NATIONAL LIBRARY OF MEDICINE




         Bethesda, Maryland 
 
 
NOTES
OF
LECTURES
TUEORY AIVD PRACTICE OF MEDICINE,
DELIVERED IN THE
JEFFERSON MEDICAL COLLEGE,
PHILADELPHIA.
SECOND EDITION, CORRECTED,
BY JOHN EBEREE, Ml. D.
            CINCINNATI:
PUBLISHED BY COREY & FaIRBANK, 200, MAIN »TREHT.
                1834 
EASTERN DISTRICT  OF PENJSSYLVAMA,  to wit:

             BE IT  REMEMBERED, That on the twelfth day of October,
  (L. S. )  in the fifty-second year of the Independence of the United States of
           America, A. D. 1827, John Eberxe, M. D. of the said District,
hath deposited in this Office the Title of a Book, the right whereof he claims as
author, in the words folio >ving, to wit:

  "Notes of  Lectures on the Theory and Practice of  Medicine:
"delivered  in  the  Jefferson Medical  College,  at  Philadelphia.
"By  John  Eberle,  M. D."

  In conformity  to the Act  of Congress of the United States, entitled,  "An
Act for the encouragement of learning, by securing the copies of maps,  charts,
and books, to the authors and proprietors of such copies, during the times therein
mentioned."  And  also to  the  Act,  entitled, "An Act supplementary to an
Act, entitled, 'An Act for the encouragement of learning,  by  securing the co-
pies of maps, charts, and books, to the authors and proprietors of such  copies,
during the times therein mentioned,'  and  extending the benefits thereof to the
arts of designing, engraving,  and etching,  historical and other prints."
                                       D. CALDWELL,
                            Clerk of the Eastern District of Pennsylvania. 
PREFACE.
  This little work is published expressly for the use
of the students attending the author's lectures on the
Theory and Practice  of  Medicine.   It embraces
little more  than the main propositions and facts,
which  form the ground-work of the lectures;  in
other words,—the text upon which he enlarges and
comments in  extemporary discourse;  and  which,
especially, the  student  ought  to impress upon his
memory.   The  practice of taking notes, though at-
tended with some  advantages, is  nevertheless, on
the  whole, calculated  to  lessen the  benefits to be
derived from oral instruction.   The train of thought
and reasoning  is interrupted;  and the mind irregu-
larly hurried along  the current of the speaker's ob-
servations—seizing somtimes upon remarks that are
comparatively unimportant, at the expense of others
of a more useful and interesting import; and losing
in a great  measure the general spirit and scope of
the  speaker's discourse,—more especially when the
subject is one  of general  disquisition.  These dis-
advantages, it is believed, will be diminished, if not
wholly obviated, by works constructed  on  the plan
of the  present one.   Being secure of the  text, or pro-
positions,  the student may yield his mind,  without
embarrassment, to the  explications and discussions
of the lecturer.  His efforts,  too, in recalling  to his
mind  the observations he may have heard from the 
vi
PREFACE.
speaker, will be  greatly favored,  by looking over,
in private, the sketch which is thus placed in  his
hands.
  The author acknowledges, that  this manual does
not corne up to the idea he has formed, of the pro-
per construction of a text book of this kind; but?
such as it is, he flatters himself, that it will in some
degree answer the intentions for which it was  com-
posed;  and with  this hope, he  respectfully  dedi-
cates it to those students of medicine, who do him
the honor of attending his lectures. 
TABLE  OF  CONTENTS.
Anasarca,	-	.	185
Angina pectoris, Arachnitis, or Hydrocepalus acutus, Ascites,		-	183 66 186
Asthma,	-	-	180
Bronchitis, acute, -	.	-	89
---------chronic,	-	-	90
Cholera,	-	-	192
Chorea,	.	-	170
Cold,	_	-	11
Colic, flatulent,	_	.	193
bilious,	.	-	194
Colica pictonem, Critical days, Croup, spasmodic, Cynanche tonsillaris,	-	-	196 26 91 93
Cynanche trachealis, Cystitis,	-	-	90 104
Diabetes,	-	-	107
Diagnosis, general, Diarrhoea,	-	-	13 190
Dropsy, Dysentery, -	-	-	184 79
Enteritis, acute,	-	-	77
-------- chronic,	-	.	83
Epilepsy, Epistaxis, Erethism of the brain,	-	-	162 138 70
Erysipelas, Exanthemata—Small	pox,	-	132 116
Fever in general, and causes of,		-	9
-----, its general course, -----, Intermitting, -----, Remitting,		-	29 33 40
----■, Yellow,	-	.	44
-----, Inflammatory, —-*--, Typhus, ----, Catarrhal,	-	-	47 52 51
Fevers, Type of,	-	-	29
 
Vlll
CONTENTS.
Gastritis, acute,	.	72
-------- chronic,	.	74
Gout, ...	-	111
Haematemesis, -	.	139
Haematuria,	.	141
Hasmoptisis,	-	143
Haemorrhois—Piles,	-	11
Haemorrhagiae,	-	137
Hemiplegiae,	-	157
------------chronic,	-	101
Hepatitis, acute,	-	99
Hydrothorax,	-	187
Icterus—Jaundice,	-	205
Indigestion, -	-	201
Inflammation in general,	-	60
------------chronic,	-	65
i? "D-r-I^.		ib.
Mental diseases—Mania,	.	211
Neuroses—Apoplexy,	-	153
Nephritis,	-	103
Paralysis, -	-	157
Paraplegia,	-	158
Parotitis, -	-	94
Paralysis partialis—local palsy,	-	159
Peripneumony,	-	86
Peritonitis, acute, -	-	95
--------- chronic,	-	98
Pertussis—Whooping cough,	-	176
Phrenitis, - -	-	105
Phtisis pulmonalis,	-	145
Pleuritis, acute,	-	85
--------chronic,		90
Pneumonia biliosa,	-	88
Prognosis, -	-	23
Pulse,	-	19
Rheumatism, acute, . -	-	105
~-----------chronic, -	-	109
Rubeola—Measles,		125
Scarlatina,	-	128
Scrofula,		208
Softening of the brain, -	-	71
Tetanus,		172
Variola, -	-	116
Variola vaccina,		121
Varioloid, -	-	*123
Varicella—Chicken pox,	-	125
Verminous affections,		214
 
NOTES OF  LECTURES.
                    CHAPTER I.

               OF  FEVER IN  GENERAL.

Idiopathic—(seldom.)
Symptomatic,—dependant on:
     local irritation
     ----inflamation,
        generally seated in the mucous tissues j—frequently in the
        serous.
Proximate Cause:
   located in the capillary system of blood vessels.  (See
   Practice of Med. Chap. 1.)
        The morbid actions of the heart and arteries are mere sym-
        pathetic phenomena, dependent on a primary local irritation
        of a part or the whole of the sanguiferous capillary system.
The proximate cause consists:
   in a deranged condition of the vital properties of the
   capillary  system---whence  result irregular  actions
   from the impression of normal and innormal irritants.
Remote causes of fever: divided into;
   predisposing and exciting;
        There exists, however, no essential distinction between the
        predisposing and exciting cause.  Every predisposing cause
        may become an exciting cause,by continued or intense action.
Predisposition consists for the most part  in:
   local, and rarely in mere
  general debility.   (See Pract. Med. p. 28.)
               B 
10
OF FEVER IN GENERAL.
The origin of all possible cause of fever is quadruple.
1. Retained recrementitious materials, in consequence of
   the accidental torpor of one or more  of the  emunc-
   tones.
2. Substances generated  in the system, independent  of
   organic actions, worms, acid, &c.
3. Materials generated out of the body: miasmata, heat,
   cold, &c. &c.
4. Substances generated  by diseased organic  actions—
   contagious.  (See Pract. of Med. p. 31.)
General nature of these causes.
   They are irritants:
   Some of them invariably produce the  same disease, as
   the contagious.
   Certain  distinct febrific causes cannot develop their
   morbid effects at one and the same time in the same
   system: measles and small-pox.
All morbid agents act primarily on the nervous system.
   Through the lungs and respiratory passages,
   The stomach and intestinal canal,
   The skin, and
   The blood.
        It is highly probable that all seriform morbific agents act on the
        system through he respiratory organs. Some  of them may be
        absorbed into the circulation, and act upon the nervous extre-
        mities of the blood ; others may act directly on the nerves of the
        mucous membrane of the respiratory passages.  The former
        mode of acting, is, I presume, generally, if uot always the case.
The causes of fever are divided into three classes.
1. Sensible properties of the atmosphere: heat,  cold, moi-
   ture, electricity, &c» &c.
2. Contagious,—the result of  organic actions.
3. Miasmata,—the result of physical  changes.
Heat.  Specific  temperature  of the  human body, 98<>.
   Most agreeable temperature of surrounding air, 65o.
   Atmospheric heat not a deletereous agent y predisposes
   to the influence of morbific causes; increases the secre-
   tion of bile; indirect cause of disease, by favoring the
   generation of miasmata. 
OF FEVER  IN  GENERAL.
11
       Dr. Johnson observes, that solar heat only produces the pre-
       disposition; while terrestrial exhalatious, and vicissitudes of
       temperature, call into action the principal diseases of warm cli-
       mates.  (See Pract. Med. p. 39.)
Cold.  No positive existence—a mere  relative degree of
  temperature; lessens the action of the  heart and arte-
  ries ; causes a shrinking of the surface of the body; di-
  minishes  sensibility and contractility; produces irresis-
  tible disposition to sleep; and depresses the moral and
  physical energies of the system, wheu long and intense-
  ley  applied.  Suddenly or transiently applied, it  ex-
  cites the  nervous system.  In alternation with heat, a
  fertile cause of  disease; the diseases resulting from its
  influence, mostly pneumatic, catarrhal, or rheumatic;
  cold water externally applied, or received into the sto-
  mach  when the body is heated  and in a free state of
  perspiration,  often  proves suddenly   fatal.  Always
  more injurious in its influence, when accompanied by
  moisture.  (See Pract. Med. p. 35.)
Miasmata. Heat and moisture essential to the production
  of miasmata*   Moisture need not be abundant; in-
  undated grounds  extricate little or no miasmata; hence
  the rainy seasons of tropical  countries are the most
  healthy.   Miasmata are seldom generated at a temper-
   ature  below 80q ; their precise nature  unknown; there
   is reason to believe, that they consist of particles of pu-
   trid vegetable and animal matter, dissolved in aque-
   ous vapour.  Chemical analysis  can  detect no differ-
   ence between the air of marshes and  atmospheric air.
   Gaspard's experiments on putrid matters received
   into the  body, support the opinion that marsh mias-
   mata consist of putrid vegetable and animal matter
   suspended in the air.
     Miasmata possesses greater specific gravity than at-
   mospheric air;  they  are conveyed  to a  considerable
  *It has lately been contended, that moisture is not essential to the generation
mata: but, as I believe, without good grounds. (Ferguson.) 
12
OF FEVER IN GENERAL.
  distance by  currents of wind; the distance at which
  they are capable of infecting, by being thus carried, is
  from two to  three miles(Bancroft says, but one fourth
  of a mile;) storms and violent blasts disperse and ren-
  der them innocuous; more danger in miasmatic atmo-
  sphere at night than during day; most danger  about
  the setting or rising of the sun; situations are protec-
  ted from the effects of miasmata, by interposing obsta-
  cles, as houses, walls, wood, hills, &c; long and gra-
  dual exposure to miasmata, destroys  the susceptibility
  of the system to their  more violent  influence.   Per-
  sons unaccustomed  to them seldom escape  disease,
  when subjected to their action.  They produce inter-
  mittents and remittents, of various grades  of violence.
  (See Pract. Med. p.  40.)
Contagion. A deletereous agent, generated by the living
  body in a  state of disease.  The diseases produced
  by this class of causes, preserve a determined or spe-
  cific character; contagious diseases divided into  chro-
  nic and acute; the later seldom affect the same person
  more than once;—the former may affect repeatedly; in
  the acute, there can be no relapse.  Contagious matter
  either a palpable substance, or an imperceptible efflu-
  vium ; chronic contagious affections always produced
  by the former, and by actual contact; some acute con-
  tagious diseases communicated both by  contact and
  and through the medium of the air; that is, both by a
  palpable virus and an effluvium.  Typhus fever, under
  certain circumstances, contagious; appears to be pro-
  pagated by  effluvia  only.
     Contagious effluvia extend but a short distance, suffi-
  ciently  concentrated to produce disease.   The experi-
  ments of Dr. O'Ryan make it but a few feet—four or
   five feet; currents of air will convey it much further;
   contagions  rendered harmless by diffusion in the air;
   hence the utility of  free ventilation; contagion attach-
   es itself to various substances; the substances most 
general diseases.
13
apt to receive and retain it, are,  wool, hair, cotton,
wood, cloths,  &c; contagion  influenced by  certain
occult conditions of the atmosphere; contagious disea-
ses communicated from the inferior  animals to the
human species.
   Disinfecting means; cleanliness; free  ventilation;
muriatic and nitrous vapors; lime; fumes of sulphur,
and heat.  (See Pract Med. p. 56.)
CHAPTER  II.
GENERAL DIAGNOSIS.
  Diagnostic signs  divided into those  exhibited by the
countenance; the attitude;  the  nervous  system; the
dgiestive organs; the circulatory system;  the  respir-
atory  organs; the circular surface; the  lymphatic
system; the secretions.
The  Countenance.  The features  to be  particularly
  examined, are: the eyes the prolabia; the nostrils; the
  lips; the brows.
In acute simple fever; eyes and face red; respiration hur-
  ried ; motions of  the nostrils rapid.   In acute sympa-
  thetic fever, these signs are absent. (Hall.)
Acute pain, from inflammation in the chest: features
  much contracted; the alae nasi acute and elevated, the
  nostrils contracted and expanded by  the acts of respi-
  ration, sometimes a vivid flush terminating abruptly—
  heat inconsiderable.
Dull pain in the chest: less constriction of the features; 
14
general diagnosis.
   an expression of great anxiety; nostrils widely dilated
   before inspiration.
Effusion into the lungs: countenance livid, anxious, tur-
   gid, with great dyspnoea, and dilation of the nostrils on
   inspiration.
The phthisical countenance.
Acute pain in the abdominal viscera: features acute;
   forehead wrinkled; brows knit; nostrils drawn up and
   acute; under lip drawn down, exposing the teeth.
Organic affections of the heart: countenance anxious;
   vividly flushed; prolabia livid: face turgid, cedematous.
   cold.  In hydrothorax, the face has a pale-livid aspect,
Soporose affections: flushed, livid, tumid, eyes closed or
   open and fixed, mouth frequently drawn to one side.
In syncope: pale, shrunk, cold, and death-like.
In chlorosis: pale, exsangueous; icterode; puffy; a pe-
   culiar darkness occupying the eyelids, and extending
   towards  the  temples  and cheeks, and sometimes sur-
   rounding the mouth.
Distinction between the icterode appearance, and the dif-
   ferent shades of icterus, (Hall) the yellowish tinge in
   in the latter is particularly seen in the albuginia of the
   eyes; in  the former, the eyes remain  untinged.  The
   tinge of  icterus depends on bile; that called icterode,
   on a morbid action of the cutaneous capillaries. (Hall.)
Chronic irritation of the bowels: puffy  countenance;
   upper lip pale and swollen; occurs in verminous affec-
   tions and in scrofula.
Attitude.  The healthy attitude:
   Advantages to be obtained from  position, in the treat-
   ment of  diseases.
Preternatural determination to  a part, diminished by  ele-
   vating such part: the head to be raised, in apoplexy;
   the extremeties, when  affected  with inflammation.
Supine position, with tremulous motion, indicates much
   muscular debilty. 
general diagnosis.
15
Fever from acute local inflammation; not attended with
  with muscular prostration.
Characteristic position in hydrolhorax: in slight cases,
  head and shoulders elevated when in bed; in severe
  cases, inability to lie down.  The erect position more
  urgent, when complicated with organic affection of the
  heart.  When sitting up, hands forcibly pressed on the
   chair on which the patient sits; or leaning back, with
   the arms and hands placed behind the back. (Hall.)
 Thoracic effusion, distinguished from mere organic dis-
   ease of the heart and lungs, by the effects of firm pres-
   sure  on  the  epigastric  region, and  bodily  exertion.
   Effects of pressure, in effusion: general agitation, cough
   and a sense of suffocation; not so, or but slightly, in or-
   ganic affections of the heart and lungs; bodily exertion
   excites more dyspnoea, and distress in effusion, than in
   organic affections.
 Position assumed by the patient, in abdominal inflam-
   mation, with acute pain: fixed,  carefully avoiding all
   motion and pressure; generally on  the back, knees
   drawn up, and head and shoulders a little elevated.
 Position assumed in spasmodic pains of the abdomen.
   constantly changing posture,  desirous of pressure on
   the abdomen, recumbent on the belly, &c.
 Position on the back, with knees constantly elevated, in
   the latter stage of acute diseases, a sign of retention of
   urine.
                                  *
 The Tongue.  Attention to be paid to its colour, its sur-
   face, its shape, and the manner in which it is protruded.
 A white and slightly loaded tongue, indicative of slight
   gastric derangement and moderate febrile excitement.
 A clean,deep red, smooth tongue, indicates inflammation
   or high irritation  of the mucous membrane of the sto-
   mach and intestinal canal.
 Tongue seldom much affected in acute symptomatic fe-
   vers, from wounds or external inflammations. 
16               general diagnosis.

Florid papillae protruding through a layer of white fur,
  characteristic of scarlatina. (Hall.)
Diagnosis, from the appearance of the tongue, between
  phthisis, and hectic with cough, from hepatic and gas-
  tric affections:  tongue natural in the former; covered
  with brown fur in the latter.
A pale and tumid  tongue, with large papillae, indicative
  of gastric debility—met with in chlorosis.
A contracted and pointed tongue, frequently an attendant
  on cerebral or meningeal inflammation.
A flabby and dilated tongue occurs in congestive states of
  fever.  (Miner.)
A yellow and bitter tongue, indicative  of biliary derange-
  ment.

Morbid  States  of the Nervous System.
Disturbed Sleep.   Coma always denotes oppression of
  the brain,
Wakefulness, a sign of great irritation or exhaustion.
Sudden  starting  in  sleep—intestinal  irritation  from
  worms, &c.
Hurried wakings, with a horrific sense of suffocation, a
  sign of organic diseases of the heart.
Strabismus,  double-vision, signs of cerebral affection.
Torpor of the sense of touch.
Morbid sensations.
       In strumous disease of the mesentary, an unusual sensibility to
       cold constitutes a peculiar and very early symptom. (Hall.)
  Pain may arise  from inflammation, from spasm, and
from nervous irritation.  They have each their peculiar
character.
Inflammatory pain: tenderness  of the part,  increased
  by pressure; throbbing or burning continuous, and at-
  tended by febrile excitement.
Spasmodic pain: paroxysmal, not throbbing, nor bur-
  ning,  relieved by pressure, and  seldom attended with
  fever. 
general diagnosis.
17
Neuralgic pain: transient but violent paroxysms, darting
  along the nerves with the rapidity of lightning; no swel-
  ling, no heat, and readily renewed by the slightest touch.
Inflammatory pain, modified by the nature of the struc-
  ture in which the inflammation exists.   Diagnastic in-
  ferences.   Pain referred to parts  remote from that in
  which the  primary  affection resides.

Alimentary Canal.
Nature  and appearances of  the  alvine discharges.
  Clay-coloured, faeces indicate deficiency of bile—met
  with in jaundice.   Diagnosis between  infantile remit-
  tent and hydrocephalus—the alvine discharges in the
  former are dark brown, or mud-like, and very fceted—
  in the latter, glairy dark-green, like chopped spinage.
   (Cheyne.)
Watery and  reddish stools, like  the washings  of flesh.
Mucous and  bloody stools.

Respiratory Organs.  Accelerated respiration always
  attended with frequency of the pulse.   Irregular and
  unequal respiration indicates  cerebral oppression;—
  slow, irregular, and sterterous breathing, attends a high
   degree of  cerebral compression.
Abdominal respiration, indicates pneumonic inflamma-
   tion.
Breathing with the intercostal muscles,  without  the ac-
  cessory action of the abdominal muscles, indicates ab-
  dominal inflammation.
Peculiar respiration inhydrothorax: inspiration quick, and
  with great effort; respiration slower, without effort.
  (Hall.;
The effects of corporeal exertion on respiration: produ-
  ces great dyspnoea  in hydrothorax, and still more in
  organic cardial affections.
Wheezing respiration—in asthma, cynanche trachealis.
  Hurried, panting, and heaving respiration, with sighing,
                 c 
18
GENERAL DIAGNOSIS.
  often attends intestinal  irritation  and exhaustion from
  haemorrhage.  (Hall.)

Cough.  When the efforts of coughing are anxiously re-
  pressed, there is probably inflammation in the chest or
  abdomen.
Spasmodic cough—in pertussis—sometimes from irrita-
  tion of the stomach.

Sputa.  White cream-like, in chronic bronchitis.
Effects of full inspiration  and expiration, as a diagnostic*

Cuticular  Surface. Its  temperature; its colour; its
  state of dryness or  moisture; its  fulness  or construc-
  tion;  its roughness or smoothness.
A yellowish  tinge indicates biliary derangement; not to
  be confounded with the sallowness which  occurs in
  cancer and chlorosis.
A purple or bluish colour occurs in infants, from pervi-
  ous foramen ovale.
Dark coloured or purple spots,—extravasations of blood.
A pale, semi-transparent skin, particularly of the pro-
  labia and face, manifests paucity, or very  serous, blood
  —after profuse bleedings and from anwmia.
Cold skin, with  a feeling of internal heat, denotes inter-
   nal congestions.
Color mordax—in typhus.
Permanently dry and husky  skin, indicates torpor or
   chronic disease of the liver.

Urine.  Small in quantity, and red in inflammatory affec-
   tions ; copious and limpid in nervous diseases.
Bilious urine.
The various sediments—lithates; phosphates; the former
   are red or purple—the latter, white or pale yellow.
See Dr. Hall's work on Diagnosis. 
the pulse,                  19
CHAPTER III.
THE PULSE.
  The pulse varies with the age of individuals; at birth,
at beats from 130 to 140 in a minute: mean rate for the
first month, is 1*20; limits during the first year, are 106 to
120; for the second year, from 90 to  100, for the third,
from 80 to 90—nearly the same for the fourth, fifth, and
sixth years; in the seventh year, pulse about 78; from the
twelfth year, it differs but little  from  that of adult age,
which  is estimated at from 60 to 80, according to indivi-
dual constitutions, &x. (Heberden.) The common stan-
dard of frequency may be placed at from 70 to 75  beats
in a minute. (Falconer.) From the 45th to the 60th  year,
the pulse gradually becomes slower; after this period, it
again rises  in frequency. (Floyer.)  Generally more fre-
quent in women than in men. (Falconer.) Climate influ-
ences pulse; more frequent in hot than in cold countries.
The time of day: slower in  the morning than at other
times;  most frequent soon after dinner; slower during
sleep than in the waking state.  Bodily exercise accele-
rates the  pulse; varies according to the position of the
body; slowest while lying down; slower when sitting than
when standing. (Dr. Robinson.) Mental excitement influ-
ences the pulse; joy, and anger, render it fuller and more
frequent; grief, sorrow, and fear, depress it.
Mode  of examining the pulse. (Celsus, Rush.) Not to
  be examined  immediately on  entering  the patient's
  room;—the examination  to be repeated at short inter-
  vals; should be felt in both  wrists, the arm having its
  muscles relaxed by proper positions; two or three fin-
  gers  to be applied to the artery; thirty or forty pulsa-* 
20
THE  PULSE.
  tions are to  be felt at each examination; examined in
  different  positions  of the body: talking  must be for-
  bidden.

Pathological Condition of the Pui.se;  considered
  in relation:
     1. To the force of the pulsations.
     2. To the rythm or mode of the pulsations.
     The most prominent and useful pathological  states
  of the pulse, consist in '.frequency, quickness, strength,
  fullness, hardness, and irregularity.
     A frequent  Pulse is one  in which the pulsations
  succeed  each other with preternatural rapidity;a pulse
  beating  more than 160 in a minute, is scarcely to be
  counted; great frequency  of pulse  always connected
  with great prostration of the vital energies; frequency,
  with fulness and  strength of pulse, more dangerous
  than  the same degree of frequency, with softness and
  moderate fulness.    When  it rises above 120, in in
   flammatory fevers, much danger is to be apprehended,
   (Heberden.)
     Slow Pulse: occurs from cerebral compression,--
   internal venous congestions,  and  impairment of the
   vital  energies; as in apoplexy, congestive fevers,  and
   malignant fevers.
      Quickness of pulse: often confounded, improperly,
   with frequency.  Quickness refers to the suddenness
   with which each individual  pulsation is made—fre-
   quency has reference to the number of pulsations in a
   given time.  Quickness,  however, is generally atten-
    ded by  frequency.
      A  strong Pulse  is one which  gives the  sensation
    of preternatural resistance to the finger, during the di-
    astole; not to be confounded  with a hard pulse.  It is
    Aard, when the artery is felt firm under the finger like
    a tense cord, both in its systole and diastole—some-
    times called corded.   Strength and great frequency 
THE PULSE.
21
never united, a strong pulse seldom exceeding 115 beats
in a minute; a strong pulse indicates energy of the vi-
tal powers, and is therefore favorable.
   A feeble  Pulse, the reverse of a strong pulse: it
is feeble, when the artery produces a weak impulse
against the finger, during its diastole.  Feebleness and
softness of pulse, not synonymous—the artery may re-
sist  pressure, and yet pulsate very feebly.   The pulse
is sojt, when the  artery appears to be filled, and  yet
offers no resistance, vanishing by slight pressure.
   A very  soft Pulse seldom  attended with  great
frequency, or with irregularity; occurring in the  ad-
vanced stages of fevers, favourable, when joined with
great difficulty of respiration, and suffused countenance,
in pneumonic inflammation, indicative of much danger.
   Full Pulse.  Never very frequent;  sometimes
much  slower than natural.
   Small Pulse—the diameter of the artery is smal-
ler than natural; in inflammations seated above the di-
aphragm, the pulse is generally full—when seated below
it is small.  (Borden.)
   Depressed Pulse: small, and apparently feeble, and
occasionally quick, does not depend on actual debility
or exhaustion, but  on internal venous  congestion.—
Blood-letting will raise this pulse; distinguished from a
small  and  weak pulse—by attending to the prevailing
diathesis,—by suffering a few ounces of blood to flow,
and watching its effects,—and  by observing the period
of the disease in which it occurs; if it is small and ob-
scure in the beginning of acute diseases, we may pre-
sume it is depressed.
   Intermittent  Pulse: when not attended by other
alarming symptoms, not in general a  dangerous sign;
pulse  sometimes habitually intermits;  it is said to be
of dyspeptic origin; occurs frequently  in old  age, and
then probably depends commonly on some affection of
the heart; occurs also in affections of the brain; a very 
22
THE  pulse.
   unfavorable sign, in the advanced stage of fevers, with
   great prostration; is said frequently to precede a criti-
   cal diarhoea. (Senac, Solano, Coxe.)
Unequal Pulse:  synonymous with irregular pulse.—
   Characterized by a constant variation of the pulsations,
   in frequency, quickness, size,  hardness, &c.  More
   dangerous than an intermittent pulse.  Dicrotus pulse,
   twice-beating.
     Gaseous Pulse : tumid—inflated—soap-bubble: al-
   ways indicates much prostration.
     Undulating  Pulse: a wave-like rising and falling
   of the pulse; generally large, soft, and feeble.  When
   very small, it is termed creeping; highly dangerous.
     A morbidly  natural PuLSE:occurs in malignant
   fevers;  exceedingly unfavourable; can  only be distin-
   guished from a healthy pulse by the concomitant symp-
   toms.
     Shattered Pulse: pulse feels like a shattered quill
   under the finger—occurs in opium eaters.
     Obstructed  Pulse: artery remains equally full du-
   ring its diastole and systole.

The Compound Pulses.  The principal are the syno-
   cha; synochus; synochula; typhoid; and typhus.
     1. Synocha:  hard, full, frequent, and strong; indi-
       cates high imflammatory excitement.
     2. Synochus: full,  round, active, but not hard: oc-
       curs in the hot stage of intermittents;  in remit-
       tents, &c.
     3. Synochula: quick, tense, small, hard, vibrating:
       occurs  in  sub-acute rheumatism—inflammation
       of the intestines, peritoneum, &,c.   It is the hec-
       tic pulse.
     4. Typhoid: quick, small, slightly tense, not hard,
       and somewhat  frequent: in the  advanced sta-
       ges of billious  fevers—the result of irritation in
       an exhausted state of the system. 
general prognosis.
23
5.  Typhus: small, very frequent, somewhat quick:
  occurs in the advanced stages of jail, hospital, and
  other varieties of typhoid fevers.
CHAPTER IV.
GENERAL  PROGNOSIS.
  The evidence of a single  symptom not sufficient to
give a decisive prognosis; the cause, the concomitant phe-
nomena, the temperament and habits  of the patient, &c,
must be carefully estimated.
The Countenance.  The more it varies from its natural
  expression, the more unfavourable. Hippocratic coun-
  tenance— nose  pointed, eyes sunk,  temples  hollow,
  ears cold and shrivelled, the lobes everted ; skin on the
  forehead hard, tense, and dry, countenance pale, livid,
  or leaden: a fatal symptom, in the last stage of acute
  diseases.  One  eye becoming smaller than the other,
  a bad sign;  still worse  (Stoll)  when objects appear
  less to one eye; lividity of eyelids, lips, and  alw nasi,
  unless in chills,  very unfavorable;- pointed nose, and
  much  motion of the nostrils during inspiration, bad.
Attitude.  Constant position  on the back, and sliding to-
  wards the foot of the bed,  unfavourable; it betokens
  great prostration: same position, with open mouth, di-
  lated pupils, or involuntary discharges, still worse.  In-
  sensibility, with  mouth firmly closed and eyes fixed, a
  forerunner of convulsions;  great desire to sit up, with
  dyspncea, and livid countenance, fatal in pneumonic
  diseases; still more certainly fatal, when attended with 
24
GENERAL PROGNOSIS.
  & good  pulse.  (Baglivi.)   Most  favorable  posture,
  that which approaches nearest to health; reaching into
  the air, and picking the bed-clothes, bad; always unfa-
  vorable, when visceral  inflammations supervene  to
  simple fevers; tumefaction of the abdomen, and tender-
  ness to pressure indicate  danger; laborious breathing,
  with  short, irregular, and interrupted acts of inspira-
  tion,  is a bad sign; a still more dangerous sign, is ex-
  clusive abdominal respiration, attended with strong mo-
  tion of the alee nasi by the respiratory act;  sterterous
  breathing, attended with  a rattling in the upper part of
  the chest, is highly dangerous, though not invariably a
  fatal  sign; short and very accelerated breathing, al-
  ways a bad sign; free and easy  respiration, favoura-
  ble ; hiccough, in the advanced stages of fevers, indi-
  cates danger.
Constant wakefulness, or somnolency, is unfavourable—
  when great pain in the head, pulsation of the carotids,
  and a puffed  red countenance attend tho latter, there is
  much danger.  Unequal  distribution of temperature—
  a sensation of cold externally,  and  of  heat internally,
  are bad signs;— still more unfavorable, when a sense
  of burning heat on the surface is attended by a feeling
  of cold internally.
Intellectual and moral habits.  When  these are chan-
  ged;  when old associations are interrupted; new anti-
  pathies formed;  when the moral become profane and
  loose in their language, it is a dangerous sign.
Partial insensibility of the sensorial functions, more
  favorable than great acuteness in this respect.  Into-
  lerance of light, with involuntary flow of tears, filmy,
  protruded, or very sunken eyes, very bad.
The excretions.  Urine: black,  chocolate-coloured, fe-
  tid— or watery and fetid, highly unfavorable; a good
  sign,  when after having been crude and watery, it de-
  posites a reddish sediment-still more favorable, when
  attended  with a moist skin, of natural warmth.  Sup- 
GENERAL PROGNOSIS.
25
  pression of urine, in protracted and violent cases of fe-
  ver, a very bad sign.
Perspiration: when general, with no very low or high
  temperature of the skin, favorable; profuse and cold
  sweats, about the head, face, and on the arms and legs,
  highly dangerous;  partial sweat, appearing in  large
  drops, a bad sign; profuse, clammy and cold, always
  dangerous;  and when attended with a very small and
  frequent pulse, fatal.
Alvine discharges: very liquid, frothy,  green-bad signs;
  watery reddish discharges, resembling the washing
  of flesh, and attended with tympanitic swelling  of the
  abdomen, a most  unfavorable  sign.  The  expulsion
  of wind with crepitus, a good sign.  (Rush) Bloody
  stools without tenesmus, in the latter periods of bilious,
  malignant, or other violent typhoid fevers,  highly m>
  favorable;  less dangerous in  strictly inflammatory
  fevers.  Involuntary  discharge of faeces, among  the
  most unfavorable signs.
Vomiting.  Black flocculent discharges, from the sto-
  mach, exceedingly dangerous;—less dangerous,  when
  the  black or  porracocs matter is not  flocculent  but
  uniformly mixed with the other fluids thrown up.  A
  rumbling noise in the stomach, when liquids are swal-
  lowed, a bad sign—never occurs in the early periods
  of fever, and generally attended with  meteorism. Sud-
  den and very forcible ejection from the stomach is un-
  favorable—it  occurs  in yellow fever.  (Rush.)  Very
  frequent vomiting, with great tenderness in  the epigas-
  trium, in fevers, a  very unfavorable sign.
The tongue: covered with a brown or black  crust, with
  deep cracks in it, dangerous; black and dry, with black
  sordes  adhering to  the teeth,  highly unfavorable; a
  dark brown, contracted, hard, and shrivelled tongue,
  almost always fatal; tongue soft, moist,  and light red,
  favorable; secretion of saliva, a good sign; difficulty
  of putting out the tongue, and then keeping  it between
  the teeth  a long time, without retracting it, is  a bad
                d 
26                GENERAL PROGNOSIS.
  sign—a total inability to  protrude it, alike unfavora-
  ble; a red, smooth, and shining, or a pointed, dry and
  red (round the edges) tongue, indicates considerable
  danger—it is a sign of strong gastro-enteritic  inflam-
  mation.  Total absence of thirst, with a dry and rough
  tongue, is a bad symptom.
        Besides the appearance enumerated above, a variety of other
        circumstances demand attention, in forming an opinion as to
        the probable event  of diseases.  Thus, inflammatory fevers
        are generally less dangerous than remitting fevers; and these
        latter, less dangerous than typhus and malignant fevers. In
        general, the more a  fever is connected with local inflamma-
        tions—or rather, the more  serious the local inflammations
        are, from the importance of the parts they attack, the more
        danger is to be apprehended.  The type, too,  must be taken
        into view.  As a general rule, intermittents are  less danger-
        ous than remittents, and remittents less than  continued fe-
        vers.   The more irregular the  type of typical fevers, the
        more unfavorable.  The appearance and progress of what
        are termed the crises  will  also  aid in forming  a prog-
        nosis. Unusual or contradictory phenomena are unfavorable;
        when a patient declares himself well, at the same time  that
        the symptoms indicate considerable disease, it is a bad sign.

                CRISIS---CRITICAL DAYS.
The  ancients  observed  certain regular periods  in  the
  course  of  many febrile diseases,  at which prominent
  changes are wont to  occur, accompanied  by  certain
  evacuations, and  followed  generally by temporary or
  permanent abatement of the symptoms.  These eva-
  cutions, and their  associated phenomena, are termed:
     Crises.   No febrile or noxious matter, as was once
     supposed, thrown  off by these critical  evacuations.
     Critical discharges the effecl,\\ot the cause  of the me-
     lioration  of disease  which follows, or attends their
     occurrence.  The doctrine of critical  days gener-
     ally  discredited at  present; there is  probably good
     foundation for  the  doctrine.   Crises  divided into
     simple and compound;  in the simple, the  evacua-
     tion  is  made through  one emunctory only—in the
     compound, through several.   The most prominent
     precursory phenomena {perturbationes critical) of 
GENERAL  PROGNOSIS.
27
     crises are: an increase of all the symptoms—watch-
     fulness, chills, and rigors—tremor of the whole body
     —-anxiety  and jactitation—quick and irregular re-
     spiration—Obtuseness  of hearing—vertigo—coma,
     &c.  There are certain days in the course of fevers
     upon which  crises  are particularly apt to occur.
     These are the critical days; crises  occur however
     occasionally on other days.   The critical days, ac-
     cording to Hippocrates, are the 3d, 5th, 7th, 9th,
     11th, 14th, 17th, 21st, 27th, and 3-lih.   According
     to Cullen, the 20th, not the 21st day, is the critical
     day—he acknowledges no critical  day beyond the
     20th.   Critical  days  divided into perfect, second-
     ary,  and intercurrent.   Galen regarded the 7th,
     14th, 21st, 28th, or the septenary periods as the true
     critical days;—the secondary,  are the intermediate
     days between these septenary periods, i. e. the 4th,
     llth, lHth, 25th, &c.   The  intercurrent days are
     the 5th, 9th, 13th. (Galen.)

        All forms of fever appear to have  a tendency to some one of
        the principal types. A single tertian may be regarded as fe-
        ver in its elementary  form. In this form a paroxysm and
        crisis  occur on every odd day.  Now if we consider a conti-
        nued fever as made up of tertian paroxysms, protracted and
        running into each other, we perceive from its tendency to the
        original type, how the phenomena of crisis should occur on the
        odd days.

Salutary may be distinguished from insalutary dischar-
  ges by the following circumstances.
To be salutary, they must  be neither too copious, nor too
  scanty; they must correspond with the nature of the fe-
  ver,—haemorrhage is most salutary in inflammatory,
  and  diarrhoea, in bilious fevers—perspiration is more
  beneficial in catarrhal  fevers than diarhoea.  A dis-
  charge from  one emunctory only,  seldom beneficial;
  perspiration  is  never salutary unless the urine at the
  same time becomes charged with a sedimentous matter;
  and vice versa. 
28
GENERAL PROGNOSIS.
The evacuations (critical) which usually attend the com-
  mencement of convalescence, are:
Critical haemorrhages: generally preceded by increase
  of arterial action; and salutary, partly from the loss of
  the blood, and chiefly by the new arterial excitement
  by which they are attended.
        It is owing to the previous excitement of the arterial system,
        essential to this kind of critical evacuation, that it cannot be
        substituted by  an  artificial abstraction of  blood.  This  fact
        proves, that such  evacuations do not, strictly speaking,  pro-
        duce the amendment which follows, but that  they are effects
        or manifestations, of a previous salutary change in the vital
        actions.

Crisis by haemorrhage is chiefly confined to inflammatory
  fevers;  occurs sometimes in typhus fevers; epistaxis,
  the most common critical haemorrhage—usually pre-
  ceded by flushed face, red and suffused eyes—sneezing,
  ringing in the ears,  &c.
Critical sweat.  The most common crisis; must he gene-
  ral over  the body,  attended with a  warm  skin  and
  turbid urine.  Its approach indicated by: a soft,  full,
  wave-like pulse; a stinging, or itching sensation on the
  surface, red, warm skin and scanty urina
Critic d discharge of urine: must be copious; the morn-
  ing urine best for inspection; critical urine exhibits at
  first,  a cloud, floating in ihe upper part  of the vessel—
  then  a  globular  body about the middle—and finally a
  sediment; (Vogel, Richter, &c.) should be attended
  with  a soft or moist skin;  preceded by pains in  the
  loins; frequent inclination to urinate; uneasy or burn-
  ing sensation in  the genital organs, dry, harsh skin;
  thirst, and a soft and active pulse.
Critical alvine discharges:  most frequent in bilious fe-
  vers—occur during  the remission  of fevers—are copi-
  ous;  signs of approach, a peculiar trembling  of  the
  under lip—stammering—a full, active pulse, pain  and
  noise in the bowels; discharge of wind—moist  tongue
  —paucity of urine.  (Richter.)  Critical  emesis, very
  uncommon. 
GENERAL PROGNOSIS.
29
By crisis, in the most general acceptation of the term, is un-
derstood that period in the course of a fever, at which a deter-
mination either to death or convalescence takes place, and in
which therefore the fate of  the patient is determined.   This
decision must  necessarily always occur in the ultimate point
of violence of the disease.
CHAPTER V.
OF THE GENERAL  COURSE, TYPE,  AND
            STAGES  OF FEVER.
Fevers divided in relation to their course into:
              Acute, and
              Chronic.
  The former generally make their attack suddenly, and
proceed  through  their course in a comparatively short
period.
  The latter commence less violently, and pass slowly
through  their course.
  In general, the more violent the disease, the more ra-
pid its progress.
  The course of a fever may be divided into five periods.
(See Pract. Med. p. 61.)
     1. The forming stage—the period between the im-
       pression of the febrific cause and the development
       of the fever;—distinguished by certain phenome-
       na, called premonitory symptoms   Its duration
       very various; not always attended by signs of de-
       viation from  health.   In general, the  more pro-
       tracted the premonitory signs, the more protracted,
       or slow, will be the course of the subsequent  fe-
       ver, &c. 
      GENERAL COURSE, &C. OF FEVER.

   It is during the struggle between the system and the morbific
   cause—while the former is gradually yielding to, and passing
   under the dominion of the latter, that the premonitory symp-
   toms occur.

  The  most common  premonitory symptoms  are:
  loss  of appetite:  irregular  bowels; yawning,
  stretching; mat aise; interruption of ordinary ha-
  bits and  appetites, such  as disgust for tobacco,
  coffee, <Slc, thirst, nausea, eructations, dry skin,
  slight chills, healing up of old ulcers, &,c.  These
  symptoms show that  the nervous system,  the di-
  gestive organs, and the skin, are the first to suffer
  in the evolution of fever.
Some diseases have peculiar premonitory symptoms,
  as the measles.   A morbific  cause may produce
  the premonitory symptoms,  without being ade-
  quate to the full development of the disease.
2. The cold, or second stage:  a  sensation of cold
  almost  invariably introduces  a  febrile reaction;
  frequently no real  subduction of temperature in
  the febrile chill;  it depends therefore often on an
  altered state of sensibility to heat.  Symptoms at-
  tending this stage:—skin pale, contracted, dry—
  shrinking of the surface—respiration  irregular,
  oppressed, anxious—a small dry cough—tongue
  dry—head confused, pulse small and  frequent—
  nausea and vomiting; the sensation of cold may
  be generally  or partially diffused over the body.
  The relation between the violence and  duration of
  the stage, to the ensuing stage of reaction, is di-
  rect; the former being violent and short, the reac-
  tion will most probably be vigorous; weak and pro-
  tracted chills usually followed by feeble reaction.
     A  chill occurring in an advanced period of a
  remittent, indicates that it is about altering its type
  or form; occurring in the advanced period of vis-
  ceral inflammations, indicates the occurrence ol
  suppuration; crises and metastases sometimes pre-
  ceded by chills. 
GENERAL COURSE, &C. OF FEVER.        31
    Hot, or third stage of fever: characterized by: in-
       creased heat of the skin; return of the natural ful-
       ness and color of the surface; pulse full, vibrating,
       and vigorous; pain and throbbing in the head;
       eyes prominent, and very sensible to light; a dry
       skin; urine small, and high colored.
     The fourth period, or sweating stage: profuse and
       general perspiration; sedimentous urine; diminu-
       tion  of pains in  the  head, loins, &x;  pulse soft
       and  full, &lc.
     The fifth period, or the period of convalescence:

  The course of every fever is either:
     1. Continued:  very slight  evening exacerbations,
       and  morning  remissions.   Total absence of re-
       missions and exacerbations very rare, if ever.
     Remitting:  prominent and regular remissions and
       exacerbations.
     3. Intermitting: regular paroxysms and perfect in-
       termissions.

  One  paroxysm, with  its  intermission, constitutes its
revolution.  According  to  the duration of the revolu-
tion, fevers are divided into:
     1. Quotidian, occupying 24  hours.
     2.  Tertian,     do.     48   do.
     3. Quartan,    do.     72   do.

The form which fevers assume in this respect, is called
  their type.  There are therefore three principal types:
  i. e. the quotidian, the tertian, and the quartan types.
  Quotidians generally come on in the morning; tertians
  about  noon; and quartans in the afternoon.
     Tertians  divided into simple and double.
  Double tertians:  paroxysms occur daily; but the pa-
     roxysms of the alternate days are similar in violence,
     time of occurrence, and duration, and differ in these
     respects from those which  occur  on the intervening
     days. 
 32        GENERAL COURSE, &LC. OF FEVER.

   Intermittents rarely are of'the double tertian type, from
     their commencement; they generally commence as
     simple tertians, and duplicate their type afterwards;
     the new or  accessory paroxysms generally milder
     than the original; double  tertians generally return
     to the simple type, before they terminate; a  change
     from the simple to the double type, is unfavorable.
   Other variety of compound types: tertiana duplicata;
     —haimitritteus ;—tertiana triplex.
   The  quartan type  is also  susceptible  of duplication.
     The double quartan has two paroxysms every fourth
     day. Authors mention triple quartans, three parox-
     ysms occurring on every fourth day—these are very
     uncommon.
       The difficulty  of arresting the course of an inter-
     mittent, in  general, is proportionate to the time occu-
     pied by each paroxysm.
   Intermittents are said  to be anticipating, when the
     paroxysm comes on earlier every succeeding recur-
     rence—and postponing, when it occurs later  at
     each return.   When the paroxysm is postponed to
     about eight o'clock in the evening, it frequently does
     not come on until the next morning.  In like man-
     ner, the paroxysm of an anticipating ague, occur-
     ring at eight o'clock in the morning, will have  its
     next paroxysm on the evening of the day preceding
     that on which it should happen. (Wilson.)   Favo-
     rable, when the paroxysms are postponed; unfavo-
     rable, when anticipated.
   Attypic, or erratic fevers: no regular type; rheumat-
     ism—catarrhal fever.
Fevers often change their type—the conversion of type
   seldom suddenly effected. 
INTERMITTING FEVERS.             33
CHAPTER VI.
PARTICULAR  FEVERS.
         OF INTERMITTING FEVERS

General Character. A succession of regularly recurring
  febrile paroxysms—commencing with chills, and ter-
  minating in profuse perspiration, with intervals of per-
  fect remission from fever.
Types: the quotidian, the tertian, the quartan, and com-
  plications of these primary types.
Stages: the cold, the hot, and the sweating stages.
Symptoms—Of the cold stage: lassitude, yawning; skin
  pale and shrunk; pulse small and frequent; rigors more
  or less strong; mind  confused and inattentive—when
  violent, comatose; urine pale and crude; thirst great;
  respiration quick and anxious; lasts from  fifteen mi-
  nutes to several hours.
Hot stage: at first, nausea and bilious vomiting; skin hot
  and dry; face flushed and full; pulse  full, frequent, and
  strong; respiration free and regular; head-ache—urine
  high colored and scanty.
Sweating stage: profuse perspiration; pulse soft and mo-
  derately full; urine copious and sedimentous; a gra-
  dual  abatement of all the  symptoms of the previous
  stage, until it terminates in the state of intermission, or
  apyrexia.
Anomalous symptoms: the cold stage has been absent;
  sweat  sometimes absent in the third  stage,  being sub-
  stituted by other evacuations.
Masked Agues^ (Febres Intermittentes Larvata.)  In-
  termittents under various assumed forms: as epilepsy,
                    E 
34
INTERMITTING FEVERS.
  mania, hemicrania, tooth-ache, cramp in the stomach,
  dysentary, cholera, &c.  Diagnosis of masked agues:
  their  periodioity; the cotemporaneous  prevalence of
  intermitting fevers; slight sensations of cold, preceding
  the attacks; gentle perspiration, with turbid urine at-
  tending their disappearance. (See Pract. Med. p. 74.)
In infants, the paroxysm sometimes commences with con-
  vulsions.  Distinct rigors are not common in infants.
  Intermittents divided into the:
       Inflammatory,
       Congestive,
       Gastric, and
       Malignant.—(See Pract. Med. p. 73.)
     1. Inflammatory Intermittents: of frequent occur-
       rence: quotidians more apt to assume this charac-
       ter than tertians, and  tertians than quartans.  Oc-
       cur most commonly in young and plethoric sub-
      jects, and in the spring and winter seasons; rigors
       strong in the first, and action intense in the second
       stage; intermission imperfect, the pulse retaining
       a preternatural  quickness  and tension,  and the
       thirst and heat of the surface remaining  greater
       than natural; often slight pectoral affections.  The
      primae  vice seldom  much loaded with bile and
       saburral matter; little or no manifestation of intes-
       tinal irritation.
     2.  The congestive variety: not common; occurs in
       persons  of debilitated habits of body—in the irri-
       table and nervous.   Cold stage, very protracted,
       attended with deep-seated pain in the head, verti-
       go, syncope, a sense of weight in the breast, coma,
       and a  small, trembling, weak, pulse.  Hot stage,
       imperfectly developed—the system  remaining op-
       pressed; the surface cool; the breathing confined
       and anxious; countenance  pale; pulse frequent,
       small, and somewhat tense; and a sense  of heat
       internally.  (Pract. Med. p. 75.)
     3. The Gastric variety: the majority  of our autum- 
IN IERMITT1NG  FEVERS.
35
      nal intermitents are of this character: they are at-
      tended with strong marks of irritating  matters in
      the prima via; there is nausea, bilious vomiting,
      bitter taste; weight and fulness in the epigastrium;
   •  great pain in the forehead; foul tongue; quivering
      of the under lip; countenance, and tunica albugi-
      ginia, tinged with  yellow; urgent desire for acid
      drinks.
    4. Malignant Intermittents.  Rapid in their course
      —sweat, in the third stage, generally very copious
      and  fetid; haemorrhages from the nose, bowels,
      gums, &c.; petechia; and other symptoms denot-
       ing malignity. (Alibert.)
Intermittents occasionally cure other affections; such
  as cutaneous eruptions,  hysteria, gout, asthma, hypo-
  chondriasis, and epilepsy.   (Fordyce, Vogel.)
In relation to the natural duration  of intermittents, it
  would appear, that quotidians, when left to themselves,
  have a tendency to terminate  on the 14th;  tertians on
  the 21st; and quartans about the end of the 6th week.
Prognosis.  When simple intermittents prove fatal, it is
  generally in the cold stage—death then occurs in  the
  way of apoplexy; most dangerous in weak and cachec-
  tic habits of body.  Postponing more favorable than
  anticipating agues; scabby eruptions, re-appearance of
  suppressed  discharges, &c. favorable; integrity of the
  digestive functions, a good sign; change from the quo-
  tidian  to the tertian favorable.   Delirium  more unfa-
  vorable than mere coma; occurs in the worst forms of
  the disease.  Tumid and painful  abdomen,  with op-
  pressed respiration, hiccough, &c.; colliquative diar-
  rhoea ; bloody urine, red and suffused eyes—are bad
  signs.   Great  debility during the intermission,  with
  oedem of the legs and feet, restlessness, languor, sigh-
  ing, dry tongue, or bilious vomiting, very unfavorable.
   (Pract. Med. p. 77.)
 Circumstances peculiar  to  the varivus types:  Cold 
36
INTERMITTING FEVERS.
   stage longer in tertians than in quotidians—hot stage
   longer in the latter than the former; &c. &c.

             CAUSES OF INTERMITTENTS,

   The  principal—almost exclusive—cause of intermit-
 tents, is marsh miasmata, called by the Italians, nialaria.
   Intermittents are the first grade of miasmatic  fevers—
 most common during the autumnal months, in the marshy
 districts of temperate climates.   The operation  of mias-
 mata is favored, by  sudden changes of weather, damp-
 ness, and whatever debilitates the body.
   Miasmata often remain dormant in the system for a
 long time.
   Other causes:—worms and other irritating substances
 in the intestines;  suppressed habitual discharges, &c.
 (Pract. Med. p. 79.)
 Proximate Cause.
 Spasm of the extreme  vessels (Cullen's doctrine) ob-
  jected to.
Irritation and inflammation of the mucous membrane of
   the intestinal tube, objected to.  (Broussais.)  (Pract.
   Med. p. 80.)

                    TREATMENT.

Treatment divided into that which is proper during
       the paroxysm, and that which is to be used in
       the intermission.
The former is palliative, the latter curative.
 Treatment in the paroxysm. Cold stage: mild and warm
  diluent drinks.  In debilitated and  nervous subjects,
  external  and  internal stimulants, particularly artificial
  heat.  In vigorous subjects, however, such practice is
  by no means proper.   An emetic given in this stage,
  one of the best means to shorten its duration.   Opium
  administered just before or soon after the accession of
  the paroxysm, often highly useful in moderating the fit.
  [Trotter.] 
INTERMITTING FEVERS.
37
Compression by the tourniquet, has been found useful to
  put a stop to this stage. [Kellie.]   Its modus operandi
  explained.
Treatment in the hot stage.   The object is to moderate
  the violence of the febrile reaction, and to hasten the
  supervention  of the  sweating stage.  The remedies
  employed for this purpose are: bleeding in cases of vio-
  lent reaction,  cool diluent drinks, and the usual anti-
  phlogistic remedies.  A draught of cold water, when
  the skin is very dry and hot, is both grateful and bene-
  ficial,  predisposing to perspiration.   Emetics not pro-
  per in this stage.   Excessive vomiting best checked by
  opium  and the effervescing draught.  Opium highly
  recommended in this stage, by Dr. Lind; injurious  in
  intermittents of  a  marked phlogistic character; highly
  useful  in cases of feeble reaction.  Not often necessary
  to use  remediate treatment, in this stage. [Pract. Med.
  p. 32.]
Treatment during the Intermission.  It is in this stage,
  that the radical cure of the disease is to be attempted.
  In prescribing with this view, attention must be paid  to
  the four modifications described above.
In  inflammatory intermittents, the febrifuge  tonics are
  not to  be used, until the phlogistic state of the system
  has been reduced by a strict antiphlogistic treatment.
  (Pract. Med.  p. 84.)
In  the congestive and malignant modifications, stimu-
  lants and tonics must be resorted to, early and freely.
  (Pract. Med. p. 75.)
In  the gastric modification, emetics and  cathartics are
  important preliminary remedies.

Cinchona—the  most efficacious tonic febrifuge we pos-
  sess—must be employed during the apyrexia.  Not  to
  be employed,  where a phlogistic diathesis prevails—
  that is, where  the pulse is tense and quick, with a feel-
  ing of general uneasiness, head-ache, dry and warm
  skin, are present in the intermission; in such case, anti- 
38
INTERMITTING FEVERS.
  phlogistic measures must be  premised.   The bark to
  be promptly and largely given, in cases of great weak-
  ness, or in such as are of a malignant character.  Au-
  thors express contradictory opinions, with regard to
  the  necessity of purgatives and emetics, as measures
  preparatory to the use of the cinchona.  They are very
  generally useful, and should be premised; not always
  indispensable, however—more essential  in the young
  and plethoric, than in the infirm and aged.  The cin-
  chona has no peculiar tendency,  as was  once, and by
  some is still supposed, to produce visceral indurations;
  these are consequences of the improper use of the
  bark—in other words, of its employment in a promi-
  nent phlogistic state of the system—other tonics will do
  the  same.  The existence of visceral obstructions form
  an objection to the use of the  bark; a mild mercurial
  course must be premised—or the bark may be given
  in conjunction with  mercury.  From an ounce to an
  ounce and a half, will in general suffice for a  cure—
  when it  purges, give opium  or  kino.  When much
  acidity exists in the primae vise, combine  it with an al-
  kali.  The bark often advantageously combined with
  aromatics, as serpentaria, cloves,calamus aromaticus,
  black pepper, capsicum, &c. &c.
Sulphate of Quinine, a most  valuable preparation of
  cinchona; given in doses of from one to three grains,
  every one or two hours; sometimes purges, for which
  opium is the proper remedy.  A variety of other vege-
  table tonics  have  been  recommended in this disease;
  as Augustura bark, cornus florida, Leriodendron
  tulipifera, aristologia  serpentaria, oak bark,  the
  various species of willow,  horse chesnut,  and  the
  officinal tonic bitters.   Coffee, recommended by Rich-
  ter and Grindel.  Tela aranearum, a useful remedy.
The Muriate of Ammonia in combination with tonic
  bitters, highly useful, according to  Richter, in agues
  attended with visceral obstructions.
Arsenic, highly efficacious; best adapted to cases attend- 
INTERMITTING FEVERS,
39
  ed with rather a full, robust, and unirritable habit,—a
  moderately full, but soft and regular pulse,—and unac-
  companied by  local congestions.   In debilitated, ca-
  chactic or scorbutic habits, often injurious; improper
  also in phthisical habits.   Should be given in as large
  doses as the stomach will  bear; apt to produce dropsi-
  cal swellings.  From  ten to fifteen drops of Fowler's
  solution, with ten or fifteen drops of laudanum,  every
  four hours.
Prussiate of iron has been  given with considerable suc-
  cess.   Dose from five  to eight grains every two hours,
  for an adult.                            n  „
Sulphate of zinc, an article of very considerable emcacy,
  in the treatment of this disease.   In combination with
  capsicum, I have found  it almost as certain a remedy
  as the quinine.  I give it according to this formula:
  r Sulph. zinci, gr. x. Pulv. capsici, ejj Conserv  rosar.
  q. s. M. in pil. No. xl. dividend. S. one every two hours
 The power of the imagination over the system, is often
  strikingly illustrated in its effects on this disease ;--tne
   source of the occasional efficacy of all  the various
   charms, amulets, &c. so  frequently resorted to against
   this disease, by the ignorant and superstitious.
 Intermittents exceedingly apt to relapse; relapses particu-
   larly  favored by exposure to a  damp and cool air; by
   errors in diet; the depressing passions, &c.
 Intermittents apt to give rise to secondary affections, the
   most common of which are: oedema of the feet; enlarge-
   ment and induration  of the  spleen and liver; jaundice,
   dropsy ;■—sometimes hemicrania, vertigo, epilepsy, and
   phthsis.   See Practice of Med. vol. 1. 
40               REMITTING FEVER.
CHAPTER VII.
               REMITTING  FEVER.


 Character. Fevers whose symptoms suffer regular exa-
   cerbations  arid remissions, but no perfect intermis-
   sions.
 Symptoms: Symptoms of the forming stage, similar to
   those of intermittents.  When the disease is fully deve-
   loped, there are, pains in the head, back, and lower ex-
   tremeties; an icterode tinge of the eyes; nausea; some-
   times bilious vomiting; fulness and tension in the prae-
   cordia; pulse full, frequent, and rather soft; tongue foul,
   at first white, afterwards brownish; taste bitter.  In  the
   course of about twenty-four hours, a remission of these
   symptoms takes place; after a short remission, the fe-
   brile symptoms rise again; ajid after a certain period,
   again suffer more or less  remission.   This  answers to
   the mild form of the disease.  See Pract. of Med. p.  97.
 The type of remittents is generally the double tertian;
   sometimes the quotidian.   The exacerbations of quo-
   tidian  remittents  commonly begin about nine or  ten
   o'clock in the  morning; those  of tertians considerably
   later.
Remittents sometimes  assume a very violent and  even
   malignant character: the febrile heat is intense;  thirst
   excessive; head-ache, and pains in the loins, very vio-
   lent ; great anxiety of feeling; distressing sense of ful-
   ness in the epigastrium.   In twenty-four hours, nearly
   a complete intermission ensues.  A second and more
   violent paroxysm soon comes on; the eyes become red
   and watery; the epigastric distress is horrible; there is
   nausea, with constant retching or bilious vomiting. An-
   other remission occurs, followed by a third exacerba- 
REMITTING FEVER.                 41
  tion, which often terminates in death, or  a favorable
  crisis.   The  disease sometimes assumes  more of a
  chronic character;  and in this case, great prostration
  ensues, with almost constant delirium; a quick, irregu-
  lar, and  frequent pulse: in  some instances, the pulse
  becomes almost natural—a sign of great danger.  Be-
  sides the  foregoing  symptoms, the following occur, in
  violent cases of this form of fever: tongue clammy, fetid,
  black; eyes red, watery, or dry; urine brown, blackish,
  offensive—sometimes wholly  suppressed;  alvine dis-
  charges watery, red, black,  or bloody; abdomen tym-
  panitic, petechias, haemorrhages.
       In the temperate climates, and in situations not abounding in
       materials for the production of miasmata, remittents are gene-
       rally mild and regular in their course. In proportion as we
       approach the tropical regions, we find the disease assuming a
       more violent and anomalous character.

Remote Cause. Marsh miasmata the  principal  cause
  of this form of fever;  other causes may produce it,—
  as worms, and other irritants, acting on the alimentary
  canal.
Proximate  Cause.   Irritation, or  sub-acute inflamma-
  tion of the mucous  membrane of the intestinal  tube,
  with prominent hepatic derangement.

       In some cases, prominent intestinal irritation is connected with
        an abundant secretion of bile; in others,vthe intestinal irrita-
       tion is connected with great congestion and torpor of the liver,
        little or no bile being thrown into the bowels during the early
       period of the disease.  To the former class of remittents, we
       may therefore apply the term Gastric ; and to the latter that
        of Hepatic.

Gastric  Modification; characterized by: bitter or pu-
  trid taste; tongue covered with a thick yellowish slime,
  which by degrees becomes dry, cracked, and blackish;
  disgust for every kind of food; urine jumentose; dis-
  tress and weight in the stomach; abdomen tense and
  tender; pain in the loins and knees; intense pain in  the
                         f 
42
REMITTING FEVER.
  forehead; distinct remissions  and  exacerbations.—
  Pract. of Med. p. 100.
Hepatic Modification : the most rapid and dangerous
  form of the disease; characterized by: intense febrile
  heat during  the exacerbations; delirium, fulness, ten-
  sion, and pulsation in the right hypochondrium; tongue
  at first clean, great irritability of the stomach;  conti-
  nued vomiting of a glairy fluid; the skin becomes icte-
  ric; towards the termination of the disease, the liver,
  inmost instances, pours out an abundance of dark co-
  lored bile, which is evacuated by stool, and sometimes
  by vomiting.   The stools, in  such instances, are black
  and pitchy.
The diathesis of remittents always essentially inflamma-
  tory, though in  some violent instances much nervous
  depression and debility exists.   Dr. Good calls  these
  asthenic remittents,—I prefer the term typhoid.
Treatment.   The  indications  are: 1. To moderate  the
  action of the  heart and  arteries.   2. To remove  the
  irritating contents of the bowels, and moderate intesti-
  nal  irritation.   3. To restore the healthy functions of
  the liver.  To answer these intentions, we employ:
     1. Bleeding.   Not often  necessary, in the milder
       cases of our autumnal remittents.  Indispensable
       when the pulse is full, vigorous, and hard, the skin
       very hot and dry, and the head-ache intense.
     2. Purgatives.  Mild mercurial purgatives, of pri-
       mary importance  In mild cases, with little gas-
       tric irritability, an emeto-cathartic often useful in
       the commencement; inadmissable, however, in the
       higher grades of the disease.

        There are no remedies more  useful in the treatment of remit-
        tents, than purgatives; and yet there are perhaps no other me-
        dicines so frequently employed to an injurious extent.  Violent
        and irritating cathartics, when frequently administered, sel-
        dom fail to"excite a degree of irritation in the mucous mem-
        brane of the alimentary canal, which but too often brino-s on
        a train of" symptoms of the most dangerous and fatal charac- 
REMITTING FEVER.
43
        ter.  The thin watery stools, of a muddy or reddish color; the
        tympanitic state of the bowels; the abdominal tenderness; the
        suppression of urine, &c.  which are sometimes observed in
        the advanced stages of this  disease, are generally the result of
        the imprudent employment of active  cathartics.   Although I
        would strenuously protest against the frequent employmeut of
        active cathartics during the course of remittiug fever, I would
        by no means proscribe them wholly (as is done by Broussais)
        as remediate means in this form of fever. In the commence-
        ment of the disease, one or two active purgatives are not only
        admissable, but, according to general  experience, decidedly
        useful.  Subsequently, however, the milder laxatives only
        ought to be employed; and  these are indispensable, throughout
        the whole course of the disease.—See Pract. of Med. p. 108.

Diaphoretics, &c.  Nitre  in combination with tartar-
   ized antimony and calomel,  generally useful in  the
   early stage of mild remittents; improper where there
   is great irritability of the stomach; injurious, also, when
   it excites  much purging.   The saline effervescing
   draught an  excellent medicine; spiritus mindereri
   also useful: these two latter articles, particularly useful
   to allay gastric irritability.
Calomel.  An important remedy in remitting fevers.  In
   the commencement given with a view both to its pur-
   gative and constitutional effects;  should be  early and
   regularly given, until its specific operation becomes ma-
   nifest ;  never to be continued until ptyalism comes on;
   strong  mercurial excitement, injurious.  In the advanc-
   ed periods of the disease, the mercurial influence gene-
   rally detrimental.
In the high or  malignant grades of this disease—that
   which  I have termed hepatic, from the engorged and
   inactive state  of the hepatic system—emetics, emeto-
   cathartics, and strong  purgatives, useful in the com-
   mencement of the milder forms of the disease, are alto-
   gether inadmissible.  The first object is to allay gastric
   irritability, which is generally very great.  For this pur-
   pose, blood-letting is the most important measure; sina-
   pisms to the region of the stomach, are good; a draught
   of cold water has been recommended; the warm  bath
   after venesection;  potio Riverii. 
44
YELLOW FEVER.
When the irritability  of the  stomach is in some degree
  subdued, Calomel  is an important remedy; it should
  be given in doses of from  ten to twenty grains every
  four or five hours, until the evacuations become bilious.
  If the calomel  do not prove purgative, mild laxatives
  must be occasionally given with it.  Two or three al-
  vine evacuations daily are indispensable, so soon as the
  liver has been excited to action by the calomel.  Nitre,
  and  the antimonial preparations, are  objectionable.
  Acidulated drinks  are salutary.  Physicians do  not
  agree with regard to the propriety of using tonics du-
  ring the remissions.   Lind, Clark, Balfour, and others,
  strenuously contend for the  vigorous employment of
  bark. Johnson, Burnet, and others, condemn this prac-
  tice as  pernicious.  Pract. Med. p. 112.

        My own views on this subject are, that the cinchona may be
        used with advantage, during the remission, when there are
        no violent visceral congestions, and where the liver has resum-
        ed its proper action.  As long, however, as the liver remains
        engorged and inactive, the employment of the bark can seldom
        fail to do injury.  After the bile makes its appearance in the
        alvine evacuations, and a complete remission occurs, the liberal
        use of the sulphate of quinine will generally prove decidodly
        beneficial.

                    YELLOW  FEVER.

Synonymes.   Typhus Icterodes;  Maladie de  Siam;
        Bulam Fever; Vomito Prieto; Causes.

Symptoms.  First stage: faintness, giddiness, slight chills;
  then sudden evolution of intense febrile  reaction, with
  severe pain in the head, inflamed eyes;  intolerance of
  light; dry and burning  skin;  great thirst: pain in the
  loins and  lower extremeties; tongue covered with a
  whitish mucus, or but little altered from its healthy as-
  pect ; nausea and vomiting; transient and partial sweats.
  This stage lasts from twenty-four to sixty hours.

        The disease sometimes commences with sudden loss of muscu-
        lar power, and depression of nervous energy—the patient fall-
        ing down, as if stunned by a blow. 
YELLOW  FEVER.
45
 Second Stage.   With the exception of vomiting, all the
   symptoms abate; the pulse sinks to the natural standard,
   the heat of the skin becomes  reduced,  and the patient
   expresses himself much relieved.   The vomiting how-
   ever  continues, the fluid  ejected containing membra-
   neous flocculi; the desire for cold water  is urgent, but
   when swallowed, is immediately rejected; the albugi-
   nia,  and the skin  of the neck and  breast, acquire a
   yellow tinge.  This stage lasts from twelve to thirty-
   six or forty-eight hours.
Third stage.  Pulse sinks; frequent and forcible vomit-
   ing;  matter thrown up of a black color,  resembling
   coffee-grounds suspended in a glairy fluid; an acrid or
   burning sensation in the stomach-, diarrhoea of green
   or black matter; whole surface of a dirty yellow;* hae-
   morrhages violent; delirium; hiccough, coma, insensi-
   bility, convulsions, death.

        " Soreness in the oesophagus; heat and acrid sensation in the
        stomach;  urgent  thirst; hunger; violent delirium; despon-
        dency; enlargement of the blood-vessels and  red-yellow color
        of the white of the eye, either singly or collectively, indicate
        extreme danger."  (Johnson.)

Appearances on dissection.   A black viscid fluid in the
   stomach;  mucous membrane of this organ inflamed,
   and covered with gangrenous spots; sometimes large
  portions sphacelated; small intestines inflamed; colon
  generally sound, but often contracted; concave surface
  of liver inflamed.
Cause.   The effluvium generated by  animal and vegeta-
   ble matters, in a state of putrefactive decomposition, its
  common  remote  cause—hence its  almost continued
  prevalence  in  the  marshy  districts of  intertropical
  regions.

        This opinion is disputed by many; but a great majority of those
* Many cases are not attended by this yellow hue of the skin. 
4(5
YELLOW  FEVER.
        whose knowledge on this point is derived from personal obser-
        vation, maintain its correctness.  (Pract. of Med. p. 118.)

Europeans arriving in hot climates, where the disease is
  endemic, almost exclusively obnoxious to it. Persons
  having once had the disease, lose in some degree their
  susceptibility to a subsequent attack.
The influence of the remote cause is promoted by, intem-
  perance, excessive fatigue in the sun; exposure  to the
  damp and cool night air, &c.
Not contagious.  Many assert that under certain circum-
  stances, this disease is not contagious:—some maintain
  its unconditional and  essentially contagious character.
Black  Vomit: not  bilious, matter;—appears to proceed
  from sanguineous transudation in the stomach.   The
  liver is torpid and congested, the biliary secretion be-
  ing deficient.  The yellow color of the skin is probably
  the result of a  vicarious secretion of a bilious matter
  into the subcutaneous texture.  Different opinions  on
  this subject.   Pract. Med. p. 117.
Treatment.  Much diversity of sentiment in relation to
  the treatment of this disease.   It appears, however, that
  the weight of good authority is in favor of: full bleed-
  ing; mercurial purgatives; cold affusions, and applica-
  tions to the head; the free use of mild diaphoretic or
  acidulated drinks—in the first period of the disease.
  Prompt and decisive  bleeding is particularly beneficial
  in the commencement of violent cases, where the pulse
  is full and hard.  In the milder cases, it may common-
  ly be advantageously omitted.
In  the second stage, mild aperients;  diaphoretic and
  cooling drinks; enemata; calomel, with a view  to its
  constitutional and aperient effects;  cool affusions, with
  tonics and stimulants, if the pulse becomes feeble.
In  the third stage, stimulants  and tonics; enemata; mild
  drinks.
The usual  saline diaphoretics are of little or  no service,
  in this form of fever.  The  vigorous employment of 
             inflammatory fever.              47

cinchona, or quinine,  is  strongly recommended  by
some, during the remissions.
CHAPTER VIII.
CONTINUED  FEVER.
Continued fevers are either:
       Sthenic, or
       Asthenic.
The former are diseases with irritated vascular excite-
  ment—the  vital  energies being unimpaired or in-
  creased; these are usually  called inflammatory, or fe-
  vers with a phlogistic diathesis.
The latter  are diseases with  irritated vascular excite-
  ment,  and an impaired state of the vital energies;
  these are the typhous fevers.  See Pract. of Med. p. 125.

                INFAMMATORY FEVER

Synonymes.  Arden t fever ; febris irritativa ; synocha ;
                  febris vasorum.

Character.  Vascular excitement vigorous; pulse full,
  hard, and strong; heat of the skin intense; urine scanty
  and high colored: thirst great; eyes red, incapable of
  bearing the light; pulsating pain in the head; sensorial
  powers little affected.
This form of fever is seldom introduced by  a long train
  of premonitory symptoms;  and in this, it differs essen-
  tially from typhus.   The heat of the surface, of the kind 
48
INFLAMMATORY FEVER.
   called  burning.  Delirium not a common symptom.
   The pulse seldom beats more than 110 in a minute.
   The blood, when drawn, separates rapidly into its con-
   stituent parts—the  crassamentum contracting into a
   firm mass, on the top of which a yellowish mass of fi-
   brine collects,  forming what is termed the buffy coat,
   or inflammatory crust.   Pract of Med. p. 129.

        A somewhat similar covering is sometimes formed on the blood
        of typhous patients.  The inflammatory buff has a uniformly
        yellowish -white appearance.  That  which is sometimes seen
        on the blood of typhous patients, presents an  iridescent  ap-
        pearance—reflecting the colors of the rainbow, when held in
        certain positions.  It is also much more brittle  in its texture,
        than the former.  [Richter.]

Inflammatory fever  never  very protracted  in  its course;
   generally terminates  in some manifest  critical dis-
   charge ; haemorrhage from the nose, and increased flow
   of sweat the most common.  Most apt to occur in per-
   sons of rdbust and vigorous constitutions,  and between
   the ages of twenty and forty.
Cause.  The most common causes are: Atmospheric vi-
   cissitudes ; violent passions; wounds and other injuries;
   a peculiar  atmospheric constitution.   Sudden sup-
   pression of  perspiration  by cold, is however  the most
   common sporadic cause.  Hence, inflammatory fevers
   most prevalent in cold and variable climates, or during
   the spring of temperate latitudes; more prevalent also
   in elevated,  dry, and sandy situations, than in localities
   of an opposite character.   Pract. of Med. p. 140.
Diagnosis  between sthenic and asthenic fevers some-
   times very difficult.
The constitution  and habits of the patient, the nature of
   the predisposing and exciting causes, will aid us in the
   diagnosis.   In  very  doubtful cases, we must have re-
   course to the indices ex nocentibus et juvantibus—
   the indications drawn from the effects of  immediate
   agents.
Prognosis.  Simple inflammatory fever, the least dan- 
inflammatory fever.
49
  gerous variety of continued fevers; when attended with
  visceral  inflammation, dangerous;  the  danger being
  proportionate to the violence of the local inflammation,
  and the importance of the organ inflamed.  When pro-
  tracted, it is apt to assume a typhoid  character.  A
  sudden and copious discharge of limpid urine, or thin
  watery  alvine  discharges, are unfavorable   Slight
  haemorrhage from  the nose, a moist and  soft skin, pale
  and turbid urine,  are favorable  signs.   Delirium not
  generally a bad sign.
Treatment.  The principal indications are:  to mode-
  rate the action of the heart and arteries, and to restore
  the healthy functions of the cutaneous exhalents.  The
  remediate measures are:  [Pract. of Med. p  140.]
Blood-letting: this  is the  most important remedy.  It
  should  be early employed, and to the extent of pro-
  ducing a decided impression on  the system.   One de-
  cisive bleeding will do more good than double the same
  quantity of blood  drawn at several  smaller bleedings.
  To produce a proper impression, without too great an
  expenditure of blood, the bleeding should  be from a
  large orifice.  Repeated small  bleedings, during the
  course of a fever, are more apt to prostrate the system,
  than the same quantity of blood  drawn at one or two
  bleedings in the beginning.  The pulse must be our
  principal  guide, as to the quantity  and repetition of
  bleeding.   The inflammatory character of the blood,
  generally, an indication of  the further necessity of
  bleeding.  This indication cannot always be relied on
  —it is fallacious in rheumatism, in which  the  blood
  will often exhibit the buffy coat, after bleeding has been
  carried to the utmost allowable extent.
Cathartics.  Useful not only by evacuating the irritating
  contents of the bowels, but also  by  their direct deple-
  tory effects.   The  saline cathartics  are the  best;  be-
  sides their evacuating effects, they have an antiphlogis-
  tic operation, analogous  to nitre.   Violent  and very
  frequent catharsis,  injurious.
G 
50
inflammatory fever.
 Emetics: seldom proper in inflammatory fevers.
 Diaphoretics  are  important remedies in this variety of
   fever.   Of these, nitre and antimony are the most va-
   luable—they are best given in combination; 10 grains
   of nitre with 1-10 of tart. ant. every hour or two. When
   the bowels are torpid, a grain or  two of calomel may
   be added.   Care must however be taken, not to conti-
   nue the calomel so as to produce  ptyalism—this effect
   could  not  fail  to do  harm.   When the nitre excites
   gastric pain  and  watery purging, a few grains of pulv,
   ipecac, compos, may be advantageously combined with
   it.  These effects are  also lessened by giving the nitre
   in some mucilage.
 Antimony, peculiarly beneficial  in febrile diseases; inde-
   pendent of its diaphoretic effects,  it has a direct seda-
   tive operation; it appears, also, to  act as an alterative,
   that  is, to change the action  of the capillary system
   generally.  Its good effects in fevers are independent
   of the nausea which it is apt to create.  Cullen, how-
   ever, was of a different opinion.  The Italians employ
   it in large doses, as a contra-stimidant; in other words
   as a sedative.
 Other diaphoretics  employed in sthenic fever, viz.  the
   saline effervescing draught; spiritus minderiri; muriate
   of ammonia; sweet spirits of nitre    These  are useful,
   after the febrile  excitement has been somewhat sub-
   dued.
During the whole course, an antiphlogistic regimen must
   be rigidly observed.
        The antiphlogistic plan of treatment consists not only in the
        application of such remedies as are  calculated to reduce the
        actions of the system, but also in the  careful removal of every
        thing which has a tendency to  irritate or excite in an inordi-
        nate degree.  In inflammatory  fevers, the irritability of the
        nervous and sanguiferous systems is  morbidly increased;  and
        hence,  even the ordinary stimulants  of light, sound food,  &c.
        become a  source of increased irritated action. The influence
       of these must therefore be avoided, as much as circumstances
        will allow. 
catarrhal fever.
51
                  CATARRHAL fever.

 Character.  A sthenic fever, with prominent irritation
   of the mucous membrane of the respiratory passages.
 Symptoms.  At first, lassitude and slight chills;  then
   more or less febrile reaction,—attended with a frequent,
   quick,  and somewhat tense pulse; severe pain in  the
   head, face, or jaws; sneezing, dry cough, and  hoarse-
   ness ; a watery discharge from the eyes and nose; eyes
   red  and  painful; transient stitches through the chest;
   often rheumatic pains in the back and extremeties.
   There are considerable remissions in the morning, and
   exacerbations in  the evening   During  the first three
   or four days, the  urine is  high colored and free from
   sediment.  About the fourth or fifth day,  the febrile
   symptoms begin  to decline; the urine  theiVbecomes
   pale and turbid, and the skin uniformly moist; the dis-
   charge from  the nose and bronchia becomes thicker
   and yellowish.

        The existence of the latter cause is inferred from the circum-
        stance of this form of fever occasionally prevailing epidemi-
        cally,—extending itself over whole continents, and even passing
        from one continent to another.

 Causes. Atmospheric vicissitudes—a specific miasma, or
   a peculiar constitution of the atmosphere.
 Prognosis.  Not  in general a  dangerous form of fever;
   most dangerous in infants and in very old people; apt
   to excite phthisis  in those who are predisposed to it.
 Proximate Cause.  Irritation and inflammation in  the
   mucous membrane lining the respiratory passages, with
   disordered action of the cutaneous capillaries.
Treatment. Moderate bleeding, in the young and robust;
   in the aged and in infants, generally unnecessary,  and
   often improper.   Mild laxatives useful  in all cases.
   Mild diaphoretic drinks, such as infusion of eupatori-
   um, sage, camomile, &c. together with pulvis antimo-
   nialis, spiritus mindereri, or spir. nit. dulc. are impor- 
52
TYPHUS.
  tant remedies.   Blisters to the breast, when the pneu-
  monic symptoms are severe.
  Mild Expectorants, to relieve the cough.

                      TYPHUS.

Typhus is by no means so common a disease as is gene-
  rally supposed.  The term typhous is  frequently ap-
  plied to fevers essentially distinct from typhus.  Syno-
  chous and catarrhal fevers are often improperly deno-
  minated typhous.
Typhous divided into four periods, viz,  the forming
  stage, the stage of invasion, the stage of excitement,
  and the stage of collapse.
Symptoms—Of the forming  stage.  Lassitude, giddi-
  ness, and dull pain in the  head; a peculiar uneasy sen-
  sation in the stomach, nausea, and sometimes vomiting;
  want of appetite; thirst,  pale and shrunken counte-
  nance;  tremor of the  hands;  eyes dull and heavy;
  muscular debility.  This stage lasts from three to se-
  ven days.
Stage of Invasion.  Slight chills, alternated with flushes
  of heat; tongue whitish or clammy;  entire disgust of
  food; nausea and vomiting; a sense of weight and anx-
  iety in the praecordium.  This stage lasts from six to
  twenty-four  hours.
Stage of Excitement.  Face full and flushed; pulse full,
  somewhat resisting, and  accelerated;  skin dry  and
  warm;  lips parched; thirst urgent, bowels constipated;
  eyes  red and watery; slight and transient delirium; vi-
  gilance; obtuseness of hearing; weight and oppression
  in the chest; tenderness and fulness of the hypochon-
  dria; catarrhal and peripneumonic symptoms; mind,
  about the third day,  confused, as if stunned; great re-
  luctance to  mental and corporeal action.  About the
  fourth day,  a red  milliary eruption often makes its
  appearance.  Hildebrand regards this as an essential
  exantheme of this disease.  The voice is at first rather 
TYPHUS.
53
  plaintive, but in the advanced periods of bad cases, it
  becomes guttural, and •' at last, truly sepulchral." The
  body exhales a peculiar odour,  in this disease.   This
  stage lasts usually about seven days; at the end of this
  period, it  terminates in the
Stage  of  Collapse.   This stage is  characterized by:
  great prostration of muscular power; torpor of the sen-
  sorial functions;  a very frequent  and  feeble pulse;
  tongue .brown, dry, at last black; incrustation  of the
  teeth with a blackish matter; short and feeble respira-
  tion ; difficult  deglutition; almost  constant delirium;
  coma; tongue  tremulous, and  put out with  difficulty;
  subsultus tendinum; hiccough; heat of the skin intense
  and  acrid; unequal distribution of the animal tempera-
  ture; diarrhoea, with pain in the bowels, in the  latter
  periods of severe cases; urine pale; tympanitic bowels;
  sometimes petechias.
The foregoing sketch applies to typhus in its regular and
  simple form.  In this form, there are manifest morning
  remissions,  and evening  exacerbations.   Typhus is
  subject to various  important modifications.   In some
  instances,  local inflammations supervene,  forming
  what Dr.  Armstrong calls
Inflammatory Typhus.   The organs most liable to be-
  come the seat of inflammation are, the lungs, the brain,
  the intestinal canal, the liver, and the peritoneum.—
  The mucous membrane of the alimentary canal and
  the arachnoid of the brain, the most commonly affect-
  ed.  The theories of Broussais and Clutterbuck refer-
  red  to.  In some  instances, the stage of excitement
  does not  become  developed,  the stage  of oppression
  continuing throughout the whole course of the disease*
  This variety constitutes Dr. Armstrong's.
Congestive form of typhus.  This modification is cha-
  racterized by: a want of reaction; great prostration and
  sinking,  from  the commencement;  deep pain  in the
  head, and in vertigo; face pale  and dingy; respiration
  anxious and oppressed; pulse small and  variable; skin 
54
TYPHUS.
   cool, damp, and relaxed; countenance bewildered or
   vacant; eyes dull, watery, and red,  or glairy and  sta-
   ring, without redness; bowels at first constipated—to-
   wards the conclusion, copious involuntary stools; tongue
   pale and tremulous, becoming at last brown and rough;
   petechias; passive  haemorrhages;  coma; sometimes,
  -from the beginning, complete torpor and insensibility.
Dr. Armstrong's opinion that the depressed and  prostrated
   state of the system depends  on internal venous con-
   gestion, refuted.

        The  internal congestions are most probably the consequence,
        and not the cause, of the impaired or depressed condition of
        the vital energies.  When the remote cause of typhus acts
        with great intensity upon the system, the vital pow.ers are sud-
        denly prostrated; in consequence of which, the heart and the
        capillary system act feebly—the blood  recoils from the surface
        to the central vessels, and  gives rise  to internal congestions,
        which the .enfeebled heart is now unable to overcome.  Pract.
        of Med. p. 151.

Causes of  Typhus.   Typhus almost peculiar  to  the
   cold seasons of the temperate climates.  Smith, Ferriar,
   and Wedekind, have seen it during  the hotest weather
   in summer.   Propagated by a specific contagion: evi-
   dence adduced in  support of this assertion.   Typhus
   occasionally originated by other causes than contagion
   —deficient and unwholesome  food, and the  contami-
   nated air of confined  and  crowded  apartments,  the
   most common causes of this kind.

        Upon the subject of the origin and mode of propagation of
        this disease, physicians are  by  no means unanimous. Some
        regard typhus as always and essentially a contagious disease,
        while others deny that it is ever communicated in this manner.
        The weight of good testimony is in favor of the occasional ge-
        neration of the disease, by causes entirely distinct from conta-
        gion. When once generated,  it may, aud frequently does,
        spread from the sick to the healthy, in the manner of a contagion.

Prognosis.   Free and spontaneous vomiting, in the be-
   ginning, particularly when it relieves the giddiness, ge-
   nerally indicates a mild course of the disease.   Ha* 
TYPHUS.
55
   morrhage  from the nose, about  the  seventh  day, is
   favorable.  Very manifest remissions in the morning,
   are always a good  sign.  Moderate diarrhoea, during
   the first days, is favorable; but when it occurs in  the
   latter periods of the disease, it is a very bad sign. Great
   thirst, in the stage of collapse, is favorable; so also is a
   moist tongue, in this stage.  The absence of important
   or violent local inflammations, always  a good sign.
   Diminution of the frequency of the pulse, and of  the
   acrid heat of the skin, is favorable.   Among the symp-
   toms which are particularly unfavorable, are:  great
   change of the expression of  the countenance,  in  the
   beginning of the disease; entire absence of thirst; con-
   stant and violent delirium; early petechise; strong  pe-
 ^  ripneumonic symptoms; swelling of the parotids.  The
   most dangerous  signs, in the last stage, are: blindness,
   involuntary flow of tears; difficult deglutition; palsy of
   the  tongue; constant low  murmuring;  and  entire
   abandonment of himself; a  very frequent and small
   pulse; pain in the region of the bladder; tenderness and
   tumefaction  of the abdomen; floccitatio; continued
   motion of the hands and fingers; diarrhoea; insensibi-
   lity to  the vesicating effects of cantharides; hiccough;
   aphthee in the mouth; suppression of urine, &c.  Pract.
   of Med. p. 159.
Treatment.  The first object  is to remove as much as
  possible the remote cause, or  to  lessen  its activity.
  With this view,  the patient^s to be removed from the
  confined and contaminated air in which the disease
  was contracted;  or  if this cannot be done, the apart-
  ment in which he lies must be freely ventilated.
  Diversity of opinion, in relation to the treatment of ty-
  phus.   Many physicians maintain, that no  remedial
  treatment is adequate to interrupt the course of the dis-
  ease, when once  completely formed.   (Smith, Hilde-
  brand.)  This I  believe to be an  erroneous opinion.
  Attention to the several stages  of the disease, all-impor-
  tant in  its remediate treatment. 
56
TYPHUS.
In the forming stage, the indications are: to overcome
  the torpor of the external capillaries; to determine the
  circulation to the surface;  and interrupt the morbid
  sympathetic actions  throughout the system.  For this
  purpose, emetics are highly serviceable; given soon af-
  ter the attack of the disease,  they  will often interrupt
  its course.  After the operation of the emetic,
  Mild purgatives should be employed.  Two or three
   alvine evacuations should beprocured daily.
 Diaphoretic ptisans, beneficial in this and the subse-
   quent stage; such as infusions of eupatorium,  catnip,
   sage, &c.
 Calomel: In the early periods of the  disease, this article
   is often decidedly useful.  Slight mercurial influence,
   the most effectual means of arresting typhus in its early
   stage; two grains of calomel  may  be given every four
   hours, until the gums become slightly inflamed.  The
   constitutional influence of mercury  generally  perni-
   cious after the disease is fully developed—its benefits
   being restricted to the first five or  six days.  Calomel
   no less beneficial, in the early stages of congestive fe-
   vers.  (Armstrong.)  It has  a powerful  tendency  to
   equalize the circulation; it raises the pulse, restores
   warmth to the skin, and increases  the general energy,
   in such cases.
 In  the stage of excitement, a more or less antiphlogistic
   treatment becomes necessary.  Mild cathartics par-
    ticularly useful  in  this *tage—they moderate at once
    the general excitement, the heat  of the skin, and the
    force of the pulse.
  Cold Affusions.  When the skin is  hot and dry, in this
    stage of typhus,  the  affusion of cold water is often
    highly beneficial.   As the stage of collapse approaches,
    the temperature of the water should be raised.   Cold
    affusions are improper,  when the skin is below the
    natural temperature,  and a  sense of chilliness is pre-
     senter when there is profuse perspiration.  Common
     salt may be advantageously  added to the water, parti- 
TYPHUS.                    57
  cularly  when  there is  much prostration.  When the
  heat of the body is unequally distributed, neither cold
  nor  tepid affusions are  proper: local inflammations
  also form an objection to cold affusions.  In such cases,
  sponging the body with tepid water will sometimes do
  good.
Diaphoretics, of the refrigerant class, useful during the
  stage of excitement.
Bleeding, very rarely called for, in cases of simple typhus.
Stage of Collapse.  In this stage, stimulants and tonics
  are the appropriate remedies.  Wine, serpentaria, ca-
  lamus aromatics, ammonia, opium, aether, phosphorus,
  camphor, and musk,  are the most useful.  Of these,
  wine, ammonia, camphor, and opium, are the  best.
  When  stimulants render the pulse fuller and slower,
  and the skin moist and cooler, they may be continued
  with confidence;  but when  the  pulse  becomes more
  frequent and corded, the  countenance flushed, with an
  increase of restlessness and delirium, under their use,
  they are doing injury, and  must be discontinued.   Cam-
  phor particularly serviceable, where there is much de-
  lirium ; combined with nitre and calomel, useful even
  in an earlier period, when the disease is complicated
  with peripneumonic symptoms.   Small doses of opium,
  with  infusion of serpentaria, beneficial in pneumonic
  typhoides.   Musk said to be particularly useful, in ty-
  phus of habitual drunkards.  Opium serviceable, when
  in the last stage, where there is much restlessness, de-
  lirium, and other symptoms of nervous  irritation; com-
  bined with  calomel and chalk,  excellent to check the
  diarrhoea, which  sometimes supervenes in this stage.
Distinction between true and false debility.  In the for-
  mer, there is an actual  impairment of the vital powers;
  in the latter, the powers  of the system  are oppressed,
  generally, in consequence of intestinal irritation.  False
  debility sometimes  occurs before  the supervention  of
  the stage of collapse—if, through mistake of its nature,
  stimulants are given, injury will be done.  The diagno-
  sis between true and false debility.  In false debility,
                          H 
58
TYPHUS.
  or prostration from intestinal irritation, there are, gene-
  rally, much jactitation; flushed countenance; eyes suf-
  fused ; extremities cold; pulse irregular and very small;
  hurried and anxious respiration; stupor; little or no
  delirium: it generally comes on suddenly/" In debility,
  or sinking from an impaired state of the  vital powers,
  the prostration usually comes on gradually; delirium is
  almost constant; skin hot, the heat being  of the acrid
  kind, {color mordax;) the countenance is sunken and
  inanimate, with subsultus tendinum, &c.  Observations
  on the  use of laxatives, in the stage of collapse. They
  are often  highly serviceable.  They should  be given
  in conjunction with stimulants, such as ammonia, wine,
  alchohol, &c.  One or two  stools should be procured
  daily.
Cinchona not in general  of much use; when in the latter
  stage, the tongue and skin are dry, and there  is much
  delirium, coma, and subsultus tendinum, the bark is
  improper.
Blisters seldom serviceable, in simple typhus.
Diet.   Solid food injurious: farinaceous and mucilaginous
  substances, the only  nutriments  admissible.   Barley
  water, and thin oat-meal gruel, should be freely allow-
  ed, in the stage of collapse.
In typhus complicated with local inflammation, bleeding,
  in the second stage, is  often  indispensable: it must be
  early employed; delayed beyond  the thirty-sixth hour
  after the  beginning of the inflammation, it will most
  commonly do harm.  Sufficient blood should be drawn
  at once, to make a decided impression on the system.
  Small bleedings,  however frequently repeated, afford
  no permanent advantage.   Cupping or leeching may
  be  beneficially employed, when general bleeding is
  contra-indicated,
Calomel  with Opium, a  valuable remedy  after proper
  depletion, in  typhus with pneumonic systems.   One
  grain of each may be  given every four hours.   This 
TYPHUS.
59
   remedy is  hurtful, when the inflammation is seated in
   the brain.

        In prescribing depletory measures in typhus, even when con-
        nected with inflammation, it should be kept in mind, that there
        is always lurking at the bottom a radical  tendency to a state
        of exhaustion or prostration.

 Typhus in which reaction does not take place, or Con-
   gestive Typhus.  Bleeding recommended  by  Arm-
   strong and  others.  Objections stated against this prac-
   tice, and reasons given  in favor of the  employment of
   stimulating frictions, warm applications to the exter-
   nal surface, and warm and gently  stimulating drinks.

        Applications of this kind not only cause a determination to the
        surface, and thereby relieve the heart and arteries, but they
        also tend  to invigorate  and  support the* general energies of
        the system,  by the stimulus they impart to the nervous extre-
        mities of the surface.

Blisters, purgatives, calomel, and opium,  are important
   remedies in this modification of the  disease.   Further
   observations on the beneficial  influence of calomel, in
   congestive states of fever.   While this remedy  is gi-
   ven, with a view both to its purgative and constitution-
   al effects, warm and stimulating applications should be
   made externally.  A blister to the  epigastrium  will of-
   ten do much service in such cases.   (Armstrong.) 
60           inflammation in general.
CHAPTER  IX.
        INFLAMMATION IN GENERAL.


Phenomena.   Pain, increased heat, redness, and swell-
  ing.   Pract. Med. p. 172.
1. Pain.  Not always,though generally, present; gener-
  ally, the looser the instructure,the less pain; sometimes
  absent, in peripneumonia, gastritis, pericaradatis, &c;
  inflammatory pain always increased on pressure, and
  may be thus distinguished from spasmodic pain.  The
  nature of the structure inflamed modifies the character
  of the pain.  The violence of the general febrile reac-
  tion, proportionate to the intensity of the pain.
2. Increased heat. Not always present; actual degree of
  heat never raised above  98Q.  The  sensation of heat
  depends on the altered state of the sensibility  of the in-
  flamed part.
3. Redness.  Almost an invariable phenomenon of in-
  flammation; arises from  the intromission of blood into
  the  serous capillaries; generally remains after death;
  redness, by itself, no certain sign of previous inflamma-
  tion ; the serous capillaries  may become injected with
  red blood in articido mortis, although sound before;
  importance  ofthis knowledge, in autopsic  examina-
  tions.
4. Sivelling.   The effort of effusion into the surrounding
  cellular tissue;  the firmer the structure,  the less swell-
  ino*
Inflammation is located in the capillary  system.   The
  more abundant the capillaries of a part, the  more apt
  is it to become inflamed.  The mucous, serous, cellu-
  lar, and dermoid systems, being very vascular, are very 
inflammation in general.            61
   subject to inflammation; the contrary obtains with the
   osseous, the cartilaginous,and the tendinous structures.
   (Bichat.)
JEtiology.   Inflammation may be produced—1.  By the
   direct operation of irritants on a part.   2. By the indi-
   rect operation of irritants on parts, through the medi-
   um of the nervous system.  3. By general irriatted vas-
   cular excitement.  4. By metastasis.
Whatever be the exciting cause of inflammation, the follow-
   ing changes take place in progress of its evolution: viz,
   irritation; then alteration of the vital properties /and
   finally, an afflux of blood to the part.   These changes
   often succeed each other so rapidly, that  they seem to
   arise simultaneously.   A change of the  vital  proper-
   ties is essential  to inflammation; preternatural deter-
   mination to a part, without altered sensibility and con-
   tractility, constitutes  congestion, or local  plethora—
   not inflammation.  (Bichat.)
Are the capillaries of an inflamed part in a state of debil-
   ity, and is the velocity of the blood circulating in them
   diminished—or, are they in a state of increased actionP
   Vacca, Lubbock, Allan  Phillip, and  Hastings, have
   written in support of the former opinion; but the sub-
   ject is still sub judice.

        My  own view  on this subject is, that the inflamed capillaries
        ought to  be regarded as being in a state of  irritated excite-
        ment; and that this irritated condition may be connected either
        with an increased or with decreased power of action.  In this
        respect, local inflammation corresponds with that general irri-
        tated vascular excitement, which constitutes fever.  The heart
        and arteries are in a state of irritated action, with increased
        power of acting in synocha.  In typhus, there is also general
        irritated excitement; but it is connected with a fundamental
        debility of the vital powers.  There is therefore, according
        to my apprehension, a typhous and a synochal state of inflam-
        mation; and this corresponds with the results we obtain from
        remedial applications.  May we not explain these different
        diatheses of inflammation, by the greater or less degree of or-
        ganic injury sustained by the nervous filaments of the inflamed
        capillaries?   When a part  is irritated, so as merely to  exalt
        the sensibility of the capillaries, by exciting their nervous tex- 
62           inflammation  in general.
       ture, the consequent inflammation will probably be one of in-
       creased capillary action, and demand sedatives for its cure:
       When, on the contrary, the irritating cause acts with such vio-
       lence as to cause structural lesion in the nervous extremities,
       the inflammation resulting from its action will, I conceive, be
       characterized by debility, and stimulating  applications, as is
       the case in scalds and burns.

Termination of inflammation. These are quadruple:—
  Pract. of Med. p.  175.
1. Resolution.   Inflammation is said to terminate in re-
  solution, when it declines and disappears without any
  structural lesion, or perceptible discharge.  Resolution
  is more prompt, in proportion as the organ  affected
  possesses ahigherdegree of vitality; in the serous mem-
  branes, the progress  of inflammation is particularly
  rapid.   (Bichat.)  Resolution is often accompanied by
  an increase of the natural secretions of the part: this is
  particularly noticed in the mucous and serous mem-
  branes ; also, in rheumatic inflammation.
2.  Effusion.   The effusion may be blood, lymph, or se-
  rum.  The termination by  effusion of blood, most
  common  in  the  mucous membranes;   effusions  of
  lymphond serum, almost peculiar to the serous mem-
  branes—the  former  fluid forms  a bond of union be-
  tween the serous membranes.  Such adhesions never
  occur  in  the mucous  membranes.    Serum seldom
  abundantly exhaled, until the inflammation hasassum-
  ed a chronic or sub-acute character.  Dropsies are the
  consequence of this mode of termination.  Effusion of
  lymph into the substance of the solid viscera, result in
  induration.
3.  Suppuration.  The cellular, serous, and mucous tis-
  sues, are most prone  to  this termination; the bones
  and tendons never suppurate.' The mode of suppura-
  tion different in the different structures;  in the mucous
  membranes, it is a morbid secretion, the pus  having a
  whitish, cream-like appearance.  In the serous mem-
  branes, pus is formed by a kind of exhalation, and is a
  thin whitish, or whey-like fluid, sometimes mixed with 
INFLAMMATION IN GENERAL.
63
  flakes.  In the cellular tissue, pus collects in  circum-
  scribed cavities,  called abscesses, and is of thick and
  uniform consistence and pale yellow colour, exhibiting
  to the microscope minute globules suspended  in  a se-
  rous fluid.  Symptoms denoting the occurrence of sup-
  puration, in the inflammation of eternal organs: a sen-
  sation of weight in the inflamed part; change  from the
  acute to a dull throbbing pain; rigors; pulse  losing its
  tension and hardness, and becoming soft and full; night
  sweats, and other symptoms of hectic.
4. Gangrene,  Never occurs in the cartilages, nerves, or
  bones.  The cellular, mucous, and serous tissues, are
  mostp'rone to it;  more common  in  the peritoneum,
  than in any of the other serous membranes; of the mu-
  cous membranes, than  lining the alimentary canal is
  most subject to  it.  The  occurrence of gangrene is
  denoted  by,  sudden  cessation of pain; sinking pulse;
  cold extremities; cold sweat; delirium; and cadaverous
  countenance.
        There exists in the different forms of inflammation,  an "origin-
        al disposition to terminate in one mode, rather than another:
        thus, in boil and whitlow, it  is to suppurate; in carbuncle,to
        slough; and in  mumps, to resolve: and this  disposition is so
        strong, that it is very difficult to procure any  other termina-
        tion."

 Varieties of inflammation.  Inflammation occurs under
  five prominent modifications, corresponding to the five
  elementary tissues—  viz. the cellular membrane and
  parenchyma of the solid viscera:  the serous mem-
  branes ; the mucous membranes; the skin, or dermoid
  tissue; and the fibrous membranes.
     1. Inflammation  of  the cellular membrane,  or
       phlegmonous inflammation.  Characterized by,
        great swelling, throbbing pain, and by its mode of
        suppurating; the pus being collected in circum-
        scribed cavities.  Diffuse cellular inflammation,
     2. Inflammation  of the  serous membranes, or
        serous  inflammation. Pain very acute  and Ian- 
64           INFLAMMATION IN GENERAL.
      cinating—rapid in its course; no  tumefaction;
      much sympathetic excitement of the general san-
      guiferous system, terminating in the exudation of
      coagulable lymph or serum, or the secretion of a
      whey-like pus; adhesions  are peculiar to this va-
      riety of inflammation; it rarely terminates in gan-
      grene.
    3. Inflammation of the mucous membrane, or mu-
      cous  inflammation.   Almost always produced
      by  sudden  atmospheric  vicissitudes,  in conse-
      quence of the close sympathy which subsists be-
      tween these membranes and the skin.  Sometimes
      prevails epidemically.  Pain not very severe; un-
      attended with swelling of the subjacent cellular
      tissue; concomitant fever not intense; never termi-
      nates without an increase of mucous secretion.
      No adhesions ever formed.
    4. Inflammation of the skin, or erysipelatous in-
      flammation.  Pain of the stinging or  burning
      kind; spreading; forming vesicles; never suppu-
      rating in circumscribed cavities; dependent on a
      specific cause.
    5. Inflammation  of the fibrous membranes, or
      rheumatic inflammation.   Pain intense and ach-
      ing; does not terminate in abscess or suppuration;
      terminates by an exudation of a gelatinous matter;
      or by earthy depositions; is wandering, accom-
      panying  fever  always synochal;  rarely  proves
      fatal, except by metastasis to organs essential to life
Diagnosis of internal inflammations.   The existence
  of internal inflammation is ascertained by: the continu-
  ance of the pain;  the appearances of the  blood; the
  state of the general vascular excitement; the effects of
  external pressure; the effects of position; the character
  of the functional derangements; the temperature of the
  skin; and the nature of the exciting causes. 
PHRENITIS.
65
              CHRONIC INFLAMMATION.

Chronic Inflammation is generally, though not always,
  the consequence  of acute  inflammation.  Doctrines
  concerning its nature.
The effects of Chronic Inflammation,—dropsical effu-
  sions, and tuberculated accretions in the serous mem-
  brane; phthisis, diarrhoea, dyspepsia, and various other
  affections in the mucous membrane, &,c.
Treatment.   The  indications in the  treatment of acute
  inflammation, are—1. To diminish  the momentum of
  the general circulation; 2. To drive the blood from the
  inflamed part; 3. To alter the action  of the inflamed ca-
  pillaries ; and  4. To change the inflammatory  condi-
  tion of the blood.
CHAPTER X.
INFLAMMATION  OF  THE BRAIN.
Encephalic Inflammation is divided into two varieties—
  viz. Phrenitis and Arachnitis.

                    PHRENITIS.

In Phrenitis, the substance  of the brain, as well as its
  membranes, are involved in inflammation.
Symptoms.  Synocha; fixed and intense throbbing pain
  in the head; face full and flushed; eyes inflamed; into-
  lerance of light; heariug at first morbidly acute, at last
                       i 
66
ARACHNITIS.
  almost complete deafness, furious delirium from  the
  commencement, and constant wakefulness.
Causes.  Insolation.  Distinguished from mere syno-
  cha, with high cerebral excitement, by the following
  circumstances.   In phrenitis, there is always  promi-
  nent derangement of the organs of sense—in synocha,
  hearing and vision are but little affected.  In phreni-
  tis, the internal functions are always much disturbed—
  in synocha, this is rarely the case.  In synocha, the
  pulse is hard, full, frequent, and vibrating, from the
  beginning—in phrenitis,  it does not becmoe so until
  the inflammation is fully formed.
Prognosis.   Haemorrhage from the nose  is favorable,—
  from the bowels, in the advanced stage, unfavorable;
  coma supervening to delirium, a fatal sign.
Autopsic Phenomena.  Flakes of coagulable lymph, pus,
  and serum between the membranes; sometimes adhe-
  sions; abscesses in the substance of the brain; ero-
  sions of the dura mater.
Treatment.   Vigorously antiphlogistic.  Prompt and de-
  cisive bleeding,  both general and local; cold applica-
  tions to the shaven scalp;  cathartics;  the  refrigerant
  diaphoretics; blisters to the nape of the  neck, after  the
  febrile excitement has been moderated by depletion.
  The head should be kept in an elevated position,  and
  the chamber dark, noiseless, and  cool.   Digitalis  and
  nitre, after the disease has been in some degree subdued.
  Pract. of Med. p. 257.

      ARACHNITIS, OR HYDROCEPHALUS  ACUTUS.

This is a much more common form of encephalic  inflam-
  mation than the preceding one.  It has of late years
  been extensively investigated, by Martinet and Ducha-
  telet, of Paris, whose pathological researches, in rela-
  tion to it, are highly interesting and valuable.   I treat
  of hydrocephalus and arachnitis under the same head;
  for it is now placed beyond all doubt, that the malady 
ARACHNITIS.
67
  known and described under the name of hydrocepha-
  lus, is neither more nor less than arachnoid inflamma-
  tion.  The term  hydrocephalus is  indeed altogether
  inappropriate to the disease;  for  instead of directing
  the mind to the primary and essential affection, it has
  reference only to one of the occasional consequences of
  the disease.   Pract. of Med. p. 262.
Symptoms.   Often very gradual in its approach.  In this
  case, there are transient  pains in  the head  and abdo-
  men ; the patient is  dull,  fretful, restless,  and discon-
  tented ; countenance pale, with an occasional flush on
  the cheek; the brows  contracted, appetite  variable;
  bowels torpid, or mucous diarrhoea; starting and grind-
  ing the teeth during sleep.  After these symptoms have
  continued for an indefinite time, hose which characte-
  rize the disease in its full development come on: these
  are—severe pain in the  head, nausea and vomiting;
  deep  sighing, occasional  somnolency,  and slight deli-
  rium ; very dilated or contracted pupils; an expression
  of surprise and stupor in the countenance;  slight red-
  ness of the conjunctiva; paralysis of the upper eye-
  lids; squinting; eyes turned up, so as to hide the cornea
  under the upper lid; towards the last, constant somno-
  lency, interrupted by spells of great anxiety and rest-
  lessness, or fits of violent  and frightful screaming, para-
  lysis of one side; convulsions; death.   The patient can
  seldom be induced  to utter more  than monosyllables.
  The pulse is at first irritated, frequent, and tense; when
  somnolency comes on, it  becomes slower; towards the
  termination, it again becomes very frequent.
The disease is sometimes ushered in by  convulsions.  I
  have seen it come on without any febrile excitement,
  the countenance remaining pale, with cold hands, deep
  sighing, a peculiar expression of surprise, vomiting, and
  constipation.   It sometimes comes on in the shape of
  a  remitting fever.  After  a  few  day's  languor  and
  drooping, fever ensues, attended with head-ache, flush-
  ed countenance, tenderness of the abdomen, stupor du- 
68
ARACHNITIS.
   ring the exacerbations, the patient screaming and start-
   ing up in great alarm, great irritability of the stomach,
   obstinate constipation, &c.
 Predisposition.   Hereditary, in  some instances;  the
   scrofulous diathesis predisposes to it.
 Exciting causes.   External injuries; dentition; intesti-
   nal irritation; suppression of serous discharges of
   cutaneous eruptions,  particularly about the head; fre-
   quently the consequence of cholera, whooping cough,
   measles, and scarlatina.
 Diagnosis.  Arachnitis to be distinguished from infan-
   tile remittent, by the regularity of the remissions in the
   latter, and the character of the stools.   In infantile re-
   mittents,  the stools are fetid, and of a dark-brown or
   mud-like appearance—in arachnitis, they are  dark-
   green and glairy.
 The  connexion between arachnitis and  cholera infan-
   tum pointed out.
 Prognosis.  Always highly dangerous; deep somnolen-
   cy, paralysis,  blindness, strabismus,  and  convulsions,
   indicate a fatal termination.
 Autopsic phenomena.  Commonly, general redness of
   the arachnoid membrane; sometimes it is opaque  and
   thickened, with a purulent, sero-purulent, or sero-gela-
   tinous effusion on the surface, more or less serous effu-
   sion into the ventricles, and between the lamina of the
   arachnoid.
 Treatment.  The indications are—1. To moderate the
   general febrile excitement; 2. To subdue  the local en-
   cephalic inflammatory  affection of the brain; and  3.
   To remove those causes which tend to keep up a pre-
   ternatural determination to the brain.
For this purpose are employed:
Bleeding, copious  and prompt, both general and local.
   The blood should be suffered to flow, until an approach
   to syncope is induced;—leeching  on the crown of the
   head.  (Duchatelet.)  Generul always to be premised
   to local bleeding. 
ARACHNITIS.
69
 Purgatives are of great importance.   Calomel the best
   purgative, on account of the torpor of the liver in  the
   early period of the disease.  Where worms are sus-
   pected, spigelia and senna should be used.

        In cases depending on intestinal irritation,—and the  majori-
        ty of cases in infancy  are of this kind,—violent purging ia
        improper.  Mild laxatives, however, are of the utmost impor-
        tance .  Where the disease has been brought on by external in-
        juries to the head, or where the arachnoid inflammation is
        idiopathic, the more  active purgatives may be employed with
        advantage.

Revulsive applications.  Cold applications to  the  head;
   blisters; pediluvium; cupping.  Blisters are usually ap-
   plied to the shaven scalp—I prefer placing them  be-
   hind the  ears, or on the nape of the neck, while ice or
   or other cold applications are made to the scalp, and
   sinapisms laid on the  soles of the feet.
Mercury: with a view to its constitutional influence, one
   of our most useful  remedies in this disease.   Percival,
   Dobson,  Rush,  Cheyne, and  others,  mention  cases
   which yielded to it.
James's Powder.  Dr.  Stocker states,  that  this article
   has  a decided tendency to  diminish the  circulation to
   the  head; and  of  the truth of this observation, I have
   had repeated evidence.  It is best given in combination
   with calomel, in this disease.
Dover's Powder.  Drs. Brooke, Percival, Cheyne, and
   Crampton,  speak highly of the efficacy of this article
   in hydrocephalus.   In cases depending on  intestinal
   irritation, after  adequate depletion, it may sometimes
   prove serviceable.   In the idiophatic form of  the dis*
   ease, however, all opiates are injurious.
Digitalis has been recommended; and, from its tendency
   to lessen the action of  the heart and arteries, it may un-
   doubtedly be employed with occasional advantage, 
70
ERETHISM  OF THE BRAIN.
       ERETHISM OF THE  BRAIN. (Dr. Nicholl.*)

Infants are subject to a morbid condition of the cerebral
   structures, which appears to consist in a highly irrita-
   ble or sensitive state of the nervous centre; being unat-
   tended by inflammation, or increased  momentum of
   blood in the cerebral vessels.   I have  frequently wit-
   nessed this affection, and think it a subject of sufficient
   importance and interest, to introduce it to the attention
   of the medical student.   It is characterized by: wake-
   fulness; irritable temper; retina very sensible to light;
   contracted pupils, much action of the limbs; head often
   moved from side to side, extreme fretfulness; frequent
   crying, without any apparent cause—the  little  patient
   being " soothed only by tossing it, by carrying it about,
   putting  it to the breast, or letting it  suck the cheek of
   the nurse, or its own fingers;" increased secretion of
   tears; bowels generally relaxed, without a disordered
   state of the stools.  When sleeping, the  child often
   starts, and is readily awakened; when awrake, it starts
   at the slightest noise, or on being slightly touched; of-
   ten shrieks out, as if it were pricked with a pin; the
   fists are frequently clenched, the thumb being bent in,
   and the fore-arms bent upwards on the arms.  Some-
   times  the  child presents, for a short time, a  state of
   opisthotonos, " its legs being drawn up, and  the head
   thrown backwards."

       In adults, this erethismal state of the brain shows itself by "ir-
       ritability of temper," inability to bear the effects of  the most
       trifling sounds, wakefulness, restlessness, febrile symptoms," &c.

Subjects of a scrofulous diathesis are particularly predis-
   posed  to this morbid cerebral irritability.
  * Practical Remarks on  Disordered States of the Cerebral  Struc-
tures, occurring in infants.  By Whillock Nicholl, M. D. &c. &c. Lon-
don, 1821. 
SOFTENING OF THE  BRAIN.
71
Causes: dentition;gastric irritation, from various causes;
  torpor  of the liver, &c.
Treatment.  Exercise in  the open air; small doses of
  ipecac, compos.; a mild unirritatingdiet; leeches to the
  temples; lancing the gums;  mild aperients and diure-
  tics; pediluvium.
             SOFTENING OF THE BRAIN.


This form of cerebral disease has of late been abundant-
  ly noticed by  the  French  pathologists.  Recamier,
  Bayle,  Cayol,  Brichereau, Rostan, and Lallemand,
  have published numerous interesting observations, con-
  cerning its symptoms and pathology.  The disease con-
  sists in a softening, or kind of liquefaction, of"a portion
 _ of the brain, with vascular injection of the rest of its
  substance.  Rostan divides the disease  into two peri-
  ods.
The symptoms of the first period are: a fixed and vi-
  olent pain in the  head,  often continuing  for several
  months; vertigo; obtuseness of the mental faculties,
  the memory being weak, and  the ideas confused;
  questions are answered after long hesitation; dejection;
  querulousness; indifference to surrounding occurrences;
  drowsiness; tingling and numbness  in the fingers; fre-
  quently perverted vision, and  occasionally total blind-
  ness ; dull  hearing,—sometimes very acute; frequently
  nausea and  bilious vomiting; tenderness of the epigas-
  trium ; constipation; pulse variable, sometimes hard and
  full; occasionally  there  is delirium, with fever, and
  much agitation.
The second period is characterized by a gradual or sud-
  den paralysis of one limb, sometimes of half the body;
  consciousness and intellect remain; questions are an-
  swered with very great difficulty, the patient generally
  expressing his desires by automatic  movements; some- 
73
ACUTE GASTRITIS.
  times perfect coma; death commonly follows, in two or
  three days.
The corpora striata,and thalami opticorum, have been
  most frequently found the seats of this softening.
The inflammatory nature of this disease has  been much
  doubted by some; but the facts  and arguments  addu-
  ced by Lallemand, render the opinion of its  being of an
  inflammatory  character exceedingly  probable.  This
  writer thinks that the softening is " the effect of inflam-
  mation arrested in its course by death, before purulent
  suppuration has had time to take place."
Diagnosis.   A contraction of the flexor muscles of the
  limb, is  particularly characteristic of this disease.—
  " Sometimes," says  Lallemand," this amounted only to
  simple rigidity of the limbs; at others, it was carried so
  far, that the patient's fist was kept rigidly applied to the
  shoulder,  and the heel to the buttock."  Contrary to
  what takes place in  apoplexy, the mouth is drawn to-
  wards the paralyzed side.
Treatment.  General and local bleeding; sinapisms to
  the  feet;  cold applications  to the head;  cathartics;
  blisters to the back  of the  neck; calomel, with a view
  to its salivant effect.
CHAPTER XI.
              ACUTE GASTRITIS,

Symptoms.  Burning and  lancinating  pain in the sto-
  mach ; frequent  vomiting, particularly on swallowing
  fluids; urgent desire for cold drink; constipation; fever, 
ACUTE GASTRITIS.
73
   with a small, hard, and frequent pulse.  After a draught
   of cold water, a temporary mitigation of the gastric
   pain occurs; difficulty of swallowing; disgust of warm
   drinks; great prostration  of strength  from the begin-
   ning.  Pract. of Med. p. 106.
 Diagnosis.   Distinguished  from  spasm  and  flatulent
   pains, by the following circumstances.   In gastritis,
   the pulse is small and tense—in cramp, it is generally
   natural.  In the former, there is violent and frequent
   vomiting—in the latter, this  rarely  occurs.   Warm
   drinks excite instantaneous vomiting, in gastritis—in
   spasm, they do not.   The  pain of gastritis is continu-
   ous—that of spasm is paroxysmal or intermitting.   In
   gastritis, the patient lies on his back, without  moving,
   with his knees drawn up—in  cramp, he sits up, with
   his body  bent forward, or writhes about during the vio-
   lence of the pain.  In gastritis, the skin is hot  and dry
   —in cramp, it is generally cool and moist.  Hiccough
   is a common symptom in gastritis—in spasm, it sel-
   dom occurs.
 Autopsic phenomena.  The inner coat of the stomach
   thickened and red, with gangrenous, eroded, or ulcer-
   ated spots.
 Causes.  Mechanical irritants; poisons; cold water, swal-
   lowed while the body is in a state of free perspiration;
   over-distention with food or drink; the sudden applica-
   tion of cold to the surface; suppression  of habitual dis-
   charges, &c.
Treatment.  Bleeding; the smallness of the pulse and
   prostration in the beginning of the disease, no objec-
   tion, but on the contrary a strong indication of the ne-
   cessity of prompt and copious depletion.  The pulse
   becoming fuller and less frequent, is an evidence that
   the disease is yielding.
Blisters over the epigastrium, are next in importance  to
   bleeding;  they are  to be preferred to leeching, and
   should be early applied.  Costiveness must be obviated
   by  enemata.   Cathartics, and the usual internal anti-
K 
74
CHRONIC GASTRITIS.
  phlogistics wholly inadmissible.  Copious draughts of
  bland, mucilaginous drinks, beneficial.
Opium, a valuable remedy in this disease: after the vio-
  lence of the local and general  inflammatory excite-
  ment has been  moderated by depletory measures, I
  know of no remedy that is so  useful in allaying the vo-
  miting and gastric pain, and  producing a general and
  salutary diaphoresis, as opium in large doses.  I have
  given two grains of this narcotic, in some exceedingly
  violent cases, with the happiest effect.

                CHRONIC  GASTRITIS.

Chronic inflammation of the mucous membrane  of the
  stomach, is of much  more frequent occurrence than is
  generally supposed.  The .worst forms of dyspepsia,
  and all that host of  inveterate gastric and bilious de-
  rangements, of which  so much*is heard,  and the true
  nature of which  is so often misunderstood, are, in nine
  cases out of ten, the consequence of a more  or less
  phlogosed  condition of the mucous membrane of the
  stomach.  We are  indebted  to the French patholo-
  gists, and more especially to  Broussais, for much new
  and valuable information, in relation to this  variety of
  phlegmasial disease.  Pract.  of Med. p. 191.
Symptoms.  A pricking, lancinating, or burning pain in
  the  epigastric or hypochondriac region; the  pain  is
  constant and harassing, generally confined to a very
  circumscribed spot, and  often attended with a feeling
  of constriction;  sometimes a  sensation is felt,  as if a
  ball were pressing on the diaphragm;  at others, as if
  a bar were fixed across the stomach, impeding degluti-
  tion ; depraved  and impaired appetite, often  general
  abhorrence of food; indigestion,  vomiting, or nausea;
  load at the stomach after eating; pulse but little excited,
  and heat of  the surface natural, except during diges-
  tion, when they are a  little elevated; great costiveness
  during the first  period, but mucous diarrhoea after the 
CHRONIC  GASTRITIS.                 75
disease has become  inveterate;  the patient becomes
irritable, dejected, taciturn, discontented; tongue of the
color of logwood, with a strip of thin fur along its cen-
tre.   In  inveterate  cases,  emaciation,  with  the skin
drawn  tight over the muscles, so  that it cannot  be
pinched  up.   This tightness of the skin  is the  most
constant diagnostic sign of the  disease.   Mere gastric
debility may be distinguished from  it by the effects of
an emetic: when fever, pain, and  anorexiar  become in-
creased after the operation  of an emetic,  we may  be
sure  of the existence of  high irritation, or phlogosis,
in the mucous membrane of the stomach.

        Mr. Barras has published some interesting observations, in
        the Revue Medicale, for November and December 1825, on
        gastralgia, and the frequency with which it is mistaken for
        gastritis.  He gives the following,  among others, as diag-
        nostic symptoms between those two affections.

      I. "In chronicgastro-enteritis, the  pain is generally obtuse;
        often felt only on pressure,- is never absent.   Gastralgic pain,
        on the other hand, is often extremely violent; is often, when
        most violent, relieved, rather  than increased by  pressure.
        It often radiates from the epigastrium towards the thoracic
        parietes, the  back, and the shoulders; is  of  an intermittent
        character, sometimes entirely disappearing,  to return with
        more or less violence.

      2. In chronic gastritis, the tongue,  which is generally  red on
        the sides and at the top, is covered in the  middle with a kind
        of dry mucous crust, resembling  a false  membrane, the
        breath is fetid, with a bitter taste in the mouth; there is thirst.
        In gastralgia, the tongue is white; saliva abundant, no
        thirst, but sometimes a repugnance even to liquids.

      3. In gastritis, the appetite is  always bad, and  sometimes
        amounts to a universal disgust towards every kind of food.
        In gastralgia, the appetite is variable, null, slight, natural,
        often greater than in health.

      4. In chronic gastritis, the ingestion of a small quantity of food
        renews the patient's sufferings; excites a febrile movement in
        the system, and the digestion is always imperfect.  There is
        often rejection of the food by vomiting, a little  time after  eat-
        ing; or if there be no vomiting, the patient is oppressed dur-
        ing the digestive process, with  a sense of  weight, distention, 
CHRONIC  GASTRITIS.
  nausea, acid or acrid eructations, and irritation of the bow-
  els, or diarrhoea, in the advanced stages.  In some cases of
  gastralgia, the pain is relieved, at least for a time, by eat-
  ing food in considerable quantity, and the digestion is com-
  plete, or even too quick.   In the generality of cases, howev-
  er, of gastralgia, the presence of food in the stomach renews
  the pain; but not fill some time after eating, generally  one,
  two, or even three hours; at which time  the  patient expe-
  riences weight and mal aise at the epigastrium, as if there
  was a foreign body in the stomach.   There are nausea,  bor-
  borygmi, flatulent colic, eructations of air, but without fetor
  or causticity.   Sometimes indeed, patients will taste the ali-
  ments that they  have swallowed in the  air which  they
  eructate, but digestion  is completed,  and diarrhoea is very
  rare.   Constipation is  generally  obstinate, and  the urine,
  especially when the gastralgia is in a high degree, is usually
  pale,  voided frequently, and in small quantities at a time.

5. Chronic gastritis never fails to impair the process of nutri-
  tion, inducing hectic fever, characterized  by  hardness  and
  frequency of the pulse, heat of the skin, and evening exacer-
  bations, with loss of flesh and  strength, sallowness of the
  countenance, with a peculiar dark tinge, and finally death.

6. In some violent and  prolonged cases of gastralgia, the  pa-
  tients experience difficulty of breathing, palpitations of the
  heart, wandering pains, and peculiar  sensations of coldness,
  and especially in  the  arms, loins,  and  lower extremeties.
  The sleep is sometimes good, sometimes agitated, sometimes
  null;  yet, in the mornings, the patient g'e'ts up refreshed, and
  feels quite well, till  breakfast renews the gastric sensibility.
  Nothing of this kind obtains in latent gastritis.
7. Those who are affected with chronic  inflammation of the
  digestive tube, are melancholy, morose, and impatient; but
  this is nothing to the state of moral depression and anxiety
  which obtains in gastralgia,   In this last, there is ineffable
  despondency; disgust of life, or fear of death in the extreme;
  the slightest sensation  in the stomach, awakens the patient's
  terrors; he is tremblingly alive to  every look of his physi-
  cian—to every word which is spoken by his friends respect-
   ing his complaint; he  is afraid of taking any thing  into his
  stomach, as he knows, by  doing so, he  will aggravate the
   complaint; he is convinced  that his disease  is mortal—be-
   comes entirely absorbed by his own sensations, and indiffer-
   ent to every thing else.  But any diminution or cessation of
   the gastralgia, immediately changes  the scene from despair
   to sanguine hope—to be again reversed on  the  slightest ac-
   cession of the pain." 
ACUTE ENTERITIS.
77
Causes.   Indigestible and irritating diet; acrid medicines
  received into the stomach; the abuse of spirituous li-
  quors ; exposure to a cold and damp atmosphere; fre-
  quently the consequence of acute gastritis.
Treatment.   Almost the whole remediate management
  depends on the proper regulation of the diet, together
  with the employment of leeches or blisters to the epi-
  gastrium.   The food must be chiefly liquid, and as
  mild as possible; mucilaginous fluids, such as decoc-
  tions of barley, rice, or thin gruels, are the best articles
  of food; animal jellies are proper—so is boiled milk,
  with water.  I have found small doses of ipecacuanha
  and calomel in combination, decidedly advantageous;
  —one-eighth of a grain of the former, with one fourth
  of a grain of the latter, may be administered three times
  daily.   A  weak  emulsion of bals. capaiva  has  also
  been found serviceable: this article, though irritating,
  has a peculiarly beneficial operation in  chronic phlo-
  gosis of the mucous membranes.

                  ACUTE  ENTERITIS.

Symptoms.   Fixed, burning pain in the abdomen, gene-
  rally about the umbilical region; obstinate constipation,
  nausea  and vomiting, the latter being sometimes so se-
  vere,  as to communicate inverted action to the intes-
  tines,  and  produce stercoraceous discharges by the
  mouth;  fever, with a small, frequent, and  tense pulse;
  very rarely, the pulse is full and hard; dry and red
  tongue,  urgent thirst; dry and hot skin; urine  high co-
  lored, and  small in quantity; respiration short, and per-
  formed  by  the intercostals exclusively; position on the
  back, with  the knees and  shoulders elevated.
    When the upper  part  of the colon is affected, acute
  enteritis is often attended by symptoms of pleuritic or
  hepatic  inflammations.
Diagnosis.   In pleurisy, the pulse is full  and hard—in
  enteritis it is small and tense; abdominal respiration in 
78
acute enteritis.
   pleurisy—not  so  in  enteritis;  abdomen tender, and
   painful to pressure, in enteritis—not so in pleurisy.
     Spasmodic pain distinguished from enteritis, by: the
   paroxysmal character of the pain; the constant change
   of position; the ease obtained by pressure on the abdo-
   men ; natural temperature and moisture of the skin, and
   the want of thirst, which characterize spasm of the in-
   testines.  The reverse, in all  these circumstances, ob-
   tains in enteritis.
     The only favorable termination is in resolution; sup-
   puration is rare; gangrene is more common, and is al-
   ways fatal.   The disease would seem sometimes  to
   prove fatal, without any of the usual terminations of in-
   flammation.  Pract. of Med. p. 199.
Prognosis.  Always very uncertain; an almost imper-
   ceptible pulse,  with cold hands and feet, indicate great
   danger; diffusion of the pain throughout the abdomen
   dangerous; tumid and tympanitic abdomen, a bad sign;
   frequent vomiting, in the latter stage, highly unfavorable.
Treatment.  Copious  depletion in the early stage.   Dif-
   ference of opinion  concerning the propriety of employ-
   ing active cathartics; mild laxatives very useful; dras-
   tic purgatives,however,are improper; decisive bleed-
   ing  an essential preliminary to the  use of laxatives;
   calomel, or castor oil, in conjunction with opium, good
   articles for the  purpose.   Opium an important remedy
   in the latter period of the disease, after the violence of
   the local and general inflammatory excitement has been
  .moderated by depletory remedies.  It promotes the
   operation of purgatives, determines to the surface, pro-
   duces diaphoresis, and relieves the distressing pain suf-
   fered in this disease.  When opium is given, it should
   be in large doses.  Two grains may  be given every
   two  hours.   Pract. of Med. p. 201.

       Large doses of opium have a much less tendency to increase  or
       support the  inriammatory diathesis, than small ones. The sen-
       sibility and irritability of the system are greatly reduced, by a
       large dose of this valuable narcotic;  and with them, all those 
DYSENTERY.
79
     morbid phenomena which depend on, or are influenced by, a
     preternaturally sensible state of the system, are moderated.

  Blisters to the abdomen are indispensable. ^ Leech-
ing, and fomentations are recommended; blistering,
however, is preferable.
  The ordinary internal antiphlogistic remedies fre-
quently do harm.  Mild diluents, of the mucilaginous
kind, very useful; great attention to the diet, necessary
during convalescence; the most unirritating food is
alone admissible.
In the variety of enteritic inflammations noticed above, the
   inflammation is seated  chiefly,  if not exclusively, in
   the peritoneal coat of the intestines.   Obstinate costive-
  ness is an essential symptom of this form of the disease.
  There is another variety of acute enteritis, in which the
  mucous membrane of the intestinal tube is  the exclu-
  sive seat of the inflammation; and which is  essentially
  attended by mucous stools, more or less ntixed  with
  blood, and by tenesmus.  This  latter form of the dis-
  ease constitutes:
                     DYSENTERY.

Character.  In inflammation of the mucous membrane of
  the intestinal canal, attended by  fever, frequent bloody
  or mucous stools,  griping,  and  tenesmus.  Pract.  of
  Med. p. 206.
Symptoms.   The fever  generally becomes  developed,
  before the enteritic symptoms— sometimes the reverse
  takes place.  The violence of the tenesmus, a  pretty
  correct criterion of the violence of the disease; tormina
  most  severe, just before the calls to stool; constant
  soreness of the abdomen; evacuations sometimes whol-
  ly mucous; more commonly mixed with blood—occa-
  sionally, altogether blood; smell of the stools, at first, dis-
  agreeable, but not  fetid—towards the last, of a cadav-
  erous, penetrating fetor.   In violent cases, colliquative 
80                  DYSENTERY.
   diarrhoea sometimes come on, a few days before death.
   Tongue at first white, afterwards  brown,  rough, and
   dry along the middle, with a red  and moist border;
   clean and florid along the edges and tip, or smooth,
   clean, and deep red over its whole surface, in protract-
   ed  cases.  In some very protracted cases, the tongue
   and fauces become aphthous.   The stools are never
   colored with bile.  The skin is always dry.
Autopsic appearances.  The traces of inflammation are
   sometimes confined entirely to the colon; more com-
   monly, however, marks of inflammation appear through-
   out the whole intestinal canal;  but even  where this is
   the case, the colon and rectum exhibit much stronger
   marks of disease than the other portions of the intes-
   tines.  Very frequently, the mucous membrane of the
   colon and rectum  is found ulcerated, thickened, soft,
   pulpy.   The liver is frequently found to  have suffered
   structural derangement; it is most commonly enlarged,
   and in a state of great sanguineous congestion. Pract.
   of Med. p. 208.
Causes.  Checked  perspiration, by the application of
  cold.  Analogy between dysentery and catarrh, found-
  ed on the similarity of their aetiology.   Suppressed
   perspiration always among the first morbid phenomena
   of dysentery.  Deranged function of the  liver and the
  skin are invariably present.  (Johnson.)   " The period
  most favorable for the production of dysentery, is when
  a cold and  moist autumn succeeds a warm and dry
  summer." (O'Brien.)   Dysentery appears often to be
  the  production of  the joint influence of atmospheric
  vicissitudes and marsh miasmata,   Sporadic causes,
  such as, unripe fruit; indigestible and unwholesome
  food;  irritating  substances received into the bowels.
  Not contagious.   Scyballa have been much accused
  of giving rise to dysentery; the correctness of this accu-
  sation is denied by Dr. Johnson, and I believe very
  justly.  I have seen a very great number  of dysenteric
  patients; and yet the number of cases in which I have 
DYSENTERY.
81
  noticed the discharge of these hardened balls of faeces,
  is exceedingly small.
Prognosis.  Cases in which the stools consist almost en-
  tirely of blood, are generally more tractable than when
  the discharges are principally mucous.   Colloquative
  diarrhsea, at an advanced  period, very unfavorable;
  stools of a penetrating and cadaverous smell,  a  very
  bad sign.  Tympanitis,  with small mucous stools, or
  with fetid sanious discharges  from the bowels, highly
  unfavorable.   A small,  frequent  pulse, with a  sunken
  and  cadaverous countenance, hiccough, and cold ex-
  tremities, indicate a fatal termination.   Bile appearing
  in the  stools, is a favorable  sign.
Treatment.  The indications are—1.  To moderate the
  febrile excitement,  when excessive; 2. To restore the
  functions of the skin and liver; 3. To subdue the local
  inflammatory affection of the bowels.
        In estimating the comparative importance of these indications,
        it is necessary to recollect, that suppression of the cutaneous
        exhalation, and consequent torpor of the liver, with an engorg-
        ed state of the portal circulation, is antecedent to and causative
        of the intestinal phlogosis, and that the reaction of the  heart
        and arteries is consecutivs to this local inflammation.
        From these circumstances, therefore, it seems evident that the
        restoration of the cutaneous and hepatic  functions, constitutes
        the most important indication in the treatment of this malady;
        for in proportion as we succeed in the  fulfilment of this in-
        dication, so do we equalize the circulation, lessen the determin-
        ation to the bowels, and consequently moderate the  local in-
        flammation upon which the peculiar symptoms of the disease
        depend.
Bleeding. A very important and often indispensable aux-
  iliary remedy, though rarely in itself sufficient  to cure
  the  disease,  Analogy between dysentery and rheu-
  matism, in this respect.   Vide Pract.  of Med. p. 213.
Purgatives.  Constant and active  purgation, injurious;
  mild laxatives,  however,  should be  repeated  almost
  daily; calomel, succeeded by  a dose  of castor  oil; or
  this  latter article alone, are excellent laxatives in this
  disease.  Purgatives  advantageously given in conjunc-
                            L 
82
DYSENTERY.
   tion with opium.   Spirit,  tereb. given with ol. ricini,
   often renders the operation of the latter  more certain
   and  less painful.   (Cheyne.)  This is  confirmed by
   my own experience.  Cream of tartar recommended
   as a purgative.  (Cheyne.)   Modus  Operandi of pur-
   gatives in the cure of dysentery.
Emetics too much neglected  in dysentery.   Most writers
   recommend tartrate of antimony.   I regard ipecacu-
   anha as the best emetic in this disease.  Emetics not
   useful or proper in the latter period of the disease; their
   beneficial operation confined to its commencement.
Diaphoretics are among the  most  valuable  curative
   means in this disease.  The bowels having been ade-
   quately evacuated by mild laxatives, and bleeding hav-
   ing been practised, where  the violence  of  the febrile
   symptoms  demanded,  diaphoretics,  in conjunction
   with calomel, is the sheet-anchor of our hopes.   Do-
   ver's powder, a peculiarly  excellent  diaphoretic in this
   complaint, on account of its conjoint anodyne and dia-
   phoretic operation.  Six grains of this article, with
   three or four grains of calomel, may be given every six
   hours.   A combination  of  calomel, opium,  and anti-
   monial powder, an  excellent diaphoretic anodyne.
   (O'Brien.)  Cullen's objections to opium, in this  dis-
   ease, noticed  and refuted,   Observations on the great
   usefulness of this narcotic  in dysentery.
        Dr. Cheyne states, that, in  the epidemic dysentery which pre-
        vailed in Ireland a few  years ago, he met with many cases in
        which the ordinary plan of treatment by  diaphoretics, purga-
        tives, and calomel, made no impression on the disease.  These
        cases were attended by intolerance of slight pressure on the ab-
        domen, agonizing pain, unceasing tenesmus, \hegreat pyrexia.
        In these cases, he derived the greatest advantage from opium,
        in four  or five grain doses,  in conjunction with bleeding, and
        scruple doses of calomel.
Calomel, with a view to its specific or constitutional ope-
   ration,  a valuable remedy in this disease.   Ptyalism
   only proper in very protracted or chronic cases.   Its
   beneficial operation chiefly dependent on its powers to 
CHROVIC ENTERITIS.
83
   excite the various  secreting organs, particularly the li-
   ver, which is always torpid and congested in dysentery;
   and on its tendency  to equalize the circulation.
 Blisters, leeches, or emollient poultices to the abdomen,
   often highly beneficial.
 Anodyne Enemata,  relieve the distressing tenesmus and
   tormina.   The warm bath is also a very useful auxi-
   liary remedy.
 Balsam capaiva, a valuable medicine in chronic dysen-
   tery.   (Pemberton, Cheyne, and Johnson.)
 Astringents may, under certain circumstances, be advan-
   tageously employed; generally speaking, however, they
   do more harm than good.  Other remedies mentioned,
   and their merits discussed.

                CHRONIC ENTERITIS.

This modification of enteric inflammation, is of frequent
   occurrence.   Its  symptoms  are  often  obscure and
   equivocal.  Most of the cases usually termed maras-
   mus, consist of chronic inflammation of the  mucous
   membrane of the bowels.   Chronic diarrhoea also ge-
   nerally depends on this grade of  internal  phlogosis,
   Pract. of Med. p. 221.
Symptoms.  No distinct abdominal pain; obtuse pain on
   firm pressure on the abdominal parietes; a sense of
  soreness also is felt; muscular debility; pulse small and
  weak;  cold hands and feet; slight febrile exacerbations
  in the evening; pain in the bowels, or nausea, after tak-
  ing food; frequently  constant diarhcea;  in inveterate
  cases, the skin is dry and sallow;  sleep  interrupted;
  tongue smooth and red round the edges, and brown in
  the middle; great emaciation; painful diarhcea, alter-
  nating  also with costiveness;  appetite variable, being
  sometimes voracious, at others entirely^gone; the food
  is often evacuated  from the bowels, in an imperfectly
  digested state;  the  alvine evacuations vary in appear-
  ance; sometimes slimy and small in quantity, at others 
84
CHRONIC  ENTERITIS.
  copious,  liquid, and dark.   The disease continues for
  many months, and even for  several years.
Causes.  Sometimes the consequence of acute phlogosis
  of the mucous membrane of the bowels; irritating and
  indigestible food; the influence of a cold and damp at-
  mosphere ; drastic cathartics, and other irritating sub-
  stances, whether received from without, or  generated
  in the bowels.
Treatment.  Leeches, or blisters to the  abdomen; the
  former are generally thought the most  valuable.  Al-
  most every thing depends on proper dietetic regulations.
  The food should be of the mildest kind, and " such as
  leaves the least  feculence to pass along the intestines."
  A liquid farinaceous diet  must be enjoined; animal
  food, in a solid form, is improper.   Barley, rice, oat-
  meal, tapioca, &,c. are to be used in the form of soup,
  or gruel.  Over-distention of the stomach, even by the
  mildest food, is highly injurious.  Mild laxatives are
  to be occasionally given; active articles of this kind, in-
  jure ; castor oil will answer.
Balsam copaiva, a very valuable remedy.
Spir.  terebinth, given in emulsion, often highly useful.
          It may appear inconsistent to recommend balsam capaiva
        and spirits of turpentine, in this affection after having declar-
        ed that the most unirritating diet is a sine qua non on its  treat-
        ment, and that active cathartics are injurious,, on  account of
        the irritation they produce in the phlogosed structure.
          Whatever may be the conclusions of reason, on this subject,
        experience, which is always our best  instructor, teaches, that
        both the articles in question are often decidedly  beneficial in
         the present variety of intestinal  phlogosis. There is nothing
        more extraordinary in this, than in what  is observed' in the
        treatment of some other varieties of inflammation.  In catar-
         rhal ophthalmia, soothing applications are undoubtedly pro-
        per; yet the application of a weak solution of lunar caustic, or
        of small portions of precipitate ointment, will very  frequently
        produce an immediate amendment in  the disease,  whilst as-
        tringent washes seldom fail  to do mischief.

Opium, with calomel, in small doses.   The pulv. ipecac.
  composit.; mucilaginous  drinks; and  minute doses of
  pulv. ipecac., may be employed with benefit. 
ACUTE PtEURITIS.
85
CHAPTER  XII.
INFLAMMATION  OF  THE LUNGS,  AND THEIR
                  APPENDAGES.


                 ACUTE PLEURITIS.

Symptoms. Pungent pain in the chest, much increased by
  inspiration; cough dry, or attended with  a glairy and
  nearly colourless sputa; pulse full and hard; difficulty
  of lying on one side; respiration chiefly performed by
  the abdominal muscles.  When the inflammation ex-
  tends to the substance  of the lungs, there  is generally
  bloody expectoration.
Causes.  Sudden exposure to cold, when the body is in
  a state of free perspiration; atmospheric  vicissitudes;
  metastases of gout, erysipelas, acute and chronic cuta-
  neous affections, suppressed  catamenia, rheumatism.
  It appears sometimes to depend on epidemic causes.
Autopsic phenomena.   The pleura is red, and punctu-
  ated with an infinite number of red points; frequently
  covered with an immense number of milliary tubercles;
  false  membranes sometimes  adherent  to its internal
  surface; adhesions between  the pleura  costalis  and
  pleura pulmonalis; occasionally, effusions of sero-puru-
  lent,  or serous fluid, into the chest.   Pract. of Med.  p.
  280.
Prognosis.  Acute pleurisy not a very dangerous disease;
  its conseqences to  be dreaded, in persons predisposed
  to phthisis; the more the inflammation extends to the
  lungs, the more danger; the supervention of diarrhoea,
  a fatal sign; convulsions and coma no less unfavorable. 
86
PERIPNEUMONY.
                   PERIPNEUMONY.

In peripneumony, the inflammation is seated principally
  in the substance of the lungs.  It is characterized by
  the following
Symptoms.   Difficult and oppressed breathing; dull pain
  in the chest; cough, with viscid sputa, mixed frequently
  with blood; pulse at first hard; afterwards weak, soft,
  obstructed,and irregular; inability to lie on the sound
  side; the sputae are  of yellowish, or greenish white;
  exceedingly tenacious; somewhat diaphanous, and  in-
  termixed with bubbles of air.  (Lsennec.)
Autopsic phenomena.   The structural changes classed
  under three heads.
     1. Engoument, or choked lung.  Lungs partially
       crepitous, of a  livid color, containing an abun-
       dance of frothy, serous fluid, in its substance.
     2. Hepatized lung.  Lungs not crepitous; resembl-
       ing the  liver in weight, consistence, and color,
       having entirely lost its cellular structure, and ac-
       quired a granulated appearance, with no extrava-
       sated fluid in its substance.
     3. Hepatized and granulated structure, with  an
       abundance of an opaque, yellowish, viscid  mat-
       ter, in its substance.  This fluid is the result of
       pulmonary suppuration.  (Lseannec.)
Diagnosis.   Peripneumony, distinguished from pleuritis,
  by:  (Pract. of Med. 286.)
Percussion.  Inperipneumony, the sound of the diseased
  side is obscure, and differs from that produced on the
  sound side, which is more clear.  In pleurisy, percus-
  sion produces the same sound on both sides.  Pressure
  made on the abdomen, in pleurisy, does not aggravate
  the pleuritic pain; in peripneumony, strong abdominal
  pressure  immediately  excites  distressing involuntary
  cough, oppression, and a sense of suffocation.  Posi-
  tion.   In pleurisy, the patient lies on the affected side; 
PERIPNEUMONY.
87
   in peripneumony, on the sound side.   Pressure on the
   intercostal spaces, produces pain in pleurisy, but not in
   peripneumony; the pain in the former is lancinating, in
   the latter it is dull.
Prognosis.   Favorable signs: a copious expectoration
   of a thick  yellowish  matter; increased discharge  of
   urine; general, but not profuse perspiration, with an
   abatement of the pain, oppression, and cough.  Unfa-
   vorable signs: pain and oppression diffused, dry cough;
   or thin dark colored expectoration; countenance livid;
   great dyspnoea; weak, soft, and frequent pulse; deliri-
   um; coma; internal feeling of cold, while the  surface
   is hot; a copious and limpid urine in the  commence-
   ment; rattling in the chest; disposition to  elevate the
   head and shoulders, and bare the breast.
Treatment.   Bleeding; all important; to be  employed
   more cautiously in the advanced periods of  peripneu-
   mony, than in pleurisy.  Blisters to the thorax, indis-
   pensable ; more efficacious than leeches; should be early
   applied.  Cathartics, of the  drastic kind, improper;
   mild laxatives beneficial.    Emetics  seldom useful.
   Diaphoretics  of considerable advantage; nitre, with
  tart, antimony, commonly employed; muriate ammo-
  nia, instead of nitre, recommended by Richter; I have
  often found it decidedly beneficial.  Expectorants very
  useful, after the general febrile excitement has been mo-
  derated; the mildest and least stimulating articles of
  this class, should at first be  used.  I have found the
  following a most excellent expectorant, R. extract, gly-
  .cvr-:  3Jj. Kermes mineralis, gr. xv. tinct. thebaic, gr. xl.;
  infus.  polygalse seneg.  sviii. M. dose, a table-spoonful
  every two hours.  Opium, in conjunction with calo-
  mel, a most valuable medicine in peripneumony, after
  the disease has continued three or four days.  When
  the expectoration is copious,  and of a proper consis-
  tence, opium should be given in very small quantities.
  The pills of Pariset answer a good purpose, under such
  circumstances—they consist  of a fourth of a  grain of 
88
PNEUMONIA BILIOSA.
  opium, with a twelfth of a grain of tart, antimony—one
  to be taken every four hours.  In pneumonic inflam-
  mation, from repelled cutaneous eruptions, measles, or
  scarlatina, camphor is, according to Richter,]a valua-
  ble remedy—particularly when combined with pulv.
  ipecac, compos.  Mucilaginous drinks, &lq.

                  PNEUMONIA BILIOSA.

This variety of pneumonia [is produced by the combined
  agency of marsh miasmata, and sudden atmospheric
  vicissitudes.  Pract. of Med. 283.
Symptoms.   Along with the ordinary pectoral symptoms
  of pneumonia,  there  are others, indicative  of much
  functional derangement of the hepatic system, such as:
  fulness in the right hypochondrium; pain in  the back
  andfimbs; yellowness of the tunica albuginea and skin;
  sometimes mucous and bloody discharges  from  the
  bowels, with  tenesmus and acute head-ache.  These
  symptoms  generally  precede the occurrence of the
  thoracic  affection, for  several days.  The [attending
  fever is somewhat remittent; bilious vomiting is fre-
  quent ; tongue covered with a brown fur; pulse  com-
  monly small, quick, frequent, and slightly tense.
Treatment.   Great discrepancy of opinion on this sub-
  ject; some recommend very copious bleeding—others
  condemn it, and I think with propriety.
Emetics are of primary importance.   Gentle  laxatives
  are to be daily employed—for this  purpose, calomel,
  with ipecacuanha, answers exceedingly well; from ten
  to fifteen grains of the former, and six or eight grains
  of the latter, generally vomits once or twice,  and pro-
  cures several bilious stools  afterwards.  Blisters less
  serviceable in this than in the preceding varieties of
  pneumonia.  Opium, in conjunction with calomel, a
  remedy of great value.  Expectorants,  useful; diapho-
  retics of minor consequence. 
ACUTE  BRONCHITIS.
89
                 ACUTE BRONCHITIS.

 This variety of pulmonary inflammation is generally de-
   scribed under the  name of peripneumonia notha.  It
   consists of acute inflammation of the mucous mem-
   brane of the bronchia,  with great sanguineous con-
   gestion of the  lungs.   Much of the peculiar charac-
   ter of the disease depends on  this congestion.  Old
   people and infants most subject to it.
 Symptoms. Great oppression and tightness in the breast;
   cough; severe pain in the forehead, greatly increased
   by coughing;  expectoration; at first, a  viscid, and
   frothy white mucus, becoming mixed with blood, as
   the disease advances; sometimes vomiting; febrile ex-
   citement not violent; pulse, and heat of the  surface, not
   much above the natural standard; tongue moist and
   white; countenance pallid; little or no pain in the
   chest; the pain is dull, and attended with very oppress-
   ed breathing; vertigo; delirium seldom; wheezing re-
   spiration.
There is in this disease a particular tendency to  effusion
   into the substance of the lungs; and it is generally from
   the occurrence of this circumstance, that the disease
   proves fatal.
Autopsic phenomena.   The lungs do  not collapse;
   bronchia filled with a tough mucus, mixed with bloody
  serum and pus; a frothy fluid escapes from the substance
  of the lungs, when cut into; capillaries of the  mucous
  membrane, red  and enlarged; sometimes the pulmon-
  ary structure is  more or less hepatized. The  mucous
  membrane of the bronchia is manifestly the principal
  and primary seat of the disease.
Prognostic  observations.  Ratio Symptomatum.  Diag-
  nostic phenomena.
Treatment.   Moderate bleeding, in  the  commence-
  ment, often beneficial—hazardous, after the disease has
  made some progress; cathartics of the active kind, in-
                         M 
90
CYNANCHE TRACHEALIS.
  jurious—not so, mild aperients.  Emetics among the
  most useful remedies, in this disease; they  may often
  be advantageously repeated two or three times.   Ex-
  pectorants of the  stimulating kind, such as polygala
  senega, and gum  ammonia, are beneficial.  Active
  stimulants must be given with the expectorants, when
  the pulse becomes very small, frequent, and soft.  Cam-
  phor, and carbonate of ammonia, are the most valuable
  for this purpose.  Opium, less serviceable in this than
  in the  preceding varieties of pneumonic  disease.  In
  the commencement of the disease, small doses of opi-
  um and calomel allay the cough, and promote expecto-
  ration ; but after expectoration is fully established, opi-
  um tends  to produce dangerous  engorgement of the
  bronchial cells, by allaying the desire to  cough, and
  consequently to expectorate  the  mucus so copiously
  secreted by the bronchial glands.  Blisters can never
  be omitted with propriety.   ] have seen much benefit
  derived from large  emollient poultices applied to the
  thorax.  Diaphoretics, of the mildly stimulating kind,
  are useful remedies in this disease- -such as: infusions
  of eupatorium, sage, balm, the spiritus mindireri, with
  laudanum, pulv. ipecac, compos. &,c.   The inhalation
  of the steam of warm vinegar and water.

    CHRONIC  PLEURITIS, AND CHRONIC  BRONCHITIS.

 As these two varieties of pulmonary  inflammation are ge-
- nerally attended with symptoms similar to  those which
  occur in phthsis pulmonalis,  I shall  treat  of them un-
  der the general head of Pulmonary Consumption.

                CYNANCHE TRACHEALIS.

 Character.   An inflammation of the glottis,  larynx, and
  upper part of the trachea, attended with a hoarse and
  ringing cough, sonorous respiration, and a  sense of suf-
  focation.
 Symptoms.   It  commonly  comes on gradually:—At 
CYNANCHE TRACHEALIS.
91
  first, a hoarse cough, with slight difficulty of breathing;
  afterwards fever, respiration becoming more and more
  difficult, each inspiration being attended with a pecu-
  liar ringing sound; countenance full  and flushed,
  during the first  stage.  The dyspnoea becomes at last
  exceedingly great; the head is thrown  back,  and the
  mouth kept open; the eyes are prominent, and the
  countenance pale, livid, and expressive of great agony;
  the breathing becomes wheezing, in the latter period of
  the disease; expiration is quick, inspiration difficult and
  slow; cough sometimes attended with a rattling sound,
  and the expulsion of very tough mucus.  Insensibility
  and stupor generally close the scene.  The symptoms
  occasionally remit for a short time.
 Causes.  Exposure to a cold and damp air, the most
  common cause; most prevalent in spring and autumn;
  children between the ages of  one and seven years, al-
  most exclusively  the subjects of this disease—it very
  rarely occurs in adults.  Proximate cause.
Ratio Symptomatum.   The suffocated respiration may
  depend on one or more of the following circumstances:
  —1.'Tumefaction and inflammation  of the glottis; 2.
  Obstruction of the glottis by  coagulable fluid, in the
  form of a false membrane or a concrete mass; 3. From
  the inflammation extending to the minute ramifications
  of the bronchia, and giving rise to effusion into the air-
  cells.
Prognosis.  The  disease is  always to be regarded  as
  highly dangerous.  The more the^inftammation extends
  into the bronchia, the greater the danger.  When the
  attack comes on suddenly, with high febrile excitement,
  there is more danger than  when its  approach is gra-
  dual.   Very shrill sounding cough and respiration, un-
  favorable.  In general, however, it is difficult to form
  a correct prognosis.  Pract. of Med. p. 305.
Spasmodic Croup, essentially distinct from inflammatory
  croup.   They may be distinguished by the following
  circumstances—viz.  Spasmodic Croup is sudden  in 
92                spasmodic croup.
  its attack, and unattended with fever—Cynache Tra-
  chealis  generally  comes  on gradually;  when its  at-
  tack is sudden, it is always with fever.   In the former
  there are intermissions,  in the latter remissions only.
  Cough,  with a discharge of viscid mucus from the
  trachea, always  present  in inflammatory  croup—in
  spasmodic croup, coughing is rare and always dry.
  In the latter,  no shrillness  of voice—the pulse small
  and contracted.
Treatment.  Bleeding, to syncope or an approach to it,
  in the early period, of the utmost  importance;  during
  bleeding, the feet  should  be placed  in  warm water.
  The advantages of bleeding almost entirely confined to
  the first stage.  Emetics  next in importance to bleed-
  ing.  Calomel, with a small portion of tart, antimon.
  an excellent article for this purpose—preferable, I.think,
  to tart, antimon. alone.   Emetics often operate  with
  great difficulty, after the disease has continued for some
  time—the cause of this  explained.  The  warm foot
  bath, the bleeding, promote  this  operation.  Emetics
  do good, by discharging the viscid mucus from the tra-
  chea, and by  equalizing  the circulation.*  Cathartics
  are valuable remedies, in  this disease.  Calomel is
  the best article for  this purpose—large  doses,  by
  exciting vomiting as well as purging, peculiarly benefi-
  cial.  Pract.  of Med. p. 306.

          From ten to fifteen grains may he given tc children of from
        two to five years old.  This quantity hardly ever fails to ex-
        cite active purging and vomiting. The nausea, consequent re-
        laxation produced by calomel, are generally of much longer
        duration than that which is caused  by the usual emetics; and
        in general, the impression made on the disease by this medi-
        cine, is much more permanent than  that  which results from
        the operation of other emetic and cathartic substances.

The tincture of lobelia inflata, very  useful  as an emetic,
  in this disease.  Errhines employed with benefit.
Calomel, with a view to its constitutional influence, high-
  ly recommended  by some.   Blisters and rubifacients 
CYNANCHE TONSILLARIS.
93
   to the throat, never to be neglected—the latter are pre-
   ferable, from the suddenness of their effects.  Spir. tur-
   pentine, with spir. camphor, excites inflammation in a
   few minutes.  The warm bath, a very useful auxilli-
   ary remedy.  Polygala senaga, useful in slight  cases,
   and for the sequalse of violent cases,  such  as a  dry
   and hoarse cough, with slight difficulty of breathing.
Kali  sulfuratum strongly  recommended, of  late in
   this  disease.   (Double, Mesner, Senff,  Albers,  Ju-
   rine.)

          This remedy does not deserve the praise bestowed upon it
        by some late continental writers.  It appears  nevertheless, to
        be useful in slight cases, aud is said to be particularly benefi-
        cial only about the period when the exudation of the coagula-
        ble fluid occurs.  (Raiman.)  Our success in the treatment
        of this disease, depends almost wholly on being able to subdue
        the tracheal inflammation  before the  exudation of  the viscid
        mucus fakes place; a vigorously antiphlogistic treatment, in the
        commencement upon which any reliance can be placed.  Af-
        ter the exudation has taken place, our principal objects should
        be, to expel the mucus from the trachea before  it has time to
        concrete, by the  occasional use of emetics.

The application of a  solution of lunar caustic to the upper
   partof the larynx,  and about the tonsils, has lately been
   recommended as useful in separating   the  false  mem-
   branes which form in and about the glottis, in  this dis-
   ease.

               CYNANCHE TONSILLARIS.

Character.  Inflammation of the tonsils, soft palate  and
   fauces, with synocha fever.
Symptoms.   Tonsils, and soft  palate,  red  and  much
   swollen; deglutition very painful and  difficult,—some-
   times impossible;  more  difficulty in swallowing liquids
   than solids; respiration impeded; speech indistinct;
   hearing dull; tongue swollen; white, and covered with
   a thick layer of transparent  mucus; pulse  full,  hard,
   and frequent; copious secretion of a ropy saliva. 
94
PAROTITIS.
Cause.   Cold and damp air; or cold in any manner ap-
  plied, so as to cause a sudden check on the perspiration,
  may be regarded as  the  exclusive cause  of this dis-
  ease.  Persons become predisposed  to the disease,
  by suffering  an attack of it.  The principal danger
  arises from the swelling of the tonsils, which may pro-
  ceed to the extent of entirely interrupting  respiration.
  When it does not end in  resolution, it almost  always
  terminates in suppuration.  Frequent attacks of the dis-
  ease are apt to produce permanent enlargement of the
  tonsils.  The inflammation has been known to extend
  into the larynx, in which  case the danger is greatly in-
  creased.
Treatment : strictly and actively antiphlogistic.  Scari-
  fying the tonsils;  emollient and acidulated gargles;
  warm pediluvium; blisters and leeches  to  the throat;
  emetics; nauseating doses of antimonials.

                     parotitis.

Character.  Inflammation and tumefaction of the parotid
  glands, occasionally epidemic,  and  manifestly  con-
  tagious.
Symptoms.  Hard swelling of one  or both parotids—the
  swelling increasing till the fourth  day, and then declin-
  ing gradually.  Skin over the  tumour seldom  red or
  inflamed; the breasts in females, and testicles in males,
  often  swell, about the period of  the declension of the
  parotid tumefaction; a sudden metastasis often takes
  place from the parotids to these parts.  Fever generally
  mild, sometimes violent.
Children, and young  persons are most subject to this dis-
  ease—it rarely occurs in old age.  It is most common
  during cold and damp weather.
Prognosis.   Not in general a dangerous affection; be-
  comes  more or less dangerous, by being translated to
  other parts—as the genital organs, the lungs, the brain,
  the stomach.   I have known a case  terminate fatally 
acute peritonitis.               95
  in less than an hour, by metastasis to the  brain; when
  transferred to the testicles, they occasionally suppurate
  —an occurrence always exceedingly painful, and some-
  times fatal.
Treatment.   In mild cases, little more is necessary than
  keeping the bowels open,  and using gentle diaphoret-
  ics.   The  parts  should be kept warm—great care
  must be taken,  to avoid taking  cold.  When the in-
  flammatory symptoms are violent, an active antiphlo-
  gistic treatment is necessary.   When the swelling dis-
  appears in the neck, and shows itself in the testicles, a
  blister should be laid on the parotids, and every effort
  made to excite a general diaphoresis.  To discuss the
  hard swelling which sometimes remains  after the in-
  flammatory symptoms have  disappeared, frictions on
  the tumour, with mercurial ointment, spirits of camphor,
  or rubifacient liniments, should be  used.
CHAPTER XI.
             ACUTE PEROTINITIS.

Symptoms.  At first, lassitude, pain in the  limbs; chills;
  then, head-ache, a sense of weight in the epigastrium;
  an acute pain in some part of the abdomen, at first con-
  fined to a  small space,  but soon extending itself over
  the whole belly: the pain is acute and constant—some-
  times fixed, and at others wandering from one part to
  another.   As the disease proceeds, the abdomen be-
  comes  tumid, and exceedingly painful to pressure
- I he patient's position is on his back, with  the knees 
96
ACUTE perotinitis.
   and shoulders raised, carefully avoiding all motion of
   his body.   The  bowels are constipated, and  moved
   with much difficulty; pulse commonly small, hard, and
   quick;  tongue white and moist, the edges and raphe
   being sometimes very red; nausea and vomiting, in
   the early stage; the face is generally pallid, exhibiting
   a peculiar sharpness of feature.  Constant wakefulness
   throughout  the whole course of the disease; delirium,
   except towards the end  of fatal cases, rare; breathing,
   in the latter period, laborious—inspiration being par-
   ticularly difficult, and attended  with an expression of
   pain in the  countenance; suppression of urine, a com-
   mon occurrence.  When the disease occurs in the puer-
   peral state,  the lochia cease, and  the breasts  become
   flaccid.  Peritonitis is rapid in  its course.  Pract. of
   Med. p. 226.
Causes.  Mechanical injuries of the abdominal viscera;
   violent and  long  continued corporeal exertions; stric-
   ture of the colon  and rectum;  extravasations of blood,
   bile, urine, faeces, chyle, &c. into the cavity of the ab-
   domen; the  action of cold on the surface of the body;
   wet and cold feet; drinking cold water, when the body
   is in a  state  of free perspiration; perspiration; sudden
   suppression  of hemorrhoidal discharge of lochia, &,c.
Prognosis.  Favorable symptoms.  Abatement  of the
   pain.   Ability to bear abdominal pressure; a soft, mo-
   derately  full, and not  very frequent pulse; moist and
   warm skin;  free alvine evacuations; power of changing
   the position, and  resting easy on either  side; free dis-
  charge of urine;  restoration (if in the puerperal state)
  of the lochia;  refreshing sleep.   Unfavorable signs
  Suppuration, or effusion, is indicated by, diminution of
  abdominal pain; a feeling of weight in the hypogastric
  region; irregular chills;  coldness of the extremities,
  a soft and feeble pulse.   Gangrene, by sudden and en-
  tire cessation of pain; extreme smallness and frequency
  of the pulse, with  great prostration; Hippocratic coun-
  tenance. 
acute peritonitis.
97
 Autopsic phenomena.  Redness and thickening of the
   peritoneum; false membranes.  A collection of fluid,
   sometimes turbid or whey-like, at others  limpid  and
   reddish—rarely blood.   Adhesions between the bowels
   are common.   Gangrenous spots, and redjlakes ad-
   hering to the peritoneum.

        The dissections of Broussais, Abercrombie,*and others, show,
        that the peritoneum investing the stomach, intestines, liver,
        &c. may be inflamed, and even gangrenous, whilst the struc-
        tures of these*organs themselves remain perfectly sound.

 Treatment.  Prompt and very copious depletion in the
   commencement, is the principal remediate measure to
   be relied on   From thirty to forty ounces of blood,
   drawn soon  after the development of the disease, will
   often subdue it so much  as to secure a speedy success
   in removing it.  The benefit of bleeding is confined
   chiefly to the first twenty-four hours; during this  pe-
   riod, the bleeding may be repeated, two, three, or even
   four times, according to the violence of the inflamma-
   tory symptoms.
Leeching the abdomen, highly beneficial; after the leech-
   es are  removed, emollient poultices or  fomentations
   should  be applied.
Purgatives, of the active kind, do much  good; they
   should not be  given, until  decisive bleeding has been
   practised.  From the torpor of the bowels, large doses
   are required: the more active the  purgative, the more
   good will it do.  Calomel,  followed by castor oil and
   spirits of turpentine, decidedly the most valuable pur-
   gatives in peritonitis.   Calomel and jalap will often an-
   swer.
After the local and general inflammatory symptomsJiave
   been somewhat reduced by the foregoing means,* opi-
   um, in combination with calomel, is a remedy of great
   efficacy.  Cathartics  may be effectively employed, at
   the same time that opium  is used.  Large doses of
  opium in this  disease, as in enteritis, promote the ope-
                         K 
98              CHRONIC peritonitis.
  ration of cathartics.  (Armstrong and Johnson.)   The
  warm bath, a very useful auxiliary.  Blisters to the ab-
  domen, important.   Anlimonials seldom admissible,
  on account of the great gastric irritability.  If collapse
  ensues, wine  and ammonia must be given.  Diet of
  the simplest and most unirritating kind.

                CHRONIC PERITONITIS.
When not the consequence of the acute form of the dis-
  ease, its approach is so gradual and insidious, that it
  rarely becomes  the object of medical attention,  until
  organic disorder or effusion has taken  place.  Pract.
  of Med. p. 233.
Syniptoms.   A constant feeling of uneasiness in the ab-
  domen, with  soreness to pressure, or sudden motions
  of the body, as coughing;  sneezing;  the skin and ab-
  dominal muscles often lie loosely over the peritoneum,
  giving a sensation to  the touch, as if a  tight  bandage
  were underneath, over which  the skin and muscles
  easily slide.   (Pemberton.)  Sometimes, a sensation
  as of a ball rolling about the abdomen, is experienced.
  (Broussais.)  Pulse rarely affected, except towards the
  evening, when it becomes slightly accelerated.   The
  duration  of the disease very  variable—from a few
  months to several years.  Very  rarely  cured—Brous-
  sais, at first, thought it incurable.  It  always terminates
  either in effusion or disorganization of the peritoneum
  —most commonly, in  both these ways.  The effused
  fluid  is either serous, limpid,  whey-like, or  reddish,
  with purulent flakes; the peritoneum is  thickened, or
  covered with  an infinite number of milliary tubercles;
  the intestines are  often found  agglutinated into one
  mass.

        Most cases of incurable Ascites depend on  chronic inflamma-
        tion of the peritoneum, and consequent structural derangement.
        Indeed, it is not improbable, that in all cases of dropsy of the
        abdomen, the peritoneum is in a state of chronic or sub-acute
        inflammation.  In treating of Dropsies, this subject will be
       fully discussed. 
acute hepatitis.
99
Treatment.  External vesicating or rubifacient applica-
  tions  are of primary importance.  Blisters,  cupping,
  and frictions with tartar emetic ointment, are the bes ;
  moxa is a powerful agent.  Diuretics are recommen-
  ded.  Dr. Johnson speaks highly of the following diu-
  retic mixture.   R. acid tartar, ej. Sodse  carbon, gr.
  xxiv.  Infus. digital. 3ss.  Spir. nit. dulc.  3J.  Tinct.
  scilfce gtt. iv. Aq. menthse 3jj. m. ft.  This draught is
  to be taken  two or three times  daily.
Gentle laxatives, such as cream of tartar and acetate of
  potash are to  be employed.^  Small doses of calomel
  and diuretics given conjointly;  diaphoretics also; par-
  ticularly antimony with minute portions of opium may
  be beneficially employed.
Perfect rest and  quietness  are  of great importance.
  (Broussais.)   Anodynes—particularly hyocyamus,
  and conium maculatum, are serviceable.    A  simple
  and unirritating diet indispensable.

                  ACUTE HEPATITIS.

Symptoms.  Acute pain in the  right hypochondrium,
  aggravated by external pressure, and generally by lying
  on the left side; pain in the shoulder and clavicle of the
  right,—sometimes the left side;  commonly a dry cough,
  with difhculy of respiration; nausea and bilious vomit-
  ing; generally an icteric hue of the albuginea and skin;
  urine charged with bile; scalding of the urine; thirst
  great; heat of the surface intense;  tongue white, or
  covered with a yellowish fur;  pulse, hard,  full, and
  strong; bowels costive.  In hot climates,  acute hepa-
  titis is often attended from the beginning,  with small
  liquid and slimy discharges from the bowels.  These
  cases are violent and rapid in their progress, although
  the pain in the region of the liver is seldom very great
  (Johnson.)   Delirium more common in hepatitis, than
  in  any other of the  phlegmasial  affections,  except
  phrenitis 
100
ACUTE HEPATITIS.
The symptoms vary according to the part of the liver prin-
  cipally affected; more pain in the thorax and shoulder
  when the convex surface is inflamed; when the con-
  cave part is the seat of inflammation, there is more gas-
  tric distress, vomiting, aud  nausea.  Inflammation of
  the interior part, known by the great aggravation of the
  pain, on  external pressure.   Pract. of Med. p. 238.
Diagnosis.  Distinguished from pleurisy, by the greater
  severity of the cough and dyspnoea in the latter.  The
  easiest position in hepatitis, is on the affected side,—in
  pleuritis, on the sound side,  \n hepatitis, pressure on
  the right  hypochondrium aggravates the pain; pressure
  on the intercostal space does not—the reverse obtains
  in pleuritis; often bloody  expectoration in  pleuritis,—
  in hepatitis seldom  if ever.   In peripneumonia, as in
  hepatitis, jhe  patient lies easiest on the affected  side,
  but in the former, respiration is principally performed
  by the abdominal muscles, whereas, in the latter, by the
  intercostal muscles exclusively,   The  diagnosis be-
  tween hepatitis and gastritis not difficult—the extreme
  prostration—the immediate rejection by the stomach of
  every thing swallowed—the small and tense pulse, &c.
  which attend gastritis, distinguish it prominently from
  hepatitis.  The absence of fever, and the intermitting
  character of the pain, distinguishes spasm of the gall
  ducts, and the passage through them of biliary concre-
  tions, from hepatitis.  Pract. of Med. 242.
  Hepatitis, if it does  not end in resolution, generally ter-
  minates in suppuration.   The degree of danger from
  suppuration,  depends much on the situation of the ab-
  scess, and the  nature of the contiguous  parts.  When
  the abscess points outwardly, it may be opened by an
  incision,  and  the matter discharged externally.   It
  sometimes breaks into the bowels, the matter being dis-
  charged  by stool; occasionally it  bursts through  the
  diaphragm into the cavity of the thorax, or into the sub-
  stance of the lungs, in which latter case  the matter is
  expectorated.   Recoveries  after this latter  accident 
ACUTE HEPATITIS.
101
  exceedingly rare; always fatal when it bursts into the
  cavity of the abdomen.
Gangrene an exceedingly rare termination of hepatic in-
  flammation.  Doctrines of Saunders and Puchelt con-
  cerning the pathology of acute and chronic hepatic in-
  flammation, introduced and discussed.
Causes.   The influence  of cold after profuse  perspira-
  tion; violent exercise; contusions of the region  of the
  liver; wounds and injuries of the  cranium; the  irrita-
  tion of biliary concretions; suppression ofhoemorrhois;
  violent rage, or deep sorrow, excessive use of spiritu-
  ous liquors.  Dr. Johnson's cutaneo-lupatic sympa-
  thy, and its application to the aetiology of hepatitis, no-
  ticed.  Hepatitis most common in hot climates; solar
  heat and miasmata prominent agents in the production
  of this disease—they powerfully predispose to,  rather
  than excite the disease: heat excites the skin, and mi-
  asmata the liver, to inordinate action; the cold night
  air checks the former, and consecutively the latter; fe-
  ver is evolved, and inflammation established in the liver.
Treatment.  Bleeding, both with a view of reducing
  the general inflammatory condition of the system, and,
  by this effect, of promoting the operation of mercurial
  remedies.  Bleeding and mercurial purgatives, with
  an epispastic to the right hypochondrium, constitute
  the important remedies during the first few days. Hav-
  ing reduced, by adequate depletory measures, the ge-
  neral afebrile excitement, our main object must be to
  bring the  system under the influence of mercury  as
  speedily as possible.   Calomel and opium, in combi-
  nation, a very excellent article for this  purpose.
Purgatives of primary importance throughout the  whole
  course of this disease;  calomel should  form  a part of
  them.   Antimonials, with nitre, useful auxiliaries.

                CHRONIC HEPATITIS.

Symptoms.   Dyspeptic symptoms; countenance sallow
  contracted, and expressive of ill health; dull pain, with 
102              CHRONIC HEPATITIS.
  uneasiness, tension, and sometimes tumefaction  in the
  right hypochondrium;  bowels  irregular, commonly
  costive; sometimes diarrhoea alternating with costive-
  ness; aching pain in in the right shoulder; urine tinged
  with  bile,  and voided  with a  scalding  pain; tongue
  white, rather dry; gums unnaturally hard; a conti-
  nued dryness and constriction of the skin; difficulty
  of resting  easy on  the left side;  a short and dry cough;
  slight febrile exacerbations, as the disease advances;
  emaciation, and finally, hectic with a puruloid expecto-
  ration.
Terminations: occasionally in suppuration; more fre-
  quently in induration and enlargement; sometimes the vo-
  lume of the liver becomes contracted. Though indurated,
  and more firm in  its substance than natural, it is often
  specifically  lighter than  in its  healthy state.   (Saun-
  ders.)  The substance of the liver usually exhibits an
  ash or clay color.
Causes.  Chronic hepatitis sometimes the consequence
  of the acute form of the disease.  Most frequently the
  result of the slow operation of the same causes that
  produce acute hepatitis, i. e. the slow and constant ope-
  ration of marsh miasmata, &c.  The abuse of spiritu-
  ous  liquors, a common cause  of chronic  hepatitis.
  Protracted dyspepsia produces it,
Treatment.  A strictly antiphlogistic regimen, aided
  by mild aperients, and  blisters over the region of the
  liver, are  important auxiliary measures  for reducing
  slow hepatic inflammation.  Without mercury, howev-
  er, these remedies would be of little avail; it is upon
  this potent medicine that we must principally depend
  for success, in the treatmeut of hepatic  inflammation,
  whether of an acute or chronic character.  Ptyalism
  must be avoided-, the slightest manifestation of the mer-
  curial influence is sufficient.  A mild  and protracted
  course of mercury will do most good.   The nitro-mu-
  riatic acid bath, much extolled by Dr. Scott; it is un-
  doubtedly  a remedy of considerable power in the cure 
NEPHRITIS.
103
  of chronic hepatitis.  The nitric  and muriatic acids,
  in the  proportion of two drachms of each to a gallon
  of water, will make a bath of proper strength.  It should
  be heated to the temperature of 96°, and the feet and
  legs immersed in it for half an hour, just before going
  to bed.   Pract. of Med. p. 252.

                     NEPHRITIS.

Symptoms.  Pain in the renal region;frequent and small
  discharges of high-coloured urine; nausea and vomit-
  ing ; numbness of the thigh of the affected side; retrac-
  tion  of the testicle;  pain relieved by bending the body
  forwards or towards the  affected side; costiveness; skin
  hot and dry; pulse full and strong.
Diagnosis.  In inflammation of the psoas muscle, bending
  the body forwards increases the pain; there is no nau-
  sea and vomiting, nor retraction of the testicles, in this
  affection, as in nephritis.  Pract. of Med. p. 245.
Causes.  The influence of cold; mechanical injuries;
  irritating substances absorbed  into the circulation, as
  turpentine and cantharides; violent exercise, as jump-
  ing, lifting heavy weights; metastasis of gout and rheu-
  matism ; calculous concretions.
Unless resolution takes place before the seventh or eighth
  day,  suppuration generally ensues.   The pus some-
  times  discharged with  the  urine;  the  suppuration
  often continued for a long time—producing hectic and
  great emaciation, or  what has  been called  tabes re-
  nalis.    Sometimes  the  matter points externally; in
  which case, fistulous openings  are apt to remain.  A
  puruloid fluid in the  urine not to  be  confounded with
  pus.   The former may arise from mere irritation, from
  urinary calculi in the  kidneys, or sub-acute inflamma-
  tion of the neck of the  bladder.   Puruloid matter dis-
  tinguished from pus,  by the latter fluid sinking down
  and forming a close layer along the bottom of the ves-
  sel in which the urine is left standing;—puruloid fluid
  remains more  or less suspended in the urine.   Gan- 
104                    CYSTITIS.
  grenea very rare occurrence  in  renal inflammation.
  Pract. Med. 346.
Nephritis is apt to leave  a] predisposition to  lithic-acid
  calculi.  (Prout.)
  Treatment.  Decisive,  general, and local  bleeding.
  Cupping over the lumber region,  particularly  benefi-
  cial ;  active purgatives required; much relief obtained
  from emollient enemata, and constant fomentation to
  the regiou  of the  kidneys; warm bath; sinapisms;
  blisters generally condemned,  on  account of the  ten-
  dency of cantharides to irritate the urinary organs; I
  have found them highly beneficial, and never injurious.
  Anodyne enemata, after  the inflammation has been
  somewhat subdued, useful.  For the pain and soreness
  left by an attack of nephritis, uva ursi is a valuable re-
  medy—highly  useful, also, when suppuration or ulce-
  ration exists.  Opium advantageously given with uva
  ursi,  in nephritic cases; one fourth of a grain of the
  former, with fifteen or twenty grains of the latter, should
  be given thrice daily.  Nitre not a proper remedy in
  nephritis.   Antimonial  diaphoreties beneficial, if the
  stomach will^retain them.

                      CYSTITIS.

Symptoms.   Severe burning and throbbing  pain, with a
  feeling'of constriction in the hypogastric region;—pain
  greatly increased by pressure; constant and ineffectual
  desire to pass urine; pulse, frequent, hard, and full; skin
  dry and hot; thirst very  urgent;  great  restlessness;
  nausea and frequent vomiting; slilicidium of the urine;
  as the disease proceeds, swelling in the loins;  rigors;
  cold extremities; delirium,  &c.
Causes.  Mechanical irritation by the presence of foreign
  bodies in the bladder; retained  urine; external injuries
  on the hypogastric region; irritation from acrid  sub-
  stances absorbed and conveyed to the bladder, as can-
  tharides, turpentine, &c.; metastasis of rheumatism; ir- 
acute rheumatism.
105
  ritating injections into the urethra;  gonorrhoea;  sup-
  pressed perspiration, from the  sudden  application  of
  cold.   Pract. Med. 353.
Treatment.   Cystitis rapid in its course, and highly  dan-
  gerous.   The most prompt and decisive depletion  is
  necessary; local bleeding, by leeches or cups, from the
  pubic region and perineum, of great importance; fomen-
  tations and emollient enemata, efficient auxiliaries; sin-
  apisms after proper depletion.  Internally, opium and
  calomel,  in frequent and large doses.  (Prout.)   Blis-
  ters of doubtful propriety; bowels to  be kept open by
  laxative enemata; cathartics seldom advantageous; the
  urine to be drawn off by the  catheter,  and  emollient
  fluids injected  into  the bladder.   Nitre  is  injuri-
  ous.
                 CHAPTER XIV.


             ACUTE  RHEUMATISM.


Character.  Inflammation in the fibrous structures about
  the joints, wandering,  and attended with severe  pain,
  more or less swelling,  and synocha fever.
Symptoms.  Chills, alternating with flushes of heat, total
  inappetency, general soreness of the flesh, and lassitude,
  introduce the disease.   After some time, usually about
  twenty-four hours, the  rheumatic inflammation  mani-
  fests itself*  One or more joints become swollen, red,
  and extremely painful, the -pain being  greatly aggra-
  vated by motion; pulse full, hard, and frequent; bowels
  constipated; skin hot, and often covered with profuse
  perspiration;  remissions  in  the morning,  and nightly
                          o 
106
acute  rheumatism.
  exacerbations.  The  inflammation  generally  passes
  from joint to joint.  The blood is always buffy.
Rheumatism rare in infancy and old age.  Most common
  between the  ages of sixteen and forty-five.  Very fat
  persons less subject to it than  lean and muscular ones.
  A predisposition to rheumatism sometimes hereditary;
  derangement of the digestive  functions sometimes pre-
  disposes to it—so does the excessive use of spirituous
  liquors,  and  the imprudent use of mercury.  Pract,
  Med. p. 370.
Causes:   The influence of variable temperature almost
  the only exciting cause.
Rheumatic inflammation seated in the fibrous textures
  of the body;  essentially  distinct from common inflam-
  mation; shifts its place like gout; metastases to  impor-
  tant internal organs, always very dangerous; rarely ter-
  minates in suppuration; never terminates in resolu-
  tion, without the concomitance of general, but not
  profuse, perspiration, and the deposition of a lateri-
  tious sediment by the urine.   Neither of these  occur-
  rences  to be regarded  as critical, when they  appear
  separately; a very copious sweat is no uncommon oc-
  currence in  this disease; but it is never attended by
  any marked  abatement of the rheumatic symptoms,
   unless the urine at the same time deposits a red sedi-
   ment.  Rheumatism is seldom fatal, except by metas-
  tasis to important internal parts.
 Acute rheumatism, occurring in persons exposed to the
   influence of marsh miasmata, assumes a modified cha-
  racter.   There are, in such cases, conjoined with the
   rheumatic affection, prominent symptoms of derange-
   ment of the  biliary organs—such as, an icteric hue of
   the tunica albuginea:  a brown and bitter tongue; great
   head-ache;  bilious vomiting, &c.   After each act of
   vomiting, the pains remit.  This variety of the  disease
   has been called  bilious  rheumatism.  Pract.  Med. p.
   371.
 Treatment.   Bleeding, an important auxiliary reme- 
ACUTE  rheumatism.
107
   dy, though not by itself adequate to subdue rheumatic
   inflammation.  Its employment necessary to moderate
   the general and local inflammatory action, and thus to
   prepare  the  way  for the beneficial operation of other
   remedies.  Buffy blood, no indication, in this disease,
   for further depletion.  Excessive  blood-letting favors
   metastasis to internal parts.  (Johnson)  An early
   translation of the disease to the diaphragm, heart, or
   other internal  viscus, demands prompt  and copious
   blood-letting, followed by full doses of opium icith ca-
   lomel.
 Cathartics always decidedly beneficial; they often sub-
   duct the general  inflammatory excitement more effec-
   tually than bleeding.  Calomel, followed by sulphas
   sodte, or sulphas magnesite, the best purgatives.  Vio-
   lent purging  not proper—being incompatible with that
   regular action of the cutaneous exhalents, which is in-
   dispensable to the removal of this affection.
 Emetics.   Recommended by  Haygarth  and Horn.   I
   have known the operation of an  emetic to produce im-
   mediate relief of three or four hours'duration. In bilious
   rheumatism, (acute gastric  rheumatism of Richter,)
   emetics are,  very generally,  promptly and decidedly
   beneficial.   Tart, antimon.  the best emetic.   Pract.
   Med. p. 376.
Sudorifics.   Profuse perspiration is  seldom  beneficial,
   but often injurious.   Gentle  diaphoresis, however, is
  always serviceable.   Antimonials, in small doses, with
   calomel, or pulv.  ipecac, compos, so managed as  to
  keep up a moderate action of the cutaneous exhalants,
   will  assist very materially in subduing the disease.
  Tart antimony, in the proportion of two grains to eight
  ounces of water, given in doses of a table-spoonful ev-
  ery three hours, has been found  very efficacious.
Opium, a valuable remedy under proper management—
  not to be used until  the general inflammatory excite-
  ment has been moderated by depletory measures—to
  be used in large doses, conjointly with tarU antim. ca- 
108             ACUTE RHEUMATISM.
  lomel, or ipecac.   Large doses have less tendency to
  increase the phlogistic diathesis, than small ones.  A f-
  ter proper depletion, three or four grains should be given
  at once.  Calomel and  opium, particularly valuable :
  two grains of the  former, and one of the latter article,
  to be given every three  or four hours, until the gums
  become slightly affected.  Ptyalism to be avoided.
  In the sub-acute form of the disease, mercury is parti-
  cularly beneficial.
Colchicum,  a very  valuable remedy, both in acute and
  chronic rheumatism.  The vinous tincture generally
  employed, in doses of from  thirty to forty drops every
  four hours, with a small portion of magnesia.  1 have
  known violent cases of the disease yield speedily to this
  remedy.  Its  effects are to  be carefully watched; for
  given in over doses, or continued too long, it produces
  great prostration, violent vomiting  and purging, cold
  sweats, syncope, and convulsions.   Th^ following for-
  mula for using the colchicum, is  recommended by
  Scudamore: K Magnes. calc. gr. xx.   Sulph. magnes.
   3j.  Tinct. colchici.  vinos. 3j.   Aq. fontanae, q.  s.   To
  be taken at once, atid  repeated every four hours.—
   Pract. Med. p. 379.
 Extract of Stramonium, a powerful  and efficacious re-
   medy in acute  rheumatism,  after  the inflammatory
   symptoms have been moderated.   (Marcet.)   I have
   repeatedly  employed it, with signal advantage.  It is
   to  be used with great caution, on account of its effects
   on the brain—the most singular and violent maniacal
   state  of the mind being readily caused by it.  Of the
   best extract, a quarter grain is sufficient to begin with,
   to be very gradually increased to one grain, and conti-
   nued till vertigo is produced.
  Local applications.  Cold water, applied to the inflamed
   joints, generally gives temporary relief, but has a ten-
   dency to produce sudden translation of the disease to
   internal parts, and consequently to do mischief  Scu-
   damore's liniment, composed of one part of alchohol, 
CHRONIC RHEUMATISM.
109
  with three parts of camphorated mixture,  a valuable
  topical remedy.  Blisters, after the inflammatory ex-
  citement has been moderated, often decidly advanta-
  geous.  Leeching too  much  neglected—1 have fre-
  quently known the application of a large number of
  leeches to a joint, procure immediate  and  permanent
  relief.
Pressure and  tight bandages  recommended bv Balfour.
               Do                  .
  Observations on  this practice—sometimes  beneficial,
  in the sub-acute form of the disease.

                CHRONIC  RHEUMATISM.

Symptoms.  Little or no swelling, or redness of the parts
  affected; no fewer;pain sometimes confined to one or
  two joints—sometimes felt  only on motion. In some
  instances, the rheumatic form is persistive; in others, af-
  ter having continued for a time, it goes off, leaving the
  parts somewhat stiff and debilitated.  The skin is gene-
  rally dry and harsh.
Sequela.  A thickened and knotty state  of  the tendons;
  hardness of  the bursae mucosa?; wasting of the muscles
  about the affected joints; rigidity and thickening of the
  ligaments, and consequent stiffness of the joints, are con-
  sequences of severe and protracted rheumatism.
Diagnosis.  Chronic rheumatism in the muscles of the
  loins, (lumbago,) distinguished from nephritis by the
  aggravation  of pain on bending the body  forwards, as
  well as by the absence  of nausea and vomiting, retrac-
  tion of the testicle, and urgent desire to pass urine, which
  characterize the latter complaint.
Mercurial or syphilitic rheumatism, distinguished from
  rheumatism produced by other  causes, by the  perios-
  teum  of the tibiae, ulnae  or os frontis, becoming thicken-
  ed and tender to pressure, together with the history of
  the case.                                      J

Causes.  Frequently the  result of the acute form of the
  disease; continued exposure to a damp and cold  atmos- 
110
CHRONIC RHEUMATISM.
  phere; improper exposure, while  under the influence
  of mercury; atmospheric vicissitudes.
Treatment.  Though not generally indicated, bleeding
  is proper as a preliminary measure in robust  and ple-
  thoric subjects.
Sudorifics are useless.
Diaphoretics are beneficial.  G. guaiacum much recom-
  mended ; best adapted to cases occurring in subjects of
  a relaxed or phlegmatic habit of body, and in old peo-
  ple.   In young,  vigorous, and  plethoric subjects, it
  rarely does good, and sometimes harm.
Antimony, a useful article in this disease.  I have deriv-
  ed much advantage from its use, in  conjunction with
  infusion of the root of burdock, (arctium lappa.)  A
  grain of tart, antim. disolved in a pint of strong infusion
  of this root, should be taken daily.
Mercury, much recommended for  its powers in this dis-
  ease  particularly  useful, when   the  disease arises
  from cold,  while  the  system  is  under  the  influ-
  ence of mercury—the  usual  diaphoretic decoctions
  advantageously used along with it.  I  have  derived
  much advantage from mercury, conjointly with the fol-
  lowing decoction: K.Rad. sarsaparil. 3jjj. Fol. chyma-
  phyl, 3jss. Rad. mezer, 3jj. Cort.  ulm. fulv. gj.  Aq. bul-
  lient. ftjjj. To be boiled down to  three half pints. Dose,
  a wine-glass-full, four times daily. Dr. Otto, of this city,
  states that he has seldom been disappointed in curing
  the disease by  salivation, continued  for three  or four
  weeks. Calomel and opium.
Stramonium, an efficacious remedy  in this form of the
  disease.   Scudamore speaks highly of extract of stra-
  monium and lactucarium,  in combination—a quarter
  grain of the former, with two grains of the latter may
  be given every four hours.
Colchicum,  no less useful in this, than  in acute rheuma-
  tism.
Spirits of turpentine, much and deservedly recommend-
  ed, particularly when it is seated in the hips or loins. 
GOUT.
Ill
  (Home.) Dose, from twenty to forty drops, thrice dai-
  ly-
Phytolacca decandra.  The  tincture of the berries  has
  been used with advantage.  Zanthoxylum fraxine-
  um.
Solanum dulcamara, in recent  cases from  suppressed
  perspiration.
Hyoscyamus.   The extract a valuable palliative, in pain-
  ful inveterate cases.
Compression by the tourniquet—acupunctuation—elec-
  tricity—galvanism, have all been employed. with  de-
  cided benefit.  Exercise of the  whole body, to  a  de-
  gree sufficient to excite perspirations, has performed re-
  markable cures.   Rubifacients.

                       GOVT.

  Gout  is divided into the acute, the chronic, and the re-
trocedent  varieties.   Pract, Med. p. 386.
Symptoms.   Of the acute form.   Violent inflammation
  of the ball of the great  toe  of one foot, attended with
  excruciating pain, redness of the skin, distention of the
  neighboring veins, and, at the end of  about  forty-eight
  hours, oedema.   The attack generally occurs between
  12 and three o'clock at night.   There are slight remis-
  sions  in the morning, and violent exacerbations  at
  night.  The  paroxysm seldom  terminates before  the
  sixth, or continues beyond the tenth day.- The oedema
  confines some days after the inflammation has subsided.
  After the disease has disappeared in one foot, it some-
  times makes an immediate  attack ^on  the other.  The
  disease is generally preceded by a train of premonitory
  symptoms, most  commonly indicative of gastric dis-
  order.
Though in its  first  attacks  confined exclusively  to the
  feet, gout seizes  upon  many other parts, during the
  same paroxysm, after the system has become enfeebled
  by  frequent recurrences of the  disease.. Pulse, in sc- 
113
GOUT.
  vere attacks, full, hard, and strong; in slight cases, the
  constitutional symptoms not prominent; the digestive
 functions always considerably disturbed; bowels tor-
  pid ; urine scanty, and of a deep red color,  depositing
  a pink or lateritious sediment.  The inflamed parts are
  exquisitely sensible to the slightest touch.
Sequela.   Frequently, structural derangement of the li-
  ver; permanent  debility of the stomach.  Thickening
  and shortening of the ligaments, and distention and in-
  duration of the bursae mucosae, are the most common
  local consequences of gouty inflammation.  Gouty con-
  cretions not very frequent.
Predisposition.   The predisposition to gout sometimes
  hereditary, though not so frequently as is generally
  supposed.  It is most commonly acquired, by the ope-
  ration of the following, and perhaps other causes—viz.
  the depressing passions, severe and protracted study;
  the habitual use of high-seasoned animal food and  vi-
  nous liquors, with an indolent or inactive course of
  life.
Gout rarely occurs before  the 20th  year of age—most
  apt to commence its attacks between the 30th and 40th
  years.
Exciting causes.  Excessive intemperance;—redundan-
  cy of bile; an accumulation of acid  in the stomach;
  cold and humidity; external injuries; fatigue,and men-
  tal anxiety; violent passions.   Pract. Med. p. 392.
Proximate cause.  Some  writers regard the proximate
  cause of gout to consist in an  excess of the elements
  of uric acid, (Brandt, Home,) and others, in an excess
  of phosphoric acid, (Bertholet,)  Scudamore's objec-
  tions to these doctrines, stated and assented to.   Debi-
  lity  and disorder of the digestive organs, has been re-
  garded  as the  proximate  cause of  gout:—objections
  stated to this doctrine.   According  to Broussais,  the
  proximate cause of the disease consists in a peculiar
  irritation of the mucous membrane of the alimentary
  canal.  I think  it not improbable that derangement of 
GOUT.
113
   the assimilative functions, with general plethora, in
   conjunction with such  a peculiar irritation in the ali-
   mentary canal, constitutes the fundamental pathologi-
   cal condition of gout.   Pract. Med. p. 394.
 Treatment.  To obviate the recurrence of the disease,
   we must remove, as much as possible, the predisposing
   and exciting causes, and restore the healthy action of
   the digestive organs.  A simple and digestible diet must
   be enjoined, and the use of wine and condiments inter-
   dicted.  The  occasional use of mild  aperients, and
   some of the bitter tonics, is proper.
 The treattnent during the paroxysm.  Bleeding, though
   highly recommended by some, is not in  general  a re-
   medy of much importance in the paroxysm of gout, ex-
   cept when it is suddenly translated to the brain.   Copi-
   ous bleeding favors metastasis.   Emetics proper only
   when  the stomach  is surcharged with indigestible ali-
   ment.
Cathartics and diuretics are decidedly beneficial, in the
   treatment of gout.  Two or three evacuations  should
   be procured daily.  Calomel, with rhubarb, an excel-
   lent purgative in  this disease.   Scudamore recom-
   mends the following cathartic: R. Extract, colocynth.
   compos. 3ss.  Calomel, gr.  xv.  Tart, antim. gr. i. M,
   Divide into 16 pills.  Dose, two or three in the evening.
   Diuretics and purgatives, exhibited conjointly, partic-
   ularly  useful.   Thus: R. Magnes. calc. gr. xx.   Sul-
   phat. magnes. 3jSs. Vini. colchici. 3jss.   Aq. fontan. q. s.
   To be taken at once, and  repeated every four  or five
   hours.   (Scudamore.)   I have found this mode of ex-
   hibiting diuretics and purgatives in union, highly bene-
   ficial.
Colchicum—the  ancient  hermodactylus, a remedy of
   great powers in this disease.  It seldom  fails to cure
   the local symptoms  speedily; but, according  to some
   writers, it leaves the disposition to the disease much
  stronger, and  leads more rapidly to the chronic form.
  I think it probable, that these evil consequences are
                          p 
114
GOUT.
   the result of the improper or inordinate use of this ar-
   ticle, and that under judicious management, it is as
   safe as it is valuable.  The latest and best authorities
   on this subject, recommend it to be given in conjunction
   with magnesia.
Eau medicinale, a celebrated French nostrum.  The
   tincture of while  hellebore, and laudanum, &c.
Opium is  a  valuable  palliative in cases attended with
   extreme pain.  It should be freely administered;  one
   grain  every  hour or two, until the pain remits; it ren-
   ders the pulse softer and less frequent, causes a  gentle
   diaphoresis, and tranquillizes the nervous system.  Its
   modus operandi explained.
Local remedies.  Leeches increase rather than diminish
   the pain; blisters not useful, except to recal the disease
   to the extremities, when it  has passed on to more im-
   portant parts by  metastasis; warmth, by the  applica-
   tion of flannel or cotton, an old and popular practice,
   though attended  with no advantages.  Cold  applica-
   tions  will speedily relieve the pain, but are apt to pro-
   duce dangerous metastasis.   Evaporating lotions, of
   a stimulating character, are frequently beneficial.
Treatment proper during convalescence.  After slight
   attacks,  and before the constitution has suffered much,
   little or  nothing  need be done during convalescence.
   But in violent and protracted cases—particularly after
   repeated attacks have impaired the constitution, medi-
   cal treatment during convalescence is of the  greatest
   consequence.   In cases of this kind, it is necessary to
   restore the energies of the digestive organs, as well as
   of the liver, skin, and  kidneys.   For  this purpose,
   small doses of blue pill, with the occasional use of rhu-
   barb and magnesia,  and  a weak infusion of colomba,
   &c, in general  answer very well.  Gentle exercise also
   must be  enjoined. The  application of a flannel roller
   to the  affected parts,  highly useful, when permanent
   swelling and debility  remain.
Chronic Gout.  A  strong gouty diathesis, without suffi- 
GOUT.
115
   cient constitutional vigour  to produce high inflamma-
   tory affection of the joints.  It is characterized by pro-
   minent and harassing symptoms of dyspepsia; irritabi-
   bility of temper, and despondency and irresoluteness of
   mind; palpitations, with a sense of tightness at the pit
   of the stomach; cramps in the extremities, particularly
   at night; dull pain in some of the joints, attended with
   a sense of numbness and weight in the  affected part;
   sleep unsound, and interrupted by sudden  startings;
   permanent oedema left in the affected parts; tenderness
   and aching of the ancles, rendering progression diffi-
   cult and painful;  skin  sallow, dry, and contracted;
   bowels costive, and  in  very bad  cases much  general
   debility, wasting of the flesh of the lower extremities,
   a dry and short cough, &c.
Treatment.  The principal indications in the treatment
   of this form of gout are; to strengthen the system in
   general, and the  stomach in particular*  For this
   purpose, a  mild and digestible diet, with gentle exer-
   cise,  cold bathing,  mild aperients, and the occasional
   use of the mercurial alterative pill, are our most useful
   remediale measures.   To  relieve the distressing ner-
   vous  irritation,  opium, lactucarium, stramonium, or
   hyoscyamus, are to be occasionally used.   1 have found
   a combination of opium, camphor, and nitre, an excel-
   lent anodyne in such  cases.  Tonics seldom service-
   able.   Pract. Med. p. 395.
Retrocedent Gout.   The  disease is called retrocedent,
  when the inflammatory affection of the joints suddenly
  and entirely ceases, at the same time that some internal
   part becomes affected.   The  part to which it is most
  apt to be transferred, is the stomach; sometimes it falls
  upon the lungs, at others the brain, and occasionally
  the heart becomes its seat.   When the stomach, in-
   tense pain, anxiety, nausea, and vomiting, occur; when
   to the lungs, asthmatic symptoms supervene; when
  the lieart becomes affected, pain in the cardiac region,
  with violent palpitation and  syncope, ensue; metastasis 
116                  SMALL-POX.

  to the brain, produces insensibility, coma, apoplexy, or
  palsy.   Any of these translations of the disease, are ex-
  ceedingly dangerous.
Metastasis to internal organs most commonly produced
  by the application of cold to the inflamed joint; any
  thing which rapidly debilitates the system, as bleeding,
  violent purging, sudden fright, &,c, may cause metas-
  tasis.
Treatment.  When the  disease attacks  the stomach,
  warm  brandy, or  laudanum joined  with aromatics,
  must be freely  administered, and a sinapism laid over
  the epigastrium.   Opiates, antispasmodics, and sina-
  pisms or blisters to the chest, when the lungs are af-
  fected.  Metastasis to the brain, to be treated by prompt
  and copious bleeding, cold applications to the head,
  sinapisms to the feet, and stimulating purgative enemata.
The gouty diathesis  predisposes to: apoplexy, asthma,
  hydrothorax, ascites, erysipelas.
CHAPTER XV.
                 EXANTHEMATA.

                     SMALL-POX.

Small pox is divided into two varieties, the confluent and
  distinct.  The distinctive character of the former is:
  pustules confluent,depressed,irregularly circumscribed,
  the intervening spaces being pale, and the fever conti-
  nuing after the eruption is completed.   The distinctive
  character of the  latter is: pustules distinct, elevated, 
SMALL-POX.
117
   distended, circular; the intervening spaces being red,
   and the fever ceasing, when the eruption is completed.
 Description of the distinct kind.  At first aching pain
   in the back and lower extremities, lassitude and loss of
   appetite, slight chills, nausea and vomiting, with some
   soreness in the fauces, and finally, fever.  Towards the
   end of the third day of the fever, the eruption makes
   its appearance, first on the face and neck, and succes-
   sively on the inferior parts.
 Just  before the eruption  appears, adults generally per-
   spire freely;  and sometimes become comatose.  Chil-
   dren frequently suffer convulsions at this period; the
   fever ceases by the fifth  day.   At first the eruption con-
   sists of small red spots, rising, by degrees, into pimples,
   then becoming vesicular on the  top, with  a small pit
   in the centre, and finally about the eighth day, becom-
   ing pustular, and of a  spheroidal shape.  About this
   period, the face and eye-lids swell; the tumefaction
   subsiding again about the eleventh day.   The pustules
   are at their full and perfect  state  on the twelfth day;
   from this date they begin to shrink and dry, the matter
   forming crusts of a  brown colour; in a few days more,
   these crusts fall off, leaving the skin underneath of a
   brownish red color.
The pustules are surrounded  by an areola, of  a damask-
   rose color.   When the  pustules are numerous, some
   degree  of fever occurs on the tenth or eleventh day.
  In these cases, there is  usually some soreness  of the
  throat, hoarseness, and a copious discharge  of a thin
  fluid from  the mouth.   The eruptive  fever is  of the
  synochus, and not  unfrequently of the synocha grade.
The confluent  variety. In this variety, all the above-
  mentioned symptoms  of the  early  stage are severer.
  The accompanying fever at first synocha, then typhoid;
  pain in the loins, in  the forming stage very severe; the
  severer this pain, the more certainly will the  disease
  assume the confluent character.  (Richter.)   Seldom
  any profuse perspiration just before the appearance  of 
118
SMALL-POX.
   the eruption, as in the  distinct kind; instead of this,
   diarrhoea often occurs at this period.  Great soreness
   and redness of the fauces, and generally a copious flow
   of saliva.  The pustules appear earlier than in the dis-
   tinct kind—seldom later than the beginning of the third
   day—very rarely as late  as the fourth  or fifth day.
   The pustules not surrounded  by an inflamed  margin,
   where they are separated—the intervening skin  re-
   maining  pale  and  flaccid; the  face is  always much
   swollen—the swelling coming on earlier  than in  the
   distinct variety, and  declining about the tenth day.
   The matter in the pustules is never thick  and  yellow,
   as in  the distinct variety; but of  a whitish brown, and
   sometimes dark color.
About the eleventh day, the pustules break, and pour  out
   a  fluid which hardens  into brown or black crusts.
   When these fall off, the skin underneath desquamates,
   producing small and  permanent depressions,  or pits,
   in the skin.  The  fever does not cease,  but remits on
   the appearance of the eruption, increasing again about
   the sixth  day,  and continuing throughout the whole
   course of the disease.
The regular course of small-pox includes  therefore four
   distinct stages, viz: 1st. The eruptive fever, including
   a period  of from two to four days days:   2d. The  pe-
   riod of eruption, of  about two  days continuance:  3d.
   The period of maturation, or filling, which occupies
   about three days: 4th. The period of exsiccation, or
   drying of the pustules, which terminates about the  fif-
   teenth day from the commencement of the disease,
Chrystalline small-pox.   In  this variety, the  fluid in
   the pustules is colorless,  having no purulent  appear-
   ance.  The pustules, though not confluent,  are never
   surrounded by a florid areola; the swelling of the face
   is often  suddenly transferred to  the hands and feet;
   fever typhoid; pustules, pale or lead-colored.
Small pox often remarkably  modified by the influence of 
SMALL-POX.
119
   the contagion of measles.   These two diseases cannot
   go on at one and at the same time, in the same system.
   Hunter's doctrine of the incompatibility of two kinds
   of morbid action,  referred to.   Its applicability to the
   explanation  of the  modus operandi of medicines, in
   the cure of diseases.  Remarks on the power of this,
   and other forms  of exanthematous diseases, of destroy-
   ing the susceptibility of the system to a second infection.
 Autopsic plienomena. In violent cases,  pustules in the
   larynx, trachea, and bronchia, inflammation of the
   mucous membrane  of the alimentary canal, is inva-
   riably found.
 Prognosis.  The  more the  disease retains  the  distinct
   form, the safer.  The confluent form, always danger-
   ous; and the danger is greater, according as the fever
   assumes more of a typhous character.
 Observations on the origin of small-pox.  The opinion
   maintained, that  the disease often originates spontan-
   eously without the immediate agency of contagion.
 Treatment.   The heating plan  of treatment, pursued
   formerly, did  much injury.  An anti-phlogistic treat-
   ment is all-important; by  moderating the eruptive fever
   the eruption  is rendered more scanty; and the  whole'
   disease, consequently, more mild.  Moderate bleeding
   should  be practised, when the febrile excitement  is
   violent; copious bleeding being very rarely demanded.
   Mild cathartics, highly useful through the whole course
   of the eruptive  fever.  Violent purging improper,  in
   the distinct variety of the disease,—not so in the more
   indignant and  confluent kind, where they will often do
   much good.   (Mead, Friend, Cleghorn, Huxham.)

       The supervention of a spontaneous diarrhoea, in the early stage
       of confluent small-pox, is almost always followed by a less nu-
        merous crop of pustules, and by  an abatement of the febrile
       excitement, and of the swelling of the face and hands.

Calomel is the  best purgative in small-pox; many main- 
120                  SMALL-POX.
   tain that it possesses a peculiar power of moderating
   the violence of the disease.
 Emetics, sometimes useful in the beginning of the disease.
   particularly in  the confluent variety.
 Diaphoretics, of the refrigerant class,  are beneficial,  as
   nitre, antimonials, saline draught, spir. mindereri.
 Cool air.  The free admission of cool air into the apart-
   ments of small-pox patients, together  with  the use of
   cooling acidulated drinks, light and cool coverings,
   is one of the most important improvements in medicine
   that has ever been made.  The patient should be laid
   on a mattress, and the temperature of his apartment so
   regulated, as to communicate to him rather a sensation
   of coolness than warmth.
 When the eruption of the  confluent variety of the disease
   is attended by fever of a typhous grade—which is some-
   times, though rarely, the case, the diet, instead of being
   cooling and diluent, must be stimulating and nourish-
   ing.   Wine, here, is  a very useful remedy; the carbo-
   nate of ammonia also answers well.   When delirium
   attends a weak grade of reaction in this disease, cam-
   phor is the best stimulant.   Cinchona, a valuable re-
   medy during the suppurative stage of confluent small-
   pox, with typhoid fever.  Opium, in combination with
   camphor, very  beneficial,  when the  pustules are slow
   in filling up, or the fluid in  them remains watery.—
   Warm fomentations to the feet, and leeches  or blisters
   to the scalp, useful, when the brain  becomes much af-
   fected.   Diarrhoea, in the secondary fever of conflu-
   ent small-pox, is unfavorable, and must  be  checked by
   prepared chalk, suspended in some astringent vegetable
   infusion.  Opium and camphor, an effectual means of
   checking obstinate vomiting—an occurrence  always
   dangerous  in small-pox.  Epileptic convulsions, just
   before the eruption, not particularly  dangerous in dis-
   tinct small pox—more dangerous in the confluent va-
   riety.
The use  of lunar caustic, as a local  application to the 
VARIOLA VACCINA.
121
  pustules, has of late been recommended and success-
  fully practised, in France, for the purpose of lessening
  the number of pustules, and by so doing, rendering the
  disease milder and less dangerous.
Cauterization of the pustules, on the first or  second
  day, will destroy them.
       In 1825, M. Velpeau read a memoir before the Royal Acade-
       my of Medicine, of Paris, tending to prove, that, if thepustuleg
       of small-pox are cauterized, during the first two days, with lu-
       nar caustic, the progress of the pustules will be arrested.  This
       practice was fully tested some time after, by  Dr. Meyreux.
       According to his report, it appears, that if the variolous pus-
       tules are opened with a lancet, and touched with a pointed piece
       of lunar caustic, on the first or second day of their appearance,
       they will be wholly destroyed, and leave no marks; but on the
       third day, it will be quite useless.

                  VARIOLA VACCINA.

Origin of the disease.  The vaccine matter,  originally
  obtained from  a pustular disease affecting the udders
  of cows—hence its name.  The grease of horses, and
  cow-pox, were, at first, thought  the  same disease; and
  this opinion is strongly supported by the experiments
  of Mr. Ring, Friese, Loy, and Sacco; they having pro-
  duced  genuine cow-pox, both in the vaccine and  hu-
  man systems, by the  matter of grease.   Dr.  Jenner
  could not communicate the vaccine disease to a  person
  who had previously been  affected by the disease  pro-
  duced  by the grease.  Matter taken  from a peculiar
  pustular disease, which occurs about the head and nose
  of sheep, will, according to Richter, Sacco and  others,
  produce a  pustular affection in the human subject, si-
  milar to cow-pox, and capable,.it is said, of destroying
  the susceptibility to  the subsequent influence of the va-
  riolous contagion.
Description.  The vaccine disease can only be commu-
  nicated by inoculation,  or by bringing the virus in im-
  mediate contact with a part denuded of the  cuticle.
  The matter being inserted under the  cuticle, the pus-
                           Q 
122
VARIOLA  VACCINA.
  tule commences and proceeds in the following manner:
  —on the second day a small point; on the third day
  more distinct;  on the fourth day slightly elevated like
  a small pimple, and surrounded  with a narrow and
  faint areola; on the fifth day more elevated, vesicular,
  circular, its surface flattened, with a small dark depres-
  sion in its centre, containing a colorless fluid; on the
  ninth day the  pustule is in its full state of  perfection,
  the areola being large and of a beautiful damask-rose
  color; at this period, slight constitutional symptoms ge-
  nerally occur.  The areola efflorescence not  essential
  to the protecting power of the disease.  On the eleventh
  or twelfth day the  centre of the pustule becomes dark-
  er, which gradually extends to the circumference, so
  that a  brown scab is formed by the fourteenth day.
  The scab becomes darker until it acquires a dark ma-
  hogany color, and in five  or six days more falls off
  There  is seldom more  than one pustule; instances of
  several, and even  numerous pustules, have, however,
  occurred.
The vaccine disease often subdues other affections; crus-
  ta lactea, scrofulous swellings, ophthalmia,  whooping
  cough, have yielded  permanently to the influence of
  this disease.
Herpetic and other cutaneous affections, may occasion
  such a deviation in the vaccine pustule, from its genu-
  ine character and course, as to render  it ineffectual as
  a preventive of small-pox.  Diseases of the skin, from
  which a  fluid exudes, capable of conversion into a
  scab, are particularly apt to disturb the specific charac-
  ter of the vaccine disease.
Measles and cow-pox may go on simultaneously in the
  same person.
Diagnosis, between the spurious and genuine disease.
  In the spurious, the point of inoculation is already con-
  siderably inflamed and elevated on the second day; on
  the fourth or fifth day, an irregularly defined efflores-
  cence  appears, and scabbing is completed as early as 
VARIOLOID.
123
   the seventh or eighth day; the pustule is  irregular or
   angulated in its circumference, and without a depres-
   sion in its centre.
 The spurious  disease may be produced by, 1. The ex-
   istence of some cutaneous affection in the vaccinated
   patient; 2. Matter taken from a spurious pustule; and,
   3. Matter that has  suffered some change  by  long
   keeping.
 The matter should be taken from the pustule for vaccina-
   tion, between the seventh and ninth day.   The scab is
   generally used for vaccination.
 Appearance of the genuine scab.   Smooth, dark-brown,
   rather brittle than tenacious, and of a regular circum-
   ference.

        In taking either matter or the scab for vaccination, it is of the
        utmost importance to be  well assured that tbe person from
        whom it  is taken is healthy; and particularly that he was not
        affected with any other cutaneous disease, during the progress
       of the vaccine infection.

 General  remedial treatment,  very rarely   necessary.
   Local applications, such as cold water, a weak solution
   of sugar of lead, emollient poultices, to moderate  the
   local inflammation, are sometimes required.
 The prophylactic power of the vaccine disease discussed.

                      varioloid.

Some regard this disease as sui generis; others, and with
  correctness,  I  think, consider it as small-pox modi-
  fied, by the  system  having previously undergone the
   vaccine, or some other modifying influence.   Varioloid,
   or modified small-pox, is no new disease,—having been
   observed  and described for centuries past, under the
   different names of chicken-pox, horn-pox,  swine-pox,
   &c.  Proofs adduced of  the variolous  origin of this
  disease.  The  most  conclusive of which is, that  mat-
  ter taken from a varioloid pustule,  has produced ge-
  nuine small-pox. 
124
varioloid.
Description.  This disease varies exceedingly in its ap-
  pearances,  course,  and  degrees of violence.   The
  eruptive fever is generally very mild, and of irregular
  continuance, varying from two to  five days; a roseolous
  rash  often precedes the  eruption.  (Thomson.)   At
  first, small papulae appear, some of which  soon dry off,
  the others change to vesicles containing a thin limpid
  fluid, as early as the first or second day;  generally
  about the third or fourth day,  these vesicles burst or
  decay; frequently, small areola surround the vesicles.
  This is the mildest form of the disease, and is scarcely
  distinguishable from chicken-pox.  Sometimes the erup-
  tive fever is violent; the eruption having more the cha-
  racter of pustules with slight central depressions, re-
  maining five or six days before  they begin to dry off
  Occasionally the scabs do not fall off until the ninth,
  tenth or twelfth day.
  The following circumstances constitute the prominent
  and characteristic features of the disease:—
     1.  The eruption appears in successive clusters, and
       at uncertain periods after the beginning of the fever.
     2.  The  vesicles seldom if ever enter into complete
       suppuration.
     3.  There is no secondary  fever.
     4.  The drying off or scabbing occurs generally be-
       tween the fifth and seventh day; the scabs falling
       off as early as the eighth or ninth day.
     5.  They leave no pits, but red -disks or elevations.
It is pretty certain, from recent  observations, that the va-
  riolous contagion does occasionally operate on the sys-
  tem, and produce varioloid disease, even after the most
  perfect vaccination.  This,  however, is not  often the
  case; and the frequency of this disease (varioloid) must
  be, in a great measure, ascribed  to the previous vacci-
  nation having been rendered imperfect, by one or more
  of the following circumstances:—
     1. Pre-occupation of the skin by herpes or some other
       cutaneous disease. 
RUBEOLA.
125
     2. Vaccination with spurious matter.
     3. Depriving the vaccine pustule incautiously of its
        contents.
     4. Injury done to the vesicle in its early stage.

        In relation to the character of the cicatrix, Dr. Gregory makes
        the following observations.  " It would be improper to over-
        look the remarkable connexion that subsists between the degree
        of perfection in the vaccine cicatrix, and the violence of the se-
        condary disease,  (varioloid.)  When the  scar on the arm is
        perfect, that is, distinct, circular, radiated, and  cellulated—but
        above all, when it is small, so that  ii may be  covered with a
        split pea,  the secondary affection (varioloid,) will be slight,
        and hardly deserve the name of a disease.  On the other hand,
        whenever the scar is large, and bears the marks of having been
        formed by high local inflammation, and wants the other distinc-
        tive characters just mentioned, the chance of having secondary
        small-pox in after life, will be greater, and, cm'eribus paribus,
        there will bee stronger likelihood of its proving severe."

               VARICELLA—CHICKEN-POX.

Description.   Little or no eruptive fever; the eruption
   consisting  of  transparent  pea-sized  vesicles,  coming
   out  in  successive crops,  bursting at  the top about the
   third day, and concreting into thin brown crusts by the
   fifth day—leaving no  scar when they fall off.
Medical treatment rarely necessary.
Are small-pox and  chicken-pox produced by the same
   virus, as has been, and is still, by many, supposed?

                  RUBEOLA--MEASLES.

Description.   The disease frequently  commences  with
   the symptoms of common catarrh—namely, lassitude,
   slight chills,  sneezing, watery and slightly  red eyes,
   cough,  and some degree of hoarseness.  More com-
   monly, however, the catarrhal symptoms do not super-
   vene, until the fever is fully developed.  The fever is
   often mild; sometimes it is violent from the  commence-
   ment.  The skin is  hot and dry, the tongue white and 
126
RUBEOLA.
  punctuated with prominent red points.   About the
  fourth day of the fever, the eruption appears, first on
  the face, extending gradually  down over the  whole
  body. Nausea and vomiting, and sometimes slight de-
  lirium, and even coma in violent cases, occur shortly
  before the appearance of the  eruption.  On the sixth
  day, the eruption begins to fade on the face, but not on
  the rest of the body; but on the seventh day, it begins
  to become paler on the other parts, except  on the backs
  of the hands, where it remains vivid until the eighth
  day.  About the ninth day, the eruption presents a
  faint yellowish appearance, and desquamation begins
  on the face, which, in two days more, is completed over
  the whole body.  Occasionally, the eruption comes out
  as early as the second day, and sometimes, though
  very rarely, as late as the seventh day.  The eruption
  is not uniform, but forms irregular patches, approach-
  ing the semi-circular or crescent shape.  (Willan.)
Commonly, the face swells considerably during the'height
  of the eruption.  The fever does not abate on the ap-
  pearance of the eruption,  but, on the contrary, in-
  creases.  The catarrhal symptoms, also,  increase in
  violence.  Diarrhma often  comes on about the  time
  the eruption declines, which, when not excessive, is fa-
  vorable.  The fever almost always declines pari passu
  with the desquamation; in some instances,  however,
  though rarely, it continues and even  becomes more
  alarming after this period.  There is a  very strong
  tendency to pectoral inflammation in this disease.—
  Pneumonia and croup, most  apt to occur about the
  time the eruption begins to decline.  Ear-ache, inflam-
  mation  and swelling of the eyelids;  swelling of the
  glands about  the neck; herpes, porriginous  pustules,
  tumid lip, serous discharges from behind the ears, and
  tedious  suppurations, are among the sequelae of the
  disease.   These consequences are generally the result
  of improper management—particularly of incautious
  exposure to cold and damp air, and sometimes of con- 
RUBEOLA.
127
   stitutional predisposition.   In children of an irritable
   habit of body, and disordered bowels, the breathing
   becomes sometimes  much  oppressed and  anxious,
   although no pectoral inflammation exist. (Armstrong.)
   The oppressed respiration, here, depends on irritation.
   and  must not be confounded with the oppressed re
   spiration from  pulmonic  inflammation;—for, in th<
   former, bleeding would injure, in the latter, it woulc
   be indispensable.
 Diagnosis.  Dyspnoea from irritation is variable, inter
   mitting, being sometimes very great, at others quite
   easy.  Is increased on assuming the erect position;
   the respiratory motions of the chest being very percep-
   tible.  When produced by inflammation, the  oppress-
   ed breathing is permanent—is relieved by the erect
   position, the muscles of the abdomen being  strongly
   moved  in the acts of respiration. (Armstrong.)  Bron-
   chitis is distinguished by the difficulty of respiration
   being attended with a  pale and anxious countenance,
   livid lips, unequal distribution of animal temperature,
   and rattling noise in the chest.
 Treatment.   Very  little remedial treatment required
   in mild and regular cases.   Gentle aperients, and tepid
   diluent drinks, are in  general sufficient.   When  the
   eruptive fever is very moderate, the mildly stimulating
   diaphoretic ptisans  are serviceable—such  as  infusion
   of sage, marjoram, balm, &c.   Bleeding rarely neces-
   sary, in cases unattended by local inflammation. When
   the  general  febrile excitement  is violent,  moderate
   bleeding will prove beneficial; and  in cases attended
   with  pulmonic, or other internal inflammations, bleed-
   ing, both local and general, must be promptly and free-
   ly employed, together with epispastics over the inflam-
   ed part; the warm  bath,  impregnated with salt, and
   antimonials.
In instances where  the eruptive fever is imperfectly de-
   veloped, m  consequence of great internal venous con-
  gestion—a condition characterized by a feeble pulse 
128
SCARLATINA.
   pale countenance,  and general depression of the vital
   energies—it is necessary to  resort to the warm bath,
   stimulating frictions, blisters, moderate depletion, and
   the internal use of warm and  gently stimulating drinks.
   A weak solution of carbonate of ammonia, is an excel-
   lent article  in such cases.  Calomel, in large doses,
   with camphor, pulv. antimonialis, and a few drops of
   laudanum, recommended by Armstrong.
 Profuse diarrhcea and vomiting, about the time the rash
   is appearing, is apt to  check the progress of the erup-
   tion, or cause  its  total  disappearance,—the face be-
   coming pale, the breathing oppressed, the pulse feeble,
   with stupor, or constant disposition to syncope.   Here,
   opium, alone or with camphor, is a & valuable remedy.
Emetics particularly  useful, when  bronchitis occurs, or
   when the air passages are loaded with phlegm.  (Arm-
   strong.)
The air of the apartment in which the patient lies, should
   be kept at a temperature, ranging  from  65Q to 70°.
   Great care required during  convalescence, to avoid
   exposure to variable, cold, and damp weather.

                     SCARLATINA.

Scarlatina is  divided into three varieties, viz. Scarlatina
   Simplex, S.  Anginosa, and S. Maligna.
Symptoms of Scarlatina Simplex.   It commences with
   the usual symptoms of the initial stages of febrile dis-
   eases.  About forty-eight hours after the commence-
   ment of the fever, a scarlet eruption appears, first on
   the face, then on the neck trunk,  and finally over the
   whole body.  This eruption  consists  of innumerable
   little pimples running into each other; it is sometimes
  uniformly diffused, at others it appears in large blotch-
  es; pressure with the finger, causes a momentary dis-
  appearance of the redness.  Soreness in the throat, is
  generally felt, soon after the fever is developed.    The
  skin, during the eruptive stage, is dry, rough, and hot; 
SCARLATINA.
129
   the face flushed;  tongue white, with  a streak of red
   round the edges;  entire loss of appetite; bowels costive.
   About the fourth  or fifth day, the fever and the erup-
   tion begin to deeline, and in two days  more disappear
   altogether; the cuticle generally desquamates after the
   eruption has disappeared.
S. Anginosa.  Eruptive  fever more violent than in the
   preceding variety.  Head-ache, nausea, vomiting, pra>
   cordial oppression, and muscular prostration, very con-
   siderable in  the  commencement  Stiffness and dull
   pain in the muscles of  the  neck.  The eruption  ap-
   pears on the second or third day of the fever, at which
   time the fauces exhibit a swollen and inflamed appear-
   ance,  attended with painful deglutition.   Pulse  fre-
   quent, and more feeble than in the simple variety.   In-
   tense heat of the surface, and great thirst.  Tongue dry,
   and very florid along the edge; great restlessness and
   prostration.   Ulcers on  the  tonsils, particularly if the
   fever continues beyond the fifth day.   White flakes of
   coagulable lymph, adhering to the tonsils, readily mis-
   taken for ulcers.  The ulcers generally cast off superfi-
   cial sloughs, as the fever declines, and then heal; some-
   times they become foul, and discharge a thin and acrid
   fluid, which  being swallowed,  occasions  exhausting
   diarrhoea.  Deep and fatal coma sometimes occurs  in
   the stage of  excitement.  Abdominal inflammation
   casionally supervenes.   Anasarca, a  frequent conse-
   quence of S. Anginosa.
Scarlatina Maligna, commences like the former varie-
  ties.  Eruption, at first pale, assuming afterwards a
   dark or livid red  eolor; very variable in its duration,
  and time of appearance.   Heat of the skin variable, and
  seldom great.   Pulse, at first, active,  soon becoming
  small and feeble.   Delirium an early symptom.  Eyes
   dull and heavy, and cheeks livid.   Greyish ulcers soon
   visible on the  tonsils—becoming finally covered  with
   dark sloughs.   Fauces clogged with viscid phlegm, im-
  peding respiration.  A thin acrid fluid discharged from 
130
SCARLATINA.
  the nostrils, in the advanced period of violent cases.
  S. Maligna differs from S.  Anginosa, principally in
  the sudden and dangerous collapse which occurs in the
  former.   The supervention of the collapse, announced
  by diminution  of the heat of the surface, great prostra-
  tion, frequent  and feeble pulse, dark brown or black
  tongue; petechia and haemorrhage, occur towards the
  conclusion of  fatal cases—seldom before  the tenth or
  twelfth day.   Dr. Armstrong's division of S. Maligna,
  into three varieties, viz. the inflammatory, the conges-
  tive, and the mixed.
Treatment.  Emetics, of great  benefit  in  the forming
  stage, particularly of the anginose and malignant va-
  rieties.   Gentle purgatives, and the warm bath strong-
  ly impregnated with salt, are also decidedly beneficial
  in this stage.  During the stage  of excitement of the
  mild variety of the disease, purgatives, tepid affusions,
  cooling drinks, ventilation, a light diet, with rest, are in
  general  all that is required.  The daily employment
  of mild laxatives, and  the careful avoidance of expo-
  sure to cold and damp air, is the best mode of prevent-
  ing  the  dropsical  swellings, so  apt to occur during
  convalescence.  In the stage of excitement of S. An-
  ginosa,  cold  affusions are  highly useful.  Cold affu-
  sions and purgatives most beneficial, when used con-
  comitantly, particularly during the  first three  days of
  the stage of excitement. (Armstrong.)
After the third day, the affusions  should be tepid, unless
  the general excitement and  heat of the skin still remain
  very considerable.  The skin must be above the natu-
  ral temperature, and dry, to justify the use of cold af-
  fusions.   When visceral inflammation exists,  with an
  active pulse, bleeding will be proper,-1-when, however,
  general debility accompanies the local  inflammation,
  our dependence must be placed on the internal exhibi-
  tion  of  opium with calomel, and the  application of
  emollient cataplasms over the inflamed organ.  Blis-
  ters useful, in such cases, during the first few days  of 
SCARLATINA.
131
   the stage of excitement—in the stage of collapse, they
   do harm; rubifacients  maybe  employed  advantage-
   ously.  To cleanse the  ulcers in the fauces, and expel
   the viscid matter lodged there, emetics are often decid-
   edly useful; gargles, acidulated  with nitric or sulphur-
   ic acid, are beneficial.  Moderate portions of wine, and
   the milder tonics, useful during  the stages of collapse,
   and convalescence.
In the inflammatory variety of S. Maligna blood-letting
   is an important remedy.  The benefits of bleeding con-
   fined to the first twenty-four or thirty hours of the stage
   of excitement; the blood should be  suffered to  flow,
   until a decided  impression  is  made on  the  system.
   Purgatives  particularly serviceable,  during the  stage
   of excitement, in this variety; and  calomel is the best
   article for this purpose.  Tepid affusions, to be used
   during the use of purgatives.

        The highly inflammatory  form of Scarlatina Maligna, when
        treated by prompt bleeding and purging, in the early period of
        the stage of excitement, seldom sinks into a low collapse; and
        when this stage supervenes, after the employment  of proper
        depletion, in the commencement, itis rarely necessary to resort
        to active tonics or stimulants.

When the disease  assumes  the congestive character—
   that is, when, instead of manifest febrile excitement, the
   face remains pale, the skin cool, the sensorial functions
   blunted,  with great  anxiety and prsecordial  oppres-
   sion,  the  warm  saline  bath,  followed  by  stimu-
   lating frictions, and the application of bottles  or blad-
   ders filled with hot water, together with the free  use of
   warm diaphoretic ptisans, such  as infusions of catnip,
   balm, or eupatorium perfoliatum, and large doses  of
  calomel,  (fifteen or twenty grains) are the remedies to
   be particularly relied  on.   Dr.  Armstrong advises
  bleeding, which, though  a  hazardous remedy, may,
   with cautious management, do  much good.  Calomel
   in large doses, particularly efficacious.  Having estab-
   lished a general febrile reaction, by the means just men* 
132
ERYSIPELAS.
  tioned, recourse should be had to the milder stimulat-
  ingremedies,such as infusion of serpentaria, wine whey,
  and, as the disease advances, and the signs of prostra-
  tion become more prominent,  carbonate of ammonia,
  wine, camphor and  opium.   Capsicum, an excellent
  medicine inthestage of collapse, both as a gargle, and as
  an internal remedy.
       Two table-spoonfuls of red pepper, and two tea-spoonfuls of cu-
        linary salt, are to be beat into a paste, on which half a pint of
        boiling water is to be poured, and strained off when cold.  An
        equal quantity of very sharp  vinegar being added to this in-
        fusion, a table-spoonful  of the mixture, every hour, is a pro-
        per dose for an adult.  Mr.  Stephens asserts^ that he gave it
        in four hundred cases, many of which it cured, after they had
        assumed the most alarming state.  I have, in a few instances,
        employed this remedy with signal advantage.

Cinchona, formerly much employed in this  disease; it is
  inferior, however, to the carbonate of ammonia  and
  opium, capsicum, serpentaria^ and camphor.

                      ERYSIPELAS.

General description.  Fever, varying in different cases,
  from the highly inflammatory to the low typhous grades.
  Superficial inflammation sometimes preceded, at  oth-
  ers followed by the fever—commencing in an  irregu-
  larly circumscribed blotch, and soon  extending itself
  over a greater or less extent of surface; no pulsation or
  tension felt in the  inflamed part, the pain being of the
  burning and pungent kind; tumefaction often conside-
  rable.  Small vesicles, or blisters, containing a limpid
  fluid, appear after the inflammation has continued for
  some  time.   When resolution is about taking place,
  the inflamed and red surface becomes pale or  brown-
  ish-yellow ; soon  after which the cuticle desquamates-.
  No regularity, either in the duration of the inflamma-
  tion, or its time of appearance.
Erysipelas occurs under several modifications,  each ma-
  nifesting prominent  peculiarities, both in relation to
  the local  and general phenomena,  viz. 
ERYSIPELAS.
133
1. Erysipelas phlegmonodes.  Fever, of the syno-
  cha grade; erysipelatous inflammation, generally
  occurring in the face—sometimes on the extremi-
  ties.   Color, bright red; swelling, about  the se-
  cond day of the fever; and vesicles about the fourth
  day; about the sixth day, the swelling and fever
  begin to subside, and desquamation of the cuticle
  takes place by the eighth day.   Very  rarely ter-
  minates in suppuration.  In old people, sometimes
  protracted  to the twelfth or fourteenth  day.  Dif-
  fers  principally from the other varieties, in the
  high grade of febrile excitement which attends it.
2. Erysipelas  oedematodes. Color of  the inflamed
  skin, pale red or  yellowish  brown; heat and
  burning pain, inconsiderable; swelling comes  on
  gradually,  has a shining surface, and pits, on
  strong pressure.   Vesicles are  very  numerous
  and small—burst, on the second or third day, and
  change to dark colored scabs.  When the head is
  affected, the  swelling is so great, as to close the
  eyes, and render the whole face exceedingly bloat-
  ed.  Vomiting is an early symptom, and delirium
  and coma often supervene, as the disease ad-
  vances.* The debilitated, and  habitually  intem-
  perate, most  subject to this variety of the  disease.
  Dangerous, when the head is its seat—rarely so,
  when  the  extremities alone are affected, except
  when it terminates in suppuration.
3. Erysipelas  gangrenosum.  Usually  occurs  in
  the face  and neck; attending fever of a  typhous
  grade; slow delirium  and coma, almost invari-
  ably attend throughout its whole course; inflamed
  skin, of a dark red or livid color;  blisters small
  but not numerous, often terminating in gangre-
  nous  ulcers.  Suppuration and gangrene of  the
  cellular substance very common.   Always tedious
  and dangerous.
4. Erysipelas eraticum.  Inflamed blotches appear 
134
ERYSIPELAS.
       ing in succession on various parts of the body—
       the first blotches generally disappearing before the
       last make their appearance.
     5. Erysipelas  neonatorum—a variety of the dis-
       ease peculiar to  infants soon after  birth.  It al-
       most always commences about the genitals or um-
       bilicus, and thence spreads over a greater or less
       extent of the body.   The affected parts swell con-
       siderably, become  hard, are of a dark red color,
       and very painful to pressure.  Generally connect-
       ed with green and  fetid discharges from the bow-
       els, and colic pains;  it continues from seven to
       fourteen, or even twenty-one days.  Apt to termi-
       nate in gangrene and  tedious suppurations.
Suppuration, in erysipelatous inflammation, always com-
  mences in the cellular membrane; the pus formed is
  thin and acrid, and never  collected  in circumscribed
  cavities.
Erysipelatous inflammation, sometimes extends to the in-
  ternal viscera—not by metastasis, as some have alleg-
  ed, but by a spreading  of the inflammation  from the
  external to the internal parts.  The organ most [com-
  monly thus affected is the brain—an occurrence gene-
  rally fatal.
There is a variety of erysipelas, attended withf prominent
  symptoms of disorder of the biliary system, and fever
  of the synochus grade.  This is the erysipelas phleg-
  monodes biliosum, which  has been lately so  well des-
  cribed  by Mr. Copeland  Hutchinson.  The fever in
  this variety of the disease,  resembles the ordinary bi-
  lious remitting  fever.  The whole surface,  in some
  cases, acquires an icteric  hue.  The pain and irrita-
  tion are great.
Causes.   A natural predisposition  to this^disease appears
  to exist in some instances.   Habitual intemperance in
  persons of a cachectic disposition, predisposes^to ery-
  sipelas.  In  persons either  naturally or accidentally
  predisposed to the disease, it may be produced by lo- 
ERYSIPELAS.
135
  cal injuries, particularly of the scalp.  Violent rage has
  been  known to produce it. (Richter.)   A  peculiar
  constitution  of the atmosphere, and  hence its occa-
  sional epidemic  appearance.  Intestinal irritation;
  this I believe to be a very frequent cause of erysipelas;
  it is unquestionably so in infants.  The contaminated
  air of crowded and ill-ventilated apartments; hence
  its frequency in ill-ventilated and  crowded hospitals.
  Derangement of the biliary organs.  Some observa-
  tions  on the inflammation produced by the rhus toxi-
  codendron.
Treatment.—The general treatment must accord with
  the character of the attending fever.   It must be strictly
  antiphlogistic, when the fever is of the synocha grade;
  though frequent or copious bleeding  is rarely neces-
  sary, unless coma or violent delirium exists.  Cathar-
  tics are among the most useful general remedies in this
  disease.  Purging is especially beneficial when the face
  is affected.   The saline cathartics the best in the phleg-
  monoid variety;  calomel to be preferred when symp-
  toms of biliary disorder attend.  Two or three alvine
  evacuations should be procured every twenty-four
  hours.  Emetics highly beneficial in the beginning of
  the disease—more especially in the bilious modifica-
  tion.  Diaphoretics are serviceable.  The saline mix-
  ture, with  a small  portion of tart, antim. a good dia-
  phoretic.  I  have  derived  much  benefit from small
  doses of ipecac, and calomel in combination.  When
  the fever is of a typhoid grade, mercurial laxatives, in
  conjunction with stimulants or tonics, are to be chiefly
  relied on; the carbonate of ammonia, and sulphate of
  quinine, exceedingly valuable in such cases.   Opium
  with  sulphate of quinine, particularly  valuable after
  symptoms of gangrene have made  their appearance in
  the gangrenose variety.  In the early period, however,
  of this variety, free purging with calomel, will render
  the necessity of stimulants and tonics less urgent in the
  latter stages. 
136
ERYSIPELAS.
After suppuration has taken place, opium, camphor, and
  quinine, are to be employed in doses corresponding to
  the degree of prostration.

        In every variety of this disease, laxatives are of primary im-
        portance.  From considerable experience in the treatment of
        this malady, I am satisfied  that alterative  doses of calomel,
        with the daily employment of saline purgatives, will do more
        towards the reduction of the disease, than, perhaps,  any other
        plan  of general treatment that can be adopted.  The calomel
        may be advantageously combined with small portions of ipeca-
        cuanha.  One grain of the former, and three of the latter may
        be given  every four hours.

Local Treatment. Certain external applications gener-
  ally decidedly beneficial, the assertion of Bateman and
  others  to the contrary notwithstanding.  Cold applica-
  tions, such as solutions of sugar of lead, cold water, or
  emollients, generally do harm,   The applications must
  be of a stimulating character.  A solution of corro-
  sive sublimate in water, in the proportion of four grains
  to an ounce of water, is an excellent application.  The
  blue mercurial  ointment is  also a very good local re-
  medy ;  I have frequently employed it with much  ad-
  vantage*  I have  also  used a  weak  solution of sul-
  phate of copper, with  prompt success.  A solution of
  lunar caustic, in the proportion of four grains to one
  ounce of water, will sometimes do much good.   I have
  used it in two instances with manifest advantage.
Blisters  are often highly useful.   They must be  laid im-
  mediately over the inflamed surface.   Lard, used by
  Brodie with benefit.
  * Both these remedies were  first recommended by American physi-
cians; the former, by Dr. Schott of Philadelphia, and the latter, by Dr.
Dean of Chambersburg. 
HEMORRHAGIC.
137
CHAPTER XVI.
                 HEMORRHAGIC.

 Hemorrhages are divided into active and passive.  In
   the former  there is a preternatural determination of
   blood to the place from which the haemorrhage occurs,
   with  an increase of local vascular action, heat, and co-
   lor.  In the latter, there is no sanguineous congestion,
   nor increased activity of the capillaries from which the
   blood flows.   Bichat contends that, whether of the ac-
   tive or passive kind, spontaneous haemorrhages are al-
   ways mere sanguineous exhalations, and never the
   consequence of rupture of a vessel.  This  opinion is
   not sustained by general observation.
 Haemorrhages  occur  much more commonly from the
   mucous membranes, than from the other structures of
   the body.  Local congestion, in the part from which
   the blood flows,  is almost invariably  present.   This
   congestion may be the result of an irritation existing
   in the part, or of one seated elsewhere.  Excessive loss
   of blood,  with the excess of serum—intestinal irrita-
   tion—organic disease—obstruction.
A natural predisposition to haemorrhage exists in some
   individuals—and  this is even hereditary in some in-
   stances.  Remarkable instances of  this kind are on
   record.   The predisposition  to  the  different kinds of
   haemorrhage, varies with the age of individuals.  Thus
   the haemorrhages of  young people, occur generally
   from parts situated above the diaphragm; whilst in per-
   sons of advanced age, they are most apt to  take place
   from  parts situated below  this dividing muscle.  Du-
  ring childhood, bleeding from  the nose is  most com-
   mon;  between the age of puberty and thirty years from
                         s 
138
EPISTAXIS.
  the lungs; in middle life from the rectum, and invery
  old people, from the kidneys and bowels.
Prognosis.   Passive haemorrhages more dangerous than
  active ones.  The  cause of this  explained.  When
  they depend on organic disease, they are more intrac-
  table.  The prognosis depends, in a great degree, on
  the organ from which the  haemorrhage proceeds; a
  haemorrage from  the lungs being cteteris paribus,
  more dangerous than one from  the stomach.
The general indications in the treatment of haemorrhages
  are, 1. To diminish  the momentum of the blood in
  the general circulation, when it is preternaturally aug-
  mented ;  2.  To lessen the  determination of blood to,
  and  moderate the  local vascular action  in, the  part
  from which the haemorrhage occurs.  The diet should
  be simple and unirritating.

                     EPISTAXIS.

Premonitory symptoms of the active variety.  Weight
  and tension in the temples; throbbing pain in the head;
  strong pulsation of the temporal arteries; ringing in
  the ears; vertigo; flushed countenance; tickling in the
   nose. In weak and irritable subjects, there are, in ad-
   dition to these symptoms, others denoting a nervous
  or spasmodic condition, viz. creeping chills;  a copious
  flow of pale urine; disposition  to syncope; cold extre-
  mities, &c.  The  blood seldom flows from both nos-
  trils at the same time.
Exciting causes.  Whatever is capable of causing a pre-
  ternatural determination of blood  to  the head,  may
   produce  this haemorrhage.
Prognosis. Frequent  bleeding from the  nose  during
  childhood, is often  connected with a natural predispo-
  sition to  haemoptysis and phthisis in after-life.   When
  epistaxis  occurs frequently  in  advanced age, we may
  presume  the existence of visceral obstruction, or pre-
  disposition to apoplexy.  It may be regarded as salu- 
hjbmatemesis.                 139
  tary in the  stage of excitement, in all forms of fever;
  in the  stage of collapse, it is a  fatal sign.   Epistaxis
  most  dangerous in debilitated and  irritable subjects.
  Seldom, though sometimes fatal, from the mere loss of
  blood.
Treatment.   When this haemorrhage occurs in conse-
  quence of the suppression of some habitual sanguineous
  evacuation, it must not be arrested  unless it  become
  excessive.   When it is attended with a strong pulse,
  and with manifest symptoms of cephalic congestion,
  bleeding from the arm, and warm pediluvium, cold ap-
  plications to the head, cooling drinks, the internal use
  of large doses of nitre, laxative enemata, and rest  with
  the head in elevated position, are the measures to  be
  principally relied on.
Styptics are  improper under the circumstances just men-
  tioned—they are often required, however, in cases at-
  tended with feeble arterial action, from exhaustion or
  habitual  debility.   The most useful styptics are, alum,
  kino, spirits of turpentine, and sugar of lead.  In obsti-
  nate cases, a blister to  the back of the neck, will often
  succeed after other applications have failed. The inter-
  nal use of sugar of lead, is an excellent remedy in ev-
  ery variety of spontaneous haemorrhage.  Mechanical
  compression, by means of dossils  of lint  introduced
  into the nostrils, rarely fails to arrest the bleeding.

                    ilematemesis.

Premonitory symptoms.  These are almost always pro-
  minent.  The principal are;  weight and pressure  in
  the stomach, want of appetite,  or voraciousness,  acid
  eructations, pain in the hypochondria, nausea, anxiety,
  ringing in the ears, disposition to syncope, small, con-
  tracted, ami irritated pulse, alternate  flushes of heat and
  chills, palpitation, cold extremities, pale and contracted
  countenance, and  finally, increasing anxiety and con-
  striction about the breast, and obtuseness of the senses. 
140
H^EMATEMESIS.
  The quantity of blood thrown up is generally conside-
  rable, and  almost  always very dark—sometimes in
  clots, occasionally, quite fluid.   Relief is felt after the
  blood is thrown up.   The darker the blood, the longer
  it must have lain in the stomach, and the slower must
  have been the effusion.   A portion of the  blood al-
  ways passes into the bowels, and is afterwards evacu-
  ated by stool.
Causes.   Impeded circulation of the blood in the abdo-
  minal viscera, from visceral indurations; hence its fre-
  quency in habitual drunkards.  Suppressed menstrua-
  tion ; particularly in females soon  after the age of pu-
  berty,   Suppressed haemorrhoidal  discharge; habitual
  constipation; pregnancy; mechanical injuries or erosion
  of the mucous membrane of the stomach.
Prognosis.   Not attended with great danger, when  it
  occurs in  conseqnence of suppression of the menses, or
  haemorrhois; by recurring frequently, however, it leads
  to dropsy, inveterate dyspepsia, hysteria, hypochondri-
  asis, &/C  It is not apt to become habitual.   It is more
  dangerous when  it arises from visceral indurations^

TreatxMent*  Bleeding,  when the  pulse is tense and
  corded.   Revulsives, (i. e.) sinapisms to  the  epigas-
  trium, or dry cupping; warm pediluvium, purgative en-
  emata.  Internal styptics, viz. sugar of lead, muriated
  tincture of iron; spirits of turpentine; alum-whey; mu-
  riate of soda; cold water; decoction of nettles, (urtica
  dioica.)   Of these I have found the spirits of turpen-
  tine the most effectual.   From ten to fifteen drops are
  to be used every half hour.  Internal remedies are,
  however, rarely particularly beneficial, incases depend-
  ing on organic visceral disease.   In  chachectic females,
  the muriated tincture  of  iron is an excellent internal
  remedy for habitual haematemesis.  Emetics lately re-
  commended by Dr. Sheridan.  Purgatives strongly
  recommended  by Hamilton, particularly  when  the
  disease occurs in females between the ages  of eighteen 
HEMATURIA.
141
   and thirty, and is unattended by visceral disorganiza-
   tion.  I have used them with advantage.

                     HEMATURIA.

 The haemorrhage may proceed from the urethra, the blad-
   der, the  ureters, or the kidneys.  When from  the
   urethra, the blood is unmixed with urine, and flows
   without any evacuant effort.  When from the bladder,
   there is dull pain or a sense of uneasiness in the region
   of this viscus, accompanied  with painful erections, and
   burning pain  in the glans penis—the blood not being
   intimately mixed with the urine, but suspended in small
   flakes or  coagula in it. When the blood comes from
   the kidneys, it is very intimately mixed with the urine,
   without flakes or small coagula, and settling down into
   a uniform mush-like substance at the bottom of the ves-
   sel in which the urine is left standing.
 Old people, particularly those  who are affected with hae-
   morrhois, are most subject to this haemorrhage.  Cor-
   pulent and plethoric  females are  apt to void bloody
   urine, about the period when the menses cease to recur.
 Causes.   Mechanical irritation from calculi or  other
   causes; acrid substances conveyed to the bladder, eith-
   er through the medium of the circulation, or by injec-
   tion ; organic affections of the urinary passages; sup-
   pression of menses or haemorrhois; gonorrhoea; denti-
   tion. (Richter.)
Prognosis.  Seldom  attended with  immediate  danger.
   When habitual, it is apt, in old  people, to terminate in
   dropsy.
Treatment.   Bleeding when the pulse is active, assisted
   with purgative enemata.  When occasioned by calcu-
   li, opium, with sugar of lead, and the warm bath, are
   generally beneficial.  When acrid or stimulating sub-
   stances conveyed into the bladder through the  circula-
   tion, or otherwise, are its cause, the free use of mucila-
   ginous drinks, with  opium, will  prove most beneficial. 
143
H4SMORRHOIS.
  The muriated tincture of iron, is an excellent inter-
  nal astringent in cases not immediately the consequence
  of irritation from calculi, or other irritating substances.
  Twelve drops may be given three or four times daily.
  In  habitual haematuria, a caustic issue on the inner
  part of the thigh, or near the  groin, on the abdomen,
  has been known to do much good.   Uva ursi, decoc-
  tion of peach leaves, and other astringents rarely bene-
  ficial.
                 ILEMORRHOIS--PILES.

A discharge of blood, without tenesmus, from small vari-
  cose tumours on the verge of or within the anus. When
  these tumours do not discharge blood, they are called
  blind piles, (hamorrhoides c&cte.)   They are called
  external or internal, according as  they are  situated
  within or without the anus.
Premonitory symptoms.  Before the blood  begins  to
  flow, the patient  usually  experiences various affec-
  tions: viz. head-ache, vertigo, stupor, drowsiness, diffi-
  culty of  breathing, nausea, colic pains,  pain in tlie
  loins,  a sense of fulness  and  heat,  itching and pain
  about the anus, and often slight fever (molimina hce-
  morrhoidalia.)
The blood sometimes flows, only when faeces  are evacu-
  ated—sometimes it flows  without the discharge of fae-
  ces.  The loss of  blood is often very great.  I have
  known it so great as to prove fatal.   It not unfrequent-
  ly induces great debility, terminating in a leucophleg-
  matic  condition, or dropsy.   A  sudden cessation  of
  haemorrhoidal flux, is apt to be followed by other and
  more dangerous affections, as apoplexy, palsy, asthma,
  &c.
Causes.  These are sometimes entirely local in their cha-
  racter and  operation, viz:  pregnancy, parturition, irri-
  tating purgatives and enemata, protracted constipation,
  ascarides, sedentary employments, compression of the
  abdomen, by tight clothing, &,c.  There exists in some 
HAEMOPTISIS.
143
  individuals  a natural predisposition  to  haemorrhois.
  In such persons, every thing that has a  tendency to
  promote congestion in the portal circulation, will rea-
  dily give rise to the disease, particularly  between the
  thirtieth and fiftieth years of age.  Females, who men-
  surate regularly, are less subject to it than males.  It
  rarely occurs in children.
Treatment.  May we safely attempt to remove or sup-
  press this disease?  When it depends on local causes,
  and has  not yet become  habitual, the sooner we re-
  move it the better.  In cases, however, that depend on
  constitutional predisposition, and that have not become
  habitual, from long continuance, or frequent repetition
  or where the general health, or some other chronic af-
  fection, has been improved by its supervention, it is ne-
  cessary to proceed with caution in the application of
  remedies.  In many instances  the haemorrhoidal  dis-
  charge obviates other and much more dangerous  ma-
  ladies, by removing or  diminishing congestion in the
  abdominal viscera—a source of much more disease
  than seems to be commonly supposed.  The principal
  indications are: to counteract  inflammation, and local
  plethora  in the parts; to obviate the occasional  causes
  of the disease, and to moderate the discharge,  when
  excessive, by local  applications.  To answer these in-
  tentions, mild aperients, rest in a horizontal posture,
  simple and unirritating  diet, cooling drinks, cold  and
  mildly astringent applications,  will in general suffice.
  When the inflammation runs high, general blood-let-
  ting,  with emollient and anodyne applications, are be-
  neficial.

                     haemoptisis.

Haemoptisis is generally preceded  by slight chills, cold
  extremities, constriction in the breast, palpitation, alter-
  nate flushing and dullness, an irritated, contracted, and
  feeble pulse, dryness of the fauces, a salty or  sweetish 
144
HiEMOPTlSIS.
  taste, a'sensation of warmth rising in the breast, atten-
  ded with a saltish taste, slight cough, and  finally, hae-
  morrhage. Sometimes, however, it comes on suddenly.
  The quantity of blood brought up, is generally small,
  and mixed with the natural mucus of  the  bronchia;
  occasionally the bleeding is rapid and copious.
Predisposition.  Some individuals have a natural pre-
  disposition to this variety of haemorrhage.   Such per-
  sons  have narrow and depressed breasts, high shoul-
  ders, long and slender necks, fair hair, blue eyes, de-
  licate and  fair skin, sound and very  white teeth, red
  cheeks, a clear but feeble voice—they are irritable and
  passionate, and subject to glandular swellings about
  the neck, and catarrhal affections, which pass off slow-
  ly.  They are most liable to this haemorrhage, between
  the ages of fifteen and twenty-five.
Exciting Causes. Atmospheric vicissitudes; violent bo-
  dily exertions; the abuse of spirituous liquors; suppres-
  sion of habitual discharges; repulsion of chronic cuta-
  neous eruptions; drying up old ulcers or issues; metas-
  tasis of gout; mechanical  irritation  of the respiratory
  passages, by particles of matter floating in the air, or
  gaseous  substances; intestinal irritation; organic  dis-
  eases of the heart, pregnancy, &c.
Prognosis. Rarely  fatal merely from  less  of blood—ge-
  nerally the first decided  step  towards  consumption,
  particularly in such as are naturally predisposed to it.
  When no predisposition to phthisis  is present, haemo-
  ptisis will frequently pass off, without terminating in
  the former malady.
Treatmant.  Blood-letting is indispensable, when the
  pulse is tense and  hard.   It is necessary  to draw blood
  until the pulse becomes soft.   A large sinapism should
  be immediately applied to the breast.  Astringents gi-
  ven  internally will sometimes put a prompt stop to the
  haemorrhage, particularly after venesection.  Sugar of
  lead is the best article of this kind;  when  the pulse is
  weak, it may  be advantageously combined with opium. 
PHTHISIS PULMONALIS.
145
   From one to two grains of the lead may be given ev-
   ery twenty minutes,  until the bleeding is checked.   In
   violent cases,  six or eight grains should be given at
   once.  Large  doses of nitras potassce, are an excel-
   lent remedy in  pulmonary haemorrhage; it may be given
   in combination with tart, antimony.  Common salt is a
   familiar and useful remedy in haemoptisis.  In chronic
   spitting of Mood, digitalis, with milk or a farinaceous
   diet,  the occasional loss of small portions of blood, blis-
   ters to the breast, and the careful avoidance of every
   thing that can cause inordinate excitement, are the
   principal  remediale measures to  be  depended  on.
   Wearing  flannel next the skin, and avoiding the influ-
   ence  of sudden changes of  weather, are  circumstances
   of much importance, in  the chronic form of the disease.
   Nothing, perhaps, is equal to a uniformly warm climate.

                PHTHISIS PULMONALIS.

Consumptive symptoms may arise from various and dis-
  tinct  pathological conditions.  They may depend on
  1. Chronic bronchitis;  2. Ulceration of  the larynx or
  trachea; 3. Chronic pleuritis; 4. Inflammation and sup-
  puration of the  substance of the lungs: and 5. Tuber-
  culous matter in the pulmonary tissue, constituting ge-
  nuine phthisis pulmonalis.
The first variety is generally  the result of catarrh, and
  usually called catarrhal phthisis.   This, of all the va-
  rieties of consumption, is the most sanable, particular-
  ly so long  as  the inflammation of the mucous  mem-
  brane does not  extend to  the subjacent  parts, or has
  not terminated in ulceration.  The diagnostic symp-
  toms  m the early stage, are: Countenance pale; lips
  bluish; hands and feet often cold, and the temperature
  of the  surface  variable; cough deep, and expectoration
  tree from the  beginning;  slight soreness  in  pharynx-
  much  oppression, but little  or no pain in the  chest-
  cough rarely  excited  by full inspiration.  Cough al-
                         T 
146
PHTHISIS PULMONAL1S.
  ways severest in the morning, attended with wheezing
  respiration, until the mucus, collected during the night,
  is expectorated.   In all these circumstances, it differs
  from tuberculous phthisis.   In the advanced stage, it
  cannot be distinguished from the latter, or genuine form
  of the disease.
Catarrhal consumption often goes on to a fatal termina-
  tion,  without any breach of continuity or ulceration
  whatever—the pus expectorated  being  a mere secre-
  tion from the inflamed bronchial  surface.  When this
  variety  of consumption is connected with prominent
  derangement of the liver and stomach, it  forms what
  has been denominated dyspeptic  phthisis.  In this
  combination, we  have,  in  addition to  the  ordinary
  symptoms of phthisis, dyspeptic  symptoms,—such as,
  furred tongue, foul breath, unnatural stools, capricious
  appetite, distended epigastrium.
The majority of consumptions, in  this and similar cli-
  mates, are of the catarrhal or bronchial kind.
When ulceration of the  larynx  or  trachea is its cause,
  the disease  is called  laryngeal or tracheal  phthisis.
  This is a rapid and fatal disease, the instances of reco-
  very  being  exceedingly  few.   One of the first, most
  constant, and characteristic  symptoms, is a change of
  voice—losing at first its clear sound—then becoming
  hoarse  or indistinct, and finally scarcely audible.—
  When the larynx is principally affected, we have the
  following characteristic phenomena: pain in the larynx,
  increased by coughing and  pressure; cough  most vio-
  lent in the morning, on rising out  of bed; suddenly and
  violently excited, by inhaling cold air and irritating va-
  pors, by swallowing food, and by the use  of irritating
  gargles and acid drinks.   When the trachea alone is
  affected, the  pain is always  increased by bending the
  head backwards, or turning it round, and is  generally
  felt about its bifurcation.  The cough is not excited by
  gargles, or the inhalation ofcoldairand vapours, but
  readily  by active bodily exercise, and by swallowing—- 
PHTHISIS PULMONALIS.            147
   the cough not coming on until the food has descended
   as low down as the sternum, when  it is often brought
   up again.  Inspiration, during coughing,  is generally
   stridulous, as in croup.  The fits of coughing are fre-
   quently preceded by sneezing.  In coughing, the patient
   puts his hand to the throat, near the breast.  The ex-
   pectoration generally  consists of small portions of yel-
   low pus, suspended or mixed with a large portion of
   bronchial mucus.   The most frequent causes of this
   variety of phthisis are  catarrh, whooping-cough, croup,
   and syphilis.
Chronic pleuritis, gives rise  to  the third variety of
   phthisis.  It is the result of effusion into the cavity of
   the  chest—a  termination which always  takes place,
   sooner or later, in chronic inflammation of the pleura.
   As the effusion increases, the lung on the side on which
   it occurs, becomes more and more compressed, until it
   is reduced to so small  a bulk, as  to seem almost  com-
   pletely destroyed.   Sometimes ulceration takes  place
   in the pulmonary pleura, in which case, the effused pur-
   ulent, or sero-purulent fluid, is discharged by cough-
   ing.  When this occurs, hectic, with its usual train of
   symptoms, ensue.  This variety  of phthisis is  charac-
   terized by. increased oppression in the breast, on  lying
   down; anhelalion, by  ascending stairs, or  other bodily
   exercise;  alleviation,  in a  sitting posture; generally,
  some soreness of the integuments of the affected  side;
  pain in the side, confined to a certain space; difficulty
  of breathing, progressively increased; and, finally, the
   absence of pus in the expectoration, and irregularity in
   the hectic symptoms.
This variety of phthisis is of a very fatal character; though
   instances  of recovery do sometimes occur, by;  1.  A
   gradual absorption of  the effused fluid, the  lungs form-
  ing adhesions with the costal pleura; 2. The escape
  of the fluid, by the formation of a fistulous passage
  from the cavity of the chest into the bronchial tubes;
  3. By the formation of an opening through the inter-
  costal spaces, and the  escape of the fluid externally. 
148
PHTHISIS PTLMONALIS.
Inflammation, terminating in pulmonary abscess, con-
   stitutes the fourth variety.  This variety is of very rare
   occurrence.
Tubercular phthisis.  This variety occurs only in per-
   sons of a strumous or scrofulous diathesis.  Tubercles
   never formed, without a naturalpredispositionto them.
   They  are scarcely organized, being probably  formed
   by  exudations  into the  cellular tissue  of the lungs.
   They  do not always  lead to consumption — remaining
   dormant sometimes, without  materially affecting the
   general health.  Their formation sometimes very rap-
   id ;  in which case the  usual phenomena  of inflamma-
   tion generally attend.  Tubercles are never absorbed;
   hence the utter incurableness of perfectly formed tuber-
   culous phthisis.  The  conversion of tuberculous sub-
   stance into a fluid, not  the result of suppuration, but of a
   peculiar  process of softening.  (Laennec.)   The sur-
   face of the cavities of softened tubercles, is lined with a
   white, opaque, and soft membrane.  Pus is afterwards
   secreted  by this  membrane.   (Bayle.)   Under this
   membrane, another one is formed,  as the disease ad-
   vances, of a white, semi-cartilaginous appearance, which
   eventually forms a complete lining to the ulcerous exca-
   vations, and gives them a fistulous  character.  This
   latter membrane exists sometimes before the softening
   has  taken place—constituting  the encysted tubercle of
   Bayle.   There is often more or less chronic bronchi-
   tis,  co-existing with pulmonary tubercles; and hence
   puriform expectoration may occur,  before these tu-
   mours have undergone the softening process. (Pearson.)
   There are two, and sometimes three, morbid processes,
   in every case of tubercular phthisis; 1. Tubercular ac-
   tion; 2. Chronic bronchitis;  3.  Inflammation of the
   pulmonic tissue, generally chronic.
Although art cannot cure tubercular phthisis, in  a  state
   of full  development, spontaneous cures have  been
   known to take place, after the  tuberculous matter has
   been evacuated. ( Laennec.)   This occurs in two ways: 
PHTHISIS PULMONALIS
149
  1. By the cavity  becoming lined by a semi-cartilagi-
  nous substance, forming " a kind of internal cicatrix,
  analagous to a fistula:" 2.  By the cavity being obliter-
  ated by cellular, fibrous, or cartilaginous substai>(v.
Exciting Causes.   All fixed irritations in the abdominal
  viscera; repelled  cutaneous eruptions; suppression  of
  habitual evacuations; atmospheric vicissitudes; intem-
  perance in spirituous drinks; sedentary employments;
  the incautious use of mercury; haemorrhages; depress-
  ing passions; the inhalation of irritating substances; ra-
  pid growth, syphilis;  onanism.   Of all these  causes,
  suppression  of the cutaneous exhalation by cold,  is
  the most common and powerful, in calling into ac-
  tion this fatal malady in those who are predisposed
  to it.
Characteristic symptoms of the commencement and
  course of phthisis.  Tension and slight aching in the
  breast; slight, short and dry cough;  slightly oppressed
  perspiration—a sense of tightness being  felt in  some
  particular part of the chest, on inspiration.   At length
  moderate febrile  symptoms in the evening; the  pulse
  and respiration being preternaturally frequent; cough-
  ing in the morning, great susceptibility of taking  cold;
  torpor  of the  bowels; frequently a benumbing and
  drowsy feeling; tongue moist, covered with a thin white
  fur.  As the  disease  advances, the cough becomes
  more and more troublesome;  there is great sensibility
  to low temperature; pearly whiteness of the eyes; skin
  often hot; lips, tongue, and  fauces  often dry;  slight
  chills in the evening, followed by febrile exacerbations,
  with  a burning heat in the  palms of the hands  and
  soles of the feet; expectoration at first scanty and frothy,
  finally thick,-puruloid, and often  streaked with blood',
  becoming more purulent as the disease goes on; the
  pain in the chest, and evening fevers, becoming strongs
  er and stronger; the patient lies easy only on one  side-
  profuse sweats occur during the night; the burning in
  the palms of the hands and soles of the feet is distress- 
150
PHTHISIS PTLMONALIS.
  ing; the pulse very frequent,  tense, and quick;  and
  small during the febrile exacerbations, but slower and
  languid in the morning.   The cheeks have a circum-
  scribed flush, during the  febrile  excitement.  Besides
  the evening exacerbation, there is, in most instances,
  but a slight one about twelve o'clock in the day.   To-
  wards the conclusion, colliquative diarrhoea comes on,
  the voice becomes hoarse, the fauces aphthous, the feet
  cedematous; there is sometimes slight delirium; more
  commonly, however, the mental faculties remain entire
  to the last moment.
Tests for pus.   Muriate of ammonia coagulates pus—
  but not mucus.  Pus does not coagulate by heat—mu-
  cus does.   Water added to the solutions of pus in sul-
  phuric acid, and a solution of pure potash separately,
  produces in each a copiate precipitate.
Dr. Young''s test.—A small portion of pus, put between
  two glasses, will, when held  near the eye, and  looked
  through at a distant candle, exhibit an iridescent spec-
  trum, of which the candle is the centre;—mucus does
  not exhibit this phenomenon.

Treatment.   One of the most important remedial mea-
  sures, in every variety of the disease, is, to restore  and
  maintain the regular action of the cutaneous exha-
  lents.   This is to be done by wearing flannel next the
  skin,  by minute, doses of tartarized  antimony,  and by
  avoiding atmospheric vicissitudes.   We must also  en-
  deavor to remove every source of irritation, and to
  prevent as much as possible,  an, inflammatory con-
  dition of  the  system—particularly in the incipient
  stage.   With this view, a strictly antiphlogistic regi-
  men is  to  be enjoined, together with occasional small
  bleedings, where the pulse demands it, the use of digi-
  talis, and mild aperients, with gentle exercise on horse-
  back or in a carriage.   Another important measure, is
  to divert as much as practicable, the undue determina-
  tion of blood to  the pulmonary system, by means of 
PHTHISIS  PULMONALIS.
151
  blisters, cupping, and  especially  by tartar  emetic
  ointment applied to the breast.

       Although we cannot expect to cure tubercular phthisis by these
       or any other remedial measures, when once  fully developed,
       yet by a strict adherence to them in the incipient stage, we
       may often suspend the disease permanently, or retard its pro-
       gress in the more advanced periods.   Catarrhal consumption
       is not so irresistible in its course, and will not unfrequently
       yield to remedial treatment, even when considerably advanced.

The use  of mercury discussed—generally injurious in
  tubercular phthisis,   In  consumption from chronic
  bronchitis, balsam  copaiva is an excellent remedy.
  "It appears to have a  specific  influence over the mu-
  cous  membrane  of the  trachea  and its  branches."
  (Armstrong.)  I have myself employed it with decided
  advantage in this variety of phthisis.   The inhalation
  of the fumes of tar, has of late years'been much extol-
  led in the cure of consumption.  Its  power has been
  overrated.   In tubercular phthisis  it generally does
  harm; in chronic bronchitis it may, and no doubt  has
  often done good—but even in this variety of the disease,
  it generally proves injurious, when the habit of the body
  is irritable, and the inflammation active.  Dr. Hastings
  speaks very favorably of  a combination of extract of
  stramonium, and  pulv. ipecac, compos., in the pro-
  portion of one-fourth of a grain of the former, with two
  grains  of the latter, taken three  times daily.   Cincho-
  na is valuable in the advanced stage of catarrhal con-
  sumption. (Broussais,  Hastings.)   A change  of cli-
  mate will sometimes remove the disease, when reme-
  dial treatment is inadequate.
Tracheal phthisis almost invariably terminates fatally.
  Mercury is said to have  been beneficial, particularly
  in cases dependent on a syphilitic taint.   An equable
  and mild temperature is one of the most important cu-
  rative means in this, as in the other varieties of phthisis.
  Blisters should  be applied to the throat, and kept  dis-
  charging.   Armstrong asserts,  that bals. copaiv. is  as 
152
PHTHISIS PULMONALIS.
  beneficial in this, as in the catarrhal variety, when em-
  ployed previous to the occurrence of ulceration. When
  ulceration exists, large doses of  cicuta, with  minute
  portions of niurias hydrarg. are said to be serviceable.
Phthisis depending on chronic pleuritis, is more amen-
  able to remedial  treatment.  Here, our chief reliance
  is to be placed on external vesicating or irritating ap-
  plications to the chest.  Tartar emetic ointment is the
  best.   Active diuretics are beneficial.  Squill, in com-
  bination with calomel, is a good article for this purpose.
  Digitalis  and  squill, useful when effusion  has taken
  place.
Prussic acid, is much extolled  by some  in phthisis.   It
  is, however,  a dangerous remedy, and must be em-
  ployed with the utmost caution; one sixteenth of a drop
  is sufficient for a dose.  Sugar of lead an  excellent
  remedy to check the colliquative  night sweats.  Phe-
  landrum  aquaticum, much recommended by the Ger-
  man physicians in catarrhal (phthisis pituitosd) con-
  sumption.  It  is given in doses of from  sixteen  to
  twenty grains, three times daily.   I have known it do
  much good in the advanced stage of the disease.  Am-
  pelopsis hedera, appears to be  a useful remedy in this
  variety  of the  disease.* (Atkins.)  The bark of the
  wild cherry  tree (prunus virginiand) is a valuable
  tonic in consumption/}"  Opium  the best euthanasia]
  remedy.
   * Phil. Med. and Surg. Jour. Oct. 1826.

| Vide Eberle's Mat. Med. Article Prun. Virgin. 
APOPLEXY.
153
CHAPTER  XVII.
                     NEUROSES.

                      APOPLEXY.

Character.   Abolition or suspension of the animal func-
   tions,—the organic functions being uninterrupted; with
   laborious, generally sterterous, breathing.
Description.  Generally preceded by premonitory symp-
   toms—such as,  vertigo,  drowsiness, dull pain in the
   head,  irregular and  involuntary  contractions of the
   muscles of the face, turgidity of the vessels of the head,
   bleeding from the nose, ringing in the ears, loss of me-
   mory or speech, dimness of sight, indistinct articulation.
   Sometimes the attack is sudden, without premonitory
   symptoms.   Sterterous breathing,  not  invariably pre-
   sent in the attack, as is generally alleged.   The pulse,
   during the apoplectic state, is at first full, slow, regular,
   and often hard; towards the conclusion of fatal cases, it
   becomes  frequent,  irregular, and weak.   The face is
   livid and full; the eyes prominent, and often blood-shot;
   the  pupils much dilated, or permanently contracted.
   The attack may last from a few hours to several days.
   Apoplexy seldom  if ever destroys life suddenly, as
   is the case with affections of the heart.  Most apt to
   occur between the  ages of  forty and sixty.  Persons
   who have short thick necks, and are of a full and ple-
   thoric habit, and indulge freely in eating, drinking, and
   sleep, are most liable to this disease.  Great heat and
   cold predispose to it.
Exciting causes.  Whatever tends to determine  the cir-
   culation inordinately  to the head,  may produce apo-
   plexy.   The most common of these causes are, over-
                          u 
154
APOPLEXY.
  distention of the stomach with rfood; the use of indi-
  gestible and  stimulating diet; the intemperate use of
  spirituous liquors;  violent straining in lifting,  or in
  evacuating faeces:  violent anger; the direct rays of a
  vertical sun; extreme cold weather;  the cold stage of
  intermittents; stooping, or other  positions in which the
  head is in  a depending state; impeding the return of
  blood from the head, by wearing cravats too tight, and
  turning the head to look back.   Apoplexy is also pro-
  duced  by the suppression of habitual discharges; by
  the healing of old ulcers; by metastasis of gout.  Irri-
  tation in the stomach and bowels is a frequent cause of
  this disease.
Proximate  Cause.   Interruptions of the functions of the
  brain, and consequent deficiency of nervous influence
  in the parts furnished with cerebral nerves.  Does this
  interruption of the cerebral functions depend on com-
  pression of the brain, or  on mere deficiency of arterial
  blood circulating in this organ, as has been lately main-
  tained ?   I believe that both conditions (i.  e.) compres-
  sion of the brain, and deficiency of arterial blood in it,
  are necessary to the production  of genuine apoplexy.
  Cerebral compression may be the result of mere vascu-
  lar turgescence, or of extravasation  of blood upon, or
  into, the substance of the brain; or, finally, of serous ef-
  fusion into its cavities, &,c.   Blood  is very rarely ex-
  travasated upon the  surface of the brain, or into its
  ventricles,  but  almost  always  into  its  substance.
  (Bricheteau, Rochaux.)
Diagnosis. Distinguishable from syncope and asphyxia,
  by the pulse and respiration.  The pulse is full, strong,
  and slow, in apoplexy;  in syncope  and asphyxia, it is
  small  and feeble,  and sometimes wholly suspended.
  Respiration  in apoplexy is slow, laborious, and sterte-
  rous; in asphyxia and syncope,  it is  feeble and almost
  imperceptible.  Apoplexy, not easily  distinguished from
  intoxication; the smell of the breath, habits of the pa-
  tient, &,c. will inform us on this point. 
APOPLEXY.
155
Prognosis.  Generally  unfavorable.   When the result
  of  mere sanguineous  congestion in the brain, it is  in
  general readily relieved. When effusion of serum, or ex-
  travasation of blood has occurred, it is rarely cured.
  Extravasation of blood into the brain, is not necessarily
  fatal, as was formerly thought.

        The observations of Brichteau, Seres, Rochaux, and Riobe,
        prove, that when blood is extravasated into the substance of
        the brain, a cyst is formed around  the coagulum, and that this
        coagulum is  afterwards absorbed  by the vessels of this cyst.
        The cyst finally becomes absorbed itself, and leaves a yel-
        lowish cicatrix or laminated tissue, which is sometimes found
        to contain a small portion of serum.

Apoplexy may be divided into two varieties; viz. simple
  apoplexy,  which is not  accompanied by paralysis;
  complicated  apoplexy, which is attended by loss  of
  motion, on one  or the  other  side of the  body.   Mr.
  Seres, of Paris, has ascertained  that simple apoplexy
  depends on serous effusion  into the ventricles or cir-
  cumvolutions of the cerebrum, without any organic le-
  sion of the cerebral substance.  In complicated apo-
  plexy, the substance of the brain is  altered; excava-
  tions are found  in it, filled with blood of various ap-
  pearances, according  to the  time which may have
  elapsed between the extravasation and death—the por-
  tions of brain immediately surrounding these clots, be-
  ing red, indurated, or yellow.   Mr. Seres concludes,
  from his observations on this subject, that:—

    I. When  no symptoms of paralysis attend, we may
       presume that the seat of the disease is in the me-
       ninges, and that the substance of the  brain is not
       altered.   This  variety,  he accordingly calls me-
       ningeal apoplexy.
    2. When the  disease is  complicated with paralysis,
       the cerebrum is the part principally or wholly af-
       fected ; and  this variety he calls cerebral apoplexy. 
156
APOPLEXY.
       It appears, from the observations  that have been
       made in  the Parisian hospitals, that meningeal
       apoplexy occurs  most commonly in  the fifteenth,
       and after the sixtieth year of age.
Cerebral apoplexy generally makes its attack suddenly.
  Meningeal apoplexy usually comes on gradually.  In
  this variety, the mouth is never drawn to one side, and
  the patient lies in a straight position.  Paralysis almost
  invariably  occurs on  the  side  opposite to  the one in
  which the cerebral  lesion  exists.   This was observed
  in 171 subjects who had  died  of cerebral apoplexy,
  accompanied with hemiplegia.  When the paralysis is
  universal, the  extravasation and cerebral lesion occur
  in the substance of the tubar anulare, or along  the
  base of the skull.  Death,  from apoplexy, explained.
Tteatment. The chief indications in the treatment of
  apoplexy, are: to lessen  the determination of blood to
  the brain, and to moderate the momentum of the ge-
  neral circulation.  This is effected by general and  lo-
  cal bleeding, active purgatives,  revulsive applications,
  abstemiousness  in diet, and stimulating drinks, &c.
  During  the apoplectic  attack prompt and copious
  bleeding, stimulating  purgative enemata, cold applica-
  tions to the head, sinapisms to-the feet,  cups applied to
  the temples and the back of the neck, and an elevated
  position  of the head, are the remedial measures  to be
  relied on.  When apoplexy comes on, soon after a
  full meal, an emetic should be administered;  blood
  should, however, be previously  drawn.  Under  other
  circumstances, emetics  are improper,  as  they have a
  decided  tendency to produce cephalic congestion.  On
  this  subject, there has been much controversy.  I have
  found castor oil, and  spir. turpentine, in  combination,
  an excellent  purgative—it having  rarely failed in  my
  hands to  excite copious  purging, which, though of
  much importance,  it  is often exceedingly difficult to
  procure. 
PARALYSIS.
157
                       PARALYSIS.

Character.   Diminution or entire loss of voluntary mo-
   tion, or of sensation, or of both, in some particular part
   of the body, without coma.
Description.   Often the consequence of apoplexy;  but
   frequently also, independent of it.   Most commonly,
   there is only loss of voluntary motion—sensibility re-
   maining entire, or even  morbidly  increased.   Total
   abolition of sensibility, very rare.  The  palsied  limbs
   generally become soft, wasted, and shrunk—often with
   a peculiar sensation in them, as if insects were creeping
   over them  (formication?)  Mental hebetude, frequent-
   ly in palsy—especially weakness, and sometimes total
   abolition of the memory.  Entire change of the natu-
   ral disposition, occasionally occurs in this disease.
 Paralysis is divided, by nosologists, into three varieties,
   viz: hemiplegia, paraplegia, and local palsy.

        The question, why the  power of motion is sometimes  lost,
        while that of sensation remains, and vice versa, has given rise
        to much controversy among physiologists. Galen supposed that
        there were two sets of nerves—one destined to sensation, the
        other to motion.  What  this sagacious physician alleged, on
        mere speculative grounds, has recently been actually demon-
        strated  by Magendie, and Charles Bell.   It appears, from the
        experiments of these and other physiologists, that each nerve
        is composed of two distinct parts—the one for motion, and the
        other for sensation.  From this anatomical  fact, we perceive
        in what manner the phenomenon in question mav occur.

                      HEMIPLEGIA.

Paralysis, confined to one side, including the  whole half
   of the body, generally  the consequence of apoplexy;
   the apoplectic symptoms are sometimes so slight, as to
   escape notice. Injuries done to the head may produce it.
Cerebral compression, or structural lesion, the proxi-
   mate cause of hemiplegia.   Seres denies that compres-
   sion is ever the cause, either of apoplexy or hemiple- 
158
HEMITLEGIA.
  gia; his experiments, however,are not conclusive; they
  are contradicted by those of Portal, and of Mr. Astley
  Cooper.
Hemiplegia  often comes on  gradually,  with the usual
  symptoms of approaching apoplexy; occasionally,  its
  attack is sudden.  Anomalous symptoms.  This  af-
  fection sometimes terminates in a few days—more ge-
  nerally several months;  and occasionally it  remains
  permanently.  Sometimes a greater or less degree  of
  amendment occurs,  and then the disease  remains sta-
  tionary.

                   PARAPLEGIA.

Paralysis of the whole lower  half of the body, the parts
  above the hips remaining  unaffected,  Occurs most
  commonly after the middle  period of life;  and  accord-
  ing to Baillie, more  frequently in men than women.
Causes.  Most commonly seated in the  brain, (Baillie,
  Earle, Halford, Copeland;) sometimes in the spinal
  marrow, producing an interruption to the passage  of
  the nervous influence  along  the  spinal cord, to the
  nerves of the lower extremities.  The most common  of
  those causes, which  act immediately on the spinal
  marrow, are: thickening of the theca vertebralis; serous
  effusions into it, exostosis on the internal surface of the
  vertebrae.   The higher these causes exist in the medulla
  spinalis, the higher  will the paralysis extend.   When
  above the fifth cervical vertebra, the hands will be pa-
  ralysed ; if below the eighth, they will not be affected.
  The effusion may occur, first between the membranes
  of the brain, and  afterwards sink  down  in the theca
  vertebralis,  and press  upon the  lower portion of the
  spinal cord.
When the brain is the  primary seat of the disease,  pain
  in the head, giddiness, drowsiness, impaired vision, and
  defective memory,  usually precede the paralytic at-
  tack.   The paraplegiac affection always comes on 
PARAPLEGIA.                 150
  gradually—first by stiffness and slight difficulty of di-
  recting the motions of the  lower limbs;  by degrees,
  the assistance of a stick is required to balance the body;
,  the urine  is voided with difficulty,  and finally  passes
  off involuntarily—the  paralysis  becomes more and
  more complete, the faeces passing off unrestrained by
  the will.

         PARALYSIS PARTIALIS--LOCAL PALSY.

Local paralysis consists of want of motion, or of sensa-
  tion, or of both, in some particular part or organ of the
  body.  It may  attack some viscus,  or  the organs of
  sense, destroying or blunting their respective functions.
  It occurs  in one extremity; in the muscles of degluti-
  tion;  in those  of the organs of speech, and  even in
  a single muscle.  It most frequently, however,  occurs
  in the muscles  of the face.  Persons affected with fa-
  cial paralysis,  are deprived of the power of closing or
  opening the eyelids—of contracting the brow—of ele-
  vating the nose or lip—of shutting the mouth—of re-
  taining the saliva—of raising the corner of the mouth—
  of whistling or  blowing, Slc.  The wing  of the nose,
  on the palsied side,  is collapsed; the mouth  drawn
  towards the opposite  side; the  teeth  exposed.  The
  power of masticating remains—the tongue  too retains
  its powers.
Causes.  Facial  paralysis is  produced by  some  injury
  sustained  by the portio dura, either in consequence of
  surgical operations, abscesses, bruises, or other injuries
  in the parotid region.  It occurs also in consequence
  of thickening of the sheath of this nerve; of necrosis at
  the canal of the] temporal bone,  through which it
  passes out; and  frequently from sudden exposure to
  cold, producing inflammation of the nerve.   11 has been
  produced by  a  blow on the head; by the suppression
  of cutaneous eruptions; and by tumours pressing on
  this nerve. 
160                 paraplegia
Paralysis of the wrists is produced by the poisonous influ-
  ence  of lead; by bilious colic; and sometimes by dy-
  sentery.  Whatever interrupts the free nervous com-
  munication between a part and the common sensorium,
  may produce paralysis in such part.
Treatment.   Blood-letting of primary  importance in
  the commencement of hemiplegia,  preceded  by apo-
  plectic symptoms, and attended with a full and strong,
  or small and tense pulse.  In some instances the pulse
  is small and feeble, in which case, bleeding is of course
  to be  avoided, or at most used with particular circum-
  spection.  Purgatives,  perhaps, still more beneficial
  than blood-letting.   In debilitated, leucophlegmatic, or
  hydropic subjects, mustard or capsicum may  be very
  advantageously given in union  with cathartics.  An
  ordinary dose of calomel and jalap, with from 20 to 30
  grains of mustard, or from six to eight grains of capsi-
  cum, forms an excellent  purgative under such circum-
  stances.  Emetics have  been particularly recommend-
  ed in  hemiplegia.  They must be given in large doses,
  on account of the  unirritable state of the stomach in
  this complaint.  They are useful when ihe attack of
  the disease occurs soon after a full meal, or during the
  existence of dyspepsia  In recent cases, with signs of
  cephalic congestion, they are hazardous,  unless blood
  be previously drawn.  Stimulating enemata are useful
  remedies.  Much advantage may be derived from ru-
  bifacient, vesicating, and stimulating applications to the
  paralytic parts.  The depletory remedies just mention-
  ed, cease to  be proper after the disease has assumed a
  chronic character—that is, after  the apoplectic sym-
  toms have disappeared,  and the undue determination
  to the head no longer exists.  Means  of an opposite
  character are now to be  used, i. e. external and inter-
  nal stimulating remedies.  The former are sinapisms,
  warm bathing,  blisters, moxa,  cupping, galvanism,
  electricity, and frictions with the flesh brush, dry flan-
  nel, or with stimulating  fluids.   Blisters and sinapisms 
PARAPLEGIA.
101
  must be employed with caution, when the paralysis is
  complete, lest sloughing or mortification ensue.  They
  should be employed only as rubifacients in such cases.
  In general, mere dry frictions, with flannel or the flesh
  brush, will do more good than where rubifacients are
  used.  Electricity has  been  employed with success
  in this city.  It must  never  be employed in strong
  shocks; weak sparks are more efficacious, and  less
  apt to injure.   Galvanism is more efficacious  than
  electricity: it must be  applied with only a moderate
  force.  Moxa has been used with success in general
  paralysis,  applied along each side  of the  spine, near
  the first dorsal vertebra, by Dupuytren
Among the internal remedies, the  following  are the
  most useful:—Rhus toxicodendron.  I have succeed-
  ed in curing two cases of hemiplegia, by the saturated
  tincture of the leaves of the rims.  The dose is from
  twenty to  sixty  drops,  three  times daily.  Professor
  Ossan of Berlin, recommends it to  be given according
  to the following formula:—K. Tinct. rhois,  toxicoden.
  gss. Tinct. aconit. neamont.  Tinct. guaiaci. aa 31J- m.
  Dose, forty drops every three hours.  The nux vomi-
  cahas of late years been much employed, and notun-
  frequcntly with success, in paralysis.  When used in
  adequate doses, it produces strong convulsive contrac-
  tions, more particularly in the  paralytic  parts.   The
  extract is usually  employed.   It may be commenced
  with  in  the dose of two grains, twice a day, and 'gra-
  dually increased until the spasmodic contractions come
  on.   The  arnica montana, is a favorite remedy with
  the  German physicians in paralytic affections,  Mus-
  tard seed,  internally, has been found useful; I have em-
  ployed  it with advantage in hemiplegia.  Iodine  has
  been used with  success, in paralysis depending on tu-
  mours or fluids pressing on the  brain or spinal cord.
  Dr.  Manson has  related some remarkable instances
  of its beneficial operation. in paralysis of the tongue,
  a few drops of the ol. cajeput, put on the organ daily,
                         x 
102
EPILEPSY.
  has been found serviceable.  Chewing the root of the
  anthemis pyrethrum, has also done good in palsied
  tongue.   Would not moxaustion over the mastoid re-
  gions prove beneficial in this variety of palsy?  In pa-
  ralysis from lead, mercury is an excellent remedy; the
  nitrate of silver has also been used with advantage,
  in this species of paralysis.   When the wrists are pal-
  sied, the application of a splint along the inner side of
  the fore-arm has done much good. (Pemberton.)

                      EPILEPSY.

Character.  Convulsions returning at uncertain inters
  vals—accompanied with loss  of sense and voluntary
  motion, and terminating in deep sleep.
Premonitory symptoms.   A  confused and wandering
  state of the mind; vertigo;  ringing in  the ears;  indis-
  tinct vision; pain in the head; pain and anxiety in the
  precordial region; change of the natural  disposition;
  spasmodic twitches of the muscles of the face; aura
  epileptica, and a feeling  of  terror  and alarm are the
  most common.
Symptoms of the paroxysm.   The  attacks frequently
  occur at night, while the patient is asleep.   If he is
  sitting or standing,  he suddenly falls down, and be-
  comes more or less violently convulsed.   The counte-
  nance  is frightfully distorted, and generally of a livid,
  and sometimes  almost black hue—occasionally it is
  pale; the veins  of the head and neck  are turgid; the
  heart palpitates violently, and the breathing is oppress-
  ed and  laborious,  and in violent cases sterterous.  A
  copious flow of frothy  saliva  occurs towards the
  termination  of the paroxysm.  As  the  convulsions
  abate, stupor or deep sleep comes on, out of which the
  patient awakes in a state of mental torpor or confusion,
  which often continues for many hours—the counte-
  nance exhibiting a fatuous and stupid cast.  The dura-
  tion of the paroxysm varies in different cases, from a 
EPILEPSYi
163
   few minutes to several hours.  Sometimes there is but
   one fit at a time; at others, three or four, and even more
   paroxysms, occur in  quick succession, before the dis-
   ease terminates.   The fits are in general  more pro-
   tracted in children than in adults.  Sometimes the at-
   tacks are strictly periodical in their recurrence, more5
   generally, however, they return at irregular intervals
   and the duration of these intervals is exceedingly vari-
   ous.  Epilepsies, depending on intestinal irritation and
   catamenial irregularities, are most apt to become pe-
   riodical. (Richter.)   The periodicity of this disease is
   ascribed  to  lunar influence, by  Mead, Balfour, and
   others.   This opinion is not supported by sufficient tes-
   timony to entitle it to credit.
Epilepsy  is seldom fatal, except by the intervention of
   apoplexy.  By repeated recurrence, it never fails to im-
   pair the understanding—terminating sometimes in per-
   fect idiotism.
Autopsic phenomena.  According to Wentzel, the cere-
   bellum is much more frequently  found diseased than
   the cerebrum.  The pineal gland is often found in a
   morbid state;  tumours and other structural derange-
   ments are, in some instances, discovered in the cere-
   brum.  In the cerebellum, have been  noticed indura-
   tions and a peculiar  friable matter between its lobes,
   with destruction  of a portion of their substance.   In
   many instances,  however, not the slightest traces of
   organic disorder  are discoverable, either in the cere-
   bellum or cerebrum.
Predisposing causes.   Predisposition sometimes consti-
   tutional, and even hereditary,  and always augmented
   by the  attacks of the disease.   Young people,  about
   the age  of puberty, most liable to epileptic attacks.
Exciting  causes.  Some  act directly on the brain—the
   disease being then called  idiophatic.   Others act on
   remote  parts—affecting  the  brain sympathetically—
   this constitutes symptomatic epilepsy.   Among the
  former causes,  are: malformation of the skull; depress- 
104
KPILKPSY.
  ed bones;  exostosis from the internal surface  of the
  cranium; organic derangements; vascular  congestions
  and effusions in the brain, &c.  Among the most com-
  mon causes of the latter class, are: intestinal irrita-
  tion from worms and other irritants; dentition; suppres-
  sion of the catamenia, of hsemorrhois* and of perspira-
  tion; the drying up of old ulcers and issues; the  reper-
  cussion  of exanthematous eruptions, or of chronic cuta-
  neous diseases, as measles,  small-pox, itch, and tinea
  capitis.   Excessive sanguineous and other evacuations;
  onanism; various poisons, both vegetable and mineral;
  habitual intemperance in  the Use  of spirituous li-
  quors;  pregnancy; irritation from biliary concretions
  and urinary calculi; sudden and violent terror; anger,
  and grief; disagreeable  and strong impressions  on the
  senses;  spiculae of bones, tumourSj &c. pressing upon^
  and irritating some nerve; the sight of a person affected
  with the disease.
Proximate cause.  Various opinions  expressed by au
  thors.   A temporary local turgescence of the cerebra
  vessels,  is probably the immediate cause of the epilep-
  tic paroxysm. (Johnson.)  According to Mansford, an
  accumulation of electric matter in the brain, constitutes
  the proximate cause.  Others regard organic derange-
  ment of some part of the brain as the immediate cause.
  I regard the first opinion as the most probable.
Diagnosis.   Sometimes  confounded   with  hysteria.
  They may be distinguished by the following circum-
  stances. In  hysteria,  there  is no foaming at the
  mouth,  nor is the countenance so Iwid and distorted
  as in epilepsy; the hysteric paroxysm does not termi-
  nate in  heavy sleep, as  does the epileptic.   In  hyste-
  ria, there  are globus hystericus, involuntary laughing,
  weeping, and other hysteric symptoms.
Prognosis.   Not much immediate  danger.  In relation
  to its sanability, however, the prognosis is always favor-
  able.   Symptomatic, more frequently cured than idio-
  pathic epilepsy.  Cases depending on catamenial irre- 
EPILEPSY.
165
  gularities, in young females, most frequently yield to
  remedial  treatment.  The more frequently it has re-
  curred, the more difficult the cure.  Epilepsies  that
  come  on  soon  after birth,  are hardly ever cured.
  Cases  produced by falls and blows on  the  head, are
  very generally incurable.  From the period of denti-
  tion, to that  of puberty, the most favorable age for the
  cure of this disease.  It is more unfavorable, when
  the precursory symptoms consist of some affections in
  the head,  than when they are felt in other parts,  par-
  ticularly the extremeties.   Protracted sleep and  stu-
  por after the paroxysm, very unfavourable.
Treatment.  In prescribing  for epilepsy, we must  first
  endeavor to ascertain its original exciting cause—its
  duration—the time and manner of the  first attack—;
  the constitutional habits of the  patient—his  age,  pur-
  suits, concomitant disorders, temper, and mode of liv-
  ing.  It is upon these circumstances alone that a ra-
  tional  treatment  can be founded.  The treatment is
  divided into palliative and  curative.   The former
  applies to the paroxysms—the  latter  to the  intervals
  between them.   The attack  may sometimes  be  pre-
  vented during tlie period of the premonitory symp-
  toms,  by bleeding where there  are marks of general
  plethora, brisk  cathartics, emetics, a draught of  cold
  water, and ligatures round the limb, above  the part to
  which the aura (where this sensation precedes the at-
  tack)  has risen.  Richter asserts, the emetics are  par-
  ticularly  useful in warding  off an approaching parox-
  ysm, in cases that continue from habit, after the origi-
  nal exciting cause no longer exists.  I have known an
  epileptic person, who  could prevent  the  paroxysm,
  when  he felt it approaching, by a draught of cold water.
  Jahn mentions similar cases.
During  the paroxysm, our principal objects is to lesson
  the preternatural determination to the head, and with it
  the chance of apoplexy.  With this view, bleeding in
  full habits, an elevated position of the head, with  cold
  applications to  it, the removal of every thing which 
166
ECILEPSY.
   may compress the veins of the neck, and sinapisms to
   the feet, may be beneficially employed.   No treatment
   will either  materially mitigate or shorten the parox-
   ysm.
 The radical cure is to be attempted during the intervals.
   Where the exciting cause can be ascertained, and is of
   a nature capable of being removed, this should be im-
   mediately attempted, as the  first and  most important
   curative measure.  When gastric irritation from worms,
   acidity, and other causes,  exists as its cause—as is of-
   ten the case  with  young  children,  anthelmintics,
   emetics  or  purgatives, absorbents and  tonics, are pro-
   per.  In verminous epilepsy, valerian, in union v/ith
   small doses of calomel and flores zinci, has been found
   efficacious.   When suppressed perspiration has given
   rise to the disease, diaphoretics should be employed;
   here, camphor with  tarter emetic, guaiacum, sulphur,
   together  with the warm bath, warm clothing, and dry
   frictions, particularly serviceable.   When repercussion
   of utaneous affections,  or the dying up of old ulcers,
   was the  original cause, issues, vesicatories, pustulating
   applications, warm bathing,  frictions, and  stimulating
   diaphoretics, are the appropriate remedies.   When the
   disease  arises from menstrual irregularities, means
   must be employed  to obviate the morbid determina-
   tion to the uterine system.  Here, bleeding is general-
   ly an indispensable  remedy; the  warm semicupium,
   frictions about the back and  loins, stimulating enema-
   ta,  the internal use of spirits  of turpentine, of tincture
   of cantharides, and other emenagogues, (after proper
   depletion,)  are  peculiarly serviceable.  In  epilepsy
   from dentition, blisters behind the ear, leeching, pur-
   ging, scarifying the gums, and^a mild diet, are especial-
   ly indicated.  When onanism is its cause, camphor e-
   ternally, with cold  applications to the genitals,  and a
   seton in  the back of the neck, have been found bene-
   ficial.
Memedies that are employed empyrically, or that  are 
EPILEPSY.
167
   supposed, or do possess specific anti-epileptic powers:—
 Valerian.  A very ancient remedy.  It should be given
   in as large doses as the stomach will bear—a drachm
   three times daily.  It forms a principal ingredient in
   the famous  powder  of Ragoloi,  which according to
   Knopf's  analysis, is composed of Valerian, gj.  Pow-
   dered orange leaves, ^j.  Muriate of Ammonia, grs. ii.
   and ol. cajeput, gtt. iv.   Richter has  cured inveterate
   cases with this remedy.
 The Misletoe, recommended by De Haen, Van Swieten,
   Hufeland, Stark, Richter.   Cullen thinks it may have
   done good, from its having early been an object of su-
   perstition, and thus bringing with it the powerful aid of
   the imagination.  Frazer states that he  cured nine out
   of eleven cases, with the viscus quercinus, in doses of
   from gij. to 3ij. twice daily.  Dr. Fothergil and Wilan,
   speak well of its powers in this disease.
Animal Oil of Dipple.   According to Richter, particu-
   larly valuable in epilepsies from  metastasis of gout,
   rheumatism, and repelled cutaneous eruptions.
Spirits of Turpentine.   Lately much extolled  for its
   virtues in this disease.   Drs.  Latham, Young, Perci-
   val,* Money, and  Prichard, have used it with decided
   success.  Dose from 3Jss. to 3iij. thrice  daily.  I have
   lately cured a case with this remedy.
Paeony root.  Agaricus Muscarius.  Both much used,
   formerly.
Artemisia Vulgaris.  Has lately been used with singu-
   lar success, in the Polyclinic Institution  at Berlin; and
   late  numbers of  Hufeland's Journal, contain several
   well authenticated cases of its successful employment.
   It is said to be particularly useful epilepsies, coming on
   about the age of puberty, and more so in females than
   in males.  The root is given in doses of about thirty
   grains, four  times daily, and gradually increased.  Et-;
   muller says of it—mire in epilepsia valet.
Camphor, Musk,  Castor, Assafxtida.  The  first of
   these articles is said to be particularly adapted to cases 
168                  EPILEPSY.
   arising from  repelled cutaneous affections, and from
   onanism.
 Stramonium, Belladonna.  Both these narcotics have
   been employed with occasional success in epilepsy.  1
   once succeeded in removing the disease in  a child, by
   means of belladonna and cuprum ammoniacum. Hufe-
   land speaks highly of the tincture of Stramonium, and
   Odhelius cured eight out of fourteen cases,  in the hos-
   pital of Stockholm, with this remedy.
 Opium.   Epilepsy  has been cured by this  narcotic.—
   Darwin cured two cases  with it, and Dr. Huxy relates
   an instance of its successful use.  Richter states, that
   cases produced by mental excitement, pain,  or exhaus-
   tion, are often benefited by it.
Phosphorus.  This potent article is  recommended  by
   Horn, Lobenstien-Lcebel, and Van  Hoven.   It is im-
   proper in cases attended  with general plethora,
Zinc.  A valuable remedy in this disease.  It should
   be given in  large doses.  Dr. Guthrie commenced
   with eight grains  of the flores zinci, and increased the
   dose until it amounted to two scruples a  day.  Many
   cases are reported of its successful employment.  The
   sulphate less useful than the flowers of zinc, in epilepsy.
Cuprum Ammoniacum.  Cullen speaks favorably of its
   powers in this disease. The  number of cases report-
   ed of its efficacy,  is not inconsiderable.  I have used i|
   with success in one case.
Acetate of Lead.  Dr. Rush gave this article  with  suc-
   cess in epilepsy.  About fifteen years ago, I  reported a
   case  which yielded to its powers.  This  case was
   strictly  periodical—the paroxysms  returned  at each
   full moon.  Three grains were given morning, noon,
   and  evening, for  three or four days previous  to  the
   usual period  of return, and continued for three days
   after this period.  It was  not till the fifth period of re-
   currence, that the disease was subdued, and the per-
   son has continued free from the complaint to this day,
  although he had  suffered its periodical  attacks  for 
EPILEPSY.                  169
   seven or eight years before he  come under my treat-
   ment.
 Tin.  Strongly recommended  by Dr. Shearman, in a
   late Number of the London Medical  Repository.  He
   employed the elutriated oxyd  of this metal, in doses of
   from sij. to 3j. night and morning; and, he assures us,
   with much success.
 Nitrate  of Silver.   This article possesses more reputa-
   tion, as a remedy in this disei.se, than any oilier article
   of the materia medica.  It should be gicen in as large
   doses  as the stomach will bear.   We may commence
   with one grain three times daily,  and increase it gra-
   dually, which may often be done to a  surprising extent.
   Dr. Powel has ascertained, that triple the quantity of
   this article may be taken without inconvenience, in the
   form of pills, as in solution.
 Mercury has been used with success in epilepsy, by Bur-
   serius, Tissot, Houssel, Willis, Etmul.ler, Frank, Rich-
   ter, Cullen, Locher, and others,   It is seldom used at
   the present day.
 Galvanism has been found beneficial in this disease.   It
   should be applied steadily and constantly.  (See Mr.
   Mansford's work on this subject.)
 Setons and issues.  These are  ancient remedial means,
   in  epilepsy.  They  have, no doubt, been  employed
   with advantage, particularly in cases  depending on re-
   percussion of chronic cutaneous affections.  In one in-
   stance, I have known a caustic issue on the back of the
   neck  aggravate the disease greatly.   Larrey speaks
   very favorably of bleeding from the back  of the head,
   followed by blisters, moxas, or other  counter-irritants,
   on and about the head.   Tartar emetic ointment has,
   by its  pustulating  effects, cured  this disease.  (Crei<di-
   ton.)  The actuil cautery was used  by the ancients,
   and by De Haenand Larrey among the  moderns, with
   success, in this disease.
The following composition has  been employed,-in this
   city, with decided benefit, in  epilepsy.  R. Pulv. Zin-
                          Y 
170
CHOREA.
   giberis, Pulv. Salvia? officinal, P. Sem. Sinapi,  a"a  3j.
   M. Dose three tea-spoonfuls every morning, fasting,
   with an occasional purgative.
 Music.   Quarin cured a girl by music.   Other cases, to
   the same effect, are mentioned by Bruckman and Lich-
   tenthal.

                        CHOREA.

 Chorea  almost  always occurs before or  about the age
   of puberty—rarely beyond the twentieth year of age.
   It is always gradual in its approach.  During the form-
   ing stage, the appetite is variable; sometimes ravenous;
   the  bowels  constipated;  vertigo; palpitation of the
   heart; oppression and anxiety in the  precordial re-
   gion; fulness and  tension in the head, with occasional
   metnal confusion; cold feet;  variable disposition; itch-
   ing in the  nose, &,c.  The first manifestations of the
   spasmodic affections are, slight,  irregular  motions  of
   the muscles of the face,  and an awkwardness in the
   gait—progression  becoming  starting  and  hobbling.
   The irregular involuntary actions gradually increase in
   violence and constancy, until the arms and legs are al-
   most in continual motion, and the countenance various-
   ly and uninterruptedly distorted.   The voluntary mus-
   cles alone  are affected.  Like epilepsy, chorea, by long
   continuance, weakens and finally destroys the intellec-
   tual powers   In verv protracted cases, some degree of
   fever generally supervenes, and the muscles waste and
   become flaccid.   During sleep, the irregular muscular
   contractions often cease.

        There issnmeihing very remarkable in the circumstance, that
        the irregular motions, which  the utmost exertion of the will
        cannot control during the period of its activity, cease, when it
        is no longer operative during sleep.  It would seem, that the
        stimulus of volition is in s jine degree essential to the disease.

Chorea  occurs more frequently in  girls than boys.  In
   about  twenty  cases I have seen of this disease, there 
CHOREA.
171
   was but one instance in which the patient was a male.
   Children of a -i,ervous temperament, are most liable
   to the disease.
Exciting causes.   Intestinal  irritation from various ex-
   citing substances lodged in the alimentary canal; feur
   and terror; repercussion  of chronic cutaneous  erup-
   tions ; cold; suppression of catamenia.  It is sometimes
   the  consequence of typhous and other severe forms of
   fever.
Proximate cause.  I believe it to be  essentially a cere-
   bral  affection, because:  1.  The  volttatary  muscles
   alone are affected: '2. The  intellectual  faculties soon
   suffer: 3. The loss cl the power of volition over its le-
   gitimate dependencies.
Prognosis. Not often fatal.  When  produced by worms,
   or other irritating substances in the  intestinal cinal, it
   generally yields, without much difficulty,  to  remedial
   treatment.  When  caused  by cold,  also,  it is seldom
   very difficult 10 cure.
Treatment.  In plethoric subjects, with a super-excited
   state of the pulse;, bleeding is proper.   Generally, how-
   ever, sanguineous evacuations are not required.  Pur-
  gatives  are among the most valuable remedies we
   possess,  in  this disease. (Hamilton.)  In a  majority
   of cases, the  bowels  are  infarcted  with  feculent
  matter, and  this appears often to exist, as  the primary
  cause of the disease;  hence the utility of  daily purga-
  tion, in  many  cases.  When worms are the  cause of
  the  disease, anthelmintics, but particularly spirits of
  turpentine, with castor oil, are particularly beneficial.
  Tonics ought to be  employed, in alternation with pur-
  gatives,  unless contra-in licated by the state cf the sys-
  tem.   The co'd bath, bitter infusions, suh-enrbonan- of
  iron, quinine, and flowers of zinc, are the tonics usu-
  ally  employed.  They are especially advantageous du-
  ring  the  period of convalescence.   The titrate of
  silver has been employed successfully in this disease.
  (Crampton.)   Of the remedies  that have been used 
172                   TETANUS-
  with success, in this disease, arc the following.   Che
  nopodium ambroscides.   Dose bj.  in powder, three
  times daily.  (Hufeland, Plenk.)  Cardamine praten-
  &is.   The flowers are recommended by Mr G. Baker.
  Dose 3J.  Camphor, in combination  with Valerian.
  (Wilson,  Pitt.) Belladonna  Stramonium,  Opium,
  have been recommended, but have very properly fallen
  into  disuse.   Cuprum ammoniacum; Wilson  relates
  cases that were cured with this article.  (Lond. Med.
Phys. Juur.')  Electricity, very moderately applied, has
  done good.  Rubifacients, beisters, tartar emetic oint-
  ment\, along the course of the spine, are  remedies of
  considerable power in  this disease.   The diet must be
  simple, unirritating, and digestible.

                      TETANUS.

Character.  Tonic spasms of the voluntary  muscles,—
  the  powers of sensation and thought remaining unim-
  paired.
Tetanus is divided into different varieties, viz:  trismus
  opisthotonos,  emprosthotonos, pleuroihotonos.  In
  the first, the muscles of the jaw are chiefly affected; in
  the second,  the extensors of the back, producing recur-
  vation of the  body; in the  third, those on the anterior
  part, producing incurvation; and in the last, those on
  the side are principally affected, causing a lateral cur-
  vature.  It is divided also into idiopathic and  trau-
  matic—the  former  variety  being  the result of general
  causes—the latter, of external injuries.  This division
  has  an important bearing both on  the prognosis and
  treatment of the disease.
Symptoms.   Its approach is almost always  gradual, the
  symptoms  being developed  in the following  order.
-  Slight difficulty of deglutition and change of the voice;
  an uiieasy sensation in the praecordial  region; stiffness
  in the muscles of the neck and jaws.  These symptoms
  having increased to a considerable degree of violence, 
TETANUS.
173
  sudden painful retractions about the ensiform cartilage,
  with simultaneous retraction of the head, occur.  De-
  glutition  is painful  and difficult, and  re-excites  the
  spasms.  The spasms acquire more and more violence
  and frequency, until  the retraction of the head, and ri-
  gidity  of the whole body become truly frightful.  The
  mind is seldom affected; the appetite generally remains,
  and digestion  goes on regularly.  Costiveness  almost
  always attends.  The muscles supplied with gangli-
  onic nerves, and those which move the fingers, re-
  main free from spasm, until near the fatal  termination
  of the disease.  The disease usually terminates  before
  the fidh or sixth  day—sometimes it  continues much
  longer; and occasionally it assumes a chronic form.
Causes.  Various  injuries.  Contused,  lacerated,  and
  punctured  wounds, most apt to  produce  tetanus.   A
  partial division or laceration of a nerve apt to excite it.
  The introduction of cold and damp air into gun-shot
  wounds, when casting off their slough, favors the intro-
  duction of tetanus.   (Larrey.)   The application  of
  caustic to encysted tumours; compound fractures; the
  insertion of artificial teeth; amputation; ligatures, in-
  cluding nerves; cutting corns too closely, &,c. have all
  frequently  produced  the  disease.   Cold and  damp
  night air, after fatigue and exposure to a  high  degree
  of atmospheric heat  during the  day, is the most com-
  mon general cause.   Hence its  frequency in tropical
  climates.   Atmospheric heat a powerful predisposing
  cause of tetanus.   Traumatic tetanus generally  comes
  on about the eighth or ninth day after the  infliction of
  the wound; frequently not until it is cicatrized.
Proximate anise.   Galen, Willis, Hoffman, Frank, and
  Burserius,  referred  the original  seat of the disease to
  the spinal marrow, and this opinion  obtains  pretty
  generally at the present day.  It is supported  by  the
  post-mortem appearances, imd the circumstance,  that
  the muscles, supplied by  spinal nerves, are almost ex-
  clusively affected. 
174
TETANUS.
Prognosis.   Traumatic  tetanus, seldom cured.  The
  idiopathic form, less difficult of cure.  According to
  Parry, the disease always terminates fatally,  when  the
  pulse rises to 120 beats in a minute, on the first day; if,
  by  the fifth day, it does not  exceed 110, a favorable
  issue may be expected.
The favorable signs are: a very gradual supervention of
  the disease;  abdomen  not very hard;  bowels easily
  moved; moist and moderately warm skin; sound sleep;
  an  increased flow of saliva;  a mtoral  expression of
  the countenance.  When the majority, or all of these
  circumstances occur, we may entertain hopes of reco-
  very.  The unfavorable signs are: a sudden  and vio-
  lent invasion of the disease; great rigidity of the mus-
  'desof the back, neck, and abdomen; violent pain and
  retraction in  the pit of the stomach; very hard and  re-
  tracted abdomen;spasmodic twitches of the muscles of
  the neck and jaws, on firm abdominal pressure; hydro-
  phobic symptoms. (Morrison.)
Treatment.  Divided into prophylactic and curative—
  the former refers to the prevention, the latter to the
  removal of the disease.  Wounds or  injuries  from
  which tetanus is apprehended,  should be  brought to
  suppurate as soon as possible.  For this purpose, sca-
  rification, free division with  the knife, irritating appli-
  cations, such as spirits of turpemine, caustic, &c. are
  employed. When the disease has made its appearance,
  constitutional  are to be used conjointly  with the local
  remedies.  The most important of these are:—
Blood-letting, employed ad, deliquium, in  conjunction
  with mercury and opium, has cured  the disease. (Med.
  and Phys. Jour. 1N21.—Medico Chir. Trans, vol. i\.)
Purgafires  always proper, as auxiliary means, particu-
  larly in trismus naseenthim.  (Chalmers Hamilton.)
Opium, is one of the most efficacious remedies we possess
  in this dis<"i3!\   It must  be given in large and frequent
  doses.  Dr. Morrison, who was particularly successful
  with it, commenced with 100 drops of laudanum, and 
TETANUS.
175
  increased each succeeding dose, by one  third  this
  quantity every two hours.
Mercury, highly and deservedly recommended by many,
  in the treatment of this disease.  It is more efficacious
  in idiopathic, than traumatic tetanus.   It may be ad-
  vantageously used, conjointly  with the warm  bath,
  opium, Slc.
Spirits of turpentine, has recently been successfully em-
  ployed  by Drs.  Hutchinson,  Toms, and Mott.  Dr.
  Mott's case is a striking example of its usefulness in
  this disease.  After the hot and  cold baths, tobacco,
  opium, bark and wine, and blisters to the spine, had
  been fairly tried without benefit, a tea-spoonful of tur-
 pentine, ^icen everyfifteen minutes, relieved the spasms
  in two hours; and by continuing its use until 123 tea-
  spoonfuls were taken, the disease was perfectly removed.
Wine, and other  alcoholic liquors.  This was a  favo-
  rite remedy with Rush.   Opium is now generally, and
  I think properly, preferred.  When employed, it must
  be very freely given.  Rush gave it in conjunction with
  bark and mercury.
Tobacco, both by the mouth, and in the form of enemata,
  has been found decidedly beneficial.   An interesting
  example of its efficacy, is related in the third volume of
  Dublin Hospital lieporls, by Dr. O'Beirne.   Dr. An-
  derson used tobacco baths, fomentations, and enemata,
  with success, in several cases.   (Med. Chir. Traps, of
  Edinburgh, vol. i.)  It must be employed with caution.
Cold affusions, a very ancient remedy in tetanus.  (1 lipp.
  Aphor.  Lib. iv. Sect. v. Aph.  2., and  Lib. v. Sect. ii.
  Aph. 2 ! ) They were successfully used by Drs. Wright,
  Cochrane, and  Currie.  I have known a  case cured
  by salivation and cold affusions, conjointly.
Cantharides.  given internally, has effected  cures.  Dr.
  Brown, (New York.  Med.  Rep< s. vol  iv.) cured a
  case witii this medicine.  It should be  given so as to
  produce stranguary.
Prussic acid.   Cases of its successful employment in 
176
WHOOPING COUGH.
   this disease, are related by Drs Pattison, and Trezevant.
 The warm hath, a useful adjuvant; it generally procures
   temporary relief   Some practitioners have found it to
   do harm; paiticularly Dr. Hillary.   The exertion and
   movement which  it requires of the  patient, is said, by
   Dr. Morrison, to do injury.
Blist rs along the  whole tract of the spine, have done
   much good in this disease;  a more powerful, prompt,
   and efficacious means of this kind, however, is the ap-
   plication of caustic potash, as  first recommended by
   Dr. Hartshorne of this city.  (Eclectic Keper. vol. vii.)
   Whatever other remedies may be employed, the appli-
   cation of  this caustic along  the course of the  spine
   should never  be  neglected.  The  cases  which have
   been reported, illustrative of its efficacy are by no means
   few.
The actual cautery along the spine, is said by Mursina,
   to have effected a  prompt and perfect cure.  The good
   effects which I have witnessed from the application of
   the actual cautery, in deep seated articular inflamma-
   tion, convinces me that there is  no  means in our  pos-
   session, by which  we can produce so prompt and pow-
   erful an impression  on the inflammation of internal ca-
   vities  and parts, as this potent agent.

           PERTUSSIS--WHOOPING COUGH.

Character.   A contagious cough—paroxysmal, convul-
   sive,  and  suffocative;  inspiration during  the cough
  shrill—the cough  frequently terminating in vomiting'
Whooping cough may be  divided into three stages: I.
  The forming stage; characterized by the usual symp-
  toms of ordinary catarrh ; i. e. lassitude, weakness, and
  head-ache; sneezing; slight hoarseness; discharge of
  thin mucus from the nose; restless sleep; inappetency;
  and generally  slight febrile symptoms;  the cough is
  shrill, dry, and  comes  on in sudden but short parox-
  ysms,  without  whooping.  This  stage lasts from  two 
WHOOPING COUGH.
177
   to three weeks: The convulsive stage;  characterized
   by violent paroxysms of convulsive and suffocative
   cough, the inspirations being  difficult and  stridulous,
   and attended with a sense of obstruction  or spasmodic
   stricture of  the glottis.  These paroxysms return at
   first five or six times daily, and gradually increase in
   frequency, so as, at last, to return almost  hourly.  The
   approach of a fit of coughing, is always announced by
   a sense of stricture in  the breast, and titillation in the
   larynx  and praecordiae.   The paroxysm  lasts  from a
   half to four or five minutes, and terminates by vomiting,
   or the discharge of a  large quantity of  viscid  mucus
   from the bronchia.   Pain is felt in  the breast, immedi-
   ately after the  cough.  The duration of this stage is
   very various: in general it lasts from four to six weeks:
   3. The stage of declension;  this stage begins, when
   the spasmodic  and suffocative  character of the cough
   begins to abate. The  declension of the disease  is al-
   ways very gradual; its  duration is as various as that of
   the other stages—commonly from two to  four weeks.
Prognosis. Whooping cough is seldom fatal, except by
   the supervention of bronchitis, hydrocephalus, cynanche
   trachealis,  pneumonia, convulsions, or marasmus.__
   Sequellte.  Glandular swellings, dropsy, epilepsy, op-
   thalmia, struma, rickets, general cachexy, phthisis, &c.
Proximate cause.  The opinions on this subject are ex-
   ceedingly various.   Marcus,  Whatt, and others, re.
  gard it as a  peculiar species of bronchial inflamma-
   tion.  Webster regards the  brain  as  its  primary dis-
   ease.   Albers considers it as depending on a peculiar
   irritation of  the eighth  pair of nerves.   Some view the
  stomach as its original location; and others regard it
  as a  spasmodic  disease, allied to  asthma.  My own
  opinion coincides with  that of Albers.   My reasons for
  rejecting the doctrine of its being an inflammatory af;
  fection,  are stated  in the lecture.  The inflammatory
  symptoms which frequently occur in  this disease, are
  not essential, but accidental to the disease.  In many 
178
WHOOPING COUGIT.
  cases, not the slightest febrile symptoms occur; and
  when we reflect on the almost constant agitation and
  irritation which the lungs suffer from  the cough, we
  have good grounds for believing, that the inflamed ap-
  pearance of the  mucous  membrane of  the bronchia,
  so commonly found on post-mortem examination is the
  effect, and not the cause of the disease.
Treatment.  It  is generally  believed, that whooping
  cough, like the exanthematous fevers, cannot be arrest-
  ed  in its course, but that, when once developed, it ne-
  cessarily passes through its different stages.  This
  I hold to be an  erroneous opinion, being  thoroughly
  persuaded,  that it is susceptible of being arrested at
  any time, whether in its forming,  convulsive,  or de-
  clining stage.
Bleeding and leeching.   Both may be employed with
  decided advantage, in cases accidentally complicated
  with inflammatory symptoms, or where much cephalic
  congestion exists.  The  disease cannot, however, be
  subdued by them.
Purgatives of the mild kind, are proper, in cases attended
  with constipation, a loaded state of the bowels, or pre-
  ternatural determination  to the head.
Emeties, always beneficial, unless great gastric irritability
  exists.  They free  the  bronchia and  trachea of the
  viscid mucus with which they are loaded, and perhaps
  do  good by their impressions on the pneumo-gastric
  nerves.
Narcotics.  Belladonna is a  valuable  remedy.  It is
  much  used in  Germany and France.  I have em-
  ployed  it in a number  of cases,  with great  advan-
  tage.  Dose for a  child under one  year, 1-2 grain;
  from two to three years,  2 1-2 grains of the powdered
  root.   Conium  maculatum, rhus vernix, hyoscya-
  mus, opium, lactuca rirosa,pulsaiilla nigricans, and
  solanum nigrum,  have all  been used and praised as
  remedies in this disease.
Antispasmodics.   Assafeetida in emulsion, useful, where 
WHOOPING COUGH.
179
   ho symptoms of febrile irritation exist.   Musk, valeri-
   an, amber, castor, &c. have been beneficially employ-
   ed.  Not a great deal, however, is to be expected from
   this class of remedies.
 Tonics.  Cinchona, quinine, flowers of zinc,  and arse-
   nic, are remedies of much value, where no signs of in-
   ternal inflammation exist.  I have given large doses of
   quinine, with marked advantage.
 Expectorants, are seldom  of much service.   Pearson's
   alkaline solution, and Kerme's mineral, suspended in
   in a mucilaginous fluid, are among the best of this class
   of remedies.
 Lobelia inflata.   I have found the tincture of this plant
   a most valuable remedy in whooping cough.   From
   ten to fifteen drops are to be given, four times daily, to
   a child between the first and second years of age.
 Tinct. Cantharidcs, highly recommended by Armstrong,
   Chalmers, Millar, Buchholz,  Loder, Lettsom, Hufe-
   land, and  others. It must  be  used  until slight ardor
   urinae occurs.
External applications.  Frictions, with tartar  emetic
   ointment, along the spine, or over the precordial re-
   gion, will generally prove decidedly useful.  This prac-
   tice originated with Autenrieth.  (Richter.)   Blisters
   and rubifacients are indispensable, when pulmonic in-
   flammation exists.
Balsam Copaiva,  is a remedy  of  inestimable powers,
   when the disease has degenerated into chronic bron-
   chitis, and the expectoration is  puruloid.
Inhalations.   The inhalation of balsamic vapors,  the
   nitrous  acid  vapor, and the vapor of tar,  are strong-
   ly recommended by some recent writers.  1 have used
   the nitrous acid  vapor with benefit,  in several  violent
   cases.
Tlie diet should be simple  and unirritating; and great
  care must  be taken against the influence of cold and
  damp weather. 
180
ASTHMA.
                      ASTHMA.

Character,   Great difficulty of breathing, attended with
  a  sense of suffocation, great thoracic  constriction,
  wheezing, and cough.
Symptoms.  The attack usually preceded by premonitory
  symptoms; such as drowsiness; head-ache; itching of
  the skin; flatus; heart-burn; acid eructations; sickness;
  fulness and anxiety about the praecordia; weight over
  the eyes, &,c.
The paroxysm generally comes on at night, during sleep.
  It is characterised by inexpressible anxiety; very labo-
  rious wheezing, and suffocative breathing; great tight-
  ness about the chest; countenance bloated and livid—
  —sometimes pale; cold extremities; intense desire for
  cool fresh air; incapability of lying  down; pulse fre-
  quent, irregular,  and often intermitting; abdomen dis-
  tended with wind; cough, at first dry; a copious  expec-
  toration of viscid mucus occurring in the course of
  some hours, bringing with  it considerable temporary
  relief   The symptoms remit greatly, during the  ensu-
  ing day.  On the next night, however, the fit generally
  returns.  In this manner, it often goes on with  remis-
  sions by day,  and exacerbations by night, for five  or
  six days; and  sometimes much longer.
Predisposition.   The disease rarely occurs before the
  age of puberty.  The predisposition appears to consist
  in  an irritable and weak condition of the respiratory
  organs.  It seems, in some instances, to be hereditary.
  Persons of weak muscular  power,  and disposition  to
  obesity and corpulency, are most liable to the disease.
Exciting causes.   Particular  conditions  of the  atmos-
  phere, in  relation to its humidity, electricity and tem-
  perature ; various irritating substances conveyed to the
  lungs;  suppression of accustomed  discharges; reper-
  cussion of cutaneous affections; metastasis of gout or
  rheumatism;  general plethora; gastric and intestinal 
ASTHMA.
181
    irritation; derangement of the digestive functions; cer-
    tain odours; indigestible aliment; anger, and terror.
 Authors have divided asthma into a great many varie-
    ties.  It does not appear to me, that these distinctions
    are of any practical utility; although it is unquestion-
    ably of much importance to attend to the nature of the
    exciting cause,  in prescribing for the disease.
 Proximate  cause.   The opiuions on this subject very
    various.   Cullen ascribed it to a preternatural spasmo-
    dic constriction of the bronchiae.  Parry to a vasculaf
   fulness of the bronchial membrane, by which the air
    cells are mechanically diminished.  Potter, to general
    venous congestion of the lungs.  Bree, to an irritation
    seated within the air cavities, caused by  a viscid and
   irritating serum.  My own opinion is, that it depends
   on a peculiar irritation of the pneumogastric nerves, in
   consequence of which, the regular transmission of the
   nervous influence to the lungs,  is interrupted.   This
   opinion is  founded: 1.  On the effects which are pro-
   duced on respiration, by dividing the  eighth pair of
   nerves, which  entirely  resemble the  phenomena  of
   asthma: 2. The suddenness with which the spasmodic
   breathing may often be allayed, by certain medicines,
   as the lobelia inflata:  and,  3. The beneficial effects
   resulting from the transmission of the galvanic influ-
   ence through the lungs.
Treatment.  Bree affirms, that we can do but little tow-
   ards mitigating  the  paroxysm.  He is wrong; I;have
   often seen  the paroxysm arrested, in less than thirty
   minutes.
Bleeding.  When the disease arises from the suppression
   of some habitual evacuation, and is  attended  with ge-
   neral plethora, blood-letting is indispensable.  When-
   ever the pulse is hard and tense, blood should be drawn.
Emetics, are  much recommended by some.  When gas-
   tric  irritation exists, from  indigestible  diet,  or other
   causes, they are serviceable.  Under  other  circum-
  stances, they seldom do much good. 
182                   asthma.
 Purgatives beneficial, when the bowels are disordered*
   Bree recommends chalk, in union with rhubarb.
 Expectorants, a useful class of remedies in this disease,
   Floyer regarded vinegar of squills as a specific  in this
   disease, which, however, it is very far from being.
 Diuretics, are serviceable, in  dropsical habits.  A copi-
   ous flow of urine, is always a favorable occurrence.
 Antispasmodics,  are  seldom useful.   In habitual or
   chronic asthma, opium with ether, has been found bene-
   ficial.
 Narcotics.  Hyoscyamus, stramonium, tobacco, and opi-
   um, have been recommended.   They are occasionally
   palliative, particularly in protracted or habitual cases.
   The root  of the stramonium  is to be  cut  fine, and
   smoked in a pipe.
 Symplocarpus frntida.  I have known the infusion of the
   root of this plant, give great and prompt relief.
 Lobelia inflata.  I regard this vegetable as decidedly the
   most valuable remedy we possess, for arresting or miti-
   gating the asthmatic paroxysm.  My own experience
   corresponds entirely with the statements published by
   Drs. Thatcher, Stewart, Cutler, and others, of its valu-
   able remediate effects in this disease.   I have known a
   violent fit of ashma completely allayed  in the course of
   thirty minutes.
 Coffee.   A cup of very strong  coffee will  often procure
   much alleviation in this  complaint. (Percival.)
 Digitalis, in combination with small doses of opium, re-
 •  commended by Drs. Ferriar and Percival.
Prussic acid, employed with advantage  by Drs. Oliver
   and Granville.
Galvanism has of  late years been employed with  much
   advantage in this complaint, by Dr. Philip and others.
   The galvanic influence  must  be communicated with
   much force.   The  two wires  of a  weak  galvanic
   trough,  are  to  be attached, one to a piece of  metal
   placed on the pit of the stomach, and the other on the
  side of the neck, over the par vagum. 
ANGINA  PECTORIS.
183
 The prophylactic  remedies are of the tonic kind.  Bark,
   iron, tonic bitters, with occasional mild aperients,mode-
   rate exercise, and above all, a light and digestible diet,
   with the use of the cold shower bath, are to be used
   during the intervals of the attacks.

                  ANGINA PECTORIS.

 Symptoms.   Sudden and violent pain about the sternum,
   extending to the arms, attended with great anxiety, dif-
   ficulty of breathing,  and a sense of suffocation; pulse
   seldom materially affected—sometimes irregular or in-
   termitting ; countenance pale  and expressive of intense
   anxiety; extremities cold.  The attack usually comes
   on while the patient is walking.  At first, it lasts but a
   few minutes, and returns after long intervals; but by
   degrees the fits recur oftener, and become more pro-
   tracted.
Predisposition.  It occurs more frequently in males than
   females; and exceedingly seldom  in young persons.
   Subjects of a gouty or rheumatic habit, with a tendency
   to corpulency, are most liable to the disease.
Causes.  Ossification  of the  coronary arteries, and
   valves of the heart; dilatation of its ventricles; a soft-
   ened structure  of the heart, and  other organic  affec-
   tions of this organ, and of the adjoining parts.  In some
   cases, however, not the slightest traces of structural de-
   rangement are found on dissection.  Dr. Johnson thinks,
   that a neuralgic  affection of the cardiac plexus may
   produce it—an opinion which is, I think, well founded.
   From all that has been ascertained in relation to this
   subject, it would seem, that angina pectoris is an  affec-
   tion which may be excited by a variety of causes; and
   it appears to me  probable, that the essential nature of
   the disease,  consists in an irritated condition of the
   cardiac nerves.
Prognosis.  The disease is generally believed to be in-
   curable; and  when it depends on structural derange-
   ment of the  heart, it undoubtedly is so.   There  are 
184
DROPSY.
  some well attested cases on record, however, which
  yielded to remedial measures.   Death almost always
  occurs suddenly.  Fothergill, Wichmann.
Treatment.   For the relief of the paroxysm, bleeding,
  opium, hyoscyamus. a recumbent posture, and perfect
  rest and quietness, are often found beneficial. To pre-
  vent the return of the disease, the following remedies
  have  been  employed  with  advantage.   Guaiacum;
  opium, musk, and camphor in union, (Shaefer;) cicuta,
  assafeetida, and camphor, (Johnson;) flowers of zinc
  and  opium,  (Perkins;) lime  water  and antimony,
  (Smith;) Frictions with tartar emetic ointment on the
  breast, (Godwin;) phosphoric acid, (Baumes, Richter;)
  James's powder,  (Smith;) a rigid antiphlogistic regi-
  men,  (Odier;) arsenic, (Hufeland,  Blane;) prussic
  acid; hyoscyamus; stramonium; cuprum ammoniacum,
  &c.   All kinds of spirituous drink are  injurious; so
  are strong mental emotions; inordinate venereal indul-
  gence ; strong corporeal exertions; sudden atmospheric
  vicissitudes; indigestible and irritating articles of  food,
  &c.
              CHAPTER XVIII.

                     DROPSY.

Pathology of Dropsy.  Dropsical effusion is not, pro-
  perly speaking, a disease, but only an effect of disease.
  The morbid condition upon which the dropsical effu-
  sions depend,  is either inflammation, or a state of the
  exhalents  closely allied  to inflammation.    (Rush.)
  The doctrines  which allege, that torpor of the absorb- 
ANASARCA.
185
   ents, or relaxation of the exhalents, is the proximate
   cause of the effusion, are examined, and their insuffici^
   ency pointed out.  There is, no doubt, always deficient
   venous absorption,—because that condition of the ca-
   pillaries, which disposes to excessive exhalation, is es-
   sentially connected with a congested state of these ves-
   sels, and congestion,  or vascular fulness, always im-
   pedes absorption.  (Magendie.)   Observations on the
   character of the urine, in hydropic diseases.   In some
   instances,  the urine contains  more or less serum;  in
   others,  it is  entirely destitute of it.  According to the
   observations of Blackall, Willis, and  Ayre, it is in the
   subacute and idiopathic forms of dropsy, that the urine
   is  loaded  with  the  greatest quantity  of serum.  In
   dropsy from scarlatina, there is generally a large quan-
   tity of serum in the urine.   In local dropsies, not atten-
   ded  with  general excitement, the  urine  is  seldom
   charged with any serum.  (Ayre.)
When the heart sympathizes v/ith  the  local or  general
   morbid action of the exhalents, febrile symptoms at-
   tend.   When the morbid excitement of the exhalents
   does not extend to the heart, the general circulation is
   languid, and debility and relaxation characterize the
   disease.
The general indications in the treatment of dropsy, are:
   2. To  procure  the absorption and elimination of the
   effused  fluid:   2. To correct  the morbid action of the
   serous exhalents, from which  the effusion takes place.
Dropsy is divided into three principal varieties: viz. Ana-
   sarca, ascites, and hydrothorax.

                     ANASARCA.

In this variety, the effusion takes place  into the cellular
   tissue.   It may be either local or general.   A part that
   is anasarcous, pits on pressure.   It almost always be-
  gins in the feet or legs—the swelling diminishing dur-
  ing the  night, and  increasing towards evening.  The 
186
ASCITES.
  urine in this, as in the other varieties of dropsy, is al-
  ways scanty and high colored; the countenance is sal-
  low, the general system sluggish, and there is usually
  much sleepiness.  Anasarca is  frequently connected
  with effusion into the abdomen and chest.
Causes.  Local anasarca may be produced, by whatever
  impedes the return of the blood from a part—as, indu-
  rated glands pressing on large veins, ligatures, &c.  It
  arises also from mere general debility; diseases of the
  heart; phthisis, &c.
General Anasarca may result from hemorrhages, diar-
  rhoea, diabetis, and other circumstances that  rapidly
  exhaust the  system.   Observations on the manner in
  which these causes produce dropsy. Sudden suppres-
  sion  of perspiration, particularly after scarlatina,
  measles, or while under the  influence of mercury, a
  frequent cause of general anasarca.  Dropsy from this
  cause always decidedly phlogistic.   General anasarca
  may also result from the internal use of arsenic—from
  torpor of the kidneys—from amenorrhcea, general pie*
  thora, with a relaxed habit, chronic diseases, intestinal
  irritation, &c.   Observations on  the modus operandi
  of these causes.
Proximate  Cause.  A  sub-inflammatory action of the
  exhalents  of the cellular tissue, attended with increased
  exhalation, and diminished venous absorption.   It ap-
  pears to  me probable, that congestion in the venous
  capillaries, performs an important part in the  produc-
  tion of dropsical accumulations.  This idea is discussed
  at length, in the lecture.

                       ASCITES.

Abdominal dropsy.  Its causes are sometimes local, at
  others general.   The local causes are such as impede
  the circulation through the portal  system of vessels—*
  among which, visceral indurations, particularly of the
  liver and  spleen, are the most common.   Dr. Ayre de^ 
HYDROTHORAX.
187
   nies that visceral  obstructions produce dropsy; they
   notwithstanding frequently do so.   The most common
   general cause of ascites, is cold, either generally or lo-
   cally applied.   When the result of this cause, its cha-
   racter is always conspicuously inflammatory; the blood
   usually exhibiting the buffy  coat;  the skin being dry
   and hot; the pulse frequent  and tense, and the urine
   loaded with serum.  Ascites is seldom wholly free from
   anasarca.  Intestinal irritation sometimes gives rise to
   abdominal dropsy.   It occurs as the sequel of peritoni-
   tis.  Diagnosis.
 Proximate cause.  A morbid action of the exhalents of
   the peritoneum, attended with capillary congestion,
   and diminished venous absorption.

                    HYDROTHORAX.

 Serum effused into the cavity of the thorax.  It is charac-
   terized  by the following
 Symptoms.   Oppression  in the chest; difficult respira-
   tion, particularly when  lying  down,  or  ascending
   heights; dry cough; a sense of suffocation, when in a
   recumbent  position; sudden starting  during  sleep;
   pulse  intermitting, or  irregular;  thirst considerable;
   urine scanty; oedema of the feet; a pale bloated coun-
   tenance, &c.   Divided into symptomatic and idiopa-
   thic.  The first arises from  organic affections,—the
   latter from general causes.
 Causes.   Organic affections of the heart.   When from
   this cause, the effusion occurs on both sides.  Chronic
   pleuritis*, a frequent cause of hydrothorax. It  may
   also result from a tuberculous state of the  pleura, and
   even from  structural disease  of the stomach and liver.
   This is by far the  most frequent variety of hydrotho-
   rax, and is almost always incurable.
Idiopathic hydrothorax, is of very rare occurrence, and
   generally easily  cured.   The effusion almost always 
188
HYDROTHORAX.
  occurs only on one side—that side becoming sometimes
  considerably enlarged, by the pressure of the fluid;
General plethora, predisposes to hydrothorax; particular-
  ly in persons  who have passed  the  middle period of
  life, and who indulge in  the pleasures of the table, and
  use but little exercise.
Diagnosis.   A sense of suffocation on lying down, and
  on firm pressure on the abdomen, will generally distin-
  guish it from mere organic disease of the heart.  Per-
  cussion produces a dull sound, and the stethescope
  detects the absence of the respiratory murmur.
Treatment.  When  the heart sympathizes with the
  primary local  irritation, or  with the morbid action of
  the capillaries from which the effusion occurs, blood-
  teiting is an important remedy.   It is indicated in all
  cases,  in which  there is tension  and quickness of the
  pulse.  Local bleeding, from the thorax  or abdomen,
  recommended by Ayre,  in hydrothorax and ascites.
Diuretics, are important remedies in hydropic diseases,
  Their operation is,  however, rather palliative than cu^
  rative—-that is, they evacuate the effused  fluid, rather
  than correct the morbid action on which the  effusion
  depends.   In full and phlogistic habits, their operation
  is promoted by bleeding and cathartics.   When the
  effusion is  very extensive, and the blood has been de-
  prived of a great portion of its  serum, copious draughts
  of water promote  the  operation of diuretics.  The
  mode in which diuresis removes dropsical effusion ex-
  plained.    The  most useful diuretics in  dropsy, are:
  squills, digitalis, tobacco, cantharides; acetate, nitrate,
  and tartrate of potash; colchicum,  wild  carrot  seed,
  erigeron heterophyllum, and juniper berries.
The squill, is the best diuretic in hydrothorax.  It is best
   adapted to cases in  which the urine is very scanty,
   h:gh colored, and sedimentous, and not attended with
   much febrile excitement.  Its virtues are much enhanc-
   ed  by givino- it in  union with calomel, especially  in
   hy'drothorax.° Very advantageously combined with 
HYDROTHORAX.
189
   digitalis and nitre.  The reason why  calomel  and
   squills, in  combination, are more beneficial in hydro-
   thorax, than in the other varieties of dropsy, are three-
   fold; "1. absorption; 2. diuresis; 3. determination to
   the glands of the mouth and throat, causing a deriva-
   tion from the vessels of the pleura."
Digitalis.  Some greatly extol its virtues in dropsy—oth-
   ers speak lightly of it  It does not appear to do much
   good, in subjects of a tense fibre, and robust  habit of
   body.  In persons of a contrary habit,  with a  pale
   countenance, cold skin, and weak pulse, it often proves
   decidedly beneficial, (Withering,  Maclean.)   Digi-
   talis, is  the best diuretic in dropsies following scarla-
   tina.  It is almost always beneficial, when the urine is
   coagulable by  heat, small in quantity, somewhat tur-
   bid,  and depositing a  branny sediment,  when cold.
   (Blackall.)  It [almost  always fails to do good, when
   the urine, though serous, is pale, crude, and without
   Sediment.  It is generally given, in- combination with
   squill or calomel.   I prefer giving it in union with nitre
   and calomel.  In feeble habits, it may be advantageous-
   ly combined with opium.
Cantharides, more particularly  useful in anasarca, after
   scarlatina. (Ferriar.)  Nitre  is an excellent  remedy,
   when the febrile  excitement runs  high.  Diuretic
   drinks, such as infusion of juniper berries, wild  carrot
   seed, &,c. should be freely allied.
Cathartics.  Valuable remedies in ascites and anasarca
   —-not so in hydrothorax.  Their  modus operandi ex-
   plained.   The articles of this class, most beneficial,
  are; tartrate of potash; elaterium; gamboge, &x.   Of
  these the  tartrate  of potash  is  both the safest  and
   the most useful.  I have employed the following  diu-
  retic  composition,  with more uniform, and  prompt
   advantage, than  any other article, or combination of
  articles I have ever tried.   R. Tart, potas.  3iss. Sulph*
  potas. 3ss. Pulv. Scillae,  3ij.  Tart. Antimonii, gr. ij.
  Dose, a tea-spoonful, four or five times daily.   This 
190
HXDROTHORAX.
   rarely fails to excite very copious watery stools, and at
   the same time, free diuresis.   It is particularly useful
   in ascites.  I have generally derived much more bene-
   fit from gamboge, than from elaterium.  It is particu-
   larly useful in ascites.  It may be advantageously com-
   bined with cream of tartar, in the proportion of 2 grains
   of the  gamboge, to 30 of the latter article, repeated
   every three or four hours.   It produces copious watery
   stools,
Mercury, is a remedy of valuable powers in hydropic
   diseases.   Generally given in uuion with diuretics,par-
   ticularly squills and digitalis.  Should be given until
   the mouth is slightly affected by it.  Relaxed and scor-
   butic habits, inimical  to  its beneficial influence.   Es-
   pecially valuable,  where there  is organic disease  of
   the liver.
Sulphuret of Iron.  I have  seen  much good done by
   this article, in cases attended with a relaxed and very
   debilitated state of the system; particularly in the ana-
   sarca of females, from excessive sanguineous discharges.
   It acts as a powerful diuretic, as well as tonic.
Diaphoretics, are indicated, when the disease is the con-
   sequence of suppressed  perspiration from cold.  Anti-
   monials, in such cases, act beneficially.
Blisters,  and rubifacients, to the chest or abdomen, in
   hydrothorax and ascites, are strongly recommended by
   Ayre.  I  have seen much  good derived from a blister
   over the abdomen,  in a case of ascites.   Tapping.

                     DIARRHC3A.

"Character.   Frequent feculent stools, generally copious*
   always more liquid than natural, commonly attended
   with griping, but free from tenesmus and fever.
^Causes.  Some act directly on the alimentary canal; oth-
   ers indirectly, through the medium of the general  sys-
   tem.  Of the former kind, are: indigestible and irritat- 
diarrhoea.
xm
  ingarticles of food; acrid secretions; worms; acid, and
  other irritating substances received into the stomach.
  Among the  more general causes, are: dentition; cold,
  particularly when connected  with humidity;  the re-
  percussion of cutaneous eruptions; various general and
  local diseases, as phthisis, affections of the liver, &c. It
  may also be excited by violent mental emotions, as ter-
  ror and grief.
Proximate cause.   An increased irritability of the in-
  testines, giving rise to increased peristaltic motion.  In
  protracted cases, the mucous membrane Of the intes-
  tines is generally in a state of chronic  inflammation,
  and frequently more or less ulcerated.  (Broussais,
  Abercrombie.)  According  to Broussais,  when  diar-
  rhoea continues beyond  the thirtieth  day, it almost in-
  variably depends on organic disorder  of the mucous
  membrane of the colon.  He asserts, that Chronic in-
  flammation of this membrane exists in all cases. This
  is doubtful.   When ulceration exists, it is always most
  conspicuous in the caecum, and the lower  part  of the
  colon.
Treatment.  The principal indications are: to subdue
  the irritability, or phlogosis of the bowels; and  to re
  move  as much  as possible, all local irritating causes.
  These indications are to be fulfilled: 1. by determining
  the circulation to the surface,  and thereby  lessening
  the afflux of blood to the vessels of the intestines; and,
  2. by prescribing the most simple and unirritating arti-
  cles of food.  To allay intestinal irritability, and  deter-
  mine to the surface, opium,  with small doses of calo-
  mel, or of ipecacuanha, and  minute portions of calo-
  mel alone,  are  excellent remedies.  Mild  laxatives
  should be premised.  In the diarrhcea of children, at-
  tended with a tumid and hard abdomen, laxatives are
  our principal  remedies.  Astringents, with  mild to-
  nics, useful, in  diarrhoea from  mere debility of the
  stomach.  Astringents improper, where there is much
  griping and tenderness of the abdomen, and  in all in? 
192
CHOLERA.
   veterate cases.   Absorbents proper, when acidity is
   the cause.  Balsam Copaiva, on excellent remedy in
   very protracted and  obstinate cases.   I have used spi-
   rits of turpentine with much advantage, in such cases.
   A flannel roller round the abdomen, beneficial in all
   cases.  A farinaceous diet is of the utmost consequence,

                      CHOLERA,

Character.  Frequent and violent  vomiting and  purg*
   ing, with severe griping and cramps in the extremities.
Symptoms.  Its attack is almost invariably sudden.—
   There is at first pain and tension in the epigastric re-
   gion—followed soon by colic pain about the umbilical
   region,  attended  with  nausea,  upon  which vomiting
   and purging speedily ensue,  The discharges are at
   first watery and  without  bile;  nor is there often bile
   thrown  from the stomach, in the commencement.  Af-
   ter the disease  has continued for some time, however,
   bile appears in the evacuations.   The most distressing
   symptom, is the excessively severe cramps which oc-
   cur in the abdominal muscles, and the extremities, in
   violent  cases.  Cholera seldom continues more than
   24 hours—it often terminates  in  death,  within two
   hours.
Causes.   A superabundance  of bile in the stomach, is
   not, as was formerly, and is still thought by many, the
   immediate exciting cause of cholera.   There is, on the
   contrary, a deficient  secretion of bile—the liver being
   in  an inactive  and congested condition.   The torpor
   of the liver, is generally in direct proportion to the vio*
   lence of the disease.   (Johnson.)
Treatment.  The principal indications are: to  allay
   the  morbid irritability of the alimentary canal; to re-
   store the regular action of the skin and liver; and to de-
   termine the circulation from the  internal to the external
   parts.   At first, bland diluents are proper.  Opium in
   large doses, either alone, or in combination with calo-r 
COLIC.
193
   mel; sinapisms to the abdomen; the warm bath; spiced
   brandy; nitric acid vesication; and anodyne injections;
   are the remedies  upon which  our dependence must
   be placed.   Of these remedies,  opium largely given,
   and sinapisms  to the abdomen, are decidedly the most
   efficacious.   Calomel should be given with the opium.
   Calomel is a valuable remedy,  by itself; half a grain
   should be given every  half hour.  Bleeding has been
   useful in the Asiatic cholera.  It is seldom  indicated
   in the disease,  as it occurs in our climate.

                       COLIC.

Colic is divided into several varieties,  according to the
   nature of the exciting causes.
Flatulent colic, so called from the prominent symptoms
   of indigestion and flatulency which attend.  It is pro-
   duced by irritating and indigestible articles of diet.—
   Debility of the digestive organs, predisposes especially
   to this variety of colic.  The colic pains  come on, an
   hour or two after the indigestible diet is taken.  Some-
   times the food passes into the bowels in an imperfectly
   digested state, and then the pain  does not come on so
   soon, and is felt low down in the abdomen.   At first,
   there is a sense of distention in the pit of the stomach,
   followed soon by pain, which rapidly increases, until it
   acquires an intense degree of violence.   The pain oc-
   casionally remits.   During the exacerbations, the pa-
   tient throws himself about, and presses firmly on his
   abdomen with his hands.  Large quantities of air are
   from time to time forced up, or pass off downwards.
Diagnosis.  Distinguished from enteritis,  by the agita-
   tion of the patient; by the relief obtained from abdomi-
   nal pressure, and by the pain frequently remitting.  In
   all these respects, the reverse obtains in enteritis.
Prognosis.  Generally not  dangerous, unless it  termi-
   nates in  inflammation,  which sometimes, though not
   often, occurs.  It sometimes produces a paralytic state
                          B* 
194
COLIC,
  of a portion of the bowels, giving rise to habitual cos-
  tiveness.
Treatment.  In slight attacks, carminatives and ano-
  dynes are often sufficient to procure relief.   Remedies
  of this kind generally answer well, when the stomach
  does not  contain any irritating substances.  When it
  does contain  irritating  substances, an ipecacuanha
  emetic must be given.   Purgatives to be used when
  the pain is below the stomach; they may be advanta-
  geously combined with aromatics.   1 prefer castor oil
  and spirit of turpentine, in union.   Enemata, always
  useful.  Where the pain is excessive,  opium, in very
  large doses, with calomel, is a valuable remedy—it
  does not materially impede the subsequent operation of
  the necessary  purgatives.
Bilious colic, so called, from the bilious vomiting, and
  other symptoms, manifesting functional derangement
  of the liver.
The more urgent and peculiar symptoms of this variety
  of colic, are generally preceded by head-ache, want of
  appetite,  bitter taste in the mouth, thirst, and bilious
  vomiting.  The colic pains are excessively acute; pres-
  sure at first gives relief; but the abdomen becomes ten-
  der to the touch, as the disease advances.   Immediate-
  ly after vomiting, the pain suffers  a temporary abate-
  ment.  The bowels are generally immoveably torpid.
   About  the second or third day,  the eyes and skin  be-
   come yellow.  Tremor, numbness, and  paralysis of
   the arms, occasionally occur in  this disease.   Eructa-
   tions are common, and afford temporary relief
 Causes.  Marsh miasmata.  It occurs most commonly
   during the autumnal months, particularly after a long
   continuance of hot and humid weather.  It may, how-
   ever, be produced also by causes of a sporadic character.
 It is generally believed, that the liver is in a state of mor-
   bid activity—that it secretes a superabundance of bile.
   Dr. Staly contends, that the liver is torpid—that there 
COLIC.
195
   is a deficiency of bile.  I have come to the same con-
   clusion.
        That there is functional derangement of the liver in this vari-
        ety of colic, does not admit of a doubt; but I do not believe the
        biliary secretion superabundant, but on the contrary diminish-
        ed and vitiated.  That this is the case, may be inferred from
        the analogy which subsists between bilious colic and cholera
        morbus.  Dr. Gregory observes that bilious colic is  closely
        allied to cholera, occurring along with it, and apparently dif-
        fering from it only in some unessential features.  Now it ap-
        pears to be well established, I think, that in  cholera, the liver
        is far from being over-active—that it is, in fact, in an engorged
        and torpid condition, secreting but a very small portion of
        bile.  Excessive irritability of the stomach, and torpor, with
        congestion of the liver almost always appear in connexion with
        each  other.   We have a further support  for this opinion, in
        the fact, that, whenever the alvine discharges become bilious,
        an amendment takes place.

Treatment.  The principal indications are:  1. To free
   the bowels from their irritating contents: 2. To allay
  the irritability of the stomach and  bowels:  and, 3. To
  restore the healthy action of  the  liver.   Emetics  are
  very  useful in the  beginning, when  there  is not  full
  spontaneous vomiting.  Purgatives are of primary im-
  portance.   They can  seldom be given, however, with
  effect, until the  gastric irritability is allayed.  Small
  doses of calomel,  1-2 grain—given every half hour,
  answer well to prepare the stomach for the reception
  of purgatives.  Our principal reliance must be  placed
  on the full operation of purgatives.  Opium, given in
  full doses,  affords much  advantage after  free purging;
  it should always  be given in combination with calomel.
  Mild  aperients  to  be used, for several days after the
  bowels have been once freely evacuated.   Epispastics,
  sinapisms, and warm fomentations, are valuable aux-
  iliaries.   Bleeding must be fully  employed in  robust
  and plethoric subjects, with the view of  obviating in-
  flammation.  Alkaline remedies are proper, when acid
  exists in the primae viae; magnesia is the best article of
  this kind.   The warm bath, is a useful auxiliary.   The 
196
COLICA PICTONUM.
  utmost caution is to be used in relation to diet and ex-
  posure, during  the period of convalescence.  There
  are few diseases which are so apt to return, from errors
  in these respects, as  the present one.  Flannel should
  be worn round the abdomen.   Very cold drinks must
  be avoided, during convalescence.

                  COLICA PICTONUM.

This variety  of colic  is known by  various names; as,
  painter's colic, dry gripes, Devonshire colic, colica
  pictavensis, rachialgia metallica, and saturnine  colic.
The disease generally comes on gradually, and is gene-
  rally preceded by symptoms of gastric  derangement
  such as irregular appetite;  constipation; foul eructa-
  tions; transient pains in  the abdomen; languor; pale
  countenance, &c.   This variety of colic is attended
  with constant and extremely severe pain about the um-
  bilical region;  the  abdominal parieties are hard, and
  forcibly retracted; and the bowels almost immoveably
  constipated.   The  pain suffers occasional remissions,
  but no perfect intermissions, as in  the other varieties
  of colic.   It sometimes assumes a chronic form, pro-
  ducing wasting and palsy  of the fore  arms.   The
  predisposition to it is greatly increased, by having once
  suffered an attack.
  Causes.   Lead; hence its  frequency with  painters,
  glaziers, and workers in lead factories.   Sudden at-
  mospheric vicissitudes, (Larrey;) new and sour wines;
  unripe fruits, &c.
Treatment.  The indications are: 1. To obviate inflam-
  mation: 2. To relieve the  spasms of the bowels: and,
  3. to evacuate them.
Bleeding should  be freely employed in robust and ple-
  thoric subjects—or when the pulse is hard, quick, and
  tense. Opium with calomel, is a remedy of primary
  importance.  Both  these  articles should  be given in
  very large doses, with the view of relieving the intesti- 
DIABETES
197
   nal spasm, and bringing on an early mercurial action.
   Two grains of the  former, with the same quantity  of
   the latter, may be given every two hours, until the pain
   and spasms are relieved.  Purgatives to be given after
   the opiates.  They seldom  fail to excite  purging,  as
   soon as the gums are affected with  the mercury, and
   when preceded by very full doses of opium.   Purga-
   tives  should  be given in a liquid form.   Cold water,
   dashed on the abdomen and thighs, has  been found
   useful in promoting the operation of cathartics.  Alum,
   in fifteen grain doses, every three hours, much recom-
   mended by Richter.  Stimulating enemata, highly be-
   neficial.   The warm bath,  a useful auxiliary.   To re-
   lieve  the paralysis and other sequellae,  mercury is the
   best remedy.   Nitrate of silver has also been success-
   fully used, for the relief of the paralysis.   Pemberton's
   splint.

                      DIABETES.

This disease consists in the secretion and voiding of an
   unusually large quantity of  urine, attended with a very
   dry skin;  great thirst; slight febrile movements;  vora-
   cious appetite; a sense of weight and uneasiness in the
   stomach;  white and foul tongue: great lassitude; pain
   and weakness in the loins; irregular bowels; cold feet;
   dull and heavy eyes; and towards the last, great  wast-
   ing of the  flesh, and debility; vertigo; head-ache; diffi-
   culty  of breathing;  spongy  gums;  offensive  breath;
   constant drowsiness; and hectic fever.  Prout  men-
   tions  inflammation and uneasiness  about the external
   orifice of the urethra.
Diabetes occurs under two distinct forms,  viz: diabetes
   mellitus, and diabetes insipidus.  Of the latter  there
   are three varieties; 1. That in which the urine contains
   an excess  of urea; 2. That in which the urine is albu-
   minous-, and, 3.  That in which it is surcharged with
   phosphates. 
198
DIABETES.
Diabetes Mellitus.   In this variety, the urine is saccha-
  rine, of a pale straw color, sometimes approaching to
  a  greenish hue; its smell resembles that of milk.  It
  always  contains less urea than healthy urine.  Prout,
  who restricts the term diabetes to this variety, says, that
  diuresis is not essential to the disease.
A natural predisposition to diabetes exists in some indi-
  viduals. I have known three members, out of one fa-
  mily, die of this disease.
Of the exciting causes, we know little or nothing.
Proximate cause.   The  opinions on  this head are ex-
  ceedingly  various.  Sydenham, Rollo,  Cullen, and
  Others,  regard derangement of the digestive functions,
  and want of energy in the assimilative |powers, as the
  primary affection.  Objections stated to this opinion.
  I regard diabetes, as a disease essentially and prima-
  rily located in the kidneys,—the stomach, lungs, skin,
  and in short the whole system, becoming secondarily
  affected.  The sugar contained by the urine, is wholly
  the result of a morbid action of the kidneys, for the se-
  rum of the blood of diabetic patients, does not contain
  a particle of it.  It would seem, that the urea which is
  secreted with the  urine in health, is  converted into su-
  gar in diabetes.  The analogy between urea and sugar
  pointed out.   Sugar contains just double the quantity
  of oxygen and carbon, and the same quantity of hy-
  drogen, as  urea—this  latter substance  possessing, in
  addition, a large proportion of azote, of which sugar is
  destitute.  As diabetic urine contains very little or  no
  urea, we may regard the sugar it contains, as a deprav-
  ed secretion of urea.
Prognosis. Diabetes mellitus, is  an  exceedingly obsti-
  nate and dangerous affection, the instances of recovery
  from it being comparatively very few.
Treatment.  Various and diametrically opposite plans
  of treatment, have been recommended.   Bleeding has
  been used with success, by Watt.  In recent cases of a
  phlogistic character, it  is often  benefioial; not  so in 
DIABETES.
199
  protracted cases, or where there is much exhaustion.
  Topical bleeding,  sometimes useful.  Opium holds a
  high rank, as a remedy in this disease.   Feriar gave
  it in union with bark and uva ursi.   Prout prefers the
  pulv. ipecac, compos.   Opium, with carbonate of iron,
  has been used with much advantage in chronic cases,
  with much debility and nervous irritation.  (Latham,
  Prout.)   Sulphate of quinine, a useful article in such
  cases.  Magnesia, strongly recommended by Dr. Trot-
  ter; I have known it to do some good.  Emetics, used
  successfully, by Richter.  Warm  bath and frictions
  with the  flesh  brush,  useful auxiliaries.  Exclusive
  animal diet, is generally admitted, as decidedly the
  best kind of food in diabetes.   Of late, Dr. Starkey has
  published some cases, from which it appears, that, con-
  trary to  the generally  received opinion, a vegetable
  diet is sometimes more beneficial, than one consisting
  principally,  or  wholly, of animal substances.  He
  cured cases with a vegetable diet, and one drachm  of
  phosphate of soda, three times daily.  Other remedies
  have been  recommended, such as:  cuprum ammonia-
  cum ; alum  in  2j. doses; tincture of cantharides; cam-
  phor ; hepatized ammonia; phosphate of iron, &,c.
Excessive diuresis, with an excess of urea.  Urine
  generally pale; reddening litmus, when first voided;
  free from sediment, being prone to decomposition; and
  becoming alkaline.  The desire to pass urine is fre-
  quent and urgent; the urine apt to be increased  in
  quantity, by cold weather.  The functions of the skin
  are natural; the pulse  remains unaffected; no particu-
  lar thirst, or craving for food; the bowels are in general
  regular.  Persons of a thin and spare habit, about the
  middle period of life, most subject to it.
Causes.  Whatever  debilitates the general system, and
  particularly the urinary organs, as masturbation.
Treatment.  Tonics, with  alkaline remedies and opi-
  um. Mercury, in alterative doses; purgatives. (Prout.)
Excessive diuresis,  with  phosphatic salts in the 
200
diabetes.
  urine.  Symptoms.  Great general  irritability; dys-
  peptic phenomena; sometimes costiveness; at others,
  debilitating diarrhcea, the stools being very unnatural
  in appearance; pain and uneasiness in the loins; coun-
  tenance sallow and haggard.   As the disease proceeds,
  great " languor, depression of spirits, coldness of the
  legs, complete anaphrodisia, supervene.  The urine is
  pale, very  prone to decomposition."   (Prout)  The
  sediment consists chiefly of the phosphates.
Causes.  Injuries done  to the  back—excessive fatigue-
  depressing mental emotions—irritation about the neck
  of the bladder, by calculi, and other circumstances.
Prognosis.   The prognosis is in  general  unfavorable,
  particularly when resulting from injury of the back.
  (Prout.)
Treatment.  Opium is, according to the experience of
  Prout, the only remedy that can be employed with
  any particular advantage, to allay the excessive general
  irritability  which  prevails in this  disease.  After the
  morbid irritability has been allayed, tonics must be
  given in conjunction with the opium—such as the  mi-
  neral acids, cinchona, iron,  uva ursi, and bitters.  A
  stimulating plaster to the back and loins will prove
  beneficial.   A strong infusion of alchemilla arvensis,
  has been found useful.   Hyoscyamus,  with uva ursi,
  very serviceable, where the constitution is sound, and
  the irritation is confined to  the urinary organs.  The
  diet should be digestible, mild, and nutritious. (Prout.) 
INDIGESTION.
201
               CHAPTER  XIX..

                  INDIGESTION.

Symptoms.  Variable appetite—generally none; flatu-
   lence, distention, acid eructations, and colic pains, after
   eating.  These symptoms characterize the  slighter
   cases of the disease.  By repeated errors in diet, or
   long continuance, it generally assumes a more aggra-
   vated  form; in  which case the stools lose their natural
   appearance,  becoming  bilious, very  fetid, sometimes
   of a very dark  color, at others too light or greenish,—
   and often mixed with portions of undigested food; the
   skin becomes sallow; the urine high colored, and sedi-
   mentous; diarrhcea,followed by constipation;  griping;
   a sense of weight in the right hypochondrium; tender-
   ness of the epigastrium; a foul and clammy tongue; de-
   bility,  particularly  after the operation of purges; gene-
   ral despondency and irritability of temper; emaciation;
   a  haggard expression of the countenance; frequently
   uneasiness of lying on the left side, and at last inability
   to rest easily on either side; a shrivelled and dry state
   of the  skin, in protracted cases; great sensibility to low
   temperature, &c.
Causes.   There are two conditions necessary for healthy
   digestion, viz:  1. The secretion of a due quantity of
   healthy gastric liquor; 2. A healthy tone of the mus-
   cular coat of the stomach.   Whatever therefore  de-
   ranges either of these two functions, impairs digestion.
   The remote causes which are capable of effecting these
   morbid changes, act either directly on the stomach, or
   indirectly through the medium of the general system.
   Of the former kind are: all kinds of substances  capable
   of irritating the stomach—such as irritating and indi- 
203
INDIGESTION.
  gestible articles of diet; the habitual use  of spirituous
  drinks; the excessive use of condiments, opium, and
  other narcotics; the immoderate use of very warm, or
  very cold drinks; chronic hepatic disease; over-disten-
  tion of the stomahc,  by food or  drink—of all the
  causes  of  indigestion, this latter one is the most com-
  mon.  The circumstance which most commonly gives
  rise to over-distention of the stomach, is rapid eating;
  high seasoning, and frequent variety of food is also a
  fiequent cause of over-distention. Over-distention does
  injury, by weakening  the muscular fibres of the sto-
  mach, and by irritating the nerves of  this  organ.—
  (Among the causes that affect the stomach, secondari-
  ly, through the general system, are:  the depressing pas-
  sions; intense study;  excessive venereal indulgence;
  and whatever debilitates the general system.
Proximate cause.  Irritation of  the  nerves  of the sto-
  mach, and debility  of its muscular  fibres, either exist-
  ing singly or conjointly.  In consequence of these con-
  ditions, the solvent gastric fluid becomes  either de-
  praved in quality, or deficient in  quantity; and the
  contents of the stomach are not adequately embraced,
  and propelled forwards to the pyloric extremity.
Observations on the  multifarious  sympathetic  effects  of
  gastric irritation, from imperfectly digested food in the
  primae viae, and on the morbid effects which result from
  the absorption^ imperfectly elaborated chyle into  the
  circulation,
Treat3Ient,  The treatment of indigestion is divided
  into dietetic  and medicinal.  In slight cases, a  proper
  attention to diet,  with the occasional use of mild aperi-      j
  ents, and a rigid avoidance of the exciting causes, will
  rarely fail to establish a  cure.   In all cases, whether
  simple or complicated, mild or violent, an undeviating
   attention to diet, is essential to the  management of  the
   disease.  No particular direction in relation to the kind
   pf diet, can be laid down, which  is applicable to  all 
INDIGESTION.
203
  Cases.  Some dyspeptics  feel relieved by  articles of
  food, which are altogether intolerable to others.   Ev-
  ery dyspeptic must learn, in a great measure, from his
  own experience, what will, or will not, agree with him.
  The degree of violence of the disease, too,  has an im-
  portant influence upon the power  of the stomach, to
  bear particular kinds of food.  What may be taken
  without inconvenience in the first periods, will general-
  ly become insupportable in the latter  stages of the dis-
  ease.  At first, when mere  debility  of the stomach
  exists, the more digestible kinds of animal food, are
  decidedly the best; but if the  disease continues, until a
  high degree of irritation, or  chronic  phlogosis, exists
  in the mucous membrane of the digestive  organs, ani-*
  mal food is no longer proper—the disease  then requir-
 ing the mildest articles of the farinacious  kind.   Ani-
 mal is undoubtedly more digestible than vegetable food;
 and where the gastric irritation is not very considera-
 ble, it will very generally be taken with the least incon-
 venience.  As a general rule, therefore, we may lav it
 down, as  an  established principle, that animal food is
 the most proper; and of this, the  most tender muscular
 parts are to be used.  The  flesh  of old is in general
 more digestible than that of young animals.   Mutton,
 and most kinds of game, are of easy digestion.   Pork
 is  generally  difficult  to  digest,  yet some  dyspeptics
 bear it better  than  other  meats.  Acescent and oily
 articles are most  difficult  of  digestion.  Venison is
 perhaps the most digestible of all meat.  New bread
 is of exceedingly difficult digestion.  Simple  roasting
 and boiling is  the best mode of preparing  meat for
 weak stomachs. All kinds of fried articles of food, are
 intolerable. Cheese, milk, cream, and  butter, are ge-
 nerally oppressive.   Spices and condiments should be
 taken very  sparingly.   Fresh vegetables are very gene-
 rally injurious,  particularly, cabbage, peas,  and beans.
 Of fruits, cucumbers, pears, melons, currants, are.  the
most indigestible.  The food  should be taken chiefly 
204
INDIGESTION.
  in a solid state.  Slow eating, and perfect mastication,
  are  all-important  observances for dyspeptics.   Not
  much drink should  be taken during meals, or  soon
  after.  Moderate portions of good brandy, answer well
  in slight  cases, but are improper in the more aggravat-
  ed ones.  Simplicity in diet  is of the  utmost impor-
  tance ; and what is of equal, if not of still greater im-
  portance, is, to avoid over-distending the stomach.
Medicinal treatment.   In slight and recent cases, gentle
  emetics and aperients, to remove the irritating contents
  of the stomach and  bowels, with  the use of mild to-
  nics; alkalines when the eructations are acid, and an
  animal diet, will generally remove the disease.  To re-
  lieve the gastric pains, small doses of opium may be
  occasionally used.   When functional disease of the li-
  ver  exists, alterative doses of blue pill,  with  the occa-
  sional exhibition of  some gentle laxative, are of  great
  utility.   Care must be taken, however,  not to continue
  "the use of the mercury, until the general system becomes
  affected  by it.  General mercurial excitement, is always
  improper, in dyspepsia. The nitro-muriatic acid, will of-
  ten prove serviceable, as a local tonic, and by its action
  on the liver.   When the gastric irritation has assumed
  the character of chronic inflammation, that is, when
  the  epigastrium becomes tender to pressure, the  pulse
  tense and irritated, the tongue red, &c.  tonics, emetics,
  animal food, and all  stimulating remedies, are injurious.
  The diet must  be  of the  lightest farinaceous kind;
  leeches, or blisters to the epigastrium, are often highly
  useful; the nitrate of potash, dissolved in some mucila-
  ginous fluid, the occasional use of fluid  purgatives, and
  gentle diaphoretic drinks, with  the  use of very  small
  doses of the blue pill, must be resorted to.  In very
  protracted cases, attended with a broken down constitu-
  tion and general irritation, mercury is improper. 
JAUNDICE.
205
                 ICTERUS--JAUNDICE.

 Symptoms.  Skin and eyes yellow; faeces clay colored;
   urine bilious, communicating a yellow stain; generally
   slight pyrexia; occasional pain (sometimes very violent)
   in  the  epigastrium;  indigestion; languor,  nausea; a
   sense of fulness in the stomach; torpor of the bowels;
   colic pains:  drowsiness; bitter taste;  debility, and in-
   disposition to mental exertion; disturbed sleep, &c.
 The fundamental affection is either an idiopathic or sym-
   pathetic derangement of  the biliary organs, or~of the
   duodenum, by which the bile is either obstructed in
   its passage into the intestines, or its secretion is  sus-
   pended.
 The occasional causes are very various.  The principal
   are: intemperance in the use of spirituous liquors; ir-
   ritating substances in the primae viae; cold; suppression
   of acute and  chronic cutaneous eruptions; acrid  bile
   irritating the common duct; biliary concretions plug-
   ging up the duct; violent anger; injuries and concus-
   sion of the brain; spasm of the duodenum, or of the
   common bile duct; induration and enlargement of the
   pancreas;  grief;  terror;  constipation;  viscid mucus
   clogging the orifice of the common duct; retained me-
   conium; indurated  liver;  and, in short,  whatever is
   capable either of suspending the secretion  of bile, or
   preventing its natural egress from the  liver.  When it
   depends on spasm or biliary concretions, the pain is
   occasionally very violent.
Proximate cause.  The external icteric phenomena, de-
   pend on the secretion of bilious matter into  the subcu-
   ticular tissues, in  consequence either of the resorption
   of bile into the general circulation, or of the retention
   of its elements in the mass of the blood, in case of he-
   patic torpor.  When this occurs, the general capillary
   system, and particularly the cutaneous capillaries, per-
   form the office of the liver vicariously,  and  free the 
206
JAUNDICE.
  blood of a portion  of its  superabundant biliary  ele-
  ments, by depositing them into the skin, &c.
Observations on the ratio symptomatum.
Great wasting  of the flesh, and  dropsy, are common se-
  quellae of very  protracted and obstinate  cases.  The
  jaundice of new-born infants, is generally transient, and
  of no particular moment.  When it depends on chro-
  nic hepatic  disease, it is  seldom cured.  In general,
  however,  it is not a dangerous affection, though often
  of difficult removal.
Treatment.  The mode of treatment should of course
  be modified, according to the nature of the fundamen-
  tal hepatic affection.   When there is fever, with symp-
  toms  of local inflammation,  bleeding  and blistering,
  with mercurial  purgatives, must be chiefly relied on.
  When spasm of the common duct may be presumed
  to be the primary cause, which is attended with violent
  pain,  constant nausea, and frequent vomiting, opium,
  stramonium,  hyoscyamus;  emetics,  in  nauseating
  doses; valerian;  assafeetida;  infusion  of chamomile;
  purgatives; the  warm  bath; emollient cataplasms, or
  fomentations to  the epigastrium; anodyne frictions, and
  enemata.  When torpor of the liver exists, as the fun-
  damental pathological condition,  (in which case, there
  is little or no pain experienced,) calomel is the  princi-
  pal remedy—it should be given in purgative doses.
  Benefit may also  be derived from infusion  of taraxa-
  cum;  saponaria; alkalies;  ammoniac; mercurial  fric-
  tions on the  right hypochondrium; antimonials;  blis-
  ters and sinapisms on the region of the liver; and ac-
  tive purgatives.  When biliary concretions exist, as the
  cause of the disease, emetics; purgatives, the warm
  bath;  electricity; opium;  stramonium;  hyoscyamus;
  alkaline remedies; copious bleeding; nauseating doses
  of antimonials; are serviceable. Durande recommends
  a mixture of vitriolic ether and spirits of turpentine, in
  the proportion of two parts of the  former, to one of the
  latter, in doses of twenty drops, four or five times daily, 
scorbutus.
207
  as a valuable remedy.   Guyton Morveau recommends
  a solution of the yoke of eggs, in vitriolic ether, as very
  efficacious.

                     SCORBUTUS.

Symptoms.  First stage.   Unusual  languor, and  want
  of muscular energy; stiffness of the knees; depression
  of spirits; a pale,  sallow, lead-colored, bloated coun-
  tenance; skin  dry, and covered with  livid spots and
  blotches; particularly on the thighs, legs, arms and ab-
  domen; oedema about  the ancles;  gums  spongy, and
  apt to  bleed on being  touched; fetid breath; a disa-
  greeable putrid taste; desire for fresh vegetables, and
  acids; the blood is black, thick, and dissolved, with a
  great abundance of serum; pulse soft and weak.  As
  the disease advances, other symptoms, which mark the
Second stage, occur, viz: Stiffness of the joints;  indura-
  tions of the muscles; pains in the  thighs, back,  loins,
  and  particularly in  the knees; oppressed respiration;
  colic pains;  sub-cutaneous  extravasations of blood;
  ulcers,—particularly on the calves  of the legs, and
  thighs, with cedematous, flabby, and bloody edges, dis-
  charging dissolved blood and ichor; muddy and high
  colored urine; passive  hemorrhages from the gums,
  nose, rectum, bladder, &c.;  sloughing of the gums, the
  teeth becoming loose  in  their sockets; re-opening of
  old and cicatrized  sores; brittleness of the bones; syn-
  cope on the slightest motion.
In the third stage, there is extreme debility; frequent
  syncope; great oppression of breathing;  a cadaverous
  exhalation from the body; sometimes palsy of one or
  more extremities;   emaciation; occasionally  dropsy,
  jaundice, and finally extreme exhaustion,  with an irri-
  tated pulse.
Causes.  Persons  of a debilitated and  phlegmatic  habit
  of body, with a disposition to obesity, are  most subject
  to the disease. The occasional causes are: innutritious 
208
SCORBUTUS.
  diet, conjoined with fatiguing labor, and exposure to a
  damp and impure air; excessive  and repeated he-
  morrhages; impure diet; anxiety of mind, with a  se-
  dentary mode of life; the habitual and intemperate use
  of spirituous liquor; the continued use of either exclu-
  sive vegetable, or much  salt animal diet.  A damp
  and impure air, is a powerful co-operative cause with
  vitiated, or exclusive salt animal food, &,c.
Proximate cause.. A morbid process of sanguification,
  and a consequent morbid condition  of the blood.
Treatment.  The first and most important of the treat-
  ment is the removal of the causes which have produced
  the disease.  When it is the result|of impure diet, and
  a vitiated  and damp air, more wholesome food and air
  are necessary.   When exclusive salt animal] food is  its
  cause, vegetable acids, and a vegetable diet are the ap-
  propriate remedies.  If an exclusive  vegetable, or fari-
  naceous  diet, has given rise to it, animal food, with
  moderate exercise in the open air, is to be prescribed.
  All sorts of fermented liquors; acid fruits; alkalescent
  plants; pure fresh water;  cleanliness; free 'ventilation;
  are remedial in this disease.  The vegetables which
  have been  found  most beneficial, are: scurvy-grass;
  garlic; water-cress; garden-cress; the fruit of the cloud-
  berry ; (Chamae-morus;) cabbage, in the form of sour
  krout; cochlearia, &c.

                     SCROFULA.

Scrofula may be  divided into two periods, or states—the
  one that peculiar diathesis, called the scrofulous habit;
  the other, the disease in its state of development and ac-
  tivity.  The scrofulous habit, or predisposition, may  be
  acquired  from accidental causes, or from hereditary
  transmission.  The scrofulous habit is characterized  by
  the following circumstances; a particular delicacy and
  languor  of countenance; smooth,  soft,  and  flaccid
  cheeks; a dull  lead-colored circle around the mouth, 
SCROFULA.                 209
   With fine  red  lips; swollen upper lip; inflammation
   of the edges of the eye-lids—particularly in children;
   weak digestive powers; scabby  eruptions about the
   head; irregular state of the alvine  discharges; slow
   growth  of the body;  aptitude to take cold,  &c.—
   This dormant  state of  the disease may  continue for
   years, or  pass off, under favorable  circumstances.
   More generally, however, it becomes gradually deve-
   loped, under the influence of various exciting causes;
   the  lymphatic glands along the neck, and other parts
   become  enlarged; and by degrees pass into a state of
   slow inflammation, terminating in induration, or suppu-
   ration—the ulcers thus formed,discharge a thin,  milky,
   and  somewhat  viscid fluids—are but  little painful, and
   exceedingly slow  in cicatrizing.   The cicatrices are
   uneven, and irregular; the eyelids and conjunctiva be-
   come inflamed, as well as the mucous membrane of
   the nose, and bronchia.   In a more advanced state of
   the  disease, the salivary and thyroid glands, and the
   pancreas, and other glandular parts, enlarge; eruptions
   appear on the skin; emaciation ensues: the extremities
   of the long bones enlarge; ulcerations occur, particu-
   larly in  the cartilaginous  and  glandular structures;
   some of the bones become carious; the large joints in-
   flame and  suppurate; the spine becomes diseased; the
   nose, and palate, are destroyed by ulceration; in short,
   there is scarcely any part of the body, which is  not
   sometimes  the  seat of its frightful ravages.  The most
  common course of scrofula, however, is the formation
  of tubercles in the lungs, and consequent phthisis pul-
  monalis.
Scrofula  occurs more  frequently in children, than  in
  adults.  The scrofulous habit,   is rarely formed after
  the period  of manhood.   The most common causes
  which produce this morbid  habit, are: cold and  atmo-
  spheric vicissitudes; indigestible  and  unwholesome
  food; excessive  indulgence in eating;  confinement and
  want of exercise; long exposure to  a  humid atmos*
                      D* 
210                   SCROFULA.
  phere; mental disquietude;  chronic irritation in the
  stomach and bowels, from worms  and other  causes;
  exposure to cold and humidity, during convalescence
  from various diseases, particularly measles, scarlatina,
  whooping cough;  in short, whatever permanently de-
  bilitates the system, more especially during childhood.
Proximate-cause.  The scrofulous habit, consists proba-
  bly in constitutional, or acquired excess of irritability
  in the lymphatic system, in connexion with a weak con-
  dition of the assimilative powers.
Treatment.  To counteract the scrofulous habit, great
  care is required, to  avoid the exciting  causes.  The
  integrity of the digestive,  perspiratory, and  hepatic
  functions, is to be  maintained, and the tone of system
  supported.  This is to be done,  by the occasional use
  of mild aperients; alterative doses of mercury; warm
  clothing;  mild vegetable tonics; exercise in the open
  air; a simple, but nutritious diet;  sea-bathing; the tepid
  shower bath;  dry frictions; alkalines, when gastric
  acidity prevails.  When the disease is established, the
  same course of treatment is required, with additional
  remedies, varied according to existing circumstances.
  When the disease  exists in the state of lymphatic glan-
  dular tumors, iodine, bathing with salt water, leeching,
  and emollient  poultices • are often beneficial.  In this
  state, advantage may also be occasionally derived from
  the extracts of conium maculatum, dulcamara, hyoscy-
  amus,  belladonna, and  minute portions of muriate of
  mercury.   In general, however, irritating applications
  are improper, so long as the tumours remain indolent.
  When scrofulous ulcerations exist, benefit may be de-
  rived from liquor potassae;  the narcotic extracts just
  mentioned; themuriatesof mercury,gold, barytes, lime;
  ptisans from tussilagafafara; sarsaparilla; arctium
  lappa.  I have seen more good  done, by minute doses
  of muriate  of  mercury, and large ones of extract of
  conium, than by any other remedies.  Farr speaks in
  the highest terms of the efficacy of large doses of the
  liquor potassae, and mercurial frictions used conjointly 
MENTAL DISEASES.               211
                CHAPTER XX.

               MENTAL DISEASES.

  The diseases of the mind may be divided  into four
  classes, viz: mania, monomania, dementia, idiotism.
     1. Mania.  General derangement of the mind, cha"
       racterized by  a rapid succession of incoherent
       ideas—delirium;  violent  excitement of the pas-
       sions, expressed by great agitation; cries, singing,
       menaces, and fury.
     2. Monomania.   Partial insanity—the patient be-
       ing insane on one particular subject only.  This
       class comprehends a great many varieties, as no-
       stalgia, fanaticism, hypochondriasis,  misanthropy,
       &c.
     3. Dementia.  Imbecility of mind—the reasoning
       faculties being defective,  and  memory weak or
       obliterated.   It occurs in very old people; and af-
       ter diseases of the brain, as apoplexy, epilepsy, &c.
     4. Idiotism.    Defective  intellectual development,
       amounting sometimes to a total absence of mind;
       and, in some instances, even to a destitution of the
       instinct, which leads to the gratification of the ani-
       mal appetites.
General symptoms.  Sensibility impaired;  appetite, de-
  praved, null, or voracious; constipation; fever in mania,
  and in  the beginning of monomania; skin dry, and of
  a yellowish brown color; in women, suppressed or ir-
  regular menstruation.
Causes.  Hereditary  predisposition, has an  important
  share in the aetiology of mental diseases.  Mental de-
  rangement from hereditary predisposition, is generally 
212               MENTAL DISEASES.
   announced " by  whimsicalities of disposition; certain
   singularities of character; caprice in taste and habits;
   peculiar and evilly intentioned conduct; little aptitude
   to the study of the exact sciences; and in unmethodical
   taste for the arts  of display, and the pleasures of imagi-
   nation."
Among the most common occasional causes  of insanity,
   are.- violent passions; intense application to one object;
   jealousy; excessive joy, sorrow, hatred,  terror, or sur-
   prise; religious enthusiasm; unrestrained imagination;
   poverty;  excessive  ill  treatment;  disappointed  love,
   ambition, vanity;, mortified pride; chagrin; the crisis
   of female life, suppression of  habitual discharges; re-
   percussion of chronic cutaneous  affections;  drunken-
   ness ; parturition; pregnancy; epilepsy; blows  or  falls
   on the head; acute and chronic diseases.
Development, Progress, and Termination of Insanity.
   The development of insanity,  in its incipient stage, is
   generally marked by a  change in the habits, tastes, at-
   tachments, and passions of the patient.  As the mental
   disorder advances, vigilance,  head-ache, loquacity, or
   taciturnity; inconsistency in conduct; wild and ruinous
   enterprises; a neglect of the ordinary occupations; un-
   usual prodigality; inconsistent conduct; incoherence of
   ideas; and, finally, fixed monomanic hallucination, de-
   lirium, or general aberration of the perceptive and  rea-
   soning faculties.
Insanity is sometimes periodical—at others, it is tempo-
   rary:—passing off either spontaneously, or in  conse-
   quence of remediate treatment; sometimes,it assumes
   a fixed and incurable  state.   Chronic, or incurable
   mania,  or  monomania, frequently terminates in  de-
   mentation.  (Georget.)   Idiotism is always iucurable.
   Dementia is usually  preceded  or followed by paralysis.
Prognosis.  Recovery occurs most frequently between
   the ages of twenty and  thirty. It  seldom terminates
   favorably after the fiftieth year of age.  When insanity
   is connected with paralysis, or epilepsy, it may be re- 
MENTAL DISEASES.
213
  garded as incurable.  A recovery of the general health
  of the system, without a corresponding melioration of
  the  mental  hallucination, is  an unfavorable sign.  It
  has  been observed, that cold  is more favorable to re-
  covery, than warm weather.
Pathology of Insanity.  Many pathologists contend, that
  the mind is never deranged idiopathically; but always
  in consequence of some  physical  disorder,  whether
  functional or organic, of the animal system.  To this
  opinion, 1 am myself inclined to give my assent.  This
  subject is fully discussed in the lectures.
Treatment.   The treatment is divided into moral and
  remedial  management.   Under the head of moral
  treatment, are: a soothing, mild,  and conciliatory ma-
  nagement; the absence of all coercive measures, unless
  imperiously demanded by  the violence of the maniacal
  fury, or attempts to injure themselves or others; a  sepa-
  ration of the patient from all objects calculated to recal
  the sentiments, or passions, which gave rise to the dis-
  ease ; a judicious diversion of the mind, from the ob-
  jects upon which the thoughts are habitually directed,
  and  an encouragement to  reflection "upon  subjects of
  personal conduct and thought."  To restrain and sub-
  due  the turbulent, it is often sufficient to envelope the
  head suddenly with a cloth, so as to prevent them from
  seeing.  The most furious generally become  calm, so
  soon as they are thus  prevented  from seeing.  The
  false ideas and fancies of insane persons, should never
  be encouraged, nor  vehemently  contradicted.   By
  watching  favorable opportunities, circumstances will
  generally  occur, which, by a  few judicious remarks,
  may lead them to doubt of the  correctness of their no-
  tions; " and doubt of the correctness of their own per-
  ceptions, marks  the period for persuasion and convic-
  tion of error."
Convalescents from insanity, should be suffered  to  asso-
  ciate freely with each other;  nothing, says Georget,
  promotes recovery more  than such  an intercourse. 
214
VERMINOUS DISEASES.
  Mechanical employments are often of great benefit in
  the management of lunatics.
Remedial management.  The remedies most efficacious,
  are: blood-letting, where there is much arterial excite-
  ment; purging; blisters; the cold shower bath; frictions;
  tepid bath; mild and digestible diet; enemata.
VERMIMOUS DISEASES.
Various opinions concerning the origin and  formation of
  worms, in the intestinal canal.  It does not appear that
  they are received from without, because they are never
  found out of the animal body; and when removed out of
  the body, they speedily die; and, lastly, earth worms,
  and such as live in water, do  not change their forms,
  when received into  the  intestinal canal.   There are
  five varieties  of intestinal worms.
     1.  Tricocephalus dispar.   These worms are from
       an inch and a. half, to two inches in length. About
       two thirds of their length  is almost as  thin as a
       horse hair, the remaining and posterior part being
       considerably thicker, and terminating in a rounded
       extremity.   They are found  principally in the
       ccecum.   They are seldom numerous.
     2.  Ascaris vermicularis, {oxyuris vermicular is,)
       These are exceedingly short—not more than two
       lines in length, very thin and white.  Their usual
       seat is in the rectum.
     3.  Ascaris lumbricoides..   These worms are from
       two or three, to ten or twelve  inches in length,
       round, of yellowish white, or brownish red color,
       of nearly a uniform thickness, except at the extre-
       mities, which taper to a  blunt point.  They are
       from two to three lines in thickness.  They  inha-
       bit the small intestines chiefly; but occasionally
        ascend into the stomach.
     4. Ttenia  lata, (liothricocephalus latus.)   This
        worm often acquires a very great length—from 
verminous diseases.
215
      twenty to thirty feet and more; it is from four to
      six lines in breadth, flat and white, resembling a
      piece of white tape, and composed of a series of
      concatenated joints.   It inhabits the upper  por-
      tion of the bowels and the stomach.  The head is
      armed with two processes, by which the worm
      attaches itself to the intestines.
    5. Taenia solium, (T. Cucurbitina.)  This worm
      is rarely, if ever, voided whole; it generally passes
      off in short joints, resembling, in some measure,
      the seeds of gourd.   Pieces, however,  upwards
      of twenty feet, of this worm, have been voided.
      The head is small, and furnished with four small
      apertures.  (Oscula.) It inhabits the small  intes-
      tines chiefly.
Symptoms.   Countenance pale, lead-colored, with occa-
  sional  transient flushes; eyes dull; pupils dilated, with
  a bluish semicircle around the lower eye-lids; tickling
  in the  nose;  tumid upper' lip; occasional  head-ache,
  and humming in the ears; copious secretion of saliva;
  tongue slimy or furred; breath foul; variable appetite—
  being sometimes voracious—at others   wholly  gone;
  transient pains  in the stomach; occasional nausea and
  vomiting; pains in  the abdomen—particularly  about
  the umbilical region; frequent slimy stools, or costive-
  ness; urine turbid, yellowish, or milky; abdomen tumid
  and hard, with  emaciation of the other parts of the
  body;  lassitude; irritability of temper.   None  of these
  symptoms, however, are certain indications of the exis-
  tence of worms in the bowels—the only certain indica-
  tion being the appearance of them in the evacuations
  from the bowels or stomach.
The opinion which is expressed by some,  that worms are
  harmless in the intestinal canal, is without  foundation.
  It is nevertheless probable, that that peculiar condition
  of the alimentary canal, which favors the production of
  worms, is more frequently the cause of mischief, than
  the worms themselves.   Worms give rise to  a variety 
216
VERMINOUS DISEASES.
  of affections, such as chorea, epilepsy; hydrocephalus;
  emaciation; convulsions; paralysis, and a vast variety
  of anomalous disorders.
Treatment.  In prescribing for the removal or destruc-
  tion of worms, it is of some consequence to confine the
  patient to a spare and liquid diet, and to exhibit two or •
  three mild cathartics a few days previous to the  exhi-
  bition of the proper  anthelmintic  remedies.   With
  these preparatory measures, the ordinary vermifuge re-
  medies will disappoint us much  more seldom than
  without them.  My  own plan of treatment  for the ex-
  pulsion of the lumbricoides, is to put the patient on a
  liquid diet, and to give a small dose of Epsom salts
  every morning, for three  days in succession.  On the
  fourth morning, 1 order a decoction of the root of spi-  -
  gelia, in the proportion of an  ounce of the root to one
  pint of water, and boiled down to half a pint.   This
  being sweetened, is to be drunk in the course of three
  or four hours; and immediately after the whole of the
  decoction is taken, an active dose of calomel and jalap
  —or  what is perhaps still better, castor oil and turpen-
  tine,  is to be taken.  I have rarely failed, by this me-
  thod, of removing worms, where  they  existed.   The
  most  efficacious anthelmintics, for the  destruction of
  ascarides lumbricoides, besides spigelia, which I regard
  as decidedly the  best, are: sem. santonici; chenepodi-
  urn anthelminticum, dolichos pruriens; calomel, garlic,
  conferva helminthcordon, and geoffrea surinamensis.
The removal  of ascarides, is often exceedingly difficult.
  Remedies employed in the form of enemata, are  gene-
  rally  more efficacious, than when given by the mouth.
  My usual prescription for the expulsion of these worms,
  is to exhibit three or four aloetic purges every second
  day, together with two or three enemata, composed  of
  a solution of common salt daily.  Injections of a solu-
  tion of aloes—of lime water,  or of infusions of any of
  the ordinary  anthelmintics,   v/ill  occasionally  bring
  away these troublesome little worms.  I have, in  a few 
                VERMINOUS DISEASES,            217

  instances, brought them away in great quantities, by in-
  jections composed of spirits of turpentine, mixed with
  milk.  The introduction of a bougie, smeared over with
  mercurial ointment, has  been employed  effectually
  against these worms.  Nils Rosen speaks very favora-
  bly of injections compsed of a drachm of refined su-
  gar,  dissolved in warm milk.
For the expulsion  of the tape-worm, a great  variety  of
  remedies and modes of treatment have  been recom-
  mended.  The anthelmintics  that  have been  found
  most efficacious against this species of intestinal worm,
  are:  polypodium  filix mas; spirit of turpentine; tin;
  valerian, and the bark of the pomegranate root.   The
  latter article has been  particularly recommended  of
  late years, as a powerful  remedy against the  tapeworm.
  Whatever mode of treatment be adopted, it  is always
  of much consequence to prepare the patient, by diet and
  laxatives, before  the proper vermifuges are  given.   A
  spare and liquid diet,  with the daily use of small doses
  of saline purgatives, for five or six days, will  greatly in-
  crease the chance of procuring the  expulsion of the
  worm, by the use  of anthelmintics.  The following  is
  the substance of some of the most celebrated methods of
  treatment recommended for the removal of this worm.
Alston's method.  An  active purge; next morning, one
  ounce of pure tin  filings; on the second, third, and
  fourth mornings, half an ounce of the same  metal, fol-
  lowed, on the fifth morning, by an  active purge.  Des-
  saulVs method: mercurial frictions on the  abdomen,
  followed by a drastic  mercurial  purge.    Ileren-
  scJiwanoVs method: one drachm of powdered male fern
  root, mornings and evenings, on an empty stomach, for
  two  days in succession; on the morning of the third
  day,  take the following:  R. G. Gambog. gr. xij.  Sub-
  carbonate potass, gr. xxx. Sapon Venet. gr. ij.  Misce.
  Three hours after this, an ounce of ol. ricini. is  to be
  taken.   Hufeland's method: a cup of a decoction  of
  garlic in milk, every morning, on an  empty stomach, 
218
VERMINOUS DISEASES.
  with a table-spoonful of castor oil every morning, noon,
  and evening, half an ounce of the filings of tin, once
  daily, and frictions with petroleum, en  the abdomen.
  This must be continued  for several weeks.
Spirits  of turpentine, has  been employed with much
  success for the expulsion of taenia.   From two to three
  ounces of this article, should be given at once; and
  followed, in two hours,  by a dose of castor oil.  The
  bark of the pomegranate root, has been recently strong-
  ly recommended, for the removal of taenia.
FINIS 
 
 
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