on dissection are very various; in most instances, however, there are points of ulceration of various sizes and shapes, and in some cases surroun- ded with a kind of fungous elevations. In many of these cases lar^e portions of the internal surface of the mucous membrane of the colon exhibit an extremely ragged and uneven appearance. and even on those parts wliich do not undergo disorganization. tho surface of the mucous membrane shows a quite irregular and corrugated appearance, and seems to be considerably thickened. Eclectic Reformed Practice. So far as the proper treatment is concerned in cases of this kind, much diversity of opinion exists in the minds of eclectic practitioners as weU as physicians gen- erally. Ordinarily, a mild evacuant course will be found best adapted to the circumstances usually attendant on cases of this description. A gentle restorative and sustaining purgative will 740 CHRONIC ENTERITIS. answer a valuable purpose at first, such as a combination of the finely pulverized root of the leptandria virginica and neutral- izing physic, in the proportions of equal parts, say about fifteen grains of each. This will usually operate with decided energy as a purgative, and leave the system but very little debilitated. A most vigorous and efficient course of measures should be taken to restore the functions of the skin, such as the industrious apphcation of the ley bath, at least as often as twice a day, and the use of the rum sweat at least as often as once a day, or oftener if thought necessary; the ley bathing should be accompanied with brisk and active frictions ; in many cases it will be found advantageous to follow each application of the ley bath by a strong decoction of the bark of the quercus alba, which should also be applied by means of brisk frictions, using a flannel cloth or a piece of sponge for this purpose. As soon as this bathing process is concluded, the patient should be covered warm in bed, with a hot brick to the feet, and allowed to remain undisturbed for two hours or longer, during which he perspires freely, as a general thing, which may be looked on as a very desirable result, tending directly to a salutary end. When the circumstances of the case are such as to indicate the existence of hepatic torpor, with a saUow complexion, a dark or brownish fur on the tongue, with occasional nausea, and a sense of oppression about the stomach, the occasional operation of a mild emetic will be found highly useful in the treatment, not only for the purpose of increasing the determination of blood to the sur- face, and removing the existing inactivity of the superficial capil- laries of the system, but restoring the natural action to all the torpid internal secretory surfaces. Another measure which I regard as of essential importance as an antiseptic restorative and astringent measure, is the betula lenta or black birch bark, to be administered to the patient in the form of strong decoction, made by adding one ounce of the bark to one pint of water, and to have it submitted to the action of boiling water for half an hour or until the strength is pretty well extracted. Of this about two tablespoonsful taken once in two hours will generally exert a very favorable influence, diminishing the relaxation of the bowels, strengthening the mucous membrane, CHRONIC ENTERITIS. 741 and imparting a tone and vigor to the general system which pro- duces a well marked improvement in the nature of the case. I must not omit to mention that in all those cases which are marked with the evidences of acidity in the stomach and bowels, as many are, the remedy Avhich ordinarily proves most successful is the neutralizing extract given in doses of three or four teaspoonsful once in two or three hours; to be continued as long as the evi- dences of acidity remain. Very often this medicine affords the desired relief in a very short time. Some of the most triumphant results I have ever witnessed in cases of this kind have been ef- fected by local, external applications, calculated not only to pro- duce counter-irritation, but likewise to impart such principles to the system as would invigorate it, and secure in the end highly beneficial alterative influences. No application Avhich I have ever seen used, seems to exert so beneficial an influence as the irrita- ting plaster, applied largely over the surface of the abdomen, and renewed after the usual method, and kept discharging for several weeks freely. In this as in many other cases, this inval- uable measure does not so fully manifest its benefits during the continuance of its active effects on the parts on which it is applied, but they seem to come on in a more decided manner after the discontinuance of the plaster. I have known its operation in several instances to be followed by quite a crop of pretty large abscesses, having the appearance of common boils, and after these have disappeared, all the evidences of chronic inflammation have subsided. XXII. ACUTE BRONCHITIS, PERIPNEUMONIA NOTHA; OR, ACUTE INFLAMMATION OF THE BRONCHIA. When considered in its widest sense, this disease is one of remarkably frequent occurrence. Like many other maladies, it exists in very various degrees of violence ; from the mildest catarrhal affection, up to the severest and most threatening inflam- matory disease. It consequently becomes a disease of the very first importance to the practitioner, and should command at his hand a proportionate amount of attention, not only in reference to its nature and tendency, but also in regard to the best and most successful modes of medication. Symptoms. In its mildest form it exists as a common cold, or as it is sometimes expressed, a cold in the breast, with a little hoarseness, slight cough, a sense of heat or soreness in the chest. The cough at first is usually dry, but afterwards the expectoration becomes quite free, and the sense of soreness passes off without much additional trouble. But in the common variety which usu- ally occurs, it commences, as above mentioned, with sensations of lassitude, uneasiness and constriction in the upper part of the chest, with aching of the limbs and chilliness, which is soon followed by fever. There are also felt a sensation of diffused heat, tight- ness, stricture, weight or soreness through the chest, especially the upper part of the chest, and in all severe cases the breathing is very much oppressed, with nothing like acute pain; cough is usually among the first symptoms, and, not unfrequently, very severe, increasing the pain in the forehead, which is almost inva- riably present to a very considerable extent. The cough is at first quite dry, but soon large quantities of matter are expec- torated ; at first, a frothy white mucus is raised, becoming mixed ACUTE BRONCHITIS. 743 Avith blood as the disease advances ; the cough is freer, especially in the morning ; the respiration is often wheezing, and often much oppressed, inspiration being difficult; the skin is husky and dry ; pulse frequent but not full or hard, and there is a flushed state of the face ; fever; a furred state of the tongue ; scanty and high colored urine, and, in many cases, nausea and Aromiting. The excitement in these cases abates in the morning, but increases in the afternoon and evening, in the same manner as it does in febrile and inflammatory diseases. In general, as the disease advances the matter expectorated becomes thinner and more brittle, and loses much of its tenacity. The countenance is moist and pallid, but very little pain in the chest, but rather a sense of oppression ; the flush on the cheek is diffused and not circumscribed, as in cases in which the inflammation is mainly in the substance of the lungs. There is much tendency to effusion in this case. Indeed, it is a matter of much surprise to all who are not duly aware of the great extent of the pulmonary mucous surface, to see such enor- mous quantities of the mucous secretion as are throAvn off in a case of this kind. Infants and very old persons, are said to be comparatively exempt from this disease. HoAvever, it cer- tainly \rery often attacks small children, and, in such cases, the matter expectorated is not ordinarily tinged with much blood, and in very many cases no signs of blood can be noticed. Much of the peculiar character of this malady is attributable to the san- guineous congestion that exists in the case, in the lungs. When the mucous secretion becomes very copious, cough abates in sever- ity ; the soreness, tension and fever, subside to a considerable extent; the farther down the mucous membrane of the bronchial tube is in a state of inflammation, the greater the dyspnoea, the sense of impending suffocation and oppression, and the more incom- plete the oxygenation of the blood will be, as well as its decar- bonization, and, as a matter of consequence, the more rapid will be the depression of strength; all parts immediately feel the depressing influence of such a state of things. Some cases of this kind seem to be accompanied with a spas- modic tendency in the bronchial tubes. These cases are marked by paroxysms, not very dissimilar to those of asthma, occurring 744 ACUTE BRONCHITIS. at uncertain periods, and they are often so very severe as to threaten immediate suffocation. Bronchitis is not unfrequently complicated with bilious and gastric symptoms, such as nausea, occasional vomiting, yellow tinge of the skin and eyes, tenderness in the epigastrium, a loaded and foul tongue, with a remittent form of fever. In other cases, which commence Avith all the well developed symptoms of bronchitis, and continue Avith severity until such a modification takes place, as to constitute the case one of actual inflammation of the substance of the lungs, this condition is marked by increase in the difficulty of breathing, which seems to occur in paroxysms; a Avheezing respiration; the patient finds difficulty in speaking; the expectoration is more completely tinged with blood. Those symptoms dependent on deficient aeration of the blood, are a pale and livid state of the face ; a purplish hue of the lips; cold state of the extremities; pulse small and feeble. A mucous rale, which appears to be almost universal over the chest, can be heard. It occasionally happens in cases of this sort, that one of the larger bronchial tubes becomes obstructed by a concrete mass of mucus, and almost instantaneously proves fatal. Physical signs are, that percussion produces the same sound on both sides, and the sound is clear. The dry, sonorous and sibilant rales, in the earher stages of the disease, but afterwards the moist or mucous rales, more or less mingled with the dry, are noticeable in the case. The respiratory murmur, though generally heard over the whole extent of the lungs, is found to be absent in certain locations, especially in the advanced stages of the disease. Morbid appearances are, that the bronchial mucous membrane is thickened, red and inflamed, often rough and deprived of its natural polish, and, in a very feAV cases, rough and gangrenous. The tubes are much loaded with the undischarged mucous secretion. Causes. Among the various causes which may be concerned in producing this disease, none is so frequent as cold. It is, per- haps, more apt to produce this malady, Avhen applied partially, as on the back of the neck, chest, or to the feet, or to the whole of the body Avhen it has been previously heated and in a state of perspiration, from fatigue or any other cause. Sometimes it is ACUTE BRONCHITIS. 745 suddenly produced, by passing from a cold room into one which has a high temperature suddenly, and by the inhalation of irritating vapors or dust. It is very apt to occur in the latter part of the fall, winter or spring, when the atmosphere is pretty heavily charged with moisture. Cases may occur, however, in the midst of summer. It is apt to prove most fatal, in young children and very old persons. Bronchitis very often results from other dis- eases, such as measles, hooping cough, small pox, typhoid and scar- let fevers, inflammation of the lungs, pleura and pericardium, asthma, &c. Epidemic influenza is a very prolific cause of it. Eclectic\Reformed Practice. No class of medicines exerts so important an influence as well chosen emetics. In the treatment of this disease, every circumstance connected with the case seems to indicate their use in the strongest manner. So far as my own experience enables me to determine, I have found none to answer the purpose better than the acetous tincture of sanguinaria cana- densis and lobelia, given in the usual doses every ten minutes, until free, full and copious vomiting takes place, at least as often as four or five times. This emetic should by all means be repeated as often as once or twice in twenty-four hours, should the condition of the patient's respiratory ogans require it, which is indicated by a rather oppressed and difficult respiration. Next in point of importance to proper emetics, stand the ex- pectorant diaphoretics, which are also strongly indicated in the treatment of this kind of disease, and for the purpose of insuring the full benefits of their operation on the patient, the feet should be freely immersed in hot weak ley water, and the legs actively bathed with the same, for ten or fifteen minutes; and the same process extended over the whole body. After this preparatory process is properly carried out, the patient should be covered up warm in bed, with a hot brick to his feet, and a strong decoction made, by adding one quart of boiling water, and con- tinuing the boiling process for half an hour or longer, to one ounce each of pulverized asclepias tuberosa, and eupatorium per- foliatum, and one-half an ounce of sanguinaria canadensis; after straining and sweetening, this should be taken as hot as the patient could bear it, in doses of from one or two tablespoonsful to one-third of a teacupful of ordinary size, every ten or fifteen 746 ACUTE BRONCHITIS. minutes, until it produces free and copious perspiration, Avhich should be continued for several hours. For the further purpose of insuring more effectually the sweating process, the bitter herb fomentations, during the Avhole attempt to produce sweating, should be applied; it will not only act as a valuable auxiliary in the production of the desired perspiration, but will fulfill all the indications of a counter-irritant. The compound decoction above mentioned, promotes the perspiration, opens the respiratory passages, facilitates expectoration, and increases the urinary dis- charge, as well as produces a moderate degree of nausea, all of which indications it is very desirable to fulfill, in the most effec- tual manner in the treatment of this disease. The bowels, in cases of this kind, require to be moved occasionally; and for this purpose, nothing seems to answer better than the anti-dyspeptic pills, in doses of two or three, and if they should fail to operate, to repeat the dose in four or five hours. For operating on the bowels, in cases of young children, the neutralizing medicine in the usual doses, in such cases, will be found well adapted to the treatment of the case. It not only produces the desired opera- tion on the bowels, but acts very efficiently on the kidneys, and thus acts an important part in diminishing the bronchial mucous inflammation. The discharges from the bowels are very much charged with mucus, and appear, in this way, to diminish the accumulation on the lungs. A combination of equal parts of the apocynum cannabinum and asclepias tuberosa, taken freely in the form of decoction or infusion, Avill be found a valuable medicine for the purpose of producing some nausea and laxative effect on the bowels, as well as for their diuretic and expectorant Airtues. For all the purposes of an admirable nauseant, mild emetic and valuable expectorant, the folloAving preparation ansAvers remarka- bly well. The tincture is prepared as follows: Take bloodroot, lobelia herb, skunk cabbage root, and pleurisy root, each one ounce, in coarse powder, alcohol, three pints, and water, one pint; allow it to stand two weeks, frequently shaking it. Prof. J. King, of the Memphis Eclectic Medical College, to whom I am indebted for this valuable compound, remarks as follows: " This is a valuable preparation for croup, whooping-cough, bronchitis and asthma, and is excellent for children as an emetic, ACUTE BRONCHITIS. 747 being gentle, safe and certain, and for all who are troubled with difficulty of expectoration, tightness across the chest, or who are loaded Avith phlegm. I invariably use this tincture, in all cases, where it is necessary to vomit children, and so valuable do I deem it that I would not be without it for a great considera- tion." One or two teaspoonsful may be given to an adult as often as may be necessary, to promote the freedom of expectoration; it should be given in a little slippery elm tea, or any other conve- nient vehicle. Children from one to five or six years old may take from one-half to a tablespoonful every ten minutes, till it vomits several times freely. It should be given in a little warm, sweet- ened water or tea for this purpose. Large sinapisms should be used freely in this case whenever there is much oppression of breathing. Onion poultices applied over the chest for the same purpose, will be found highly useful. The onions for this purpose should be first well roasted and bruised, and formed into a poul- tice. The vapor of hops and hoarhound, formed by boiling in equal parts of water and vinegar, will be found a valuable means to promote the freedom of the expectoration and to render the mucous secretion less tenacious. This measure should be frequently repeated, according to the urgency of the symptoms. XXIII. DYSENTERY: INFLAMMATION OF THE MUCOUS MEM- BRANE OF THE LARGE INTESTINES, ESPECIALLY THE COLON AND RECTUM. This disease, Avhen fully formed, is marked by small, bloody and mucous stools, attended with griping tenesmus pain in the bowTels, and fever. It may commence in quite a variety of ways; for example, an attack may be ushered in by a distinct chill, which may be followed by a fever, without, at first, any signs of enteritic inflammation, but in the course of a day or tAvo, the signs of dysentery may be developed. It may also commence with pains in the bowels, gri- ping and tenesmus, from the very commencement, without being preceded either by chill or fever; and again the symptoms of enteritic inflammation may commence simultaneously with those of the chill and fever; and, in other cases, may be ushered in as a consequence of previous diarrhoea; the attack may also be im- mediately preceded by one of either cholera-morbus or Asiatic cholera, and very soon assume the well denned characteristics of dysentery. It may likeAvise exist, in complication with a great variety of other forms of disease, such as bilious remittent fever, as well as several other forms of fever, rheumatism, &c. It may exist under every variety of gradation, from the mild- est to the most malignant and fatal disease known in the catalogue of human maladies. It is, perhaps, not an easy matter to deter- mine, at all times, upon what this great diversity of the disease depends. Much will depend on the differences in the degrees of activity of exciting causes, as well as on the special constitutional predisposition of the patient to the disease at the time of the attack. No fact is better established, in reference to the history DYSENTERY. 749 of dysentery, than this extreme difference in the violence of the malady, at different seasons of the same year, and during succes- sive years of its epidemic prevalence. Throughout the whole of one year, it may assume a very mild and manageable form, when, during the next, it may present us with the frightful evidences of its desolating ravages on every side, in despite of every effort put forth to stay its onward progress, and to wrest the sufferer from its deadly grasp. It may prevail either endemically or epi- demically. I will, however, without any further preliminary observations, proceed at once to enumerate the symptoms of the simple and uncomplicated form of the malady. Symptoms. In the commencement, a little uneasiness and pain in the bowels are usually felt, and after the lapse of a short time discharges take place, at first, perhaps, consisting principally of the contents of the bowels, but subsequently of very little else but mucus and blood. These discharges are preceded by a sense of tormina and griping, and the griping pains do not cease till the discharge takes place, when a little temporary ease follows, which, however, is not of long duration; for soon again a sense of weight, burning and general uneasiness is felt, and a desire again to get over the stool, w7hich, when yielded to, the patient is only able to discharge .a very small quantity of blood and mucus as before. Sometimes, however, the discharges consist almost exclusively of blood; in such cases they are regarded as more favorable. These discharges occasion a burning sensation in the rectum, especially severe when they are in the act of passing. The feeling of tenesmus increasing, the desire to be straining over the stool is almost incessant. The number of passages from the bowels is almost incredibly great, occurring as frequently as from fifteen to twenty, to one hundred or more times per day. In some cases, small hardened lumps of faecal matter are dis- charged, called scybala, productive often of much cutting and severe pain in the act of escaping. The discharges in nearly every instance are preceded by a griping sort of pain, of greater or less severity; the discharges at first have but little smell, but afterwards a peculiarly disagreeable odor. The extent of the in- flammation in these cases may be ascertained with considerable accuracy by making proper pressure along the course of the colon, 750 DYSENTERY. and if much pain is felt below the stomach, and across the abdomen, the presumption is that the arch of the colon is affected, and indeed, the whole of the intestine. The tongue is at first covered with a white thick coat of fur, which gradually acquires a darker aspect as the disease continues to advance; the margin and tip of the tongue often become red; occasionally there is nausea and rarely vomiting. There is in every case of ordinary severity more or less fever; indeed it occasionally happens that the attack is ushered in with regular and proper stages of parox- ysm of fever, before any signs of enteritic inflammation are de- Arcloped. Accompanying the fever, which is present in this complaint, there is an obstinately dry and husky state of the skin, and in many cases there may be slight occasional sensations of chilliness; thirst is usually great; the pulse is accelerated, and usually somewhat strong and forcible; the urine scanty and high colored; the liver in most cases torpid, and in a state of san- guineous congestion. Notwithstanding the multiplicity of dischar- ges which the patient has, most of the intestinal track is in a state of obstinate constipation, a small portion of the colon and rectum being in a state of preternatural activity only so far as the in- flammation actually extends. In this disease there is usually much tenderness to pressure over the whole extent of the abdomen. Colliquative diarrhoea takes place in the more adAranced periods of the disease, and may be justly regarded as a very unfavorable symptom. A small, fluttering or intermitting state of the pulse may be regarded as indicating some danger, more especially when it is accompanied by a cold, clammy and sticky state of perspi- ration over the surface generally. But the appearance of bile in the discharges, a moderately moist and warm skin, with an increase in the quantity of the urine and a sedimentous deposit, accompanied with abatement of abdominal pain, may be regarded as showing favorable changes. Occasionally, in cases of this kind, the patient complains of oppression in the epigastric region, frequent vomiting, icteric hue of the skin, eyes and tongue, the urine being highly charged with bilious matter. When thus characterized, they are cases of bilious dysentery. In ships, besieged toAvns, prisons, camps and marching armies, DYSENTERY. 751 where causes calculated to depress the vital powers and influence the constitution exist—a form of dysentery sometimes prevails which has been denominated adynamic, camp or jail dysentery. Cases of this kind are marked by symptoms of peculiar severity and malignancy, such as great thirst, a frequent, feeble, irregu- lar pulse, nausea and vomiting, a foul, broAvn or black dry tongue, often with a dark sordes about the teeth, a dusky skin, Avith livid spots or petechia on it; the skin sometimes cold, and at others Avarm; reddish-brown or blackish discharges from the bowels, more copious than in the common forms of dysentery; hemor- rhages ; low delirium; stupor; subsultus tendinum. In these cases there is great prostration of strength from the very begin- ing. This is usually a very fatal form of the disease, unless promptly arrested. Dysentery may also be complicated Avith intermittents and re- mittents. In fact, cither of these miasmatic forms of disease may manifest themselves in the form of dysentery, coming on once a day, or once in tAvo days, or indeed assuming any of the types of intermitting fever; or the case may assume the form of remitting fever. In all such cases, as has been suggested before, they should be regarded and treated as cases of intermittent and remittent disease, the dysenteric symptoms being matters of sec- ondary and inferior consideration. There is also a form of dysentery associated with typhus fever which has been by some denominated typhus dysentery. This form bears the same relation to the typhus fever, as the bilious dysentery bears to the bilious intermitting or remitting fever, and derives no additional consequence, only such peculiar features as may be dependent on its association Avith either of these cases respectively. Dysentery prevails as an epidemic, endemic, or sporadic dis- ease ; more commonly, however, as an epidemic; sometimes re- markably mild in its character, and at others very malignant and severe. Nothing can exceed the diversities of character Avhich it may assume in this respect at successive seasons. During one season it may be very mild and manageable, and the very next it may be very severe, and yield with much difficulty to treat- ment. 752 DYSENTERY. Morbid appearances observed after death, are, signs of inflam- mation and ulceration of the rectum and lower portion of the colon. Sometimes, indeed, the whole of the colon exhibits signs of inflammation. There is in these cases evident thickening of the mucous membrane as far as the inflammation may have exten- ded. Sometimes gangrenous spots may be seen on the surface of the boAvels where superficial sloughs penetrate even through the coats of the intestine, except, perhaps, the peritoneal coat. The mucous coat appears to be everywhere thickened, at least as far as the inflammation may have extended. Causes. The predisposition to attacks of this disease seems to be greatly increased by the long continued influence of a high temperature, augmenting the irritability of the mucous membrane of the alimentary track, relaxing the skin and increasing also its susceptibility to the influence of cold, disordering, at the same time, the liver, so as to make it much more susceptible to morbid impressions. No cause is more apt to excite this disease into action than cold, especially when it is combined with moisture. Cold, damp night air is very apt to produce an attack, particularly when the patient's system has been much relaxed by unusual muscular exertion and fatigue ; exposure, under such circumstan- ces, is very apt to produce an attack. Unripe and acid fruits may, and often are concerned in the production of this complaint. Indeed, it seems that anything which is very liable to undergo the acetous fermentation is very apt to produce an attack. Some pathologists contend, with much plausibility, that the existence of an acid in the alimentary canal is an indispensable preliminary condition to the production of a Avell marked case of dysentery. So far as my own observation and experience has enabled me to form an opinion in reference to this matter, I am led to favor this view of the subject, for I have scarcely ever known a case of dysentery in Avhich the eridences of acidity did not abound to a very considerable extent. I am further led to favor this vieAv of the pathology of dysentery, from having witnessed the beneficial effects of alkaline preparations in the treatment of its attacks. Many other reasons might be adduced to sustain this view of the subject, and the principal objections which have been urged DYSENTERY. 753 against the acid theory, are very easily met and refuted, or, in some manner, answered successfully. There can be no just grounds to deny the assumption that acids may not acquire such a degree of activity as to become the source of irritation and inflammation, wliich take place on the mucous surface of the bowels in this case. Eclectic Reformed Treatment. As it regards the measures which should be adopted in the remedial management of this malady, much will depend on the stage and violence of the attack as well as on the constitution and temperament of the patient, and the epidemic constitution of the year. In most common cases of the past season, I have found admirable effects to result from the use of the podolphyllin and neutralizing physic, both in a state of fine powder, given in the proportion of three-fourths of a grain of the former to three grains of the latter, in a little sweetened water, once in three hours, until it operates very actively both on the stomach and bowels, some four or five times; at least, given in this manner to the extent of two or three doses, it not unfrequently vomits the patient three or four times; also operates several times as a purgative. After the operation is com- pletely over, the administration of the leptandrin, in doses of two grains every two hours, in conjunction with about two or three grains of the diaphoretic powder, wrill be found well calculated to prevent any further tormina, tenesmus, or griping pains, which maybe inclined to mark the further progress of the case, should the attack be not entirely subdued. The success of these meas- ures in the treatment of dysentery, stand, so far as I have been able to learn, without a parallel in the history of practical medi- cine to any and all plans and systems whatever. During the past summer and fall, I treated several hundred cases of this disease, according to the foregoing plan, in this city, without the loss of a single case. All were cured with an astonishing degree of promptitude, and a like degree of success has attended this prac- tice wherever it has been vigorously carried out in the hands of others during the past season. My experience in this plan o£ treating this disease has been limited to the past summer and fall,. and I am consequently unable to determine the efficacy of this. particular treatment of the disease in question, as it might present 48 754 DYSENTERY. itself at other seasons. The presumption is, however, from the completely controlling power which it seemed to manifest in the very severe form which prevailed during the past season, that a similar character of success might be anticipated in the disease as it might hereafter prevail. Should the foregoing measures fail to afford the desired relief, the patient should be submitted to the action of the rum sweat, and the effects should be continued by placing hot bricks or boiled ears of corn, hot, enclosed in a proper envelop, at the feet, back, legs and thighs of the patient, who should, at the same time, drink freely of some warm diluent tea, as often as once in ten or fifteen minutes. The common sweating powder answers this pur- pose remarkably well, prepared by adding one pint of boiling water to one ounce and a half of the powder, and allowing it to steep or simmer half an hour or longer, until the strength is out, then take half a teacupful every twenty minutes, hot as can be borne, and keep the patient, if possible, in the perspiration sev- eral hours, if necessary. The success of this measure is very much promoted by the previous use of the alkaline bath, which, under all circumstances, seems to have a very good effect in pre- paring the system for a favorable perspiration. This measure should be repeated according to circumstances. Some of the cases of this disease require the use of emetics of the milder kind, such as the acetous tincture of sanguinaria can- adensis and lobelia inflata, to be given as usual, to the extent of operating with a moderate degree of freedom whenever the cir- cumstances of the case might seem to require the operation of an emetic. Many of the milder cases of this disease seem to yield spee- dily to the operation of the neutralizing extract; or neutralizing physic given to the extent of operating on the bowels in a mild way, occasionally. Pour one pint of boiling water on one ounce of the ingredients for this preparation, and simmer it for half an hour or longer, strain, sweeten, and take two tablespoons- ful every hour until it operates, and then use it in smaller quanti- ties and at more distant intervals until the disease is completely checked. Advantage may be gained in the treatment of this disease by DYSENTERY. 755 inducing the patient to subject the parts most affected to the action of the bitter herb fomentation, by sitting over it as he would the stool. The tenesmus, pain, and tormina, are generally much relieved by this process, and even while the patient is in bed these sensations of distress are much relieved by placing a hot iron or brick at the termination of the rectum, and maintaining it there so as to keep up a sweating process, as much as possible, of all the neighboring parts. Mucilaginous and soothing drinks, such as flaxseed tea, marshmallows tea, or infusion of ulmus fulva, will be found very appropriate drinks. Injections of neutralizing physic thrown into the bowels occasionally, Avith mucilages and anodynes, and nervine agents, will be found to exert a very ben- eficial influence in the treatment of this disease, and should not be omitted. As an astringent and healing medicine in this disease, a strong decoction of the geranium maculatum, made by boiling in sweet milk, constitutes an excellent preparation for children, or, indeed, older persons, to be given once in an hour or two, in doses of one tablespoonful or more, according to the age of the patient. This medicine is sometimes given with much advantage in connection with a strong tea of the leaves of rubus strigosus, which is also a mild astringent and antiseptic of decided value. The occasional application of an extensive mustard plaster to the abdomen, will be useful in diminishing the inflammation, pain and soreness in this part, throughout the whole period of the treatment. A valuable domestic remedy is prepared by taking equal parts of vinegar and water, hot, and dissolving common salt in it until it is completely saturated, and giving it in doses of a tablespoon- ful once in an hour or two, until it operates on the bowels, and completely changes the character of the discharges, so that no blood is seen in them. This I have often known to effect cures when nearly all the usual measures relied on, had been ineffectually tried. XXIV. ACUTE HEPATITIS. This is a disease which we occasionally encounter in practice, more especially during the colder and more variable seasons of tropical climates. It consists essentially of acute inflammation of the liver, and its peculiar features are materially modified by the exact location of the inflammation. The symptoms which mark its attacks, are ordinarily about as follows. More or less acute pain in the right hypochondriac region, sometimes in the epigastric and left hypochondriac, increased by pressure; this pain not unfrequently extends to the shoulder and to the clavicle, sometimes with a much greater de- gree of severity than is experienced in the region of the liver; and it is found that the pain is very much aggravated when the patient lies on the left side; the character of the pain depends on the portion of liver which is mainly involved in the inflamma- tion ; for instance, if the inflammation shall be principally located on the surface, affecting more or less the peritoneal coat of this organ, the pain will be much more acute and lancinating, than if the inflammation affect only the substance of this organ; we shall observe that the pain will be of a much duller character, and pass with so much intensity to the shoulder or clavicle. The respira- tion is difficult, with a dry, hacking kind of cough, and not unfre- quently there is nausea, with a kind of bilious vomiting, with an icteric hue of the eye and skin. The secretions appear to be charged with more or less bile, especially the urine, causing a sickening sensation when it is evacuated ; the tongue is covered with a yellowish fur, and there is a bitter taste in the mouth ; the pulse is commonly strong, hard and full, though in some few cases it may be small and weak throughout the whole course of ACUTE HEPATITIS. 757 the attack; the bowels are almost invariably costive in cold and temperate latitudes; but in Avarm climates it not unfrequently happens that the bowels are loose, and that copious liquid and slimy discharges take place, which appear to extinguish the strength rapidly and tend to a fatal termination in a brief period of time. From the intimate sympathetic relations which exist in the diseased organ and the brain, delirium is very apt to exist as a symptom, perhaps more so than in any of the phlegmasial dis- eases. If the convex surface of the liver should be the principal seat of the disease, then there will be more pain in the shoulder, more oppression of respiration, more cough, and in short much more evidence of its influence on the lungs. If, on the other hand, the concave surface shall be the principal seat of the dis- ease, then the symptoms which arise, will resemble more closely those which would result from a diseased state of the abdominal viscera; there would be more gastric distress, nausea and vom- iting. Diagnosis. It becomes necessary, in the examination of this malady, to distinguish it from certain other forms of disease, with which it is liable to be confounded, by a careless and inattentive observer. From pleurisy it may be distinguished by the character of the pain being of a more darting and lancinating nature in pleuritis than in hepatitis ; by the fact that respiration in pleurisy is chiefly performed by the abdominal muscles, and in hepatitis by the inter- costal ; the skin in cases of hepatitis is of a much yellower tinge than it is in pleuritis. The pain is not only of a duller kind in cases of hepatitis, but it extends very generally to the clavicle or shoulder blade, which is not the case in pleuritis. A deep inspi- ration is productive of much more pain in pleuritis than it is in hepatitis; pressure on the intercostal spaces gives rise to severe distress and pain in pleurisy, while in the case of hepatitis it does not produce much pain. The cough is much more severe and respiration more difficult in pleuritis than in hepatitis. There is bloody expectoration often in pleurisy when the inflammation ex- tends to the pleura; not so in hepatitis, except in such cases as are complicated with pneumonia. Hepatitis is distinguished from inflammation of the lungs, by 758 ACUTE HEPATITIS. the state of the respiration being more difficult in the latter than in the former; more cough in the latter than in the former. In inflammation of the lungs there is bloody expectoration, in hepa- titis none. Respiration is performed in pneumonia chiefly by the abdominal muscles, and in hepatitis by the intercostals. The skin in hepatitis has a yellow tinge, in pneumonia more nearly of its natural color. In cases of inflammation of the lungs a circum- scribed flush is seen on the cheek, and in hepatitis there is no such flush on the cheek. Hepatitis is distinguished from gastritis, by the character of the pain in gastritis, being of the burning kind in the latter, and there being a much greater degree of mus- cular prostration in gastritis than in hepatitis. In gastritis the pulse is small and corded; in hepatitis full, hard and strong. Breathing in gastritis is performed chiefly by the agency of the intercostal muscles, and in hepatitis the same; but there is in he- patitis an extension of pain to the shoulder, and in gastritis no such extension occurs. The prompt rejection of hot drinks when taken into the stomach in gastritis, and their retention in hepatitis, are circumstances Avhich serve to characterize these cases very dis- tinctly. It can also be very easily distinguished from the spasm of gall ducts by the intermitting character of the pain in the latter case, and its continuous nature in the former case. In hepatitis the skin is hot and dry, but in spasm of the gall ducts it is nearly, if not quite, natural. These circumstances are sufficient of themselves to make the proper distinction between the various cases with which it may be blended, and the form of disease under consideration. Acute hepatitis usually terminates by resolution, wliich is the most favorable mode of termination; sometimes, hoAvever, it ter- minates by the formation of abscess, which may point in different directions in different cases. Occasionally, it points in such a manner that its contents are discharged through the common duct into the bowel, and in other cases it points towards the thorax, and the matter may ultimately be discharged through the respi- ratory passages by expectoration, as in cases of pulmonary abscess. Adhesions may form between the peritoneum lining the surface of the liver and the partial investment of the same membrane, which ACUTE HEPATITIS. 759 attaches itself to the arch of the colon or some other portion of the intestinal track, and by ulceration a direct communication be formed between the cavity of the abscess and that of the bowel, and the matter be poured directly into the bowel. Gangrene may be mentioned as one of the rare terminations of hepatitis. Causes. Among the various causes which may be concerned in the production of this disease, perhaps none plays a more important part than the influence of cold, operating on the system, after it has been subjected to the effects of long continued heat, which exercises a powerful relaxing effect on the whole body, and renders the tendency to morbid impressions much greater by vir- tue of a great accumulation of excitability on the sentient extrem- ities of the nerves of the various secretory surfaces, and especially of the skin and liver. Both of these tissues are brought under the influence of a high atmospherical temperature to a much greater extent than any of the other organs of the body, as may be readily perceived by a reference to the amount and character of their peculiar secretions. When we reflect on this fact, so generally acknowledged by pathological writers, as well as the additional fact of the very close and intimate sympathy existing between the skin and liver, we cannot fail to see that a great ap- titude must necessarily exist to the occurrence of this disease under the influence of the circumstances now under consideration. It may result from the influence of other and different causes, such as wounds, injuries, bruises or blows, and the suppression of customary evacuations, hemorrhoidal discharges, and also from the excessive use of ardent spirits. Violent fits of anger and rage are occasionally concerned in originating an attack of this com- plaint. Miasmatic agencies are not by any means unfrequent causes to operate in laying the foundation of an attack of this complaint; hence the greater frequency of its occurrence in the miasmatic districts of hot climates, as well as in temperate latitudes. Eclectic Reformed Practice. There are perhaps very few phlegmasial diseases affecting the human body requiring a more thorough and efficient course of evacuant treatment than this, and very few in which this plan of treatment appears to be better borne and is more promptly successful. The administration of 760 ACUTE HEPATITIS. the hepatitic powder for some six or eight hours, in doses of one- third of an ordinary sized teaspoonful every hour, will be found a very proper preliminary step to the administration of an emetic, which may be composed of equal parts of finely pulverized san- guinaria canadensis, ipecac and lobeha inflata, given in doses of from one-half to a teaspoonful every ten or fifteen minutes, in a little warm water or tea sweetened, until it vomits the patient some four or five times freely. The prior use of the hepatic powders serves to prepare the system for a favorable and full operation by the emetic, and in like manner exerts a favorable influence in preparing the patient for the subsequent operation of an active and efficient purgative, which should, as a general rule, be used as soon as the operation of the emetic subsides. The podophyllin is found very well adapted as a purgative for this case, and it should be given in doses of one half a grain every two hours, until it operates actively some four or five times. This purgative exerts a specific and powerfully controlling influ- ence in cases of this kind on the liver, and seems to be well adapt- ed to the treatment of this as well as many other inflammatory diseases. It is very efficient in the promotion of the biliary secretion, and in the removal of congestions of this as well as of other parts of the body, and commends itself to the confidence and respect of all liberal and progressive practitioners of the heal- ing art. I have knoAvn in many cases the most prompt and sur- prising relief to be obtained from the use of this agent in the management of attacks of acute hepatitis ; and from the power it manifested in these cases, I am of opinion that it exerts a more decidedly controlling power than any agent known to the medical profession, not even excepting the mercurials. The apphcation of the alkaline bath at all times, when it is desi- rable to diminish the force, fullness and frequency of the pulse, and restore the action of the skin, becomes a remedial means of prime importance in the treatment of this case, and will be accom- panied with the most salutary results, when timely and appropri- ately used—particularly, when it becomes an object, as it often does, to produce perspiration, it acts most powerfully in bringing about this result. Another measure commends itself to our confi- dence, in the treatment of those cases which are accompanied with ACUTE HEPATITIS. 761 much pain, namely, a large sinapism over the region of the liver, Avhich should be allowed to remain until it produces a powerful effect on the skin, by turning the surface quite red. This meas- ure is not unfrequently productive of much advantage, by the relief of the pain and reduction of the inflammation. One of the best forms of sweating medicine with which I have a practical acquaintance, in this disease, is the common sweating powders, prepared by adding one pint of boiling water to one tablespoonful of the ingredients, and making a strong infusion; strain, and take from one to three tablespoonsful every twenty or thirty minutes, as long as it may be desirable to keep up a free perspiration. The bathing process with the alkaline wash, should be used in connection with this. The occasional operation of purgatives and emetics becomes necessary, in the prosecution of the treatment of severe attacks of this complaint. If there should be considerable enlargement of the liver, with a tendency to the formation of an abscess, I know of no measure upon which I should rely with so much confidence, as on the scarificator and cups, which should immediately be followed by either the irritating plaster or a suitable issue ; in the event of either of these alternatives being chosen, the discharges which would follow should be kept up for some time. A pill, composed of extract of dandelion and pulverised sanguinaria canadensis, each one grain, and -^ of a grain taken as often as once in two hours through the day, answers a valuable purpose as an alterative in all those cases in which there is a lingering degree of hepatic torpor, following an attack of the more acute form of the malady. XXV. CHRONIC HEPATITIS: CHRONIC INFLAMMATION OF THE LIVER. This disease is one of remarkably frequent occurrence, and presents itself under numerous grades of violence : from the mild- est degree of inactivity and torpor, up to the severest forms of chronic inflammation. Indeed, it would be difficult to find any case with symptoms of dyspepsia, Avhich does not at the same time present us with many of those which are ordinarily considered as marking some grade or other of what is commonly termed chronic liver complaint. Symptoms. A dull pain in the region of the liver, sometimes in the right and sometimes in the left side, frequently extending to the shoulder blade or clavicle; slight hacking or dry cough ; a sense of weight or fullness in the region of the liver; bowels cos- tive, especially in the earlier periods of the attack, and, in the more advanced stages of the disease, costiveness is not unfre- quently alternated with looseness, affording, in many instances, evidence of the formation of abscess, and a discharge of its matter into the bowels through the common duct of the liver, or in some other manner ; a sense of heaviness and fullness in the right hypo- chondriac region, as well as more or less tenderness on pressure ; a harsh, dry, constricted state of the skin, and a cold state of the hands and feet; sometimes, however, a sense of heat in the palms of the hands and soles of the feet, more especially in the advanced stages of the complaint, Avith hectic fever and night sweats ; ema- ciation and debility. Also a numerous train of dyspeptic symptoms, such as eructation of acid materials; heart burn; a sense of fullness about the stomach, and oppression; tongue covered with a brownish fur; head ache or dizziness; yellowish tinge of the skin and eyes; CHRONIC HEPATITIS. 763 urine small in quantity, and high colored, and the discharges from the boAvels are often of a pale color; patient often experiences slight chilly sensations, followed by febrile exacerbations, more especially towards evening ; loss of appetite ; palpitation ; nausea and sometimes vomiting; often swelling and fullness in the region of the liver ; sometimes pain in these cases extends to the small of the back; pulse is generally small, quick and somewhat corded; loss of appetite, and weakened, imperfect digestion; stupor and sleepiness are not unfrequently present; a feeling of restlessness and general uneasiness is felt. The pain consequent on the exist- ence of inflammation, varies in character according to the special seat of the inflammation. When it is mainly seated on the upper and convex surface, affecting the peritoneal investment of that organ, the pain is much more acute, and there is a more decided extension of the effects of the disease to the viscera of the thorax, giving rise to pulmonary symptoms. But Avhen the inflammation affects the internal structure of the liver, then the pain is much duller and more obscure, and there is not so striking a development of thoracic symptoms, neither is there so much pain in the clavicle and shoulder. When the inflammation affects more particularly the inferior surface, and involves the peritoneal coat of this organ, it is observed that the pain is more acute, and there is much greater disturbance of the abdominal viscera, giving rise to a greater vari- ety of gastric symptoms, and much less intensity of effect on the clavicle and shoulder, by the development of pain. In addition to the symptoms already named, the patient's position is not very erect, but somewhat stoop shouldered, inclining forward. The foregoing symptoms, in their various degrees of combination and connection, will pretty effectually cover all the symptoms that present themselves in this disease, which is susceptible of so much variety in the degrees of its violence. Causes. Chronic hepatitis may follow as an effect of the acute variety, or may result from the operation of quite a variety of causes which are known to be capable of giving rise to it. Slow inflammatory attacks of disease generally operate in the produc- tion of this form of complaint; such as cold, which in a very gradual manner often results in producing confirmed attacks of this malady, by striking a torpor on the capillaries of the surface. 764 CHRONIC HEPATITIS. That influence is very promptly transmitted to the internal secre- tory surfaces generally, and especially to the liver. A corres- ponding degree of torpidity readily follows, and a state of mor- bid excitability grows up in this great central gland, which results in the gradual formation of the disease in question. Sedentary and inactiA-e habits are quite liable to be concerned in the forma- tion of this malady; a sudden check of perspiration, when the body is in a state of relaxation, will in many instances act as an exciting cause, more especially in hot climates, where the liver is almost constantly in a state of superexcitation, especially during the Avarm seasons of the year, when there is a much greater sensibility in this organ than during any other period of the year. This complaint seems to prevail much more extensively in hot climates, and in those districts of country in which miasmatic diseases abound, from which latter circumstance it has been in- ferred that miasma had a tendency to produce it. So far as my own observations on this point would enable me to form an opin- ion, I have no hesitation in declaring my conviction that this doc- trine is well founded. A fruitful cause of this malady is the use of so much mercurial medicine ; indeed, this may justly be re- garded as one of the most prolific sources of the disease in this country, where this very foolish and pernicious practice is so generally tolerated. No custom is fraught with a greater amount of evil to the health and happiness of man, and none more richly merits the universal reprobation of all humane and benevolent minds. The perpetuation of this monstrous and murderous evil is predicated on the stupid and ridiculous conviction that exists in the minds of a large number of the medical profession, whose conservative and hide-bound notions of medical progress and im- provement are such as would act as a most direful paralysis on all the brilliant and splendid advances of this truly noble and life-giving science, which are calculated to make it the glory and honor of the present enlightened age. But it is needless further to depict the consequences of a course of medication which is at once the disgrace and shame of such practitioners as are disposed to refuse to find any thing better and safer, and to repudiate every well directed effort for the introduction of a safer and more successful mode of practice. CHRONIC HEPATITIS. 765 Eclectic Reformed Practice. For the successful treatment of this malady several prominent and leading indications require to be properly fulfilled, such as the restoration of the functions of the liver and skin; the proper evacuation of the stomach and bowels; the production of an equal state of the circulation and excitability, and the gradual restoration of the tone and strength of the whole system. Among the agencies which are well adap- ted to the fulfillment of the required indications, the occasional administration of mild but efficient emetics and purgatives will be found highly useful, and worthy of confidence when judiciously selected and used. One of the best forms of emetic is prepared by taking equal parts of finely powdered ipecac and lobelia, and giving it in doses of from half to a teaspoonful every fifteen or twenty minutes, mixed in a little warm water or herb tea, until it operates on the patient some three or four times freely. After the lapse of some two or three hours, an active purgative should be given, composed of twenty grains of pulverized senna leaves, ten grains of pulverized jalap, and one grain and a half of podo- phyllin. These evacuants should be administered as often as once a week, according to the foregoing directions. In addition to these measures of treatment, the restorative bitters should be given in doses of from one half to a wine glass full, morning, noon and night, a little while before eating. These bitters are among the very best tonic alterative and laxative medicines that are, at present, known. They not only act specifically on the liver, but tend to arouse it from a state of torpor and inaction to the performance of its proper functions, while they at the same time rapidly increase the tone and energy of the whole system, and promote the action of all the secretory organs to the faith- ful performance of their appropriate functions. It is remarkable with what rapidity the general energies of the system are restored under the use of this invaluable preparation of tonic and altera- tive bitters. This is among the very few medicines which, while it stimulates the stomach and bowels, and acts as a tonic, laxative and hepatic, has the power to restore their lost action and give them a proper tone, and improve them in a remarkable manner. In- deed it may with great propriety be doubted Avhether or no there is within the knowledge of the medical profession any such valu- 766 CHRONIC HEPATITIS. able agent for the various purposes aforesaid. It possesses diu- retic properties of no ordinary value,«as well as perhaps has a more extended range of application than any other known prep- aration designed for the fulfillment of the same general indications. The anti-dyspeptic and hepatic pill will be found to be highly useful, in the treatment of this form of disease, by giving one morning and night in conjunction with the bitters above men- tioned. The patient should be directed to soak the feet thoroughly in hot weak ley water, as well as bathe the whole body in the same, by means of soft flannel cloths moistened in this alkaline wash, and applied with brisk and active frictions, and the patient's body after being thus bathed should be properly dried by the agency of warm and dry flannel cloths. This operation should be re- peated every night and morning. This alkaline bathing process is of the utmost importance in the treatment of this as well as all similar cases, not alone for the purpose of cleansing the sur- face- by the removal of all those lodgments of matter, by which the skin is incrusted, but also to impart a gently stimulating in- fluence to that sensitive tissue, which will have a tendency to recall back the lost energies of cutaneous circulation, and thus restore to the skin its proper action and moisture, a condition absolutely indispensable to the complete and successful manage- ment of this disease. The influence of this simple, yet effica- cious measure of treatment is not confined to the restoration of the proper functions of the skin alone, but is admirably adapted in its secondary influence to arouse the dormant poAvers of the internal viscera, especially the liver, stomach and bowels, and thus enable these parts to resume the exercise of their appro- priate functions, the interruption to which was mainly attribu- table to the deranged state of the skin. There can be no ques- tion that one of the leading causes of failure in the treatment of diseases of this class, among the great body of the orthodox practitioners, is ascribable to the very general neglect of proper management of the skin. A judicious and well directed course of endermic medication scarcely ever fails to exert an influence on the system which favors the resolution of internal conjestions, torpor, or inflammatory conditions, and thus tends to insure with CHRONIC HEPATITIS. 767 a much greater degree of certainty the salutary operations of all internal medicines; and as another consequence prevents the liability, to a considerable extent, of the occurrence of gastro- intestinal inflammation and other unpleasant events. A most excellent alterative and hepatic for all those cases of this complaint, which are marked with much acidity of the stomach and other dyspeptic symptoms, will be found in the hepatic powder, combined with neutralizing physic, in the pro- portions of two parts of the latter to one of the former, taken in doses of one-third of a teaspoonful every three hours through the day, mixed in any convenient vehicle for the purposes of adminis- tration. I have known this compound, in several instances, to produce actual salivation, which continued for several days quite profusely, without giving rise to any of those disagreeable and deleterious effects usually consequent on salivation from the mer- curial medicines, such as ulceration of the parts affected, and similar consequences. Neither will any injurious or permanently debilitating effects follow to the constitution from its use. It seems to act as an efficient deobstruent, as Avell as stimulant, neutralizer and tonic. It has been used in numerous cases with the most undoubted evidences of benefit. In connection with the other features of its operation already described, it operates on the bowels, at least, sufficiently to prevent the usual inconvenien- ces of constipation, which are apt to complicate attacks of this complaint. The alterative syrup will be found especially useful in all such cases as may be marked with the usual evidences of the scrofu- lous diathesis, such as lymphatic glandular obstructions, together with similar indications of scrofulous disease. It should be given in doses of from a half to a wine glass full, morning, noon and ni"-ht. This is a valuable alterative tonic and deobstruent, and slightly laxative. In those cases in which there is considerable enlargement of the liver it will often be found that the application of the strengthening and adhesive plaster, by being placed directly over the affected organ, will exert a beneficial influence. But in a greater number of cases of this kind, the irritating plaster, con- tinued in such a manner as to keep up a suppuration, will be 768 CHRONIC HEPATITIS. productive of a much greater degree of benefit, especially when it is continued for several weeks in succession. A combination of equal parts of the extract of leontodon tarax- acum and the pulverized sanguinaria canadensis, formed into common sized pills, will be found a most useful and reliable alter- ative, laxative and deobstruent, in cases of this kind, when given in doses of one pill every two hours. The characteristic evi- dence of their operation on the liver is a heavy, dull and aching sensation in the region of that organ, produced by this med- icine. For the relief of cases of this disease in which there is great debility and looseness of the bowels, leptandrin, given in doses of about one grain, with one-eighth of a grain of podophyllin, will be found to exert a favorable influence, provided this dose is repeated three or four times, daily. Much benefit will result in these cases from bathing the whole surface of the body with a strong decoction of the white oak bark, especially when the patient is assailed with the symptoms of the hectic condition. This measure is well adapted to impart tone and energy to the flagging power of the system. Another medicine may be confi- dently recommended for the relief of diarrhoea under the circum- stances of the case, and that medicine is the black birch bark in decoction. XXVI. NEPHRITIS, OR INFLAMMATION OF THE KIDNEYS. This disease commences differently when it is the effect of dif- ferent causes. In some cases its invasion is sudden and violent, in others it is ushered in in a much more gradual manner, but with symptoms which are unequivocally indicative of an acute inflammatory state of these organs, either of one or both the renal glands, more commonly of one. The symptoms are pain of a severe aching character, deep- seated in the lumbar regions, much increased by any concussion of the body, but not very materially aggravated by pressure over the region of the kidneys. The pain, although of a deep, dull, aching character, generally has periods of darting along the course of the ureters, and the testicle of the affected side is retracted, and there is a sense of numbness on the inside of the thigh. The pain in this affection is relieved by bending the body forward. Usually there is nausea and vomiting occurring in these cases as well as colic pains; in some instances the urine is small in quan- tity and high colored, and occasionally tinged with blood, with an urgent, frequent and troublesome desire to void it. If both kid- neys are affected with inflammation, it occasionally happens there is nearly a complete suppression of the urinary secretion; the patient usually inclines the body a little forward, and toward the affected side when in bed and lying on the back; there is fever, thirst and a dry skin; the pulse is at first full, hard and strong, but soon becomes smaller, softer and weaker, particularly in those cases accompanied by nausea and vomiting to any very consider- able extent, which features of the case naturally have a tendency to prostrate the vital powers more or less. 49 770 NEPHRITIS. There is, perhaps, no other pathological condition (with which we have an acquaintance), with which this affection is liable to be confounded, but with psoas inflammation. Bending the body forward in cases of psoas inflammation produces pain, but it does not in nephritis. In nephritis, there are nausea and vomiting; in cases of psoas inflammation, none. There is retraction of the testicle in nephritis, but there is none in psoas inflammation, nei- ther is there any very urgent and frequent desire to evacuate the urine, but this symptom is very apt to be present in cases of inflam- mation of the kidneys. Causes. No circumstance is more frequently concerned in giving rise to this malady than cold, checking as it does, the func- tion of perspiration and producing a chill; the effects of this check are felt in every part of the system, and should there exist at that time a greater tendency to irritation and inflammation in the kid- neys than in any other part, an attack follows with all the attending train of consequences. Nephritis sometimes follows from a trans- lation of rheumatism or gout from the extremities to the kidneys, and also from the recession of certain eruptive diseases. The irritation of gravel in the kidneys may, and often does become a source of this complaint. Violent straining and injuries may become a source of this malady. The active principle of can- tharides and of spirits of turpentine may frequently produce this complaint, as both of these agents seem to have a specific ten- dency to act on the kidneys. Violent exercises, as jumping, hfting, or heavy loads, such are among various causes which may operate in giving rise to this complaint. If this complaint does not terminate in resolution in four or five days, it not unfre- quently passes on to suppuration, and the purulent matter passes off with the urine. If this state of discharge should continue any considerable length of time, emaciation would follow, and not unfrequently, general hectic symptoms would take place. In some instances of the formation of abscesses in the kidneys, the abscess points externally, and ultimately a fistulous opening is formed, and a very disagreeable sore is continued for a long time, if not cured by proper management. The gangrenous termina- tion is mentioned as being within the range of possibility by several of the systematic authorities. NEPHRITIS. 771 Attacks of nephritis are unusually apt to give rise to a dispo- sition in the constitution to the formation of the lithic acid dia- thesis, and a consequent liabihty to calculus disease. Eclectic Reformed Practice. An active purgative adminis- tered in the early stage of the treatment of this affection usually tends very much to dimmish the force of the inflammatory excite- ment, more especially, if it be of such a character as that its operation is of long duration. There are, perhaps, few medi- cines or combinations of medicines so well calculated to fulfill the designs of a purgative, in this case, as the podopoyllin, given in doses, to an adult, of one-half a grain every two hours, until two or three operations take place. The use of the warm bath and the bitter herb fomentations will be found of the first importance in the treatment of these cases, if carried out vigorously in the earlier stages of the attack, more especially the repeated use of the partially medicated vapor bath as applied in the common bitter herb fomentation. The early and constant use of demulcent, soothing and efficient diu- retics, such as the root of althea officinalis in decoction or infusion, prepared by adding one pint of boiling water to about two ounces of the green bruised root, and direct the patient to drink it freely; it operates as a diuretic very favorably, exerts a sooth- ing, cooling and most decided effect in arresting the inflammatory tendencies of the disease. The apphcation of a large onion poul- tice, prepared by roasting the onions and bruising them pretty thoroughly before forming them into a poultice, and applying the poultice directly over the small of the back, on the lumbar regions, and allowing it to remain for some two hours or more, when it may be substituted by a new one—I have known this measure to produce a very favorable influence, especially in con- nection with the use of the bitter herb fomentation at the same time applied to the abdomen, and the administration of some suitable diaphoretic, as the diaphoretic powders, given in strong decoction or infusion of asclepias tuberosa, drinking the latter freely and frequently, not only for the sake of obtaining its dia- phoretic influence, but also for the purpose of procuring its diuretic powers of operation wliich it possesses in no inconsiderable degree. The occasional apphcation of sinapisms, of a large size, to the 772 NEPHRITIS. lumbar region, will be productive of a most beneficial effect in arresting the progress of the disease. Very mild emetics have been found quite useful in many attacks which had proved some- what obstinate under the influence of the means that had been depended on for the relief of the patient. Large emollient poultices of the althea officinalis, applied quite largely over the whole extent of the lumbar portion of the verte- bral column, embracing also quite a portion of the lower dorsal, repeated and renewed pretty frequently would usually be followed by favorable consequences. Cupping along the course of the spine, especially immediately over the lumbar region, will, in many cases, be found quite ben- eficial ; and to restore the equilibrium of the circulation and the excitability of the system is a prominent indication, the fulfillment of which is extremely desirable in this as well as other forms of the disease, which claim the attention of the practitioners of the healing art. In the treatment of those cases of this malady which have assumed the chronic form, the indications will, in many respects, be the same, modified, however, by the nature of the existing con- dition of the general system. XXVII. CYSTITIS; OR, INFLAMMATION OF THE BLADDER. This disease occurs occasionally, and it may involve the whole structure of the bladder, or only a small portion of this viscus, as in those cases where its force is mainly spent on the mucous mem- brane of the neck, and similar instances of its partial and local effects on other parts of the bladder. The symptoms are, a sense of constriction over the region of the bladder ; a violent, lancinating pain, which is sometimes of the throbbing kind, extending to the perineum, and, in some instances, to the testicles, and to the upper and insides of the thighs. The pain and sense of constriction are in the hypogastric region. The pain is increased by the application of pressure, made on the hypo- gastric region or on the perineum. A great desire to evacuate the contents of the bladder; frequent ineffectual attempts to uri- nate, with strangury or dysury. The urine which is passed off is of a deep red, tinged with blood. A constant stillicidium of urine takes place in many instances. The pulse is full* strong, hard and frequent; nausea and vomiting ; costive bowels, and sometimes a sense of tenesmus, from the extension of the irritation to the rectum; the patient feels depressed, and quite restless; the skin is hot and dry, and tongue furred; patient feverish and thirsty; swelling and fullness in the loins and hypogastric region. Like other inflammatory attacks this may terminate either in resolution, suppuration or gangrene, or in the thickening and indu- ration of the coats of the bladder. The symptoms indicative of the occurrence of resolution are, a general moist and soft state of the skin; a turbid and somewhat copious urine, passed without difficulty ; without the usual evidences of decreased strength, and general subsidence of the inflammatory and febrile symptoms. 774 CYSTITIS. Suppuration is not a frequent termination of this malady. This mode of termination is indicated by the subsidence of the violence of the symptoms of pain and fever; with rigors or chills, and the appearance of a whitish, purulent matter, in the urine. The lar- gest portion of the fatal cases, terminate in gangrene, which is shown by the sudden cessation of the pain, cold state of the extrem- ities, profuse, clammy sweats, much prostration of strength, weak state of the pulse, a sunken aspect of the countenance, as well as hickup. The causes are numerous; such as mechanical injuries ; retained urine; irritating substances in the bladder; the absorption of the active principle of cantharides and the spirits of turpentine ; metas- tasis of gout or rheumatism; irritating injections; the introduc- tion of instruments; difficult parturition ; cold apphed to the feet or any part of the body; injuries produced by the use of obstet- rical or other instruments. Eclectic Reformed Treatment. Diuretic and mucilaginous drinks, taken freely, will be found highly useful in the manage- ment of this complaint. For this purpose, an infusion of the roots of the althea officinalis, prepared by adding one quart to two ounces of the green root, bruised, forms a good preparation, which, if taken in doses of from half to a teacupful every twenty minutes, until it produces copious diuresis, will have an admirable influence in arresting the pain and inflammation. Much relief is generally obtained by this measure, when pushed to the proper extent. The partial medicated vapor bath will be found highly advantageous, if used freely, so as to produce a copious perspiration. The com- mon bitter herb fomentations, will answer the desired purpose remarkably well. In conjunction with this measure, the diapho- retic and easing powders, given in small portions, say five grains once in half an hour, so as to insure a copious perspiration, the tendency to Avhich will be much increased by the application of the bitter herb fomentation, in substance, enclosed in cloths, to the lower portion of the abdomen, and renewed as often as once eArery twenty minutes or oftener, as hot as the patient can bear them. Some advantage will result from the use of hydragogue purgatives, occasionally given in mild and moderate doses. In the treat- ment of this affection, also, it will be found that much advantage CYSTITIS. 775 will result from large poultices of roasted onions, applied to the small of the back or over the lumbar vertebrae, as well as to the perineum. A strong decoction of the bark of the root of the peach tree, taken freely by the patient, is a medicine worthy of much confidence as a soothing astringent, laxative and diuretic, well adapted to many cases of this complaint. It may be prepared by adding one pint of boiling water to one ounce of the bruised bark of the root, and given in doses of from one to three tablespoonsful every half hour, for a longer or shorter period, as the circum- stances of the case may seem to require. In severe cases of this kind, cupping to the perineum and hypo- gastric region, will be found well suited to afford relief. = In the treatment of the chronic form of this complaint, some modification of remedial measures becomes necessary. A more rigorous and energetic course of local means will be found essen- tial to success, especially in those cases in which the inflamma- tion is principally located in the neck of the bladder, or at least near it; when a thickened state of the mucous membrane follows, and occasionally ulceration. The application of an issue or an irritating plaster, and the keeping up of a purulent discharge for five or six weeks, is a measure of the first importance. It should be used, however, with others which may be indicated by the circumstances of the case, and calculated to restore the functions of the skin, such as alkaline bathing and active frictions, and such constitutional alteratives as the alterative syrup, stillingia sylvatica, or restorative bitters, or, indeed, any similar prepa- rations which may be thought to have an especial application to the case. XXVIII. ERITHISMUS MERCURIALIS. MERCURIAL FEVER. We come now to the consideration of a form of fever which is dependent upon a specific and peculiar cause, and which has not ordinarily been recognized by systematic writers as a distinct and separate affection. Notwithstanding this, however, many have taken occasion to make some reference to this malady in a some- what vague and indefinite manner, not appearing willing to acknowledge its existence as frequently as it occurs, nor indeed to have given the subject that extensive critical investigation which would qualify them to point out its peculiar features, under the variety of forms which it may be capable of assuming. But few of the great mass of medical practitioners have realized, themselves, the obhgations which they owe, by virtue of their position as conservators of the public health, professing, as they do, implicit obedience to the high and holy behests of a humane and benevolent science, to an honorable profession and to a con- fiding public, by an adequate examination of this fearful malady as it exhibits itself in the great variety of forms which it is capa- ble of assuming. On page 216 of Marshall Hall's work on the Principles of the Theory and Practice of Medicine, we are informed that Dr. Bate- man, Avho ultimately fell a victim to this horrible malady, says: " It is evident that the features of the malady are not sufficiently known, even to the most enlightened members of the profession." On the succeeding page of the same work, Mr. Pearson ob- serves that the gradual approach of this diseased state, is com- monly indicated by paleness of the countenance, a state of general inquietude and frequent sighing. The respiration becomes more frequent, sometimes accompanied MERCURIAL FEVER. 777 with a sense of constriction across the thorax; the pulse is small, frequent and often" intermitting, and there is a sense of fluttering about the praecordia. Further, erithismus is characterized by great depression of strength; a sense of anxiety about the prae- cordia ; irregular action of the heart; frequent sighing ; trem- bling, partial or universal; a small, quick, and sometimes inter- mitting pulse; occasional vomiting; a pale, contracted counte- nance ; a sense of coldness; but the tongue is seldom furred ; nor are the vital or natural functions much disordered. When these or the greater part of these symptoms are present, a sudden and violent exertion of the animal powers sometimes proves suddenly fatal. As it respects the manner in which this affection approaches, it will be found to be various in different cases. If an attack should come on while a patient is under the influence of a course of mercurial medication, in the progress of an attack of fever from any sudden exciting cause which may develop its effects, the patient will be apt to be seized with a rigor of more or less sev- erity, which generally increases till he feels as if his bones were about to be dislocated, also with a most intense and urgent desire for acid drinks. These will probably be the most urgent symptoms at first, showing the change of character. We have more frequently noticed it commencing with the fol- lowing train of symptoms, in some respects not very unlike the symptoms of the forming stage of other fevers, namely: with stretching; yawning; lassitude ; aching pains in the loins and extremities; a sense of weariness of the whole body; burning sensation along the whole course of the oesophagus, which in some instances extends throughout the alimentary track; the rigors commence and continue till the whole system is convulsed or greatly agitated, with a decided increase of the burning sensation already mentioned; an insatiable desire for acid drinks; an intolerable suffocating heat; a highly flushed countenance, imparting to the hand the sensation of calor mordax, or stinging heat, with mer- curial fetor in the breath, and in some cases from the emanations of the body; an accelerated, but quite compressible pulse, bound- ing at the rate of from 140 to 160 per minute; and a highly sen- sitive state of the skin, with the carotids beating violently. The exacerbations as well as remissions or intermissions are extremely 778 MERCURIAL FEVER. variant, both with regard to their respective degrees of violence and duration, as well as in regard to the periods of their recur- rence. The symptoms characteristic of poisoning by mercury exist in almost every imaginable grade of violence, from the mildest to the most malignant and fatal form. Diagnosis. From other forms of fever it may be distinguished by the peculiar burning sensation along the oesophagus and alimen- tary canal; the very urgent desire for acid drinks; the longer continuance and greater severity of the rigors; the extremely sensitive condition as well as stinging heat of the skin; the very frequent but compressible state of the pulse ; the fact that patients complain in the midst of severe rigors of intense heat; the mercurial fetor in the breath and perspirable matter of the skin ; the diversity in the various conditions of the pulse with respect to frequency, force and volume; the great variation in the dura- tion, violence and time of the recurrence of the paroxysms; the slight coppery taste in the mouth; the soreness and paleness of the gums. In the rigors of the regular intermittent we find a sense of numbness, but in the rigors of mercurial fever there is a burning sensation in the skin. The above list of symptoms will enable the accurate observer to distinguish this case from every other form of fever. It is very true that they do not all appear in every individual case of this disease, but it is believed a sufficient number occur to distin- guish it with a good degree of certainty. Eclectic Reformed Treatment. Inasmuch as there seems to be an alkaline poison produced by the operation of mercurials on the human system, by the union of certain principles with the acids of the body, producing thereby a deficiency in the quantity of the acid principle, which is shown on the part of the patient by the insatiable desire which he experiences for acid drinks, it indi- cates at once the proper measures of treatment. The indications of nature will at all times command the attention and respect of every practitioner who desires to attain to a point of eminence in his profession, which is in some degree commensurate Avith the honorable aspirations of a well balanced and properly directed mind. He Avho, in the language of a noted but misguided medi- MERCURIAL FEVER. 779 cal professor, undertakes to kick nature out of doors and disre- gard her admonitions, will find himself groping his way in the dark, throughout the whole course of his unprofitable and dis- creditable career as a medical man, and it Avould be far better for such a man to withdraw at once from the ranks of a profes- sion which he must most certainly forever disgrace. But to re- turn to the treatment, it will be found that acid drinks, such as lemonade, apple water, tamarind water, vinegar with Avater, may be taken pretty freely by the patient. At the same time the whole body should be bathed or sponged by vinegar, slightly warm, repeatedly, with a view of charging the system as completely as possible with the acid principle, which seems to be deficient as above suggested. This treatment is generally productive of the most favorable results in moderating and subduing the violence of the excite- ment, more especially in those cases in which the attack arises from the effects of mercurials, but recently taken, or while the patient is under actual salivation, and is suddenly affected by cold, or some other cause capable of developing the poisoning effects of mercury. In addition to the treatment above suggested, mild laxatives or purgatives, such as neutralizing physic, or the common hydra- gogue purgative, should be administered in their ordinary sized doses, whenever the circumstances of the case may seem to de- mand their use. The mild demulcent drinks are also very appro- priate. Among these, perhaps none is better than the infusion of the root of the althea officinalis, taken moderately free as an occasional drink; the flaxseed tea or the mucilage of ulmus fulva, and perhaps a few others of a similar nature. Many of these cases which seem somewhat tedious, and incline to assume the chronic nature, will be greatly benefited by the use of the alter- ative syrup or Smith's anti-mercurial syrup, both of which are medical compounds of great value in the treatment of this, as well as many other maladies, which seem to be uncontrollable by the means ordinarily depended on for their relief. INDEX TO VOL. I. jEsculapius deified Ague and Fever cold stage forming hot sweating causes complications diagnosis modifications periodicity discussed post mortem appearances prognosis treatment palliative radical Ague, anticipating deferring erratic cake masked American Electicism Amygdalitis Anal Fistula description treatment Angina cause of chronic tonsillaris termination of treatment Ani, Prolapsus causes treatment Anti-dyspeptic pill Aptha; cause and treatment Armstrong on Typhus Ascaris Lumbricoides symptoms treatment Ascaris Wrmicularis symptoms treatment Asiatic Cholera anatomical character blood in cause of diagnosis history of Page. Page. 4 Asiatic Cholera— 40 nature of 549 43 prognosis 551 42 reaction and convalescence in 511 41 rice-water discharges 544 45 6tages and symptoms 537 57 treatment 552 53,81 Aspedium filix mas, remedy for 58 worms 599 46,78 Assyria, early history of medicine in 4 50 Bailey on Periodicity 51 ices 55 Bell on Congestive Fever 72 57 on Fowler's Solution 08 58 on Intermittent Fever 70 58,60 Bengal Fever 87 62 Bilious Colic 495 42 anatomical development 498 42 cause and nature 497 42 symptoms 496 56 treatment 499 47,78 Bilious Fever St'. 15 treatment 113 363 Black Vomit, description 177 4812 Bleeding in angina 362 483 Blood in yellow fever 178 481 Blood letting, effects of 295 358 Boerhaave's reform 7 35!) Bone's Bitters, recipe 83 362 Bostock, quotation from 8 363 Botanies 12 365 Bowels, inflammation of 407 360 acute 408 •1SS cause 413 4NJ diagnosis 413 ■UK) symptoms 408 522 treatment 414 352 chronic 417 352 treatment 418 131 obstructions and symptoms 509 584 treatment 512 589 Brain, inflammation of 321 596 anatomical relations 327 586 cause 332 f)S'l diagnosis 326 596 prognosis 327 531 symptoms 323 545 treatment 333 543 chronic 337 546 Broussais' theory 31 549 Buchanan, quotation from 13 532,536 Cancer of the Rectum 465 782 INDEX. Cancer of the Rectum— treatment Cancrum Oris Canker, cause and treatment Case, Dr. Chapman's Nosology Chills and Fever Chomcl's treatment of typhoid use of chloride of soda Cholera Asphyxia Cholera Epidemic anatomical character blood in causes diagnosis and nature 549, j history of 532, i reliction and convalescence rice-water evacuations recipes 552,554, stages and symptoms. treatment lecture on, by Dr. Morrow report on, by Dr. Jordori Cholera Morbus anatomical character cause diagnosis and treatment symptoms Chronic Dysentery treatment Classification of diseases Clinic remarks Coleman, Dr. Asa, on milk sickness Colic, varieties bilious cause and nature symptoms treatment lead cause and nature diagnosis and prognosis symptoms treatment painters' wind symptoms and treatment Colitis treatment Congestive Fever complications description of by Dr. Armstrong degeneration diet malarial origin not contagious not typhoid symptoms treatment Congestive Intermittent Constipation, character of cause symptoms treatment Contagion of Typhoid Continued Fever Controversies in medicine Costiveness Crisis of Fever Cullen's Nosology age. Page. Cullen on Periodicity 51 406 Cynanche Tonsillaris 363 352 cause and termination 366 352 character 364 370 prognosis 366 17 treatment 367 40 Determination to Brain 124 228 Diarrhcea, symptoms 419 230 treatment 420 531 Digestion, process of 391 531 Dioscorea for Bilious Colic 499 545 Diseases, general distinctions 17 543 investigation of 18 546 of the rectum 459 550 Dothin Enteritis 201 536 Dixon on Yellow Fever 169, 187 541 Dogmatists 6 544 Dyspepsia 390 555 symptons 391 537 treatment, hygienic 397 552 medical 404 556 Dysentery 422 560 acute 423 523 causes 428 526 post mortem 429 525 prognosis 428 527 symptoms 424 524 treatment 430 438 adynamic 426 440 epidemic 435 16 chronic 438 457 duration 440 578 post mortem 439 493 symptoms 438 495 treatment 440 497 Eclectic Medicine, its object 12 496 its claims 13 499 Egyptian priests of antiquity 4 501 Empirics 7 504 Enteric Fever 401 505 Enteritis 407 502 cause and diagnosis 412, 413 505 prognosis and post mortem 411 501 symptoms 408 493 treatment 414 494 chronic, symptoms 417 422 treatment 418 429 Epidemic Cholera 531 130 anatomical character 544 143 blood in W3 131 causes 546 139 diagnosis and nature 549 147 history of 532,536 137 prognosis 551 136 reaction and convalescence 541 135 rice-water discharges 544 137 symptoms and stages 537 140 treatment 552 53 Erratic Ague 42 516 Eye, disease of, a case 345 51 s Father of Medicine 5 517 Fauces, inflammation of 358 519 causes and treatment 35'.! 218 chronic 36J 200 Fever, in general 21 8 and ague 40 516 causes of :-6 30 classes of 40 17 congestive 130 INDEX. 783 Page. Fever— oontinued' 201 crisis of 30 follicular 201 intermittent 40 pernicious 149 treatment 154 remittent or bilious 86 treatment 113 symptomatic and idiopathic 31 typhoid 300 treatment 225 yellow 163 treatment 193 stages of 22 cold 24 declining 29 forming 22 hot 26 Fissure of the Rectum, description 479 treatment 480 Fistula in Ano 482 description 483 treatment 484 Flux 422 treatment 430 Gastritis 373 acute 374 cause 380 pathology 378 symptoms 375 treatment 381 chronic 384 cause and diagnosis 387 symptoms, indigestion 385 treatment 388 Gastro-intestinal Irritation 121 Gelseminum Sempervirens 65 Gendron, M. 219 Gerhard, Dr. 201 Gibson, Dr. 477 Gin Bitters, recipe 83 Glechoma Hederacea, for colic 507 Glossitis 356 cause and treatment 357 Good's Nosology 17 Greece, medicine in ancient 4 Hale 201 Haynes, Dr., on milk sickness 575 Hemorrhoids 467 cause of 471 primitive type 469 treatment 472 Hemorrhage in typhoid fever 208 Hepatic Disorder in remittent fever 123 Hippocrates, account of Historical sketch of medicine Hot stage Humoralists Hunter, Dr., on blood Idiopathic Fever Ileitis, ileo-colitis Ileus Infantile Sore Mouth cause treatment Inflammation causes changes of blood in 5 3 44 32 310 31 408 510 349 350 351 248 252 271 Page. Inflammation— chronic 270 ligatures in 320 Magendie on 275 results or terminations 255 symptoms 249 Tweedie on 282 treatment 316 bowels, of the 407 acute 408 cause and diagnosis 413 prognosis and post mor- tem 411 symptoms 408 treatment 414 chronic 417 symptoms and treatm't 418 brain „ of the 321 anatomical relations 327 causes 332 diagnosis 326 prognosis t27 symptoms 323 treatment 333 chronic 337 ear 339 treatment 342 fauces 358 cause 359 treatment 360 intestines, small 407 treatment 414 large intestines 422 mouth • 346 cause and treatment 348 symptoms 347 oesophagus 371 cause 372 symptoms 371 peritoneum, of the 444 acute 445 cause and diagnosis 450 periodicity 449 post mortem 449 prognosis 451 symptoms 446 treatment 451 chronic 455 symptoms 456 treatment 456 stomach, of the 373 acute 374 cause 380 pathological phenom- ena 378 symptoms 375 treatment 381 chronic 384 cause and diagnosis 387 symptoms, indigestion 385 treatment 388 tongue, of the 356 cause and treatment 357 tonsils 363 cause and treatment 367 Indigestion 390 symptoms 391 treatment, hygienic 397 medical 404 784 INDEX. Page. Intermittent Fever 40 causes 57 complications 53 diagnosis 58 effects of 55 modifications 46 periodicity discussed 50 post mortem 55 prognosis 57 treatment 58 radical 62 recipes for 82, 83 types of 40 stages 42 cold 43 forming 42 hot 44 sweating 45 Introductory 1 Indian hachy, cause of milk sickness 582 Jackson, Dr. 201 treatment of typhoid fever 226 Jasmine, yellow 65 Jordon, Dr. J. H., report on cholera 560 Large Intestines, inflammation of 422 treatment 430 Lead colic 501 cause, diagnosis, and symptoms 502 prognosis and treatment 505 Ligatures 321 Louis, M. 211 treatment of typhoid 232 Lumbricoides 584 treatment 595 McCall, Dr. Alexander, on milk sick- ness 582 Magendie on the blood 275 on blood-letting 295 Malaria, animal and vegetable 36 Malignant Cholera 531 Masked Ague 47, 79 Methodics 7 Miasmata, koino and idio 36, 39 how produced 37, 88 nature of 36, 39 Miasmatic Remittent Fever 88 Michigan Fever 87 Milk Sickness 567 cause and nature 572 diagnosis 571 note on 575 symptoms and cases 568 treatment 574 Dr. Coleman on 578 Dr. Havnes on 575 Dr. McCall on 582 Morrow's decease 15 lecture on cholera 556 treatment of intermittent fever 61 Necrosis 269 Nervous Fever 201 Neuralgia, case of 345 Neutralizing Physic 390 Nosology—Cullen's, Good's, Chap- man's 17 Nurse's Sore Mouth 353 treatment 354 Obstruction of the bowels 509 symptoms 510 Obstruction of the bowels- treatment i Oesophagitis case of symptoms I Otitis cause treatment chronic recipes for Painter's Colic cause and spmptoms prognosis and treatment Parasites, origin of Parry, Dr., on blood Periodicity of intermittent fever Peritonitis acute and puerperal cause and diagnosis periodicity of post mortem prognosis symptoms treatment chronic Page- ' 512 371 372 371 339 340 342 343 344 501 502 505 592 313 50 444 445 450 449 449 451 446 451 455 symptoms and treatment 456 Perlee, on yellow fever 174, 183 Pernicious Fever 149 Bell, Dr., quotation from on 160 old practice 153 prognosis 152 symptoms 150 treatment 154 Wood's views 154,157 Petechia 205 Phrenitis 321 anatomical character and prog- nosis 327 causes 332 diagnosis 326 ligatures 335 symptoms 323 treatment 333 chronic 337 Phrenology 331 Physic, Dr. 477 Piles 467 cause 471 primitive type 469 treatment 472 Pin Worm 586 treatment 597 Piperine in intermittents 67 Priests, early practitioners 4 Prolapsus Ani 488 cause 489 treatment 490 Pumpkin Seeds for Tape Worm 599 Quartan Type 40 Quintan do. 40 Quotidian do. 40 Quinsy 363 cause and treatment 367 Recipes—Alterative syrup 344 antidispeptic pills 522 for bilious colic 501 Bone's bitters 83 for cholera 552, 555 compound neutralizing physic 390 INDEX. 785 Recipes— emetic powder 432 for lead colic 505 for otitis 344 pod. lep. and taraxacum pill 84 pod. lep. sang, and tarax. pill 124 quinine and iron 116 rochelia virginiana 443 tonic in ague 83 for worms 596, 597 from Boston Journal 599 Rectum, diseases of 459 stricture of 459 treatment 460 organic non-malignant 462 diagnosis 463 treatment 464 organic malignant of 465 treatment 466 ,, fissure of, and description 479 treatment 480 fistula of 482 treatment 484 prolapsus of 488 description 489 treatment 490 Remittent Fever 86 cause 97 complications 92 correct treatment 113 convalescence 129 determination to brain 124 diagnosis 99 distinguished from intermittent 89 duration 100 febrile stage 90 forming stage 89 gastro-intestinal irritation 121 hepatic disorder 123 latent period 99 liability of persons 89, 98 modifications 91 nature of jj° post mortem 102 91 102 87,88 103 prognosis remission treatment where prevalent Wood's treatment Remittent Congestive Fever 130 Remittent Pernicious 14J continued Ibl Retention of urine in typhoid mh Rhus Toxicodendron, cause of milk Rhus Radicans. cause of milk sick- ness Sick Stomach causes and nature of note on symptoms and case of treatment Smith, Dr. Nathan treatment of typhoid Solidists Sore mouth treatment Sore throat, character of chronic 573 582 567 572 575 568 574 219 235 32 353 354 358 362 Page. 493 494 531 552 523 527 525 22 560 373 374 380 378 375 381 384 384 389 388 346 348 347 459 460 461 462 463 464 465 466 207 205 47,79 79 45 31 587 588 598 Tantini's cases of congestive fever 160 Temples of ^Esculapius 4 Tenia 587 treatment 598 Tennitus aurium 324 Terminations of inflammation 256 Tertian type 40 Thread worm 587 Thrush 349 causes and treatment 351 Tissues modify inflammation 266 Tobacco, injections of 514 Tongue, inflammation of 356 cause and treatment 357 Tonsillitis 363 cause and treatment 367 character of 364 prognosis 366 chronic 371 Tweedie, Dr., on inflammation 282 on blood 311 Types of fever 40 Typhoid Fever 200 anatomical character 210 cause 217 contagion and infection 218, 220 convalescence 247 diagnosis 223 nature of 222 prognosis 225 Spasmodic colic treatment Spasmodic cholera treatment Sporadic cholera diagnosis and treatment symptoms and cause Stages of fever Statistical report on cholera Stomach, inflammation of acute cause pathology symptoms treatment chronic symptoms diet treatment Stomatitis causes and treatment symptoms Stricture of the Rectum spasmodic treatment organic non-malignant diagnosis treatment organic malignant treatment Subsultus and sordes Sudamina Sun pain treatment Sweating stage Symptomatic fever Tape worm character and location treatment 786 INDEX. Page. Typhoid Fever- symptoms 203 treatment 2.38 by Chomel 228 by Jackson 226 by Louis 232 by N. Smith 235 Typhus Fever 130 description, by Dr. Armstrong 131 degeneration 139 malarial origin 137 not contagious 136 not typhoid 135 symptoms 137 treatment 140 Typhus Icterodes 163 Ulcerative inflammation of mouth 352 symptoms 353 treatment 353 Ware, Dr. 201 Willis on periodicity 51 Wind colic 493 treatment 494 Wood on intermittent fever 70, 75 on congestive fever 154, 157 on remittent fever 103 on yellow fever 165 Page. Worms- varieties of 584 first, ascaris lumbricoides 584 second, vermicularis 586 third, tricocephalus dispar 587 taenia solum 587 taenia lata 588 origin of 591 by Vogel 592 treatment 595 recipes for 596, 597 Yellow Fever 163 anatomical character 178 black vomit in 177 cause 181 by Dr. Perlee 183 by Dr. Dixon 187 contagion 190 diagnosis 191 description of, at Charleston 169 at Natches 174 epidemic and endemic 164 prognosis 192 symptoms 165 treatment 193 Yellow Jessamine 65 DR. MORROW'S POSTHUMOUS WRITINGS. Page. Acute Bronchitis 742 symptoms of 743 cause of 744 treatment 745 Acute Hepatitis 756 diagnosis 757 cause and treatment 759 Acute Gastritis 718 symptoms 718 diagnosis 720 treatment 722 Acute Peritonitis 685 cause 686 treatment 686 Arachnitis 656 symptoms 657 diagnosis 658 treatment 659 Bilious Pneumonia 711 symptoms 712 treatment 713 Bladder, inflammation of 773 treatment 774 Bowels, inflammation of 732 symptoms 734 treatment 734 chronic 738 treatment 739 Brain, inflammation of 651 symptoms 651 treatment 652 Bronchitis, acute 742 symptoms 743 cause 744 treatment 745 Bronchitis— chronic, symptoms 689 prognosis 690 dissection 690 treatment 6P1 Chronic Bronchitis 689 prognosis 690 treatment 691 Chronic Hepatitis 762 cause 763 treatment 765 Chronic Inflammation of Bowels 738 treatment 739 Colitis 748 treatment 753 Continued Fever 627 sthenic and asthenic 627 cause 629 symptoms 631 treatment 632 Croup 675 pseudo membranous 677 treatment 680 Cynanche Laryngea 693 symptoms 694 cause 695 treatment 695 Cynanche Tonsillaris 669 symptoms 670 treatment 671 Cynanche Trachealis (75 symptoms 676 cause 078 prognosis 679 treatment 680 INDEX. 787 Cystitis treatment Dysentery symptoms typhus morbid appearances cause treatment Ear, inflammation of treatment Enteritis, symptoms of diagnosis cause and treatment chronic, symptoms of cause and treatment Erethismus Mercurialis diagnosis treatment Fever, continued cause symptoms treatment intermitting symptoms of inflammatory malignant treatment remitting malignant gastric hepatic cause treatment modifications mercurial treatment typhus symptoms cause prognosis treatment yellow symptoms contagion treatment Gastritis, acute symptoms diagnosis cause treatment chronic symptoms cause diagnosis treatment Glossitis symptoms treatment Hepatitis, acute symptoms cause treatment chronic cause treatment Hydrocephalus symptoms diagnosis treatment 773 774 748 749 751| 752 752 753 662; 663 ! 732 733 734 738 739 776 778 778 627 629 631 633 6031 604 605 ! 606 608 613 614 617 617 618 619 624 776 778 635 636 638 641 641 646 647 648 648 718 718 720 721 722 726 726 728 728 729 665 666 667 756 757 759 759 762 763 765 656 657 658 659 Page. Inflammation, of the bladder 773 treatment 774 brain, of the 651 symptoms 651 pathology 652 treatment 652 bronchia, of the 742 symptoms 744 treatment 745 ear, of the 662 symptoms 663 treatment 663 large intestines, of the 748 symptoms 749 cause 752 treatment 753 larynx, of the 693 symptoms 694 cause 695 treatment 695 lungs, of the 704 symptoms 705 diagnosis 706 cause 707 treatment 707 intestines, of the 732 diagnosis 733 cause 734 treatment 734 kidneys, of the 769 cause 770 treatment 771 parotid gland, of the 682 treatment 683 peritoneum, of the 685 cause 686 treatment 686 pleura, of the 697 treatment 699 stomach, of the 718 symptoms 719 diagnosis 720 cause 721 treatment 722 chronic 726 symptoms 727 cause 728 treatment 729 tongue, of the 665 treatment 667 tonsils of the 669 symptoms 670 treatment 671 trachea, of the 675 treatment 680 Intestines, inflammation of 732 treatment 734 chronic 738 treatment 739 Intermitting Fever 603 symptoms 604 inflammatory 605 congestive 605 malignant 606 treatment 608 Kidneys, inflammation of 769 cause 770 treatment 771 Larynx, inflammation of 693 788 INDEX. Larynx, inflammation of— symptoms cause treatment Liver, inflammation of symptoms treatment Lungs, inflammation of symptoms diagnosis cause treatment Meningitis symptoms diagnosis treatment Mumps treatment Mercurial Fever symptoms treatment Nephritis symptoms cause treatment Otitis symptoms treatment Parotitis Pneumonia Biliosa symptoms diagnosis treatment Peripneumonia symptoms diagnosis cause treatment Peripneumonia Notha typhoides treatment Peritonitis, acute cause prognosis treatment Phrenitis symptoms pathology treatment Page. 694 695 695 656 756 759 704 705 706 707 707 656 657 658 659 682 683 776 778 779 769 769 770 771 662 663 663 682 711 711 712 713 704 705 706 707 707 742 715 716 685 686 686 686 651 651 652 652 Pleuritis • symptoms diagnosis treatment chronic treatment Quinsy symptoms treatment Remitting Fever malignant gastric hepatic cause treatment modifications Stomach, inflammation of symptoms diagnosis cause treatment chronic symptoms cause treatment Tongue, inflammation of symptoms treatment Tonsillitis symptoms treatment Trachialis symptoms cause treatment Typhus Fever cause prognosis treatment Typhus Icterodes symptoms contagion treatment Typhoid Pneumonia treatment Yellow Fever symptoms contagion treatment ERRATA. ) * 697 697 699 699 698 702 669 670 671 613 614 617 617 618 618 624 718 719 720 721 722 726 727 728 729 665 666 667 669 670 671 675 676 678 680 635 638 641 641 646 647 648 648 715 716 646 647 648 648 Page 2, line 6 from top, read " as the hireling," for " a' the hireling." Page 5, line 11 from bottom, read " Heraclitus," for " Heraclite." Page 149, heading, read "Pernicious Fever," for "Bilious Fever." Page 352, line 3 from top, read " oris," for " orris." Page 284, line 7 from top, read " lumbrici," for " lumbrica." Page 534, line 7 from bottom, read " centres of Europe," for "centres of Asia." References to " Wood's Practice," sometimes First, and sometimes Second Edition. JUN4-£-U5B